This is an HTML version of an attachment to the Freedom of Information request 'Policy relating to elective caesarean sections'.


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
North Cumbria Delivery 
Suite Guidelines 2008 
 
 
 
 
 
 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
DOCUMENT CONTROL 
 
Author/Contact 

North Cumbria Obstetric Guideline Forum 
 
Tel: 01228 814242 
 
Email:  xxxx.xxxxxx@xxxxxxxxxxxxxx.xxx.xx
 
 
Document Path & Filename 
Y:\Trust Policy Group\Ratifed\January 2008\Del 
Suite Guidelines\NC Del Suite Guidelines 2008 - 
final version.doc 
Document Reference 
NCHE-OBS001 
Version 
2.0 
Status 
Approved 
Publication Date 
22/01/2008 
Review Date 
22/01/2011 
Approved / Ratified / Notified  Governance Committee     Date: 15/01/2008 
by 
 
Trust Board                        Date: 22/01/2008 
Distribution:   
North Cumbria Acute Hospitals NHS Trust – Intranet 
 
Please note that the Intranet version of this document is the only version that is 
maintained.  Any printed copies should therefore be viewed as “uncontrolled” and as 
such, may not necessarily contain the latest updates and amendments. 
 
 
Approval/Amendment Record 
 
Version  Date  
Brief Summary of Change Author 
0.1 
25/05/2006 
First meeting to overview  R Lawley – CD / Obstetrics 
Draft 
J Eldred – Obstetrics 
D Lightfoot (SOM) – Matron 
S Forster (SOM) - Matron 
0.15 
19/07/2006 
Reviewed by appropriate 
Dr P Stride - Anaesthetics 
specialties 
Dr Q Kingsbury - 
Anaesthetics 
Dr M Ben-Hamida - 
Paediatrics 
Dr P Whitehead – 
Paediatrics 
Anne Musgrave (SOM) – 
Head of Midwifery 
S Whyte-Earl - Matron of 
Neonatal Services 
S Forster (SOM), Matron - 
CIC Midwives 
D Lightfoot (SOM), Matron – 
WCH 
Midwives  
S Hall, Midwife - 
PNH/Community Midwives 
 
NCHE-OBS001 
 
Page 2 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
L Musgrave (SOM), Matron - 
Normal Birth Group  
I Branch - Blood Transfusion 
M Knowles - Microbiology 
H Sawers – Diabetics 
Mr Reid, Mr Wijesiriwardana 
& Mr Bober – Obstetrics 
L Hipple - Obstetrics 
P Robson & B Bowness – 
Bereavement Counsellor  
G Butterworth – Document 
Standards 
1.1 
28/09/2007 
Updated following meeting North  Cumbria  Obstetric 
Guideline Group 
1.2 
02/10/2007 
Updated following meeting North  Cumbria  Obstetric 
Guideline Group 
1.3 
30/11/2007 
Updated following meeting North  Cumbria  Obstetric 
Guideline Group 
1.4 
12/12/2007 
Summary section updated  North Cumbria Obstetric 
to demonstrate agreed Guideline Group 
changes to date as agreed 
with Clinical effectiveness 
Facilitator 
 
 
Review Process Prior to Ratification: 
 
Name Of Group/Department/Committee 
Date 
Governance Committee 
14/09/2006 
Trust Board 
26/09/2006 
North Cumbria Labour Ward Forum 
20/07/2006 
North Cumbria Obstetric Guideline Group 
28/09/2007 
North Cumbria Obstetric Guideline Group 
02/10/2007 
North Cumbria Obstetric Guideline Group 
30/11/2007 
Trust Policy Group 
20/12/2007 
 
 
NCHE-OBS001 
 
Page 3 of 281 

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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
North Cumbria Delivery Suite Guidelines 
CONTENTS 
 
DOCUMENT CONTROL..................................................................................................2 
SUMMARY ......................................................................................................................5 
CHAPTER 1 - OVERVIEW ..............................................................................................8 
CHAPTER 2 - MIDWIFERY CARE ON DELIVERY SUITE..............................................33 
CHAPTER 3 - MATERNITY ASSESSMENT UNIT (MAU)...............................................47 
CHAPTER 4 - INDUCTION OF LABOUR ........................................................................51 
CHAPTER 5 - FIRST STAGE OF LABOUR ....................................................................59 
CHAPTER 6 - SECOND STAGE OF LABOUR AND INSTRUMENTAL DELIVERY........74 
CHAPTER 7 - THIRD STAGE OF LABOUR....................................................................84 
CHAPTER 8 - PERINEAL REPAIR..................................................................................94 
CHAPTER 9 - BREECH...................................................................................................100 
CHAPTER 10 - MULTIPLE PREGNANCY ......................................................................106 
CHAPTER 11 - SHOULDER DYSTOCIA ........................................................................111 
CHAPTER 12 - PRE-TERM LABOUR .............................................................................117 
CHAPTER 13 - FETAL HEART RATE MONITORING.....................................................128 
CHAPTER 14 - ANTEPARTUM HAEMORRHAGE..........................................................139 
CHAPTER 15 - POSTPARTUM HAEMORRHAGE .........................................................146 
CHAPTER 16 - MANAGEMENT OF WOMEN REFUSING BLOOD TRANSFUSION .....160 
CHAPTER 17 - THROMBOSIS AND THROMBOPROPHYLAXIS...................................164 
CHAPTER 18 - CAESAREAN SECTION, VAGINAL BIRTH AFTER CAESAREAN SECTION 
AND LAPAROTOMY.........................................................................................171 
CHAPTER 19 - ANALGESIA AND ANAESTHESIA.........................................................189 
CHAPTER 20 - INFECTION ............................................................................................203 
CHAPTER 21 - ECLAMPSIA AND PRE-ECLAMPSIA.....................................................218 
CHAPTER 22 - DIABETES..............................................................................................227 
CHAPTER 23 - LATEX ALLERGY...................................................................................238 
CHAPTER 24 - SUBSTANCE ABUSE.............................................................................244 
CHAPTER 25 - MATERNAL COLLAPSE AND ACUTE MEDICAL PROBLEMS .............251 
CHAPTER 26 - PREGNANCY LOSS AND MATERNAL DEATH ....................................260 
CHAPTER 27 - CORD PROLAPSE.................................................................................281 
CHAPTER 28 - PAEDIATRIC INVOLVMENT ON DELIVERY SUITE .............................287 
 
NCHE-OBS001 
 
Page 4 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
SUMMARY 
 
These guidelines: 
 
♦  have been produced by the multi-disciplinary groups for use by Health Care Professionals 
working on Delivery Suites within North Cumbria, this includes the Cumberland Infirmary, 
Whitehaven Hospital and Penrith Birthing Unit. 
♦  are intended to guide practice but not to replace clinical judgement. 
♦  are evidence-based where possible but otherwise reflect local practice. 
♦  are published every two years. 
 
Major changes in practice in the intervening period will be publicised and included at the rear 
of the text.  Please bring your own thoughts and recommendations to the attention of the 
North Cumbria Labour Ward Forum. 
 
The guidelines have been reviewed and amended to reflect the latest recommendations of 
NICE Intrapartum Guidelines September 2007.  These changes have been approved by the 
North Cumbria Obstetric Guideline Group and are awaiting notification to the Trust Policy 
Group, Governance Committee and Trust Board. 
 
Additions / changes highlighted in bold 
Chapter Page  Change 
1.4 
14 
Women who have any of the following problems should be 
referred directly from community midwife to the obstetrician 
(SpR or equivalent) and Lead Midwife at the acute unit.
 
1.4 15 
No 

♦ Documentation 
 
♦  Call paramedic ambulance 
♦  Inform LDRP/Delivery Suite and Obstetrician 
♦  Inform Supervisor of Midwives/Manager for support and 
advice 
1.5 15 
First paragraph - Occasionally an antenatal woman 
Last paragraph, deleted ‘sick’ 
1.5 
17/18 
Added In-utero transfer form 
1.6 
19 
Add in new information (highlighted green) 
1.7 
21 
Added in new 1.7 – Arrangements for transfer of babies to other 
units (alter following numbering).   
1.8 
22/23 
Added in new 1.8  
2.2 27 
Added in bullet point - no significant medical complication 
(see NICE Intrapartum Care Guideline 2007 – Page 21-23)
 
 
 
NCHE-OBS001 
 
Page 5 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
2.4 
27 
If deviation from normality occurs, the midwife should discuss the 
case with the Obstetrician (See 1.4) and Lead Midwife co-
ordinating Delivery Suite
 
2.5 26 
Dilatation of 4 cms (not 3) 
2.7 28 
Intermittent auscultation should be offered from the outset ‘and 
should occur for at least 1 minute’
 
2.8 28 
Blood pressure measured every 4 hours (first paragraph) 
2.14 32 
Woman receiving opiates < 2 hours ago – changed on bulleted 
list 
2.14 33 
Temperature 37.5 
5.1 
53 
Added bullet points 
Maternal 
previous mysometry / hysterotomy 
anaemia Hb <8.5 g/dl at onset of labour 
substance abuse, including alcohol dependency 
BMI > 35 kg /m2 
 
Fetal 
breech presentation or other malpresentation 
confirmed IUD 
small for gestational age pregnancy
 
5.2 52 
Observation list – ‘fetal heart every 15 minutes – ‘for at least 1 
minute’ 
Plus sentence ‘Intermittent auscultation of the fetal heart after a 
contraction should occur for at least 1 minute, at least every 
15 minutes, and the rate should be recorded as an average.  
The maternal pulse should be palpated if an FHR abnormality 
is detected to differentiate the two heart rates’
 
5.2 54 
Changed to BP every 4 hours (not 2) 
5.4 
60 
Added flowchart at the end (Delay in first stage) 
5.5 
61/62  New info added / old info deleted – Spontaneous Pre-labour 
Rupture of Membranes 
5.5 
66 
Pre-labour Rupture of Membranes at term flowchart added 
5.5 64 
Under ‘Active Management’ – changed to ‘6 or under’ 
 
 
64 
Under ‘Conservative Management’ deleted until ‘early ret’ 
6.3 68 
Sentence added in – Diagnosis of delay in the active second 
stage of labour should be made with reference to the 
algorithms on page 70-72 
Added in - The fetal heart should be monitored every 5 minutes 
after a contraction
 

73 
Delay of 2nd stage flowchart added 
 
 
NCHE-OBS001 
 
Page 6 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
7.1 78/79 New information in 7.1 to replace old 7.1, 7.2, 7.3 and 7.4. 

Also Definitions of third stage labour flowchart added 
80 
7.2 
78 
Old info on Management on Third Stage deleted, new info put in 
7.3 
82 
Figure 1 – Delete ‘syntometrine’ 
7.3 83 
Figure 2 – add in ‘do not clamp cord’  ‘until pulsations have 
stopped’
 
7.4 80 
Manual removal of placenta deleted 
81 
New information and flowchart added – Diagnosis of delay of Third 
stage – old deleted  
12.6 116 
Steroids –addition to first paragraph – The evidence for a course 
of steroids, 34-36 weeks is therefore weaker but may be 
appropriately given.
 
15.3 141/ 
 
Changes all cases of Tone, Trauma, Tissue and Thrombin to this 
142/ 
order 
143 
Change ‘gauge’ to 16 (grey) 
17.1 158/ 
Deleted old information (except for contra-indications to clexane) 
159 
and add new information  
17.3 
161 
Deleted first 2 sentences 
17.6 
163 
Thromboprophylaxis for labour assessment sheet deleted 
18.2 
167 
Added ‘emergency’, ‘urgent’, ‘scheduled’, ‘elective’ on grading 
19.1 
183 
List of women to be referred to cardiologist added 
20.7 
204 
2 bullet lists added 
21.1 212 
Change loading dose initial treatment with - in 50 ml syringe = 48 
ml.  Give as IV bolus dose over 5-10 minutes by doctor
 
21.5 
214 
Added BP info box at start 
22.4 
223 
Deleted ‘1000 mls’ 
26.23 270/ 
Maternal death – new checklist added 
271 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NCHE-OBS001 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
 
CHAPTER 1 - OVERVIEW 
 
 
 
1.1 
RESPONSIBILITIES OF STAFF ON DELIVERY SUITE ..................................16 
1.2 
HANDOVER OF CARE.....................................................................................20 
1.3 
TRANSFER OF MIDWIFERY CARE TO CONSULTANT RESPONSIBILITY ...21 
1.4 
TRANSFER INTO THE OBSTETRIC UNIT FROM HOME / PENRITH BIRTHING 
CENTRE ...........................................................................................................21 
1.5 
TRANSFER OUT OF THE OBSTETRIC UNIT TO THE TERTIARY UNIT .......23 
1.6 
USING THE NEONATAL HOTLINES FOR IN UTERO TRANSFER REQUESTS
..........................................................................................................................26 
1.7 
ARRANGMENTS FOR THE TRANSFER OF BABIES TO OTHER UNITS ......28 
1.8 
TRANSFER OF POSTNATAL WOMEN TO TERTIARY UNITS .......................29 
1.9 
LABOUR WARD FORUM .................................................................................31 
2.1  
ADMISSION IN LABOUR..................................................................................34 
2.2  
LOW RISK WOMEN .........................................................................................34 
2.3 
HOME BIRTH ...................................................................................................34 
2.4 
TRANSFER TO MEDICAL CARE .....................................................................34 
2.5 
DIAGNOSIS OF LABOUR ................................................................................35 
2.6 
THE PROVISION OF ONE TO ONE CARE TO WOMEN IN ESTABLISHED LABOUR
..........................................................................................................................36 
2.7  
ADMISSION CTG .............................................................................................37 
2.8  
BLOOD PRESSURE.........................................................................................37 
2.9 
BLADDER CARE IN LABOUR ..........................................................................37 
2.10  
CORD GAS ANALYSIS ....................................................................................38 
2.11  
NUTRITION IN LABOUR ..................................................................................39 
2.12 
VENFLON SITING ............................................................................................39 
2.13 
CONCEALED PREGNANCY ............................................................................39 
2.14 
WATERBIRTH ..................................................................................................41 
2.15 
PREVENTING PRESSURE SORES.................................................................44 
2.16 
VIDEO AND SOUNDTAPE RECORDS AND PHOTOGRAPHS .......................44 
3.1 
INTRODUCTION...............................................................................................48 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
3.1 
INTRODUCTION...............................................................................................48 
3.2 
TRANSFER OF PATIENTS TO DELIVERY SUITE FROM ANTENATAL CLINIC OR 
WARD ...............................................................................................................49 
4.1 
INDICATIONS FOR INDUCTION OF LABOUR ................................................52 
4.2 
41 WEEK ANTENATAL REVIEW .....................................................................52 
4.3 
ADMISSION FOR ASSESSMENT FOR INDUCTION.......................................52 
4.4 
OFFER OF INDUCTION FOR POST MATURITY DECLINED..........................53 
4.5 
INDUCTION REGIMEN ....................................................................................53 
4.6 
HYPERSTIMULATION......................................................................................54 
4.7 
AUGMENTATION FOR SPONTANEOUS RUPTURE OF THE MEMBRANES AT 
TERM................................................................................................................54 
4.8 
RUPTURE OF THE MEMBRANES UNDER 37 WEEKS GESTATION ............54 
4.9 
INTRA-UTERINE DEATH .................................................................................56 
5.1 
RISK ASSESSMENT ........................................................................................60 
5.2 
PARTOGRAM ...................................................................................................61 
5.3 
BIRTH ENVIRONMENT....................................................................................63 
5.4  
DYSFUNCTIONAL LABOUR ............................................................................64 
5.5 
SPONTANEOUS RUPTURE OF MEMBRANES AT TERM..............................68 
6.1 
DEFINITION......................................................................................................75 
6.1 
DEFINITION......................................................................................................75 
6.2 
DIAGNOSIS ......................................................................................................75 
6.3 
MANAGEMENT ................................................................................................75 
6.4 
INSTRUMENTAL DELIVERY............................................................................75 
6.5 
MALPOSITION .................................................................................................78 
6.6 
PAEDIATRICIANS' ATTENDANCE AT INSTRUMENTAL DELIVERY .............78 
6.7 
PERINEAL REPAIR ..........................................................................................79 
7.1    
DEFINITIONS ...................................................................................................85 
7.2 
MANAGEMENT OF THIRD STAGE .................................................................85 
7.3 
PHYSIOLOGICAL THIRD STAGE OF LABOUR ..............................................86 
7.4 
TREATMENT OF WOMEN WITH A RETAINED PLACENTA...........................87 
7.5 
THE MORBIDLY ADHERENT PLACENTA.......................................................89 
7.6 
PLACENTAL HISTOLOGY ...............................................................................90 
8.1 
PERINEAL REPAIR ..........................................................................................95 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
8.2 
CLASSIFICATION OF PERINEAL TRAUMA ....................................................95 
8.3 
ANALGESIA......................................................................................................95 
8.4 
SECOND DEGREE TEARS..............................................................................95 
8.5 
THIRD AND FOURTH DEGREE TEARS..........................................................96 
9.1 
ANTENATAL CONSIDERATIONS....................................................................101 
9.2 
ECV...................................................................................................................101 
9.3 
ELECTIVE CAESAREAN SECTION.................................................................101 
9.4 
PLANNED VAGINAL BREECH DELIVERY ......................................................101 
9.5 
TERM BREECH DIAGNOSED IN LABOUR .....................................................103 
9.6 
PRE-TERM BREECH .......................................................................................103 
10.1  
HIGH ORDER MULTIPLE PREGNANCY .........................................................107 
10.2 
INITIAL ASSESSMENT OF TWIN PREGNANCY.............................................107 
10.3 
FIRST STAGE OF LABOUR.............................................................................107 
10.4 
SECOND STAGE OF LABOUR ........................................................................108 
10.5 
THIRD STAGE OF LABOUR ............................................................................109 
11.1 
DEFINITION......................................................................................................112 
11.2 
ANTICIPATION .................................................................................................112 
11.3 
HELPERR .........................................................................................................112 
11.4 
SYMPHYSISIOTOMY .......................................................................................112 
11.5 
ZAVANELLI’S MANOEUVRE............................................................................113 
11.6 
HARD PULL......................................................................................................113 
12.1 
INITIAL ASSESSMENT ....................................................................................118 
12.2 
EXTREME PREMATURITY ..............................................................................118 
12.3 
FIBRONECTIN SWABS....................................................................................119 
12.4 
TOCOLYSIS .....................................................................................................120 
12.5 
ANTIBIOTICS ...................................................................................................122 
12.6 
STEROIDS........................................................................................................123 
12.7 
TEMPERATURE CONTROL AT BIRTH ...........................................................123 
12.8 
SURVIVAL AND MORBIDITY CHARTS ...........................................................124 
13.1 
FETAL HEART RATE MONITORING ...............................................................129 
13.2 
DEFINITIONS ...................................................................................................129 
13.3 
RISK ASSESSMENT ........................................................................................130 
13.4 
ANTENATAL FETAL HEART MONITORING....................................................131 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
13.5 
THE DAWES / REDMAN CRITERIA AS USED BY THE OXFORD SONICAID 
SYSTEM ...........................................................................................................132 
13.6 
ADMISSION CTG .............................................................................................132 
13.7 
INTERMITTENT AUSCULTATION ...................................................................133 
13.8   
CONTINUOUS MONITORING..........................................................................133 
13.9 
CATEGORISATION OF FETAL HEART RATE FEATURES ............................134 
13.10 
CTG CLASSIFICATION ....................................................................................134 
13.11   SUSPICIOUS CTG ...........................................................................................134 
13.12 
PATHOLOGICAL CTG......................................................................................135 
13.13 
FETAL SCALP BLOOD SAMPLING .................................................................135 
13.14 
DR C BRAVADO...............................................................................................136 
14.1 
INTRODUCTION...............................................................................................140 
14.2 
GENERAL MANAGEMENT ..............................................................................140 
14.3 
MANAGEMENT OF SEVERE HAEMORRHAGE IN THE COMMUNITY..........141 
14.4 
PLACENTA PRAEVIA.......................................................................................142 
14.5 
PLACENTAL ABRUPTION ...............................................................................143 
15.1 
BACKGROUND ................................................................................................147 
15.2 
MANAGEMENT OF SEVERE HAEMORRHAGE IN THE COMMUNITY..........147 
15.3 
MANAGEMENT OF MAJOR PPH.....................................................................148 
15.4 
THE ROLE OF STAFF DEALING WITH PPH...................................................151 
15.5 
SECONDARY PPH ...........................................................................................152 
15.6 
BLOOD TRANSFUSION...................................................................................153 
15.7 
RECOMBINANT FACTOR VIIA ........................................................................156 
15.8  
INITIAL MANAGEMENT OF MASSIVE HAEMORRHAGE – ORGANISING THE 
TEAM ................................................................................................................158 
16.1 
BOOKING .........................................................................................................161 
16.2 
ANTENATAL CARE ..........................................................................................161 
16.3 
LABOUR ...........................................................................................................161 
16.4 
HAEMORRHAGE..............................................................................................161 
16.5 
POSTNATAL CARE..........................................................................................162 
17.1 
CHECKLIST FOR WOMEN NEEDING THROMBOPROPHYLAXIS.................165 
17.2 
CAESAREAN SECTION IN WOMEN TAKING THERAPEUTIC DOSES OF 
CLEXANE .........................................................................................................167 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
17.3 
THROMBOPROPHYLAXIS FOR LABOUR ......................................................168 
17.4 
LABOUR IN WOMEN TAKING THERAPEUTIC DOSES OF CLEXANE ..........168 
17.5  
WARFARIN.......................................................................................................169 
18.1 
ELECTIVE CAESAREAN SECTION.................................................................172 
18.2 
EMERGENCY CAESAREAN SECTION ...........................................................174 
18.3 
 THE PROCEDURE ..........................................................................................176 
18.4 
ANALGESIA AFTER CAESAREAN SECTION .................................................179 
18.5 
CAESAREAN SECTION FOR PLACENTA PRAEVIA ACCRETA ....................180 
18.6 
CAESAREAN SECTION WITHOUT HEALTH INDICATIONS ..........................181 
18.7 
LAPAROTOMY .................................................................................................181 
18.8 
FEMALE STERILISATION................................................................................182 
18.9 
RECOVERY......................................................................................................182 
18.10 
VAGINAL BIRTH AFTER PREVIOUS CAESAREAN SECTION.......................183 
18.11 
PROPHYLACTIC ANTIBIOTICS FOR CAESAREAN SECTION ......................186 
18.12 
THROMBOPROPHYLAXIS IN PATIENTS RECEIVING SPINAL OR EPIDURAL 
ANAESTHESIA .................................................................................................186 
19.1  
PRE DELIVERY ASSESSMENT OF ANALGESIC / ANAESTHETIC PROBLEMS
..........................................................................................................................190 
19.2 
PRESENCE AND ROLE OF ANAESTHETIST .................................................191 
19.3 
EPIDURAL ISSUES (WCH ONLY) ...................................................................191 
19.4 
URGENT ANAESTHESIA.................................................................................196 
19.5 
PHARMACOLOGICAL PAIN RELIEF IN LABOUR...........................................196 
19.6 
PREOPERATIVE FASTING GUIDELINES .......................................................197 
19.7 
FEEDING IN LABOUR......................................................................................197 
19.8 
ANTACID REGIMEN.........................................................................................197 
19.9 
WOMEN ON ANTITHROMBOTIC TREATMENT..............................................198 
19.10 
COMPLICATIONS OF THE THIRD STAGE .....................................................198 
19.11 
POST-OPERATIVE CARE................................................................................199 
19.12 
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) .............200 
19.13 
THE ADMINISTRATION OF HOMEOPATHIC OR HERBAL SUBSTANCES ...200 
19.14 
FAILED INTUBATION DRILL............................................................................200 
20.1 
INTRAPARTUM FEVER ...................................................................................204 
20.2 
GROUP B STREPTOCOCCAL INFECTION.....................................................204 
 
NCHE-OBS001 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
20.3 
HERPES SIMPLEX...........................................................................................207 
20.4  
HIV ....................................................................................................................208 
20.5 
HEPATITIS B AND HEPATITIS C.....................................................................210 
20.6 
ANTIBIOTIC PROPHYLAXIS FOR CAESAREAN SECTION ...........................211 
20.7 
ANTIBIOTIC PROPHYLAXIS FOR INFECTIVE ENDOCARDITIS....................211 
20.8 
MRSA................................................................................................................212 
20.9 
INFECTION CONTROL ....................................................................................212 
20.10 
INFECTION CONTROL FOR HIV/ HBV / HCV POSITIVE WOMEN ................213 
21.1 
CRITERIA FOR INCLUSION ............................................................................219 
21.2 
ANTICONVULSANT GUIDELINES...................................................................219 
21.3 
FURTHER NOTES ON THERAPY WITH MAGNESIUM ..................................220 
21.4 
ANAESTHETIC GUIDELINES ..........................................................................221 
21.5 
ANTIHYPERTENSIVE THERAPY GUIDELINES..............................................221 
21.6 
MAINTENANCE THERAPY FOR BLOOD PRESSURE CONTROL .................223 
21.7 
SIMPLIFIED FLUID GUIDELINES ....................................................................224 
21.8 
 SUMMARY OF CARE......................................................................................225 
22.1  
GENERAL NOTES FOR OBSTETRIC STAFF ON THE MANAGEMENT OF WOMEN 
WITH INSULIN-TREATED DIABETES .............................................................228 
22.2 
MANAGEMENT OF PREGNANT WOMEN WITH INSULIN-TREATED DIABETES 
FOLLOWING EMERGENCY ADMISSION .......................................................229 
22.3  
MANAGEMENT OF STEROIDS IN PREGNANT WOMEN WITH DIABETES ..230 
22.4  
REGIMEN FOR ELECTIVE CAESAREAN SECTION, INDUCTION OF LABOUR OR 
SPONTANEOUS DELIVERY............................................................................230 
22.5  
MANAGEMENT FOLLOWING DELIVERY .......................................................234 
22.6  
ADDITIONAL POINTS FOR THE CARE OF THE MOTHER WITH DIABETES 
AFTER DELIVERY............................................................................................235 
22.7  
HYPOGLYCAEMIA IN MATERNITY PATIENTS ..............................................236 
23.1 
BACKGROUND ................................................................................................239 
23.2 
LATEX IN THE HOSPITAL ENVIRONMENT ....................................................239 
23.3 
IDENTIFICATION OF THE PROBLEM .............................................................240 
23.4 
PROVISION OF A LATEX-FREE ENVIRONMENT ..........................................240 
23.5 
TREATMENT OF ANAPHYLAXIS ....................................................................241 
23.6 
LATEX ALLERGY BOX.....................................................................................241 
 
NCHE-OBS001 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
23.7 
FURTHER INFORMATION...............................................................................242 
24.1 
AIMS .................................................................................................................245 
24.2 
INTRAPARTUM CARE .....................................................................................245 
24.3 
ANALGESIA IN LABOUR OR PRIOR TO CAESAREAN SECTION .................245 
24.4 
IMMEDIATE NEONATAL CARE .......................................................................246 
24.5 
NEONATAL WITHDRAWAL .............................................................................246 
24.6 
BREAST FEEDING...........................................................................................247 
24.7 
INFECTION ISSUES.........................................................................................247 
24.8 
THE IMPACT OF SUBSTANCE USE ON THE INFANT...................................248 
24.9 
USEFUL CONTACTS .......................................................................................249 
25.1 
MATERNAL COLLAPSE AND ACUTE MEDICAL PROBLEMS .......................252 
25.2 
TRANSFER TO THE INTENSIVE CARE UNIT.................................................254 
25.3 
UTERINE RUPTURE ........................................................................................256 
25.4 
MATERNAL STEROID COVER FOR DELIVERY.............................................256 
25.5  
MANAGEMENT OF HAEMOGLOBINOPATHIES.............................................256 
25.6 
SCREENING FOR HAEMOGLOBINPATHIES IN PREGNANCY .....................256 
25.7 
THALASSAEMIA SYNDROMES.......................................................................257 
25.8 
HAEMOGLOBIN VARIANTS – SICKLE CELL SYNDROMES ..........................257 
26.1 
BACKGROUND ................................................................................................261 
26.2 
THREATENED MISCARRIAGE........................................................................261 
26.3 
TERMINATION OF PREGNANCY FOR FETAL ABNORMALITY.....................261 
26.4 
INTRAUTERINE DEATH ..................................................................................262 
26.5 
SUPPORT NETWORK .....................................................................................262 
26.6 
TOPICS FOR DISCUSSION AND CONSIDERATION......................................263 
26.7 
MANAGEMENT OF PREGNANCY LOSS ........................................................264 
26.8 
FETUS OVER 24 WEEKS (NO POST MORTEM) ............................................266 
26.9 
FETUS OVER 24 WEEKS (FOR POST MORTEM)..........................................267 
26.10 
FETUS UNDER 24 WEEKS (NO POST MORTEM) .........................................269 
26.11 
FETUS UNDER 24 WEEKS (FOR POSTMORTEM) ........................................270 
26.12 
CYTOGENETIC SAMPLES TRANSPORT ARRANGEMENT...........................271 
26.13 
TWINS ..............................................................................................................272 
26.14 
CHAPLAINCY ...................................................................................................272 
26.15 
BAPTISM ..........................................................................................................272 
 
NCHE-OBS001 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
26.16 
REGISTRATION OF DEATHS AND STILLBIRTH ............................................273 
26.17 
PROCEDURE FOR CARE OF THE PRE-VIABLE BORN INFANT ..................273 
26.18 
MANAGEMENT OF STILLBIRTH INCLUDING DELIVERY, POSTNATAL CARE AND 
LAYING OUT ....................................................................................................273 
26.19 
PROCEDURE FOR USE OF THE CRADLE ROOM.........................................275 
26.20 
HAND AND FOOT PRINTS ..............................................................................276 
26.21 
BEREAVEMENT COUNSELLORS ...................................................................276 
26.22 
POSTNATAL REVIEW......................................................................................277 
26.23 
MATERNAL DEATH .........................................................................................277 
27.1 
CORD PROLAPSE ...........................................................................................282 
27.1 
CORD PROLAPSE ...........................................................................................282 
28.1 
CASES IN WHICH A PAEDIATRIC PROBLEM HAS BEEN IDENTIFIED 
ANTENATALLY.................................................................................................289 
28.2 
URGENT INTRAUTERINE TRANSFER REQUESTS:  THE HOT LINE PROCEDURE
..........................................................................................................................289 
28.3 
PAEDIATRIC ALERT DURING LABOUR .........................................................289 
28.4 
PAEDIATRIC PRESENCE AT DELIVERY (WCH ONLY) .................................289 
28.5   
RESUSCITATION OF NEONATES BY MIDWIVES (CIC ONLY) .....................290 
28.6 
URGENT CALL FOR PAEDIATRIC ASSISTANCE ..........................................290 
28.7 
MATERNAL ADVICE ........................................................................................291 
28.8 
ROUTINE MANAGEMENT OF THE BABY.......................................................291 
28.9 
DELIVERY IN THEATRE ..................................................................................291 
28.10 
MANAGEMENT OF BABY AT BIRTH WITH MECONIUM STAINED LIQUOR.291 
28.11 
SKIN-TO-SKIN & HYPOTHERMIA GUIDELINES.............................................292 
28.12 
HYPOGLYCAEMIA OF THE NEWBORN  - ......................................................294 
28.12 
HYPOGLYCAEMIA OF THE NEWBORN  - ......................................................295 
28.13 
UNEXPECTED ABNORMALITY OR DEATH....................................................299 
28.14 
HAEMOLYTIC DISEASE OF THE NEWBORN.................................................299 
28.15 
GROUP B STREPTOCOCCUS INFECTION ....................................................299 
28.16 
CHILD ABDUCTION – PROCEDURE FOR STAFF..........................................299 
 
 
NCHE-OBS001 
 
Page 15 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
1.1 

RESPONSIBILITIES OF STAFF ON DELIVERY SUITE 
 
Lead Midwife 
 
To work in partnership with their professional colleagues in all disciplines within the 
maternity unit 
 
This important role is to co-ordinate all Delivery Suite activities at Consultant led units.  
 
In order for this to be successful, the Lead Midwife needs:- 
 
•  Awareness of all expected admissions from the antenatal ward, maternity day unit and 
antenatal clinic.  
•  Awareness of relevant community activity e.g. BBA, women labouring at home, Penrith 
maternity unit. 
•  To ensure appropriate delegation of workload. 
•  To ensure appropriate levels and skill mix of staff present on Delivery Suite. 
•  Knowledge of all planned inductions of labour and elective LSCS. 
•  To ensure that all elective LSCS are present on the Delivery Suite and adequately 
prepared so that the elective list can commence promptly. 
•  Knowledge of all pending assisted vaginal deliveries and emergency LSCS. 
•  Knowledge of all key personnel allocated to the labour ward from SHO to consultant. This 
applies to anaesthetists and paediatricians.  Contact information should be updated on the 
white board. 
•  To provide first line neonatal resuscitation 
•  Regular updates from midwives as to the progress of their women in labour. 
•  To attend all delivery suite handovers. 
•  To co-ordinate when possible appropriate midwifery requests for medical staff attendance. 
•  To make an entry in the patient held records when a midwife seeks assistance/review. 
•  Ensure that the appropriate grade of medical staff attends or is requested as the condition 
dictates. If the Lead Midwife has concerns with the obstetric SpR’s plan of care for the 
woman then the consultant can be contacted. The SPR should be informed of the 
concerns and proposed plan of action. If a junior midwife is not in agreement with the Lead 
Midwife, then the SPR, consultant, manager and/or supervisor of midwives can be 
contacted if deemed necessary. It is preferable that the midwife communicates her 
concerns to the Lead Midwife. 
•  Expertise in co-ordinating personnel and communicating during obstetric emergencies. 
•  To provide support and advice for more junior midwives and medical staff. 
•  Ensure that all women and babies are transferred appropriately. 
 
 
NCHE-OBS001 
 
Page 16 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
Senior House Officer (SHO) 
 
To work in partnership with their professional colleagues in all disciplines within the 
maternity unit
 
 
•  The SHO carries a baton bleep 
•  The bleep holder will hand this bleep over to the incoming SHO at the end of the shift 
•  The incoming SHO will check that the white board information is correct. 
•  The hand over should be accompanied by a formal handover of patient care to the 
incoming team, by the Lead Midwife and the outgoing SpR of all the patients on labour 
ward and relevant patients on the antenatal and postnatal wards 
•  Handover occurs at 0830 hours and 2030 hours 
•  The SHO’s may vary greatly with respect to the amount of previous medical and obstetric 
experience.  They will have differing career plans with some planning to become GP’s and 
others career 
•  The SHO’s will take advice from and be guided, supported and directed by the Lead 
Midwife, Obstetric Registrar and Consultant as to priority of labour ward duties 
•  The SHO should be bleeped when required after first ascertaining that s/he is not already 
on the labour ward. The Lead Midwife should aim to be aware of ALL calls to the SHO 
unless in emergencies or when s/he is busy 
•  The SHO should see women presenting to labour ward, Maternity Day Unit or the 
antenatal postnatal ward when asked by a midwife and discuss ALL cases with a Registrar 
or Consultant 
•  The SHO should write clear, legible entries in the hand held notes which should include 
printed name, grade and signature along with the full date and time 
•  Prescribe drugs according to the agreed Guidelines and where in doubt seek the advice of 
a senior colleague. They should NOT prescribe syntocinon for the augmentation of 
labour in multiparous women 

•  The SHO should be familiar with ALL Labour Ward Guidelines 
 
Specialist Registrar (SpR) or 2nd on call 
 
To work in partnership with their professional colleagues in all disciplines within the 
maternity unit 
 
•  The registrar carries bleep 333 (CIC) or 5585 (WCH) 
•  The bleep holder will hand this bleep over to the incoming SpR at the end of the shift 
•  The incoming 2nd on call will check that the white board information is correct. 
•  The hand over should be accompanied by a formal handover of patient care to the 
incoming team, by the Lead Midwife and the outgoing SpR of all the patients on labour 
ward and relevant patients on the antenatal and postnatal wards 
•  Handover occurs at 0830 hours and 2030 hours 
•  The SpR should write clear, legible entries in the hand held notes which should include 
printed name, grade and signature along with the full date and time 
•  The Obstetric SpR should have an awareness of ALL women on the labour ward and see 
all women who are obstetric patients 
 
NCHE-OBS001 
 
Page 17 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
•  A plan of action should be always documented each time a woman is reviewed throughout 
the day or night 
•  Take opportunities to teach the SHO 
•  Delegate appropriate duties to the SHO 
•  The Obstetric SpR is the FIRST line of contact rather than the SHO for: 
Acute Obstetric Emergencies 
¾ CTG 
abnormalities 
•  The SpR should ensure that s/he is constantly updated by the Lead Midwife of ALL 
obstetric admissions to labour ward and of ALL potential antenatal or postnatal problems 
•  The SpR should ensure that s/he regularly updates the Lead Midwife of decisions made on 
labour ward 
•  The SpR should inform the Consultant of ALL women going to theatre for a caesarean 
section or trial of forceps 
•  The SpR should inform the Consultant of ALL women admitted to the High Dependency 
Unit 
•  The SpR should inform the Consultant of ALL women in labour with a breech presentation 
or twins  
•  The SpR should inform the Consultant of ALL women with a PPH or greater than 1 litre 
•  The SpR should inform the Consultant of any woman in labour at 23-32 weeks gestation 
•  The SpR should ask for senior support if labour ward is busy or s/he is unsure about a 
clinical situation 
•  The SpR should be familiar with ALL Labour Ward Guidelines 
 
Consultant or 3rd on call 
 
To work in partnership with their professional colleagues in all disciplines within the 
maternity unit 
•  The Consultant can provide senior input for labour ward in the following ways: 
¾ During the weekday between 0830 hrs and 1700 hrs from dedicated labour ward 
sessions 
¾  After 1700 hrs and at the weekends by on-call cover which can be from home  
 
The consultant can be contacted either directly from the ward – using the contact sheet 
displayed in all ward areas or via switchboard. 
 
It is the responsibility of the consultant on call to ensure that s/he is contactable at ALL times 
whilst providing the senior medical cover for labour ward  
•  The consultant should write clear, legible entries in the hand held notes which should 
include printed name, grade and signature along with the full date and time 
•  The consultant should be familiar with ALL Labour Ward Guidelines 
•  The consultant should consider being present on labour ward in the following situations 
¾  Caesarean at full dilatation 
¾  Trial of Forceps 
¾  Admission to High Dependency Unit 
¾  All vaginal breech deliveries 
¾  All vaginal multiple birth deliveries 
 
NCHE-OBS001 
 
Page 18 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
¾  Massive obstetric haemorrhage 
¾  Caesareans for placenta praevia 
¾  Caesareans on gestations less than 28 weeks 
•  In the event that an in-utero transfer is required the consultant should liase directly with the 
on-call consultant obstetrician, neonatal consultant/staff and midwifery staff in the 
accepting unit to arrange the transfer 
•  In the event that further medical/surgical opinion is required from within the hospital 
regarding a patient it is the responsibility of the Consultant to contact the relevant 
consultant or delegate this to a junior as appropriate 
 
Dedicated Session 
 
•  The consultant is onsite and always available during this session 
•  The session is normally dedicated to labour ward cover alone but occasionally may involve 
covering from an antenatal clinic so long as a SpR is available to continue the clinic if 
attendance on labour ward is required 
•  The Consultant will be available for advice by telephone or in person 
•  The consultant can by contacted by the SpR, SHO or a midwife as required 
•  The consultant will perform a ward round at 0830 hrs and 1700 hrs. This should be a full 
board round with the obstetric team and Lead Midwife and then a room round of all 
problem cases 
•  The consultant should liaise closely with the SpR to delegate duties and ensure that 
elective work is carried out as soon as possible  
•  The consultant should ensure that cases are also correctly prioritised 
 
On-call 
 
•  On a weekday evening the consultant should perform a ward round on labour ward prior to 
going home. This should be a full board round with the obstetric team and Lead Midwife 
and then consideration of the need for a room round of all problem cases 
•  The consultant should contact the Lead Midwife or the SpR for an update at some point 
during the evening usually around 2200 hours 
•  The SpR and midwifery staff can contact the Consultant on call at any time for advice, 
management decisions or to come into hospital 
•  At the weekend the Consultant should carry out a formal ward round on Saturday morning. 
This should be a full board round with the obstetric team and Lead Midwife and then a 
room round of all problem cases 
•  The round should include other relevant women on the antenatal/postnatal ward and 
maternity day unit 
•  At the weekend the Consultant should undertake further ward rounds either directly or by 
telephone during Sunday morning, the afternoons and evenings 
 
 
NCHE-OBS001 
 
Page 19 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
Locum Doctors 
 
When a Locum Doctor is going to work on the Delivery Suite, his / her previous professional 
experience must be checked in advance by a representative of the Consultant body.  In 
addition a formal introduction to the practices and guidelines of the North Cumbria Delivery 
Suite is mandatory before he / she can commence work in the area.  This introduction may be 
given by the Lead Consultant for Delivery Suite or the Consultant on-call. 
 
Wherever possible a Locum doctor should have the opportunity to work in other areas of the 
Directorate before starting shift work on the Delivery Suite. 
 
1.2 

HANDOVER OF CARE 
 
It is the responsibility of all practitioners involved in the delivery of Maternity and Obstetric 
Care to provide a personal handover of all patients who have been under their care during the 
preceding shift. 
 
1.  Details of the individual, e.g. name and parity 
2.  Date and time of admission 
3.  Details of progress since admission 
4.  Details of a plan of care 
 
For SpR’s and SHO’s – A Baton Bleep should be personally transferred at the time of 
handover. 
 
Formal handover of medical care takes place at 0830 hrs – 0900 hrs and 2030 hrs – 2100 hrs 
at CIC, at WCH 0900 hrs – 0930 hrs and 2030 hrs – 2100 hr each day. 
 
Handover at 0830 hrs should be attended by the duty Consultant, Lead Midwife, Specialist 
Registrar and SHO’s (oncoming and leaving).   
 
Handover at 2030 hrs should be attended by the Lead Midwife, Specialist Registrar and 
SHO’s (oncoming and leaving). 
 
Midwifery Handover 
 
Formal ‘group’ handover of midwifery care is lead by the Lead Midwife at 0730 hours and 
2000 hours each day on Delivery Suite at CIC.  At WCH handover times are at 0700 hrs, 1400 
hrs and 2130 hrs each day on Delivery Suite. 
 
In addition, the care of each woman on Delivery Suite is handed over from the ‘leaving’ 
midwife to the ‘oncoming’ midwife on a one-to-one basis at these times. 
 
 
NCHE-OBS001 
 
Page 20 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
1.3 TRANSFER OF MIDWIFERY CARE TO CONSULTANT 
RESPONSIBILITY 
 
When a patient under the care of midwives or a general practitioner is referred for an obstetric 
opinion, responsibility for her obstetric care may pass on to the consultant concerned or 
she/he may give an opinion and ask the midwives to continue her care.  In either case this 
should be made clear on the front of the patient’s notes. 
 
When a patient under the care of midwives or GP is referred urgently for an obstetric opinion 
or as an emergency for admission responsibility for her obstetric care is in the hands of the 
consultant on-call for the time being. 
 
When a patient in the labour ward under the care of the midwives develops an obstetric 
abnormality the midwives must transfer her care to the consultant on-call.  Often it may be 
appropriate for an obstetric junior to give an opinion.  Responsibility rests with the consultant 
on-call. 
 
When a patient whose care has been transferred to the consultant on-call requires further 
follow-up it may be appropriate for that consultant to be further involved. 
 either 
The case may be discussed with a consultant whose clinics are geographically more 
convenient for the patient. 
 or 
The consultant whose clinics are more convenient may be asked to see the patient 
 or 
The consultant (or deputy) may transfer the patient’s care back to the community midwife. 
 
In any of these situations the person responsible for the care should be clearly identifiable on 
the front of the notes. 
 
Obstetric responsibility remains with the consultant who first assumed care for the patient until 
the case has been discussed – with another consultant or midwife and the care transferred.  
The date and time of transfer of care should be recorded in the notes (unless the patient is 
seen in an ante-natal clinic, in which case care is then assumed by the consultant in charge of 
the ante-natal clinic). 
 
Every antenatal in-patient needs a named consultant (unless she has been admitted under 
midwifery care for observation and assessment of possible early labour) 
 
1.4 
TRANSFER INTO THE OBSTETRIC UNIT FROM HOME / PENRITH 
BIRTHING CENTRE  
 
1.  Safety of mother and baby are paramount at all times 
 
Transfer to hospital should be arranged at the earliest opportunity 
 
Women who have any of the following problems should be referred directly from 
community midwife to the obstetrician (SpR or equivalent) and Lead Midwife at the acute 
unit. 
 
NCHE-OBS001 
 
Page 21 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
♦ 
Meconium stained liquor 
♦ 
Slow progress in labour 
♦ 
Whenever the fetal heart auscultation is no longer normal 
♦ Malpresentation 
♦ Premature 
labour 
♦ 
Premature spontaneous rupture of membranes 
♦ Maternal 
pyrexia 
♦ 
High head in primip or parous women in advanced labour 
♦ Intrauterine 
death 
♦ Retained 
placenta 
♦ 
Post partum haemorrhage 
 
ANY OTHER SITUATION WHERE URGENT TRANSFER IS REQUIRED 
 
Direct access is available to consultant on call via switchboard 
 
2.  Summoning an Ambulance in an Emergency 
 
 
♦  Dial 999 ask for Paramedic Ambulance 
♦  Give details of emergency as requested by operator 
♦  Give specific details of location 
 
3.  Inform LDRP/Delivery Suite so that appropriate preparations can be made and relevant 
medical staff can be alerted 
 
4.  Intrapartum women must always be accompanied by a midwife 
 
NB:  Ambulance services are not directly responsible for returning midwife to base.  A 
contract taxi can be provided via switchboard at acute units. 
 
5.  In the event of an emergency occurring, the midwives must deal with the emergency 
situation working together in partnership 
 
The midwives will identify a lead midwife to co-ordinate and facilitate the appropriate care 
and initiate transfer 
 
♦  Call 999 requesting paramedic ambulance 
♦  If obstetric advice is required ask switchboard to urgently contact consultant on call to 
discuss the situation 
 
6.  If the woman/mother does not consent to transfer: 
 
 
♦ Documentation  
♦  Call paramedic ambulance 
♦  Inform LDRP/Delivery Suite and Obstetrician 
♦  Inform Supervisor of Midwives/Manager for support and advice 
 
 
NCHE-OBS001 
 
Page 22 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
The midwife is responsible for all midwifery care and cannot arrange for anyone to act as a 
substitute other than another practising midwife or a registered medical practitioner. 
 
Good contemporaneous record keeping is essential to protect the welfare of patients and 
clients. 
 
1.5 
TRANSFER OUT OF THE OBSTETRIC UNIT TO THE TERTIARY UNIT 
 
Occasionally an antenatal woman may need to be transferred out of the CIC / WCH to a 
tertiary unit.  Only the duty consultant can sanction this move and he / she should do so after 
liaising with the local SCBU and the woman who is to be transferred.  A suitable destination 
will be identified via the hotline (See over) and the Consultant Obstetrician will discuss with the 
Consultant Obstetrician at the receiving hospital to confirm that the transfer can go ahead.  
The following are situations where tertiary referral discussions should be considered: 
 
 
♦  Cystic fibrosis or severe asthma 
♦  Sickle cell anaemia, thalassaemia major 
♦  Complex hypertension and renal disease 
♦  Complex neurological conditions and complex unstable epilepsy 
♦  Complex psychiatric disorders and substance abuse 
♦ Cardiac 
disease 
♦  Complex diabetes mellitus 
♦  SLE and other connective tissue disorders 
♦  Thrombophilia and complex thrombo-embolic disease 
♦  Recipients of solid organ transplant 
♦ Severe 
pre-eclampsia 
♦  Pre-term labour and PPROM 
♦ Complex 
infections 
♦ Acute 
psychoses 
Any woman transferring to a tertiary unit will be accompanied by a midwife.  If accompanying 
medical staff are required the grade of accompanying medical staff is the responsibility of the 
consultant.  Appendix 1 – Trust policy for the safe transfer of critically ill patients. 
 
NCHE-OBS001 
 
Page 23 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
 
 
INTER HOSPITAL/COMMUNITY TRANSFER FORM 
To be used in all transfers- this is a legal record of transfer 
PATIENT DETAILS 
TRANSFER DETAILS 
 
 
NAME……………………………………………… TRANSFER FROM……………………………..
ADDRESS……………………………………….  
………………POSTCODE…………………....... RECIPIENT UNIT………………………………… 
 
  
DOB…………………………………………........  
 
HOSPITAL NUMBER……………………………. ……………………………………………………...
 
 
CONTACT NUMBER……………………….…...  DATE OF 
                          
TRANSFER…………………………… 
REASON FOR TRANSFER                                                                                                          
 
 
 
CLINICAL DETAILS ON TRANSFER 
 
BP                       FH                      GESTATION                             ALLERGIES 
 
AMBULANCE DETAILS 
 
TIME OF DECISION…………………. ……TIME AMBULANCE 
REQUESTED…………………. 
TIME READY TO TRANSFER……………………..CATEGORY………………………............... 
TIME AMBULANCE ARRIVED…………………DEPARTURE TIME…………………………….. 
 

 
PREPARATION FOR TRANSFER                                                         YES                  NO 
                 
•  TRANSPORT REQUESTED 
•  BED/COT ARRANGED 
•  MATERNAL NOTES 
•  FAMILY INFORMED 
•  DOCTORS LETTER 
•  CONTACT RECIPIENT HOSPITAL ON DEPARTURE WITH E.T.A. 
 
EQUIPMENT/TRANSFER                                                              YES                    NO     
•  SONICAID                                                                                 
•  OXYTOCIC DRUGS 
•  DELIVERY PACK/INSTRUMENTS 
•  TOWELS/ NEOWRAP 
 

 
NCHE-OBS001 
 
Page 24 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
STAFF ARRANGING TRANSFER                             ESCORTING PERSONAL  
                                                                                                                                         
    
CONSULTANT………………………………………  MIDWIFE…………………………………………… 
 
MIDWIFE……………………………………………   DOCTOR………………………………………………… 
 
AT RECIPIENT UNIT 
 
CONSULTANT…………………………………….. 
 
MONITORING REQUIRED DURING TRANSFER 
 
 
 

                              TIME 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MONITORING                           SaO2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                             RESPS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                               TEMP 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BP/PULSE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                          
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                                160 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                                150 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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                                                                   40 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

DRUGS/FLUIDS ADMINISTERED DURING TRANSFER                             Time                            Sign 
 
 
 
 
 
 
 
 HANDOVER TO RECEIVING UNIT 
  DATE……………………………….. 
 
 
ARRIVAL TIME……………………. 
NCHE-OBS001 
 
Page 25 of 281 
 
HANDOVER GIVEN TO…………………………………………………………………………………….. 
 
DOCTOR/MIDWIFE SIGNATURE…………………………………………………………………………..

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
 
 
 
 
 
 
 
 
 
 
1.6  USING THE NEONATAL HOTLINES FOR IN UTERO TRANSFER 
REQUESTS 
 
Background 
 
The neonatal service for the former Northern Region covers a population of approximately 3.2 
million, with 30,000 births annually.  Four ‘provider’ units (based in Newcastle, Sunderland, 
Stockton on Tees and Middlesbrough) perform approximately 85% of the neonatal intensive 
care, with 11 ‘non-provider’ units performing mostly special care.  The concentrating of 
neonatal intensive care services into the provider units means that perinatal transfers are 
inevitable. 
 
Referrals 
 
Requests for in-utero transfer are made via the neonatal hotlines.  As a general rule the R.V.I. 
(Newcastle – Hotline: 0191 230 3020) receives calls from Whitehaven, Carlisle, Hexham, 
Wansbeck, North Tyneside, Gateshead, South Tyneside, Sunderland and Durham.   
 
Hartlepool, North Tees, Darlington and Bishop Auckland refer to James Cook University 
Hospital (Middlesbrough – Hotline: 01642 854727) in the first instance.   
 
Procedure 
 
In utero transfer requests should only be made if a consultant obstetrician intends to transfer a 
patient, as locating a cot may take considerable time.  Requests made via the hotlines will be 
answered by neonatal staff who will ask for: 
•  Clinical details of the patient 
•  The name of the referring consultant and their contact details. 
 
The neonatal staff will then: 
 
•  Identify an available neonatal cot 
•  Either pass the details to the on-call consultant obstetrician in that unit who will contact 
the referring consultant or 
•  Will ask the referring consultant to speak to the on-call consultant obstetrician at the 
accepting unit. 
 
 
NCHE-OBS001 
 
Page 26 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
Any woman transferring to a tertiary unit will be accompanied by a midwife.  If accompanying 
medical staff are required the grade of accompanying medical staff is the responsibility of the 
consultant. 
 
Ambulance control should be contacted by the midwifery team leader or a delegated member 
of staff.  The nature of the transfer, destination, members of staff attending and the category 
should be communicated to the ambulance control. 
 
A time estimate of arrival of the ambulance should be obtained and documented on the 
transfer form. 
 
Records need not be photocopied and transferred with the patient. 
 
An accompanying letter of explanation should be written to the accepting Consultant by either 
the consultant or Registrar. 
 
The midwife accompanying the woman should document the care given on route on the 
transfer sheet. 
 
The midwife should ensure relatives have directions / telephone numbers of the receiving 
hospital. 
 
The midwife should auscultate the fetal heart on departure and on arrival at the receiving unit. 
 She should take basic equipment to conduct a delivery and keep the baby warm. 
 
If the baby delivers unexpectedly on route, the midwife’s role is to care for and comfort the 
mother and care for the baby.  Keeping the baby warm, ideally skin to skin, with the mother or 
by the use of a neowrap if the baby is premature.  The midwife should initiate basic life 
support as necessary. 
 
On arrival the midwife should inform the receiving midwife / doctor of the womans’ history on 
transfer and complete the transfer form. 
 
Transfer back to the base hospital is by ambulance.  The midwife on return should ensure the 
inutero transfer is recorded in the ‘In Utero Transfer’ book held on delivery suite.   
 
Document:  Name of Patient 
Hospital to which patient is transferred 
Reason for transfer 
Mode of transfer 
Name of Escort 
 
Patient notes to be transferred with patients 
 
NCHE-OBS001 
 
Page 27 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
1.7 
ARRANGMENTS FOR THE TRANSFER OF BABIES TO OTHER UNITS 
 
There are two Neonatal Units in North Cumbria.  The Cumberland Infirmary, Carlisle has 
twelve special care cots and the West Cumberland Hospital, Whitehaven has ten special care 
cots.  They both provide high dependency care but any babies requiring intensive care are 
transferred to the regional centre in the North East. 
 
Intensive care equipment is available on both sites and this is used on a short-term basis until 
the retrieval team from the regional centre arrives. 
 
Babies requiring intensive care 
 
•  Baby is stabilised, intubated and ventilated by the Paediatric Consultant. 
•  It is Consultant Paediatricians responsibility to liaise with the Newcastle Neonatal 
Service based on Ward 35 at The Royal Victoria Infirmary and they make 
arrangements for the transfer of the baby – Hotline number 0191 230 3020 
•  Parents should be kept informed at all times 
•  Baptism should be offered prior to transfer 
•  Photographs should be taken and a cuddly toy and blanket given to the baby 
•  The retrieval team may consist of a Doctor, neonatal nurse or paramedics.  They are 
responsible for providing the necessary equipment for transfer. 
•  Care is transferred to the retrieval team and baby is prepared for transfer 
•  All notes should be copied and an x-ray disc prepared to accompany the baby 
•  The parents should be seen by the team and directions given so they can travel to the 
receiving hospital 
 
Babies requiring transfer for other reason 
 
The Consultant Paediatrician makes the decision that the baby requires transfer for continuing 
care and arranges for the baby to be admitted to the appropriate ward / hospital in the 
Newcastle area. 
 
This may be for surgery or appointments such as scans.  Babies are also transferred back to 
North Cumbria following intensive care when their condition has improved.  They are escorted 
by a qualified nurse in a portable incubator by ambulance.  If the transfer is for an appointment 
a hospital care may be used and the baby transferred in a car seat.  The transport is booked 
by the nurse in charge via ambulance control. 
 
•  The portable incubator is checked prior to use 
•  A saturation monitor is taken 
•  An intravenous infusion pump may be required 
•  Inform transferring hospital of time of departure so that they may feed baby earlier if 
necessary 
•  Parents may be able to travel in the ambulance or car 
•  The babies should always be transferred in the portable incubator with the appropriate 
restraints or a car seat properly fitted into the car 
 
 

 
NCHE-OBS001 
 
Page 28 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
1.8 
TRANSFER OF POSTNATAL WOMEN TO TERTIARY UNITS 
 
1. INTRODUCTION 
 
During the immediate postnatal period to the time of transfer into the community complications 
may arise that require women to be transferred to other departments or tertiary centres for 
treatment.  The transfer of these patients applies to both patients being moved between 
departments but also being transferred to regional hospitals.  There is no mental health 
services locally that have mother and baby facilities therefore the on call consultant 
psychiatrist needs to assess the patient and arrange the nearest bed available should this 
situation arise. 
 
2. OBJECTIVE 
 
To use a systematic approach to ensure that patient is transferred in a safe and competent 
manner by trained personnel.  This is necessary when the capabilities of the obstetric team 
are insufficient to meet the patient’s needs and therefore transfer to another speciality is 
required. 
 
3. 
INDICATIONS FOR TRANSFER 
 
• Severe 
eclampsia 
• Postpartum 
haemorrhage 
• Clotting 
disorders 
•  Complications of underlying medical disorder, diabetes, asthma, thrombo-embolic 
disease 
•  Mental disorders: puerperal psychosis, schizophrenia, postnatal depression 
 
a) Assessment 
 
The attending midwife is responsible for prompt referral to medical staff and inform lead 
midwife for the unit 
 
Medical staff have a responsibility to ensure consultant has been notified of deterioration in 
patient’s condition that may necessitate transfer 
 
b) Control 
 
Identify the Consultant on call 
Inform Consultant anaesthetist (as necessary) 
 
c)  Communication 
 
The consultant on call is responsible for the decision to transfer the patients and has the 
ultimate responsibility for the communication.  Liaison should be directly with the on call 
consultant and midwifery / nursing staff in the accepting department / unit 
 
 
NCHE-OBS001 
 
Page 29 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
In the event of further medical / surgical opinion being required from within the hospital it is 
the responsibility of the consultant to contact the relevant consultant or delegate this to a 
junior as appropriate. 
 
Ensure patient remains fully informed of plan of care. 
Where appropriate medical staff should discuss this with relatives. 
The attending midwife should accompany the patient during the transfer process. 
 
Written records are essential from both clinical and legal perspectives. 
All documentation should be completed prior to transfer and notes must accompany 
patient on transfer.  Blood results should be recorded in notes. 
Transferring midwife is responsible to providing handover to receiving midwife / nurse.  
Ensure that the transfer form is complete 
 
d)  Transport arrangements 
 
The midwife will identify a lead midwife to co-ordinate and facilitate the appropriate care 
and initiate transfer. 
 
Call ambulance control –01228 596365 
 
Inform ambulance control that you have potential postnatal transfer.  Provide as much 
information as possible.  State which transfer category is required Emergency or Urgent.  
The consultant in charge of the patient will make the  “transfer category” decision. 
 
Preparation of the patient and transferring personnel. 
 
When transferring a patient the same level of care should be maintained throughout.  
Therefore prior to transfer the patient needs:- 
 
•  Stabilise the patient to reduce further physiological / psychological complications 
•  All necessary equipment must be checked prior to transfer 
•  Personnel undertaking transfer must be fully prepared, adequately trained and feel 
competent to do so 
 
Useful contact numbers; 
 
 Middlesbrough   01642 
854 
850850 
(switchboard) 
 Sunderland 
   0191 
565 
6256 
(switchboard) 
 
Royal Victoria Infirmary 
 
0191 233 6161 
 
 
NCHE-OBS001 
 
Page 30 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
1.9 
LABOUR WARD FORUM  
(Including North Cumbria Labour Ward Forum, Cumberland Infirmary and Whitehaven 
Labour Ward Forum) 
 
Local meetings are held monthly on each site (CIC forum includes Penrith).  Please contact 
Labour Ward Lead on either site for details. 
 
North Cumbria meetings are held quarterly.  Meetings are open to anyone who has an interest 
in the running of the Delivery Suite.  The permanent membership is as follows: 
 
North Cumbria Labour Ward Forum 
-  Lead  Consultant from both Obstetric Units 
(Chair) 
Lead Midwives (CIC, WCH, Penrith) 
Risk Midwives 
Heads of Midwifery 
Supervisor of Midwives 
Consultant Anaesthetist 
Consultant Paediatrician 
Lay Representative 
Medical Director for Governance 
Junior Midwife 
Representative of Junior Medical Staff  
SCBU Representative 
 
The aim of the group is to ensure that the principles of Clinical Governance are met in the 
delivery of intrapartum care. 
 
To achieve this the group will: 
 
♦  oversee all activity on Delivery Suite 
♦  act as a point of liaison between professional and lay groups that hold an interest in the 
functioning of Delivery Suite 
♦  record policy in updated, multi-disciplinary Delivery Suite Guidelines 
♦  verify and ratify such guidelines 
♦  audit areas of clinical practice on Delivery Suite 
♦  modify practice in the light of audit findings 
♦  ensure that a programme of multi-disciplinary training is promoted, dealing with issues 
related to the provision of intra-partum care 
♦  ensure that mechanisms are in place to maintain the ongoing training of staff active in the 
clinic area 
♦  promote an active, inclusive risk management policy on Delivery Suite 
♦  ensure that mechanisms are in place to respond to the issues raised at Risk Management 
meetings on Delivery Suite 
♦  monitor research activity on Delivery Suite 
 
Local Labour Ward Forums have the same overall aim but a greater emphasis is placed on 
the liaison between professional and lay members. 
 
 
NCHE-OBS001 
 
Page 31 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
Reference: 
 
North Cumbria Acute Hospitals NHS Trust (2005) Policy for Transfer of Critically Ill Patients 
 
NCHE-OBS001 
 
Page 32 of 281 

link to page 34 link to page 34 link to page 34 link to page 34 link to page 35 link to page 36 link to page 36 link to page 37 link to page 37 link to page 37 link to page 38 link to page 39 link to page 39 link to page 39 link to page 41 link to page 44 link to page 44 North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
CHAPTER 2 - MIDWIFERY CARE ON DELIVERY SUITE 
 
 
 
The guidelines presented in this section are compatible with the RCM Evidence Based 
Guidelines for Midwifery Led Care in Labour (Midwifery Practice Guideline) published in 2005. 
 
2.1  
ADMISSION IN LABOUR..................................................................................34 
2.2  
LOW RISK WOMEN .........................................................................................34 
2.3 
HOME BIRTH ...................................................................................................34 
2.4 
TRANSFER TO MEDICAL CARE .....................................................................34 
2.5 
DIAGNOSIS OF LABOUR ................................................................................35 
2.6 
THE PROVISION OF ONE TO ONE CARE TO WOMEN IN ESTABLISHED LABOUR
..........................................................................................................................36 
2.7  
ADMISSION CTG .............................................................................................37 
2.8  
BLOOD PRESSURE.........................................................................................37 
2.9 
BLADDER CARE IN LABOUR ..........................................................................37 
2.10  
CORD GAS ANALYSIS ....................................................................................38 
2.11  
NUTRITION IN LABOUR ..................................................................................39 
2.12 
VENFLON SITING ............................................................................................39 
2.13 
CONCEALED PREGNANCY ............................................................................39 
2.14 
WATERBIRTH ..................................................................................................41 
2.15 
PREVENTING PRESSURE SORES.................................................................44 
2.16 
VIDEO AND SOUNDTAPE RECORDS AND PHOTOGRAPHS .......................44 
 
 
NCHE-OBS001 
 
Page 33 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
2.1   ADMISSION IN LABOUR 
 
Women thought to be in labour and who arrive at Maternity Reception should be met by a 
midwife and taken directly to a room on Delivery Suite for further assessment. If a woman is 
found to be in established labour she should be admitted. The attending midwife should 
welcome the woman and her birth partner(s), introduce herself and orientate the woman to the 
department. Continuity of midwifery care is important so when possible, the midwife should 
indicate how long she will be on duty and available to provide care for the woman. 
 
2.2   LOW RISK WOMEN 
 
Women who meet all of the following criteria will have midwifery led care in labour: 
 
•  37+0 weeks gestation or greater 
• singleton 
pregnancy 
• cephalic 
presentation 
•  no obstetric complications 
•  no significant medical complication (see NICE Intrapartum Care Guideline 2007 – Page 
21-23) 
 
The following women may also be considered appropriate for midwifery led care: 
 
•  previous post partum haemorrhage < 1000 mls 
•  previous retained placenta 
 
Midwifery led care will be depicted on the Delivery Suite board in orange ink at CIC or in the 
Labour Ward book at WCH and these women will not normally be visited during medical ward 
rounds. 
 
2.3 HOME 
BIRTH 
 
There is no evidence that women at low risk of complications have a better outcome in labour 
if booking for hospital rather than home birth or birth in a midwifery lead unit. Women should 
receive unbiased information when making a choice about the place that they would like to 
give birth. 
 
Home birth is associated with the use of less analgesia, augmentation of labour and operative 
delivery. Satisfaction with care also tends to be greater in women who give birth at home. 
 
2.4 
TRANSFER TO MEDICAL CARE 
 
If deviation from normality occurs, the midwife should discuss the case with the Obstetrician 
(See 1.4) and Lead Midwife co-ordinating Delivery Suite. This transfer to high risk care should 
be indicated on the board at CIC or in the book at WCH.  The responsible consultant should 
be entered on the front sheet of the patient notes.  Staff must be informed when maternal or 
fetal complications arise. The following list is not exhaustive - common sense must be applied: 
 
•  need to discuss abnormality of the fetal heart 
 
NCHE-OBS001 
 
Page 34 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
•  need to discuss the CTG or FBS 
•  significant fresh PV bleeding 
• malpresentation 
•  slow progress in labour 
•  meconium stained liquor 
•  maternal pyrexia > 37.5 oC 
 
In these circumstances, if the woman was previously booked under a community midwife, the 
midwife looking after her on Delivery Suite must allocate a consultant to the case. The 
nominated consultant will usually be the consultant on call that day. The woman’s notes 
should also be altered accordingly.   
 
A number of other indications may arise that necessitate the transfer of care from the 
community midwife to the on call consultant after admission to Delivery Suite, including: 
 
•  under 37+0 or over 42+0 weeks gestation in labour 
•  induction or augmentation of labour 
•  use of regional anaesthesia 
•  use of antibiotics in labour 
•  instrumental birth or caesarean section 
• retained 
placenta 
•  PPH requiring blood transfusion 
• third degree tear or other trauma repaired by a doctor 
 
2.5 
DIAGNOSIS OF LABOUR 
 
The criteria for diagnosis of labour are change in cervical dilatation/effacement with regular 
contractions.  A combination of the criteria below may indicate labour: 
 
(a) 
History of regular contractions (at least 1:10) 
(b) 
Bulging membranes during contractions. 
(c) 
Spontaneous rupture of membranes. 
(d) 
History of a show. 
(e) 
Bishop score of 7 or more. 
(f) 
Cervical dilatation of 4 cm or more with full effacement. 
 
NCHE-OBS001 
 
Page 35 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
2.6  THE PROVISION OF ONE TO ONE CARE TO WOMEN IN 
ESTABLISHED LABOUR 
 
Lead Midwife needs to know the number 
 
of midwives on duty and the number of 
women in established labour 
 
 
↓ 
   
 
 
If the number of women in established     
labour exceed the number of midwives 
the following plan is to be activated by 
the Lead Midwife 
 
 
↓ 
   
 
←  Lead Midwife to discuss the elective  →  
During the Day 
workload with Consultant Obstetrician 
Out of Hours 
 
and consider delay/cancellation 
↓ 
   
 
↓ 
During the day contact a     
 
Review of numbers of 
Midwifery Manager to review 
midwives on duty with the 
staffing in all areas of 
hospital 
Directorate 
↓ 
   
 
↓ 
Review numbers of 
   
 
Consider moving HCA’s to 
midwives on duty with the 
the wards to support 
hospital 
Midwives 
↓ 
   
   
Consider moving HCAs to     
   
wards to support Midwives 
 
 
If women on Delivery suite are not in     
established labour transfer to MAU or 
AN Ward 
 
 
↓ 
   
 
   
   
Contact all community midwives 
 
 
 
↓ 
   
 
 
 
   
Contact a Midwifery Manager at home 
 
 
 
↓ 
   
 
 
Consider contacting Supervisor of 
   
Midwives for support 
 
 
 
NCHE-OBS001 
 
Page 36 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
2.7   ADMISSION CTG 
 
Intermittent auscultation should be offered from the outset and should occur for at least 1 
minute.   CTG should only be offered to women at high risk of fetal compromise (see Section 
13) or to women specifically requesting the intervention.  
 
2.8   BLOOD PRESSURE 
 
First stage of labour 
 
During the first stage of labour blood pressure should be measured and recorded once every 
4 hours. If the systolic pressure reaches 160 mm/Hg or the diastolic reaches 100 mm/Hg it 
should be rechecked at 15 minute intervals. If it remains elevated for 3 consecutive readings 
over 45 minutes then review by medical staff is required. 
 
Second stage of labour 
 
During the second stage of labour, review by medical staff is required if the systolic blood 
pressure reaches 170 mm/Hg or the diastolic reaches 110 mm/Hg for 3 consecutive readings 
over 15 minutes. 
 
2.9 
BLADDER CARE IN LABOUR 
 
The bladder is at particular risk in labour: 
•  with a prolonged second stage 
•  after regional anaesthesia 
•  after operative delivery, especially under regional anaesthesia 
 
Encourage spontaneous voiding 4 hourly in labour and record this on the partogram. If a 
woman cannot empty her bladder after 4 hours or passes small frequent amounts, an in-out 
catheter should be considered to ensure the bladder is empty. This should coincide with a 
vaginal assessment and the volume drained should be recorded. If over 500 ml then further 
bladder care must be vigilant to avoid complications. 
 
Women should be electively catheterised with a size 12 or 14 catheter after delivery if at 
particularly high risk of postpartum retention: 
 
•  women with a residual of over 800 ml in labour 
•  women who have had a difficult instrumental delivery 
•  women who have sustained a severe perineal injury 
 
In general, passage of urine should be achieved after delivery but before transfer to the 
postnatal ward, or before transfer home if early discharge from hospital is planned. If a 
postnatal woman is incontinent then in-out catheterisation is necessary to exclude retention 
with overflow irrespective of whether she is voiding spontaneously. 
 
 
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2.10   CORD GAS ANALYSIS 
 
The normal Ph of fetal blood is 7.35 or above. 
 
During labour there is a lowering of the Ph.  This is caused by the gradual accumulation of 
lactic acid (generated from anaerobic metabolism), which occurs during the transient hypoxia 
the fetus experiences with each contraction. 
 
Prolonged fetal hypoxia results in state of metabolic acidosis occurring. 
 
The fetal Ph is a good indicator of fetal well-being or compromise. 
 
A Ph reading of a specimen of cord blood taken at delivery can give valuable information 
which can facilitate the management of the neonate. 
 
It is recommended that a cord Ph should be taken from the following:- 
 
•  Non-elective Caesarean Section. 
• Instrumental 
deliveries. 
•  Deliveries which have had a FBS performed during labour. 
•  Babies requiring resuscitation at birth. 
•  Prolonged non-reassuring/abnormal CTG trace. 
•  Pre-term < 36 weeks 
• Intrauterine 
infection. 
•  Intra-uterine growth retardation 
 
METHOD 
 

♦  At delivery the cord should be double clamped with approximately four to six inches of 
cord left between the clamps. 
♦  Using a heparinised syringe and green needle.  Separate samples should be obtained 
from the umbilical vein and one of the umbilical arteries. 
♦  Samples may be obtained for up to 40 minutes from a clamped section of cord. 
 
The printed result slips should be filed into the mother’s notes.  A written record of the results 
should be recorded on the delivery section of the neonatal sheets.  It is the responsibility for 
the member of staff performing the delivery to document the results in the maternal notes. 
 
If the arterial and venous pH values are similar (within 0.02), the paired samples should be 
repeated within 30 minutes to ensure that they have been retrieved from different vessels. 
 
 
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2.11   NUTRITION IN LABOUR 
 
Fasting may result in dehydration and acidosis which can in turn increase the need for 
medical intervention. Low risk women who wish to eat and drink in early labour should be 
allowed to do so (see also the anaesthetic guidelines). 
 
The following guidelines are suggested: 
 
•  diet offered should be light, nutritious and easily absorbed 
•  narcotics are a major factor in delaying stomach emptying. If these are used, then women 
should stop eating and drinking should take only sips of water 
•  fluid may be taken throughout labour unless surgical intervention is anticipated. If there is 
a high probability of intervention however, small sips of water only should be offered 
•  the volume of fluid taken should be recorded. Fizzy drinks should not be taken 
•  sips of water with oral medicines are always permitted if necessary 
•  ranitidine should be given according to the agreed protocol  
 
2.12 VENFLON 
SITING 
 
If a venflon is needed, it should be sited by an appropriately trained midwife. If the midwife 
caring for the woman is unable to do this then she should consult the Lead Midwife co-
ordinating the Delivery Suite in the first instance.  IV access using a 18 (grey) IV catheter is 
recommended for women in labour. 
 
2.13 CONCEALED 

PREGNANCY 
 
A concealed pregnancy is where a woman, through fear, ignorance or denial does not accept, 
or is unaware of the pregnancy in an appropriate way. 
 
In a concealed pregnancy there is a higher risk of morbidity and mortality to both mother and 
baby. 
 
The mother has missed the opportunity for pre-natal diagnosis and genetic counselling. She is 
more likely to be socially excluded with a greater risk of blood borne infections, drug misuse, 
epilepsy and mental health problems compounded by poor social support. 
 
It may be important to try and find out why the mother did not attend for antenatal care. 
 
HISTORY 
 
To include Medical, Surgical, Social, Menstrual, Obstetric, Drug History
 
 
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EXAMINATION 
 
May include:-  General 
 Abdominal 
Vaginal : should not be performed until the placenta has been shown not to 
be low 
Ultrasound : The cerebellum is an accurate guide to gestational age <34 
weeks. 
 
 
 
 
Blood screening:- 
Group + Rh factor 
 
 
Full Blood Count 
    
HIV 
    
Hep 

    
VDRL 
    
Rubella 
 
If delivers before the blood results are available, cord blood shall be taken for 
Coomb’s testing and FBC.   
 
? Toxicology screen if history or examination suggests a need. 
 
AIM FOR DELIVERY IN A CONSULTANT UNIT IF TIME PERMITS 
There may be circumstances where child protection procedures must be initiated:
  The 
question of confidentiality will be overridden in these situations.  Please refer to Child 
Protection Procedures pp. 131.  Should there be any doubt about whether a woman should be 
referred, then consultations should take place with the Child Care Co-ordinator. 
 
Post-natal Structure 
 
−  Discuss contraception before discharge. 
−  Consider referral to counsellor. 
−  Usual post-natal care with referral to Community Midwife and 
Health Visitor. 
−  The General Practitioner should be informed of the delivery.   
−  Social Services should be informed as appropriate. 
−  The baby should have a full paediatric assessment if there is any 
doubt surrounding his / her gestation. 
 
Long Term 
 
Following up with GP and Health Visitor with the GP offering contraceptive advice. 
 
 
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2.14 WATERBIRTH 
 
Inclusion criteria 
 
•  singleton, cephalic presentation low risk pregnancy 
•  between 37+0 and 42+0 weeks gestation 
•  spontaneous onset of labour 
•  informed choice of mother 
 
Inclusion criteria with caution 
 
(NB – these women should be delivered in an Obstetric Unit) 
 
In the following situations, waterbirth is not absolutely contraindicated but the medical staff 
should be involved in the decision making process before waterbirth is sanctioned: 
 
•  previous caesarean section but refer to VBAC (Chapter 18) 
•  previous shoulder dystocia 
•  previous third degree tear 
 
Exclusion criteria 
 
•  induced labour when syntocinon is being used 
•  woman receiving opiates < 2 hours ago 
•  prolonged rupture of membranes > 48hrs 
•  any woman requiring IV fluids 
•  blood borne virus 
• skin 
infections 
• BMI 
>32 
•  a current history of epilepsy 
•  grand multiparity with previous third stage complications 
 
Women carrying GBS and women with risk factors for the development of neonatal GBS 
sepsis should not automatically be excluded from using the birthing pool. 
 
Antenatal prerequisites 
 
•  discussion with named midwife to include benefits and risks 
•  agreed plan for pregnancy and birth to be documented in hand held records 
 
Before entering the pool 
 
•  no electrical equipment near the pool 
•  pool temperature should be 35 – 37.50C, recorded on the partogram 
•  room temperature should be 21 - 220C, recorded on the partogram 
•  the mother should be encouraged to empty her bladder 
•  maternal and fetal observations should be recorded within normal range 
•  the mother should be made aware that she can leave the pool at any time if she wishes 
 
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First stage of labour 
 
On entering the pool, the woman must be made aware of the emergency exit procedure. 
Document this discussion in hospital. The bed should be left at the correct height and stored 
in the corner of the delivery room. Advise the woman not to get out of the pool unassisted. 
 
The pool should be filled to the level of the mother’s breasts when she is in a sitting position 
and the following should be recorded 4 hourly on the partogram: 
 
•  pool temperature, to be between 35 – 37.50C 
•  room temperature, to be between 21 - 220C 
 
Maternal and fetal observations should be taken by the midwife and recorded as per Delivery 
Suite Guidelines for labouring mothers who are low risk. 
 
The mother should be encouraged to adopt any position she finds comfortable with the 
support of her birth partner. 
 
The following are good practice points: 
 
•  the mother may use entonox if required 
•  the midwife should encourage oral fluids to prevent dehydration 
•  faecal debris should be sieved out of the pool to minimise the risk of infection from E coli.  
In the event of the pool becoming heavily contaminated, particularly in second stage, 
consider asking the woman to leave the pool temporarily to empty and refill. 
•  the mother should be encouraged to leave the pool to void urine if possible 
 
Reasons to leave pool in the first stage of labour 
 
•  any deviation from normality 
•  elevated maternal temperature – above 37.50C 
•  vaginal examination if the midwife feels this is necessary 
•  to have a systemic opiate analgesic 
•  if the mother feels faint or there are any concerns 
 
Care of mother and baby during the second stage of labour 
 
Two midwives, or one midwife plus one other member of staff, should be in attendance during 
the birth.  
 
Temperature of the pool should be maintained at 37 and 37.5 0C during the second stage. 
 
The mother should only be encouraged to push when she has the urge - this should not be 
hurried. Birth should be ‘hands off’ until baby is born, supported by verbal guidance alone. Do 
not routinely feel for cord around the neck. The baby should be born completely underwater 
with no air contact until he / she is raised to the surface gently afterwards.  Ensure the head of 
the baby emerges into air within a couple of minutes and given to the mother.   
 
 
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Do not subject the cord to undue tension at birth, to minimize the possibility of snapping it. 
 
Consider resting baby with head above the water, at the level of the mother’s uterus to 
maintain warmth. 
 
Reasons for the mother to leave the pool in the second stage 
 
•  to perform an episiotomy 
•  any fetal heart rate abnormality 
•  any other suspected abnormality 
 
Care of mother and baby during the third stage of labour 
 
The third stage should be managed as per the physiological third stage guidelines unless 
maternal condition or choice necessitates active management. For a physiological third stage, 
the cord should be left unclamped until the placenta and membranes have been expelled by 
the mother, while she remains in the pool.  Once the placenta has been expelled, the mother 
should be encouraged to leave the pool. 
 
If the third stage is to be managed actively, the cord should be clamped and cut and they baby 
passed to the partner or staff member.   Assist the woman out of the pool completely, or onto 
the pool seat as soon as practically possible, then administer the oxytocic drug.  Delivery by 
CCT. 
 
If perineal repair is required this should be delayed for one hour after birth as the tissues may 
be waterlogged and friable. 
 
Procedure for assisting women out of the birthing pool in an emergency 
 
•  Pull the emergency buzzer – call for help 
•  Place the red net underneath the woman and whilst supporting her head, lift her across 
edge of pool and onto bed 
•  At least two members of staff should be either side of the woman 
•  Once on bed assist woman into appropriate position 
•  Complete emergency procedures as appropriate 
 
Cleaning the pool 
 
Following each use, the pool should be rinsed free of debris. The entire pool and surrounding 
area should then be cleaned using a solution of a chlorine releasing agent (e.g. Haz-Tab 
granules/tablets). Rinse and then dry the pool thoroughly. If a sieve has been used ensure this 
is also cleaned as above. 
 
 
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2.15  PREVENTING PRESSURE SORES 
 
•  Women in labour should be encouraged to be as mobile as possible. 
•  Correct moving and handling practices are essential in order to prevent shear and friction 
forces during maternal repositioning. 
•  It is insufficient to relieve pressure for a matter of seconds. Women in labour require 
effective pressure area management.  
•  Women who choose to have epidural anaesthesia during labour must be recognised as 
being at high risk of developing pressure sores. 
•  Women undergoing elective or emergency caesarean section must be provided with 
pressure relieving equipment while in theatre and following delivery. 
•  The sacral area must be kept clean and dry during labour. Any excess cleaning fluid 
should be removed after epidural insertion. 
•  Correct positioning of sanitary towels and regular sanitary pad / linen changes will ensure 
that the sacral area is kept clean and dry. 
•  An adequate level of hydration must be maintained. 
•  Women should be informed of the risk of developing pressure sores and encouraged to 
participate in their own care. 
•  Mattresses should be checked regularly for signs of foam fatigue or damage. 
•  Obstetric mattresses should be at least 5 inches (preferably 6 inches) deep. 
 
2.16  VIDEO AND SOUNDTAPE RECORDS AND PHOTOGRAPHS 
 
The use of all video and sound tape recorders by non-hospital staff is prohibited in the 
Delivery and Theatre suites of North Cumbria Acute Hospitals NHS Trust. 
 
Video-photography in the delivery room is usually allowed once the baby is delivered, 
provided it does not impinge upon the work of the staff. 
 
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References 
 
Alderdice F et al (1995) Labour and birth in water in England and Wales: survey report. Br J 
Midwifery
  3: 375-382. 
 
ALSO (1996) Advanced Life Support in Obstetrics: Course Syllabus ALSO (UK) Office, 
Newcastle. 
 
Austen T et al (1997) Severe neonatal polycythaemia after third stage of labour underwater.  
Lancet  350: 1445. 
 
Baker C (1996) Nutrition and hydration in labour. Br J Midwifery 4: 568-572. 
 
Broach J, Newton N (1988) Food and bevereges in labour. Part II: the effects of cessation of 
oral intake during labour. Birth 15: 88-92. 
 
Brown L (1998) The tide has turned: audit of water birth. MIDIRS Midwifery Digest 
6: 236-243. 
 
Burns E, Kitzinger, S (2005) Midwifery guidelines for use of water in labour. Oxford Brookes 
University Press. 
 
Campbell R et al (1999) Evaluation of midwife lead care provided at the Royal Bournmouth 
Hospital. Midwifery 15: 183-193. 
 
Charles C (1998) Fetal hypothermia risk from warm water immersion. Br J Midwifery  6: 152-
156. 
 
Crawford JS (1986) Maternal mortality from Mendelson’s Syndrome. Lancet 1: 920-921. 
 
Department of Health Expert Maternity Group (1993) Changing Childbirth London, HMSO. 
 
Garland D, Jones K (1997) Waterbirth: updating the evidence. Br J Midwifery  5: 368-373. 
 
Garland D (2000) Waterbirth: an attitude to care (2nd Edition). Butterworth-Heinnmann, Oxford. 
 
Geissbuehler V, Stein S, Eberhard J (2004) Waterbirths compared with landbirths: an 
observational study of nine years. J Perinat Med 32: 308-314. 
 
Gilbert R, Tookey PA (1999) Perinatal mortality and morbidity among babies delivered in 
water: surveillance study and postal survey. BMJ 319: 483-487. 
 
Hall SM, Holloway IM (1998) Staying in control: women’s experiences of labour in water. 
Midwifery 14: 30-36. 
 
Harper B (2001) Waterbirth Bibliography In: http://www.waterbirth.org/index
 
Hundley V et al (1994) Midwife managed delivery unit: a randomised controlled comparison 
with consultant lead care. BMJ 309: 1400-1404.  
 
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Jessiman WC, Bryers H (2000) The Highland experience; immersion in water in labour. 
MIDIRS Midwifery Digest 8: 357-361. 
 
Johnston P (1996) Birth under water – to breathe or not to breathe. BJOG 103: 202-208. 
 
Malone C (2000) Pressure sores on the labour ward. RCM Midwives J  3:  
 
Morrison B, Baker C (2001) How to raise awareness of pressure sore prevention. Br J 
Midwifery 
9: 
 
Nikoderm VC (2000) Immersion in water in pregnancy, labour and birth. In: The Cochrane 
Library of Systematic Reviews, Issue 4.
 
 
Odent M (1983) Birth under water. Lancet 147: 607. 
 
RCOG (2001) Birth in Water. RCOG statement in the absence of a definitive guideline. 
 
Rosser J (1994) Is waterbirth safe? The facts behind the controversy. MIDIRS Midwifery 
Digest 
4: 4-6. 
 
Shields N et al (1998) Satisfaction with midwife managed care in different time periods: a 
randomised trial of 1299 women. Midwifery 14: 85-93. 
 
Sweet BR (1997) Mayes Midwifery: a Textbook for Midwives (12th Edition). Bailliere Tindall, 
London. 
 
Turnbull D et al (1996) Randomised, controlled trial of efficacy of midwife managed care. 
Lancet 348: 213-218. 
 
UKCC (1994) Position Statement on Waterbirths. United Kingdom Central Council for Nursing, 
Midwifery and Health Visiting, London. 
 
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CHAPTER 3 - MATERNITY ASSESSMENT UNIT (MAU) 
 
 
 
3.1 
INTRODUCTION...............................................................................................48 
3.2 
TRANSFER OF PATIENTS TO DELIVERY SUITE FROM ANTENATAL CLINIC OR 
WARD ...............................................................................................................49 
 
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3.1 INTRODUCTION 
 
The maternity assessment unit (MAU) is open 0900 hrs – 1700 hrs week days, midwifery led, 
telephone triage unit with subsequent care along side primary care and is designed to support 
but not replace community / GP care. 
 
Benefits: 
 
• Midwifery-led 
• Guideline 
driven 
•  Consistency of approach and advice 
•  Telephone triage service 
•  24 hour access to telephone advice and referral 
•  Sonography support including midwife sonographers 
•  Shorter waiting times for women 
•  A safe and relaxed environment 
 
Referrals 
 
Discussion of referrals with the MAU is encouraged after 16 weeks gestation.  It is hoped to 
avoid drop-in assessments that would be appropriately seen by the GP or community midwife. 
 
Referrals are accepted from: 
 
• Community 
Midwives 
• GP’s 
• Patients 
(Self-referral) 
• Antenatal 
Clinic 
• Antenatal 
Ward 
• Delivery 
Suite 
 
Indications for referral include: 
 
• Raised 
BP 
•  Decreased fetal movements 
•  Fetal heart rate irregularities 
•  Post dates (>41 weeks) without a plan for induction of labour 
•  Pre-term pre-labour ruptured membranes 
•  Suspected obstetric cholestasis 
•  Abdominal pain in pregnancy unless severe 
•  Vaginal bleeding unless heavy 
•  Suspected urinary tract infection 
•  Suspected deep vein thrombosis 
•  Trauma / assault 
•  Other fetal concerns 
• Postpartum 
bleeding 
•  Wound dehiscence / breakdown 
 
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Flexibility may be required between MAU, Maternity and Delivery Suite dependent upon 
staffing and bed availability. 
 
Examples of work not undertaken within the MAU 
 
• Pregnancy 
dating 
•  Viability at under 16 weeks (refer to Early Pregnancy Assessment Unit) 
•  Nuchal translucency / dating for Maternal Serum Screening 
•  Fetal anomaly screening 
•  Cervical length assessment 
•  Elective growth assessment 
 
Medical Enquiries 
 
GP’s and community midwives may still follow the previous system, contacting the on-call 
Obstetric Registrar to discuss cases.  Direct discussion with the MAU may, however, be more 
appropriate in many cases. 
 
The MAU and the role of the Early Pregnancy Assessment Unit (EPAU) 
 
At CIC this remains unchanged.   EPAU runs from Monday to Friday 0900 hrs – 1200 hrs.  
Appointments are made by telephone (01228 814256). 
 
At WCH EPAU runs from Monday to Friday 1200 hrs – 1400 hrs.  Appointments are made by 
telephone (Kirkstone Ward, 01946 693181 Ext 3257) 
 
Women presenting out of hours are seen by the on call gynaecology team (up to 16 weeks), 
though occasionally MAU assessment may be appropriate. 
 
Postnatal review / admissions 
 
Usually primary care review is appropriate.  If this is not the case then obstetric complications 
arising within 6 weeks of delivery should be first reviewed in the MAU. 
 
Obstetric problems arising more than 6 weeks postnatal are referred for discussion to the on 
call gynaecology SpR as subsequent admission would be to the gynaecology ward. 
 
Non obstetric problems should not be seen in the MAU but referred to the appropriate medical 
/ surgical / A & E Department. 
 
 
3.2 
TRANSFER OF PATIENTS TO DELIVERY SUITE FROM ANTENATAL 
CLINIC OR WARD 
 
From the antenatal clinic 
 
The consultant or his / her deputy in antenatal clinic should be informed before the transfer of 
any patient from antenatal clinic to Delivery Suite.  Arrangements for elective admissions 
 
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should be entered in the Delivery Suite diary after discussion with the senior midwife on the 
Delivery Suite, so that the staffing provision can be adjusted. 
 
From the antenatal ward 
 
Emergency transfers 
 
In an emergency, the Consultant Obstetrician or SpR will decide on the timing and the 
appropriateness of transfer to Delivery Suite.  The woman may not need to be examined 
vaginally prior to transfer. 
 
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CHAPTER 4 - INDUCTION OF LABOUR 
 
 
 
The guidelines presented in this section are compatible with the RCOG / NICE Guidelines on 
Induction of Labour published in 2001. 
 
  
4.1 
INDICATIONS FOR INDUCTION OF LABOUR ................................................52 
4.2 
41 WEEK ANTENATAL REVIEW .....................................................................52 
4.3 
ADMISSION FOR ASSESSMENT FOR INDUCTION.......................................52 
4.4 
OFFER OF INDUCTION FOR POST MATURITY DECLINED..........................53 
4.5 
INDUCTION REGIMEN ....................................................................................53 
4.6 
HYPERSTIMULATION......................................................................................54 
4.7 
AUGMENTATION FOR SPONTANEOUS RUPTURE OF THE MEMBRANES AT 
TERM................................................................................................................54 
4.8 
RUPTURE OF THE MEMBRANES UNDER 37 WEEKS GESTATION ............54 
4.9 
INTRA-UTERINE DEATH .................................................................................56 
 
 
 
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4.1 
INDICATIONS FOR INDUCTION OF LABOUR  
 
Most commonly, induction of labour (IOL) is carried out because of post-maturity. All 
inductions must be discussed with the Consultant. The indication should be recorded in the 
antenatal notes and on the front of the partogram: 
 
• post 
dates 
•  fetal indications (varied) 
•  maternal indications (varied) 
 
The decision to induce labour before 41 weeks is a consultant decision.  This decision may 
include cervical assessment and membrane sweeps. 
 
The decision to induce implies either that the mother or baby or both, will benefit and that if 
induction fails, a caesarean section may be justifiable. 
 
4.2 

41 WEEK ANTENATAL REVIEW 
 
At this visit review of the pregnancy should be offered together with a vaginal examination: 
 
•  to assess the cervix 
•  to sweep the membranes 
 
This should be documented on the IOL sheet together with the indication for IOL. 
 
•  membrane sweep may cause discomfort and ‘show’ 
•  membrane sweep increases the likelihood of spontaneous labour 
 
The process of IOL should be explained to the woman and an appointment booked with 
Delivery Suite for her to attend at term between term +10 and term + 14 days: 
 
•  earlier rather than later appointment if no ‘slots’ available 
•  earlier at the Consultant’s discretion, if the cervix is ‘favourable’ 
 
4.3 
ADMISSION FOR ASSESSMENT FOR INDUCTION 
 
When the woman is admitted, the attending midwife: 
 
•  completes the relevant part of the yellow notes 
•  makes an ‘induction of labour information leaflet’ available to the woman 
 
Medical review should be sought if: 
 
•  indicated in antenatal clinic notes 
•  a medical problem is identified by the attending midwife 
•  requested by the woman 
 
 
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4.4 
OFFER OF INDUCTION FOR POST MATURITY DECLINED 
 
When a woman declines induction she should be offered serial monitoring from 42 weeks.  
This includes measurement of amniotic fluid index and twice weekly CTG.  Induction should 
be proposed if monitoring is abnormal. 
 
4.5 INDUCTION 

REGIMEN 
 
This has been illustrated on the following pages. 
 
Prostaglandins 
 
These should usually be administered on Delivery Suite at CIC or Antenatal Ward at WCH.  
Note that non-sterile gloves may be used when a pregnant woman who is not in labour and 
who has intact membranes is being examined: 
 
•  20 minute CTG prior to insertion of vaginal Prostin tablet 
•  60 minute CTG following insertion of vaginal Prostin tablet.  This should start 15 minutes 
after insertion of the tablet. 
 
•  third dose only after discussion with the Consultant 
•  fourth dose rarely indicated and used only after discussion with the Consultant 
 
Amniotomy 
 
Amniotomy, or artificial rupture of the membranes (ARM) should be performed in a delivery 
room using a sterile plastic amnihook. Check the tip of the hook afterwards to make sure that 
it is intact. Sterile gloves should be worn when amniotomy is being performed. 
 
Syntocinon (not to be given with intact membranes or within 6 hours of prostaglandins) 
 
If the woman is experiencing contractions after her ARM: 
 
•  Advise her to mobilise for up to 4 hours then reassess her cervix 
•  Consider commencing syntocinon if no cervical change 
 
If she is not contracting after her ARM: 
 
•  Advise her to mobilise for up to 4 hours then reassess her cervix 
•  Commence syntocinon if no cervical change 
 
 
The fetal heart rate and contractions should be monitored continuously once syntocinon has 
commenced. The syntocinon regimen has been included in the following pages. 
 
For induction following previous caesarean section see Chapter 18. 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
4.6 HYPERSTIMULATION 
 
This is defined as the presence of more than 5 contractions in 10 minutes for more than 20 
minutes, or the presence of a tonic uterine contraction i.e. a contraction lasting for longer than 
2 minutes. 
 
Hyperstimulation following the administration of Prostin or Rupture of Membranes: 
•  administer 0.25 to 0.5 mg terbutiline subcutaneously 
•  monitor carefully and continuously 
•  if the CTG remains normal or suspicious, adopt a ‘wait and see’ policy 
•  if the CTG is pathological, perform an FBS or deliver, referring to the CTG interpretation 
guidelines (Section 13) 
•  Consider removing the prostin tablet. 
 
Syntocinon hyperstimulation in the presence of a pathological CTG: 
•  turn off the syntocinon and turn the woman into the left lateral position 
•  consider giving 0.25 to 0.5 mg terbutaline subcutaneously 
•  wait, sample or deliver, referring to the CTG interpretation guidelines (Section 13) 
 
Restarting syntocinon: 
•  recommence at half the previous dose, or… 
•  recommence at 0.6 ml/hr if the syntocinon has been off for more than 30 minutes 
 
Syntocinon hyperstimulation in the presence of a normal or suspicious CTG: 
• 
half the syntocinon, then… 
• 
reduce the rate of infusion further every 30 minutes until contractions fall to 3-4:10 
• monitor 
carefully 
 
4.7  AUGMENTATION FOR SPONTANEOUS RUPTURE OF THE 
MEMBRANES AT TERM 
 
See Chapter 5.5. 
 
4.8 
RUPTURE OF THE MEMBRANES UNDER 37 WEEKS GESTATION 
 
This is dealt with in Chapter 12. 
 
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North Cumbria Acute Hospitals NHS Trust 
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Publication Date:  22/01/2008 
Version 2.0 
 
 
 
 
Induction of Labour 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primigravidae 
Multigravidae 
   ↓ 
 
 
 
        ↓  
 
 
       ↓ 
 
 
 
   ↓ 
Bishop’s Score 
Bishop’s Score ≥ 6 
   ↓ 
   ↓ 
 
 
 
        ↓  
< 6 
 
 
       ↓ 
   ↓ 
 
 
 
        ↓  
 
 
       ↓ 
 
 
 
 
3mg prostin tablet posterior fornix 
amniotomy 
 
   ↓ 
 
 
 
        ↓ 
 
 
 
   ↓ 
 
 
 
        ↓ 
 
 
      after 6 hours 
 
 
 after 6 hours 
 
 
 
   ↓ 
 
 
 
        ↓ 
 
 
 
   ↓ 
 
 
 
        ↓ 
 
Re-assess Bishop’s 
Bishop’s Score ≥ 6 
 
Score < 6 
 
 
 
   ↓ 
 
 
 
        ↓ 
 
 
 
    
 
 
 
         
 
 
 
    
 
 
  Amniotomy following 
 
 
 
    
morning 
   ↓ 
   ↓ 
 
 
 
3mg prostin tablet posterior fornix 
 
   ↓ 
 
 
 
        ↓ 
 
 
 
   ↓ 
 
 
 
        ↓ 
 
 
      after 12 hours   
 
 after 12 hours 
   ↓ 
 
 
 
        ↓ 
   ↓ 
 
 
 
        ↓ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bishop’s Score 
Bishop’s Score ≥ 6 
 
   ↓ 
< 6   
 
 
        ↓ 
   ↓ 
 
 
 
        ↓ 
   ↓ 
amniotomy 
   ↓ 
   ↓ 
   ↓ 
 
 
if amniotomy is not possible after two doses of prostin 
discuss further management with the SpR or the Consultant 
 
 
 
 
 
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North Cumbria Acute Hospitals NHS Trust 
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Publication Date:  22/01/2008 
Version 2.0 
 
4.9 
INTRA-UTERINE DEATH  
 
When the patient presents after, diagnosis and counselling, she should be encouraged / 
advised to delay induction for 48 hours and offered 
 
MIFEPRISTONE 200 mg orally to “prime” the uterus for the induction process. 
 
Patient can be allowed home with open access to delivery suite for admission for induction. 
 
Admission for induction should be arranged at a convenient time 48 hours after 
MIFEPRISTONE has been given. 
 
1.   
Induction Regime - 13 – 22 weeks gestation 
 
Mifepristone 
200 mg orally 
Misoprostol 
800 micrograms vaginally followed 3 hours later 
Misoprostol 
400 micrograms vaginally followed 3 hours later 
Misoprostol 
400 micrograms vaginally followed 3 hours later 
Misoprostol   
400 micrograms vaginally 
 
Induction Regime – 22-34 completed weeks gestation 
 
MISOPROSTOL 
200 micrograms intravaginal 
MISOPROSTOL 
200 micrograms orally after 3 hours 
MISOPROSTOL 
200 micrograms orally after 3 hours 
MISOPROSTOL 
200 micrograms orally after 3 hours 
MISOPROSTOL 
200 micrograms orally after 3 hours 
 
Induction Regime – 34 weeks and above 
  
MISOPROSTOL 
100 micrograms intravaginal 
MISOPROSTOL 
100 micrograms orally after 3 hours 
MISOPROSTOL 
100 micrograms orally after 3 hours 
MISOPROSTOL 
100 micrograms orally after 3 hours 
MISOPROSTOL 
100 micrograms orally after 3 hours 
 
Artificial rupture of membranes (ARM) must NOT be carried out until labour is established. 
 
98.9% of patients will deliver within 72 hours after first dose of Misoprostol. 
 
Or 
 
2. Prostoglandin 
Induction 
 
 
Use prostaglandin dosage with normal pregnancy but the membranes should not be ruptured 
until delivery is imminent, see Chapter 26.7. 
 
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Protocol for IV syntocinon 
 
The dilution of Syntocinon used consists of 10 units in 50 ml normal saline, equivalent to 0.2 
units in 1 ml. It should be prescribed by a doctor then checked by two qualified members of 
staff. The midwives will also check that: 
 
•  the syringe is secured correctly in pump 
•  the correct pump setting initiated 
•  the infusion rate is checked, with initials from both members of staff at commencement 
 
Syntocinon Regimen 
Time (Mins) 
Syntocinon Dose  
Volume infused  
(mu/min) 
(mls/hour) 
0 – 30 

0.3 
30 – 60 

0.6 
60 – 90 

1.2 
90 – 120 

2.4 
120 – 150 
12 
3.6 
150 – 180 
16 
4.8 
180 – 210 
20 
6.0 
210 – 240 
24 
7.2 
240 – 270 
28 
8.4 
270 - 300 
32 
9.6 
 
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References 
 
Grant JM et al (1992) Management of prelabour rupture of the membranes in term 
primigravidae: report of a randomised prospective trial. BJOG 99: 557-562. 
 
Hannah ME et al (1996) Induction of labour compared with expectant management for 
prelabour rupture of the membranes at term. NEJM 334: 1005-1100. 
 
Hodnett E et al (1997) Women’s evaluation of induction of labour versus expectant 
management for prelabour rupture of the membranes at term. Birth 24: 214-220. 
 
Hughes RG, Brocklehurst P, Stenson B (2004) Prevention of early onset neonatal group B 
streptococcal disease. RCOG Green Top Guideline Number 36, RCOG Press, London, UK. 
 
Mozurkewich EL, Wolf PM (1997) Premature rupture of the membranes at term: a meta 
analysis of three management schemes. Am J Obstet Gynecol 171: 936-938. 
 
NICE Induction of Labour Guidelines (2005) 
 
Seaward PG et al (1997) International multicentre term prelabour rupture of the membranes 
study: evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients 
with prelabour rupture of the membranes at term. Am J Obstet Gynecol 177: 1024-1029. 
 
Shalev E et al (1995) Comparison of 12 and 72 hours expectant management of premature 
rupture of the membranes in term pregnancies. Obstet Gynecol 85: 766-768. 
 
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link to page 60 link to page 61 link to page 63 link to page 64 link to page 68 North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
CHAPTER 5 - FIRST STAGE OF LABOUR 
 
 
5.1 
RISK ASSESSMENT ........................................................................................60 
5.2 
PARTOGRAM ...................................................................................................61 
5.3 
BIRTH ENVIRONMENT....................................................................................63 
5.4  
DYSFUNCTIONAL LABOUR ............................................................................64 
5.5 
SPONTANEOUS RUPTURE OF MEMBRANES AT TERM..............................68 
 
 
 
 
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5.1 RISK 
ASSESSMENT 
 
On presentation to Delivery Suite, labouring women should be allocated to midwifery or 
consultant led care by the midwife. Consultant care should be allocated to women with any 
condition adversely affecting fetal or maternal wellbeing, such as: 
 
Maternal 
 
•  previous myomectomy / hysterotomy 
• placenta 
praevia 
• antepartum 
haemorrhage 
•  previous postpartum haemorrhage > 1000 ml 
•  isoimmunisation - Rhesus or other antibodies 
•  previous caesarean section 
• preeclampsia 
•  HIV / Hep B 
• diabetes 
•  other maternal medical conditions 
•  anaemia Hb <8.5 g/dl at onset of labour 
•  substance abuse, including alcohol dependency 
•  BMI > 35 kg /m2 
 
Fetal 
 
• breech 
presentation 
or other malpresentation 
• multiple 
pregnancy 
• thick 
meconium 
• polyhydramnios 
• oligohydramnios 
• congenital 
abnormalities 
•  gestation under 37 weeks 
•  previous shoulder dystocia 
•  baby under 2.5 kg estimated weight 
• confirmed 
IUD 
•  small for gestational age pregnancy 
 
Intrapartum  
 
Transfer to high risk status should be precipitated by: 
 
•  use of syntocinon 
• intrapartum 
haemorrhage 
•  fetal heart rate abnormalities 
•  fetal capillary blood sampling 
•  prolonged rupture of the membranes 
•  any other concern about the woman’s wellbeing 
 
 
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5.2 PARTOGRAM 
 
A partogram should be kept for every woman in established labour. Entries should be 
recorded legibly in black ink, timed and signed. Signatures should be accompanied by the 
name and status of the attending obstetrician / midwife, printed in capitals. When retrospective 
entries are made, they should be timed at the point of entry and approximate times of events 
described in the text. 
 
Observations 
 
The following general observations should be recorded: 
 
observation   
 
 
interval 
 
pulse 
    1 hour 
blood pressure 
 
 
4 hour 
uterine 
contractions 
  30 
mins 
 
(15 mins during syntocinon infusion) 
fetal heart rate 
 
 
15 
mins (for at least 1 minute) 
temperature 
   4 hour 
liquor 
colour 
   1 
 
hour 
 
Intermittent auscultation of the fetal heart after a contraction should occur for at least 1 minute, 
at least every 15 minutes, and the rate should be recorded as an average.  The maternal 
pulse should be palpated if an FHR abnormality is detected to differentiate the two heart rates. 
 More frequent observations may be necessary for women who are hypertensive, pyrexial, or 
have epidural analgesia. 
 
Vaginal examination 
 
In general, although there is no reliable research base upon which recommendations can be 
made for the optimal frequency and timing of vaginal examination, this will normally be 
undertaken 4 hourly. More frequent examinations may be considered: 
 
•  in dysfunctional labour 
•  in the late first stage of labour (7 to 9 cm cervical dilatation) 
 
The examinations will usually be carried out by a midwife, but vaginal examination by medical 
staff will be considered in the following circumstances: 
 
• dysfunctional 
labour 
•  established labour lasting more than 12 hours 
• malpresentation 
• malposition 
• multiple 
pregnancy 
 
Sterile gloves should be worn but swabbing the vulva with an antiseptic solution is not 
necessary. When the vulva is soiled, cleansing may be undertaken with tap water. At each 
examination, the following information should be recorded: 
 
 
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•  amount of head palpable abdominally 
•  status of vulva / vagina 
•  effacement, consistency, dilatation and vaginal position of the cervix 
•  application of the presenting part to the cervix 
•  membrane status, and colour of liquor if applicable 
•  level and position of the presenting part in relation to the ischial spines 
•  presence and degree of caput and moulding 
 
Fetal heart rate monitoring 
 
This is dealt with in Section 13. In brief, low risk women should not routinely receive an 
admission CTG. Intermittent monitoring should take place throughout the first stage of labour, 
consisting of 1 minute of cardiac auscultation with Pinnard or Doppler every 15 minutes, 
immediately following a contraction. A deceleration, baseline under 110 bpm or baseline over 
160 bpm would precipitate continuous monitoring. High risk women are usually monitored 
continuously once in established labour. 
 
Saving serum and cross matching blood 
 
Blood samples bottles should be labelled at the bedside then sent directly to the laboratory. 
 
Retrieved blood should be group and saved as a precautionary measure in the face of: 
 
•  previous caesarean section 
•  suspected fetal distress 
• breech 
presentation 
• multiple 
pregnancy 
•  eclampsia / severe pre-eclampsia 
•  antenatal anaemia (Hb less than 9 gm/dl) 
•  recent antepartum haemorrhage 
•  previous third stage abnormality 
•  maternal red blood cell antibodies 
 
Precautionary cross match of blood is not usually required in these circumstances, but should 
be considered in the following situations: 
 
•  significant intrapartum haemorrhage 
•  labour in a woman with any grade of placenta praevia 
•  maternal red cell antibodies plus the presence of any other risk factor for haemorrhage 
 
The amount of blood required for cross match will vary with the clinical circumstances and 
should always be discussed with a senior clinician. 
 
Fluid balance in labour 
 
Labouring women are at risk of hyponatraemia, particularly when having a syntocinon infusion 
under epidural blockade. To avoid this: 
 
 
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•  light breakfast may be given to women having Prostin for cervical ripening 
•  ketoneuria should be treated with intravenous Hartmann’s or normal saline 
•  intravenous dextrose should be avoided  
 
5.3 BIRTH 
ENVIRONMENT 
 
The environment in which a woman labours influences the amount of fear and anxiety she 
experiences. Labour in a high tech’ environment leads some women to feel loss of control, 
increasing anxiety and interfering with the normal physiology of labour. In contrast, measures 
taken to provide a homely environment may improve outcome for some women.  
 
Supporting women in labour 
 
One of the most important roles of the midwife / doctor is to provide the labouring woman with 
support. Studies have highlighted four dimensions to this support: 
 
• physical 
support 
• emotional 
support 
• information 
• advocacy 
 
Effective support is associated with shorter labour, less use of pharmacological analgesia and 
less instrumental delivery. 
 
Positions for labour 
 
Adopting an upright position in the first stage of labour (sitting upright, walking, squatting, 
kneeling, all fours) may be beneficial in encouraging strong uterine contractions with 
concomitant shortening of the time taken to reach full dilatation. Upright stance may also help 
to promote fetal cephalic rotation to an OA position, possibly contributing to a reduction in 
pain. Finally, the complications of aorto caval compression are only encountered in women 
opting for recumbent positions. While respecting women’s choice, midwives and doctors may 
encourage mobilisation or rest in a non recumbent position during the first stage of labour. 
 
Feeding in labour 
 
Some women may wish to continue taking a light diet during labour, particularly during the first 
stage. There is some equivocal evidence to suggest that in this population a permissive policy 
may help to reduce instrumental and caesarean delivery by reducing ketosis and fatigue. 
 
•  light snacks such as ‘toast’ may be taken in early uncomplicated labour and… 
•  fluids may be taken throughout labour but.. 
•  if surgical intervention is anticipated, fluid and snacks should be stopped… 
•  and substituted with small sips of water only 
•  the amount of fluid taken should be recorded and fizzy drinks should not be given 
•  oral medicines are always permitted if necessary 
 
 
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The risk of acidic gastric aspiration (Mendelson’s syndrome) only appears to be increased in 
women with additional risk factors for delayed gastric emptying. This includes women who 
have received parenteral or epidural narcotic analgesia. 
 
Consequently, although women should not be actively encouraged to eat during labour, a light 
diet may be allowed early in the first stage on maternal request until such time as opiates 
have been administered or an epidural sited. 
 
Labouring in water - This issue is dealt with in Chapter 2. 
 
Pain relief
 - This is dealt with in Chapter 19. 
 
5.4   DYSFUNCTIONAL LABOUR 
 
Progress of labour is defined by the rate of cervical dilatation and the speed of descent of the 
presenting part into the pelvis. There is no universally accepted definition of dysfunctional 
labour, but slower labours are associated with an increased rate of operative delivery. 
 
Definition of dysfunctional labour 
 
In the following circumstances the SpR must be involved in formulating a management plan: 
 
•  the rate of cervical dilatation is ≤ 0.5 cm / hr 
•  the presenting part is ≥ 1 cm above the ischial spines at the end of the first stage 
•  the presenting part is ≥ 2/5 palpable at the end of the first stage of labour 
 
Aetiology 
 
It is important to emphasise that dysfunctional labour is not a diagnosis. In planning 
management, an attempt should be made to determine the aetiology. Causes include: 
 
•  inefficient uterine activity 
•  fetal malposition / malpresentation 
•  cephalopelvic disproportion (absolute or relative) 
 
Note that genuine absolute CPD is unusual in the UK population. 
 
Factors to be assessed 
 
•  past obstetric history    
•  nature of the contractions 
•  pattern of cervical dilatation 
• cervical 
oedema 
•  size of the baby 
•  fetal presentation and position 
•  caput / moulding 
• pelvic 
size 
•  pelvic masses (including bladder size) 
 
 
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When present in conjunction with slow labour, the following factors must be regarded as 
concerning, and an indication for careful assessment: 
 
• multiparity 
• secondary 
arrest 
•  estimated fetal weight substantially increased compared to previous babies 
•  marked caput formation or moulding 
 
Multiparity 
 
Slow progress in labour may result from inadequate uterine activity in multiparous women and 
will often respond to augmentation. Nonetheless, dysfunctional labour in a multiparous woman 
in combination with other features such as secondary arrest, marked increase in fetal size 
compared to past deliveries or the formation of caput or moulding is particularly concerning. 
Management of such cases must be discussed with the SpR / consultant. 
 
Secondary arrest 
 
This is generally perceived to be indicative of cephalopelvic disproportion (CPD), particularly 
when associated with marked cephalic moulding. Many women with secondary arrest will 
nevertheless respond to syntocinon infusion. Before using syntocinon however, particular 
attention must be directed towards assessment of the underlying cause of secondary arrest. 
Discuss all such cases with the consultant. 
 
Management of dysfunctional labour 
 
Following assessment, the obstetrician will chose between expectant management, 
augmentation of labour or caesarean section. 
 
Expectant management 
 
In the early stages of labour, progress of ≤ 0.5 cms / hr may be normal if accompanied by 
cervical effacement and descent of the presenting part. Expectant management may then be 
considered, particularly if contractions are increasing in frequency or intensity. If possible, 
expectant management should be accompanied by mobilization. 
 
ARM by Midwife 
 
The following criteria must be met when performing amniotomy 
 
•  cervical os is 4 cm or more dilated 
•  presentation of fetus is cephalic 
•  caution should be taken if presenting part is above the ischial spines 
•  Amniotomy may be performed to attempt to accelerate labour if progress is slow. 
•  Fetal heart monitoring suggests fetal compromise 
•  Prior to application of FSE 
•  Fetal heart must be recorded prior to and following amniotomy. 
 

 
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Augmentation 
 
To augment contractions in the presence of intact membranes, amniotomy should first be 
performed. Syntocinon may then be used following the infusion protocol shown overleaf. If the 
attending midwife or doctor feels that contractions have improved significantly after 
amniotomy alone, a delay of up to 2 hours may be employed before commencing the 
syntocinon infusion. Vaginal examination should be repeated at this time however, to ensure 
that the cervix has further dilated. 
 
Protocol for IV syntocinon 
 
The dilution of Syntocinon used consists of 10 units in 50 ml normal saline, equivalent to 0.2 
units in 1 ml. It should be prescribed by a doctor then checked by two qualified members of 
staff. The midwives will also check that: 
 
•  the syringe is secured correctly in pump 
•  the correct pump setting initiated 
•  the infusion rate is checked, with initials from both members of staff at commencement 
 
 
 
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Delay in the first stage 
 

Definition of delay in the first stage 
 
 
 
  Nuliparous:  
Consider also: 
Parous: < 2 cm 
  < 2 cm dilatation 
• Descent and rotation of the fetal head 
Dilatation in 4 hrs 
  in 4 hrs 
• Changes in strength, duration and 
or a slowing in 
 
frequency of uterine contractions 
progress 
 
• Station and position of presenting part 
 
• Woman’s emotional state 
 
 
 
 
Delay suspected: consider amniotomy if membranes intact 
 
Whether membranes ruptured or intact, advise vaginal exam 2 hours later 
 
 
Amniotomy 
  Progress > 1 cm: 
Explain procedure 
 
Progress < 1 cm: diagnose delay  
return to 1st stage 
and that it: 
 
Offer support and effective pain relief 
 
Offer continuous EFM
• Will shorten 
 
labour by about 
 
an hour 
 
• May make 
If membranes 
If membranes intact: advise amniotomy. 
 
contractions 
ruptures 
Advise repeat vaginal exam 2 hrs later 
 
stronger and 
 
more painful 
 
 
Progress < 1 cm 
Progress ? 1 cm: return 
Oxytocin 
 
to first stage 
Explain that 
 
oxytocin will bring 
 
forward time of 
  Nulliparous: 
Parous: 
birth but not 
  Consider oxytocin following 

influence mode of 
 
 Abdominal palpation 
spontaneous or artificial  
birth, will increase 
 
• Vaginal exam 
rupture of membranes.  If 
frequency and 
 
before making decision about 
oxytocin used advise 
strength of 
 
the use of oxytocin 
continuous EFM. 
contractions and 
 
If oxytocin used advise 
continuous EFM 
 
continuous EFM
will be necessary. 
 
Offer epidural 
 
before starting 
 
Vaginal exam 4 hours after starting oxytocin in established 
oxytocin. 
 
labour 
Oxytocin 
 
increments > 
 
every 30 min; 
 
increase until 4-5 
 
Progress > 2 cm: 
Progress < 2 cm: 
contractions in  
 
Vaginal exam 4 hourly 
Consider CS 
10 min
 
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5.5 
SPONTANEOUS RUPTURE OF MEMBRANES AT TERM 
 
Spontaneous pre-labour rupture of membranes at term 
 

•  There is no reason to carry out a speculum examination with a certain history of 
rupture of the membranes at term. 
 
•  Women with an uncertain history of pre-labour rupture of the membranes should be 
offered a speculum examination to determine whether their membranes have ruptured. 
 
•  Digital examination in the absence of contractions should be avoided. 
 
•  Women presenting with pre-labour rupture of membranes at term should be advised 
that: 
-  The risk of serious neonatal infection is 1% rather than 0.5% for women with 
intact membranes. 
-  60% of women with pre-labour rupture of the membranes will go into labour 
within 24 hours 
-  induction of labour is appropriate approximately 24 hours after rupture of 
the membranes 
 
Planned early birth vs. Expectant management over 24 hours 
Women in the planned early birth groups have a significantly shorter 
period of time from rupture of membranes to birth and were less likely to 
develop infection (chorioamnionitis and endometritis) compared with 
women in the expectant management groups. 
 
There was no difference between groups regarding mode of birth: no 
significant increase in the caesarean or instrumental vaginal birth rates. 
 
Babies born to women in the planned  early birth groups were less likely to 
be admitted to neonatal intensive care unit (NICU) or special care baby 
unit (SCBU).  Expectant management up to 24 hours shows no evidence 
of a significant increase in neonatal infection rates.  Longer period of time 
from rupture of membranes to active labour were associated with a higher 
incidence of neonatal infection.
 
 
•  Until the induction is commenced or if expectant management beyond 24 hours is 
chosen by the women: 
 
-  Lower vaginal swabs and maternal C-reactive protein should not be offered 
-  To detect any infection that may be developing women should be advised to 
record their temperature every 4 hours during waking hours and to report 
immediately any change in the colour or smell of their vaginal loss 
-  Women should be informed that bathing or showering are not associated with 
an increase in infection, but that having sexual intercourse may be 
 
 
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•  Fetal movement and heart rate should be assessed at initial contact and then every 24 
hours following rupture of the membranes while the woman is not in labour, and the 
woman should be advised to report immediately any decrease in fetal movements. 
 
•  If labour has not started 24 hours after rupture of membranes, women should be 
advised to give birth where there is access to neonatal services and advised to stay in 
hospital for at least 12 hours following the birth. 
 
•  If there are no signs of infection in the woman, antibiotics should not be given to either 
the woman or the baby, even if the membranes have been ruptured for over 24 hours. 
 
•  If there is evidence of infection in the woman, a full course of broad-spectrum 
intravenous antibiotics should be prescribed. 
 
•  Women with pre-labour rupture of the membranes should be asked to inform their 
healthcare professionals immediately of any concerns they may have about their 
baby’s wellbeing in the first 5 days following birth, particularly in the first 12 hours when 
the risk of infection is greatest. 
 
•  Blood, cerebrospinal fluid and / or surface culture tests should not be performed in an 
asymptomatic baby. 
 
•  Asymptomatic term babies born to women with pre-labour rupture of the membranes 
(more than 24 hours before labour) should be closely observed for the first 12 hours of 
life (at 1 hour, 2 hours and then 2 hourly for 10 hrs).  These observations should 
include: 
 
- General 
wellbeing 
-  Chest movement and nasal flare 
-  Skin colour including perfusion, by testing capillary refill 
- Feeding 
- Muscle 
tone 
- Temperature 
-  Heart rate and respiration 
 
A baby with any symptom of possible sepsis, or born to a women who has evidence of 
chorioamnionitis should immediately be referred to a neonatal care specialist. 
 
 
 
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Pre-labour rupture of the membranes (PROM) at term 
 
 
Suspected PROM 
PROM certain history 
 
 
 
Normal progress 
Offer speculum exam 
  If membranes intact advise 
Avoid digital vaginal exam in 
No speculum exam 
  women to return home 
absence of contractions 
 
 
 
PROM – Care of the woman 
 
Advise woman that: 
 
•  Risk of serious neonatal infection is 1% rather than 0.5% 
 
•  60% will go into labour within 24 hours 
 
•  induction of labour is appropriate after 24 hours 
 
No antibiotics for woman or baby without signs of infection 
If evidence of infection prescribe full course of broad-spectrum antibiotics
 
 
 
PROM >24 hrs 
  Until induction or if the woman chooses expectant management 
Induction of labour 
  beyond 24 hours 
Do not offer lower vaginal swabs and maternal C-reactive protein 
 
   
Transfer/access to 
  Advise the woman to record her temperature every 4 hours during 
neonatal care 
  waking hours and to report immediately any change in the colour or 
 
  smell of her vaginal loss 
Stay in hospital at 
 
least 12 hours after 
  Inform her that bathing or showering are not associated with an 
birth so the baby can 
  increase in infection, but that having sexual intercourse may be 
be observed 
   Assess fetal movement and heart rate at initial contact and then every 
  24 hours following membrane rupture while the woman is not in labour 
   
  Advise the woman to report immediately any decrease in fetal 
movements 
 
 
 
 
  PROM – care of the baby 
If no signs of infection do not give antibiotics to the baby 
   
  For baby with possible sepsis or born to a woman with evidence of chorioamnionitis: immediately refer to 
  neonatal care 
 
  Observe asymptomatic term babies (PROM >24 hrs) for the first 12 hours at 1 hour, 2 hours then 2-hourly for 
  10 hours: 
 
• General 
wellbeing 
 
•  Chest movements and nasal flare 
 
•  Skin colour (test capillary refill) 
 
• Feeding 
• Muscle 
tone 
 
• Temperature 
 
•  Heart rate and respiration 
  No blood, cerebrospinal fluid and/or surface culture tests for asymptomatic baby 
  Woman to inform immediately of any concerns about the baby in the first 5 days 
 
 
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Active management 
 
In both primips and multips, management depends upon cervical favourability. 
 
Bishop’s score 6 or under : 3mg Prostin vaginal tablet then syntocinon 6 hours later as per 
syntocinon regimen 
Bishop’s score over 6: 
no Prostin priming generally needed - syntocinon as per regimen 
Active Management: 
should be discussed with Obstetrician on call 
Multiple Pregnancy: 
should be discussed with the Consultant on call 
 
 
Conservative management 
 
Early return to hospital should be precipitated by: 
 
• labour 
• bleeding 
•  passage of meconium 
•  reduced fetal movements 
•  development of a temperature  
 
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Syntocinon Regimen 
 
 
Time (Mins) 
Syntocinon Dose  
Volume infused  
(mu/min) 
(mls/hour) 
0 – 30 

0.3 
30 – 60 

0.6 
60 – 90 

1.2 
90 – 120 

2.4 
120 – 150 
12 
3.6 
150 – 180 
16 
4.8 
180 – 210 
20 
6.0 
210 – 240 
24 
7.2 
240 – 270 
28 
8.4 
270 - 300 
32 
9.6 
 
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References 
 
Albers L, Schiff M, Gorwoda J (1996) The length of active labour in normal pregnancies. 
Obstet Gynecol 87: 355-359. 
 
Barrett JFR et al (1992) Randomized trial of amniotomy in labour versus the intention to leave 
membranes intact until the second stage. BJOG 99: 5-9. 
 
Goffnet F et al (1997) Early amniotomy increases the frequency of fetal heart rate 
abnormalities. BJOG 104: 340-346. 
 
Fraser WF et al (1993) The Canadian early amniotomy group. Effect of early amniotomy on 
the risk of dystocia in nulliparous women. NEJM 328: 1145-1149. 
 
NICE Intrapartum Guidelines 
 
Tufnell D et al (1989) Simulation of cervical changes in labour: reproducibility of expert 
assessment. Lancet 2: 1089-1090. 
 
NCHE-OBS001 
 
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CHAPTER 6 - SECOND STAGE OF LABOUR AND 
INSTRUMENTAL DELIVERY 
 
 

 
6.1 
DEFINITION......................................................................................................75 
6.2 
DIAGNOSIS ......................................................................................................75 
6.3 
MANAGEMENT ................................................................................................75 
6.4 
INSTRUMENTAL DELIVERY............................................................................75 
6.5 
MALPOSITION .................................................................................................78 
6.6 
PAEDIATRICIANS' ATTENDANCE AT INSTRUMENTAL DELIVERY .............78 
6.7 
PERINEAL REPAIR ..........................................................................................79 
 
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6.1 DEFINITION 
 
The second stage extends from full cervical dilatation to birth. It may have two components: 
 
Passive without 
pushing 
Active  
with pushing 
 
6.2 DIAGNOSIS 
 
The second stage of labour is diagnosed: 
 
•  when the presenting part of the baby is visible 
•  on routine repeat vaginal examination, or… 
•  on vaginal examination performed when the woman feels an urge to push 
 
6.3 MANAGEMENT 
 
Flow charts for guidance can be found in the following pages. In general, adequate 
contractions should be maintained. Diagnosis of delay in the active second stage of labour 
should be made with reference to the algorithms on page 70-72. Maternal involvement in all 
decision-making is of paramount importance in the second stage of labour. 
 
•  The fetal heart should be monitored every 5 minutes after a contraction. 
•  Every 30 minutes document frequency of contractions 
•  Every hour check BP, pulse, offer vaginal examination 
•  Every 4 hours check temperature 
•  Regularly check frequency of bladder emptying 
•  Assess progress, including fetal position and station 
•  If woman has full dilatation but no urge to push, assess after 1 hour 
•  Discourage the woman from lying supine / semi-supine 
•  Consider woman’s position, hydration and pain-relief needs 
•  Provide support and encouragement 
 
 
6.4 INSTRUMENTAL 
DELIVERY 
 
Indications 
 
•  non progressive second stage (see the following flow charts) 
•  clear evidence of fetal compromise 
 
9 hypoxic 
9 infective 
9 haemorrhagic 
 
•  maternal request, distress or inability to push 
•  maternal conditions in which active pushing is contraindicated 
  
 
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Prerequisites for instrumental vaginal delivery 
 
• 
appropriately experienced operator 
• 
full cervical dilatation 
• ruptured 
membranes 
• adequate 
analgesia 
• empty 
bladder 
• 
cephalic 1/5 or less on abdominal palpation 
• 
cephalic zero station or lower on vaginal examination 
• 
no known cephalopelvic disproportion 
• defined 
position 
 
Consent 
 
Before delivering a baby with forceps or ventouse, an attempt must be made to obtain consent 
from the labouring woman by making sure that the woman: 
 
•  is aware of your rationale for intervention 
•  has a basic understanding about the process of instrumental delivery 
•  understands the common risks of the procedure 
•  is given clinically reasonable alternatives 
•  agrees to the procedure 
 
It is accepted that when a woman is in pain or has been given analgesics, it will be impossible 
to guarantee that you have obtained valid, fully informed consent. This does not mean that 
you should not try. 
 
Make sure that the woman is aware of your rationale for intervention 
 
Always tell the woman why you want to assist delivery and record this on the partogram or on 
a consent form. 
 
Make sure that the woman has a basic understanding about the process 
 
As a minimum, the woman should be told that: 
 
• 
her legs will be placed in the lithotomy position 
• 
the bladder may need to be catheterised 
• 
an episiotomy is often required 
• 
sutures may be needed after the baby is born 
 
It is important to try to discuss possible complications from an instrumental delivery: 
 
e.g. for forceps delivery 
 
• 
baby - bruising to the face 
• 
baby - facial nerve palsy 
• 
baby - bony injury 
 
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• 
woman - genital tract laceration 
• 
woman - anal sphincter injury 
• 
woman - urinary incontinence 
• 
woman - post partum haemorrhage 
 
e.g. for ventouse 
 
• 
baby - cephalhaematoma 
• 
baby - intracranial and retinal haemorrhage 
• 
woman - genital tract laceration 
• 
woman - anal sphincter injury 
• 
woman - post partum haemorrhage 
 
Minor injuries to the baby are more common after ventouse and mothers tend to worry about 
the baby’s appearance more after ventouse delivery. In contrast, forceps damage the 
maternal anal sphincter more commonly. 
 
Other rare complications may arise – the woman should be made aware of this but a fully 
exhaustive discussion is not required in most cases. 
 
An attempt at instrumental vaginal delivery does not always succeed, particularly if the 
ventouse is being used. In these circumstances, a difficult caesarean section may be required. 
Because of this and the known potential complications listed above, alternatives to 
instrumental delivery should always be considered before the procedure starts. 
 
The alternative to intervention with forceps or the ventouse will normally be for her to have no 
intervention (ie) for her to carry on pushing. Occasionally however, the alternative of 
caesarean section may be offered as first line management. This should usually be reserved 
for cases in which there is clear concern that the instrumental delivery is likely to fail. 
 
Make sure that the woman agrees to the procedure 
 
In an acute situation in which the wellbeing of fetus is at risk, maternal consent may be 
obtained orally or by some body movement or gesture. This consent should be recorded on 
the partogram by the attending doctor at the earliest opportunity. Written consent should be 
taken when practicable however, with one copy of the consent form filed in the notes and a 
second copy given to the patient or her birth partner. 
 
Procedure For Forceps Delivery 
 
This is recorded in the following pages. 
 
Procedure for ventouse delivery 
 
This is recorded in the following pages. 
 
Catheterisation 
 
Foley's catheter should be considered for 24 hours after delivery whenever: 
 
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•  a dense epidural block has been used to facilitate instrumental vaginal delivery 
•  a spinal block has been used to facilitate instrumental vaginal delivery 
•  the vulva has been traumatised during instrumental vaginal delivery 
 
Contraindications to ventouse delivery 
 
•  prematurity (below 34 weeks gestation) 
•  face, brow or breech presentation 
•  suspected fetal bleeding diathesis 
•  failure of the procedure may be more likely in the presence of excessive caput or poor 
maternal effort. 
 
Ventouse may be used if fetal scalp blood samples have been taken in labour, but the 
operator must be confident that there has been minimal scalp trauma and that the fetus has 
been left with no ongoing bleeding from the sample sites. 
 
6.5 MALPOSITION 
 
The indications for assisted delivery when the baby is in a malposition are the same as those 
for babies presenting OA. No course of action is risk free: the operator must try to judge 
whether an attempt at instrumental vaginal delivery is likely to be less traumatic for mother 
and child than proceeding directly to caesarean section in each case. 
 
Manual rotation of the fetal head 
 
Manual rotation requires adequate analgesia and may be performed prior to applying 
ventouse or forceps. The head should be flexed during a contraction while the mother is 
encouraged to push. Rotation is achieved by applying pressure to the Lambdoid sutures. 
 
Ventouse 
 
The prerequisites, contraindications and risks are as recorded above for non rotational 
ventouse. The ventouse is more likely to fail than forceps in the presence of significant caput 
or moulding and with poor maternal effort, in which case the operator may be face with a 
difficult caesarean section with an impacted fetal head. 
 
Non-rotational forceps in malposition 
 
The operator may opt to deliver the baby without rotation if the head is in a direct OP position, 
3 cm below the ischial spines. A right medio lateral episiotomy should be employed. 
 
 
6.6 
PAEDIATRICIANS' ATTENDANCE AT INSTRUMENTAL DELIVERY 
 
A paediatrician should only be asked to attend an instrumental delivery if it seems likely that 
the baby will be in poor condition at birth. 
 
 
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6.7 PERINEAL 
REPAIR 
 
This is dealt with in Chapter 8.  
 
 
 
 
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Delay in the second stage 
 
 
Nulliparous: delay suspected if inadequate 
 
progress after 1 hour of active second stage 
 
 
 
 
Offer vaginal exam; advise amniotomy if 
 
membranes intact. 
 
Offer support and encouragement and 
 
consider analgesia / anaesthesia 
 
 
 
 
Birth within 
No birth within next hour 
Parous: active second 
 
1 hour 
(total active second stage 
stage = 1 hour 
 
= 2 hours)
 
 
 
Diagnosis of delay in the second stage 
 
 
 
 
Assessment and ongoing 
 
review every 15-30 mins by 
 
obstetrician.   
 
Do not start oxytocin 
 
 
Consider instrumental birth if 
 
concern about fetal well being or 
 
for prolonged second stage. 
 
Good progress: 
Advise CS if vaginal birth not 
 
Second stage 
possible. 
 
Birth expected to take place within 
 
3 hours of start of active second 
 
stage for Nulliparous women and 
 
within 2 hours for parous women 
 
 
 
 
Consider instrumental birth if 
 
concern about fetal well being or 
 
for prolonged second stage. 
 
Birth: 
Advise CS if vaginal birth not 
 
Third stage 
possible. 
 
Birth expected to take place within 
 
3 hours of start of active second 
 
stage for Nulliparous women and 
 
within 2 hours for parous women 
 
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Non-Rotational Forceps Delivery 
 

Abdominal palpation 
Ask for consent – document this 
Adequate analgesia 
Ask for help 
 

empty the Bladder 
 

full Cervical dilatation 
 

Define the station and position 
remember the risk of shoulder Dystocia 
 

check the Equipment 
 

apply the Forceps and check its application 
 

Gentle traction (Pajot’s manoevre) 
 

lift the Handles as the occiput clears the pubic arch 
 

Incision – use an episiotomy 
 

when you can reach the Jaw, remove the blades 
 
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Ventouse Delivery 
 
 

Abdominal palpation 
Ask for consent – document this 
Adequate analgesia 
Ask for help 
 

empty the Bladder 
 

full Cervical dilatation 
 

Define the station and position 
remember the risk of shoulder Dystocia 
 

check the Equipment 
 

apply the cup to the posterior Fontanelle 
 

Gentle traction 
 

Halt 
if the cup avulses 3 times 
if there is no descent over 3 contractions 
if the head has not delivered in 20 minutes 
 

Incision – consider using an episiotomy 
 

when you can reach the Jaw, remove the cup 
 
 
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References 
 
Albers L, Schiff M, Gorwoda J (1996) The length of active labour in normal pregnancies. 
Obstet Gynecol 87: 355-359. 
 
Carroli G, Belizan J (2002) Episiotomy for vaginal birth. Cochrane Database of Systematic 
Reviews, Issue 4. 

 
De Leeuw JW et al (2001) Risk factors for third degree perineal injuries during delivery. BJOG 
108: 383-387. 
 
Gardosi J, Hutson N, B-Lynch C (1989) Randomised controlled trial of squatting in the second 
stage of labour. Lancet 2: 74-77. 
 
Gardosi J, Sylvester S, B-Lynch C (1989) Alternative positions in the second stage of labour: 
a randomized controlled trial. BJOG  96: 1290-1296. 
 
Johanson R (1997) Choice of instrument for vaginal delivery. Curr Opin Obstet Gynecol 9: 
361-365. 
 
Johanson RB et al (1999) Maternal and child health after assisted vaginal delivery: five year 
follow up of a randomised controlled study comparing forceps and ventouse. BJOG 106: 544-
549. 
 
Johanson RB, Menon V (2002) Soft versus rigid vacuum extractor cups for assisted vaginal 
delivery. Cochrane Database of Systematic Reviews, Issue 4. 
 
Menticoglou SM et al (1995) Perinatal outcome in relation to second stage duration. Am J 
Obstet Gynecol 
173: 906-912. 
 
NICE Intrapartum Guidelines 
 
O’Grady JP, Pope CS, Patel SS (2000) Vacuum extraction in modern obstetric practice: a 
review and critique. Curr Opin Obstet Gynecol 126: 475-480. 
 
Parsons JE, Hedayati H, Crowther CA (2002) Rectal analgesia for pain from perineal trauma 
following childbirth. Cochrane Database of Systematic Reviews, Issue 4.  
 
Saunders N, Paterson C, Wadsworth J (1992) Neonatal and maternal morbidity in relation to 
the length of the second stage of labour. BJOG 99: 381-385. 
 
Tufnell D et al (1989) Simulation of cervical changes in labour: reproducibility of expert 
assessment. Lancet 2: 1089-1090. 
 
NCHE-OBS001 
 
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CHAPTER 7 - THIRD STAGE OF LABOUR 
 
 
 
7.1    
DEFINITIONS ...................................................................................................85 
7.2 
MANAGEMENT OF THIRD STAGE .................................................................85 
7.3 
PHYSIOLOGICAL THIRD STAGE OF LABOUR ..............................................86 
7.4 
TREATMENT OF WOMEN WITH A RETAINED PLACENTA...........................87 
7.5 
THE MORBIDLY ADHERENT PLACENTA.......................................................89 
7.6 
PLACENTAL HISTOLOGY ...............................................................................90 
 
 
 
 
 
 
 
 
 
 
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7.1     DEFINITIONS 
 
Definition of the third stage 
 
For the purposes of this guideline, the following definitions are recommended: 
 
•  The third stage of labour is the time from the birth of the baby to the expulsion of the 
placenta and membranes 
 
•  Active management of the third stage involved a package of care which includes all of 
these three components: 
-  Routine use of uterotonic drugs 
-  Early clamping and cutting of the cord 
-  Controlled cord traction 
 
•  Physiological management of the third stage involved a package of care which 
includes all of these three components: 
-  No routine use of uterotonic drugs 
-  No clamping of the cord until pulsation has ceased 
-  Delivery of the placenta by maternal effort 
 
Prolonged third stage 
The third stage of labour is diagnosed as prolonged if not completed within 30 minutes 
of the birth of the baby with active management and 60 minutes with physiological 
management. 
 
7.2 
MANAGEMENT OF THIRD STAGE 
 
Observations by a midwife of a woman in the third stage of labour include: 
 
•  Her general physical condition, as shown by her colour, respiration and her own report 
of how she feels 
•  Vaginal blood loss 
 
In addition, in the presence of haemorrhage, retained placenta or maternal collapse, frequent 
observations to assess the need for resuscitation are required. 
 
Physiological and active management of the third stage 
 
Active management of the third stage is recommended, which includes the use of oxytocin (10 
international units [IU] by intramuscular injection), followed by early clamping and cutting of 
the cord and controlled cord traction. 
 
Women should be informed that active management of the third stage reduces the risk of 
maternal haemorrhage and shortens the third stage. 
 
Women at low risk of postpartum haemorrhage who request physiological management of the 
third stage should be supported in their choice. 
 
 
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Changing from physiological management to active management of the third stage is 
indicated in the case of: 
 
• Haemorrhage 
•  Failure to deliver the placenta within 1 hour 
•  The woman’s desire to artificially shorten the third stage 
 
Pulling the cord or palpating the uterus should only be carried out after administration of 
oxytocin as part of active management. 
 
In the third stage of labour neither umbilical oxytocin infusion nor prostaglandin should be 
used routinely. 
 
If the placenta is not delivered within 30 minutes 
 
The midwife should: 
 

•  Check for signs of separation 
 
If the placenta appears to be separated try to effect delivery by: 
 
•  Emptying bladder by voiding or catheterisation 
•  Encourage maternal effort pushing, squatting, without CCT 
•  Put baby to the breast if woman agreeable 
•  Record maternal observations of pulse and blood pressure 
•  Bear in mind that excessive CCT and / or excessive fundal pressure may cause uterine 
inversion 
 
7.3 
PHYSIOLOGICAL THIRD STAGE OF LABOUR 
 
Third stage management should be planned antenatally and documented in the notes.  
 
Advantages 
 
Physiological third stage offers continuation of the normal physiological process of labour. 
There is no evidence of clinically significant increased morbidity for low risk women. 
 
Disadvantages 
 
In comparison to active management, a larger blood loss may be anticipated when managing 
the third stage physiologically and the length of third stage is likely to be longer. 
 
Mechanisms of physiological management of the third stage of labour 
 
See figure 2. 
 
Good practice points 
 
•  the midwife needs to be competent in caring for a woman during expectant management 
 
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•  the woman should never be left unattended 
•  pulse and blood pressure should be recorded every 30 mins 
•  the woman needs to be kept warm. This will reduce her risk of PPH 
•  leave the cord unclamped and uncut until the placenta separates 
•  the woman should adopt an upright position if possible 
•  if estimated blood loss exceeds 500ml, resort to active management and seek assistance 
•  if the woman has not delivered her placenta after 60 minutes refer to medical staff 
 
 
7.4 
TREATMENT OF WOMEN WITH A RETAINED PLACENTA 
 
Intravenous access should always be secured in women with a retained placenta. 
 
Intravenous infusion of oxytocin should not be used to assist the delivery of the placenta. 
 
For women with a retained placenta oxytocin injection into the umbilical vein with 20 IU of 
oxytocin in 20 ml of saline is recommended, followed by proximal clamping of the cord. 
 
If the placenta is still retained 30 minutes after oxytocin injection, or sooner if there is concern 
about the woman’s condition, women should be offered an assessment of the need to remove 
the placenta.  Women should be informed that this assessment can be painful and they 
should be advised to have analgesia or even anaesthesia for this assessment. 
 
If a woman reports inadequate pain relief during the assessment, the healthcare professional 
must immediately stop the examination and address this need. 
 
If manual removal of the placenta is required, this must be carried out under effective regional 
anaesthesia (or general anaesthesia when necessary). 
 
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Diagnosis of delay in the third stage 
 
 
 
 
>30 min after birth with active 
> 1 hour after birth with 
 
management 
physiological management 
 
 
 
 
 
Revert to active management: 
 
Give 10 IU oxytocin IM and apply 
 
controlled cord traction 
 
 
 
Secure IV access 
Placenta delivered 
 
 
 
 
 
OXYTOCIN 
 
Injection of 20 IU in 20 ml of saline into the 
 
umbilical vein, proximal cord clamping 
 
No IV oxytocin infusion 
 
 
 
 
 
 
Oxytocin 
Oxytocin not effective 
 
effective 
Within 30 mins 
 
 
 
Placenta delivered 
 
Use analgesia or anaesthesia for 
 
assessment 
 
 
 
If women reports inadequate pain 
 
relief, stop assessment and address 
 
this need 
 
 
 
Use effective regional or general 
 
anaesthesia for manual removal of 
 
placenta 
 
 
 
 
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7.5 
THE MORBIDLY ADHERENT PLACENTA 
 
The diagnosis of placenta accreta classically is based upon histological investigations rather 
than clinical findings or antenatal imaging. There are three histological grades: 
 
• 
accreta 
villi attached to the myometrium 
• 
increta 
villi extending into myometrium 
• 
percreta 
villi penetrating myometrial wall 
 
The condition arises in between 1:2000 and 1:7000 pregnancies, the incidence rising in recent 
years. Associations have been described with placenta praevia, previous caesarean section 
and myomectomy but placenta accreta may also arise in women without these risk factors. 
 
Antenatal imaging 
 
Placenta accreta cannot be diagnosed with confidence by ultrasound but its presence may be 
inferred when the normal hypoechoic interface between the placenta and myometrium is lost. 
Venous lakes may also be found in association with the condition. Some reports suggest that 
magnetic resonance imaging can improve antenatal assessment but this has yet to find a 
place in routine clinical practice. If the diagnosis is suspected antenatally, counselling should 
cover the topics of surgical and conservative management at delivery and consider tertiary 
referral. 
 
Surgical management 
 
Suspicion of placenta accreta often arises only when a placenta cannot be removed by 
standard manoeuvres and a clear plane of cleavage cannot be found by digital exploration at 
caesarean or during examination under anaesthesia after vaginal birth. Excavation of the 
placental tissue from deep within the myometrium should be avoided as this is likely to lead to 
haemorrhage. The Consultant Obstetrician should be informed and will wish to confirm the 
findings. 
 
The traditional management of placenta accreta is to perform a hysterectomy. When this is 
undertaken promptly, a reduction in maternal mortality can be demonstrated. If the placenta 
has already been removed and heavy bleeding is encountered, tamponade may be attempted 
using gauze or an inflatable Cooke Catheter.  Ligation of the internal iliac arteries is unlikely to 
control bleeding sufficiently well to enable preservation of the uterus. Wedge resection of the 
placental bed has also been described but is not presently recommended. 
 
 
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Conservative management 
 
Rather than perform a hysterectomy or attempt piecemeal removal of the placenta, in the 
absence of haemorrhage, the cord may be cut short and the placenta left in situ. If the 
morbidly adherent placenta is identified during caesarean, the uterus should then be closed in 
the standard fashion. A Foley catheter should be inserted and generous intravenous access 
gained. 
 
A uterotonic drug such as 800 mcg rectal misoprostol should be given in addition to broad 
spectrum antibiotics (eg) co-amoxyclav for 10 days. Methotrexate is not recommended as it 
does not appear to alter clinical outcome. 
 
If the woman is going to experience post partum haemorrhage this is most likely to arise over 
the next 24 hours so over this time, regular observation of pulse, blood pressure, fundal height 
and vaginal bleeding should be maintained on Delivery Suite.  
 
Follow up after discharge from hospital must be agreed with the Consultant but may include 
daily follow up by the Community Midwife and weekly review in antenatal clinic or on MAU. In 
addition to history and general examination at weekly follow up, a full blood count and β-hCG 
level should be checked. A well maintained Hb concentration and progressively falling β-hCG 
suggest that the placental tissue is involuting. Ultrasound is not routinely required. 
 
Reports suggest that morbidly adherent placenta managed in this way can be completely 
resorbed into the maternal circulation. Occasionally, placental tissue is expelled from the 
uterus spontaneously after a variable time interval. A second surgical procedure aiming to 
remove placental tissue should however be carried out if secondary post partum haemorrhage 
arises with the placenta still in situ. In such cases, hysterectomy is likely to be required. 
 
7.6 PLACENTAL 
HISTOLOGY 
 
The placenta should be saved and sent for histology in the following circumstances. 
•  multiple pregnancy (if babies the same sex) 
• pre-term 
delivery 
•  intrauterine growth retardation 
•  Apgar under 7 at 5 minutes 
• fetal 
abnormality 
 
• suspected 
chorioamnionitis 
•  fetal death, regardless of request for  post mortem 
 
 
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figure 1 
 
 
active management of the third stage of labour 
 
 
 
discuss - consent - document 
 
ensure the bladder is empty 
give syntocinon 10 iu im 
 
with the anterior shoulder 
or as soon after the birth of the baby as possible 
 
clamp and cut the cord 
skin to skin contact where the mother agrees 
 
observe for external signs of separation 
cord lengthening, small trickle of fresh blood, uterus firm and rising in the abdomen 
then try 
 
controlled cord traction 
 
if signs of separation have not been recognised 
after 4 minutes 
carefully check uterus is firm and well contracted 
then try 
 
controlled cord traction 
 
abandon if the cord tears or snaps 
try maternal effort alone 
then 
seek medical help 
 
seek medical help if the placenta is not delivered within 30 minutes of birth or if estimated 
blood loss of more than 500 ml arises before delivery of the placenta 
 
check the placenta for completeness 
exclude active bleeding 
confirm that the uterus is firm and well contracted 
estimate the blood loss and document 
 
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figure 2 
 
 
physiological management of the third stage of labour 
 
 
 
discuss – consent – document 
 
normal first and second stages of labour 
 
no additional risk factors 
 
omit oxytocic agent 
offer skin to skin contact 
 
consider putting the baby to the breast 
 
do not clamp or cut the cord until palsations have stopped 
do not palpate the uterus 
 
keep the mother warm and encourage an upright posture 
record her pulse and BP every 30 minutes 
 
deliver the placenta and membranes by 
 
maternal effort and gravity 
 
check the placenta for completeness 
exclude active bleeding 
confirm that the uterus is firm and well contracted 
estimate the blood loss and document 
 
if 
estimated blood loss over 500ml 
length of the third stage over 60 minutes 
concerns regarding maternal condition 
then 
seek medical assistance 
 
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References 
 
Armstrong CA, Harding S, Dickinson JE (2004) Clinical aspects and conservative 
management of placenta accreta. The Obstetrician and Gynaecologist 6: 132-37. 
 
Austin J (2003) An audit of third degree perineal tears. Br J Midwifery 11: 649-654. 
 
Begley C (1990) A comparison of active and physiological management of the third stage of 
labour. Midwifery 6: 3-17. 
 
Carroli G, Bergel E (2004) Umbilical vein injection for management of retained placenta. In: 
The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.  
 
Fleming N (1990) Can the suturing method make a difference in postpartum perineal pain? 
Nurse Midwifery 
35: 30-33. 
 
McDonald S, Prendiville W, Elbourne D (1999) Prophylactic syntometrine versus oxytocin for 
delivery of the placenta. The Cochrane Library of Systematic Reviews, Issue 4. 
 
Metcalfe A et al (2002) A Pragmatic tool for the measurement of perineal tears. Br J Midwifery 
10: 412-417. 
 
NICE Intrapartum Guidelines 
 
Prendiville WJ et al (1988) The Bristol Third Stage Trial: active versus physiological 
amangement of the third stage of labour. BMJ 297: 1295-1300. 
 
Rogers J et al (1998) Active versus expectant management of the third stage of labour: The 
Honchinbrooke randomised controlled trial. Lancet 351: 693-699. 
 
Sanaullah F, Moran P, Loughney AD (2002) The role of ultrasound in intrapartum care. BMUS 
Bulletin
 10: 23-27. 
 
Walsh D (2000) Perineal care should be a feminist issue. Br J Midwifery 8: 125-129. 
 
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CHAPTER 8 - PERINEAL REPAIR 
 
 
 

8.1 
PERINEAL REPAIR ..........................................................................................95 
8.2 
CLASSIFICATION OF PERINEAL TRAUMA ....................................................95 
8.3 
ANALGESIA......................................................................................................95 
8.4 
SECOND DEGREE TEARS..............................................................................95 
8.5 
THIRD AND FOURTH DEGREE TEARS..........................................................96 
 
 
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8.1 PERINEAL 
REPAIR 
 
Whenever possible the person delivering a woman should undertake perineal assessment and 
any necessary repair, under experienced supervision if necessary, with minimum delay.  This 
should be done by vaginal and rectal examination, using the finger lift technique, under 
adequate light.  Lithotomy position is not usually needed. 
 
8.2 
CLASSIFICATION OF PERINEAL TRAUMA 
 
1st degree 

fourchette, superficial perineal and vaginal tissues 
 
2nd degree  - 
the above, plus muscles of perineal body 
 
3rd degree 

the above, plus partial or complete disruption of the anal sphincter 
 
3a 

under 50% of the external anal sphincter involved 
3b 

over 50% of the external anal sphincter involved 
3c 

internal anal sphincter torn 
 
4th degree 

the above, plus anal epithelium 
 
8.3 ANALGESIA 
 
Adequate analgesia is essential.  For local infiltration, 1% lignocaine may be used up to a total 
of 20 ml, this total including any lignocaine infiltrated prior to episiotomy.  If perineal analgesia 
remains inadequate, the duty anaesthetist should be informed. 
 
8.4 
SECOND DEGREE TEARS 
 
The management of a second degree tear is usually surgical since functional outcome after 
conservative management is unclear – there is little clear evidence to guide a woman so that 
she can make an informed choice.  When a decision is made not to suture, the reasoning 
should be documented and the notes signed by the attending midwife. 
 
In suturing a second degree tear, the aims are to achieve: 
 
♦ Anatomical 
re-alignment 
♦ Haemostatis 
♦  Healing by first intention 
 
Thereby reducing the risk of infection and restoring normal function. 
 
Suture material 
 
Vicryl and Vicryl Rapide are the suture materials of choice as they cause less perineal pain 
than other materials.  Of the two, Rapide is absorbed more quickly (42 days versus 90 days), 
but there is no clear evidence to show that either one has a clinical advantage over the other. 
 
 
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Suture to the vaginal wall 
 
As there is no firm evidence to inform practice, the vaginal wall may be closed with either a 
locking or a non-locking continuous suture.   
 
Suture to the perineal body 
 
Either continuous or interrupted sutures may be used to appose the disrupted muscles of the 
perineal body, moving from deep to superficial tissues in order.  
 
Suture to the skin 
 
The use of a subcutaneous suture on the perineal skin is associated with less short-term pain 
than interrupted sutures and is the technique of choice.  The incidence of dysparunia after 3 
months is similar in both groups.  Non-closure of perineal skin is equally effective but offers no 
particular benefit in terms of healing or pain. 
 
Diclofenac sodium 
 
A 100 mg diclofenac sodium rectal suppository may be offered at the end of the procedure. 
 
Operator skill 
 
Practitioners should be appropriately trained and supervised to ensure a consistent high 
standard of perineal repair. 
 
Documentation 
 
The repair should be documented in full on an operative procedure sheet.  Needles, 
instruments and swabs should be counted and documented at the beginning and at the end of 
the procedure.  The operator is responsible for safe sharp disposal. 
 
8.5 
THIRD AND FOURTH DEGREE TEARS 
 
Recognition and initial response 
 
Any tear causing partial or complete disruption of the anal sphincter is a third degree tear 
while involvement of the anal / rectal mucosa is fourth degree.  The Consultant should be 
informed if the middle grade obstetrician is not experienced / trained. 
 
♦ Consultant 
Obstetrician 
♦ Experienced 
SpR 
 
After repair, complete an adverse event form and the audit form and inform the consultant 
 
 
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Repair 
 
This should be undertaken in theatre with adequate 
 
♦  Exposure of tissues 
♦ Light 
♦  Analgesia (spinal or epidural) 
 
The following sutures are suggested: 
 
Mucosa 
 
interrupted or continuous subepithelial 3/0 vicryl  
 
Sphincter 
 
internal 
end to end anastamosis with 3/0 PDS 
 
 
 
external 
overlapping or end to end anastomosis with 3/0 PDS 
 
Vagina 
 
continuous suture with 2/0 vicryl or vicryl rapide 
 
Perineal body 
continuous or interrupted 2/0 vicryl or vicryl rapide 
 
Perineal skin  
continuous subcuticular 2/0 vicryl or vicryl rapide 
 
Although there is no clear evidence of benefit, a stat IV dose of 750 mg cefuoxime and 500 
mg metronidazole should be administered in theatre.  A 100 mg diclofenac sodium rectal 
suppository may be given for analgesia at the end of the procedure if it is not otherwise 
contraindicated. 
 
A Foley catheter should be considered after the repair of a third or fourth degree tear. 
 
Postnatal Care 
 
Antibiotics 
A seven day oral course of cefalexin and metronidazole is currently 
recommended although clear evidence of benefit is lacking. 
 
Analgesia 
Oral analgesia should be adequate but preparations containing codeine 
should be avoided as they are constipating.  See postnatal ward 
analgesia guidelines. 
 
Laxatives 
To discourage straining, good hydration should be maintained and 
Docusate sodium 200 mg bd or prophylactic lactulose or fybogel may be 
given for 7-10 days. 
 
Review 
Patients should be reviewed daily on the postnatal ward.  The patient’s 
own consultant should be informed if this has not already occurred. 
 
Exercises
 
The woman may commence gentle pelvic floor exercises in the days 
after sustaining a third or fourth degree tear.  These may be of long term 
benefit and there is no evidence to suggest that they are detrimental to 
healing. 
 
 
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Repair breakdown  Under no circumstances should a broken down repair be re-sutured.  
Expert opinion must be sought from Mr Matar. 
 
Follow up 
All women should be offered a follow up in her own consultant’s 
antenatal clinic approximately 6 weeks after delivery to discuss the 
events surrounding delivery.  Follow up at the urogynaecology clinic 
should also be offered after 6-9 months. 
 
 
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References: 
 
Austin J (2003) An audit of third degree perineal tears.  M J Midiwf 11: 
 
Blaisdell P (1940) Repair of the incontinent sphincter ani.  Surg, Gynecol Obstet 70: 692-697. 
 
Draper J, Newell R (1996) A discussion of some of the literature relating to history, repair and 
consequences of perineal trauma.  Midwifery 12: 140-145. 
 
Fleming n (1990) Can the suturing method make a difference in post partum perineal pain?  
Nurse Midwif
 35: 
 
Gee H et al (2001) Management of third and fourth degree perineal tears following vaginal 
delivery.  RCOG Clinical Green Top Guideline No 29, RCOG Press, London, UK. 
 
Gordon B et al (1998) The Ipswich Childbirth Study 1: A randomised evaluation of two stage 
postpartum perineal repair leaving the skin unsutured.  BJOG 105: 435-440. 
 
Johanson FR et al (2002)  Methods of repair for obstetric anal sphincter injury.  Cochrane 
Database of Systematic Reviews Issue 4. 
 
Kettle C et al (2002) Continuous versus interrupted perineal repair with standard or rapidly 
absorbed sutures after spontaneous vaginal birth: a randomised controlled trial.  Lancet 359: 
2217-2223 
 
Kettle C, Johanson RB (2002) Absorbable synthetic versus catgut suture material for perineal 
repair.  Cochrane Database of Systematic Reviews Issue 4. 
 
Kettle C, O’Brien PMS (2004) Methods and materials used in perineal repair.  RCOG Clinical 
Green Top Guideline No 23, RCOG Press, London, UK 
 
Metcalfe A et al (2002) A pragmatic tool for the measurement of perineal tears.  BJM 10: 
 
Parks AG, McPartlin JF (1971) Late repair of injuries of the anal sphincter.  Proc Roy Soc Med 
64: 1187-1189 
 
Parsons JE, Hedayati H, Crowther CA (2002) Rectal analgesia for pain from perineal trauma 
following childbirth.  Cochrane Database of Systematic Reviews Issue 4 
 
Sultan AH et al (1999) Primary repair of obstetric anal sphincter rupture using the overlap 
technique.  BJOG 106: 318-323 
 
Walsh D (2000) Perineal care should be a feminist issue.   BJ Midwif 8: 
 
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CHAPTER 9 - BREECH 
 
 
 
9.1 
ANTENATAL CONSIDERATIONS....................................................................101 
9.2 
ECV...................................................................................................................101 
9.3 
ELECTIVE CAESAREAN SECTION.................................................................101 
9.4 
PLANNED VAGINAL BREECH DELIVERY ......................................................101 
9.5 
TERM BREECH DIAGNOSED IN LABOUR .....................................................103 
9.6 
PRE-TERM BREECH .......................................................................................103 
 
 
 
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9.1 ANTENATAL 
CONSIDERATIONS 
 
Before labour, breech presentation may be suspected on abdominal palpation but diagnosis 
rests with abdominal ultrasound. Once breech presentation has been confirmed at 36+0 
weeks gestation, options for management should be discussed and documented in the notes: 
 
•  attempted external cephalic version 
•  elective caesarean section at 39+0 weeks gestation or later 
•  planned vaginal delivery 
 
Antenatal counselling should include reference to the Term Breech Trial: 
 
•  planned vaginal delivery is associated with significantly higher rates of neonatal morbidity 
and mortality than planned caesarean section  
•  planned vaginal delivery is associated with no difference in rates of maternal morbidity and 
mortality than planned caesarean section 
•  two year follow up demonstrated no continued benefit after caesarean section but firm 
conclusions could not be drawn as the original study was not designed to measure long 
term outcomes.   
 
9.2 ECV 
 
1. 
A detailed ultrasound scan should be performed at some time prior to the procedure. 
2. 
The procedure should be performed on Delivery Suite. 
3. 
Ultrasound scanning should be available for the duration of the procedure. 
4. 
CTG should be performed after the procedure whether or not it was successful. 
5. 
Tocolysis may be indicated.  Nifedipine 20 mg orally 30 minutes prior to the event. 
6. 
There should be a maximum of three attempts at version.  This can be repeated one 
week later. 
7. 
The patients who are Rhesus negative should have Anti D administered. 
 
9.3 
ELECTIVE CAESAREAN SECTION 
 
This may be carried out beyond 39+0 weeks gestation. 
 
Prior to elective caesarean, the surgeon should confirm that the baby is still presenting by the 
breech by portable ultrasound. In the event of spontaneous cephalic version, the decision to 
cancel or continue with the caesarean should be based on other obstetric factors but must 
also take into consideration the wishes of the woman. The duty Consultant must be kept 
informed. 
 
9.4 
PLANNED VAGINAL BREECH DELIVERY 
 
First stage of labour 
 
On admission to the Delivery Suite in spontaneous labour: 
 
•  confirm that antenatal counselling has been adequate 
•  confirm that the woman wishes to proceed with vaginal delivery 
 
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•  document this discussion on the partograph 
•  gain IV access 
•  full blood count plus group and save serum 
•  inform the duty consultant 
 
Thereafter: 
 
•  monitor the fetal heart continuously 
•  assess progress 4 hourly or more frequently if clinically indicated  
•  epidural should be considered but is not mandatory (WCH only) 
 
Augmentation of labour with syntocinon is uncommon and should only be undertaken with 
good evidence of inadequate uterine activity, after discussion with the duty Consultant. 
  
Second stage of labour 
 
When full dilatation has been confirmed, inform: 
 
•  the lead midwife on Delivery Suite  
•  the anaesthetist / ODA and theatre team 
• SCBU 
•  the obstetric SpR and the duty Consultant 
 
Allow sixty to ninety minutes for the breech to descend spontaneously if the fetal heart rate 
features remain reassuring. Check the position and the station of the breech after this time. 
 
Conduct of the delivery 
 
Delivery should be supervised by the SpR or the duty Consultant. The fetal heart rate should 
be monitored throughout. Good practice points follow: 
 
• lithotomy 
position 
•  empty the bladder 
•  ensure adequate analgesia 
•  allow spontaneous descent of the breech 
 
As the maternal perineum stretches, consider episiotomy with careful guarding of fetal tissues. 
The breech should then be allowed to descend with maternal effort alone (‘hands off the 
breech’) with the sacrum lateral / anterior. Baby’s legs may be swept laterally or allowed to 
deliver spontaneously and the arms may be delivered spontaneously, by sweeping medially 
across the chest or by Lovsett’s manoeuvre. For the head: 
 
•  allow descent until the occiput is visible, then use… 
•  non-rotational forceps, or… 
•  Mauriceau-Smellie-Veit (but do not place a finger in the baby’s mouth) 
 
MODIFIED MARICEAU SMELLIE VEIT MANOEUVRE TO DELIVER THE HEAD. 
 
Everything about this manoeuvre is designed to promote flexion. 
 
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Place the other hand beneath the baby: put two fingers over the baby’s maxillae. 
 
Deliver the head by flexing it through the pelvis – maternal effort, the occipital finger, pressure 
to the maxillae and raising the body of the baby through a large arc. When the baby’s body is 
vertical, an assistant can hold the feet.  Application of suprapubic pressure by an assistant to 
flex the head through the pelvis may also be used. 
 
9.5 
TERM BREECH DIAGNOSED IN LABOUR 
 
When breech presentation is first suspected in labour, the SpR should be informed. He / she 
should palpate the abdomen, perform a vaginal examination, then confirm presentation with 
portable ultrasound. All relevant information should be recorded on the partogram, such as: 
 
• parity 
• maternal 
height 
•  previous delivery details 
 
• cervical 
dilatation 
•  progress in labour to date 
•  membranes intact or ruptured 
 
•  clinically or ultrasonically estimated weight of this baby 
•  station of presenting part 
•  flexion or extension at the baby’s knees 
•  flexion or extension at the baby’s neck 
 
Continuous fetal heart rate monitoring should be instituted on the diagnosis of breech. Unless 
delivery is imminent, counselling should be based on the findings of the Term Breech Trial in 
the absence of more accurate data. This work presents data regarding the outcome of 
planned vaginal delivery in a subset of women who were not induced or augmented: 
 
•  planned vaginal delivery has a relative risk of serious fetal morbidity or mortality of 2.05 
compared to planned caesarean section (1.6% vs 3.3%) 
•  no figures are given on maternal morbidity 
•  previous obstetric history has not been accounted for in this calculation 
 
An algorithm for practice has been included. ECV may be attempted if an experienced 
practitioner is available and the clinical scenario allows - good analgesia, high breech, intact 
membranes, maternal consent. Tocolysis with terbutiline (0.25 mg sc) may be a useful step. 
 
9.6 PRE-TERM 

BREECH 
 
Breech presentation is an independent risk factor for neonatal morbidity and mortality in pre-
term birth. Although data are sparse, there is no conclusive evidence that a blanket policy of 
delivery by caesarean for a labouring pre-term breech reduces either morbidity or mortality. 
Findings of the Term Breech Trial cannot be applied to this population. Management of the 
pre-term labouring breech should therefore be discussed with the duty Consultant, with 
reference to the principles detailed in Chapter 12. 
 
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Breech diagnosed in labour 
  
 
 
Ë 
 
 
Ì 
Delivery 
 
 
 
 
 
Delivery 
thought 
to 
be 
     not 
thought 
to 
be 
imminent 
     imminent 
È 
 
 
 
 
 
 
 
È 
 
SpR   
 
 
 
 
 
consider ECV 
or 
Consultant 
     È 
to attend 
 
 
 
 
 
 
 
delivery      experienced 
practitioner 

 
 
 
 
 
 
 
favourable USS assessment ? 
 
 
 
 
 
normal CTG ? 
 
 
 
 
 
consent ? 
 
Ë 
 
 
Ì 
 
   yes   
 
 
      no 
theatre     counsel 
epidural 
 
 
 
 
for CS 
tocolysis 
     
 
È 
 
 
 
 
Ë 
 
 
Ì 
 
 
 
 
if vaginal 
 
 
 
success   failure 
 
           delivery 
 
 
 
    È   
 
 
   È   
 
 
requested 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
monitor 
 
 
counsel  
 
 
SpR 
 
 
 
    È   
 
 
for CS  
 
           or Consultant 
 
 
 
aim for 
 
 
   È 
   to 
attend 
vaginal  
 
           if vaginal 
 
 
 delivery 
 delivery 
 
  delivery 
 
 
 
 
 
requested 
 
 
 
 
 
SpR 
 
 
 
 
 
or Consultant 
 
 
 
 
to attend delivery   
 
 
 
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References 
 
Hannah M, Hannah W (1996) Caesarean section or vaginal birth for breech presentation at 
term. BMJ 312: 1433-4. 
 
Hofmeyr GJ, Hannah M (2002) Planned caesarean section for term breech delivery. Cochrane 
Database of Systematic Reviews Issue 4.
 
 
Young PF, Johanson RB (2001) The management of breech presentation at term. Curr Opin 
Obstet Gynaecol 
13: 589-593. 
 
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CHAPTER 10 - MULTIPLE PREGNANCY 
 
 
 
10.1  
HIGH ORDER MULTIPLE PREGNANCY .........................................................107 
10.2 
INITIAL ASSESSMENT OF TWIN PREGNANCY.............................................107 
10.3 
FIRST STAGE OF LABOUR.............................................................................107 
10.4 
SECOND STAGE OF LABOUR ........................................................................108 
10.5 
THIRD STAGE OF LABOUR ............................................................................109 
 
 
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10.1   HIGH ORDER MULTIPLE PREGNANCY 
 
The principles of care involved in managing high order multiple pregnancies are the same as 
those discussed below for twin pregnancy.  The optimal mode of delivery in a high order 
multiple pregnancy should be determined by the consultant obstetrician.  The most frequent 
mode of delivery is caesarean section. 
 
10.2  INITIAL ASSESSMENT OF TWIN PREGNANCY 
 
Each woman with a twin pregnancy should have a plan for delivery documented in her 
antenatal notes. If none can be found, a full history should be taken, abdominal and vaginal 
examination performed and the abdomen should be scanned to confirm presentation. The 
decision to plan for vaginal delivery or caesarean section will be based upon several factors: 
 
•  presentation – if the first twin is a breech at full term, caesarean is usually recommended 
although there is little evidence to guide practice in this respect. Presentation of the 
second twin does not often have a major influence on the planned mode of delivery  
 
•  growth – poorer outcomes after labour are more common if there is evidence of growth 
restriction in either twin, particularly if the growth is discordant  
 
•  chorionicity and amnionicity – there is no evidence to suggest that all mono chorionic twins 
should be delivered by caesarean but mono amniotic twins should not be subjected to 
labour 
 
•  gestation – caesarean section is not necessarily beneficial for very preterm twins in 
spontaneous labour, whether the first twin is cephalic or breech, unless there is evidence 
of fetal compromise 
 
•  the plan for delivery should be formulated in conjunction with the duty Consultant. 
 
•  maternal preference – this will be the final arbiter in planning mode of delivery for term 
twins and will influence your management of preterm twin delivery 
 
10.3  FIRST STAGE OF LABOUR 
 
On admission to Delivery Suite in spontaneous labour: 
 
•  confirm that antenatal counselling has been adequate 
•  confirm that the woman wishes to proceed with vaginal delivery 
•  document this discussion on the partogram 
•  gain IV access, full blood count, group and save serum 
•  inform the duty Consultant 
 
Poor quality CTGs are common in twin labours but effort should be made to ensure that both 
babies are monitored continuously throughout labour. This may be achieved with dual 
abdominal transducers or with a combination of scalp electrode (first twin) and abdominal 
transducer (second twin). 
 
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•  assess progress 4 hourly or more frequently if clinically indicated  
•  epidural should be considered but is not mandatory – clear evidence of benefit is lacking 
(WCH only) 
 
Augmentation of labour with syntocinon should only be undertaken after discussion with the 
duty Consultant and with good evidence of inadequate uterine activity. 
 
10.4  SECOND STAGE OF LABOUR 
 
When full dilatation has been confirmed, inform: 
 
• the 
anaesthetist 
•  SCBU / Paediatrics as required 
•  the senior obstetric SpR (if appropriately experienced) or the duty Consultant 
•  the senior midwife on Delivery Suite 
• theatre 
team 
 
The following equipment and drugs should be readily accessible throughout the second stage, 
either in the delivery room or in the adjoining corridor: 
 
•  portable ultrasound scanner 
• forceps 
trolley 
• ventouse 
•  IV syntocinon for augmentation of contractions (10 iu in 50 ml n/saline) 
• ergometrine 
•  IV syntocinon for infusion in the event of PPH (40 iu in 1000 ml n/saline, 250 mls per hr) 
 
Staff present at the birth 
 
Two midwives should be available throughout the birth of twins. 
 
The Obstetric SpR and / or duty Consultant should also be present in the delivery room if 
either twin is thought to be non cephalic, if there are concerns about the progress of labour or 
if the wellbeing of either twin is in doubt. The Obstetric team should otherwise be available on 
the Delivery Suite in case assistance is requested. 
 
The need for the paediatric on call team should be determined on a case by case basis. 
 
Delivery of the first twin 
 
After spontaneous labour, the aim is to deliver both twins vaginally, in a safe manner, without 
unnecessary intervention. The descent and delivery of the first twin should therefore follow 
standard second stage guidelines as long as the second twin maintains a normal CTG. Use of 
forceps or ventouse should be based upon standard parameters but may also occasionally be 
carried out in order to gain access to the second twin. 
 
Delivery of the first twin should be carried out by the midwife if its presentation is cephalic and 
if the birth is unassisted. The Obstetric SpR or the duty Consultant will usually deliver the first 
 
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twin if forceps or ventouse are to be used or if it is not cephalic. In some circumstances 
however, the duty Consultant may allow the attending midwife to deliver a breech first twin 
under his/her direct supervision if there are no additional clinical concerns. 
 
Delivery of the second twin 
 
After delivery of the first twin, the presentation of its sibling should be confirmed on 
abdominal palpation by the attending midwife. The Obstetric team should be asked to confirm 
presentation by ultrasound scan in cases of doubt. Thereafter, if presentation is cephalic, 
descent of the presenting part should be awaited in the usual way. Syntocinon may be infused 
if uterine activity is thought to be inadequate 5 to 10 minutes after delivery of the first twin, with 
infusion rates following the standard regimen. Amniotomy is recommended once the head 
reaches the ischial spines and assisted delivery thereafter should only be offered using 
standard Obstetric parameters. 
 
If the lie of the second twin is transverse, external cephalic version may be attempted. 
Once the fetal head is above the pelvis, the lie should be stabilised externally while syntocinon 
infusion is commenced. Amniotomy should then be undertaken once the head descends into 
the pelvis. As an alternative, internal podalic version may be used in the management of a 
transverse second twin. One or both heels are grasped, preferably through intact membranes, 
and brought through the cervix and vagina onto the perineum. Breech extraction follows, the 
membranes rupturing spontaneously during the process. This must only be attempted by 
appropriately trained personnel. 
 
If the lie of the second twin is breech, either external cephalic version or assisted vaginal 
breech delivery may be undertaken. Management should be determined by the most senior 
Obstetrician attending the birth. In some circumstances, the duty Consultant may allow the 
attending midwife to deliver a breech second twin under his/her direct supervision if there are 
no additional clinical concerns. Breech extraction may also be considered in experienced 
hands if concerns arise regarding fetal wellbeing. 
 
On average, as the length of time between delivery of the twins increases, the outcome for the 
second twin worsens. This does not mean that artificially shortening the delivery interval will 
necessarily improve the outcome for the second twin, but it illustrates the need for careful 
CTG monitoring and intervention if the second twin shows any evidence of compromise. 
 
10.5  THIRD STAGE OF LABOUR 
 
For active third stage management give Syntometrine (unless ergometrine is contraindicated) 
with the anterior shoulder or soon after the birth of the second twin. Label the umbilical cords 
as 'twin 1' and 'twin 2' and take cord gases from both placentae. In the case of same sex 
twins, the placenta should be sent for histological examination after it has been clinically 
inspected. The placenta from discordant sex twins should only be sent if there are other 
concerns. 
 
Syntocinon and saline should be ready in the room to make up into an infusion if PPH arises, 
but this should not be given routinely as a prophylactic measure. 
 
 
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References 
 
Bakker M et al (2004) Quality of intrapartum cardiotocography in twin deliveries. AJOG 2004: 
191: 2114-2119. 
 
Blickstein I, Louis KG (2003) Outcome of triplets and high-order multiple pregnancies. Curr 
Opin Obstet Gynecol
 15: 113-117. 
 
Chanhan SP et al (1995) Delivery of the nonvertex second twin: breech extraction versus 
external cephalic version. Am J Obstet Gynecol 173: 1015-1020. 
 
Feng TI, Swindle RE Jr, Huddleston JF (1995) A lack of adverse effect of prolonged delivery 
interval between twins. J Mat Fet Invest 5: 222-225. 
 
Greig PC et al (1992) The effect of presentation and mode of delivery on neonatal outcome in 
the second twin. Am J Obstet Gynecol 167: 901-906. 
 
Hartley RS, Hitti J (2005) Birth order and delivery interval: analysis of twin perinatal outcomes. 
J Mat Fet Med Neonatal Med 17: 375-380. 
 
Houlihan C, Knuppel RA (1996) Intrapartum management of multiple gestations. Clin Perinatol 
23: 91-116. 
 
Jones HW (2003) Multiple births: how are we doing? Fertil Steril 79: 17-21. 
 
McDonald S et al (2004) Prophylactic ergometrine-oxytocin versus oxytocin for the third stage. 
Cochrane Review. 
 
Miller DA et al (1996) Vaginal birth after caesarean section in twin gestation. Am J Obstet 
Gynecol
 175: 194-198. 
 
Pons JC et al (2002) Delivery of the second twin: comparison of two approaches. Eur J Obstet 
Gynecol Reprod Biol 
104: 32-39. 
 
Rabinovici J et al (1987) Randomized management of the second nonvertex twin: vaginal 
delivery or Caesarean section. Am J Obstet Gynecol 156: 52-56. 
 
Sansregret A et al (2003) Twin delivery after a previous caesarean: a twelve-year experience. 
J Obstet Gynaecol Can 25: 294-298.  
 
Scher AI et al (2002) The risk of mortality or cerebral palsy in twins: a collaborative population-
based study. Pediat Res 52: 671-681. 
 
Smith CS et al (2005) Mode of delivery and the risk of delivery related perinatal death among 
twins at term: a retrospective cohort study of 8073 births. BJOG 112: 1139-1144. 
 
Zhang J et al (2004) Delayed interval delivery interval and infant survival: population based 
study. AJOG 191: 470-476. 
 
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CHAPTER 11 - SHOULDER DYSTOCIA 
 
 
 
11.1 
DEFINITION......................................................................................................112 
11.2 
ANTICIPATION .................................................................................................112 
11.3 
HELPERR .........................................................................................................112 
11.4 
SYMPHYSISIOTOMY .......................................................................................112 
11.5 
ZAVANELLI’S MANOEUVRE............................................................................113 
11.6 
HARD PULL......................................................................................................113 
 
 
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11.1 DEFINITION 
 
 
Shoulder dystocia is the impaction of the anterior shoulder against the symphysis pubis after 
the fetal head has been delivered. It may be recognised clinically as a failure to deliver the 
shoulders with ‘normal traction’. 
 
11.2 ANTICIPATION 
 
Although as many as 50% of cases arise in a ‘low risk’ population, some risk factors have 
been recognised: 
 
•  previous history of shoulder dystocia 
•  large baby on abdominal palpation 
•  baby over 4 kg on ultrasonic estimation 
•  delay in the first stage of labour 
•  delay in the second stage of labour 
• assisted 
delivery 
•  head retreating from perineum during pushing (‘bobbing’) 
 
If shoulder dystocia is anticipated, the following steps should be taken during delivery: 
 
•  inform the lead midwife and the obstetric SpR 
•  get a second midwife into the room to assist 
•  remove surplus furniture from the room 
•  empty the bladder 
•  explain to the parents what they may be asked to do 
 
11.3 HELPERR 
 
This mnemonic will help you to remember how to manage shoulder dystocia although the 
order in which manoeuvres are performed may vary in practice – the mnemonic should be 
used in conjunction with good clinical practice. Rotational enter manoeuvres and removal of 
the posterior arm are for example interchangeable. The most experienced clinician present 
should co-ordinate the team’s efforts but any doctor or midwife trained in the techniques 
employed may actually deliver the baby. 
 
During the birth, contemporaneous notes should be kept.  Following delivery complete the 
summary sheet to SD, see page 96.  After the birth, the notes should be completed. These 
steps can help to avoid confusion in the recall of events. 
 
11.4 SYMPHYSISIOTOMY 
 
If the baby cannot be delivered despite working through all of the HELPERR manoeuvres, the 
Consultant Obstetrician may consider symphysisiotomy. The procedure should take place in 
the operating theatre under general anaesthetic unless a dense regional block is already in 
place. The woman should be placed in the lithotomy position, but each of her legs should 
receive additional supported from a member of staff. The abdomen and vagina should be 
prepped, the legs draped then a rigid catheter run into the urethra and palpated with the left 
 
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hand through the anterior vaginal wall. The catheter should be rolled laterally away from the 
midline, then the symphysis incised.  Delivery of the baby may then be attempted by 
downwards traction, by suprapubic pressure or by internal rotation / Woods Screw. Repair of 
the symphysis is not normally necessary. 
 
A Foley’s catheter should be passed and left in place for a minimum of 7 days after this 
procedure and oral antibiotics should be continued for one week. 
 
11.5  ZAVANELLI’S MANOEUVRE  
  
This should only be considered by the Consultant Obstetrician after failure of all of the 
HELPERR manoeuvres and in the continued presence of a discernible fetal heart rate. The 
woman should be given 0.5 mg sc terbutiline for tocolysis then transferred to the operating 
theatre. A general anaesthetic should be administered unless a dense regional block is 
already in place. The fetal head is then rotated on the perineum to an OA position, flexed, 
then returned to the uterus with pressure from the flat of the hand on the baby’s occiput. The 
bladder should then be catheterised, the abdomen prepped in the usual way and a caesarean 
section performed. After delivery of the placenta, the uterus and cervix should be examined 
carefully to exclude visceral trauma. At the end of the procedure, the vagina, perineum, anus 
and rectum should be examined and repaired in the usual way. 
 
The catheter should remain in place for a minimum of 72 hours after this procedure and oral 
antibiotics should be continued for one week. 
 
11.6 HARD 

PULL 
 
Throughout the shoulder dystocia, normal traction should be applied (ie) the amount of 
traction you would normally apply when delivering a baby without a shoulder dystocia. 
However, if: 
 
•  standard HELPERR manoeuvres have failed to deliver the baby 
•  you are unable to carry out a symphysisiotomy or Zavanelli’s manoeuvre for any 
reason 
•  you have clear evidence that the baby’s life is in jeopardy, such as fetal bradycardia 
 
…then you should pull as hard as is necessary to deliver the baby. In doing this it is accepted 
that the baby is likely to suffer brachial plexus and bony injury. It is also accepted that the 
injuries suffer may cause long-term disability. The alternative of death or damage due to 
prolonged hypoxia are however even less desirable. 
 
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Help 
call for help obstetric SpR 
paediatrician 
senior midwife 
additional midwife and a support worker 
consider calling the Obstetric Consultant 
inform the anaesthetist 
 
E  
Episiotomy 
evaluate for an episiotomy 
may be deferred until after McRobert’s 
 

Legs 
place legs in McRobert’s position 
 
 
hyperflexed at the hips, slightly adducted 
 
 
attempt to deliver for 30 seconds 
 

Pressure 
constant suprapubic pressure 
 
 
behind the anterior shoulder 
 
 
attempt to deliver for 30 seconds 
 
 
 
 
 
 
 
 
 
 
rocking suprapubic pressure 
 
 
behind the anterior shoulder 
 
 
attempt to deliver for 30 seconds 
 

Enter 
finger behind the anterior shoulder 
 
 
push the anterior shoulder into oblique 
 
 
attempt to deliver ± two handed technique 
 
 
 
finger behind the posterior shoulder 
push the posterior shoulder into oblique 
  
Woods screw manoeuvre 
continue rotation a further 180o 
attempt to deliver 
 

Remove 
remove the posterior arm by grasping the 
posterior forearm and sweeping it across the chest 
 
 
attempt to deliver 
 

Roll  
roll the woman onto all fours 
 
 
attempt to deliver 
 
If all of these measures fail, start again while awaiting the consultant’s attendance. 
 
 
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MANAGEMENT OF SHOULDER DYSTOCIA 
 
- file this in the notes after use - 
 
 
Time Personnel 
Order 
 
Head delivered 
 
 
 
 
H – Help called 
 
 
 
 
E – Evaluate for episiotomy 
 
 
 
 
L – Legs into MacRoberts 
 
 
 
 
P – Pressure - suprapubic 
 
 
 
 
E – Enter manoeuvres (detail)   
 
 
R – Remove posterior arm   
 
 
                                                   
R – Roll &/or repeat (detail) 
 
 
 
Additional manoeuvres (detail)   
 
 
Baby delivered 
 
 
 
State which shoulder impacted right 
Left 
 
State amount of traction  
normal 
increased 
 
 
 
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References 
 
Gherman RB (2003) New insights to shoulder dystocia and brachial plexus palsy. Obstet 
Gynecol Survey
 58: 1-2. 
 
Gherman RB (2002) Shoulder dystocia: an evidence-based evaluation of the obstetric 
nightmare. Clin Obstet Gynecol 45: 345-362.  
 
Lam MH, Wong GY, Lao TT (2002) Reappraisal of neonatal clavicular fracture. Relationship 
between infant size and risk factors. J Reprod Med 47: 903-908. 
 
Robinson H et al (2003) Is maternal obesity a predictor of shoulder dystocia? Obstet Gynecol 
101: 24-27. 
 
Sandmire HF, DeMott RK (2002) Erb's palsy without shoulder dystocia. Int J Gynaecol Obstet 
78: 253-256. 
 
Spellacy WN (1999) Shoulder dystocia risks. Am J Obstet Gynecol 180: 1047. 
 
Zelig CM, Gherman RB (2002) Modified Zavanelli manoeuvre for the alleviation of shoulder 
dystocia. Obstet Gynecol 100: 1112-1114. 
 
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CHAPTER 12 - PRE-TERM LABOUR 
 
 
 
12.1 
INITIAL ASSESSMENT ....................................................................................118 
12.2 
EXTREME PREMATURITY ..............................................................................118 
12.3 
FIBRONECTIN SWABS....................................................................................119 
12.4 
TOCOLYSIS .....................................................................................................120 
12.5 
ANTIBIOTICS ...................................................................................................122 
12.6 
STEROIDS........................................................................................................123 
12.7 
TEMPERATURE CONTROL AT BIRTH ...........................................................123 
12.8 
SURVIVAL AND MORBIDITY CHARTS ...........................................................124 
 
 
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12.1 INITIAL 
ASSESSMENT 
 
A full history should be taken from any woman presenting to Delivery Suite with suspected 
preterm labour. This should be recorded in the patient’s notes - annotation of the partogram is 
not sufficient unless labour is well established. The information should include: 
 
•  previous obstetric history 
•  previous medical history 
•  history of present pregnancy to date including an estimate of gestation 
•  present history of contractions or other pain 
•  present history of vaginal loss of blood or liquor 
• urinary 
symptoms 
•  symptoms of systemic illness 
 
On abdominal examination, the fundal height should be estimated and the presenting part 
determined. The presence of uterine or renal angle tenderness and the presence of palpable 
uterine contractions should also be recorded. 
 
A speculum examination should then be performed by the SHO or SpR in order to: 
 
•  assess cervical effacement and dilatation 
•  obtain an endocervical swab, chlamydial swab, HVS and low vaginal swab   
•  determine whether or not the membranes remain intact 
 
Digital examination should be avoided if at all possible as this may increase the risk of 
infection. Pelvic examination need not be repeated when a woman has been transferred from 
another hospital if the above steps have already been taken. 
 
The following investigations should be performed: 
 
• FBC 
•  group and save serum 
• CRP 
•  urine dipstick analysis 
• MSU 
•  urine microscopy if indicated by the history and examination 
 
Portable ultrasound 
 
Abdominal portable ultrasound examination may be used by a trained operator to assess fetal 
viability, presentation, estimate fetal weight, measure the liquor volume and determine the 
placental site. It is also occasionally possible to determine cervical dilatation by ultrasound. 
 
12.2 EXTREME 
PREMATURITY 
 
If a women is admitted in labour < 26 weeks the Consultant Obstetrician should be informed of 
her presence. 
 
 
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12.3 FIBRONECTIN 
SWABS 
 
Fibronectin swabs may help to guide management in suspected preterm labour, when a 
woman has: 
 
•  contractions at least once every ten minutes, but… 
•  intact membranes, and… 
•  cervical dilatation below 3 cm 
 
There are some circumstances in which a swab is not helpful: 
 
•  proven rupture of the membranes 
• antepartum 
haemorrhage 
•  sexual intercourse within the last 24 hours, which gives a high false positive rate 
 
The sample should be collected before digital examination is carried out. First, a speculum is 
passed without prior lubrication. Next, the sterile swab provided in the fibronectin kits is 
rotated around the posterior fornix of the vagina for 10 seconds. Subsequent steps to be taken 
in performing the assay are explained clearly in the literature attached to each fibronectin kit. 
 
Negative swab 
 
It is reasonable to withhold tocolysis and steroids if the fibronectin swab is negative. Instead, 
the woman should be observed until contractions settle and the results of other investigations 
have been obtained. 
 
Positive swab 
 
A symptomatic woman with a positive swab has an increased chance of giving birth before full 
term. Steroids and tocolysis should be offered in such cases, even when cervical dilatation is 
below 3 cm and the membranes are intact. 
 
 
Test result 
Probability 
of  Risk of RDS at  Rate of RDS at  NNT * 
birth within 10  32 weeks’ 
32 weeks’ 
days of test (%)  gestation 
gestation (%) 
No test 
4.5 
0.53 
2.0 
109 
Test 
positive 
20.6 0.53 11.0  17 
Test negative 
1.0 
0.53 
0.4 
509 
 
* NNT - Number of women needed to treat with steroids to prevent one case of RDS. 
 
 
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12.4 TOCOLYSIS 
 
The SpR may sanction the use of tocolytic drugs. Tocolysis has the following aims: 
 
• delay 
delivery 
•  allow steroid administration 
•  allow time for transfer to another unit when SCBU has no available cots 
  
Suppression of uterine activity is not usually recommended however, in the presence of: 
 
•  fetal gestation greater than 33+6 weeks 
• antepartum 
haemorrhage 
•  clinical evidence of chorioamnionitis 
 
Nifedipine  
 
Nifedipine is generally safe and may have a tocolytic efficacy similar to that of atosiban. One 
of the commonest regimens currently used is: 
 
• 
30 mg slow release nifedipine (adalat retard) stat, followed by… 
• 
20 mg slow release nifedipine (adalat retard) 8 hourly for 48 hours 
 
If nifedipine is used for tocolysis, monitoring should be instituted for at least the first 2 hours: 
 
•  maternal BP every 15 minutes 
• CTG 
 
Nifedipine is not currently licensed for use in preterm labour however adverse fetal and 
maternal outcomes have been reported in the literature, so it should only be used when 
sanctioned by the Consultant Obstetrician. Caution is particularly advocated with: 
 
• 
maternal cardiac disease 
• maternal 
hypertension 
• pre 
eclampsia 
• 
evidence of pre existing fetal compromise 
 
Atosiban (Tractocile) 
 
Atosiban, an oxytocin receptor antagonist, is the only current tocolytic that is licensed for the 
treatment of preterm labour. It has few side effects but treatment costs are high, so it should 
only be used if there is clear evidence of preterm labour. If the membranes are intact and the 
cervix 3 cm or less dilated, this evidence should include the presence of a positive fibronectin 
swab. The drug administration regimen is shown overleaf. 
 
 
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Atosiban dose regimen 
 
 
prerequisites 
 
regular uterine contractions lasting 30 seconds at a rate of ≥ 4 in 30 minutes 
 
cervical dilation of 0 to 3 cm 
 
gestation from 24+0 to 33+6 weeks 
 
a normal fetal heart rate 
 
Atosban may be administered even if other tocolytics have already been administered 
 
 
it is administered intravenously in three successive stages 
 
(1) 
give a bolus dose of 6.75 mg 
dilute a 0.9 ml vial of atosiban for injection with 10 ml n/saline 
inject iv over 1 minute 
 
then 
 
(2) 
give a continuous high dose infusion at a dose of 18 mg / hr for 3 hours 
remove 10 ml fluid from a 100 ml bag of n/saline 
add two 5 ml vials of atosiban for infusion, giving a total of 75 mg in each bag 
infuse at a rate of 24 ml / hr 
 
then 
 
(3) 
give a continuous low dose infusion at a dose of 6 mg / hr for up to 45 hours 
reduce the rate of infusion above to 8 ml / hr 
 
 
The bolus, high dose and low dose infusion bottles are all clearly labelled. Please follow 
the manufacturer’s instructions carefully. 
 
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12.5 ANTIBIOTICS 
 
The ORACLE Trial 
 
Women in preterm labour who have clear evidence of infection should be offered antibiotics 
(see Section 20). Results of The ORACLE Trial suggest that between 24 and 36 weeks 
gestation, where there is no clear clinical evidence of infection: 
 
preterm labour with intact membranes   
 
erythromycin has no definite role 
        see 
GBS 
guidance 
below 
 
preterm labour with ruptured membranes * 
erythromycin may reduce neonatal 
infection after birth 
 
preterm, prelabour rupture of the membranes * 
erythromycin may reduce neonatal 
infection after birth 
 
* Prescribe erythromycin 250 mg qds orally for 10 days. 
 
Augmentin should not be used in women at risk of delivering before term as this drug 
increases the incidence of neonatal necrotising enterocolitis. 
 
Neither Erythromycin nor Augmentin has a discernible effect on the incidence of maternal 
infection or chorioamnionitis. 
 
Antibiotics for GBS 
 
When a woman goes into preterm labour, her baby is at an increased risk of developing early 
onset GBS sepsis after birth. Even without clear evidence of infection, antibiotic prophylaxis 
with iv penicillin or clindamycin should therefore be offered.  
 
 
 
 
Prematurity under 37 weeks 
 
 
Risk of early onset GBS infection in the neonate without IAP is 1:400 
 
Risk of early onset GBS infection in the neonate with IAP is 1:2186 
 
 
 
Prematurity under 35 weeks 
 
Risk of early onset GBS infection in the neonate without IAP is 1:286 
 
Risk of early onset GBS infection in the neonate with IAP is 1:1253 
 
 
 
 
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12.6 STEROIDS 
 
Women who seem likely to give birth between 24+0 and 33+6 weeks gestation should be 
offered betamethasone to reduce the risk of neonatal intraventricular haemorrhage, 
respiratory distress syndrome (RDS) and death. The evidence for a course of steroids, 34-36 
weeks, is therefore weaker but may be appropriately given.  Since most literature relates to IM 
administration - there is little information regarding the efficacy of oral steroids – a dose of 12 
mg betamethasone IM should be given with a second identical dose 24 hours later. There is 
no evidence to support an accelerated second dose, say after 12 hours, even if rapid delivery 
seems likely. 
 
• 
before 34+0 weeks, treatment of 5 women with steroids will prevent one case of RDS 
• 
from 34+0 to 35+6 weeks, treatment of 94 women will prevent one case of RDS 
• 
most benefit occurs when steroids are given between 24 hours and 7 days before birth 
 
In general, a single course of steroids is recommended.  
 
If a second course is considered discuss with the Consultant.  If the risk of preterm delivery 
remains high some time after administration of the first course however, a second course of 
betamethasone may occasionally be given 14 days later.  
 
Evidence for a second course is very limited however. A second course of steroids should 
only be countenanced by a consultant obstetrician. 
  
Administration of betamethasone should be avoided if there are clear signs of systemic 
maternal sepsis. In the presence of definite evidence of chorioamnionitis, the administration of 
betamethasone should first be discussed with the on call consultant and its relative merits and 
potential adverse effects discussed. 
 
12.7  TEMPERATURE CONTROL AT BIRTH 
 
When a baby is born before 33+6 weeks gestation, neonatal hypothermia may arise. This is 
worth preventing as hypothermia is a major risk factor for morbidity and mortality in preterm 
infants (CESDI 27/28 project www.cesdi.com). Babies lose heat through different mechanisms 
- convection, evaporation, conduction and radiation. The first two of these account for most 
heat loss but their effect can be countered by placing any preterm baby in a specially provided 
plastic bag for initial resuscitation after delivery. These are available on the Delivery Suite and 
should be used as follows: 
 
Preparation prior to delivery 
 
Standard resuscitation equipment should be ready. Environmental factors should be optimised 
(eg) doors and windows closed to prevent drafts, overhead heater turned on and warm towels 
provided. A plastic temperature control bag then be placed on the resuscitaire to warm. 
 
NCHE-OBS001 
 
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At delivery (the neonatal team will lead on this) 
 
The baby should be placed immediately into the bag – do not waste time drying the baby. The 
standard ABC procedure should then be followed. All resuscitation procedures, including 
cardiac massage if needed, can be performed with the bag in situ. A hole can be cut in bag to 
access the umbilicus if necessary. 
 
Transfer to SCBU 
 
The baby should be transferred on the resuscitaire while still wearing its bag.  On admission to 
SCBU the baby will be placed in / on a pre-warmed incubator / platform.  Once the incubator 
side doors have been closed, the plastic bag will be removed through the portholes prior to 
measure axilla temperature.  If nursed on a platform the plastic bag will remain in place. 
 
12.8  SURVIVAL AND MORBIDITY CHARTS 
 Birth weight (g) 
 
96 
 
 
 
 
 
 
 
 
 
 
 
99 
3000 
73-100 
94-100 
97 
 
 
 
 
 
 
 
 
 
 
99 
99 
2750 
89-100 
91-100 
95-100 
90th percentile 
97 
 
 
 
 
 
 
 
 
 
 
 
98 
98 
2500 
94-99 
94-100 
96-100 
10th percentile 
97 
 
 
 
 
 
 
 
 
 
96 
97 
98 
2250 
96-99 
92-99 
96-99 
97-100 
98 
 
 
 
 
 
 
 
81 
93 
96 
98 
98 
2000 
97-99 
98-91 
89-97 
95-99 
97-99 
98-100 
97 
 
 
 
 
 
 
73 
90 
95 
97 
98 
98 
1750 
97-99 
56-86 
84-94 
93-97 
96-99 
97-99 
98-100 
96 
 
 
 
 
32 
86 
85 
92 
95 
97 
98 
99 
1500 
95-98 
12-82 
49-80 
79-90 
90-95 
94-97 
96-98 
97-99 
9-100 
92 
 
 
 
 
57 
77 
87 
92 
94 
96 
97 
98 
1250 
91-94 
43-70 
71-83 
85-90 
90-94 
93-96 
94-98 
96-99 
97-100 
 
76 
 
 
20 
41 
60 
73 
80 
84 
87 
90 
94 
97 
1000 
73-79 
14-33 
33-60 
55-66 
69-77 
77-84 
84-88 
84-91 
87-94 
89-96 
92-100 
32 
 
8 
12 
28 
38 
46 
50 
54 
59 
67 
80 
93 
750 
28-37 
5-14 
13-23 
24-34 
34-44 
40-53 
43-59 
44-64 
47-70 
51-81 
56-94 
82-100 

 



7 
8 


 
 
 
 
500 
2-6 
1-5 
2-7 
3-10 
4-13 
4-16 
3-18 
3-22 
 
 
 
 
 
 
 
 
 
 
 
 
 
250 
 
 

15 
29 
47 
65 
79 
88 
93 
96 
97 
98 

4-11 
11-20 
25-34 
43-52 
61-69 
76-82 
86-90 
92-95 
95-97 
97-99 
97-100 
 
22       23        24        25         26        27         28        29         30        31         32 
Gestation (weeks) 
Draper’s Charts: Predicted survival (%) of infants alive at the onset of labour 
 
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Publication Date:  22/01/2008 
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Morbidity data 
 
Newcastle 1994-8 (booked) 
 
Gestation 
23 24 25 26 27 28 29 30 31 
(weeks) 
Survival (%)  33 25 50 42 82 98 96 98 98 
Disability in  - - - - - - - - - 
survivors 
(%) 

  
Northern Region 1990-91 
 
Gestation 
23 24 25 26 27 28 29 30 31 
(weeks) 
 
Survival 

16 24 51 50 76 79 91 92 96 
(%) 
 
Disability in  
50 37 21 15 26 15 11  
 
6  
 

survivors 
(%) 

  
UK (Epicure 1995) 
 
Gestation 
23 24 25 26 27 28 29 30 31 
(weeks) 
 
Survival 

20 
33 
52 
- - - - - - 
(%) 
 
Disability in  
35 
29 
24 
- - - - - - 
Survivors 
(%) 

 
NCHE-OBS001 
 
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References 
 
Baud O et al (1999) Antenatal glucocorticoid treatment and cystic periventricular 
leukomamacia in very premature infants. NEJM 341: 1190-1196. 
 
Besch NJ, Perlstein PH, Edwards NK, Keenan WJ, Sutherland JM (1971) The transparent 
baby bag. A shield against heat loss. NEJM 284: 121-124. 
 
Bortolus R et al (2000) Nifedipine administered in pregnancy: effect on the development of 
children at 18 months BJOG 107: 792-794. 
 
Brodman ML et al (1994) Wide-band transabdominal cerclage for a foreshortened, 
incompetent cervix.  Obstet Gynecol  84: 704-706. 
 
Crowley P (2002) Prophylactic corticosteroids for pre-term birth. Cochrane Database of 
Systematic Reviews Issue 2. 
 
Draper ES, Manktelow B, Field DJ, James D (2003) Tables for predicting survival for preterm 
births are updated. BMJ 327: 872. 
 
Groom KM and Bennett PR (2004) Tocolysis for the treatment of preterm labour – a clinically 
based review. The Obstetrician and Gynaecologist 6 (1): 4-12. 
 
Honest H et al (2002) Accuracy of cervicovaginal fibronectin test in predicting risk of 
spontaneous preterm birth: systematic review. BMJ 325: 301-311. 
 
Hughes RG, Brocklehurst P, Stenson B (2004) Prevention of early onset neonatal group B 
streptococcal disease. RCOG Green Top Guideline Number 36, RCOG Press, London, UK. 
 
Kenyon SL, Taylor DJ, Tarnow-Mordi W (2001) Broad-spectrum antibiotics for preterm, 
prelabour rupture of fetal membranes: the ORACLE I randomised trial. Lancet  357: 979-988. 
 
Kenyon SL, Taylor DJ, Tarnow-Mordi W (2001) Broad-spectrum antibiotics for spontaneous 
preterm labour: the ORACLE II randomised trial. Lancet 357: 989-994. 
 
King JF et al (2002) Calcium channel blockers for inhibiting preterm labour. Cochrane 
Database of Systematic Reviews Issue 4. 
 
Le Flore JL et al (2002) Association of antenatal and postnatal dexamethasone exposure with 
outcomes in extremely low birth weight neonates. Paediatrics 110: 275-279. 
 
Lowe M et al (2004) Prospective randomized controlled trial of fetal fibronectin on preterm 
labor management in a tertiary care center. Am J Obstet Gynecol 190: 358-362. 
 
Lyon AJ, Stenson B (2004) Cold comfort for babies. Arch Disease Childhood: Fetal & 
Neonatal Edition 
89. 
 
McDonald IA (1957) Cervical suture. J Obstet Gynaecol Br Empire 3: 346-350. 
 
 
NCHE-OBS001 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
Moutquin JM et al (2000) Double blind, randomised controlled trial of atosiban and ritodrine in 
the treatment of preterm labour: a multicenter effectiveness and safety study. Am J Obstet 
Gynecol
 182: 1191-1199.  
 
Papatsonis DN et al (2000) Neonatal effects of nifedipine and ritodrine for preterm labor. 
Obstet Gynecol  95: 477-481. 
 
Penney GC and Cameron MJ (2004) Antenatal corticosteroids to prevent respiratory distress 
syndrome. RCOG Green Top Guidelines: Guideline Number 7. RCOG Press, London, UK. 
 
Shirodkar (1955) Cervical suture. The Antiseptic 52: 299-300. 
 
Vohra S, Frent G, Campbell V, Abbott M, Whyte R (1999) Effect of polyethylene occlusive skin 
wrapping on heat loss in very low birth weight infants at delivery: a randomized trial. 
Pediatrics 
134: 547-551. 
 
Zaveri V et al (2002) Abdominal versus vaginal cerclage after a failed transvaginal cerclage: a 
systematic review. Am J Obstet Gynecol 187: 868-872. 
 
NCHE-OBS001 
 
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CHAPTER 13 - FETAL HEART RATE MONITORING 
 
 
 
The guidelines presented in this section are compatible with the RCOG / NICE Guidelines on 
Electronic Fetal Monitoring published in 2001. 
  
13.1 
FETAL HEART RATE MONITORING ...............................................................129 
13.2 
DEFINITIONS ...................................................................................................129 
13.3 
RISK ASSESSMENT ........................................................................................130 
13.4 
ANTENATAL FETAL HEART MONITORING....................................................131 
13.5 
THE DAWES / REDMAN CRITERIA AS USED BY THE OXFORD SONICAID 
SYSTEM ...........................................................................................................132 
13.6 
ADMISSION CTG .............................................................................................132 
13.7 
INTERMITTENT AUSCULTATION ...................................................................133 
13.8   
CONTINUOUS MONITORING..........................................................................133 
13.9 
CATEGORISATION OF FETAL HEART RATE FEATURES ............................134 
13.10 
CTG CLASSIFICATION ....................................................................................134 
13.11   SUSPICIOUS CTG ...........................................................................................134 
13.12 
PATHOLOGICAL CTG......................................................................................135 
13.13 
FETAL SCALP BLOOD SAMPLING .................................................................135 
13.14 
DR C BRAVADO...............................................................................................136 
 
 
 
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13.1  FETAL HEART RATE MONITORING 
 
Cardiotocograph (CTG) machines use doppler to detect movement in the mother’s abdomen, 
including movement of the fetal heart. Before this can be displayed on the monitor, extraneous 
‘noise’ (such as movement in the mother’s blood vessels) has to be filtered out by the 
machine. This is usually achieved successfully but sometimes a ‘trace’ can be displayed on 
the machine even after fetal death has occurred. In these cases, the signal is derived from 
maternal tissue movement. To guard against this, the Medical Devices Agency recommends: 
 
•  the fetal heart should identified by auscultation with a Pinnard before the CTG is attached 
•  if a problem is encountered in identifying the fetal heart, ultrasound should be used to 
confirm the presence of a heart beat 
•  the time and date should be checked on the monitor whenever a CTG is commenced 
•  the maternal pulse should be recorded on the CTG trace and on the partogram regularly 
•  if the maternal and fetal heart rates are similar and the maternal heart beat seems to be 
synchronious with the sound coming from the monitor, the presence of a true fetal heart 
beat must be confirmed by other means (such as ultrasound or fetal scalp electrode) 
•  anyone making management decisions based on a CTG should sign both the trace and 
the subsequent action plan recorded in the notes 
 
13.2 DEFINITIONS 
 
Baseline rate 
The mean heart rate over 5 minutes 
 
Baseline variability 
Variation in the baseline rate excluding accelerations and 
decelerations 
 
Acceleration 
A rise in the heart rate of at least 15 bpm for at least 15 seconds 
 
Deceleration 
A transient decrease in the heart rate of 15 bpm lasting for 15 
seconds or more. Shallower decelerations may also be significant 
however from a baseline with reduced variability 
 
Early deceleration 
The nadir of the deceleration mirrors the peak of the contraction and 
recovery occurs within the contraction 
 
Variable deceleration  The timing of the deceleration is variable in relation to the peak of the 
contraction. Depth and duration may also be variable 
 
Late deceleration 
The nadir of the deceleration consistently occurs after the peak of the 
contraction 
 
Shouldering 
Small accelerations before and / or after decelerations 
 
All CTG’s should be assessed and categorised as normal, suspicious or pathological.  
 
 
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13.3 RISK 
ASSESSMENT 
 
On first admission to Delivery Suite, women in labour should be assessed and allocated low 
or high risk status. High risk status will be conferred when any one of a number of conditions 
affecting fetal or maternal wellbeing are identified. The following list is not exhaustive: 
 
Maternal 
 
• placenta 
praevia 
• antepartum 
haemorrhage 
•  isoimmunisation - Rhesus or other antibodies 
•  previous caesarean section 
• pre 
eclampsia 
•  HIV / Hep B 
• diabetes 
 
Fetal 
 
• breech 
presentation 
• multiple 
pregnancy 
• thick 
meconium 
• polyhydramnios 
• oligohydramnios 
• congenital 
abnormalities 
•  gestation under 37 weeks 
•  baby under 2.5 kg estimated weight 
 
Intrapartum  
 
Transfer to high-risk status should be precipitated by: 
 
• pyrexia 
•  use of syntocinon 
• intrapartum 
haemorrhage 
•  fetal heart rate abnormalities 
•  fetal capillary blood sampling 
•  prolonged rupture of the membranes 
•  any other concern about the woman’s wellbeing 
 
 
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13.4  ANTENATAL FETAL HEART MONITORING 
 
Purpose 
 
 
To record the fetal heart rate pattern where the gestational age is 26 weeks or more, over a 
period of time between 10-60 minutes in order to assess the well being of the fetus. 
 
Instruction 
 
The midwife will explain the purpose for and the procedure to the women. 
 
The midwife will palpate the abdomen, measure the fundal – symphysis height and auscultate 
the fetal heart with a pinards prior to the CTG. 
 
The midwife will apply tocograph and ultrasound transducers. 
 
The fetal activity button will be given to the women with instructions for use. 
 
The CTG will last 20-60 minutes when visually interpreting and 10-60 minutes when using the 
Dawes / Redman computerised fetal heart rate monitor. 
 
On completion of the trace the midwife will explain the findings to the women. 
 
The appropriate medical staff will be summoned in the event of an abnormal trace, (duty rota 
and bleep numbers available). 
 
The CTG will be repeated as indicated for each individual women (see Maternity Assessment 
Unit Guidelines).  The midwife will arrange any further antenatal follow-up care required. 
 
At all times maintain clear and accurate documentation. 
 
Key Points 
 
All CTG tracings must be clearly marked with woman’s name. 
 
Maternal pulse rate 
The woman’s DOB 
The gestational age 
The date and time the trace took place 
The signature of the midwife commencing and terminating the trace 
 
When using the Sonicaid Team Monitor the Dawes / Redman Criteria will be used in 
conjunction with the visual analysis of the raw data. 
 
3.1 
Refer to guideline ultrasound scans in the case of an abnormal CTG. 
  
 
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13.5  THE DAWES / REDMAN CRITERIA AS USED BY THE OXFORD 
SONICAID SYSTEM 
 
What parameters does the system analyse 
 
It measures the heart rate in beats per minute and fits a baseline.  From this computed 
baseline it is then able to: - 
 
ƒ  Measure accelerations and decelerations 
ƒ  Measure the overall variation of the fetal heart rate around the baseline when 
decelerations have been excluded 
ƒ  Measure the short-term variation (STV) 
ƒ  Identify episodes of high and low variations 
ƒ  Identify signal loss 
ƒ Count 
contractions 
ƒ  Count fetal movement per hour as recorded by the woman 
 
The Criteria 
 

ƒ  The baseline heart rate must be > 115 < 160bpm 
ƒ  There must be no large decelerations (of >20 lost beats) 
ƒ  There must be at least 1 fetal movement of 3 accelerations 
ƒ  The overall variation should be >=22ms 
ƒ The 
STV>=3ms 
 
At least 5 out of 6 consecutive minutes of high variation 
 
If the criteria is not met inform medical staff. 
 
13.6 ADMISSION 
CTG 
 
The admission CTG is only recommended for women in the high risk category. It consists of a 
20 minute trace in which both the fetal heart rate and contractions are clearly recorded and 
should be assessed as normal, suspicious or pathological (see below). 
 
Women whose labours have been classified as low risk may occasionally request an 
admission CTG.  Although admission CTG’s are of no proven benefit in such cases, the trace 
may still be performed after appropriate counselling as part of the woman’s choice.  
 
 
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13.7 INTERMITTENT 
AUSCULTATION 
 
This is the method of choice for fetal heart rate monitoring in low risk labours. It is defined as 
the auscultation of the fetal heart rate for one minute after a contraction: 
 
•  at least once every 15 minutes in the first stage of labour 
•  at lest once every 5 minutes in the second stage of labour 
 
The rate should be recorded contemporaneously on the partograph. Either a Pinnard or a 
hand held doppler can be used, depending upon the experience of the midwife and the wishes 
of the labouring woman.  
 
If circumstances lead to reclassification of the labour as ‘high risk’, continuous monitoring 
should be commenced. Conversion to continuous monitoring should also be expedited if: 
 
•  the baseline rate is below 110 bpm 
•  the baseline rate is above 160 bpm 
•  a deceleration is heard after a contraction  
 
13.8    CONTINUOUS MONITORING 
 
Women assessed as high risk on admission, who become high risk during labour or who have 
a suspected fetal heart rate abnormality on intermittent auscultation should be monitored 
continuously. A woman thought to be at low risk of complications may request continuous 
monitoring, but this should only be commenced after counselling: 
 
•  no proven benefit to the woman 
•  no proven benefit to the baby 
•  increased risk of operative intervention during the labour 
 
 
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13.9  CATEGORISATION OF FETAL HEART RATE FEATURES  

Figure 1 
RCOG/NICE Categorisation of FHR Features
Feature
Baseline
Variability
Decelerations
Accelerations
Reassuring       110-160
>5
none
present
non-reassuring 100-109
<5 for 
early;
?
161-180
40 to 90 min 
typical variable;
prolonged <3 min
abnormal
< 100
< 5 for 
atypical variable;         ?
> 180
over 90 min 
late;
sinusoidal
prolonged >3 min
absence of accelerations in an otherwise normal trace is of unknown 
significance 
13.10 CTG CLASSIFICATION 
 
See figure 1. This includes the formulation of an action plan. 
 
13.11  SUSPICIOUS CTG 
 
This is the presence of one non-reassuring feature, but no more than one. No abnormal 
features should be present. The attending midwife should alert the midwife in charge of 
Delivery Suite. When there is continued concern the SHO and / or SpR should be informed. 
 
•  check the quality of the trace 
•  consider using a fetal scalp electrode if the quality is suboptimal 
•  ensure the mother is not supine - encourage her to adopt the left lateral position 
 
 
Hyperstimulation (also see Section 4) 
 
•  reduce or stop Syntocinon if it is in use and if contractions are occuring > 5:10 minutes 
•  consider tocolysis with 0.25 to 0.5 mg sc terbutiline 
 
Maternal tachycardia or pyrexia (also see Section 20) 
 
•  stop tocolytics if in use 
•  consider blood cultures and triple swabs 
•  consider intravenous antibiotics   
 
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If the trace remains suspicious over a prolonged period of time, although no additional active 
intervention may be required, all other clinical considerations should be taken into account 
before coming to this conclusion. The woman and her CTG should be observed closely and 
medical review should take place hourly as a minimum. A written entry should be made in the 
women’s partogaph by the medical staff on an hourly basis in these circumstances. 
 
13.12 PATHOLOGICAL CTG 
 
This is the presence of two or more non-reassuring features on the CTG, or one abnormal 
feature. In most cases, a fetal scalp blood sample will be required to exclude acidaemia. If a 
sample cannot be obtained, delivery should then be expedited. Occasionally, delivery should 
be undertaken without recourse to fetal scalp blood sampling: 
 
•  baseline variability under 2 bpm together with late fetal heart rate decelerations 
•  prolonged fetal bradycardia lasting for more than 3 minutes with no sign of recovery 
•  technically very difficult or impossible to obtain a fetal scalp blood sample 
 
In such cases, intervention may be postponed if clear evidence emerges of recovery of the 
CTG to a normal pattern prior to delivery. 
 
13.13  FETAL SCALP BLOOD SAMPLING 
 
Ensure patient and partner understand procedure 
 
Position the patient and prepare the equipment  
 
•  usually left lateral position 
•  if the cervix is less than 3cm dilated then consider using lithotomy position 
•  select an amniscope and lubricate it with gel or cream 
•  use standard pre-heparanised 55 mcl capillary tubes 
 
Visualise and prepare the fetal scalp 
 
•  insert the amniscope 
•  clean the baby’s head with a small gauze pledget then spray the scalp with ethyl chloride  
•  spread a very thin layer of petroleum jelly on the scalp 
 
Collect the sample 
 
•  prick the baby's head firmly with the blade 
•  if an additional prick is required this should be at right angles to the first 
•  wait for blood to collect as a drop on the scalp then collect it with the capillary tube  
 
Aim to completely fill capillary tube, anything less than 70% full is likely to fail to give a pH 
result.  Any air bubbles are likely to lead to a ‘non-homogenous’ failure.  Take 3 samples if 
possible. 
 
 
 
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Sample analysis 
 
The capillary tube should be rocked gently to avoid clotting. Only those midwives trained in 
the use of the blood gas analyser should undertake this task.  At the machine the caps should 
be removed and the opposite end to that used for taking the sample introduced into the ‘clot 
catcher’ and inserted into the blood gas analyser. 
 
The commonest reasons samples are rejected are: 
 
• sample 
clotted 
• insufficient 
sample 
•  non-homogenous sample, i.e. air bubbles 
 
We should achieve 70% success rate 
 
pH 
  Subsequent 
Action 
 
≥ 7.25  
 
FBS should be repeated if the abnormality persists 
 
 
 
Frequency of sampling determined by the SpR or Consultant 
 
7.21-7.24 
Repeat FBS within 30 minutes or consider delivery if there has been a 
rapid fall since the last sample was obtained 
 
≤ 7.20  
 
Delivery is indicated 
 
 
13.14  DR C BRAVADO 
 
This mnemonic may help you to remember the features of the CTG.  
 

 
 
Define  the  Risk 

 

  Contractions 
 

  Baseline  RAte 



  Variability 

 
 
Accelerations 

 
 
Decelerations 

  Overall assessment 
  
 
 
 
formulate an action plan based on the overall assessment 
 
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References 
 
Amer-Wahlin  et al (2001) CTG only versus CTG plus ST analysis of the fetal ECG for 
intrapartum fetal monitoring: a Swedish randomised controlled trial. Lancet 358: 534-538.  
 
Ayres de Campos D et al (1999) Inconsistencies in classification of cardiotocograms and 
subsequent clinical decisions. BJOG 106: 1307-1310. 
 
Goodwin TM et al (1994) Elimination of fetal scalp blood sampling in a large clinical service. 
Obstet Gynecol 83: 971-974. 
 
Greene KR (1991). Scalp blood gas analysis in antepartum and intrapartum fetal assessment. 
Obstet Gynecol Clin North Am 26: 641-656. 
 
Hagberg B et al (2001) changing panorama of cerebral palsy in Sweden VIII. Prevalence and 
origin in the birth period 1991-1994. Acta Paediatr 90: 271. 
 
Hagberg B et al (2001) Cerebral palsy in west Sweden 1954-1994. Acta Paediatr 90: 277. 
 
Hakon Noren et al (2003) Fetal ECG in labour and neonatal outcome: data from the Swedish 
RCT on intrapartum fetal monitoring. Am J Obstet Gynecol 188: 183-192. 
 
Hofmeyr GJ, Kulier R (2002) Tocolysis for preventing fetal distress in second stage of labour. 
Cochrane Database of Systematic ReviewsIssue 4
 
Impey L et al (2003) Admission cardiotocography: a randomised controlled trial. Lancet 361: 
465-70. 
 
Johnstone FD, Campbell DM, Huges GJ (1978) Has continuous intrapartum fetal monitoring 
made any impact on fetal outcome? Lancet 1: 1298-1300. 
 
Larsen JF (1996). Why has conventional intrapartum cardiotocography not given the expected 
results? J Perinat Med 24: 15-23. 
 
MacDonald D et al (1985) The Dublin randomised controlled trial of intra partum fetal heart 
rate monitoring. Am J Obstet Gynecol 152: 524-539. 
 
Neilson JP (2003) Fetal ECG for fetal monitoring in labour (Cochrane Review). In: The 
Cochrane Library, Issue 2. Oxford: Update Software. 
 
Nelson KB, Ellenberg JH (1986) Antecedents of cerebral palsy. NEJM 315: 81-86. 
 
Rosen KG, Isaksson O (1976) Alterations in fetal heart rate and ECG correlation to glycogen, 
creatine phosphate and ATP levels during graded hypoxia. Biol Neonate 30: 17-24. 
 
Saling E (1996) Comments on the past and present situation of intensive monitoring of the 
fetus during labour. J Perinat Med 24: 7-13. 
 
 
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Surveillance of cerebral palsy in Europe (2000). A collaboration of cerebral palsy surveys and 
registers. Dev Med Child Neurol 42: 816-824. 
 
Thacker SB et al (1995) Efficacy and safety of intrapartum electronic fetal monitoring: an 
update. Obstet Gynecol 86: 613-620. 
 
Umstad MP et al (1995) Litigation and the intrapartum cardiotocography. BJOG 102: 89-91 
 
Westgate JA et al (1993) Plymouth randomised trial of CTG only versus ST waveform plus 
CTG for intrapartum monitoring in 2400 cases. Am J Obstet Gynecol 169: 1151-1160. 
 
Westgate JA et al (1999) Antecedents of neonatal encephalopathy with fetal acidaemia at 
term. BJOG 106: 774-782 
 
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CHAPTER 14 - ANTEPARTUM HAEMORRHAGE 
 
 
 
14.1 
INTRODUCTION...............................................................................................140 
14.2 
GENERAL MANAGEMENT ..............................................................................140 
14.3 
MANAGEMENT OF SEVERE HAEMORRHAGE IN THE COMMUNITY..........141 
14.4 
PLACENTA PRAEVIA.......................................................................................142 
14.5 
PLACENTAL ABRUPTION ...............................................................................143 
 
 
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14.1 INTRODUCTION 
 
Antepartum haemorrhage is the loss of blood from any part of the genital tract, after the point 
of fetal viability but before delivery of the baby. The origin of the blood loss may be: 
 
• vulval 
• vaginal 
 
• cervical 
•  uterine, not involving the placental bed 
•  uterine, involving the placental bed 
 
In practice, blood loss from the uterine cavity, involving the placental bed, is the form of 
antepartum haemorrhage most commonly associated with maternal and fetal clinical 
sequelae. These conditions form the subject matter for this section: 
 
• placenta 
praevia 
• placental 
abruption 
 
14.2  GENERAL MANAGEMENT  
 
Women with minor antepartum haemorrhage will usually be seen by the midwives and 
medical staff on the Maternity Assessment Unit in the first instance then referred to Delivery 
Suite if needed. Women with heavy bleeding may be admitted directly to the Delivery Suite, 
however. 
 
Whenever a woman with antepartum haemorrhage arrives on the Delivery Suite, the following 
measures and investigations should be instituted if not already in place: 
 
•  intravenous access gained with two large bore cannulae 
•  intravenous infusion started with normal saline or Hartmann’s solution 
 
•  full blood count 
• clotting 
screen 
•  crossmatch of at least 2 units of blood – refer to Section 15. 
• cardiotocography 
• consider 
Kleihauer 
 
The senior SpR or Consultant must be informed about any patient with bleeding sufficient to 
cause clinical concern. Pelvic examination should not be performed until this contact has been 
made and the case discussed. 
 
Anti-D should be given within 72 hours of bleeding. 
 
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14.3  MANAGEMENT OF SEVERE HAEMORRHAGE IN THE COMMUNITY  
 
When SEVERE bleeding occurs at HOME the midwife is sometimes contacted by telephone.  
In these circumstances the midwife should: 
 
1.  Obtain details of the woman’s general condition, amount of blood loss, any associated 
pain, and when she delivered. 
 
2.  Obtain details of her name, address, telephone number and GP. 
 
3.  Request a paramedic ambulance on 999 to admit to the consultant Unit. 
 
4.  Notify the GP and request attendance if it is felt necessary. 
 
5.  A midwife MAY be available to go to the house.  Consider each situation individually on 
the severity of the haemorrhage, the availability of supporting staff and the location of 
the woman. 
 
6.  If a midwife goes to the home she should, if possible, take an infusion set, Hartmanns 
Solution, a community bag and oxytocic drugs, i.e. ergometrine 0.5 mg.  Ergometrine 
may be required postnatally. 
 
ACTION BY THE MIDWIFE IN THE HOME OR IN THE MATERNITY UNIT 
 
a)  Transfer the woman in an ambulance with a doctor and/or midwife. 
 
b)  A GP should be requested urgently. 
 
c)  Monitor the woman’s condition throughout – BP, pulse, respiration, pallor, blood loss, level 
of consciousness.  Do not give any oral fluids. 
 
CONTINUE WITH FLOW CHART ON MANAGEMENT OF POST-PARTUM HAEMORRHAGE 
(See Chapter 15.8) 
 
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14.4 PLACENTA 
PRAEVIA 
 
This occurs in 0.4 to 0.8 % of pregnancies. There are many risk factors, including: 
 
•  maternal age over 35 years 
• smoking 
• high 
parity 
•  previous caesarean section 
• multiple 
pregnancy 
 
Presentation tends to be with painless bleeding and a high presenting part or malpresentation, 
though these features are variable. Diagnosis rests with vaginal or abdominal ultrasound, and 
will usually already be clearly indicated in the antenatal notes. Ultrasound diagnosis on the 
Delivery Suite may only be made by an appropriately experienced clinician. 
 
Bleeding placenta praevia, not in labour 
 
Women with bleeding placenta praevia who are not in labour may occasionally be treated 
conservatively, for example to allow steroid administration to a preterm infant. Conservative 
management should always be sanctioned by the Consultant Obstetrician. As a prerequisite, 
conservative management will rely upon a stable fetal and maternal condition. 
 
When there is evidence of fetal or maternal compromise but the Consultant Obstetrician on 
call is attending from home, delivery should not usually be delayed. The attending SpR should 
commence a caesarean section after discussion with the duty Consultant, who will give 
assistance upon her / his arrival if necessary. 
 
Bleeding placenta praevia, in labour 
 
When a woman with bleeding placenta praevia arrives on the Delivery Suite in labour, delivery 
will usually be by caesarean section. 
 
•  inform the Consultant Obstetrician 
•  inform the on call anaesthetist 
•  inform the haematology lab 
 
•  obtain venous access with two large bore cannulae (16G or larger) 
•  cross match a minimum of 2 units of blood 
•  check the full blood count and clotting screen 
 
•  transfer to theatre without delay for caesarean section 
 
Exceptions to the principle of delivery by caesarean section may arise when the leading edge 
of the placenta is more than 2.5 cm from the cervical os and there is no evidence of maternal 
or fetal compromise. The decision not to perform a caesarean section in these circumstances 
can only be made by the on call Consultant. 
 
In common with non-labouring women, when there is evidence of fetal or maternal 
compromise but the Consultant Obstetrician on call is attending from home, delivery should 
 
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not usually be delayed. The attending SpR should commence a caesarean after discussion 
with the duty Consultant, who will give assistance upon her / his arrival if necessary. 
 
14.5 PLACENTAL 
ABRUPTION 
 
This occurs in approximately 1.0 % of pregnancies. There are many risk factors, including: 
 
•  maternal age over 35 years 
• high 
parity 
• smoking 
• trauma 
• hypertension 
 
Classically, women with placental abruption attend with abdominal pain and bleeding. They 
may appear unwell, with tachycardia and hypotension. A tender, rigid uterus is common but 
not universal. Although none of these features is wholly reliable, the diagnosis remains 
primarily clinical. A negative ultrasound scan cannot exclude the diagnosis. 
 
Management of placental abruption 
 
Women with suspected placental abruption may occasionally be treated conservatively 
whether in labour or not, for example when there is an element of doubt in the diagnosis and 
the maternal and fetal conditions are stable. Any plan for conservative management should be 
sanctioned by a consultant and should include elements of Section 14.2. 
 
When there is clear evidence of fetal or maternal compromise but the Consultant Obstetrician 
on call is attending from home, delivery should not usually be delayed. The attending SpR 
should commence delivery after discussion with duty Consultant, who will respond 
immediately and attend as soon as possible and provide assistance upon her / his arrival if 
necessary. 
 
Management of suspected placental abruption 
 
•  inform the Consultant Obstetrician 
•  inform the anaesthetist 
•  inform the G Grade midwife co-ordinating Delivery Suite 
•  inform the on call haematologist if the maternal condition is giving concern 
 
 
(1) 
with no evidence of fetal or maternal compromise 
and 
a decision to try for vaginal delivery 
continuous FH monitoring 
IV access, FBC, clotting status, Kleihauer, cross match blood 
amniotomy 
 
(2) 
with clear evidence of maternal or fetal compromise 
 
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deliver by 
Grade 1 caesarean section 
or 
assisted vaginal delivery 
without delay 
continuous FH monitoring where possible 
IV access, FBC, clotting status, Kleihauer, cross match blood 
 
(3) 
with fetal demise or imminent fetal demise 
such as prolonged profound bradycardia with no previously recorded normal FH 
manage with maternal wellbeing exclusively in mind 
for example 
aim for vaginal delivery if the mother is clinically stable 
consider caesarean section if the mother is not clinically stable 
 
 
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References 
 
Ananth CV et al (2003) The effect of placenta previa on neonatal mortality: a population-based 
study in the United States, 1989 through 1997. Am J Obstet Gynecol 188: 1299-1304. 
 
Fiaz AS, Ananth CV (2003) Etiology and risk factors for placenta previa: an overview and 
meta-analysis of observational studies. J Mat Fetal Neonat Med 13: 175-190. 
 
Kayani SI et al (2003) Pregnancy outcome in severe placental abruption. BJOG 110: 679-683.  
 
Neilson JP (2003) Interventions for treating placental abruption. The Cochrane Database of 
Systematic Reviews

 
Neilson JP (2003) Interventions for suspected placenta praevia. The Cochrane Database of 
Systematic Reviews. 
 
Sheiner E et al (2003) Placental abruption in term  pregnancies: clinical significance and 
obstetric risk factors. J Mat Fet Neonat Med 13: 45-49. 
 
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CHAPTER 15 - POSTPARTUM HAEMORRHAGE 
 
 
 
15.1 
BACKGROUND ................................................................................................147 
15.2 
MANAGEMENT OF SEVERE HAEMORRHAGE IN THE COMMUNITY..........147 
15.3 
MANAGEMENT OF MAJOR PPH.....................................................................148 
15.4 
THE ROLE OF STAFF DEALING WITH PPH...................................................151 
15.5 
SECONDARY PPH ...........................................................................................152 
15.6 
BLOOD TRANSFUSION...................................................................................153 
15.7 
RECOMBINANT FACTOR VIIA ........................................................................156 
15.8  
INITIAL MANAGEMENT OF MASSIVE HAEMORRHAGE – ORGANISING THE 
TEAM ................................................................................................................158 
 
 
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15.1 BACKGROUND 
 
Primary postpartum haemorrhage (PPH) loss of over 500 ml blood within 24 hours of delivery. 
It occurs after approximately 1:10 births, but is not always clinically significant. 
 
Major postpartum haemorrhage loss of over 1500 ml blood postpartum. It may occur 
immediately, but occasionally does not become apparent for several hours. It arises after 
approximately 1:500 births. 
 
Secondary postpartum haemorrhage loss of over 500 ml blood between 24 hours and 6 
weeks after delivery. It occurs after approximately 1:100 births. 
 
The causes of postpartum haemorrhage may be remembered as - TTTT 
 
• Tone   
uterine 
atony 
•  Trauma   
genital trauma, including damage to vulva, vagina, cervix or uterus  
• Tissue   
retained 
placenta 
• Thrombin 
 
coagulopathy 
•  Infection   
secondary PPH may be caused by or associated with endometritis 
 
Major PPH remains one of the commonest causes of maternal morbidity and mortality, so it 
requires prompt recognition and effective management. 
 
•  be prepared to manage major PPH after any delivery 
•  liaise with colleagues 
•  use the major PPH drill 
 
15.2  MANAGEMENT OF SEVERE HAEMORRHAGE IN THE COMMUNITY 
 
When SEVERE bleeding occurs at HOME the midwife is sometimes contacted by telephone.  
In these circumstances the midwife should: 
 
1  Obtain details of the woman’s general condition, amount of blood loss, any associated 
pain, and when she delivered. 
 
2  Obtain details of her name, address, telephone number and GP. 
 
3  Request an ambulance on 999 to admit to the consultant Unit. 
 
4  Notify the GP and request attendance if it is felt necessary. 
 
5  A midwife MAY be available to go to the house.  Consider each situation individually on the 
severity of the haemorrhage, the availability of supporting staff and the location of the 
woman. 
 
6  If a midwife goes to the home she should, if possible, take an infusion set, Hartmanns 
Solution, a community bag and oxytocic drugs, i.e. ergometrine 0.5 mg. 
 
 
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ACTION BY THE MIDWIFE IN THE HOME OR IN THE MATERNITY UNIT 
 
a)  Transfer the woman in an ambulance with a doctor and/or midwife. 
 
b)  A GP should be requested urgently. 
 
c)  Monitor the woman’s condition throughout – BP, pulse, respiration, pallor, blood loss, level 
of consciousness.  Do not give any oral fluids. 
 
CONTINUE WITH FLOW CHART ON MANAGEMENT OF POST-PARTUM HAEMORRHAGE 
 
15.3  MANAGEMENT OF MAJOR PPH 
 
The major PPH drill (below) provides a guide to resuscitative measures that should be taken 
when managing major primary or secondary PPH. In addition to the common initial steps, the 
specific causes of PPH should be assessed in each individual and action taken accordingly. 
 
Tone 
 
•  expel clot from the vagina and uterine cavity with fundal pressure 
•  bimanually compress the uterus 
•  IV ergometrine 500 mcg 
 
Over 1500 ml loss and still bleeding? 
 
•  inform the anaesthetist and the Consultant Obstetrician 
•  consider IM carboprost 250 mcg every 15 minutes - maximum 8 doses (2 mg) 
•  consider 600 – 800 mcg rectal misoprostol 
•  transfer to theatre for EUA / laparotomy 
•  consider intra myometrial carboprost 250 mcg 
•  once bleeding has been controlled and the circulating volume restored, set up an infusion 
of IV syntocinon 40 iu in 1000 ml normal saline for 4 hours. There is no evidence for a 
reducing regimen. 
•  Administer high flow O2 at 8 litres per minute 
 
Trauma 
 
•  apply pressure over the bleeding point if it is easily identified 
•  suture in the delivery room if the bleeding point is easily identified 
•  transfer to theatre if not 
 
•  examine the anus, vulva, vagina, cervix under direct vision 
•  manually explore the uterine cavity to exclude trauma or retained placental tissue 
• consider 
laparotomy 
 
•  if the uterus has been explored, give IV co amoxyclav 1.2 gm stat 
if the uterus has been explored, set up an infusion of IV syntocinon 40 iu in 1000 ml normal 
saline for 4 hours. There is no evidence for a reducing regimen 
 
 
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Tissue 
 
•  IV Augmentin 1.2 gm 
•  manually remove placenta in the delivery room if epidural is dense enough 
•  manually remove placenta in theatre if additional analgesia is required 
 
once bleeding has been controlled and the circulating volume restored, set up an infusion of 
IV syntocinon 40 iu in 1000 ml normal saline for 4 hours. There is no evidence for a reducing 
regimen. 
 
Thrombin 
 
Risk factors for the development of coagulopathy include pre-eclampsia (particularly HELLP 
syndrome) and APH (particularly placental abruption). It may also complicate PPH due to 
other causes (Tone, Tissue, Trauma). The diagnosis should be suspected when bleeding 
continues despite the presence of an empty, well contracted uterus and in the absence of 
genital trauma. Management (cryoprecipitate, FFP, platelets, rVIIa) will be determined on an 
individualised basis after liaison with the on-call haematologist. 
 
 
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MAJOR POSTPARTUM HAEMORRHAGE 
 
1500 ml blood loss and still bleeding 
 
HELP 
 
Midwife   SpR   SHO   Anaesthetist     Anaesthetic Nurse    Senior Midwife     
 Health Care Assistant    Consultant Obstetrician 

POSITION 
 
rub-up contraction     lie flat    facial oxygen    dynamap      pulse oxymeter 

IV ACCESS 
 
2 x 16 (grey) gauge cannulae    FBC    clotting    UE    cross-match blood 
 
colloid infusion under pressure    blood transfusion 
b 
VE 
 
empty bladder    expel clot    determine cause 
 
Tissue 
 
 
    Trauma    
    Tone 
 
    Thrombin 
 
retained placenta   
 genital trauma  
uterine atony   
   abnormal clotting 
↓ 
 
 
 
↓ 
 
 
↓ 
 
 
↓ 
     analgesia  
 
compress wound      bimanual   
      liaise with 
↓ 
 
 
 
↓  compression 
  
 
haematologists 
  manual removal   
     analgesia   
 
↓ 
 
  
 
 
 
 
↓  IV 
ergometrine 
  
 
 
       repair 
 
 
↓ 
 
  
 
 
 
 
 
IM carboprost or misoprostil 
 
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15.4  THE ROLE OF STAFF DEALING WITH PPH 
 
Resuscitation of women experiencing PPH is the joint responsibility of her attending midwife, 
senior labour ward midwife, Obstetric SpR and SHO and the anaesthetist. Liaison between all 
staff members is essential. Demarcation of roles in advance is often impractical, but the 
following sections suggest areas in which each member of staff might be best employed: 
 
Midwife 
 
•  call for help 
•  lie the woman flat 
•  rub up a contraction 
•  high flow oxygen @ 8L / minute 
•  administer ergometrine 500 mcg IV 
•  set up a colloid infusion 
•  record P, BP, SAO2 every 5 minutes 
•  record fluid in / out 
•  record administration of drugs 
•  support the family 
 
Lead Midwife 
 
•  ensure all appropriate staff attending 
•  ensure blood products being retrieved 
•  liaise with SpR, anaesthetist and Consultant Obstetrician if necessary 
 
Health Care Assistant / Support worker 
 
•  retrieve blood products from Blood Bank / Theatres 
•  support the family 
 
SHO 
 
•  site two large bore venflons (16G or larger) 
•  FBC, clotting, UE, cross-match blood 
•  liaise with SpR, anaesthetist and blood bank 
 
SpR     **team leader** 
 
•  call for help 
• bimanual 
compression 
• Foleys 
catheter 
•  assess TTTT and initiate response specific to cause of haemorrhage 
•  estimate and record blood loss 
•  determine need for transfusion 
•  contact Consultant Obstetrician if blood loss over 1500 ml or theatre being considered 
 
 
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Anaesthetist 
 
•  maintain the airway 
• maintain 
breathing 
• maintain 
circulation 
•  arterial blood gases 
•  estimate and record blood loss 
•  determine need for transfusion 
•  consider need for CVP 
•  liaise with Consultant Anaesthetist where appropriate 
 
Anaesthetic nurse 
 
•  run fluid through 
•  get pressure bag 
•  get blood warmer 
•  get monitoring stack 
 
15.5 SECONDARY 

PPH 
 
In the event of secondary PPH arising in a woman at home up to 6 weeks post partum, 
ambulance transfer should be arranged for admission directly to Women’s Services rather 
than A&E. MAU review is usually appropriate but transfer to the Delivery Suite may be 
arranged directly if the woman is bleeding heavily. 
 
When managing secondary PPH, bear in mind that infection is likely to complicate the clinical 
picture. Retained products are common and may lead to both uterine atony and coagulopathy. 
 
Initial resuscitation may follow the scheme set out in the Major PPH Drill. Assessment should 
include abdominal palpation and speculum examination, at which time a high vaginal swab is 
worthwhile. If the uterus is atonic and the cervical os is gaping, retained products are likely. 
 
Abdominal ultrasound performed by a trained operator may show tissue in utero or delineate 
an irregular cavity. A negative scan does not completely exclude retained products however. 
 
Treatment with intravenous antibiotics is advisable before any attempt is made to empty the 
uterine cavity: 
 
•  co amoxyclav 1.2 gm IV tds 
 
Major haemorrhage may require evacuation of the uterus under anaesthetic without delay but 
in a woman who is clinically stable, it is reasonable to delay uterine evacuation for up to 24 
hours to allow the antibiotics to take effect. 
 
Post-operative treatment for 5 days with 375 mg oral co amoxyclav is recommended. 
 
 
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Evacuation of retained products of conception 
 
Written consent should be obtained for examination under anaesthetic and evacuation of 
retained products. The following risks should be documented, but balanced against the risks of 
no intervention: 
 
• infection 
•  trauma to uterus 
• bleeding 
•  perineal breakdown and resuturing 
 
The anaesthetist should be informed and will determine the form of analgesia to be used after 
discussion with the patient. 
 
Evacuation retained products should be by an experienced or supervised.. Digital examination 
of the uterine cavity should first be attempted. Exploration of the cavity with a blunt curette or 
ovard forceps may be required however.  
 
Treatment with drugs such as ergometrine or rectal misoprostol at the end of the procedure 
may be useful if the uterus is atonic but treatment is at the discretion of the obstetrician. 
 
15.6 BLOOD 
TRANSFUSION 
 
The decision to transfuse blood or other blood products, the volume of transfusion and the 
urgency required will be based upon several factors: 
 
•  estimated and measured blood loss to date 
• ongoing 
bleeding 
• clinical 
condition 
•  response to colloid / crystalloid 
•  intercurrent illness  
•  last recorded haemaglobin 
 
A decision to use blood products should weigh the potential benefits against the potential 
complications of transfusion, including: 
 
 
• transfusion 
reaction 
•  bactorial, viral or prion infection 
•  adult respiratory distress syndrome 
 
The attending SpR or Consultant Obstetrician and the anaesthetist should discuss these 
factors and the outcome of this discussion should be recorded in the patient’s notes.  
 
If the use of FFP, cryoprecipitate or platelets is being considered, the SpR or anaesthetist 
should liaise directly with the on-call haematologist and the Consultant Obstetrician should be 
made aware of the situation. 
 
 
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Urgency of blood requirement 
 
The table below represents a reasonable response when dealing with PPH in a woman 
weighing 60 kg at booking. Note that small women and women with pre-eclampsia are less 
tolerant of blood loss than other women.  
 
Estimated blood loss (ml)  Degree of urgency 
Request 
 
 
 
over 1000, bleeding 
Urgent (1 hour) 
Urgent cross-match 4 
controlled 
units 
 
over 1000, actively 
Very Urgent (30 minutes) 
Type-specific 6 units 
bleeding 
 
Over 2500 

Emergency (15 minutes) 
O Rh negative 2-4 units, 
then Type-specific as 
required 

 
Transport of blood in an emergency 
 
•  If blood required urgently the lead midwife should ensure that a appropriately trained 
member of staff is dispatched to retrieve it from the blood bank 
•  Between 0900 hrs – 1700 hrs either an appropriately trained member of staff or a porter 
should be asked to retrieve the blood urgently. 
•  After 1700 hrs a porter must be asked to retrieve the blood urgently 
•  Blood products should be transported in the red box available 
•  All blood products collected must be used immediately and not stored on unit or in the red 
box 
 
Safety issues 
 
•  transfusion of each unit of blood should begin within 30 minutes of retrieval from the fridge 
•  transfusion of each unit of blood should be complete within 4 hours of issue 
•  blood warmers should be used 
•  unused blood should be returned to Blood Bank within 30 minutes, otherwise it is 
discarded 
 
The Blood Fridge 
 
BLOOD MUST NOT BE STORED IN ANY OTHER FRIDGE OTHER THAN THE BLOOD 
BANK FRIDGE 
 
•  the blood fridge is situated in Path Lab, Lower Ground Floor, CIC 
•  the blood fridge is situated at the end of the corridor leading to outpatients at WCH 
 
Any blood removed from the fridge should be signed out  
 
 
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More about O Rhesus negative blood 
 
•  ensure that a pre-transfusion specimen of blood for group and cross match has been 
taken from the patient even when O Rhesus negative blood is going to be administered 
•  if you are considering giving a woman with red cell antibodies some O Rhesus negative 
blood, inform blood transfusion because haemolytic reactions can occur 
 
Refusal of blood products 
 
•  see Chapter 16 
•  the Consultant Obstetrician should be informed when any woman who will refuse blood 
transfusion is admitted in labour 
•  labour should be managed routinely, by an experienced midwife, in the first instance 
•  if caesarean section is needed, this should be performed by the Consultant Obstetrician 
wherever possible 
•  syntometrine should be given when the baby is delivered, with controlled cord traction and 
guarding for the third stage. In the first hour after delivery, the midwife should not leave the 
woman unattended 
•  if haemorrhage occurs, detection and resuscitation should be prompt. The threshold for 
intervention should be lower than in other cases. Blood loss should be quantified as 
carefully as possible throughout 
•  standard management should be commenced using the PPH drill but in addition the 
Consultant Obstetrician, Consultant Anaesthetist and Consultant Haematologist should be 
informed at an early stage 
•  colloid and crystalloid (but not Dextran) should be used in place of blood in the 
resuscitation process 
•  In very exceptional circumstances it may be appropriate to discuss the use of recombinant 
factor VIIa (rVIIa) with the haematologist as explained below. This expensive drug may 
only be used as directed by the haematologist in exceptional circumstances. 
•  when bleeding continues, the prothrombin time should be checked. An attempt may be 
made to correct this with vitamin K if abnormal, after discussion with the haematologist 
 
Vitamin K Infusion 
 
 
Abnormal prothrombin time ? 
 
 
 
 
 
 
↓ 
Dilute 5 mg konakion MM in 50 ml 5% glucose 
 
 
↓ 
 
 
 
 
 
 
     up to 25mg in 24 hours 
 
Slow IV bolus over 5 minutes 
 
 
↓ 
 
Repeat prothrombin time after 3 hours 
 
•  early recourse to laparotomy, internal iliac artery ligation and subtotal or total hysterectomy 
should be considered.  
•  post-operative recovery will normally be on the Intensive Care Unit and the use of 
erythropoietin, parenteral iron, protein supplements and hyperbaric oxygen should be 
considered in cases of severe anaemia 
•  the use of tranexamic acid, desmopressin and methylprednisolone should be considered if 
the patient continues to bleed post-operatively 
 
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Publication Date:  22/01/2008 
Version 2.0 
 
 
Trust policy for the medical treatment of Jehovah’s Witnesses 
 
The Trust’s general statement of policy in treating Jehovah’s Witnesses has been included in 
these Guidelines as an Appendix. This deals with the legal issues of competence and 
consent. 
 
15.7  RECOMBINANT FACTOR VIIA 
 
Recombinant factor VIIa may be a useful treatment in patients with severe haemorrhage 
despite attempts to correct coagulopathy and optimal surgical management. It is only 
appropriate to consider rFVIIa use when the following general points apply: 
 
Severe haemorrhage from multiple sites particularly bleeding from large raw areas despite 
attempting local measures to control. 
 
Severe haemorrhage despite attempts to correct coagulopathy with fresh frozen plasma, 
cryoprecipitate and platelets. In particular attempts to raise the fibrinogen level to >1g/l and 
platelets >20x109/l should have been undertaken prior to rFVIIa use. 
 
Continued brisk bleeding despite correction of coagulopathy and optimal surgical 
management. 
 
General management of patient is optimal – including correction of hypothermia. 
 
For maximum benefit, rVIIa should be given prior to the onset of the complications associated 
with massive transfusion. Do not use rFVIIa if overall outlook is so poor that arresting 
haemorrhage is unlikely to improve outcome. 
 
Specific indications for the use of rFVIIa 
 
Surgical 
Severe peri or post operative haemorrhage refractory to conventional 
management 
 
Coagulopathy 
Non-surgical haemorrhage associated with coagulopathy refractory to 
conventional managment 
 
Obstetric 
Severe obstetric haemorrhage requiring consideration of internal iliac artery 
ligation, uterine artery embolisation or hysterectomy. 
 
or 
 
Severe obstetric haemorrhage in women refusing blood products, when 
exsanguination appears possible. 
 
Neonatal 
Massive neonatal haemorrhage 
 
 
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Specific contra-indications for the use of rFVIIa 
 
rFVIIa may occasionally be associated with thrombosis. It should be used with caution if there 
is evidence of established disseminated intravascular coagulation. 
 
Authorisation and dose 
 
The use of rFVIIa should be approved by the duty Consultant Haematologist. As many of 
these patients are seriously ill early involvement of the duty ITU consultant is essential. 
 
rFVIIa; NovoSeven 90ug/kg rounded up to the next whole vial (1.2 + 2.4mg vials), repeated at 
3hrs if indicated. If there has been no response after 2 doses, further doses should not be 
administered. To facilitate availability, a stock of rFVIIa will be held in hospital blood banks. 
 
Assessment of response 
 
Response should be assessed on clinical grounds, including reduction or cessation of 
haemorrhage and the need for further blood product support pre/post rFVIIa administration. 
 
Assessment of safety 
 
A coagulation screen and D-Dimers should be checked immediately before and 15 minutes 
after rFVIIa administration. All patients should undergo bilateral lower limb ultrasound to check 
for DVT 3-5 days following rFVIIa administration 
 
Audit 
 
A central register of patients who receive rFVIIa is held and prospective audit of the protocol is 
undertaken to assess the appropriateness and safety of rFVIIa use. The details of all patients 
who receive rFVIIa as well as any comments about this protocol should be sent to Dr John 
Hanley, Consultant Haematologist, RVI (Tel: 24170; email: xxxx.xxxxxx@xxxx.xxx.xx). 
 
 
 
 
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15.8 
 INITIAL MANAGEMENT OF MASSIVE HAEMORRHAGE – 
ORGANISING THE TEAM 
 
HEAD 
 
• Check 
AIRWAY 
• Check 
BREATHING 
• Administer 
OXYGEN 
• Lie 
FLAT 
•  Note time of relevant EVENTS 
• Reassure 
woman 
(& partner)
ARMS 
 
Check PULSE and BP 
•  Establish LARGE BORE IV ACCESS x2 
•  Check FBC, CLOTTING, X-MATCH 4-6 units  
•  Start FLUID RESUSCITATION (initially x2L 
crystalloid) 
 
• Give 
DRUGS: 
1.  ERGOMETRINE 500microg IV/IM 
2.  SYNTOCINON IV INFUSION (10U/hour) 
3. CARBOPROST  or  PGF2α [‘HEMABATE’] 
250microg IM – repeat after 15mins  (maximum 
x 8 doses- if > 2 doses should consider moving 
to operating theatre) 
4.  Consider MISOPROSTOL 800microg PR 
UTERUS 
START HERE - CALL FOR HELP (ensure adequate and appropriate) 
• RUB-UP 
CONTRACTION 
• CO-ORDINATE: 
o  Helper 1 at ‘HEAD’ 
o  Helpers 2 & 3 at ‘ARMS’ 
•  IF BLADDER FULL or PALPABLE - CATHETERISE  
•  IF ATONY PERSISTS – APPLY BIMANUAL COMPRESSION 
•  REVIEW OTHER CAUSES – 4 ‘T’s (Tone, Trauma, Tissue, Thrombin) 
•  MOVE EARLY TO OPERATING THEATRE IF BLEEDING PERSISTS 
 
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References: 
 
Better blood transfusion – Appropriate use of blood. DoH National Guidance HSC 2002/009. 
 
Better blood transfusion website   WWW.DOH.GOV.UK/BLOOD/BBT.HTM
 
B-Lynch C et al (1997) The B-Lynch surgical technique for the control of massive postpartum 
haemorrhage: and alternative to hysterectomy? Five cases reported. BJOG 104: 372-375. 
 
Drife J (1997) Management of primary post partum haemorrhage. BJOG 104: 275-277.  
 
Ferguson JE, Bourgeois FJ (2000) B-Lynch suture for postpartum haemorrhage. Obstet 
Gynecol
 95: 1020-1022. 
 
Johanson R et al (2001) Management of massive postpartum haemorrhage: use of a 
hydrostatic balloon catheter to avoid laparotomy. BJOG  108: 420-422. 
 
Moscardo F et al (2001) Successful treatment of severe intra abdominal bleeding associated 
with disseminated intravascular coagulation using recombinant activated Factor VII. Br J 
Haematol 
113: 174-176. 
 
Sokolic V et al (2002) Recombinant factor VIIa (rFVIIa) is effective at massive bleeding after 
caesarean section -–a case report. Coll Antropol 26: 155-157. 
 
Zupancic SS et al (2002) Successful use of recombinant factor VIIa for massive bleeding after 
caesarean section due to HELLP syndrome. Acta Haematol 108: 162-163. 
 
Roger Neuberg & Kim Hinshaw - ALSO(UK) © – February 2005 
 
NCHE-OBS001 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
CHAPTER 16 - MANAGEMENT OF WOMEN REFUSING BLOOD 
TRANSFUSION 
 
 
 

16.1 
BOOKING .........................................................................................................161 
16.2 
ANTENATAL CARE ..........................................................................................161 
16.3 
LABOUR ...........................................................................................................161 
16.4 
HAEMORRHAGE..............................................................................................161 
16.5 
POSTNATAL CARE..........................................................................................162 
 
 
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16.1 BOOKING 
 
1. 
At the booking clinic all women are normally asked their religious beliefs.  If a woman is a 
Jehovah’s Witness, or it is felt that she is likely to refuse transfusion, she should be 
asked for her views and these noted in the case notes. 
2. 
If she asks about the risk of refusing blood transfusion she should be given all relevant 
information in a non-confrontational manner.  She should be referred to a consultant 
obstetrician for discussion. 
 
16.2 ANTENATAL 
CARE 
 
3. 
The woman’s blood group and antibody status should be checked during pregnancy in 
the usual way.  The haemoglobin and serum ferritin, if indicated, should be checked as 
normal. There is no indication to routinely give haematinics. 
4. 
There is no extra reason to identify the placental site in the last trimester. 
5.  There are well-described procedures for elective surgery in those refusing blood 
transfusion.  Some people will donate blood before surgery for subsequent auto-
transfusion if necessary, though others consider that this too is forbidden by their 
religion.  Blood storage should not be suggested to pregnant women, as the amounts of 
blood required to treat massive obstetric haemorrhage are far in excess of the amount 
that could be donated during pregnancy 
6.  If any signification complication is noted during the antenatal period, the consultant 
obstetrician must be informed. 
 
16.3 LABOUR 
 
7.  The consultant obstetrician should be informed when a woman who will refuse blood 
transfusion is admitted in labour.  Consultants in other specialities need not be alerted 
unless complications occur. 
8. 
The labour should be managed routinely by experienced staff. 
9. 
Oxytocics should be given when the baby is delivered.  The woman should not be left 
alone for an hour after delivery. 
10.  If Caesarean section is necessary it should be carried out by a consultant obstetrician if 
possible. 
11.  When the mother is discharged from hospital she should be advised to report promptly if 
she has any concerns about bleeding during the puerperium. 
 
16.4 HAEMORRHAGE 
 
12.  The principle of management of haemorrhage in these cases is to avoid delay.  Rapid 
decision-making may be necessary, particularly with regard to surgical intervention. 
13.  If unusual bleeding occurs at any time during pregnancy, labour or the puerperium, the 
Consultant Obstetrician should be informed and the standard management should be 
commenced promptly.  The threshold for intervention should be lower than in other 
patients.  Extra vigilance should be exercised to quantify any abnormal bleeding and to 
detect complications, such as clotting abnormalities, as promptly as possible. 
14.  Consultants in other specialities, particularly anaesthetics and haematology, are normally 
involved in the treatment of massive haemorrhage.  When the patient is a woman who 
has refused blood transfusion the consultant anaesthetist should be informed as soon as 
 
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Version 2.0 
 
possible after abnormal bleeding has been detected.  The consultant haematologist 
should also be notified, even though the options for treatment may be severely limited. 
15.  Dextran should be avoided for fluid replacement because of its possible effects on 
haemostasis.  Intravenous crystalloid and artificial plasma expanders, such as 
Haemocoel, should be used. 
16.  In cases of severe bleeding, Vitamin K should be given to the woman intravenously.  
Other drugs which have been recommended include Desmopressin, Methylprednisolone 
and Fibrinolytic Inhibitors, such as Aprotinin (Trasylol) and Tranexamic Acid.  The advice 
of the haematologist should be sought before considering the use of Heparin to combat 
disseminated intravascular coagulation. 
17.  The woman should be kept fully informed about what is happening.  Information must be 
given in a professional way, ideally by someone she knows and trusts.  If standard 
treatment is not controlling the bleeding, she should be advised that blood transfusion is 
strongly recommended.  Any patient is entitled to change her mind about a previously 
agreed treatment plan. 
18.  The doctor must be satisfied that the woman is not being subjected to pressure from 
others.  It is reasonable to ask the accompanying persons to leave the room for a while 
so that the doctor (with a midwife or other colleague) can ask her whether she is making 
her decision of her own free will. 
19.  If she maintains her refusal to accept blood or blood products, her wishes should be 
respected.  The legal position is that any adult patient (i.e. 18 years old or over) who has 
the necessary mental capacity to do so, is entitled to refuse treatment, even if it is likely 
that refusal will result in the patient’s death.  No other person is legally able to consent to 
treatment for that adult or to refuse treatment on that person’s behalf. 
 
16.5 POSTNATAL 
CARE 
 
20.  The staff must maintain a professional attitude.  They must not lose the trust of the 
patient or her partner as further decisions, i.e. about hysterectomy, may have to be 
made. 
21.  If the woman survives the acute episode and is transferred to an intensive care unit, the 
management there should include Erythropoetin, parenteral iron therapy and adequate 
protein for haemoglobin synthesis. 
 
 
 
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References: 
 
Busuttil D, Copplestone A (1995), Management of Blood Loss in Jehovahs Witness – BMJ 
311: 1115 – 1116 
 
Department of Health 91996) – The Treatment of Obstetric Haemorrhage in women who 
refuse blood transfusion.  Report in Confidential Enquiries into Maternal Deaths in UK – 1991 
– 1993, HMJO P 44 – 47 
 
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CHAPTER 17 - THROMBOSIS AND THROMBOPROPHYLAXIS 
 
 

 
17.1 
CHECKLIST FOR WOMEN NEEDING THROMBOPROPHYLAXIS.................165 
17.2 
CAESAREAN SECTION IN WOMEN TAKING THERAPEUTIC DOSES OF 
CLEXANE .........................................................................................................167 
17.3 
THROMBOPROPHYLAXIS FOR LABOUR ......................................................168 
17.4 
LABOUR IN WOMEN TAKING THERAPEUTIC DOSES OF CLEXANE ..........168 
17.5  
WARFARIN.......................................................................................................169 
 
 
 
 
 
 
 
 
 
 
 
 
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17.1  CHECKLIST FOR WOMEN NEEDING THROMBOPROPHYLAXIS 
 
On admission to the delivery suite in labour, the women’s risk status should be assessed and 
written in the box on Page 2 of the yellow notes.  If there are no risk factors on admission, 
please write “none” in the “other” box on Page 2. (This enables all carers to see the 
assessment has been done). 
 
NB:  For personal past history of VTE or thrombophilia see below.  With family history use 
clinical judgement e.g. DVT in an elderly relative following major surgery should not be 
regarded as a risk factor, but DVT in a sister on oral contraception should be.  If in doubt, ask 
medical staff or include as a risk factor. 
 
Following delivery please tick all boxes on Page 19 that are relevant.  These together with any 
risk factors identified on admission will determine whether thromboprophylaxis is required.  
Again if there are no risk factors please write “none”. 
 
1. 
Thromboprophylaxis in Vaginal Deliveries 
 
Patients with two or more risk factors will require thromboprophylaxis in the form of 
Enoxaparin. 
 
After delivery add the risk factors from the box on Page 19 of the yellow delivery notes and if 
the patient has two or more risk factors (total from both page 2 and 19), give 
thromboprophylaxis. 
 
2. 
Thromboprophylaxis for Caesarean section 
 
Elective C/S:
  These patients should have thromboprophylaxis if one or more risk factors 
present.   See checklist on Page 2 and Page 19 for risk assessment. 
 
Emergency C/S: All patients undergoing emergency Caesarean section should have 
thromboprophylaxis. 
 
Caesarean section in patients already taking prophylactic clexane 
 
At least twelve hours should elapse between the administration of prophylactic clexane and 
the use of regional anaesthesia. If elective caesarean section is being performed, the 
morning’s clexane should be omitted and the patient should be fitted with compression 
stockings. The ante natal dose of clexane should be administered after closure of the uterus 
although it may be delayed for up to four hours on clinical grounds if requested by the 
surgeon. Once daily prophylaxis will then usually be continued for six weeks postpartum. In 
the event of an emergency caesarean, if clexane has been administered within twelve hours 
of the surgery, general anaesthesia will usually be necessary. 
 
3. 
Personal past history of VTE and/or Thrombophilia 
 
Ideally a plan should have been made antenatally for these patients.  If not, these patients 
should have thromboprophylaxis in the form of Enoxaparin injections for six weeks postnatally. 
 
 
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DOSE OF ENOXAPARIN: 
 
Body weight <50 kg  
20 mg once daily s.c. 
Body weight 50-90 kg 
40 mg once daily s.c. 
Body weight > 90 kg 
40 mg twice daily s.c. 
 
DURATION 
 
Patients with two risk factors should have Enoxaparin until day 5 postnatal or discharge, 
whichever earlier. 
 
Patients with three or more risk factors should have Enoxaparin for at least three days if early 
discharge or until day 5 if still an in-patient. 
 
Patients with a past history of VTE and/or thrombophilia should have Enoxaparin for six weeks 
postnatally or as otherwise determined by Consultant or Haematologist. 
 
DOCUMENTATION 
 
CAESAREAN SECTION OR INSTRUMENTAL DELIVERY: 
 
Medical staff must ensure the post operative instructions (Page 17) are completed 
immediately following the procedure. 
 
Contraindications to clexane 
 
Clexane (and other forms of heparin) should not be used in the following circumstances: 
 
•  previous systemic allergic reaction to any heparin 
•  abnormal liver function leading to deranged clotting 
•  abnormal renal function leading to deranged clotting 
•  thrombocytopenia with platelet count below 20 x 109 /l 
 
When a woman in whom clexane is contraindicated needs caesarean section, compression 
stockings should be fitted in addition to Flowtron or sequential compression stockings. These 
may be obtained from Main Theatres. Pay careful attention to hydration post operatively. 
 
 
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17.2  CAESAREAN SECTION IN WOMEN TAKING THERAPEUTIC DOSES 
OF CLEXANE 
 
Emergency caesarean section 
 
If a woman has had a recent thromboembolism, she may require an emergency caesarean 
section despite having recently taken a high dose of clexane (175 units /kg /day). Such 
women are at an increased risk of intra operative and post partum haemorrhage. In these 
circumstances: 
 
•  omit any further clexane due to be administered prior to or during surgery 
•  fit compression stockings 
•  site a large bore cannula 
•  check her full blood count, APTT and anti Xa assay 
•  cross match 4 units of blood 
 
Inform: 
• Consultant 
Obstetrician 
• Consultant 
Anaesthetist 
• 
Haematologist on call 
 
It is unlikely that regional anaesthesia will be available to the woman in these circumstances, 
but the anaesthetist will determine this.  
 
In the event of haemorrhage during or after surgery, standard measures should be taken but 
close liaison with the on call haematologist is mandatory. Protamine may be given after 
discussion with the on call haematologist. This will reverse approximately 90 % of the anti IIa 
activity of the heparin but will only reverse about 60-85 % of its anti Xa activity. 
 
Clexane should be reinstituted at the full therapeutic dose according to its previous schedule 
or four hours after completion of the caesarean section, whichever is the later. The woman 
should be encouraged to continue to wear her compression stockings for six weeks post 
partum. 
 
Elective caesarean section 
 
If a woman taking therapeutic clexane is to have an elective caesarean, an individualised plan 
of care will be available in her antenatal notes. For example, on the day of surgery: 
 
•  she may be commenced on an infusion of unfractionated  heparin with dose adjustment 
according to APTT assay, then have the infusion stopped shortly before surgery, or… 
•  she may simply have her clexane omitted on the day of surgery.  
 
Compression stockings should be fitted and good hydration maintained. 
 
The full therapeutic dose of clexane should be recommenced according to its previous 
schedule or four hours after completion of the caesarean third stage, whichever is the later. 
 
 
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17.3  THROMBOPROPHYLAXIS FOR LABOUR 
 
Labour in women already on prophylactic doses of clexane 
 
The obstetric notes will include a plan of action for management in labour. This will usually 
involve fitting compression stockings on arrival and omitting any clexane due to be given 
during labour. Therapy should be recommenced four hours after delivery or four hours after 
removal of the epidural catheter, whichever is later. The subsequent planned duration of 
therapy will be documented in the notes. It is not necessary to check the APTT in labour. 
 
Induction of labour in women taking prophylactic doses of clexane 
 
The principles outlined above apply. Clexane should be omitted on the first day of induction 
and compression stockings fitted. Any clexane due to be given once labour has established 
should also be omitted. Prophylactic clexane should be recommenced four hours after 
delivery or four hours after removal of the epidural catheter, whichever is the later. 
 
Epidural anaesthesia will not be available for at least twelve hours after the administration of a 
prophylactic dose of clexane. 
 
17.4  LABOUR IN WOMEN TAKING THERAPEUTIC DOSES OF CLEXANE 
 
If a woman has had a recent thromboembolism, she may present in labour while taking higher 
doses of clexane (175 units /kg /day). Such women are at an increased risk of intra partum 
and post partum haemorrhage. In these circumstances: 
 
•  omit any further clexane due to be administered during labour 
•  fit compression stockings 
•  site a large bore cannula 
•  check her full blood count, APTT and anti Xa assay 
•  cross match 4 units of blood 
 
Inform: 
• Consultant 
Obstetrician 
•  anaesthetist on call 
•  haematologist on call 
 
It is unlikely that regional anaesthesia will be available to the woman in these circumstances, 
but the anaesthetist will determine this.  
 
In the event of haemorrhage, standard measures should be taken but close liaison with the on 
call haematologist is mandatory. Protamine may be given after discussion with the on call 
haematologist. This will reverse approximately 90 % of the anti IIa activity of the heparin but 
will only reverse about 60-85 % of its anti Xa activity. 
 
Clexane should be reinstituted at the full therapeutic dose four hours after completion of the 
third stage of labour or four hours after removal of the epidural catheter, whichever is the later. 
The woman should also be encouraged to continue to wear her compression stockings for 6 
weeks post partum. 
 
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Induction of labour in women taking therapeutic clexane 
 
If a woman taking therapeutic doses of clexane is being induced, an individualised plan of 
care will be available in her antenatal notes. For example: 
 
•  she may be commenced on an infusion of unfractionated  heparin with dose adjustment 
according to APTT assay, then have the infusion stopped when labour is established, or… 
•  she may be given a reduced dose of clexane (50 units /kg /day) during the initial stages of 
the induction process then have her clexane omitted in active labour 
•  compression stockings should be fitted and careful attention paid to maintaining mobility 
and good hydration 
•  the full therapeutic dose of clexane should be recommenced four hours after completion of 
the third stage or four hours after removal of the epidural catheter, whichever is the later. 
 
17.5   WARFARIN 
 
Few women taking warfarin will attend in labour. If this does occur however, a large bore 
cannula should be used to gain venous access, FBC and INR should be checked and 
repeated twelve hourly, or more frequently in the event of haemorrhage, and four units of 
blood should be cross-matched. Warfarin should be withheld from the onset of labour and until 
six hours post delivery. Regional anaesthesia will not normally be offered to women taking 
warfarin. 
 
In addition to the Consultant Obstetrician, the Haematology Consultant must always be 
contacted if a woman on warfarin attends Delivery Suite in labour. Treatment will depend upon 
the INR and the presence or absence of bleeding, but all such women are at high risk of 
bleeding. In general, the haematologist will recommend one or other of the following: 
 
•  vitamin K (iv preparations are preferred to oral preparations in labouring women) 
• FFP 
•  prothrombin complex concentrate (Beriplex) 
 
These should not be prescribed until a discussion has taken place with the haematologists. 
 
Traumatic obstetric delivery should be avoided to safeguard the baby. All ventouse deliveries 
and rotational forceps deliveries are contraindicated while gentle non-rotational forceps should 
only be attempted if the fetal head lies in an occipito anterior position, at least 2 cm below the 
ischial spines. 
 
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References 
 
Bates SM, Ginsberg JS (2002) How we manage venous thromboembolism during pregnancy. 
Blood 100: 3470-3478. 
 
Crowther MA et al (2002) Mechanisms responsible for the failure of protamine to inactivate 
low molecular weight heparin. Br J Haematol 116: 178-186. 
 
Ellison J, Walker ID, Greer IA (2000) Antenatal use of enoxaparin for prevention and 
treatment of thromboebolism in pregnancy. BJOG 107: 1116-1121. 
 
Greer IA, Thompson AJ (2001) Thromboembolic disease in pregnancy and the puerperium: 
acute management. RCOG Clinical Green Top Guidelines, RCOG Press, London, UK.  
 
Hainer JW et al (2002) Dosing in heavy weight / obese patients with the LMWH, clexane: a 
pharmacokinetic study. Thromb Haemost 87: 817-823. 
 
Horlocker TT, Wedel DJ (1998) Neuraxial block and low molecular weight heparin: balancing 
perioperative analgesia and thromboprophylaxis. Regional Anaesthesia and Pain Medicine 
23: 164-177. 
 
Nelson-Piercy C (2004) Thromboprophylaxis during pregnancy, labour and after vaginal 
delivery. RCOG Clinical Green Top Guidelines, RCOG Press, London, UK. 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
CHAPTER 18 - CAESAREAN SECTION, VAGINAL BIRTH AFTER 
CAESAREAN SECTION AND LAPAROTOMY 
 
 
 
The guidelines presented in this section are compatible with the RCOG / NICE Guidelines on 
Caesarean Section published in 2004.  Hard copies of the RCOG NICE document are located 
on the Delivery Suite. 
 
18.1 
ELECTIVE CAESAREAN SECTION.................................................................172 
18.2 
EMERGENCY CAESAREAN SECTION ...........................................................174 
18.3 
THE PROCEDURE ...........................................................................................176 
18.4 
ANALGESIA AFTER CAESAREAN SECTION .................................................179 
18.5 
CAESAREAN SECTION FOR PLACENTA PRAEVIA ACCRETA ....................180 
18.6 
CAESAREAN SECTION WITHOUT HEALTH INDICATIONS ..........................181 
18.7 
LAPAROTOMY .................................................................................................181 
18.8 
FEMALE STERILISATION................................................................................182 
18.9 
RECOVERY......................................................................................................182 
18.10 
VAGINAL BIRTH AFTER PREVIOUS CAESAREAN SECTION.......................183 
18.11 
PROPHYLACTIC ANTIBIOTICS FOR CAESAREAN SECTION ......................186 
18.12 
THROMBOPROPHYLAXIS IN PATIENTS RECEIVING SPINAL OR EPIDURAL 
ANAESTHESIA .................................................................................................186 
 
 
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18.1  ELECTIVE CAESAREAN SECTION 
 
These guidelines are provided to ensure that this operation is carried out in as safe a manner 
as possible. 
 
Indications for an elective caesarean section 
 
Elective caesarean may be performed for one or more of a number of different reasons, such 
as: 
 
• placental 
praevia 
• breech 
presentation 
•  transverse or unstable lie 
•  previous caesarean section 
•  previous third degree tear after vaginal delivery 
 
This is not an exhaustive list and the conditions listed are relative rather than absolute 
indications for caesarean. 
 
Booking an elective caesarean section 
 
The decision to perform an elective caesarean is most commonly made or confirmed in 
antenatal clinic at about 20 or 36 weeks gestation. It should always be made by the 
Consultant Obstetrician.   
 
There are 2 slots available on each caesarean section list.  If the list is already fully booked 
please discuss with Consultant Obstetrician. 
 
Except where clinically otherwise indicated, elective caesareans should be booked to take 
place no earlier than 39 +0 weeks gestation, based upon ultrasound dating. 
 
The woman’s details should always be recorded in the planned delivery diary, including her 
name, ID number, parity, gestation and the indication for caesarean.  
 
In the Antenatal Clinic the woman should be given a patient information leaflet confirming the 
date of her caesarean section. 
  
Pre Op Fasting Guidelines  
(See Chapter 19.6) 
 
Consent for the operation 
 
The clinician performing the caesarean section should obtain written consent on NHS Consent 
Form 2
. The following should be discussed and clearly documented: 
 
•  the indication for the procedure 
•  the intended benefits 
 
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•  serious or frequently occurring potential complications, including complications that can 
occur after vaginal birth but that are more likely after caesarean section, including: 
 
• haemorrhage 
 
• blood 
transfusion 
•  possible requirement for return to theatre 
•  infection- wound infection or UTI  
• thromboembolism 
•  visceral injury, notably bladder trauma 
•  cut to the baby (approximately a 2 % risk) 
 
Women considering having a caesarean should be told that they are likely to have more 
abdominal pain but less perineal pain than women giving birth vaginally. It may also be more 
difficult to establish breast feeding after caesarean but once established, birth by caesarean 
leads to no ongoing disadvantage. Finally, the average length of hospital stay is longer after 
caesarean section than after vaginal birth. 
 
The emphasis of this discussion will vary with the previous clinical history and present clinical 
circumstances. 
 
Consent for anaesthesia 
 
The clinician booking a caesarean section and obtaining initial consent should explain that in 
most cases, the operation is performed under regional anaesthesia. An anaesthetic review will 
however be performed either in the pre operative assessment clinic or after the woman’s 
admission to hospital, prior to her operation. 
 
General anaesthesia is occasionally required, for example: 
 
•  major placenta praevia 
•  anatomical abnormalities of the lumbar spine 
 
Booking elective caesarean sections from the antenatal ward 
 
Occasionally the decision to perform an elective caesarean section is made while a woman is 
resident on the antenatal ward. In this case, the responsibilities of the medical staff remain 
unchanged. The midwife allocated to the woman’s care will liaise with delivery suite to ensure 
that the workload diary is completed appropriately. 
 
Organising the elective caesarean section list 
 
Elective caesarean sections should be performed within the confines of existing elective 
caesarean section lists unless these are fully booked. If they are fully booked the best time to 
add extra cases must be discussed with the Anaesthetic Department secretary and Lead 
Midwife on Delivery Suite. 
 
 
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Trust Policy on Consent 
 
The Trust Policy on Consent is available on the Trust Intranet at 
http://nww.northcumbriahealth.nhs.uk/link.asp?pid=4272&id=11638 
 
 
18.2  EMERGENCY CAESAREAN SECTION 
 
All emergency caesareans should be graded by the attending Obstetrician in conjunction with 
the attending midwife according to the scheme below. The grade should be recorded clearly 
on the partogram and on operative delivery note. In each case, the form of anaesthesia will be 
determined by the Anaesthetist after direct discussion with the attending Obstetrician: 
 
Grade 1 - Emergency 
Immediate threat to the life of mother or fetus 
This may occur because of a number of reasons. The following list is not exhaustive: 
♦ cord 
prolapse 
♦ uterine 
rupture 
♦ pH 
≤ 7.20 on fetal scalp sampling 
♦  ante partum haemorrhage with evidence of maternal or fetal compromise 
♦  pathological CTG when FBS is inappropriate such as profound prolonged bradycardia 
 
If the decision to delivery time is > 30 minutes please generate an adverse incident form. 
 
Grade 2 - Urgent  Maternal or fetal compromise not immediately life threatening  
This may occur because of a number of reasons. The following list is not exhaustive: 
♦  failed instrumental delivery 
♦  ante partum haemorrhage without evidence of maternal or fetal compromise 
♦  pathological CTG when FBS would be appropriate but is not possible (but see above) 
♦  failure to progress in the second stage of labour 
 
If the decision to delivery time is > 60 minutes please generate an adverse incident form 
 
Grade 3 - Scheduled 
No maternal or fetal compromise but needs early delivery 
This may occur because of a number of reasons. The following list is not exhaustive: 
♦  abnormal biophysical score with a normal CTG (care individualised by fetal medicine) 
♦  failure to progress in the first stage of labour with no evidence of fetal compromise 
♦  malpresentation in labour with no evidence of fetal compromise 
 
Grade 4 - Elective  Delivery Time to suit women and staff 
This encompasses elective procedures. 
  
Decision 
 
In most cases, the decision to perform an emergency caesarean will be made by the 
Specialist Registrar after discussion with the Consultant on call and the time of the decision 
should be recorded clearly on the partogram. Only in very urgent cases should the decision 
not be discussed with the Consultant first. In such cases another member of the Delivery Suite 
staff may be delegated to contact the on call Consultant. 
 
 
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Consent 
 
In most cases there will be sufficient time to obtain informed consent in the manner described 
above. Verbal consent alone is only acceptable in exceptional circumstances. 
 
Transfer to theatre 
 
This can take place as soon as the decision has been made to perform the caesarean section 
and the various personnel have been informed.  For some women with an epidural (WCH), 
the anaesthetist may prefer to top up the epidural in the delivery room prior to transfer to 
theatre. 
 
Responsibilities of personnel 
 
Surgeon 
responsible for obtaining consent and performing the operation.  
The surgeon should confirm the swab count. 
 
Assistant 
role is to ensure good venous access is gained prior to the 
procedure, to obtain full blood count, to group and save serum or 
cross match blood where needed and to assist at the procedure. 
 
Scrub nurse 
responsible for the operative equipment, for the instrument 
count, for the swab count and for maintaining the sterility of the 
operative field. 
 
Midwife 
responsible for the woman’s care up to the point of surgery, for 
the safety and conduct of the birth partner, for care of the infant 
unless the paediatrician is present. The midwife is also 
responsible for the care of the placenta after delivery - for the 
cord gas analysis, taking of appropriate Rhesus bloods and 
possible histology referral. 
 
Support worker  
aids the scrub nurse with the operative count, providing her / him 
with equipment, swabs and sutures as required. 
 
Anaesthetist 
responsible for the anaesthetic and the immediate medical care 
of woman. She / he will determine when the procedure may 
commence. 
 
Anaesthetic nurse/ODA  
assists the anaesthetist in providing adequate anaesthesia for 
the procedure. Is responsible for setting up adequate patient 
monitoring for the anaesthetic, and drawing up relevant 
anaesthetic drugs. 
 
Paediatrician 
responsible for the immediate resuscitation of the baby where 
requested to attend. It is her / his responsibility to check that the 
resuscitaire and its associated equipment is working properly. 
 
 
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18.3  
THE 
PROCEDURE 
 
This Guideline does not aim to be prescriptive in determining operative technique. Good 
practice points follow however. 
 
Bladder drainage 
 
•  emergency caesarean section… 
•  elective caesarean section with regional block… 
•  insert a 14 French gauge Foley 
 
This may be passed into the bladder at any time before the caesarean – often after insertion 
of the spinal anaesthetic, but occasionally in the delivery room following vaginal assessment. 
 
For an elective caesarean under GA, in-out catheterisation alone prior to surgery is 
acceptable but please ensure that such women pass urine within 6 hours of completion of the 
procedure. If not, fit a Foley. 
 
Foley catheters should be left in situ for at least 16 hours.  
 
Lateral tilt 
 
Lateral 15o tilt is recommended as it reduces the incidence of maternal hypotension. It is of no 
proven benefit to the baby. 
 
Skin incision 
 
Most caesareans are performed through a transverse abdominal incision 3 cm above the 
symphysis pubis even if a longitudinal uterine incision is being contemplated. An alternative 
approach should only be used by appropriately trained surgeons where clinically indicated. 
 
Abdominal entry 
 
Joel Cohen’s approach is the preferred option in most cases with blunt dissection of the 
tissues, using scissors rather than a knife if any sharp dissection is required. 
 
Uterine incision 
 
Usually the uterine incision will be transverse in the lower segment. After uterine entry in the 
midline, blunt lateral dissection is encouraged if the lower segment is well formed as this may 
reduce blood loss. If necessary, this incision may be extended by sharp proximal dissection 
from one angle to leave a J-shaped scar. 
 
Classical incision of the uterus comprises a longitudinal incision in the upper segment. This 
may be contemplated by an appropriately experienced surgeon in the management of anterior 
placenta praevia or in the presence of a fibroid uterus. 
 
A vertical De Lee incision in the lower segment may be employed in the delivery of a fetus 
under 28 weeks gestation. Consultant help should be available in such cases. If this incision is 
 
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extended into the upper uterine segment to facilitate delivery, it should be regarded as a 
classical caesarean section scar in future pregnancies. 
 
Care should be taken on final entry into the uterine cavity in order to avoid fetal injury. The use 
of Bonney scissers or similar rather than a scalpel is acceptable for final entry for this reason. 
 
Difficulty in delivering the head 
 
This can occur because of cephalic impaction or in contrast, because of poor cephalic 
engagement. The former may be remedied by an additional assistant pushing the fetal head 
up via the vagina but if this is undertaken, a 5 day course of co amoxyclav or an alternative 
broad spectrum antibiotic should then be prescribed. In the latter case, direct application of 
Neville Barnes, Wrigley’s forceps may help. 
 
Delivery of the placenta 
 
Manual removal of the placenta at caesarean section may lead to postnatal endometritis and 
so should be avoided.  
 
Use of blunt needles 
 
Blunt needles are less likely to perforate the operator’s, the assistant’s and the scrub nurse’s 
gloves than atraumatic needles. As a result, they significantly reduce needle stick injuries and 
should be considered by all surgeons performing caesarean sections. With practice they are 
no more difficult to use than sharp needles. 
 
Uterine closure 
 
There is some evidence that single layer uterine closure is associated with less intra operative 
blood loss than two layer closure. 
 
Bladder injury 
 
If the bladder wall in incised or torn during caesarean section. Repair will be with 2-0 vicryl, 
employing a 2 layer closure. Free drainage of the bladder should be maintained for a 
minimum of 10 days with a Foley catheter post operatively and follow up arranged.  
 
The peritoneum 
 
Non closure of visceral and parietal peritoneum shortens operative time and may be 
associated with more rapid reperitonisation of the abdomen than suturing. If peritoneal closure 
is thought necessary, the choice of technique lies with the surgeon. 
 
 
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Use of drains 
 
The surgeon should consider leaving a drain in situ when: 
 
•  intraoperative haemostasis has been difficult to achieve 
•  the uterine incision has been extended at delivery 
•  the woman has had multiple previous caesarean sections 
•  previous births have been attended by massive haemorrhage 
•  the indication for caesarean section was placenta praevia or abruption 
 
Drains should be removed at the discretion of the surgeon, usually 12 – 24 hours after 
significant drainage has ceased. 
 
Fat closure 
 
Routine closure of subcutaneous fat is not recommended. There is some evidence to suggest 
however that when this layer is greater than 2 cm in depth, closure of the subcutaneous tissue 
with an absorbable suture reduces the risk of wound infection. 
 
Skin closure 
 
The suture material for skin closure will usually be prolene or vicryl. Staples reduce glove 
perforation and needle stick injuries but they have significant cost implications. 
 
Antibiotic prophylaxis 
 
The likelihood of infection rises up to 20 fold after caesarean birth compared to vaginal birth, 
and may complicate as many as 10 % of caesarean wounds unless intra operative antibiotics 
are administered. To reduce infection rates a single dose of co amoxyclav 1.2 gm IV is known 
to be effective. This is given following delivery of the baby. It is the responsibility of the 
Obstetrician to ensure antibiotics are presented and given.  This will usually be carried out by 
the Anaesthetist.  For penicillin allergic women, an alternative broad spectrum antibiotic, e.g. 
Gentamicin 5mg/kg + Clindamycin 600 mg, should be given. 
 
Thromboembolic prophylaxis 
 
Patients undergoing caesarean section are at high risk of developing postnatal venous 
thrombosis. The first dose should be given within 6 hours of surgery then continued for at 
least five days on a once daily basis. Longer periods of prophylaxis should be considered for 
women who remain immobile beyond this time. The dose varies with the patient’s weight at 
initial booking in pregnancy: 
 
 
•  at 8 am each morning, give… 
•  3500 iu for women who are 60-100 kg 
•  50 iu / kg for women below 60 kg or above 100 kg. 
 
 
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Birth partner 
 
One birth partner may accompany a woman in theatre when she is having a caesarean under 
regional block. Interpreters should be allowed into theatre in addition to the birth partner. The 
birth partner should be shown where to change into appropriate scrubs and shoes. If the birth 
partner causes disruption, he / she should be escorted from theatre by the attending midwife. 
 
Skin to skin 
 
Early skin-to-skin contact should be encouraged between mother and baby. This does not 
need to be delayed until the caesarean has been completed. To achieve this take the 
following steps:  
 
• 
maternal discussion and consent 
• 
the abdominal drape is fastened to an IV stand each side of the woman. 
• 
baby born caesarean section 
• 
cord clamped and cut by surgeon 
• 
midwife wearing gown and gloves lifts baby from table 
• 
midwife places baby skin to skin under drapes 
• dries 
baby 
• 
clean towel placed on top of baby  
 
18.4  ANALGESIA AFTER CAESAREAN SECTION 
 
Prescribed by anaesthetist.  Reviewed as indicated (minimum daily) by obstetric medical ward 
staff for side-effects or complications please. 
 
1. 
MORPHINE  Usually needed for first 24 hours only 
 
IM 10-15 mg 3 hourly PRN (+ antiemetic prescribed). 
 
2. 
DICLOFENAC 
 
i. 
100 mg PR on completion of Caesarean 
ii. 
50 mg oral tds for up to 5 days.  First dose after first solid food. 
 
CAUTION:  Contradinications include history of GI bleeding, anticoagulant treatment and 
sensitivity to other NSAIDs including aspirin. 
 
3. 
PARACETAMOL 
 
1 Gm 5 hourly for up to 5 days.  First dose as soon as oral fluids are tolerated. 
 
4. CODEINE 
 
30 – 60 mg 4 hourly PRN up to 240 mg / day. 
 
Regular codeine should be given to patients in whom diclofenac is contraindicated. 
 
 
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18.5  CAESAREAN SECTION FOR PLACENTA PRAEVIA ACCRETA 
 
Placenta praevia accreta is an indication to consider transfer to tertiary care. 
 
Consent and plan of action 
When placenta praevia accreta is suspected in a pregnant woman, possible clinical sequelae 
should be made apparent to her at an early stage and a clear plan of management set out in 
the medical records.  Wherever possible, this plan of management should be conveyed to all 
Obstetric and Anaesthetic Consultants in the hospital in advance of the likely date for delivery. 
Issues to be discussed with the woman should include those relating to: 
 
♦ surgical 
management 
♦ anaesthetic 
management 
♦ haematological 
interventions 
♦ paediatric 
interventions 
 
Anaesthetic considerations 
 
♦ general 
anaesthesia 
♦  central venous access 
♦ arterial 
line 
♦  flowtron boots and TED stockings 
Withhold enzaparin until six hours after the procedure then give 50 iu/kg booking weight for a 
minimum of 5 days. 
Additional theatre equipment  
 
♦  B Lynch suture 
♦  hysterectomy tray  
♦ Cooke 
catheter 
♦  cystoscope and imaging  
♦  pigtail stents and size 4 and 6 infant feeding tubes 
 
Surgery 
 
♦  Consultant Obstetrician and Gynaecologist should perform the procedure 
♦  try to ascertain the availability of a Consultant Vascular Surgeon before surgery 
commences 
♦  low transverse incision is adequate in most cases 
♦  placental invasion of the bladder should be assessed before the uterus is incised 
♦  inspection of the uterus may help to determining the best site for uterine incision 
♦  classical incision over the uterine fundus may be required 
♦  B-Lynch and cervical compression sutures may reduce bleeding after placental delivery 
If haemostasis is then inadequate proceed to hysterectomy. Note that early recourse to 
hysterectomy and bladder repair should be considered if the placenta accreta involves the 
bladder. 
 
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Blood availability 
 
A Consultant Haematologist should be aware that the operation is being carried out. It would 
be reasonable to request: 
♦  cross matched blood in theatre 
♦  FFP in theatre 
♦  recombinant factor VIIa in theatre 
 
Liaison with Paediatrician 
 
This is essential as many of these procedures are carried out before full term and the neonate 
may suffer blood loss during surgery, prior to birth. 
 
18.6  CAESAREAN SECTION WITHOUT HEALTH INDICATIONS 
 
When a caesarean section is requested by a woman without clear physical or psychological 
health indications, there is no compulsion upon the part of the Consultant Obstetrician to 
accede to the request. The relative risks and benefits of the procedure must be discussed with 
the patient and a decision reached based upon the merits of each case separately. 
 
Where doubt remains regarding the optimal management of any particular case, the opinion of 
a second Consultant Obstetrician or other professional such as a Consultant Psychiatrist may 
be helpful. 
  
18.7 LAPAROTOMY 
 
Laparotomy on the Delivery Suite is a relatively uncommon event, but when it occurs, it 
usually follows prior caesarean section. The commonest indications are wound pathology and 
suspicion of intra abdominal haemorrhage. 
 
Wound pathology 
 
The decision to return to theatre because of wound dehiscence, wound haematoma or 
retention of a drain should be taken in the final instance by a consultant obstetrician.  
 
Intra operatively, the sheath should always be examined to ensure its integrity. The skin will 
normally be closed with non occlusive sutures such as staples. Broad spectrum antibiotics 
should be given intra and post operatively.  
 
Haemorrhage 
 
Please refer to the massive haemorrhage guidelines in Section 15. The Consultant 
Obstetrician and a senior Anaesthetist must be informed and involved early in the 
resuscitation of any woman suspected of having intra abdominal haemorrhage after 
caesarean section. Before return to theatre is contemplated, attention must be made to 
adequate resuscitation, including: 
 
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• venous 
access 
• 
intra-vascular volume expansion 
• 
cross-matching of blood 
 
Consent must be obtained for all conceivable eventualities including hysterectomy. 
 
In the unusual event of massive secondary post partum haemorrhage requiring laparotomy, 
main theatres may be a more suitable venue for surgery than the obstetric theatres because 
of the increased likelihood of hysterectomy or the presence of intra abdominal adhesions.  
 
18.8 FEMALE 
STERILISATION 
 
Occasionally, a woman contemplating an elective caesarean section asks will request 
sterilisation. It is the RCOG’s recommendation that: 
 
•  discussion should take place at least one week prior to the caesarean section 
•  consent should be obtained at that time 
•  consent should be confirmed immediately prior to the caesarean section 
•  the procedure should be described as irreversible 
•  the failure rate should be quoted as 1 in 200 or possibly worse 
•  failure could result in ectopic pregnancy 
 
In the event of a baby being born with an unexpected complication (eg requiring resuscitation, 
a suspicion of Down’s Syndrome), the sterilisation should be deferred. 
 
Sterilisation should not be offered to women having an emergency caesarean section.  It 
should only be considered if a clear plan has been made in the antenatal period for 
sterilisation. 
 
18.9 RECOVERY 
 
CIC - Post-operative recovery is the joint responsibility of the midwife and the anaesthetic 
nurse.  
WCH – Post-operative recovery is the responsibility of the recovery nurse. 
 
The following observations should be made: 
 
•  pulse  every 5 minutes, extending to 20 minutes depending upon clinical  
condition 
•  BP 
every 5 minutes, extending to 20 minutes depending upon clinical  
condition 
• SAO2 continuously 
•  block  every 15 minutes 
•  lochia  within 30 minutes of delivery, thereafter depending upon clinical 
condition 
•  wound within 30 minutes of delivery, thereafter depending upon clinical 
condition 
 
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Medical review 
 
Women with a medical condition pre dating delivery that may affect recovery should have 
formal obstetric medical review within 1 hour.  Such conditions include: 
 
• pre-eclampsia 
• placenta 
praevia 
• diabetes 
• renal 
failure 
• cardiac 
disease 
 
Immediate obstetric medical review must be sought when any of the following arise: 
 
•  the woman feels or looks unwell 
•  systolic BP falls below 100 mm Hg 
•  maternal pulse rises to over 120 bpm 
•  significant clots of blood are passed vaginally 
•  a persistent ooze of blood is noted vaginally 
•  bleeding is noted from the wound 
•  maternal temperature is recorded ≥ 38 oC 
•  haematuria is noted 
•  oliguria is noted – under 30 ml in the first hour on the recovery area 
•  analgesia appears to be inadequate 
 
Feeding the patient post operative delivery 
 
There is no clear consensus regarding the safe time interval that should pass between the 
end of a caesarean section and the resumption of oral diet. Little hard evidence is available to 
guide practice although starvation for more than one day after surgery appears to slow 
recovery and may interfere with breast feeding. 
 
18.10  VAGINAL BIRTH AFTER PREVIOUS CAESAREAN SECTION 
 
These notes have been adapted from the Regional Guideline and the RCOG/NICE 
Caesarean Section Guidelines dealing with trial of vaginal birth after previous lower segment 
caesarean section. The measures suggested here should be applied to all labours after a 
previous caesarean, even if successful vaginal delivery has subsequently been achieved. 
Management of individual cases may vary and should be discussed with senior staff. 
 
1. Antenatal 
Counselling 
 
♦  Review old notes pertinent to the previous LSCS – directly or by correspondence 
with other hospital 
♦  Initial discussion with patient (review the labour that resulted in LSCS; discuss 
outcomes for VBAC – offer appropriate information leaflet, plan VBAC for majority) 
♦  Record final agreed plan for delivery in antenatal record (Senior Staff should be 
involved in the decision) this may be nearer term 
 
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2. 
Induction of Labour Cases in VBAC 
 
The risk of uterine rupture is increased in induced labour compared to spontaneous labour 
and this increase in more marked if both prostaglandin (PG) and oxytocin are used. 
 
Therefore: 
 
1  Induction of labour should only be undertaken for valid obstetric indications.  Offer 
membrane sweep at 41 weeks 
 
2  The preferred method of induction is by forewater amniotomy (ARM) with judicious 
oxytocin augmentation (as per unit guideline) 
 
3  PG priming should be kept to a minimum – an experienced obstetrician (at least SpR 
status) should assess the need for PG.  If PG is necessary, one 3mg tablet should only be 
used and must be administered on the delivery suite.  Further doses of PG should only be 
used after discussion with Senior Staff 
 
4  Oxytocin infusion should not be started for 6 hours following PG prostoglandin 
administration.  The maximum dose should not exceed 32 mU.min. 
 
3. 
Management of Labour for VBAC 
 
Management of labour 
 
The midwife should provide normal midwifery care throughout labour. The medical staff must 
however ensure that they are kept informed of progress in labour. Labouring women with a 
previous caesarean section should be reviewed on the twice daily ward round as a minimum 
and at the request of the attending midwife whenever clinical concern arises. 
 
At the onset of labour: 
 
♦  site a large bore venflon 
♦  check FBS, Group & Save 
♦  perform a vaginal examination 
♦  inform the SpR 
 
First stage of labour: 
 
♦  monitor the fetal heart and contractions throughout labour on the CTG 
♦  perform a vaginal examination 4 hourly up to 7cm dilatation 
♦  perform a vaginal examination 2 hourly after 7 cm dilatation 
♦  expect 1 cm dilatation per hour in established labour 
♦  inform the SpR if progress is slower than this 
 
Syntocinon augmentation
 
 
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This may only be sanctioned by the SpR or Consultant. Before syntocinon is prescribed, a full 
medical review should take place first including: 
 
♦  history of contractions noted to be less than 4 in 10 minutes 
♦  abdominal palpation performed to confirm that the fetal head is engaged in the pelvis 
♦  vaginal examination should be performed to confirm position and station 
 
Augmentation may then take place following the guidelines detailed in Section 4. 
 
Second stage of labour, if there are no maternal or fetal concerns: 
 
♦  allow up to 1.5 hours for passive descent of the fetal head if this appears to be required 
♦  allow up to 1.0 hours of active pushing 
♦  obtain medical review if delivery is not then imminent 
 
If instrumental delivery is then required: 
 
♦  the delivery should be attended by the SpR or consultant 
♦  if the vertex is higher than 1 cm below the ischial spines, consider delivery in theatre 
♦  if transfer to theatre is required, the Consultant Obstetrician on call should be informed 
 
Please also refer to the Guidelines Section 6 dealing with instrumental delivery. 
 
Third stage of labour: 
 
♦  the integrity of the uterine scar does not need to be checked routinely 
♦  if clinically indicated, the integrity of uterine scar should be formally checked in theatre 
♦  the Consultant on call should be informed if third stage abnormalities arise 
 
4. Special 

Points 
 
Length of Labour (VBAC

Inform Senior Staff when appropriate oxytocin 
augmentation does not correct progress of 
labour 
 
Intrauterine Pressure (IUP) monitoring  routine use of IUP does not improve obstetric 
outcome or reduce scar rupture rate 
 
Scar & dehiscence & rupture 
incidence 0.5% (this is not increased by careful 
augmentation) 
 
Symptoms and Signs of impending rupture 
include: 
 
Rising maternal pulse rate (MAY BE THE ONLY 
SIGN 
Acute fetal heart rate abnormalities 
Sudden cessation of contractions 
Continuous scar pain (still occurs with epidural) 
 
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Vaginal bleeding 
Haematuria 
Retraction of presenting part (on vaginal 
assessment) 
 
ALL STAFF must be aware of these symptoms 
and signs 
 
 
 
 
 
 
  
They may occur for the first time in the SECOND 
STAGE
 
 
Subsequent Labours 
The scar rupture rate increases with each 
subsequent labour: women with previous LSCS 
should have ALL subsequent labours 
managed as described above 
 
18.11  PROPHYLACTIC ANTIBIOTICS FOR CAESAREAN SECTION 
 
Augmentin 1.2 g intravenously after delivery of the baby. It is the responsibility of the 
Obstetrician to ensure that the antibiotics are prescribed and given. This will usually be carried 
out by the Anaesthetist. 
 
In cases where an allergy to Augmentin is known or suspected, than Clindamycin 900 mgs 
should be substituted. 
 
18.12 THROMBOPROPHYLAXIS IN PATIENTS RECEIVING SPINAL OR 
EPIDURAL ANAESTHESIA 
 
The objective is to try to ensure that spinal/epidural block, or removal of epidural 
catheters, is performed when anticoagulant activity is at its lowest. 
 
Low Molecular Weight Heparin (LMWH) e.g. Clexane, can safely be given the evening before 
surgery before 2000 hours. 
 
No patient should be given LMWH or Standard heparin (SH) on the day of surgery before 
going to theatre if there is any likelihood of them receiving a spinal or epidural block.  The 
anaesthetist will take responsibility for ensuring that appropriate thromboprophylaxis is given. 
 
If a patient is given LMWH or SH by mistake, the anaesthetist MUST be informed before the 
patient goes into the anaesthetic room. 
 
Thromboprophylaxis is not contraindicated in patients with epidural catheters in place, such 
catheters, however, need to be removed at a safe time.  This should be:- 
 
Standard Heparin 
4 hours after a dose with an interval of at least 1 hour before the 
next dose. 
 
LMWH 
12 hours after a dose with an interval of at least 4 hours before the 
next dose. 
 
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Heparin infusions, epidural catheters should not be removed whilst a patient is on IV Heparin. 
 
Do not remove an epidural catheter from a patient who has abnormal bleeding or abnormal 
laboratory tests of coagulation. 
 
If a patient has been on standard Heparin for more than four days, regular platelet counts are 
recommended, the platelet count MUST be checked before an epidural catheter is removed in 
these patients. 
 
If there is any uncertainty consult a senior anaesthetist. 
 
If a patient who has had a spinal or epidural block, or has an epidural catheter in-situ, 
develops any new focal neurological signs, especially numbness or weakness in the legs or 
perineum, faecal or urinary incontinence, or severe back or sciatic pain, notify a senior 
anaesthetist as soon as possible. 
 
 
 
 
 
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References 
 
Chua S et al (1990) Augmentation of labour: does internal tocography result in better obstetric 
outcome than external tocography? Obstet Gynecol 76: 164-167. 
 
Hema KR, Johanson R (2001) Techniques for performing caesarean section. Best Practice 
Res Clin Obstet Gynaecol
 15: 17-47. 
 
Induction of labour – NICE Inherited Guideline D (2001). National Institute for Clinical 
Excellence, London. 
 
Caesarean Section Clinical Guideline (2004) Published on behalf of RCOG and NICE, RCOG 
Press, London , UK. 
 
James D (2001) Caesarean section for fetal distress. BMJ 322: 1317-1317. 
 
Lydon-Rochelle M et al (2001) Risk of uterine rupture during labor among women with a prior 
Cesarean section. NEJM 345: 3-8. 
 
Mackenzie IZ, Cooke I  (2001) Prospective 12 month study of 30 minute decision to delivery 
intervals for “emergency” caesarean section. BMJ 322: 1334-1335 
 
Mangesi L, Hofmeyr GJ (2002) early compared with delayed oral fluids and food after 
caesarean section. The Cochrane Database of Systematic Reviews Issue 3: CD003516. 
 
Smaill F, Hofmeyr GJ (2003) Antibiotic prophylaxis for caesarean section. Cochrane Review. 
In: The Cochrane Library Issue 4. 
 
Steer PJ, Carter MC, Beard RW (1984) Normal levels of active contraction area in 
spontaneous labour. BJOG 91: 211. 
 
Thomas J, Paranjothy S (2001) for the Royal College of Obstetricians and Gynaecologists 
Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG 
Press. 
 
Tuffnell DJ, Wilkinson K, Beresford N (2001) Interval between decision and delivery by 
caesarean section - are current standards achievable? Observational case series. BMJ 
322:1330-1333. 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
CHAPTER 19 - ANALGESIA AND ANAESTHESIA 
 
 
 
19.1  
 PRE DELIVERY ASSESSMENT OF ANALGESIC / ANAESTHETIC PROBLEMS
..........................................................................................................................190 
19.2 
PRESENCE AND ROLE OF ANAESTHETIST .................................................191 
19.3 
EPIDURAL ISSUES ..........................................................................................191 
19.4 
URGENT ANAESTHESIA.................................................................................196 
19.5 
PHARMACOLOGICAL PAIN RELIEF IN LABOUR...........................................196 
19.6 
PREOPERATIVE FASTING GUIDELINES .......................................................197 
19.7 
FEEDING IN LABOUR......................................................................................197 
19.8 
ANTACID REGIMEN.........................................................................................197 
19.9 
WOMEN ON ANTITHROMBOTIC TREATMENT..............................................198 
19.10 
COMPLICATIONS OF THE THIRD STAGE .....................................................198 
19.11 
POST-OPERATIVE CARE................................................................................199 
19.12 
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) .............200 
19.13 
THE ADMINISTRATION OF HOMEOPATHIC OR HERBAL SUBSTANCES ...200 
19.14 
FAILED INTUBATION DRILL............................................................................200 
 
 
 
 
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19.1   PRE DELIVERY ASSESSMENT OF ANALGESIC / ANAESTHETIC 
PROBLEMS 
 
Women who may need specialised anaesthetic input should be referred during the antenatal 
period. Conditions precipitating referral include: 
 
•  heart disease, especially congenital heart disease 
•  severe respiratory disease 
•  musculo-skeletal problems (e.g.) spina bifida or a history of muscle disease 
•  previous back surgery or problems (e.g.) injuries or disc prolapse 
•  neurological problems (e.g.) intracerebral conditions or  multiple sclerosis 
•  clotting problems or those on long-term anticoagulant therapy 
•  previous anaesthetic problems (e.g.) difficult intubation or suxamethonium apnoea 
•  previous complaint relating to anaesthetic management 
•  structural facial or neck abnormalities 
•  previous major head or neck surgery 
•  BMI of 45 kg/m2 or greater at booking 
 
The above list is not intended to be complete.  There may be women who fall outside the 
above categories in whom anaesthetic assessment may be beneficial. 
 
CIC  
-   Alert Dr Stride / Dr Kennedy or Consultant Anaesthetist on call at CIC, who will 
either review immediately or suggest an appropriate course of action if this is not 
possible. 
 
WCH   -  Complete anaesthetic referral form 
 
Women should be referred in (or before) pregnancy to a cardiologist 
 
•  Patients with significant or symptomatic valvular disease 
 
•  Significant maternal congenital heart disease 
 
• Cardiomyopathy 
 
•  Ischaemic heart disease 
 
•  Left ventricular dysfunction from any cause 
 
• Pulmonary 
hypertension 
 
•  Family history of young sudden cardiac death e.g. HOCMs, 
prolonged QTs, etc 
 
 
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19.2  PRESENCE AND ROLE OF ANAESTHETIST 
 
Urgent anaesthetic assistance should be summoned in cases of collapse, cardiac arrest. The 
emergency call system (extension 2222) may be used. The duty Anaesthetist should also be 
informed in the following circumstances: 
 
• severe 
pre-eclampsia 
•  breech presentation on admission and when pushing 
•  multiple pregnancy on admission and when pushing  
•  trial of forceps when vaginal delivery seems uncertain  
•  admission of woman with cardiac disease or sickle cell disease 
•  admission of woman who would refuse blood transfusion 
•  request for epidural analgesia (WCH only) 
•  caesarean section required 
•  where specified in the case notes 
•  BMI >40 (this may have implications for the theatre table) 
 
19.3  EPIDURAL ISSUES (WCH ONLY) 
 
GUIDELINES FOR THE MANAGEMENT OF EPIDURALS 
 
Aim 
 
The aim of modern epidural analgesia during labour is to safely provide a significant degree of 
analgesia labour in those labouring women who wish to employ this technique, following 
suitable discussion with the midwifery and anaesthetic staff. 
  
Request For Epidural 
 
The midwife responsible for the patient should contact the duty anaesthetist when an epidural 
is requested and will be expected to provide the following information: 
 
♦  Name of patient 
♦  Stage and progression of labour 
♦  Any other relevant information to the placement of an epidural, such as a history of pre-
eclampsia, the diastolic blood pressure or problems with previous regional techniques. 
 
Consent For Epidural 
 
Following discussion with the anaesthetist of the major recognised possible complications, 
explicit verbal consent for the epidural must always be given by the patient in the presence of 
a midwife and recorded legibly in the clinical notes by the anaesthetist.  Evidence-based 
complications to be explicitly mentioned: 
 
1.  The potential low risk for incomplete epidural block or even failure to site. 
2.  The potential low risk of post-dural puncture headache. 
3.  Likely hypotension and the need for an IV cannula. 
 
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CONDITIONS AND EQUIPMENT REQUIRED 
 
1. 
The patient must have a large bore intravenous cannula, securely sited prior to epidural 
placement and an IV infusion of crystalloid initiated. 
 
2. 
Following aseptic placement of the epidural, a test dose (usually 3ml of 1% lignocaine) is 
employed to exclude sub-dural siting of the catheter. 
 
3. 
Establishment of the epidural analgesia is subsequently achieved using a slow bolus of 
the standard pre-prepared mix of 0.1% marcaine and 2 mcg/ml fentanyl. 
 
4. 
The epidural should be dressed with a transparent dressing so that the catheter skin 
puncture site is visible. 
 
5. 
Following establishment of epidural analgesia with the bolus dose, an epidural infusion is 
to commenced using the pre-prepared epidural mix and the automated delivery system 
at a prescribed rate by the anaesthetist (an infusion rate range is to be prescribed e.g. 6-
15 mls per hour
). 
 
6. 
The midwifery staff may vary the infusion rate within this range according to level of block 
tested to fine touch, i.e. gentle stroking of skin if inadequate or too high (in increments of 
+ 3 mls per hour). 
 
7. 
The anaesthetist will complete the epidural record form. 
 
8. 
The midwifery staff are responsible for ensuring that the pre-prepared epidural 250 ml 
mix bags are available on the labour ward and loading them into the automated delivery 
system (presently an IMED) when prescribed. 
 
9. 
Once prescribed the midwifery staff may connect the infusion system to the epidural and 
commence the infusion.  Immediate observations should be recorded as outlined on the 
epidural regime form. 
 
10.  Once the epidural is sited the patient must not be managed for any significant time 
either flat on her back or in a non-tilted position when semi-reclined.  Either of these 
positions can lead to rapid cardiovascular collapse and poor placental perfusion dur to 
either caval or aortic compression.
 
 
OBSERVATIONS REQUIRED 
 

1. 
Every 30 minutes; 
 
♦  Ask if pain relief is adequate, record pulse and blood pressure. 
♦  Record height of block to fine touch (gentle stroking of skin) in relation to sternal 
notch, xiphisternum and umbilicus. 
♦  Can the bladder be felt?  If a large bladder is palpable and no desire to void urine, 
consider placement of urinary catheter. 
 
2. 
Every 60 minutes also record maternal temperature. 
 
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REMOVAL OF EPIDURAL CATHETER 
 

1. 
Cease epidural infusion and remove the catheter only after the placenta is completely 
delivered and any necessary suturing completed. 
 
2. 
Having taken off the dressings, the catheter is removed by gently pulling on the catheter 
until fully withdrawn and checking that the catheter is complete.  If this does not work 
then repeat the manoeuvre after leaning the patient forward to mimic the insertion 
position.  If this fails contact the duty anaesthetist 
 
3. 
After catheter removal place a small sterile dressing over the insertion site. 
 
POTENTIAL PROBLEMS AND THEIR MANAGEMENT 
 
♦  INADEQUATE PAIN RELIEF 
1. 
Is the level of block adequate?  Increase infusion rate by 3ml/hr and reassess in 15 
minutes. 
2. 
Is there a “missed segment”?  Turn the patient onto the side of the painful region (or 
sit if perineal pain), increase infusion rate and reassess in 15 minutes. 
3. 
If neither of these work contact the duty anaesthetist. 
4. 
Top up boluses are only to be given by anaesthetist staff. 
 
♦  HYPOTENSION (systolic BP <90mmhg) 
1. 
Ensure that the patient is not lying or sitting without a significant degree of lateral tilt. 
2. 
If sitting, then move the patient to a more horizontal left lateral position and increase 
intravenous fluid infusion rate until BP acceptable. 
3. 
If there is no rapid improvement in BP: 
i. 
Give high flow Oxygen by face mask (12-15 litres per minute) 
ii. 
Increase the Intravenous fluid rate to maximal. 
iii. 
Switch off epidural infusion having recorded level of sensory block to ice. 
iv. 
Turn patient to left lateral. 
v. 
Contact Anaesthetist and Obstetric SHO to confirm/exclude potential causes of 
low BP. 
vi. 
Assume major haemorrhage in process until medical staff in attendance. 
 
♦ 
HIGH EPIDURAL BLOCK 
1. 
If level of block to fine touch (gentle stroking of skin) reaches xiphisternum cease 
infusion for 30 minutes and then re-commence at lower rate. 
2. 
If patient describes difficulty in breathing, stop infusion and contact duty anaesthetic 
staff immediately. 
 
♦ 
DURAL TAP 
1. 
If a dural tap is achieved during placement of an epidural DO NOT consider 
converting to a spinal catheter regime and withdraw needle and catheter. 
2. 
Attempt to re-site epidural one space above and direct catheter away from likely 
dural puncture site. 
3. 
Continue with labour management as normal. 
4. 
Inform patient and record event in clinical notes at time of puncture. 
 
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5. 
Ensure anaesthetic consultant review within 24-hours or earlier if symptomatic 
headache develops. 
 
♦  POST DURAL PUNCTURE HEADACHE 
1. 
If a headache is severe within 5 days after placement or attempted placement of an 
epidural and not responding to simple analgesia contact the duty anaesthetist to 
review the patient and confirm diagnosis. 
2. 
Re-commence IV infusion of N/Saline (1 litre, 12 hourly), encourage oral fluids and 
initiate strict supine bed rest for a minimum of 24 hours and oral analgesics. 
3. 
If symptoms persist overnight or more than 24 hours then the duty consultant 
anaesthetist should consider more invasive treatment, such as an epidural blood 
patch. 
 
HYPOTENSION IN POST SPINAL/EPIDURAL PATIENTS  
 
•  For patients with an Epidural, the prescription is on the front of the pain prescription chart 
and is valid once the anaesthetist has signed for the Epidural. 
•  For patients with a Spinal the prescription should be written up on the patient’s white 
prescription chart before discharge to the ward. 
•  The anaesthetist will determine the lowest acceptable systolic BP and will record this on 
the prescription chart. 
•  Ephedrine 30 mgs in 1 ml is diluted with 9 mls of Normal Saline in a 10 ml syringe (=3 
mgs/ml) 
•  Administer the Ephedrine via a venflon where an IVI is fast running. 
 
A  IF TARGET SYSTOLIC BP FALLS BY 10-15 mmHg 
 

1.  Give oxygen 35% via a mask for 3 litres via a nasal sponge. 
2.  Check wound and drain for excessive bleeding.  (Hypovolaemia). 
3.  Check for urine output or excessive dryness of patients mouth (Hypovolaemia) 
4.  Administer 500 mls Gelofusin/Haemacel stat (intravenous colloid) 
5.  Re-check BP after 3 – 5 minutes 
6.  If the target systolic remains below the acceptable level ADMINISTER EPHEDRINE 
3MGS IV 
7.  Re-check the BP in 3-5 minutes 
8.  Repeat the 3 mg bolus every 3-5 minutes until the acceptable level has been 
reached (limit the number of doses to 3, failure to reach the target after 3 doses 
must be reported to medical staff). 
9.  Inform medical staff IMMEDIATELY if there are signs of excessive bleeding. 
 
B  IF TARGET SYSTOLIC BP FALLS BY MORE THAN 15 mmHg OR BELOW 80 mmHg 
 
1.  Give oxygen 35% via a mask or 3 litres via a nasal sponge 
2.  Check wound and drain for excessive bleeding (Hypovolaemia) 
3.  Check urine output and excessive dry mouth (Hypovolaemia) 
4.  Administer 500 mls Gelofusin/Haemaccel stat. 
5.  Administer Ephedrine 6 mgs IV once only 
6.  Inform medical staff IMMEDIATELY who will then administer further 6 mg boluses if 
necessary 
 
 
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•  Once the target systolic has been achieved the patients BP must be checked 
every 15 minutes for 1 hour. 
•  If the BP falls again revert A or B according to the patients BP and inform 
medical staff immediately. 
•  NB Persistent Hypotension or repeated episodes may be due to Hypovolaemia 
and bleeding must be ruled out. 
 
MANAGEMENT OF SECOND STAGE WITH EPIDURAL DEPARTMENTAL POLICY 
 
1. 
If a routine v.e. is done and the patient is found to be fully dilated follow the chart below:- 
 
 
 

PRIMIP WITHOUT 
WITH OXYTOCIN FULLY 
MULTIP FULLY DILATED 
OXYTOCIN FULLY DILATED 
DILATED 
 
 
 
 
 

WAIT 1 
HOUR 
 
V.E. 
PUSH 
 
 
 
PROGRESS 
NO 
PUSH 
 
PROGRESS 
30 MINUTES 
 
 
 
  
EXPECTANT 
OXYTOCIN 
1 HOUR 
 MANAGEMENT 
1 HOUR 
 
UPTO 
 
 

THEN PUSH 
 
1 HOUR 
ACTION  
 
SEE 4 
 
 
 
2. 
Do not alter the epidural infusion rate (unless pushing inhibited by a dense block). 
 
3. 
If an operative delivery is required, the management of the epidural should be discussed 
with the consultant anaesthetist on duty. 
 
4. Reminders: 
A)  After one hour pushing (primips) or 30 minutes pushing (multips), the registrar on 
duty should assess the patient with a view to delivery. 
B)  Deliveries from anything other than the occipito anterior position should be 
discussed with the consultant on duty beforehand. 
C)  Consider risk factors 
 
 
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19.4 URGENT 
ANAESTHESIA 
 
In an emergency situation the Obstetric SpR or Consultant and the Consultant Anaesthetist on 
call Consultant should agree the urgency with which the patient should be delivered by means 
of a direct conversation. The final decision in relation to mode of anaesthesia rests with the 
Anaesthetist. The Obstetric Anaesthetists Association suggest: 
 
Grade 1 
Immediate threat to life of woman or fetus 
Grade 2 
Maternal or fetal compromise not immediately life threatening 
Grade 3 
Needing early delivery but no immediate maternal or fetal compromise 
Grade 4 
At a time to suit patient and team 
 
This grading system has now been adopted by the NC Delivery Suites. 
 
19.5  PHARMACOLOGICAL PAIN RELIEF IN LABOUR 
 
Pharmacological methods can be offered.  However labour pain can only be partially relieved 
by the use of analgesic drugs such as Diamorphine, morphine, Meptid, pethidine and entonox.  
Women need access to good information in order to be able to make informed choice and this 
should ideally take place in the antenatal period as pharmacological methods of pain relief all 
have side-effects.  
 
Attendance at antenatal classes is also associated with a reduction in the use of 
pharmacological pain relief during labour.  Available options can be discussed addressing 
personal experiences and circumstances, which may influence the woman’s ability to cope.  
However, if this has not happened and been recorded, the midwife on the labour ward must 
take responsibility for offering it.  
 
Changes to medicine legislation, which came into effect in August 2000, clarify the law in 
relation to the supply or administration of medicines under Patient Group Directions (PGD’s). 
Guidance supplied by the relevant government health department regarding implementation of 
PGD’s should be followed. Patient Group Direction is a written instruction for the supply or 
administration of medicines to groups of patients/clients who may not be individually identified 
before presentation for treatment. PGD’s are drawn up locally by doctors or, if appropriate, by 
dentists, pharmacists or other health professionals. Midwives currently offer the following 
Pethidine, Diamorphine, Meptid and Entonox covered by Patient Group Directions for North 
Cumbria Acute Hospital NHS Trust (2005). All registered midwives must adhere to the 
principles for safe administration of medicines and should exercise their professional 
accountability in the best interests of their patients (NMC 2004). 
 
Whilst Pethidine maybe the most commonly used opiate in labour, there are   doubts about it’s 
effectiveness, and concerns about its maternal, fetal and neonatal side effect.  These include 
depression of neonatal respiration, lassitude, drowsiness and depression of reflexes including 
impaired suckling. Side effects to the mother include nausea, vomiting, dizziness, dysphoria 
and drowsiness.  There appears to be benefits to the use of diamorphine as the opiate in 
labour as they found a higher level of pain relief, less maternal vomiting and a lower incidence 
of low one minute Apgar scores.  As yet no convincing research to show that alternative 
opioids are better. 
 
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19.6  PREOPERATIVE FASTING GUIDELINES 
 
To avoid aspiration of gastric contents, patients should not eat or drink immediately prior to 
anaesthesia wherever possible. 
 
The following North Cumbria Trust guidelines follow AAGBI recommendations, which are 
based on the American Society of Anaesthesiologists (ASA) guidelines.  There is little 
evidence regarding the effects of solid food ingested preoperatively but the fasting time for 
clear fluids is evidence based. 
 
• 
6 hours for solid food 
• 
2 hours for clear non-particulate and non carbonated fluids 
• 
2 hours for chewing gum 
 
Oral pre-medication can be taken with up to 75 ml of water 1 hour before anaesthesia. 
 
Patients who have had bowel preparation and breastfeeding mothers may require intravenous 
fluids prior to surgery. 
 
Adults having emergency surgery after trauma may have delayed gastric emptying,. The 
guidelines above should be followed for non-life threatening conditions but an empty stomach 
cannot be guaranteed. 
 
19.7  FEEDING IN LABOUR 
 
The following guidelines are suggested: 
 
•  light snacks such as ‘toast’ may be taken in early uncomplicated labour and… 
•  fluids may be taken throughout labour but.. 
•  if surgical intervention is anticipated, fluid and snacks should be stopped… 
•  and substituted with small sips of water only 
•  the amount of fluid taken should be recorded and fizzy drinks should not be given 
•  oral medicines are always permitted if necessary 
 
Women awaiting a scheduled operation should have no solid food for 6 hours and no 
liquid for two hours before the procedure. These restrictions should also be applied to 
women awaiting an event that has a high chance of leading to anaesthesia. The 
Anaesthetist will make a judgement if there is a need to empty the stomach. 
 
19.8 ANTACID 
REGIMEN 
 
Women at risk of operative intervention should be given 150 mg Ranitidine orally every 6 
hours during labour after appropriate explanation of its purpose if problems are anticipated. 
Oral Ranitidine is prescribed for mothers undergoing elective caesarean section.  The 
Anaesthetist’s reply / instructions should be brought to the attention of the Anaesthetist on 
call. 
 
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19.9  WOMEN ON ANTITHROMBOTIC TREATMENT 
 
The Consultant Anaesthetists have agreed to provide regional analgesia to women on anti 
thrombotic treatment as follows: 
 
Aspirin 
Epidural is not contraindicated when a woman is taking 75 mg aspirin daily. 
 
Warfarin 
Clotting status (INR, APTT and platelet count) should be checked. In general terms however, 
an epidural is contra-indicated. 
 
Low Molecular Weight Heparin 
The introduction of low molecular weight heparin to clinical practice poses a potential problem 
when regional analgesia is requested. 
 
For patients on once daily prophylactic enoxaparin regional blocks should only be considered 
once twelve hours have elapsed since the last dose. No further heparin should be given 
during labour and the heparin should not be restarted until at least four hours after the 
epidural catheter has been removed or after the spinal was performed. 
 
For patients on treatment doses of enoxaparin, 24 hours must elapse before instituting a 
regional block and again a four hour window post block should ensue before restarting the 
heparin. 
 
A high index of suspicion should be maintained when regional blocks are given to patients on 
low molecular weight heparin. Back pain, new onset weakness and numbness are the cardinal 
features of an epidural haematoma. If an epidural haematoma occurs, rapid investigation with 
MRI scanning and neurosurgical evacuation within 8 hours are essential. 
 
19.10  COMPLICATIONS OF THE THIRD STAGE 
 
Retained Placenta 
 
In the presence of effective epidural analgesia, an immediate attempt at manual removal of 
the placenta is permissible in the delivery room by the SpR.  If this is ineffective arrangements 
should be made to transfer to theatre. 
 
Massive haemorrhage 
 
The Consultant Obstetrician and senior anaesthetic staff should be made aware of massive 
primary PPH (immediate blood loss >1500ml and continuing to bleed) whether or not 
operative intervention is required. Please refer to Chapter 15. 
 
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19.11 POST-OPERATIVE CARE 
 
All women undergoing a surgical procedure need time to recover and this will usually take 
place recovery area adjacent to the Obstetric Theatres. A handover will take place from the 
Anaesthetist to an appropriately trained midwife / recovery nurse, giving details of the 
operation, anaesthetic and current status of the patient. Instructions will be given for the 
management of pain, intravenous fluids and other ongoing therapy. 
 
Electronic monitoring of pulse, blood pressure and pulse oximetry should be used together 
with clinical observations.  Constant attendance is mandatory until the mother is fully awake 
after general anaesthesia or a regional block has regressed below T10. 
 
Pain relief 
 
A rectal diclofenac suppository may be offered to women with no contraindications to NSAID 
therapy. 
 
Most women will need to stay in recovery (at WCH) or on Delivery Suite (at CIC) for a 
minimum of 2 hours. The block height to cold spray should be at or below T10 (umbilicus) 
before discharge to a ward. Prior to transfer out, both obstetric and anaesthetic factors need 
to be considered. The patient should be fully awake with stable vital signs, effective analgesia 
in place and with no signs of haemorrhage. Instructions regarding analgesia must be relayed 
to the postnatal ward. If pain relief is inadequate, contact the anaesthetist. There may be a 
simple cause (e.g.) full bladder. 
 
If a woman wishes she can have small volumes of non-carbonated oral fluids 2 hours after her 
operation. 
After 2 hours oral medicines can be restarted or instituted. 
After 6 hours a light diet can be allowed. 
 
Bladder management 
 
In women who have had a caesarean section under general anaesthesia an indwelling 
catheter is commonly used but is not mandatory. If spontaneous voiding does not ensue 
management is along the same lines as after normal delivery.  If caesarean has been 
performed under regional anaesthesia the catheter should be removed when the urine is clear 
and at least 500 mls has been passed. 
 
 
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19.12  TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) 
 
MECHANISM OF ACTION 
 
TENS applies controlled mild electrical stimulation to the skin via a series of electrodes. 
Stimulating peripheral nerve endings in this way seems to inhibit the transmission of painful 
impulses at the dorsal horn of the spinal column and activates some of the descending pain 
inhibiting systems above the spinal level. 
 
Exclusion criteria 
 
•  women with pacemakers 
•  where continuous monitoring required 
•  TENS cannot be used in the birthing pool 
 
Women planning to use TENS in labour should make their own arrangements to hire the 
apparatus. Midwives should have no involvement applying the TENS, although there is no 
evidence that TENS can harm the mother or baby. 
 
19.13 

THE ADMINISTRATION OF HOMEOPATHIC OR HERBAL 
SUBSTANCES 
 
Homeopathic and herbal medicines are subject to the licensing provisions of the Medicines 
Act 1968. Those already on the market when that Act became operative however (which 
applies to most of these substances now available) received product licences without any 
evaluation of their efficacy, safety or quality. You should ensure that you are familiar with the 
requirements of Rule 41 (1) (The Midwife’s Rules and Code of Practice, 1998) in relation to 
the administration of medicines. It is necessary, however to respect the right of individuals to 
self-administer substances of their choice. The use of such substances should always be 
recorded on the partogram. 
 
19.14  FAILED INTUBATION DRILL 
 
This is included overleaf. 
 
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Failed Intubation Drill 
 
1. 
abandon attempts to intubate quickly and implement drill 
2. 
inform surgeon of difficulty and call for anaesthetic help 
mask 
 
ventilation 
ventilation 
transtracheal jet 
failed 
LMA or 
 
 
ventilation via 
intubation 
Combitube 
 impossible 
 impossible 
cricothyroidotomy 
mask 
ventilation 
possible 
ventilate with 
allow patient 
cricoid pressure 
to awaken 
non emergency
fetal 
or 
maternal 
consider 
emergency 
 awake intubation 
or 
regional anaesthesia 
consider LMA 
or 
complete 
continue mask ventilation 
the 
 
surgery 
continue cricoid pressure 
LMA = Laryngeal Mask Airway 
 
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References 
 
Baker C (1996) Nutrition and hydration in labour. B J Midwifery 4: 568-572. 
 
Bogod D (1995) Advances in epidural analgesia for labour: progress versus prudence. Lancet 
345: 1129-1130. 
 
Broach J, Newton N (1988) Food and bevereges in labour. Part II: the effects of cessation of 
oral intake during labour. Birth 15: 88-92. 
 
Crawford JS (1986) Maternal mortality from Mendelson’s Syndrome. Lancet 1: 920-921. 
 
Elbourne D, Wiseman RA (1998) Types of intramuscular opioids for maternal pain relief in 
labour. Cochrane Library of Systematic Reviews, Issue 1 and 4. 
 
Enkin M, Keirse M, Renfrew M, Neilson J  (2000) A Guide to Effective Care in Pregnancy and 
Childbirth
Oxford: Oxford University Press 
 
Fairlie F et al (1999) Intramuscular opioids for pain relief in labour: a randomised controlled 
trial comparing pethidine with diamorphine. BJOG 106: 1181-1187. 
 
Green JM (1993) Expectations and experiences of pain in labour: findings from a large 
prospective study. Birth 20: 65-71. 
 
Howell C (1999) Epidural versus non epidural analgesia for pain relief in labour. Cochrane 
Library of Systematic Reviews, Issue 4. 
 
Malan TP, Johnson MO (1998) The difficult airway in obstetric anaesthesia: techniques for 
airway management and the role of regional anaesthestia. J Clin Anaesth 1: 104-111  
 
Mander R (1998) Pain in Childbearing and its Control.  Oxford: Blackwell Science. 
 
NMC Administration of Medicines 2004 
Nursing and Midwifery Council (2004) Midwives rules and standards 
 
Rajan L (1993) Perceptions of pain and pain relief in labour: the gulf between experience and 
observation. Midwifery 9: 136-145. 
 
Priest J, Rosser J (1991) Pethidine - a shot in the dark.  MIDIRS Midwifery Digest 1:373-375 
 
Roberts RB, Shirley MA (1976) The obstetrician’s role in reducing the risk of aspiration 
pneumonitis. With particular reference to the use of oral antacids. Am J Obstet Gynecol 124: 
611-617. 
 
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CHAPTER 20 - INFECTION 
 
 
20.1 
INTRAPARTUM FEVER ...................................................................................204 
20.2 
GROUP B STREPTOCOCCAL INFECTION.....................................................204 
20.3 
HERPES SIMPLEX...........................................................................................207 
20.4  
HIV ....................................................................................................................208 
20.5 
HEPATITIS B AND HEPATITIS C.....................................................................210 
20.6 
ANTIBIOTIC PROPHYLAXIS FOR CAESAREAN SECTION ...........................211 
20.7 
ANTIBIOTIC PROPHYLAXIS FOR INFECTIVE ENDOCARDITIS....................211 
20.8 
MRSA................................................................................................................212 
20.9 
INFECTION CONTROL ....................................................................................212 
20.10 
INFECTION CONTROL FOR HIV/ HBV / HCV POSITIVE WOMEN ................213 
 
 
 
 
 
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20.1 INTRAPARTUM 
FEVER 
 
Women in labour whose temperature is recorded as 37.8 oC or more on two occasions, 20 
minutes apart, should be investigated to identify a possible source of infection. 
 
• blood 
cultures 
• MSU 
•  HVS and LVS where possible 
•  additional swabs / cultures depending upon clinical circumstances 
 
The organisms most likely to infect the genital tract and cause pyrexia in labour are 
β haemolytic streptococci and E Coli. A triple regimen of IV antibiotics should therefore be 
given to labouring women with sustained pyrexia: 
 
• amoxicillin 
• cefuroxime 
• metronidazole 
 
If therapy is to be continued orally after delivery of the baby, co-amoxiclav should be given as 
a single agent or change according to the culture and sensitivity results if available. 
 
Allergy to Penicillin 
 
•  If gastroinstestinal symptoms only proceed with penicillin 
•  If history of anaphylaxis or rash after penicillins or cephalosporins use clindamycin 900 
mgs IV 8 hourly, changing to 300 mgs orally qds when delivered and apyrexial.  Continue 
with oral therapy until fully apyrexial for 48 hours 
 
Clyndamycin does not give gram neg cover i.e. E Coli may need to use something like 
gentamicin and change as soon as sensitives are available. 
 
Seek microbiological advice if patient collapsed or septicaemic. 
 
The paediatricians should be informed and the baby reviewed if the babies condition causes 
concern at any time. 
 
20.2  GROUP B STREPTOCOCCAL INFECTION 
 
Background 
 
Early onset Group B streptococcal (GBS) sepsis occurs at a rate of 0.5 – 1.5 per 1000 live 
births. Between 5 and 10 % of affected babies will die as a result of the infection, while others 
survive with significant neurological impairment. Predicting which babies are likely to develop 
the disease is difficult however, because although around 25 % of women are colonised with 
GBS, less than 1 % of their babies become infected. 
 
Although US based studies have shown that intrapartum antibiotic prophylaxis (IAP) given to 
women with risk factors for GBS infection is effective in preventing neonatal disease, there is 
currently insufficient evidence to recommend routine screening for all pregnant women. This is 
 
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partly due to the fact that the sensitivity of a single vaginal swab taken during pregnancy in 
detecting GBS is under 50 %. Only a combination of lower vaginal and rectal swabs using 
selective microbiological media can raise this sensitivity to over 90 %. Even where optimal 
swabs are used, the positive and negative predictive values of swabs taken more than 5 
weeks before delivery are low. This means that you cannot rely on swabs taken under current 
clinical practices to exclude the possibility of maternal intrapartum carriage. 
 
Recommendations 
 
Bearing the above notes in mind, current recommended practice is based upon the RCOG 
Green Top Guidelines (2004) and PHLS recommendations (2003), supplemented with data 
from CDCP Guidelines (MMWR 2002). 
 
Women 
 
In the following cases, triple antibiotics detailed in Section 20.1 should be given as this will 
cover possible GBS infection: 
 
•  chorioamnionitis diagnosed or suspected clinically 
•  fever in labour of unknown cause 
 
In the absence of fever or suspected chorioamnionitis, women should be offered penicillin 
prophylaxis for GBS in the following situations: 
 
•  GBS infection in a previous baby 
•  GBS detected in the vagina at any time in the current pregnancy 
•  GBS detected in the urine at any time in the current pregnancy 
 
Penicillin prophylaxis for GBS should also be considered in the following situations, but is not 
mandatory: 
 
•  preterm labour with absent or intact membranes 
•  prolonged rupture of the membranes over 18 hours at term, once established in labour 
 
The following data may be used to counsel women: 
 
 
 
Rupture of membranes over 18 hours at term 
 
Risk of early onset GBS infection in the neonate without IAP is 1:476 
 
Risk of early onset GBS infection in the neonate with IAP is 1:8351 
 
 
 
Prematurity under 37 weeks 
 
Risk of early onset GBS infection in the neonate without IAP is 1:400 
 
Risk of early onset GBS infection in the neonate with IAP is 1:2186 
 
 
 
Prematurity under 35 weeks 
 
Risk of early onset GBS infection in the neonate without IAP is 1:286 
 
Risk of early onset GBS infection in the neonate with IAP is 1:1253 
 
 
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In the absence of infection the onset of labour of should be awaited before giving IAP, this 
includes pre-labour, SROM in patients who are GBS carriers. 
 
Babies 
 
Some babies will always require antibiotics (inform the paediatrician): 
 
•  babies of any gestation with signs of sepsis 
•  multiple births where one baby is diagnosed with GBS sepsis  
 
Consider giving antibiotics to the following babies (inform the paediatrician or SCBU): 
 
•  babies born to mothers who should have received IAP but who did not 
•  babies born to mothers who received the first dose of antibiotics under 4 hours before birth 
•  preterm babies whose mothers received IAP 
•  babies born to mothers who required broad spectrum antibiotics in labour 
•  prolonged rupture of the membranes (see below) 
•  need for active resuscitation at birth 
•  antenatal concerns about fetal wellbeing 
 
Treatment regimens 
 
There is a small risk of adverse reaction to any antibiotic. In addition, the absolute risk to 
babies with some risk factors such as prolonged rupture of the membranes at term is small. 
Therefore a decision not to treat may sometimes be made. In this respect, maternal wishes 
should be sought and a contemporaneous entry made in the case notes. 
 
The aim is to achieve at least 4 hours of IAP prior to delivery, so the first dose should be given 
as soon as labour commences: 
 
•  Benxylpenicillin 3 g (5 mU) iv initially, then 1.5 g every 4 hours until delivery, or…  
•  Clindamycin 900 mg iv every 8 hours until delivery if allergic to penicillin  
 
Prolonged rupture of the membranes 
 
Almost all babies with early onset GBS sepsis develop signs of infection before 24 hours of 
age. Women who give birth having had prolonged rupture of the membranes should be 
advised that a paediatrician will want to review the baby after delivery, whether or not IAP was 
administered. Observations will then be carried out for at least 24 hours, even if antibiotics are 
not prescribed. In the presence of other risk factors for sepsis, the paediatrician may wish to 
take blood cultures from baby and to give a 48 hour course of iv antibiotics. 
 
The birthing pool 
 
Women carrying GBS or whose babies are at increased risk of developing GBS may still use 
the birthing pool for labour and delivery  
 
 
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Monitoring in labour 
 
Women whose babies are at risk of developing GBS do not always require continuous 
monitoring. The decision to use a CTG should be based on other clinical factors such as 
prematurity or fever. 
 
20.3 HERPES 
SIMPLEX 
 
Primary infection in the first and second trimester 
 
Management should be in line with the woman’s clinical condition and may involve the use of 
oral or intravenous Acyclovir in standard doses. In general, the pregnancy may be managed 
expectantly and vaginal delivery anticipated. Prophylactic Acyclovir in the last 4 weeks of 
pregnancy may reduce the risk of recurrence at term and hence the need for caesarean 
section. 
 
Primary infection in the third trimester 
 
Caesarean section should be considered for all women having a first attack of herpes simplex 
in the third trimester, particularly those with symptoms within 6 weeks of delivery because the 
risk of viral shedding in labour is high. If vaginal delivery is unavoidable then both mother and 
baby should be treated with Acyclovir. 
 
Recurrent herpes 
 
For all women with recurrent genital herpes the mode of delivery in the event of a recurrent 
infection during labour should be discussed antenatally and recorded in the notes.  
 
When a woman with a history of recurrent genital herpes simplex present to the Delivery Suite 
in labour, speculum examination should be performed 
 
•  to identify active lesions 
•  to identify whether the membranes have ruptured 
 
In the absence of active lesions at that time, vaginal delivery should be safe 
 
Traditionally in the presence of active lesions, caesarean section has been recommended to 
guard against neonatal opthalmia. The risk of this is small however and the 2004 NICE 
Caesarean Section Guideline advises that caesarean section should not now be offered for 
this indication unless as part of a research study. 
There appears to be no benefit in obtaining specimens for culture before or after delivery in 
women with recurrent herpes, whether lesions are present or not. 
 
Please keep the paediatricians informed in these cases. 
 
 
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20.4   HIV 
 
Duty of care and confidentiality 
 
All doctors and midwives have a duty to provide necessary care. A refusal to care for a mother 
with HIV infection is professionally unacceptable. 
 
A woman’s right to confidentiality is not altered by her HIV status. Before discussing her 
circumstances with members of other services her consent must be obtained. Those cases 
where breach of confidentiality are regarded as necessary are exceptional and midwives 
should take advice from their Midwifery Manager. 
 
The following advice has been obtained from RCOG Guidelines dealing with the management 
of HIV in pregnancy.  
 
Delivery by elective caesarean section 
 
Delivery by elective caesarean section near term is recommended for HIV positive women: 
 
•  the anti viral regimen will be documented in the woman’s management plan 
•  this should be prescribed on the Trust drug Kardex on the night before delivery 
•  the prescribed regimen should be commenced before surgery, as stipulated in the notes 
 
o  Zidovudine infusion 2 mg/kg current body weight for the first hour, then… 
o  continuous infusion of 1 mg/kg per hour until birth of the baby 
 
•  oral medication should be resumed after delivery 
 
The benefit of caesarean is clear for women with a detectable plasma viral load. One meta 
analysis demonstrated a vertical transmission rate 50% lower in women who underwent 
caesarean before labour or rupture of the membranes. In subsequent work, women with a 
plasma viral load of <1000 around delivery were found to have a vertical transmission rate of 1 
% when using anti retroviral therapy compared to 9.8% if no treatment was being used. 
Multivariate analysis showed transmission to be lower with anti retroviral therapy, caesarean 
section, greater birth weight and higher CD4 count. These data suggest that caesarean still 
reduces transmission when plasma viral load is <1000 copies/ml. Whether caesarean reduces 
transmission in women whose plasma viral load is undetectable using current assays (<50 
copies/ml), particularly in those taking HAART, is unknown. 
 
Some studies have suggested that postoperative complications are increased in HIV infected 
women compared with uninfected women, with complication rates related to the level of 
immunocompromise. In one RCT however, elective caesarean was not associated with 
increased morbidity or mortality compared with vaginal delivery. 
 
 
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Management of women presenting with HIV in labour, prior to full antenatal 
assessment 
 
When a woman presents with HIV late in pregnancy or in labour, rapid immunological and 
virological assessment may not be possible. Such women should be treated with anti 
retrovirals including zidovudine, lamivudine and nevirapine (HAART regimen). Zidovudine 
should be given intravenously intrapartum and HAART should be continued postpartum until 
the results of the CD4 T-lymphocyte count and plasma viral load are known. 
 
Vaginal delivery 
 
A woman with no detectable plasma viraemia (<50 copies/ml) and who has an uncomplicated 
obstetric history may express a preference for vaginal delivery, particularly if she is planning to 
return to a country with limited medical resources in the future: 
 
•  experienced personnel should care for the woman 
•  staff should wear theatre scrubs, impervious fluid repellent gowns and plastic aprons 
•  masks, goggles or visors and double gloves should be worn for the birth 
•  open footwear should be avoided – Wellingtons are best for the birth 
•  protective clothing should be removed and hands washed before leaving the clinical area 
•  all contaminated waste should be disposed of as clinical waste 
•  blood spillages should be treated with 10 000 ppm chlorine 
•  an anti viral regimen should be give, usually: 
 
o  Zidovudine infusion 2 mg/kg current body weight for 1 hour, then… 
o  Zidovudine 1 mg/kg per hour continuous infusion until the baby’s birth 
 
•  fetal scalp electrodes should not be used 
•  fetal blood sampling should not be performed 
•  amniotomy should be delayed 
 
Emergency caesarean should be performed for the usual indications, particularly aiming to 
avoid a traumatic vaginal delivery and prolonged rupture of membranes. This is because 
prolonged rupture of the membranes has been associated with a 2% incremental increase in 
mother to child transmission risk for every hour of ruptured membranes up to 24 hours. 
 
Term pre labour rupture of the membranes 
 
Caesarean section or stimulation of labour should be considered without delay – see above. 
 
Pre term rupture of the membranes 
 
In pre term rupture of the membranes the risk of HIV transmission with prolongation of the 
pregnancy should be set against the risks of prematurity. Preterm babies are more likely to be 
infected with HIV because of immature immune function, incompetent mucosal barriers and 
low levels of acquired maternal antibody. Chorioamnionitis is common after preterm rupture of 
the membranes in this group. Steroids may be used to promote fetal lung maturation. 
 
 
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•  contact the consultant obstetrician for advice 
•  mode of delivery will depend upon viral load 
•  see hospital notes for individualised management plan, where already available 
 
Induction of labour 
 
This is uncommon – an individualised care plan will be found in the notes. In general, Prostin 
tablets may be preferable to amniotomy for induction of labour as vertical transmission 
increases with the length of time membranes have been ruptured.  
 
Postpartum management 
 
In the UK, HIV positive women are advised not to breastfeed as this increases mother to child 
transmission by 14% for women infected with HIV before birth and by 30% in mothers infected 
postnatally. Women who choose to breastfeed against medical advice should be advised to 
do so exclusively, avoiding artificial milk top ups. 
 
20.5  HEPATITIS B AND HEPATITIS C 
 
Duty of Care 
 
All doctors and midwives have a duty to provide necessary care. A refusal to care for a mother 
with HBV or HCV infection is professionally unacceptable. 
 
Hepatitis B Surface Ag Positive Women 
 
Only women who are hepatitis surface antigen positive are an infection risk for staff. They 
should be cared for in a single room using universal procedures. Care should be given by staff 
known to be Hepatitis B immune: all midwives and obstetricians should be vaccinated against 
Hepatitis B and should retain documentary evidence of seroconversion. This can be arranged 
through Occupational Health. 
 
Postnatal care 
 
Normal care should be offered but gloves must be worn whenever contact with blood is 
possible. The baby’s cord should be left dry and the mother encouraged to clean the cord 
herself if necessary. 
 
The infant 
 
The infant should be regarded as sero positive for Hepatitis B antigen and precautions taken 
as for the mother. The paediatrician will decide whether passive and / or active immunisation 
is indicated, for example with a course of Hepatitis B vaccine. Breastfeeding is not 
contraindicated. 
 
Hepatitis C 
 
All women who have HCV should be regarded as an infection risk for staff. They should be 
cared for in a single room using universal procedures. Breastfeeding is not contraindicated. 
 
NCHE-OBS001 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
20.6  ANTIBIOTIC PROPHYLAXIS FOR CAESAREAN SECTION 
 
Antibiotic prophylaxis should be given to every woman having a caesarean section after the 
cord has been clamped: 
• 
Augmentin 1.2 gm IV or… 
• 
Gentamicin 5mg/kg + Clindamycin 600mg IV if the patient is penicillin sensitive 
 
20.7  ANTIBIOTIC PROPHYLAXIS FOR INFECTIVE ENDOCARDITIS 
 
The new national guidelines for the prevention of endocartitis recommends prophylaxis only in 
caesarean section, not in vaginal delivery. 
 
• 
Amoxicillin 1 gm IV + gentamicin 1.5 mg/kg IV given at induction 
• 
Teicoplanin 400 mg IV + Gentamicin 1.5 mg/kg IV 
 
Patients who should have antibiotic prophylaxis for endocarditis who are having caesarean 
section are 
 
•  Prosthetic heart valve 
•  Previous infective endocarditis 
•  Complex cyanotic congenital heart disease 
•  Transposition of great arteries 
• Fallot’s 
tetralogy 
•  Gerbode’s defect (complete AV septal defect) 
•  Surgically constructed systemic pulmonary shunts or conduits 
•  Mitral valve prolapse with clinically significant (severe) mitral regurgitation or thickened 
valve leaflets 
•  Any patient believed to have foreign material in the heart of great vessels 
•  Any other variety of arterial switch surgery 
 
The following patients do not require antibiotic prophylaxis 
 
•  Acquired valvular heart disease e.g. rheumatic heart disease 
• Aortic 
stenosis 
• Aortic 
regurgitation 
•  Mitral regurgitation, unless severe and accompanied by myxomatous degeneration of 
the mitral valve 
•  Other structural cardiac defects e.g. VSD 
•  Bicuspid aortic valve 
•  Atrial septum primum defect 
•  Patent ductus arteriosis 
•  Aortic root replacement 
•  Coarctation of aorta 
•  Arterial septa aneurysm / patent foramen ovale 
•  Hypertrophic obstructive cardiomyopathy 
• Subaortic 
membrane 
•  Uncomplicated pulmonary stenosis 
 
NCHE-OBS001 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
20.8 MRSA 
 
Handling MRSA positive women on delivery suite 
 
MRSA positive women should be placed in standard isolation while on Delivery Suite. Anyone 
examining an MRSA positive woman must wear an apron and gloves. These should be 
discarded after the examination and a hand wash undertaken immediately. 
 
Any medical equipment coming into contact with an MRSA positive women should be cleaned 
after use. Alcohol wipes should be used to clean BP cuffs, stethoscopes, chairs and couches. 
Scan probes should be cleaned with hibiscrub or T-spray. Where possible, disposable 
equipment such as disposable BP cuffs should be used then discarded.  
 
After an MRSA positive woman leaves her delivery room, give the room a terminal clean. 
 
Handling the baby of an MRSA positive woman 
 
When a baby is born to an MRSA positive woman, the paediatricians should be informed 
together with the on call microbiologist. Occasionally they will request MRSA swabs from the 
baby. If so, this should be done within 48 hours of birth. 
 
20.9 INFECTION 
CONTROL 
 
It is essential that all midwives, nurses and doctors develop and maintain high standards of 
hygiene and safety in their clinical practice to minimise the risk of accidental exposure to 
infection. In the event of a needle stick injury Occupational Health should be contacted as 
soon as possible if during working hours, otherwise contact A&E for advice. 
 
 
NCHE-OBS001 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
20.10  INFECTION CONTROL FOR HIV/ HBV / HCV POSITIVE WOMEN 
 
Admit patient directly to a single room  
Essential Equipment only in room of delivery 
Wash hands before and after contact with patient and after removing gloves 
 
 
Delivery Room 
Theatre 
 
 
 
Delivery Bed 
Theatre bed 
Equipment for VE’s del. 
      Fridge on small trolley 
Sharps Box 
Anaesthetic machine 
CTG machine 
     Resuscitation/intubation trolley 
Drip stand 
C/S tray and trolley 
      Entonox equipment - disposable 
Mayo stand 
O2 equipment 
Dip Bowls 
      Resuscitation equipment for Baby 
Mop stand 
Small trolley containing sutures & 
extra mops, dressing required for 
operation 
Diathermy machine 
      Baby’s cot 
Epidural Trolley 
Resuscitaire 
 
Vaginal Examination 

 
Protection - apron and double latex gloves. 
If amniotomy is undertaken, follow the precautions for ‘Labour and Vaginal Delivery’ 
 
Injections 
 
Protection - double latex gloves.  
Extreme care must be taken to avoid needle stick injury. The person who administers the 
injection is responsible for discarding the needle and syringe as a complete unit following use. 
 Please refer to the Trust 10 point plan towards the prevention of needlestick injuries. 
 
Epidural 
 
Double latex gloves, apron under fluid repellent gown, masks and goggles or visor 
The anaesthetist is responsible for the safe disposal of the sharps. 
 
Cannulation 
 
Protection - double latex gloves and apron 
 
 
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North Cumbria Acute Hospitals NHS Trust 
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Publication Date:  22/01/2008 
Version 2.0 
 
Venepuncture 
 
Protection - double latex gloves and apron 
Blood Samples should be double bagged and all sections of the forms to be labelled with a 
biohazard label and the air tube system is not to be used to send bloods to the labs. 
 
Entonox 
 
Preferably a disposable system should be used. Re-usable systems should be sent to the 
Sterile Services Department for processing. 
 
Operative Deliveries/Procedures Carried Out in Lithotomy 
 
All procedures carried out in lithotomy position carry an increased risk of inadvertent exposure 
to blood. 
 
Instrumental Delivery 
 
The use of forceps is recommended rather than ventouse. Protection - double latex gloves, 
cap, mask and goggles or visor, full length apron beneath a fluid repellent gown and 
wellington boots are recommended for operators and immediate assistants. Disposable 
under-buttock drapes with collection pouch for fluid are available. Perineal Repair - performed 
only by an experienced midwife/doctor. 
 
Caesarean section 
 
Essential equipment and personnel only to be in theatre. The use of disposable caesarean 
section drapes with collection pouch is recommended, as is the use of blunt needles. 
 
Placenta  
 
 
 
 
CIC  
-   Place in a clinical waste bag and into a single use placenta bin. Blue cable tie, 
label with date, time and place of origin then place in designated cart for 
anatomical waste. 
 
WCH    -  Place in yellow clinical waste bag, self seal it then place directly into sulo bin. 
 
Sterile Services Equipment 
 
 
 
 
Place in Sterile Services box. If out of hours, place safely in sluice until collection next day.  
(This is the Midwife in charge of the case’s responsibility.) 
 
Blood Gases 
 
 
 
 
 
The fetal blood sample (FBS) machine may be used. Following use, clean down with 70% 
alcohol. Inform/leave a message on the FBS machine for the technician that it has been used 
for an infected specimen. 
 
 
NCHE-OBS001 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
Linen 
 
CIC - 
 
All linen contaminated with blood or body fluids must be disposed of as infected 
linen, placed in a hot water soluble red alginate bag then placed in a clear plastic 
laundry bag.   
 
WCH   –   
All linen contaminated with body fluids and blood must be placed in the sulo bin for 
disposal. 
 
Waste 
 
CIC  
-   Waste contaminated with blood or body fluids must be disposed of as clinical 
waste. It should be swan necked, fastened with a black tag, labelled with date, 
time and place of origin.  
 
WCH   –   All contaminated waste must go in the sulo bin. 
 
Sharps Boxes 
 
Sharps should be disposed of via the normal route (placed in a ‘Sharps’ disposal box) locked 
and collected after the patient episode is completed.  
 
Cleaning of Room and Equipment 
 
It is the responsibility of the senior nurse/midwife in charge of case/theatre to ensure terminal 
cleaning is carried out appropriately. Personnel must always use universal precautions i.e. 
latex gloves and an apron. Blood spills must be cleaned up immediately with hypochlorite 
solution. 
 
Ensure adequate ventilation - open windows if possible. If any curtains are contaminated with 
blood/body fluid they should be removed and treat as infected linen.  
 
 
In the Event of Needle Stick Injury 
 
Don’t panic! 
Bleed it with a gentle pressure do not suck the injury 
Wash with soap and water 
Cover with waterproof dressing 
If the event of exposure to mucous membranes rinse with copious amounts of water  
Report immediately to Occupational Health (taking details of the source patient) or A&E if out 
of hours. 
Complete an incident form 
See Trust code of practice for innoculation injury on the intranet  
 
NCHE-OBS001 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
References 
 
Boyer KM, Gotoff SP (1986) Prevention of early onset neonatal group B streptococcal disease 
with selective intrapartum chemoprophylaxis. NEJM 314: 1665-1669.  
 
British Cardiac Society / Royal College of Physicians – www.bcs.com2004 Ramsdale et al 
 
Brocklehurst P (2002). Interventions for reducing the risk of mother-to-child transmission of 
HIV infection. The Cochrane Library of Systematc Reviews Issue 4
 
CDCP (2002) Prevention of perinatal group B streptococcal disease: revised guidelines from 
the Centres for Disease Control and Prevention. MMWR – Morbidity and Mortality Weekly 
Report 
51: RR-11. 
 
Children in Need and Bloodborne Viruses 
(http://www.dh.gov.uk/assetRoot/04/08/21/43/04082143.pdf) 
(http://www.dh.gov.uk/assetRoot/04/09/35/12/04093512.pdf) 
 
Coutsoudis A, Pillay K, Kuhn L et al (2001). Method of feeding and transmission of HIV-1 from 
mothers to children by 15 months of age: prospective cohort study from Durban, South Africa. 
AIDS 15: 379–387. 
 
Dunn DT, Newell ML, Ades AE, Peckham CS (1992). Risk of human immunodeficiency virus 
type 1 transmission through breastfeeding. Lancet 340: 585–588. 
 
Embleton ND, Wariyar UK, Hey EN (1999) Mortality from early onset group B streptococcal 
infection in the United Kingdom. Arch Disease Childhood 80: 139-141. 
 
Grubert TA, Reindell D, Kastner R et al (1999). Complications after caesarean section in HIV-
1-infected women not taking antiretroviral treatment. Lancet 354: 1612–1613. 
 
Hughes RG, Brocklehurst P, Stenson B (2004) Prevention of early onset neonatal group B 
streptococcal disease. RCOG Green Top Guideline Number 36, RCOG Press, London, UK. 
 
Impey L, Greenwood C, MacQuillan K et al (2001). Fever in labour and neonatal 
encephalopathy: a prospective cohort study. BJOG 108: 594-597. 
 
Ioannidis JP et al (2001) Perinatal transmission of human immunodeficiency virus type 1 by 
pregnant women with RNA virus loads <1000 copies/ml. J Infect Dis 183: 539–545. 
 
Leroy V et al (1998) International multicentre pooled analysis of late postnatal mother-to-child 
transmission of HIV-1 infection. Lancet 352: 597–600. 
 
Low-Beer NM and Smith JR (2004) Management of HIV in pregnancy. RCOG Green Top 
Guidelines: Guideline Number 39. RCOG Press London, UK. 
 
Lyall EG et al (2001) Guidelines for the management of HIV infection in pregnant women and 
the prevention of mother-to-child transmission. HIV Med 2: 314–334. 
 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
Maiques-Montesinos V et al (1999) Post-cesarean section morbidity in HIV-positive women. 
Acta Obstet Gynecol Scand 78: 789–792. 
 
McFaul et al BJOG 1988 
 
Mirochnick M et al (2001) Nevirapine pharmacokinetics in pregnant women and in their infants 
after in utero exposure. Pediat Infect Dis J 20: 803–805. 
 
Mwanyumba F et al (2002) Placental inflammation and perinatal transmission of HIV-1. 
Acquir Immune Defic Syndr
 29: 262–269. 
 
Nduati R et al (2000) Effect of breastfeeding and formula feeding on transmission of HIV-1: a 
randomized clinical trial. JAMA 283: 1167–1174. 
 
Oddie S, Embleton ND (2002) Risk factors for early onset neonatal group B streptococcal 
sepsis: case-control study. BMJ: 325; 308-312. 
 
PHLS Group B Streptococcus Working Group (2001) Interim ‘best practice’ recommendations 
for the prevention of neonatal group B streptococcal infection in the UK. 
 
Schrag SJ, Zell ER, Lynfield R et al (2002). A population based comparison of strategies to 
prevent early onset group B streptococcal disease in neonate. NEJM 347: 233-239. 
 
Semprini AE et al (1995) The incidence of complications after caesarean section in 156 HIV-
positive women. AIDS  9: 913–917. 
 
SUGRUE et al British Heart Journal 1980 
 
The European Mode of Delivery Collaboration (1999) Elective caesarean-section versus 
vaginal delivery in prevention of vertical HIV-1 transmission: a randomised clinical trial. Lancet 
353: 1035–1039. 
 
The International Perinatal HIV Group (1999) The mode of delivery and the risk of vertical 
transmission of human immunodeficiency virus type 1- meta-analysis of 15 prospective cohort 
studies. NEJM 340: 977–987. 
 
The International Perinatal HIV Group (2001) Duration of ruptured membranes and vertical 
transmission of HIV-1: a meta-analysis from 15 prospective cohort studies. AIDS 15: 357–368. 
 
Towers CV et al (1998) A "bloodless cesarean section" and perinatal transmission of the 
human immunodeficiency virus. Am J Obstet Gynecol 179: 708–714. 
 
Gould FK, et al. Guidelines for Prevention of endocarditis; report of working party of the British 
Society for Antimicrobia Chemotherapy journal of Antimicrobial Chemotherapy (2006) 57
1035-1042 

 
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link to page 219 link to page 219 link to page 220 link to page 221 link to page 221 link to page 223 link to page 224 link to page 225 North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
CHAPTER 21 - ECLAMPSIA AND PRE-ECLAMPSIA 
 
 
21.1 
CRITERIA FOR INCLUSION ............................................................................219 
21.2 
ANTICONVULSANT GUIDELINES...................................................................219 
21.3 
FURTHER NOTES ON THERAPY WITH MAGNESIUM ..................................220 
21.4 
ANAESTHETIC GUIDELINES ..........................................................................221 
21.5 
ANTIHYPERTENSIVE THERAPY GUIDELINES..............................................221 
21.6 
MAINTENANCE THERAPY FOR BLOOD PRESSURE CONTROL .................223 
21.7 
SIMPLIFIED FLUID GUIDELINES ....................................................................224 
21.8 
 SUMMARY OF CARE......................................................................................225 
 
 
 
 
 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
21.1  CRITERIA FOR INCLUSION 
 
Any woman with severe proteinuric hypertension, when the decision has been made to deliver 
her baby and when one of the following criteria is met (either A, B or C): 
 
A) Hypertension 
( ≥ 140/90 mm Hg) with proteinuria ( ≥ 0.3 g / day or ≥ 2+ on urinalysis) 
and at least one of the following: 
 
•  Headache, visual disturbance, epigastric pain 
• Clonus 

≥ 3 beats) 
•  Platelet count < 100 x 109, ALT > 50 IU / litre 
 
B) Severe 
hypertension 
(systolic ≥ 170 mm Hg or diastolic ≥ 110 mm Hg) with proteinuria 
( ≥ 0.3 g / day or ≥ 2+ on urinalysis) 
 
C) Eclampsia 
 
In these circumstances, the patient should be managed according to the following guidelines 
irrespective of mode of delivery or method of analgesia. 
 
Whenever a patient is commenced on the protocol, ensure: 
 
1. 
Consultant on call is aware 
2. 
Anaesthetist on call for Delivery Suite is aware. 
 
21.2  ANTICONVULSANT GUIDELINES  
 
Magnesium sulphate is the drug of choice for the prophylaxis and treatment of eclamptic 
seizures. All women who meet the inclusion criteria should be treated with magnesium. 
 
Initial Treatment 
Dilute 4g (8ml) Mg SO4, in 40 mls normal saline in 50 ml syringe  
(Loading Dose) 
= 48 ml.  Give as IV bolus dose over 5-10 minutes by doctor 
 
Maintenance Dose   
follow by an infusion of 1 g per hr 
5 g MgSO4 (10 ml) in 40 ml normal saline for 24 hours = 5 g in 50 
ml solution, i.e. 1 g per hr is 10 ml /hr 
 
Contraindications 
with severe cardiac disease or acute renal failure - use 10 mg 
Diazemuls then 2.5 mg / hr maintenance 
 
Duration of Infusion 
 while patient is on Delivery Suite (i.e.) 24-48 hrs 
 
Monitoring  
Clinical: hourly patellar reflexes after the loading dose. Use arm 
reflexes in presence of an epidural.  
 
ECG / Pulse Oxymetry: ECG is mandatory during and for 1 hour 
after loading dose. Pulse oxymetry is needed throughout while on 
MgSO4.  
 
 
NCHE-OBS001 
 
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North Cumbria Acute Hospitals NHS Trust 
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Publication Date:  22/01/2008 
Version 2.0 
 
Magnesium Levels   
MgSO4 administered according to this regimen can be used 
safely without the need to monitor Mg levels. Mg is excreted by 
the kidneys and toxicity is more likely however if there is oliguria 
(urine output < 100 ml / 4 hrs) or urea > 10 mmol / L. 
Measurement of Mg levels may facilitate care if there are signs of 
toxicity. 
 
Toxicity 
Signs of toxicity are extremely uncommon and correlate with 
magnesium levels. 
 
  
 
 
Mg level (mmol/L) 
 
Therapeutic 
Range 
       2-4 
 
 
loss of tendon reflexes, weakness, nausea, feeling of   
 

warmth, flushing, somnolence, double vision, slurred speech  
 
muscle paralysis, respiratory arrest 
 
 
 
 
6-7.5 
 
cardiac arrest 
 
 
 
 
 
 
 
> 12 
 
21.3  FURTHER NOTES ON THERAPY WITH MAGNESIUM 
 
Loss of patellar reflex 
Stop maintenance infusion 
    If 
possible, 
check 
Mg 
level 
Withhold further Mg until patellar reflexes return or Mg levels 
known.  Once tendon reflexes return, if Mg level < 4 mmol /L 
restart maintenance dose at 0.5 g / hr and recheck levels in 3 
hours. 
 
Oxygen saturation    
Commence O2, check patellar reflexes, inform anaesthetist 
persistently < 92%    
If patellar reflexes present, exclude other causes (eg) opiates, 
pulmonary oedema 
If patellar reflexes absent, see above 
 
Cardiorespiratory arrest 
Stop maintenance infusion 
    Institute 
CPR 
 
 
 
 
Administer 10 ml Calcium gluconate IV 
Intubate immediately and manage with assisted ventilation until 
resumption of spontaneous respirations 
If possible, check Mg levels 
If Mg level <2.0 mmol / L restart maintenance dose at 2 g / hr 
 
Seizure on Magnesium 
Treat seizure with a further bolus of Mg 2 g over 5 minutes 
 
 
 
 
If possible check Mg levels prior to this 
 
 
 
 
If further seizures despite this, consider: 
 
 
 
 
 
Diazemuls 10 mg IV bolus then infusion 
 
 
 
 
Thiopentone infusion on ITU   
 
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North Cumbria Acute Hospitals NHS Trust 
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Publication Date:  22/01/2008 
Version 2.0 
 
 
21.4 ANAESTHETIC 
GUIDELINES 
 
To be determined by obstetric anaesthetist: 
 
CRITERIA FOR TRANSFER TO ITU: 
 
1. Recurrent seizures 
2.  MAP > 125 mg Hg inspite IV hydrallazine and labetolol 
3.  Persistant oliguria with normal / high CVP 
4.  Pulmonary oedema with oliguria 
5.  Compromised myocardial function 
 
21.5  ANTIHYPERTENSIVE THERAPY GUIDELINES 
 
 
CALCULATION OF MAP 
CALCULATION OF MAP 
 
 
 
 
DBP + (SBP- DBP) 
(DBP x 2) + SBP 
or 
           3 
3 
 
 
Above a MAP of 140 mm Hg, a previously normotensive woman will lose cerebral 
autoregulation and is at increasing risk of cerebral haemorrhage. MAPs > 140 mm Hg 
constitute an obstetric emergency. 
 
Automated oscillometric devices may underestimate blood pressure. 
 
The drug of choice should be labetolol.  Give bolus dose of 20 mg and repeat every 20 
minutes as per flowchart overleaf until MAP is less than 125 mm or maximum dose of 200 mg 
is given. 
 
Hydralazine is first line therapy for the treatment of hypertension for women with asthma. 
 
•  Dilute 20 mg of hydralazine in 20 ml of 0.9% saline = 1 mg in 1 ml of dilute 
•  Give 5 mg by slow (1 mg / per minute) IV bolus 
•  Check BP every 5 minutes for 30 minutes or until BP is stable at MAP < 125 mg, then 
every 15 minutes for a further 60 minutes 
•  Acute treatment may be repeated every 15 minutes until 15 mg of hydralazine is given 
 
Both drugs can precipitate fetal distress and therefore continuous fetal heart rate monitoring is 
mandatory. 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
 
 
MAP > 140 mmHg 
MAP ≥ 125 mmHg 
 
 
 
Recheck BP every 5 minutes 
Recheck BP every 15 minutes 
 
If sustained over 15 minutes 
If sustained over 45 minutes 
 
 
 
Labetolol 
 
20 mg IV 
 
 
 
 
 
 
Recheck MAP  
  MAP < 125 mm Hg 
after 20 min 
MAP  ≥ 125 mm
 
Recheck BP 
 
every 15 min 
 
 
 
 
Repeat labetalol in escalating  
 
doses 40 mg, 60 mg, 80 mg  
 
every 20 min up to a  
 
maximum of  200 mg 
 
 
 
If MAP remains ≥ 125 mmHg, discuss with consultant.  Consider intra arterial monitoring / 
transfer to ITU 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
21.6  MAINTENANCE THERAPY FOR BLOOD PRESSURE CONTROL 
 
Subsequent episodes of hypertension can be managed with intermittent boluses of IV 
labetolol or hydralazine but if these are needed more than hourly, consider using an 
infusion: 
 
Labetolol infusion 
 
In a 50 ml syringe, draw up 2 ampoules of labetolol (1 ampoule contains 100 mg). This will 
give you 200 mg in 40 ml. 
 
Use a syringe driver to commence your labetolol infusion at 40 mg (8 ml) /hr 
 
Double this every 30 minutes until you get a satisfactory response (ie) MAP < 125 mmHg 
 
The maximum dose you can give is 160 mg (32 ml) /hr 
 
Hydralazine infusion 
 
In a 50 ml syringe, make 40 mg hydralazine up to 40 ml with n/saline 
 
Use a syringe driver to commence your hydralazine infusion at 10 mg (10 ml) /hr 
 
Double this every 30 minutes until you get a satisfactory response (ie) MAP < 125 mmhg 
 
The maximum dose you can give is 40 mg (40 ml) /hr 
 
Side effects include headache, flushing and dizziness - consider using labetolol if these occur  
 
NCHE-OBS001 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
21.7  SIMPLIFIED FLUID GUIDELINES 
 
infuse 85 ml Hartmann’s solution /hr 
 
if 
urine output 
under 100 ml in 4 hours 
 
check UE, FBS and clotting studies 
 
ensure significant hypovolaemia due to blood loss or DIC 
has been corrected with packed cells and/or other blood products 
 
if 
still oliguric 
 
antecubital long line 
CVP 
check the position with a CXR 
 
 


mmHg 
  4-8 
mmHg 
   >8 
mmHg 
 
give 500 ml colloid   
manage expectantly  
 
check O2 sats 
 
over 

minutes 
      auscultate 
chest 
    if 
urine 
output   look 
at 
the 
CXR 
if urine output 
 
under 200 ml 
under 25 ml   
 
in the next 8 hours   
no 
 
 
pulmonary   
in 
the 
next 
hour 
     pulmonary 
 
 oedema 
    give 
200 
ml 
colloid 
 oedema 
discuss 
with 
  over 

minutes 
    frusemide 
20 
mg 
 
consultant obstetrician 
and anaesthetist 
 
if urine output     if 
no 
diuresis 
    under 
25 
ml 
individualised care   
in the next hour 
 
 
 
 
frusemide 40 mg 
 
 
 
 
 
 
    recheck 
the 
UE 
    if 
no 
diuresis 
 
discuss 
with 
   discuss 
with 
consultant obstetrician 
 
consultant obstetrician 
and 
anaesthetist 
  and 
anaesthetist 
 
    individualised 
care 
  individualised 
care 
 
 
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North Cumbria Acute Hospitals NHS Trust 
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Publication Date:  22/01/2008 
Version 2.0 
 
21.8   
SUMMARY OF CARE 
 
Only women with severe pre-eclampsia / eclampsia should be managed according to 
this guideline. 
 
All women will remain on the delivery suite for a minimum of 24 hours after giving birth. 
Ensure that when the woman is transferred to the post natal ward, ward staff are made 
aware of the need for strict fluid balance for at least 48 hours. 
 
Aspects of Care 
 
Maternal Observations: These should be filled in hourly. Record the hourly fluid intake 
(iv & oral), urine output & fluid balance, BP, oxygen saturation & reflexes while on iv 
magnesium. Remember to document important events such as administration of 
antihypertensive treatment, epidural insertion, top ups, delivery and mark delivery 
blood loss. 
 
BP measurements: BP measurements should be made and recorded every 15 
minutes. Inform medical staff if there are two consecutive readings with MAP >125 mm 
Hg or one reading >140 mm Hg. 
 
Fluid intake: The standard IV fluid regime is 85 ml/hour, including the 20 ml of MgSO4 
each hour. Once oral fluids are established the hourly oral intake needs to be 
subtracted from the IV input (if a women is drinking 50 ml/hr, she needs 35 ml/hr IV). 
 
Urine output: This is measured hourly using calibrated urometers. Inform medical staff 
if the output is <100 ml over a four hour period. 
 
MgSO4:  This is given by IV infusion. The first signs of toxicity are loss of tendon 
reflexes & respiratory depression. Throughout the infusion, hourly recordings must be 
made of: 
 
•  Patellar and/or biceps reflex. If you fail to detect a reflex or are unhappy about the 
method of testing you must let the medical staff know immediately. 
 
•  Oxygen saturation. Inform the medical staff if this is persistently < 92%. 
 
 
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Publication Date:  22/01/2008 
Version 2.0 
 
References 
 
Belfort MA et al (2003) A comparison of magnesium sulfate and nimodipine for the prevention 
of eclampsia. NEJM 348: 304-311.  
 
Collaberative Eclampsia Group (1995) Which anticonvulsant for women with eclampsia? 
Evidence from the Collaborative Eclampsia Trial. Lancet: 345; 1455-1463. 
 
Dekker G, Sibai B (2001) Primary, secondary and tertiary prevention of pre-eclampsia. Lancet 
357: 209-215. 
 
Douglas KA, Redman CW (1994) Eclampsia in the United Kingdom. BMJ 309: 1395-1400.  
 
Duley L, Henderson-Smart DJ (2004) Cochrane Database of Systematic Reviews Issue 3. 
 
Magee L et al (2003) BMJ 327: 955-60. 
 
Scardo JA et al (1999) Am J Obstet Gynecol 181: 862-6. 
 
The Magpie Collaborative Group (2002) Do women with pre-eclampsia, and their babies, 
benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. 
Lancet 359: 1877-1890. 
 
Witlin AG (1999) Prevention and treatment of eclamptic convulsions. Clin Obstet Gynecol 42: 
507-518. 
 
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North Cumbria Delivery Suite Guidelines 2008 
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Version 2.0 
 
CHAPTER 22 - DIABETES 
 
 
 
22.1  
GENERAL NOTES FOR OBSTETRIC STAFF ON THE MANAGEMENT OF WOMEN 
WITH INSULIN-TREATED DIABETES .............................................................228 
22.2 
MANAGEMENT OF PREGNANT WOMEN WITH INSULIN-TREATED DIABETES 
FOLLOWING EMERGENCY ADMISSION .......................................................229 
22.3  
MANAGEMENT OF STEROIDS IN PREGNANT WOMEN WITH DIABETES ..230 
22.4  
REGIMEN FOR ELECTIVE CAESAREAN SECTION, INDUCTION OF LABOUR OR 
SPONTANEOUS DELIVERY............................................................................230 
22.5  
MANAGEMENT FOLLOWING DELIVERY .......................................................234 
22.6  
ADDITIONAL POINTS FOR THE CARE OF THE MOTHER WITH DIABETES 
AFTER DELIVERY............................................................................................235 
22.7  
HYPOGLYCAEMIA IN MATERNITY PATIENTS ..............................................236 
 
 
 

 
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22.1   GENERAL NOTES FOR OBSTETRIC STAFF ON THE MANAGEMENT 
OF WOMEN WITH INSULIN-TREATED DIABETES 
 
•  When a woman with diabetes is admitted to the Maternity Unit please inform the 
Diabetes team (01228 814780 / 814140, 01946 523010),  Dr. H or S Sawers and the 
diabetes specialist midwife (Angela Bell, Bernadette Bowness).  
 
• 
There is no official out of hours diabetes on-call service but it is always worth calling Dr 
Sawers’ offices (01228 814139 or 01946 523002).  The diabetes SpR may be on 
medical call, but failing that the medical registrar should be asked for advice if required. 
 
• 
Depending on the clinical status and reason for admission it may be appropriate for the 
woman to remain fully responsible for insulin dosing and administration, but a record of 
her blood sugars and insulin doses given should always be available for inspection   
 
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22.2  MANAGEMENT OF PREGNANT WOMEN WITH INSULIN-TREATED 
DIABETES FOLLOWING EMERGENCY ADMISSION 
 
• 
Obstetric problems will be complicated if blood sugars are too low or too high.  High 
blood sugars may result from infection or steroid injections.  Low blood sugars may result 
from unplanned fasting.  
 
Some practical tips on the management of diabetes: 
 
1. Pregnant women with diabetes are at high risk of developing diabetic 
ketoacidosis. Ketoacidosis occurs if there is deficiency of insulin or 
carbohydrate. 
 
2.  Ketoacidosis is a condition with 2% mortality in young people and is life-
threatening to the baby 
 
3.  Insulin must not normally be stopped and will need to be increased if there is 
intercurrent infection or steroid administration (both of which increase insulin 
resistance) (see 22.3) 
  
4.  Check for ketones by urine testing on admission.  Thereafter on each 
specimen if the patient is  
♦  unwell,  
♦  vomiting / not able to eat, or  
♦  pre-meal sugars are above 10mmol/l  
 

5.  If more than a trace of ketones is detected request an urgent lab check of urea 
and electrolytes as well as bicarbonate (all on a venous sample).  Bicarbonate 
needs to be specifically requested.  A reduced bicarbonate means acidosis is 
developing and the medical registrar needs to be alerted immediately.  What 
happens next will depend on the severity of the metabolic decompensation. 
 
6.  When insulin and dextrose are being infused always use a y-connector with 
anti-reflux valve. 
 
7.  Remember that intravenous insulin disappears from the system within minutes 
of being switched off.  When switching back to subcutaneous insulin from an 
i.v. regimen carry on with insulin infusion until 30 min after first subcutaneous 
injection of conventional rapid acting insulin (e.g. Humulin S or  Actrapid) has 
been given or until 15 min after first subcutaneous injection of rapid acting 
insulin analogue (e.g. Novorapid or Humalog) 
 
8.  Hypoglycaemia in a patient should be corrected as per guideline and should 
not normally result in subsequent insulin being withheld (see 22.7). 
 
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22.3  MANAGEMENT OF STEROIDS IN PREGNANT WOMEN WITH 
DIABETES  
 
1. 
Corticosteroids are used during pregnancy when delivery is anticipated prior to 36 weeks 
gestation, in order to accelerate fetal lung maturation and prevent respiratory distress 
syndrome. The use of steroids in patients with diabetes is associated with a significant 
worsening of their glycaemic control for up to 48 h after steroid administration, the peak 
effect usually being between 4 h and 10 h. 
 
2.  Admission is planned for such patients and intramuscular betamethasone is 
administered (12 mg repeated after 12 h). If possible avoid starting the regimen on a 
Friday or Saturday as there is not likely to be any diabetes team support when the 
decision to discontinue the regimen is being made.  
 
3. 
Following admission the patient continues to administer her usual subcutaneous insulin 
regime without any change of dosage and follows her usual dietary programme.  
 
4. 
In addition, immediately prior to the first steroid injection, a supplementary, variable dose 
intravenous insulin infusion is started and adjusted according to hourly blood glucose 
measurements. The initial dosage regimen (A, B, C or D) is determined according to her 
current total daily s.c. insulin requirement (see table).  
 
5. 
If blood glucose levels are too high on the initial regimen (glucose greater than     
10.1 mmol/l for 2 consecutive hours) the dosage regimen is moved up to the next level 
(e.g. if started on B move up to C, etc.). If the blood glucose level has dropped to less 
than 4 mmol/l on any regimen, immediately reduce by one level (e.g. if on C move down 
to B, etc.). Note: Whichever regimen is in use no i.v. insulin is given until the blood 
glucose rises to 6.1 mmol/l or above. 
 
6.  The supplementary insulin infusion is continued for at least 12 h after the second steroid 
injection.  (Do not discontinue it if more than an average of 2 units of extra insulin per 
hour has been required over the previous 4 hours) 
22.4   REGIMEN FOR ELECTIVE CAESAREAN SECTION, INDUCTION OF 
Total daily s.c  
Up to 40 U/day
40-80 U/day 
81-120 U/day  Over 120 U/day
Insulin requirement 
 
 
The insulin is delivered via a syringe driver containing 50 units 
Actrapid made up to 50 ml  by adding  49.5 ml N Saline 
Intravenous insulin infusion rate (units/hr) 
Hourly blood glucose 
A B 


(mmol/l) 
Less than 6.1 




6.1-7.0 0.5 



7.1-8.0 1 



8.1-9.0 1.5 



9.1-10.0 2 


10 
More than 10 



13 
Table modified from Kaushal, K., Gibson, J. M., Railton, A., Hounsome, B., New, J. P. & Young, R. J. -  
A protocol for improved glycaemic control following corticosteroid therapy in diabetic pregnancies 
Diabetic Medicine  20 (1), 73-75. Jan 2003 
 
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LABOUR OR SPONTANEOUS DELIVERY 
 
Women with gestational diabetes will be treated in 
the same way as other women in labour unless they 
 
are currently insulin treated 
General principles: 
 
♦ 
Induction of labour should be carried out using standard guidelines.   Ideally the woman 
should be admitted to hospital on the evening prior to induction, even if there is no plan 
to give prostaglandins.  Timing of admission may be individualised. 
 
♦  Elective caesareans should be booked into morning lists wherever possible, with 
admission to hospital on the previous evening 
 
♦  Both hypoglycaemia and diabetic ketoacidosis need to be avoided, aiming to maintain 
blood glucose as near normal as possible. 
 
♦  The woman should remain on subcutaneous insulin and continue eating until either  
 
1. 
labour is established   or 
2. 
pre-operative fasting is required 
 
♦  At the time of the first missed dose of insulin / missed meal or snack simultaneous 
infusion of Glucose 10% AND Actrapid in N. Saline needs to be set up 
 
 
Elective morning CS 
 
• For 
an 
elective morning CS reduce by 30% the previous night’s dose of any long-acting 
insulin (eg Lantus)  
 
• 
Omit breakfast and morning dose of subcutaneous insulin 
 
• 
Check blood glucose with a meter; ensure that recent U and E’s results are available 
 
• 
Before 7.30 a.m. set up i.v. infusion of: 
 
Glucose 10% + 0.15% KCl through a counter at 100ml/hr 
omit KCl if 
    
potassium level 
AND 
over 5 mmol/l
50 units Actrapid in 50ml N. saline via a syringe driver 
 
• These 
must go through a y-connection incorporating anti-reflux valve (PCA giving 
set) 
 
• 
Choose a sliding scale regime (see below) and check blood glucose levels hourly during 
labour or section and adjust insulin (or glucose) to maintain levels between 4-7 mmol/ 
 
•  The insulin and glucose regime will provide sufficient insulin and carbohydrate, but 
prolonged use (more than 24 hrs), in the absence of other fluid intake, will result in 
hyponatraemia unless sodium requirements are separately addressed by infusion. 
 
 
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•  Any other fluids which are required (e.g. blood, colloid or N Saline) should be given 
through a separate line. 
 
Pre-delivery sliding scale 
 
The basic scale delivers more glucose and more insulin than ‘usual’ sliding scales in standard 
peri-op regimen because pregnant patients are insulin resistant 
 
Blood glucose 
Insulin rate  
Hints 
mmol/l 
ml or units/hr 
Less than 4 
0 and inform 
Deal with low blood sugar by extra glucose 
doctor 
infusion (eg 100-150 ml 10% glucose) and 
aim to get insulin restarted as soon as 
possible, with a reduced sliding scale if 
necessary 
4-5 1 
 
5.1-7 2 
 
7.1-10 3 
 
10.1-15 

Check ketones….. if positive check bicarb, 
check infusion system is working, consider 
increasing sliding scale 
More than 15 
6 and inform 
Check ketones….. if positive check bicarb, 
doctor 
adjust scale 
 
 
1.  Before starting sliding scale as above consider whether it is likely to be appropriate for 
the particular patient and, if not, adjust it at the outset. 
 
2.  Assess this by working out the patient’s current total daily insulin dose and divide by 24. 
This should roughly correspond to the number of units to be infused if the blood sugar is 
in the target range (shaded above). 
 
e.g. if the total daily dose is 80 units per day the above infusion rates may need to be 
increased by approximately 50% each 
 
3.  The key to success is to reassess the appropriateness of the regimen frequently.  Blood 
glucose should be checked hourly and, if there is concern about blood glucose control, 
monitor more frequently to allow changes to be made to optimise the regimen.   
 
4.  Low bicarb (less than 20) and heavy ketones suggests diabetic ketoacidosis urgent 
medical help required!  Contact the diabetes team or the on-call medical team. 
 
 
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Notes 
 
1.  For elective CS in the afternoon: give usual short-acting insulin before breakfast and at 
10.00 h set up i.v. glucose and insulin regimen.  
 
2. For induction: the woman will continue on subcutaneous insulin until labour is 
established. Set up i.v. glucose and insulin regimen prior to first missed dose of insulin 
/ missed meal or snack  
 
3.  For admission in established labour set up i.v. glucose and insulin regimen unless 
delivery is imminent 
 
 
 
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22.5   MANAGEMENT FOLLOWING DELIVERY 
 
•  The aim of management immediately post-partum is to avoid hypoglycaemia and to 
maintain pre-prandial blood glucose levels between 4 and 12 mmol/l 
 
•  Insulin requirements drop immediately after delivery so switch to the regimen below at 
the point of delivery, individualising it as necessary 
 
Post-delivery sliding scale 
 
 
Blood glucose 
Insulin rate  
mmol/l 
ml or units/hr 
Hints 
Deal with low blood sugar by extra glucose 
infusion (eg 100-150 ml 10% glucose) and 
0 and inform 
Less than 4 
aim to get insulin restarted as soon as 
doctor 
possible, with a reduced sliding scale if 
necessary 
4-5.1 0.5 
 
5.1-7 1 
 
7.1-10 2 
 
10.1-15 3 
 
Check ketones….. if positive check bicarb, 
15.1-20 4 
 
check infusion system is working, consider 
increasing sliding scale  
6 and inform 
Check ketones….. if positive check bicarb, 
More than 20 
doctor 
adjust scale 
♦  Check blood sugars hourly to inform adjustments to insulin infusion rate 
 
♦  Once stable and tolerating diet restart subcutaneous insulin in pre-pregnancy doses, 
reducing these by a third if breast-feeding is planned. 
 
♦  Remember that intravenous insulin disappears from the system within minutes of being 
switched off.  When switching back to subcutaneous insulin from an i.v. regimen carry on 
with insulin infusion until 30 min after first subcutaneous injection of conventional rapid 
acting insulin (e.g. Humulin S or  Actrapid) has been given or until 15 min after first 
subcutaneous injection of rapid acting insulin analogue (e.g. Novorapid or Humalog) 
 
♦  Once back on s.c. insulin check blood sugars pre-meals and pre-bed and consider 
checking through the night if breast feeding.  Also check if there is concern about low 
sugars or the women is unwell. 
 
 
 
Women with gestational diabetes 
 
Those who have been insulin treated in pregnancy will not normally require any 
 
insulin post-delivery.  Simply monitor blood sugar before meals until discharge and 
 
alert diabetes team if pre-prandial blood sugars are above 7 mmol/l. 
 
 
 
 
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22.6   ADDITIONAL POINTS FOR THE CARE OF THE MOTHER WITH 
DIABETES AFTER DELIVERY 
 
1.  Remind the mother that control of blood sugars must not be too tight because of the 
unpredictable demands of the baby, particularly if breast feeding.  Sugars of 7-10 before 
meals are very satisfactory. 
 
2.  Remind the mother about the desirability of planning any future pregnancy so that pre-
conception care can be given (drug review, folic acid 5mg/day, good HbA1c etc) 
 
3.  All those with gestational DM defined by WHO criteria (whether or not insulin treatment 
was given) should have OGTT performed at 6 weeks postnatal, conducted under strict 
conditions by the Community Team.  
Implementing lifestyle changes can reduce the risk of development of later diabetes so all 
those identified as having gestational diabetes should be offered dietetic input post-
delivery to reinforce this.  
They should also have annual screening for development of diabetes mellitus thereafter 
and reassessment prior to planned subsequent pregnancy.    
 
 
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22.7   HYPOGLYCAEMIA IN MATERNITY PATIENTS 
 
1.  Hypoglycaemia is often a problem in the first trimester as women try and tighten up 
control.  It is important not to let blood sugar fall too low in order to preserve 
hypoglycaemic awareness.  Women are asked to regard a blood sugar of less than 4 as 
too low. 
 
2.  A low blood sugar requires: 
 
♦  Corrective action to restore blood sugar level 
♦  Analysis to decide whether it can be explained… 
If so, avoidance tactics for next time 
If not, reduce the dose of the responsible insulin next time 
 
3.  A high glucose product will raise blood sugar quickly but have no sustaining power so 
needs to be followed by long-acting carbohydrate (starchy food) 
 
 
So, start with: 
 
  
Cups of sugary tea take 
 
50-100 ml lucozade or 
too long to make and cool 
 
3-6 Dextrose sweets or 
Diet drinks won’t work 
 
1 tube of Glucogel 
 
 
 
 
    Once she is beginning to feel better follow on with:   2 slices bread or 
 
Cereal bar or 
Plain biscuit and glass of milk or 
Large banana 
 
Or the next meal if that was due.  Inject any insulin due with that meal after the meal. 
 
     Do not omit insulin after a hypo unless recovery has not taken place 
 
4.  Some hypos may result in impaired consciousness.  For these use glucagon 1mg   i.m. or 
s.c., or if there is venous access through a large vein use 50 ml 20% glucose (repeated if 
necessary) 
 
 
 
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References: 
 
NICE Guidelines – Antenatal Care 
 
NICE Guidelines, 15, Type 1 diabetes: diagnosis and management of Type 1 diabetes in 
adults 
 
Diabetes UK Care Recommendations for the management of pregnant women with diabetes
 
 
 
 
 
 
Kaushal, K., Gibson, J. M., Railton, A., Hounsome, B., New, J. P. & Young, R.J. - A protocol 
for improved glycaemic control following corticosteroid therapy in diabetic pregnancies.  
Diabetic Medicine  20 (1), 73-75. Jan 2003 
 
Scott DA, Loveman E, McIntyre L, Waugh N.  Screening for Gestational Diabetes: a 
systematic review and economic evaluation.  Health Technol Assess 2002;6(11)   
 
NCHE-OBS001 
 
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CHAPTER 23 - LATEX ALLERGY 
 
 
 
23.1 
BACKGROUND ................................................................................................239 
23.2 
LATEX IN THE HOSPITAL ENVIRONMENT ....................................................239 
23.3 
IDENTIFICATION OF THE PROBLEM .............................................................240 
23.4 
PROVISION OF A LATEX-FREE ENVIRONMENT ..........................................240 
23.5 
TREATMENT OF ANAPHYLAXIS ....................................................................241 
23.6 
LATEX ALLERGY BOX.....................................................................................241 
23.7 
FURTHER INFORMATION...............................................................................242 
 
 
 
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23.1 BACKGROUND 
 
Latex allergy is an increasingly common problem. Two scenarios may be encountered: 
 
Contact hypersensitivity 
 
Most often, contact hypersensitivity is seen as a localised eczematous skin reaction. It is 
common in people regularly exposed to latex, such as is found in medical gloves. Avoidance 
is the most important measure to take. For example, affected staff must have access to latex-
free gloves at work. It is rare for contact hypersensitivity to precede a more severe reaction. 
 
Acute anaphylaxis 
 
Acute immediate (Type I) allergic reactions to latex are uncommon, but are often difficult to 
recognise and manage. Swelling may affect the lips, tongue and throat, leading to stridor. 
Bronchospasm, hypotension and loss of consciousness, abdominal pain, vomiting and 
diarrhoea may also occur. Only 50 % will have an urticarial rash. Latex anaphylaxis may be 
found in association asthma, eczema, hay fever or food anaphylaxes. 
 
23.2  LATEX IN THE HOSPITAL ENVIRONMENT 
 
Products used in the hospital setting will often contain latex, as shown below. Latex-free 
alternatives are available for most products, however, while some products can effectively be 
neutralised by covering them with other materials. 
 
BP cuffs  
 
Cover thoroughly with a stockinette. You can’t get Latex Free 
 
ECG dots    
Contain Latex – use Latex Free in box 
 
venflons 
 
Contain Latex – use Latex free in box 
 
giving sets    
Contain Latex – use Latex Free in box 
 
syringes 
 
Contain Latex – use Latex Free in box 
 
gloves  
 
Use Latex Free in box.  If Latex Gloves have been worn, hands must be 
thoroughly washed and at least one hour must pass before you have 
contact with a Latex allergic patient 
 
tourniquets   
Contain Latex – do not use these. Use someone else’s hand 
 
catheters 
 
Contain Latex – use an ‘in and out’ catheter.  If caesarean is being 
performed leave the ‘in and out’ in place until after the operation 
 
epidural packs 
These are okay but discard the resistance syringe. Use a glass syringe 
from the Latex Allergy Box 
 
oxygen masks 
Green Masks (UFE Care) are ok but remove elastic strapping. Face 
masks contain Latex so use clear masks instead. For Entonox use a 
plastic mouthpiece 
 
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ET tubes 
Use Mallinckroft tubes. 
 
laryngeal masks    Okay 
 
elastoplast 
Contains Latex. Use Mefix instead 
 
venfon dressings   Contain Latex. Use Mefix instead 
 
theatre table  
Contain Latex. Double cover with Baxters drapes / green sheets 
 
table supports 
Contain Latex. Double cover with Baxters drapes / green sheets 
 
drugs 
 Drugs that need mixing (eg) antibiotics – remove the rubber bung prior to 
mixing. Use syringes from the Latex Allergy Box 
 
diathermy plates 
Do not use as prepared. Use the plate available in the Latex Allergy Box, 
then secure with Mefix 
 
The list is never ending. Please use your common sense. Think about all the products 
that you are using. Do they contain Latex?
 
 
23.3  IDENTIFICATION OF THE PROBLEM 
 
•  When a routine clinical history is being taken, the patient should be questioned directly 
about latex allergy in addition to drug and other allergies. 
 
•  Latex allergy should be suspected in a patient presenting with anaphylaxis who 
deteriorates despite treatment after reaching hospital. 
 
•  Latex allergy should be considered as part of the differential diagnosis for any in-hospital 
episode of anaphylaxis, and for any ‘anaesthetic’ reactions. 
 
•  Any patient with a severe allergy who has been seen in the Department of Immunology will 
usually wear a Medic-Alert bracelet. These should always be inspected if present. 
 
23.4  PROVISION OF A LATEX-FREE ENVIRONMENT 
 
Hospital staff with hand eczema related to latex should consult Occupational Health for 
advice. Advice about obtaining latex-free gloves is available from the Department of 
Immunology. 
 
Patients with severe systemic reactions to latex must be treated in a latex free environment as 
far as possible. Particular care should be taken when exposing the patient to gloves, airways, 
masks, iv lines, rubber bungs on drug ampoules, couches and bed liners. A pack of latex free 
emergency equipment is available on the Delivery Suite in theatre. If you have been wearing 
latex gloves, you must scrub your hands thoroughly before handling a patient with known 
severe latex reactions. 
 
 
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Publication Date:  22/01/2008 
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When a patient is being admitted for an elective procedure, identification of severe latex 
reactions should prompt an assessment of the risk of exposure in the planned procedure. 
Latex free alternatives will be required, discuss with theatres. 
 
In general, drugs in glass snap ampoules, tablets and capsules are safe. Any drug in an 
ampoule with a rubber bung should be assumed to be unsafe unless specifically identified as 
safe by Pharmacy (some bungs are made of synthetic rubber with no latex component). 
Terumo syringes are known to be safe. 
 
In an emergency, specific advice can be obtained from the on-call Immunologist (contact RVI 
switchboard). 
 
23.5  TREATMENT OF ANAPHYLAXIS 
 
•  Stop administration of drug(s) likely to have caused the anaphylaxis. 
•  Call for urgent help. 
•  Maintain airway: Give 100% Oxygen (in non-latex mask) 
•  Lay patient flat with feet elevated 
•  Secure large bore, intravenous access 
• Give 
adrenaline: 
 
Either:   IM, 0.5 mg to 1 mg (0.5 to 1.0 ml of 1:1,000) every 10 – 15 mins take pulse and 
blood pressure 
 
Or: 
IV, 50 to 100 ug slowly (0.5 to 1.0 ml of 1:10,000) every 1 min take pulse and 
blood pressure 
 
•  Start intravascular volume expansion with crystalloid or colloid (large IV cannula needed) 
•  Administer hydrocortisone 200 mg IV 
•  Consider chlorpheniramine 10 mg IV 
 
For anaphylaxis in areas other than theatres and medical wards, the on-call medical registrar 
for the site should be contacted for further advice via the switchboard. 
 
23.6  LATEX ALLERGY BOX 
 
The latex allergy box is situated in the anaesthetic room 
 
 
NCHE-OBS001 
 
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23.7 FURTHER 
INFORMATION 
 
The Regional Department of Immunology at the RVI can provide additional information and 
advice on request - Department extension 25517 
Providing care for the latex sensitive woman 
 
 
latex sensitive women must be cared for in a single room 
or 
a multi bedded room that has been unoccupied for at least one hour 
 
 
all staff preparing the room 
and 
all staff subsequently caring for the woman 
must 
wash hands and face and brush hair 
change into a clean set of clothes or uniform 
 
 
to prepare the room 
completely remove all equipment that contains latex 
do not simply store this in a cupboard in the room 
 
 
take care to remove small items like erasers and rubber gripped biros 
 
 
damp dust all remaining equipment and all surfaces 
 
 
replenish the room with latex free alternatives 
 
 
take care not to introduce latex into the room 
when administering drugs 
particularly 
drugs stored in bottles with rubber bungs 
 
 
if in doubt, check with pharmacy 
 
 
inform the post natal ward about the woman’s arrival 
 so that 
suitable post natal accommodation can be arranged 
 
 
advise the woman to bring in latex free teats if she is planning to bottle feed her baby 
 
NCHE-OBS001 
 
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Publication Date:  22/01/2008 
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References 
 
Ayeko MO, Smith NJ (1999) Coexisting allergies to latex and to muscle relaxants in a 
primigravida. Hospital Med (London) 60: 311. 
 
Chen FC et al (1999) Atopy, the use of condoms, and a history of cesarean delivery: potential 
predisposing factors for latex sensitization in pregnant women. Am J Obstet Gynecol 181: 
1461-1464. 
 
Eckhout GV Jr, Ayad S (2001) Anaphylaxis due to airborne exposure to latex in a 
primigravida. Anesthesiol 95: 1034-1035. 
 
AAGB&I, 2003 - Suspected Anaphylactic Reactions 
 
NCHE-OBS001 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
CHAPTER 24 - SUBSTANCE ABUSE 
 
 
 
24.1 
AIMS .................................................................................................................245 
24.2 
INTRAPARTUM CARE .....................................................................................245 
24.3 
 ANALGESIA IN LABOUR OR PRIOR TO CAESAREAN SECTION ................245 
24.4 
IMMEDIATE NEONATAL CARE .......................................................................246 
24.5 
NEONATAL WITHDRAWAL .............................................................................246 
24.6 
BREAST FEEDING...........................................................................................247 
24.7 
INFECTION ISSUES.........................................................................................247 
24.8 
THE IMPACT OF SUBSTANCE USE ON THE INFANT...................................248 
24.9 
USEFUL CONTACTS .......................................................................................249 
 
 
 
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24.1 AIMS 
 
•  To provide an inclusive non-judgmental service within mainstream intrapartum care 
•  To maintain confidentiality and engender trust 
•  To improve maternal and neonatal outcome, minimising the impact of substance use 
•  To encourage engagement with relevant support services where appropriate 
•  To establish close liaison between professionals through a multidisciplinary approach 
•  To encourage continuing contact with drug services after birth 
 
24.2 INTRAPARTUM 
CARE 
 
With few exceptions, intrapartum care is little different in these women. Notes should be 
reviewed for details of: 
 
• substance 
use 
• alcohol 
use 
•  evidence of IUGR 
•  child protection issues 
 
24.3  ANALGESIA IN LABOUR OR PRIOR TO CAESAREAN SECTION 
 
When a woman taking methadone attends Delivery Suite to give birth, her own supply of 
methadone should be stored in the controlled drugs cupboard and the relevant documentation 
should be completed. In labour, methadone should be administered to the woman in a 
delivery room, under the direct supervision of an attending midwife. Every effort should be 
made to confirm that the dose requested by the women concurs with the dose prescribed or 
agreed for labour antenatally. This information will be available in the antenatal notes. 
 
Any additional analgesia may be requested by the woman. Her options should not be 
restricted because of her substance use. The anaesthetist should be informed and involved in 
the decision making process. Remember: 
•  opiate analgesia may be less effective than usual because of saturation of opiate 
receptors 
•  an epidural may be preferable because of this 
 
When a woman taken Subutex attends Delivery Suite to give birth, analgesia should be non-
opiate, i.e. Meptid or Entonox. 
 
 
 
NCHE-OBS001 
 
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24.4  IMMEDIATE NEONATAL CARE 
 
Naloxone given to the neonate may precipitate acute withdrawal and is 
 
 
contraindicated 
 
Inform the paediatric team when the baby is born. 
 
The baby’s first feed should be within 5 hours and further feeds should be at no greater than 5 
hourly intervals. A nursing intervention score sheet should be started for neonatal withdrawal 
symptoms after the first feed. 
 
The baby’s first urine sample should be collected in a 10 ml universal container and: 
 
•  sent to biochemistry for a toxicology screen if the maternal drug history is uncertain. The 
result will be available in approximately 48 hours 
•  stored a –4 0C when the maternal drug history is known, in case signs of neonatal 
withdrawal develop at a later stage 
 
Maternal consent is not required for the storage of urine. 
 
Separation of mother and infant should only occur for legal or medical reasons. 
 
24.5 NEONATAL 
WITHDRAWAL 
 
A third of babies born to opiate using mothers require drug treatment. The onset and severity 
of withdrawal symptoms is difficult to predict however. For example, opiate withdrawal 
typically occurs within 72 hours but may be later with methadone while benzodiazepine 
withdrawal may not present for up to 10 days. Because of this, women should be discouraged 
from leaving hospital prior to the 4th postnatal day. A nursing intervention score sheet is 
available to monitor symptoms and provide nursing advice. Classicaly, affected babies are 
hungry but feed ineffectually. The following are scored 4 hourly or PRN 30-mins after each 
feed:  
 
• convulsions 
•  tremor when undisturbed 
•  non-stop high pitched cry 
•  sleep <1hr following good feed 
• watery 
stools 
• projectile 
vomiting 
• Pyrexia 
>38oC & Tachypnoea 
•  Yawning and hiccoughs 
•  Sweating and dehydration 
• Hypertonicity 
 
Every infant is scored for at least 72 hours. If treatment is required, the score sheet is 
continued for 72 hours after discontinuation of treatment. 
 
 
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Transfer to SCBU is based on medical grounds, such as vascular collapse or the occurrence 
of convulsions. If sedation is required it may be possible for babies to be kept on the postnatal 
ward and brought to SCBU for their medication 
 
24.6 BREAST 
FEEDING 
 
The only absolute contraindication is maternal HIV. Other women should be encouraged to 
breast feed in the short term. This is thought to reduce the incidence of sudden infant death 
and may reduce the severity of neonatal withdrawal syndrome. 
 
Women taking over 80 mg methadone per day may be discouraged from long term breast 
feeding but this issue will be raised by the multidisciplinary team in the antenatal period. 
 
24.7 INFECTION 
ISSUES 
 
Hepatitis B 
 
Breast feeding is not contraindicated. 
 
If the maternal status is unknown, temporary infant protection is provided with gamma globulin 
given within 12 hours of birth. Once maternal status is confirmed, further neonatal protection 
can be given if necessary with Hepatitis B vaccine. Consent for immunisation will be required.  
 
Hepatitis C  
 
Breast feeding is not contraindicated. 
 
An estimated 30% of substances users are Hepatitis C positive, and infant testing for Hepatitis 
C is unreliable before 1 year. 
 
HIV 
 
Breast feeding is contraindicated. 
 
Prior to discharge, liaise with community midwife/ GP/ GUM team / Consultant Obstetrician/ 
Health Care Worker/ Social Services/ drug services as appropriate. Discuss contraception and 
sexual health needs. 
 
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24.8  THE IMPACT OF SUBSTANCE USE ON THE INFANT 
 
In pregnancy, women using substances have an increased incidence of early pregnancy loss, 
prematurity, low birth weight and stillbirth. Neonatal death and sudden infant death syndrome 
are also more common. The aetiology is multifactorial and includes socioeconomic factors and 
smoking. 
 
 
 
Substance 
Direct effects and treatment aims 
 
 
 
Opiates 
IUGR, in-utero withdrawal (presents as increased fetal 
(heroin, DF118, movements occurs ~30 min after maternal symptoms). Meconium 
methadone, 
aspiration. Neonatal withdrawal in 1 in 3. Aim is for stabilisation 
buprenorphine,) 
with methadone, possible reduction or abstinence. 
 
 
Cocaine and crack  Complications related to increased vascular resistance: 
spontaneous abortion, abruption (risk x10) PROM, and fetal 
GU,CNS sequelae. No neonatal withdrawal. Aim for abstinence.
 
 
Benzodiazepines 
Facial clefts (possible risk). Neonatal withdrawal, typically at 
maternal doses >30 mg/day. Aim for stabilisation, with a slow 
reduction to abstinence. 
 
 
Amphetamines 
Maternal hypertension and cardiac arrhythmia. Cleft palate 
(possibly), fetal thrombocytopenia (rare). Neonatal withdrawal. 
Aim for abstinence. 
 
 
Cannabis 
Low birth weight (tobacco related). No neonatal withdrawal. Aim 
for abstinence. 
 
 
Ecstasy 
No neonatal effects demonstrated. Aim for abstinence. 
 
 
Alcohol 
Fetal alcohol syndrome (IUGR, microcephaly, craniofacial 
abnormalities). There is no clear dose relationship. 
 
 
Solvents 
Microcephaly, neonatal withdrawal. Aim for abstinence. 
 
 
LSD 
Increased risk of spontaneous abortion. No neonatal effects 
demonstrated. Aim for abstinence. 
 
 
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24.9 USEFUL 
CONTACTS 
 
Cumbria Drug and Alcohol Services 
113-117 Botchergate 
CARLISLE 
Cumbria 
 
Tel:  01228 882299 
 
Straightline – Drug and Alcohol Services for under 19 years 
113-117 Botchergate 
CARLISLE 
Cumbria 
 
Tel: 01228 882299  (Mobile: 0788 777 3898) 
 
Fast-track – Immediate access to someone in drug and alcohol services 
John Plaskett (Mobile:  0787 963 0512) - Available Monday – Friday 
 
CADAS (Cumbria Alcohol and Drug Advisory Service) 
Tel: 01228 544140 
 
Signpost – 24-hour telephone helpline for drug/alcohol users, family or friends 
Tel: 0800 0838449 
 
DRUG AND ALCOHOL MIDWIFE CONTACT; 
Vanessa Kelly (Mobile: 0777 0999 0038) 
 
Named Nurse Child Protection – Shelagh Dixon 
Work: 01228 814160 (pager #6461) 
Mobile 0779 522 3912 
 
Named Midwife Child Protection – Linzi Musgrave 
Howgill: 01946 62681 
Mobile: 07867 553483 
WCH: 01946 693181 ext 4253 
 
CASUMS (Child and Adolescent Substance Use / Misuse Service) 
Tel: 01228 603033 
 
Turning Point – Drug and Alcohol Services - Workington 
Tel: 01900 65737 
 
Turning Point – Family Support Group - Workington 
Tel: 01900 604086 
 
NCABS – North Cumbria Addictive Behaviour Service  
Carlisle Office  
–   Tel 01228 603020 
Whitehaven Office   –   Tel 01946 599413 
Penrith Office  
–   Tel 01768 861280 
 
NCHE-OBS001 
 
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Reference 
 
Hepburn M, Personal Communication, Nov 2003 
 
NCHE-OBS001 
 
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Publication Date:  22/01/2008 
Version 2.0 
 
CHAPTER 25 - MATERNAL COLLAPSE AND ACUTE MEDICAL 
PROBLEMS 
 
 
 
25.1 
MATERNAL COLLAPSE AND ACUTE MEDICAL PROBLEMS .......................252 
25.2 
TRANSFER TO THE INTENSIVE CARE UNIT.................................................254 
25.3 
UTERINE RUPTURE ........................................................................................256 
25.4 
MATERNAL STEROID COVER FOR DELIVERY.............................................256 
25.5  
MANAGEMENT OF HAEMOGLOBINOPATHIES.............................................256 
25.6 
SCREENING FOR HAEMOGLOBINPATHIES IN PREGNANCY .....................256 
25.7 
THALASSAEMIA SYNDROMES.......................................................................257 
25.8 
HAEMOGLOBIN VARIANTS – SICKLE CELL SYNDROMES ..........................257 
 
 
 
NCHE-OBS001 
 
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25.1  MATERNAL COLLAPSE AND ACUTE MEDICAL PROBLEMS 
 
Acute Collapse 
 
Sudden unexpected maternal collapse before, during or after delivery constitutes a medical 
emergency.  When faced with this …. 
 
approach patient 
ensuring that you yourself are safe 
 
 
Responsive 
shake and shout at the patient 
 
 
 
Leave the 
woman in the 
not responsive 
 
position you 
Shout for help 
 
found her 
 
ensure the airway is open 
Go for help 
head tilt 
chin lift 
 
 
Breathing 
check for evidence of breathing 
 
 
 
Put in the 
recovery 
not breathing 
 
position 
 
 
Go for help 
give 2 effective rescue breaths 
 
 
check the carotids for signs of a pulse 
  Pulse present 
 
 
no pulse 
Continue 
  rescue breaths 
 
until 
commence CPR 
spontaneous 
 
breathing 
15% left sided pelvic tilt 
resumes 
 
2 breaths to 30 chest compressions 
 
continue until senior help arrives 
 
 
 
 
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Additional help should always be summoned when faced with maternal collapse: 
 
♦  Midwife in charge of Delivery Suite 
♦  Senior House Officer 
♦  On call SpR 
♦  On call anaesthetist SpR and anaesthetic consultant 
♦  On call consultant obstetrician 
 
During the resuscitation procedure: 
 
♦  Gain IV access – 2 x 16g cannulae if possible 
♦  Give facial oxygen at up to 15 litres / minute 
♦  Check the blood pressure – attach to a dynamap 
♦  Check the oxygen saturation – attach to an oxygen saturation monitor 
 
By now you should be trying to determine the cause for the collapse.  Consider: 
 
♦  Bleeding – revealed or concealed 
♦ Thromboembolism 
♦  Amniotic fluid embolism 
♦ Myocardial 
infarction 
♦  Total spinal anaesthesia 
♦ Hypotension 
 
Investigations will be guided by the clinical circumstances but might usefully include: 
 
♦  Hemacue and / or haemoglobin 
♦  Clotting screen including fibrinogen 
♦  Arterial blood gases 
♦ Chest 
x-ray 
♦ ECG 
♦  Urgent cross match of 4 units of blood 
 
Further management will be planned after discussion with the consultants on call for 
Obstetrics and Anaesthesia.  This discussion will involve the on call haematologists and 
general physicians where appropriate. 
 
Consider caesarean section, primarily to assist maternal resuscitation: 
 
♦  Gestation > 24 weeks 
♦  Cardiac arrest > 4 minutes 
♦  No anticipated immediate response to alternative measures such as volume replacement 
for acute blood loss 
 
Perimortem caesarean section should be considered in any woman who presents in cardiac 
arrest or is apparently dead at gestation > 24 weeks, even when there is no anticipation of 
restoring maternal life.  The chance of intact neurologic status is related to the time interval 
 
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from cardiac arrest to delivery, varying form 98% with delivery in 0-5 minutes, to 25 % with 
delivery at 26-35 minutes post arrest. 
 
Cardiac Arrest 
 
The cardiac arrest team may be able to offer assistance when urgent medical assistance is 
required.  The on call consultant obstetrician should be made aware that the arrest team is 
being called however, usually before assistance is requested. 
 
The number to call is: 
 
♦  Arrest team is on: 
CIC   ext 2222 
WCH  ext 2222 
 
Breathing 
 
♦  Respiration rate under 8 and over 30 per minute 
♦  Oxygen saturation under 90% despite 60% inspired O2 
♦ Arterial 
PaO2 under 8 kPa despite 60% inspired O2 
♦  Discuss with obstetric anaesthetist and obstetrician 
 
Circulation 
 
♦  Pulse under 40 bpm 
♦  Sinus rhythm over 130 bpm 
♦  PH under 7.2 
♦  Bicarbonate under 20 
♦  Discuss with obstetric anaesthetist and obstetrician 
 
Renal 
 
♦  Urine output under 90 ml in 3 hours 
♦ Excluding 
pre-eclampsia 
♦ Excluding 
PPH 
♦  Discuss with obstetric anaesthetist and obstetrician 
 
Central Nervous System 
 
♦  Patient does not respond to commands 
♦  Discuss with obstetric anaesthetist and obstetrician 
 
25.2  TRANSFER TO THE INTENSIVE CARE UNIT 
 
The initial investigation and management of any acutely ill obstetric patient should be co-
ordinated by the SpR who must liaise with senior obstetric and anaesthetic staff.  Review by 
the Consultant Obstetrician should be requested at the earliest opportunity.  Please refer to 
Trust Policy ‘Safe Transfer of the Critically Ill Patient’ Policy Transfer to the Intensive 
Treatment Unit at Cumberland Infirmary, Carlisle or West Cumberland Hospital, Whitehaven 
 
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should only be undertaken however after full consultation with the Consultant Obstetrician, for 
example: 
 
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♦  after respiratory arrest 
♦  deteriorating respiratory function potentially necessitating ventilation 
♦  after cardiac arrest 
♦  deteriorating cardiac function potentially requiring specialist intervention 
♦  after massive haemorrhage with ongoing cardiovascular compromise 
♦  after major, previously unplanned surgery 
♦  organ failure outwith normal obstetric practice 
♦  GCS under 12, or under 14 and falling 
♦ Anaphylaxis 
 
25.3 UTERINE 
RUPTURE 
 
If uterine rupture is suspected then the consultant on call must be informed and attend for 
delivery and repair.  At least 4 units of blood should be cross-matched.  The paediatrician 
should be present if delivery not yet taken place. 
 
25.4  MATERNAL STEROID COVER FOR DELIVERY 
 
Women taking maintenance steroids antenatally (usually in the form of Prednisolone, 10 mg 
or more per day) should be given steroid cover in labour.  The plan of action should be 
detailed in the antenatal notes but will commonly take the form of parental hydrocortisone: 
 
♦  Hydrocortisone 100 mg IM or IV 
♦  Six hourly throughout labour 
♦  Continued postpartum until a light diet can be tolerated 
 
25.5   MANAGEMENT OF HAEMOGLOBINOPATHIES 
 
These are inherited defects of Haemoglobin resulting from: 
 
1. 
Impaired globin synthesis (thalassaemia syndromes), or 
2. 
Structural abnormality of globin (Hb variants) 
 
With the increased stress of haemopoiesis during pregnancy the clinical effects of these 
haemoglobin defects, even in the heterozygote state may complicate obstetric management. 
 
Prenatal diagnosis of a fetus at risk of a serious Hb defect is possible. 
 
25.6  SCREENING FOR HAEMOGLOBINPATHIES IN PREGNANCY 
 

1.  The important haemoglobinopathies, which should be screened for at Booking are 
Thalassaemia and Sickle Cell Disease. 
 
2.  The Haematology Laboratory will follow the recommendations of the British Committee 
for Standards in Haematology / General Haematology Task Force.  They will 
automatically screen for Thalassaemia if the Hb is low, MCH is low the MCHC is 
normal. 
 
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Any blood count that has an MCH less than 27 pg will have a ferritin assay done followed by 
electrophoresis if it is normal. 
 
Any persistent microcytosis should have Hb electrophoresis requested. 
 
3.  The midwifery staff will incorporate in the list of booking questions the enquiry as to the 
ethnicity of the patient.  If there is any chance of black African or Afro-Caribbean 
ancestry, the patient’s blood should be screened for Sickle Cell Disease. From 
knowledge of the patient’s family, it may be appropriate for the midwife to omit this 
question.  This must be on the Midwife’s responsibility and at her own discretion. 
 
25.7 THALASSAEMIA 
SYNDROMES 
 
Either the alpha or the beta globin chain synthesis is depressed. 
 
Beta Thalassaemia 
 
Major Beta Thalassaemia 
 
¾ Avoid  iron 
¾ Give  folate 
¾ Regular transfusions for anaemia 
¾ Screen partner and consider counselling and prenatal diagnosis if trait/minor 
 
Minor/trait Beta Thalassaemia 
 
¾ Give folate 
¾  Oral, not parenteral iron if low ferritin 
¾  Transfusion for anaemia 
¾  Screen partner and consider counselling and prenatal diagnosis if trait/minor 
 
Alpha Thalasseamia (Minor) 
 
¾ Give folate 
¾  Transfusion for severe anaemia 
¾  Screen partner and consider counselling and prenatal diagnosis if positive 
 
There are no specific management plans indicated in labour or postnatally for thalasseamia 
patients. 
 
25.8  HAEMOGLOBIN VARIANTS – SICKLE CELL SYNDROMES 
 
Pre-pregnancy 

¾  Counsel against conception until disease status optimised, assess renal and liver 
function. 
¾ Avoid IUCD 
¾  Counsel re. Risks of pregnancy 
¾  Screen partner and if trait or positive counsel regarding prenatal diagnosis. 
 
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Antenatal 
¾  Hb electrophoresis screening of whole population or high risk groups 
¾  Screen partner and consider counselling and prenatal diagnosis if trait or disease 
¾  Regular transfusions to maintain Hb at 9-12 g/dl with 60-70% Hb A. Discuss 
management with National Centre (via Fetal Medicine at RVI). 
¾  Prompt treatment of crises (adequate hydration, oxygen, screen for infection) may 
include exchange transfusions 
¾ Avoid tourniquets 
¾  Fetal surveillance for fetal well being 
¾  Screen for :  Urinary infection 
Hypertension/pre-eclampsia 
 
 
Renal and liver function 
SFD and Umbilical artery Dopplers 
 
Labour 
Ensure adequate hydration 
¾ Avoid hypoxia 
¾ Continuous CTG 
 
Postnatal 
¾  Consider use of prophylactic antibiotics  
¾  Maintain good hydration and oxygenation especially for the first 24 hours 
¾ Contraceptive counselling 
 
 
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Publication Date:  22/01/2008 
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Reference 
 
Browne I et al (2003) Sickle cell disease in pregnancy – Eurpoean Journal Anas.  20: 75-76 
 
Rees DC (2003) Guidelines for management of the acute painful crisis in sickle cell disease – 
British Journal Haematology – 120; 744-752 
 
 
NCHE-OBS001 
 
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CHAPTER 26 - PREGNANCY LOSS AND MATERNAL DEATH 
 
 
 
26.1 
BACKGROUND ................................................................................................261 
26.2 
THREATENED MISCARRIAGE........................................................................261 
26.3 
TERMINATION OF PREGNANCY FOR FETAL ABNORMALITY.....................261 
26.4 
INTRAUTERINE DEATH ..................................................................................262 
26.5 
SUPPORT NETWORK .....................................................................................262 
26.6 
TOPICS FOR DISCUSSION AND CONSIDERATION......................................263 
26.7 
MANAGEMENT OF PREGNANCY LOSS ........................................................264 
26.8 
FETUS OVER 24 WEEKS (NO POST MORTEM) ............................................266 
26.9 
FETUS OVER 24 WEEKS (FOR POST MORTEM)..........................................267 
26.10 
FETUS UNDER 24 WEEKS (NO POST MORTEM) .........................................269 
26.11 
FETUS UNDER 24 WEEKS (FOR POSTMORTEM) ........................................270 
26.12 
CYTOGENETIC SAMPLES TRANSPORT ARRANGEMENT...........................271 
26.13 
TWINS ..............................................................................................................272 
26.14 
CHAPLAINCY ...................................................................................................272 
26.15 
BAPTISM ..........................................................................................................272 
26.16 
REGISTRATION OF DEATHS AND STILLBIRTH ............................................273 
26.17 
PROCEDURE FOR CARE OF THE PRE-VIABLE BORN INFANT ..................273 
26.18 
MANAGEMENT OF STILLBIRTH INCLUDING DELIVERY, POSTNATAL CARE AND 
LAYING OUT ....................................................................................................273 
26.19 
PROCEDURE FOR USE OF THE CRADLE ROOM.........................................275 
26.20 
HAND AND FOOT PRINTS ..............................................................................276 
26.21 
BEREAVEMENT COUNSELLORS ...................................................................276 
26.22 
POSTNATAL REVIEW......................................................................................277 
26.23 
MATERNAL DEATH .........................................................................................277 
 
 
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26.1 BACKGROUND 
 
Failure to produce an expected live, healthy baby may lead to a sense of failure, shame or 
guilt.  The resultant low self-esteem makes it more difficult for parents to express their needs, 
leaving them feeling out of control.  The gestation at which pregnancy loss occurs makes little 
difference to the patients: it is their baby irrespective of gestational age.  Fundamental 
changes have taken place recently in our attitudes to pregnancy loss.  We know now that the 
provision of physical comfort, good communication skills, attention to spiritual needs, 
maintenance confidentiality and participation in decision making are necessary for the grieving 
family.  The provision of a designated, customised room for parents’ use is also 
recommended.  While poor practice can have a detrimental effect on a woman’s recovery, 
good management can help to restore dignity. 
 
26.2 THREATENED 
MISCARRIAGE 
 
Women with a threatened miscarriage who are less than 16 weeks pregnant are admitted to 
the Early Pregnancy Assessment Unit or the on call gynaecologist. 
 
Women with a threatened miscarriage who are 16 weeks and over are admitted to the 
Maternity Assessment Unit.  Management thereafter will be determined by: 
 
•  The presence or absence of a fetal heart beat 
•  The woman’s blood group.  Rhesus negative women should have their Kleihauer 
checked and will normally be given anti-D 250 iu by Intramuscular injection. 
 
26.3  TERMINATION OF PREGNANCY FOR FETAL ABNORMALITY 
 
The Antenatal Clinic will liaise with Delivery Suite in arranging admission at a time to suit the 
parents.  The procedure for termination and appropriateness of investigations should be fully 
explained. 
 
They may choose either to stay in the hospital until the day of termination or to return home.  
Whichever choice is made, the relevant personnel should be informed and a network of 
support initiated.  Good communication between professionals is essential. 
 
If the parents wish to return home prior to the termination they should be informed that they 
can return to hospital at any time for any reason, if they choose to do so. 
 
Teardrop stickers should be attached to the front covers of the Obstetric and handheld notes. 
They should be applied before discharge home and the date of delivery late added. 
 
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26.4 INTRAUTERINE 
DEATH 
 
Diagnosis may be made by ultrasound in any of the Directorates clinical areas.  The parents 
will then need time to come to terms with this bad news before management can be 
discussed.  This will help them take on board the information they have been given and will 
enable them to express their feelings worries and doubts. 
 
A list has been designed to help the parents think about issue surrounding the labour and 
delivery.  The procedure for induction of labour and the appropriateness of investigations 
should be fully explained.  Arrangements should be made for induction to take place at an 
appropriate time to suite the parents.  
 
Teardrop stickers are now available, for attachment to the front covers of both Obstetric and 
Handheld notes.  They should be applied at the time of diagnosis and the date of delivery 
added later. 
 
Arrangements should be made for the Obstetric notes to be sent to or kept on Delivery Suite. 
 
26.5 SUPPORT 
NETWORK 
 
Diagnosis 
 
Allow time 
 
Discussion and choices 
 
HOME 
AND / OR 
HOSPITAL 
 
 
 
 
Support network: 
Inform and offer visit by: 
Delivery suite, 24 hour service 
Community Midwife 
Community Midwife 
Chaplain 
Counsellors Counsellors 
Inform GP 
Inform GP 
 
 
48 hour return appointment 
Gradual giving of information 
 
 
Information Leaflets 
Formulation of birth plan with midwife 
 
 
Time to formulate birth plan with family 
 
 
 
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26.6  TOPICS FOR DISCUSSION AND CONSIDERATION 
 
Oral mifepristone 
 
36-48 hours later, commence 3 hourly misoprostol orally or vaginally 
 
analgesia 
 
delivery 
 
if / when to see their baby 
 
momentoes: 
Photographs:   digital x 2  and Polaroid for obstetric notes 
  
 
own 
camera 
 
 

Hand and footprints 
 
 

Lock of hair (if possible) 
 
 

Identification bands and cot card 
 
 
 
Certificate of birth (babies under 24 weeks) 
 
Registration and Stillbirth certificate (babies of 24 weeks and over) 
 
Memory boxes – WCH 
 
Caring & memory booklet - WCH 
 
Outfit for the baby 
 
Gift or toy for baby 
 
Blessing and funeral 
 
Support: 
Hospital Midwife 
 
 Community 

Midwife 
 
 
 Chaplain 
 
 Bereavement 

Counsellor 
 
Investigations, maternal and baby 
 
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26.7  MANAGEMENT OF PREGNANCY LOSS 
 
Caution must be exercised when prescribing Mifepristone and Misoprostol.  The dosage is 
dependent upon the gestational age. 
 
Pregnancy Under 24 weeks 
 
All women should be offered 200 mg oral Mifepristone priming unless contraindicated.  This is 
given in the hospital, but the woman can be allowed home 30 minutes after administration.  
She should be told to contact Delivery Suite if vomiting occurs within 2 hours, to enable the 
medication to be repeated.  The possible side effects of faintness, headache, nausea and 
vomiting and skin rashes must be explained. 
 
Admission to Delivery Suite should be arranged for 36-48 hours later.  Misoprostol should be 
given on admission to hospital (see guideline 4.8).  Side effects include diarrhoea, nausea, 
vomiting, hot flushes, dizziness, chills and headaches. 
 
Consultant review is mandatory if the patient has not delivered within 24 hours. 
 
Continued use of prostaglandins at the present dose may be considered with or without a 
delay of 24 hours.  Rarely, physical methods of uterine evacuation may be employed. 
 
See Chapter 26.8 ‘Procedure following pregnancy loss under 24 weeks’ for care of the baby 
following delivery. 
 
Pregnancy of 24 Weeks and Over 
 
All women should be offered Mifepristone priming with a single oral dose of 200 mg, unless 
contraindicated.  This is given in the hospital, but the woman can be allowed home 30 minutes 
after administration.  She should be told to contact the Delivery Suite if vomiting occurs within 
2 hours, to enable the medication to be repeated.  The possible side effects of faintness, 
headache, nausea and vomiting and skin rashes must be explained.  
 
Admission to Delivery Suite should be arranged for 36-48 hours later.  Misoprostol should be 
given on admission to hospital (see guideline 4.8).  Side effects include diarrhoea, nausea, 
vomiting, hot flushes, dizziness, chills and headaches. 
 
Consultant review is mandatory if the patient has not delivered within 24 hours. 
 
Continued use of Misoprostil at the present dose may be considered with or without a delay of 
24 hours.   
 
See Chapter 26.9 ‘Procedure following pregnancy loss at 24 weeks and over’ for care of the 
baby following delivery. 
 
Relative contraindications to Misoprostol 
 
• Uterine 
scar 
•  Chronic Pulmonary Disease 
 
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•  Chronic Cardio-Vascular Disease 
•  Chronic Renal Compromise 
 
In such cases the use of Misoprostol must be discussed with the patient’s Consultant or the 
Consultant on call for Delivery Suite. 
 
Intrauterine death at term – Initiation of Labour 
 
Pre-treatment with Mifepristone 200 mg orally should be given to help shorten the delivery 
process. 
 
Because of the theoretical risk of causing uterine hypertonicity, prostin tablets may be used to 
induce labour instead of Misprostol, at gestations beyond 37 weeks.  This is particularly useful 
when a woman has any additional risk factors for uterine rupture. 
 
•  Prostin 3 mg tablet as per induction guideline (Chapter 4.5) 
•  Side effects include diarrhoea, nausea and vomiting, hot flushes, dizziness and 
headaches. 
 
The membranes should not be artificially ruptured until delivery is imminent, except in unusual 
circumstances, e.g. clinically significant antepartum haemorrhage.  If the membranes rupture 
spontaneously before labour is established, further management should be discussed with the 
senior SpR or the Consultant. It would then be reasonable to commence intravenous 
syntocinon, depending on the stage of labour and the woman’s parity. 
 
Consultant review is mandatory if the patient has not delivered within 24 hours. 
 
Continued use of prostin tablets at the present dose may be considered with or without a 
delay of 24 hours.  Alternatively, misoprostol may be then be used at a dose of 100 mcg 3 
hourly or rarely, physical methods of uterine evacuation may be employed. 
 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
26.8  FETUS OVER 24 WEEKS (NO POST MORTEM) 
Gestation of the fetus over 24 weeks – Not to be sent to the Centre of Life 
 
Ensure Investigation checklist for late pregnancy loss and stillbirth is completed. 
 
CORRECT SAMPLES FOR CHROMOSOME ANALYSIS (CYTOGENETICS) 
 
Biopsy: Skin and Muscle: 
Approximately 1 cm of skin and muscle is taken from the back of the thigh and placed in 
sterile saline solution. 
 
Biopsy: Placental and Membrane: 
When a biopsy of the placenta is taken please include membrane in the specimen and place 
in sterile saline. 
 
Please keep all specimens in the fridge until it is collected for transport. 
 
Forms to accompany samples to include: 
•  Consent forms for chromosome (Cytogenetic) analysis after Pregnancy Loss or 
Termination 
•  Cytogenetics form must be completed and be secured with specimen 
 
Samples sent to: 
FAO Dr Carol English 
Institute of Human Genetics 
International Centre for Life 
Central Parkway 
Newcastle-Upon-Tyne 
NE1 3BZ 
 
Tel: 0191 241 8796 (Direct Line) 
 
NOTE – Please phone to notify the samples are going to be sent 
 
Samples: 
•  To be stored in the cradle room 
•  Not to be sent over weekend as Centre closed.  Samples to arrive during week prior to 
1630 hrs as Centre closes at 1700 hrs. 
•  Arrange next day delivery with TNT, Tel 0800 100 600 
•  Fill out transport label 
 
BABY 
 
•  (CIC) Telephone Mr Tremble regarding the baby.  Tel: 01228 594831 / 711543  
•  (WCH) Telephone E Kegg, Ext 2816 
•  If there are any unusual requests by parents for cremation / burial contact 
Bereavement Counsellor to ensure correct procedures are carried out. 
 
 
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Forms to accompany fetus for disposal 
(for Funeral Director) 
•  Certificate of Medical Practitioner in Respect of Fetal Remains – over 24 weeks 
•  Baby Internment Details Form 
•  Medical Certificate of Stillbirth (Death Certificate – blue book) 
•  Burial Certificate (obtained from the Registrar of Births, Marriages and Deaths) 
•  Funeral arrangement form (Stillbirth and neonatal death form) 
•  Cremation – if parents want cremation, fill in cream coloured cremation form and notice 
of cremation (pink form) 
•  Ensure information leaflet on registering deaths and stillbirths are given to parents.  
 
26.9  FETUS OVER 24 WEEKS (FOR POST MORTEM) 
Gestation of the fetus over 24 weeks – Not to be sent to the Centre of Life 
 
Ensure Investigation checklist for late pregnancy loss and stillbirth is completed. 
 
CORRECT SAMPLES FOR CHROMOSOME ANALYSIS (CYTOGENETICS) 
 
Biopsy: Skin and Muscle: 
Approximately 1 cm of skin and muscle is taken from the back of the thigh and placed in 
sterile saline solution. 
 
Biopsy: Placental and Membrane: 
When a biopsy of the placenta is taken please include membrane in the specimen and place 
in sterile saline. 
 
Please keep all specimens in the fridge until it is collected for transport. 
 
Forms to accompany samples to include: 
•  Consent forms for chromosome (Cytogenetic) analysis after Pregnancy Loss or 
Termination 
•  Cytogenetics form must be completed and be secured with specimen 
 
Samples sent to: 
FAO Dr Carol English 
Institute of Human Genetics 
International Centre for Life 
Central Parkway 
Newcastle-Upon-Tyne 
NE1 3BZ 
 
Tel: 0191 241 8796 (Direct Line) 
 
 
NOTE – Please phone to notify the samples are going to be sent 
 
POST MORTEM 
 
CIC: Mr Tremble (Funeral Director), Tel: 01228 594831 / 711543 will take the samples to the 
Centre of Life and then take the fetus and dry placenta to the RVI. 
 
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Publication Date:  22/01/2008 
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WCH: E Kegg, Ext 2816 
 
Fetus (and if requested) Placenta to go to RVI (Placenta – dry) 
 
Samples sent to: 
FAO Chris Wright (Pathologist) 

Pathology Department 
RVI 
Queen Victoria Road 
Newcastle Upon Tyne 
NE2 4LP 
 
NOTE – Please contact Chris prior to sample being sent – RVI Pathology 
 
Forms to accompany fetus 
 
•  Request for a Perinatal Post Mortem Examination – ensure arrangements to return 
baby is completed on form 
•  Consent to the post mortem examination of a baby 
 
Forms to accompany fetus for disposal 
(for Funeral Director) 
•  Certificate of Medical Practitioner in Respect of Fetal Remains – over 24 weeks 
•  Baby Internment Details Form 
•  Medical Certificate of Stillbirth (Death Certificate – blue book) 
•  Burial Certificate (obtained from the Registrar of Births, Marriages and Deaths) 
•  Funeral arrangement form (Stillbirth and neonatal death form) 
•  Cremation – if parents want cremation, fill in cream coloured cremation form and notice 
of cremation (pink form) 
•  Ensure information leaflet on registering deaths and stillbirths are given to parents. 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
26.10  FETUS UNDER 24 WEEKS (NO POST MORTEM) 
Gestation of the fetus under 24 weeks – To be sent to the Centre of Life 
 
Ensure Investigation checklist for late pregnancy loss and stillbirth is completed. 
 
CORRECT SAMPLES FOR CHROMOSOME ANALYSIS (CYTOGENETICS) 
 
Fetus: 
The fetus should be wrapped in a clean sheet and stored in the cradle room.  To be sent 
intact.  If parents refuse for baby to be sent but consent to skin and  muscle to be taken, place 
1 cm of skin and muscle in sterile saline solution 
 
Biopsy: Placental and Membrane: 
Placenta is sent dry and complete.  If a biopsy is taken please include membrane in the 
specimen and place in sterile saline. 
 
Please keep all specimens in the fridge until it is collected for transport. 
 
Samples sent to: 
FAO Dr Carol English 
Institute of Human Genetics 
International Centre for Life 
Central Parkway 
Newcastle-Upon-Tyne 
NE1 3BZ 
 
Tel: 0191 241 8796 (Direct Line) 
 
NOTE:   Please phone to notify the samples are going to be sent 
   
Not to be sent over the weekend as the Centre is closed.   
Samples to arrive during week prior to 1630 hrs as the Centre closes at 1700 
hrs. 
 
Forms to accompany samples for Chromosome Analysis to include: 
•  Consent forms for chromosome (Cytogenetic) analysis after Pregnancy Loss or 
Termination 
•  Cytogenetics form must be completed and be secured with specimen 
 
Forms to accompany fetus for disposal 
(for Funeral Director) 
•  Certificate of Medical Practitioner in Respect of Fetal Remains  
•  Baby Internment Details Form 
•  Funeral arrangement form (Stillbirth and neonatal death form) 
•  Cremation – if parents want cremation, fill in cream coloured cremation form and notice 
of cremation (pink form) 
 
 
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North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
26.11  FETUS UNDER 24 WEEKS (FOR POSTMORTEM) 
Gestation of the fetus under 24 weeks – To be sent to the Centre of Life 
 
Ensure Investigation checklist for late pregnancy loss and stillbirth is completed. 
 
CORRECT SAMPLES FOR CHROMOSOME ANALYSIS (CYTOGENETICS) 
 
Fetus: 
The fetus should be wrapped in a clean sheet and stored in the cradle room 
 
Biopsy: Placental and Membrane: 
Placenta to be sent dry and complete.  If a biopsy of the placenta is taken please include 
membrane in the specimen and place in sterile saline. 
 
Placenta:  
Please keep all specimens in the fridge until it is collected for transport. 
 
Samples sent to: 
FAO Dr Carol English 
Institute of Human Genetics 
International Centre for Life 
Central Parkway 
Newcastle-Upon-Tyne 
NE1 3BZ 
 
Tel: 0191 241 8796 (Direct Line) 
 
NOTE – Please phone to notify the samples are going to be sent 
 
Forms to accompany samples to include: 
•  Consent forms for chromosome (Cytogenetic) analysis after Pregnancy Loss or 
Termination 
•  Cytogenetics form must be completed and be secured with specimen  
 
POSTMORTEM 
 
CIC;  
Mr Tremble (Funeral Director), Tel: 01228 594831 / 711543 will take the samples to 
the Centre of Life and then take the fetus and dry placenta to the RVI.  Placenta (dry 
– put in tube - then put tube in bubble wrap box) 
WCH;   E Kegg, Ext 2816 
 
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Publication Date:  22/01/2008 
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Samples sent to: 
FAO Chris Wright (Pathologist) 

Pathology Department 
RVI 
Queen Victoria Road 
Newcastle Upon Tyne 
NE2 4LP 
 
NOTE – Please contact Chris prior to sample being sent – RVI Pathology 
 
Forms to accompany fetus 
•  Request for a Perinatal Post Mortem Examination – ensure arrangements to return 
baby is completed on form 
•  Consent to the post mortem examination of a baby 
 
Forms to accompany fetus for disposal 
(for Funeral Director) 
•  Certificate of Medical Practitioner in Respect of Fetal Remains – over 24 weeks 
•  Baby Internment Details Form 
•  Funeral arrangement form (Stillbirth and neonatal death form) 
•  Cremation – if parents want cremation, fill in cream coloured cremation form and notice 
of cremation (pink form) 
 
TRANSPORT OF FETUS / INFANT UNDERTAKER 
 
Every fetus / infant going for investigation at Newcastle (RVI / Centre For Life) must be 
transported by the undertaker. 
 
CIC; John 
Tremble 
WCH;   
E Kegg, Ext 2816 
37 Church Street 
CARLISLE 
Cumbria 
 
Tel:  01228 594831 / 711547 
Fax:  01228 536080 
 
26.12  CYTOGENETIC SAMPLES TRANSPORT ARRANGEMENT 
 
TNT have the contract to transport Cytogenetic samples to Newcastle, to arrange for 
collection telephone 0800 777222 and ask for collection (next day service). 
 
Account No. 0440069009 
 
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26.13 TWINS 
 
1. 
If a twin dies in utero, no matter what gestation and the other twin is born over 24 weeks 
gestation, the fetus has to be registered as a stillbirth. 
 
2. 
The Registrar will only accept a Stillbirth Certificate if it has a sex on it. 
 
3.  Parents are required to register the fetus and return the disposal certificate to the 
Maternity Ward.  Alternatively, forms can be given to the Community Midwife to bring 
back to the Maternity Ward. 
 
4.  The doctor who sees the fetus should, if possible, state the sex of the baby.  If not 
obvious he / she must ask pathology.  If pathology are not sure of the sex the parents of 
the fetus can be asked to choose a sex. 
 
5. 
See “Information for Parents after Stillbirth” for information regarding burial or cremation 
of fetus. 
 
26.14 CHAPLAINCY 
 
Some members of the Chaplaincy Team carry pagers and can therefore be contacted more 
quickly than by telephone, contact pagers via switchboard. 
 
An on-call rota for alternative religions is available via switchboard. 
 
26.15 BAPTISM 
 
1. 
Parents permission should be obtained and the clergyman of the appropriate 
denomination contacted. 
2. 
Ensure the correct name for the baby. 
3. 
Set a small trolley in the mothers room with a Christening bowl and spoon and flowers. 
4. 
Escort the minister to the room when he arrives and give him time to wash his hands. 
5. 
The midwife should be present to support the parents throughout the service. 
6. 
Ensure Baptismal Book is completed and signed by the Minister who will extract 
relevant information for his records.  The book is kept on SCBU. 
7. 
Hospital Baptism Certificate is given to parents. 
8. 
If death is imminent the midwife may perform the Baptism. 
 
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26.16  REGISTRATION OF DEATHS AND STILLBIRTH 
 
• 
The death / stillbirth must be registered within 5 days 
• 
Please phone Registrar (01228 607430 or 607433) to inform of stillbirth 
• 
These parents do not need notification of birth sheet 
• 
The parents must be given the death certificate issued by the doctor 
• 
The registrar will, on registering the stillbirth will issue a Certificate of Burial or 
Cremation.  If a hospital burial or cremation the certificate should be bought back to the 
maternity ward.  Funeral Directors will collect it.  If for private funeral the certificate 
should be given to the undertaker of choice.  
• 
Registration can be arranged by an appointment system if wished. 
 
26.17  PROCEDURE FOR CARE OF THE PRE-VIABLE BORN INFANT 
 
If the baby is born before 24 weeks gestation and active measures to preserve life are taken 
and the baby subsequently dies, please follow normal neonatal death procedure. 
 
If the birth is so premature that an abortion is expected, this baby may breathe at birth and live 
for a matter of minutes or hours. 
 
a)  If the paediatrician wishes, the baby should be transferred to an incubator in SCBU, or 
b)  With the agreement of the paediatrician, the baby should be wrapped up and placed in a 
Moses basket. 
If the parents wish, the baby may stay in the room with the parents until breathing 
ceases.   
If the parents do not wish this to happen, the baby may be transferred in the Moses 
basket to the nursery. 
The baby can be returned to the parents at any time should they so wish. 
 
Photographs may be taken on the infant in the Moses basket. 
 
26.18 
MANAGEMENT OF STILLBIRTH INCLUDING DELIVERY, 
POSTNATAL CARE AND LAYING OUT 
 
Labour 
 
If the mother and her partner know that their baby is going to be stillborn, an opportunity 
should be made while she is in early labour to discuss with her and her next of kin, who, if 
anyone, she would like to be present at the delivery and to introduce the idea of her holding 
her stillborn infant when it is born. 
 
The first answer must not necessarily be accepted as the right answer and supportive 
discussion will need to take place to help the parents to come to a decision. 
 
A midwife should not be expected to take charge of the case if she has never witnessed a 
stillbirth before. 
 
 
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Ideally, this midwife should be encouraged to be involved as the 2nd midwife in the providing 
care. 
 
The mother should be given adequate analgesia and if in doubt about how much she can be 
given, medical advice should be sought. 
 
Delivery 
 
The baby should be delivered into a baby wrap and wrapped in blankets. 
 
If the mother an / or father wish to hold their infant, the baby should be given to them as soon 
as possible whilst the baby still feels warm. 
 
If they do not wish to hold their infant, the baby should be placed in the cot and later taken to 
another room.  Under no circumstances should the baby be placed on the delivery trolley. 
 
If it has been an unexpected stillbirth, the paediatrician will probably be present at delivery and 
will be able to sign the stillbirth certificate.  If it is an IUD and there is no doctor present, the 
registrar should be bleeped to see the baby as soon as possible. 
 
Any arrangements the parents wish to discuss can be done so through the midwife in charge 
of the case. 
 
Postnatally 
 
Usually the parents will remain on the Delivery Suite until discharge home. 
 
Ensure the checklist is completed including the date and time for the parents to return to 
discuss the case at a later date when any test results will be available. 
 
Ensure all paperwork is filled out correctly and that specimens are collected and dispatched 
appropriately according to the guidelines. 
 
The mother and her partner should be allowed open visiting for family and friends should the 
parents wish this. 
 
The SANDS booklet should be offered to the parents prior to discharge.  The parents may 
also find comfort in receiving footprints of their baby and / or hat and bootees the baby was 
dressed in. 
 
The SANDS are also offering a small pair of teddy bears for the parents.  The first bear to be 
buried with the baby and the second bear to be kept by the parents as a keepsake. 
 
The discharge letter should be completed and sent to the GP and midwife through the postal 
system. 
 
At a suitable time, inform the parents of the various arrangements to be made.  If the parents 
cannot make any decisions prior to discharge the Community Midwife can liaise with the ward. 
 
 
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Laying Out the Baby 
 
1. 
Clamp the cord with a Hollister Clamp 
 
2. 
Gently wash off any excess blood or meconium if the skin is not too macerated. 
 
3. 
Label the baby with a namelet on the ankle. 
 
4. 
Complete details as requested on checklist sheet and on Investigation of Perinatal Death 
sheet. 
 
5. 
Dress or wrap the baby in a suitable way.  The parents may wish the baby to be dressed 
in clothes that they provide. 
 
6. 
A digital photo to be taken and put in the notes.  Then take some photos for the parents. 
The parents may wish for photos holding the fetus. 
 
7. 
A completed cot card must accompany the baby for identification purposes. 
 
8. 
When all interested parties have seen the baby, wrap the baby in an outer sheet, seal 
with tape and transfer to the cradle room. 
 
9.  In cases where the parents do not wish to see or hold the baby immediately after 
delivery, the baby should be placed in the cradle room. 
 
26.19  PROCEDURE FOR USE OF THE CRADLE ROOM 
 
1.  When parents have had the time they wish with their baby the midwife from Delivery 
Suite will put the baby in the fridge in the cradle room and complete the record book, 
which is kept on top of the fridge. 
 
2. 
If the baby is for post mortem write this in the record book in the cradle room. 
 
3.  The midwife is to inform the mortuary of any baby put in the cradle room for post 
mortem. 
 
4. 
When the baby goes for post mortem the midwife should escort the porter to the cradle 
room to collect the baby.  Both should sign the book.  When the baby is returned the 
porter is to sign the book and inform staff of the return. 
 
5. 
The fridge temperature should be at 4oC and checked daily by a nursing assistant. 
 
6.  When babies are in the cradle room please write their names on the Maternity Ward 
board. 
 
7. 
A progress report to be given at each changeover of staff, e.g. if baby has gone for post 
mortem or not. 
 
8.  Undertakers to liaise with the midwife in charge of Maternity Ward before removing 
babies from the Hospital and sign the record book. 
 
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26.20  HAND AND FOOT PRINTS 
 
This is a two person job. 
 
Equipment: Wipes 
 
 
Sensitised certificates or labels 
  White 
envelopes 
 
1. 
Ensure the child’s feet are clean and dry. 
 
2. 
The first person, using the wipe, gently wipes the child’s hand / foot.  NOTE – the wipe 
may feel dry – this is normal. 
 
3. 
The second person, holds the certificate / label while the first person positions the child’s 
foot gently, but firmly, press to make a good print. 
 
Be very careful as the wipe will also coat your fingers and if you touch the sensitised 
certificate, your fingerprint will also appear. 
 
It will take at least 30 seconds for the print to appear a pale lavender colour. 
 
4. 
Repeat the process for the other hand / foot. 
 
5. 
If the wipe is not used immediately, please store in a cool dry place, away from the light, 
and ensure that the bag remains sealed and airtight. 
 
6. 
Place the prints in a white envelope to protect them from fading. 
 
Your Manager can re-order wipes and sensitised paper as required from: 
 
 Ontiles 
Ltd 
 
7 Brockwell Park Row 
 LONDON 
 SE2 
2YH 
 
26.21 BEREAVEMENT COUNSELLORS 
 
Please ensure that bereaved parents have contact number for Bereavement Counsellor or 
Co-ordinator before discharge.   If possible arrange for the parents to meet the before 
discharge.   
 
If there are any special requests by parents for cremation / burial please contact Bereavement 
Counsellor so that she can ensure the correct procedures are put in place. 
 
 
NCHE-OBS001 
 
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Publication Date:  22/01/2008 
Version 2.0 
 
26.22 POSTNATAL REVIEW 
 
The Consultant who is responsible for the patients care should be informed about the stillbirth 
or neonatal death before the patient leaves the hospital.  The SHO or SpR on call at the time 
death is responsible for this communication. 
 
The midwife discharging the patient is responsible for making arrangements for counselling.  
This will be via the Obstetrics Secretary, usually about 6-8 weeks after the event. 
 
26.23 MATERNAL DEATH 
 
Maternal death is a death that occurs during or within a year of pregnancy childbirth or 
abortion.  It can be classified as directly related to pregnancy, indirectly related, late or 
coincidental: 
 
Direct - Deaths resulting from obstetric complications of the pregnant state [pregnancy, labour 
and puerperium], from interventions, omissions, incorrect treatment or from a chain of events 
resulting from any of above 
 
Indirect - Deaths resulting from previous existing disease or disease that developed during 
pregnancy and which was not due to direct obstetric causes, but which was aggravated by the 
physiologic effects of pregnancy e.g. Epilepsy, diabetes, cardiac disease 
 
 
Late - Deaths occurring between 42 days and 1 year after abortion miscarriage or delivery 
that are due to Direct or Indirect maternal causes 
 
Coincidental [Fortuitous] - Deaths from unrelated causes, which happen to occur in 
pregnancy or in the puerperium e.g. road traffic accident. 
 
The responsibility for notifying the Public Health Director that a maternal death has occurred 
should rest with the Consultant Obstetrician or the Head of Midwifery. 
 
Appendix 
 
In the event of the baby dying in-utero the following should be considered: 
 
Definition of a stillbirth does not include the removal of a dead baby from its dead mother at 
post mortem in order to ascertain cause of death.  Therefore registration of a baby, in these 
circumstances, over 24 weeks gestation, as a death is not legally required.  
 
If the baby is delivered during Maternal resuscitation, the baby will be registered as either live 
birth or stillbirth 
 
 
 
NCHE-OBS001 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
Checklist 
ACTION YES 
NO
DATE, 
TIME, 
SIGNATURE 
   COMMENTS 
Notify immediately: 
 
 
 
 
Consultant on call  
 
 
 
 
Midwifery Manager on 
 
 
 
 
call 
Head of Midwifery 

 
 
 
 
Supervisor of Midwives 
 
 
 
 
on call 
 

 
 
 
 
Next of kin informed by 
 
 
 
 
Senior Medical Staff 
Ensure all documentation is   
 
 
 
completed 
Mortuary informed 
 
 
 
 
Pathologist informed by 
 
 
 
 
Consultant 
Post mortem consent 
 
 
 
 
completed. 
In case of unknown cause 
Coroner can undertake this 
without consent 
Issue of Death Certificate 
 
 
 
 
Chaplain to be informed 
 
 
 
 
Inform following within 
 
 
 
 
normal working hours
Patients Consultant 
 
 
 
 
General Practitioner 
 
 
 
 
Community Midwives 
 
 
 
 
Health Visitor 
 
 
 
 
Chief Executive 
 
 
 
 
LSA Midwifery Officer 
 
 
 
 
Coroners Office 
 
 
 
 
Public Health Director 
 
 
 
 
Tel:603500 
Director of Nursing 
 
 
 
 
Clinical Director 
 
 
 
 
Medical Director 
 
 
 
 
CEMD Regional 
 
 
 
 
Coordinator 
CEMD National Coordinator   
 
 
 
 
 
 
 
 
Documentation 
 
 
 
 
Ensure all documentation is   
 
 
 
complete  
Complete Trust Incident 
 
 
 
 
Report Form 
 
NCHE-OBS001 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
Phototcopy notes at earliest   
 
 
 
opportunity 
Copy Maternal Death 
 
 
 
 
Certificate into notes 
If referred to Coroner, 
please state clearly 
 
 
 
 
 
Stillbirth 
 
 
 
 
Use stillbirth checklist in 
separate folder NB If death 
occurs in-utero, please 
refer to Appendix 
 
 
 
 
 
Serious Untoward 
 
 
 
 
Incident to be reported, in 
line with Trust Untoward 
Incident Reporting      
Policy [see policy in Risk 
Management Folder]    
 
 
 
 
 
Support 
 
 
 
 
Family Support, 
 
 
 
 
bereavement counselling 
 
 
 
 
 
Staff support & meetings 
 
 
 
 
Debriefing 
 
 
 
 
Statement writing 
 
 
 
 
Critical Incident Review 
 
 
 
 
 
 
 
 
 
 
NCHE-OBS001 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
References: 
 
Bourne S, Lewis E (1984) Pregnancy after stillbirth or neonatal death.  Lancet 289: 31-33 
 
Peppers LG, Knapp RJ (1980) Maternal reactions to involuntary fetal / infant death.  
Psychiatry 43: 155-159 
 
Robb F (1999) Congenital malformations: breaking the bad news.  Br J Midwifery 7: 28-31 
 
Estok P, Lehman A (1983) Perinatal Death: Grief support for families. Birth 10: 17-25 
 
Forrest GC, Standish E, Baum JD (1982), Support after perinatal death:  a study of support 
and counselling after perinatal bereavement.  BMJ 285: 1475 – 1479 
 
 
NCHE-OBS001 
 
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link to page 282 North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
CHAPTER 27 - CORD PROLAPSE 
 
 
 
27.1 
CORD PROLAPSE ...........................................................................................282 
 
NCHE-OBS001 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
27.1 CORD 
PROLAPSE 
 
Definition: 
 
Cord presentation is the presence of the fetal umbilical cord in advance of any other fetal part. 
 This may occur with or without rupture of the membranes. 
 
Cord prolapse is the protrusion of the cord through the cervical os.  This usually only occurs in 
the absence of membranes. 
 
Incidence of cord prolapse: 
 
Between 0.2% and 0.4 %, but may be higher in ‘at risk’ pregnancies. 
 
Risk Factors: 
 
♦ Pre-term 
♦  Small for gestational age 
♦ Malpresentation 
 
♦ Transverse 
lie 
♦  Breech presentation (particularly flexed breech and footling breech) 
♦ Face 
presentation 
♦ Brow 
presentation 
♦ Oblique 
lie 
 
♦ Twins 
♦ Polyhydromnios 
♦ Amniotomy 
 
Consequences: 
 
Prolapse of the cord may result in: 
 
♦ Cord 
compression 
♦ Vasospasm 
 
Consequences for the fetus relate to the acute interruption of blood flow in the cord. 
 
♦  Acute fetal hypoxaemia 
♦ Acute 
acidaemia 
♦ Tissue 
hypoxia 
 
♦  Low arterial cord pH 
♦  Apgar score at 5 minutes under 7 
 
 
NCHE-OBS001 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
Sometimes leading to: 
 
♦ Fitting 
♦  Long term cerebral dysfunction 
♦ Death 
 
Management: 
 
When faced with cord prolapse, the aim of management is to: 
 
♦  Keep pressure off the cord 
♦  Keep the cord warm 
♦  Delivery of the baby … 
♦  Without jeopardising the mother’s safety 
 
See the algorithm (figure 1) 
(Figure 1) 
 
Cord Prolapse 
 
Stay calm 
 
Call for help 
 
Anaesthetist & anaesthetic nurse          paediatrician 
Senior SpR / Consultant          Senior Midwife          Auxiliary 
 
use the fingers of your examining hand to apply 
pressure 
to the presenting fetal part 
 
if the cord is lying outside the vagina 
replace 
it gently into the vagina 
 
then 
roll 
the woman onto all fours 
 
and 
transfer 
her to theatre 
 
deliver her by 
caesarean section 
 
If the fetal heart is still audible 
 
 
NCHE-OBS001 
 
Page 283 of 281 

North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
Vaginal delivery in the presence of cord prolapse: 
 
In some circumstances, vaginal delivery may be preferable despite cord prolapse.  For 
example, in the presence of a dead fetus the prolapsed cord will not obstruct delivery 
vaginally.  Attention must simply be paid to any associated fetal malposition. 
 
When the fetus is alive, vaginal delivery may be considered if: 
 
♦  The cervix is fully dilated 
♦  A senior SpR or Consultant is present 
♦ It 
is 
likely that vaginal delivery can be achieved rapidly … 
♦  Without traumatising the cord 
 
These conditions may be met for example in the delivery of a second twin presenting by 
breech.  Following delivery, the operator must always document the reasons for attempting 
vaginal delivery rather than performing a caesarean section. 
 
Filling the bladder 
 
By filling the bladder rapidly with 500 ml normal saline at room temperature, pressure can be 
taken off the cord effectively.  This technique may be employed instead of rolling the patient if 
facilities are directly to hand, but transfer to theatre should not be delayed. 
 
In brief, a litre of normal saline is run through a giving set and hooked up to a Foley’s catheter. 
 The catheter is passed through the urethra into the bladder and 500 ml saline is run through 
rapidly.  The balloon of the bladder is inflated, the catheter clamped and the bag of saline 
removed. 
 
The anaesthetic should be administered and the patient prepped for surgery with the bladder 
full, but the clamp should be removed to allow the bladder to drain when the skin is being 
incised.  The operator must take particular care to avoid the bladder during the caesarean 
section. 
 
ARM with a high head: 
 
This procedure will normally be performed by the SpR or the Consultant. 
 
When an ARM is to be performed in the presence of a high head (3/5 or more palpable 
abdominally), the operator should be ready to deal with cord prolapse.  Therefore, the 
anaesthetist and Senior Midwife should be ‘made aware’ and the operating theatre should be 
available for use.  The operator may choose to have available a litre of normal saline run 
through a giving set, together with a Foley catheter. 
 
Gentle pressure should be applied to the fetal head above the pubis by an attending midwife 
while the membranes are ruptured with an amnihook.  The operator’s hand should remain in 
the vagina until the fetal head has descended low enough to prevent cord prolapse.  If 
syntocinon is to be used, this should be commenced at 0.6 ml / hr without delay. 
 
A further vaginal examination is advisable 1 hour later to confirm the absence of cord.  Vaginal 
examination is mandatory if any fetal hear rate abnormalities arise after performing the ARM. 
 
NCHE-OBS001 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
 
 
 
NCHE-OBS001 
 
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North Cumbria Acute Hospitals NHS Trust 
North Cumbria Delivery Suite Guidelines 2008 
Publication Date:  22/01/2008 
Version 2.0 
 
References:  
 
Prabulos AM, Philipson EH (1998) Umbilical cord prolapse.  Is the time from diagnosis to 
delivery critical?  J Reprod Med 43: 129-32. 
 
Runnebaum IB, Katz M (1999) Intrauterine resuscitation by rapid urinary bladder instillation in 
a case of occult prolapse of an excessively long umbilical cord.  Eur J Obstet Gynecol Reprod 
Biol 
84: 101-2. 
 
Usta IM, Mercer BM, Sibai BM (1999) Current obstetrical practice and umbilical cord prolapse. 
 Am J Perinatol  16: 479-84. 
 
Uygur D et al (2002) Risk factors and infants outcomes associated with umbilical cord 
prolapse,  Int J Gynaecol Obstet 78: 127-30. 
 
Newcastle Hospitals NHS Trust, Delivery Suite Guidelines, Sept 2004 
 
NCHE-OBS001 
 
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CHAPTER 28 - PAEDIATRIC INVOLVMENT ON DELIVERY 
SUITE 
 
 
Please also refer to the Paediatric Guidelines ‘Management of Babies at Delivery and 
on the Postnatal Wards’ 
 
 
28.1 
CASES IN WHICH A PAEDIATRIC PROBLEM HAS BEEN IDENTIFIED 
ANTENATALLY
......................................................................................................................2
89 
28.2 
URGENT INTRAUTERINE TRANSFER REQUESTS:  THE HOT LINE 
PROCEDURE
......................................................................................................................2
89 
28.3 
PAEDIATRIC ALERT DURING LABOUR
......................................................................................................................2
89 
28.4 
PAEDIATRIC PRESENCE AT DELIVERY (WCH ONLY)
......................................................................................................................2
89 
28.5   
RESUSCITATION OF NEONATES BY MIDWIVES (CIC ONLY)
......................................................................................................................2
90 
28.6 
URGENT CALL FOR PAEDIATRIC ASSISTANCE
......................................................................................................................2
90 
28.7 
MATERNAL ADVICE
......................................................................................................................2
91 
28.8 
ROUTINE MANAGEMENT OF THE BABY
......................................................................................................................2
91 
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28.9 
DELIVERY IN THEATRE
......................................................................................................................2
91 
28.10 
MANAGEMENT OF BABY AT BIRTH WITH MECONIUM STAINED LIQUOR
......................................................................................................................2
91 
28.11 
SKIN-TO-SKIN & HYPOTHERMIA GUIDELINES
......................................................................................................................2
92 
28.12 
HYPOGLYCAEMIA OF THE NEWBORN  -
......................................................................................................................2
95 
28.13 
UNEXPECTED ABNORMALITY OR DEATH
......................................................................................................................2
99 
28.14 
HAEMOLYTIC DISEASE OF THE NEWBORN
......................................................................................................................2
99 
28.15 
GROUP B STREPTOCOCCUS INFECTION
......................................................................................................................2
99 
28.16 
CHILD ABDUCTION – PROCEDURE FOR STAFF
......................................................................................................................2
99 
 
 
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28.1  CASES IN WHICH A PAEDIATRIC PROBLEM HAS BEEN 
IDENTIFIED ANTENATALLY 
 
Occasionally, a baby that may need paediatric involvement at or shortly after delivery is 
identified antenatally.  For example: 
 
• congenital 
abnormality 
•  previous cot death 
•  family history of disease 
 
When this happens, the paediatric services can be notified in advance by discussing the 
case with the paediatrician of the week at CIC or WCH. 
 
28.2  URGENT INTRAUTERINE TRANSFER REQUESTS:  THE HOT 
LINE PROCEDURE 
 
Details are included in Chapter 1. 
 
28.3  PAEDIATRIC ALERT DURING LABOUR 
 
In some circumstances it is helpful to notify the duty paediatrician where a mother is in 
labour.  This may enable the paediatrician to speak to the parents in advance of the 
delivery or to be aware of issues that may be relevant to the delivery or care of the baby 
following delivery.  These may include: 
 
•  Multiple pregnancy <35/40 
•  Suspected fetal abnormality 
• Preterm 
labour 
• Maternal 
Pyrexia 
•  When specific instructions have been given on the case notes, e.g. on an alert 
form 
•  Mother with Rhesus and / or other antibodies 
 
28.4  PAEDIATRIC PRESENCE AT DELIVERY (WCH ONLY) 
 
The duty Paediatrician should be present at delivery in the following circumstances: 
 
•  Caesarean section performed as an emergency for prolonged fetal distress 
•  Multiple births <35/40 
•  Thick fresh meconium staining of liquor 
•  Assisted delivery because of concerns about fetal wellbeing 
•  Mother with antibodies whose labour has been induced on fetal grounds 
•  Growth retardation where babies weight is < 2kg 
•  Delivery < 36 weeks gestation 
•  Prolonged fetal bradycardia 
• Cord 
prolapse 
 
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28.5    RESUSCITATION OF NEONATES BY MIDWIVES (CIC ONLY) 
 
The baby's condition at birth and the method or resuscitation, including Apgar scoring, 
will be written in the baby's notes.  Consultants should be called to be present at the 
following problem deliveries: 
 
•  Premature births at gestation 34 weeks or less; intra-uterine growth retardation 
where the baby's size is equivalent to 34 weeks or less than 2 kg. 
•  Multiple pregnancy less than 35 weeks. 
•  Significantly prolonged fetal distress. 
•  Thick meconium noted in labour. 
•  Known congenital abnormality; please discuss with the consultant on duty. 
• Cord 
prolapse. 
 
Difficulties encountered during resuscitation 
 
Midwives trained in advanced neonatal resuscitation should be in attendance. 
 
If a midwife has no response to resuscitation at 5 minutes, the consultant should be 
called urgently. The switchboard must be requested to urgently page the Consultant 
Paediatrician.  Out of hours, request switchboard to page and telephone Consultant's 
home number and request to attend Delivery Suite urgently.  Switchboard will confirm to 
Delivery Suite they are on way.  If possible, it is preferable for obstetrician or midwife to 
discuss the case directly with the paediatrician. 
 
Ventilation of the baby by the midwife continues as long as needed, or until the 
consultant arrives.  Cardiac massage is given if the heart rate remains below 60 / 
minute.  This requires an assistant for the midwife until the consultant is present. 
 
There will continue to be unexpected asphyxiated neonates, some of whom will not 
respond well to adequate resuscitation by a skilled resuscitator.  We should be well 
prepared to deal with this unfortunate situation by having trained resuscitators on site. 
 
28.6  URGENT CALL FOR PAEDIATRIC ASSISTANCE 
 
The paediatrician should be called urgently in the following situations: 
 
•  An unexpectedly unresponsive baby 
•  Thick particulate meconium staining of the liquor not previously diagnosed 
•  Any other cause for concern 
 
If a midwife has no response to resuscitation at 5 minutes or it is evident that the 
condition of the baby suggests that urgent paediatric involvement is needed the 
consultant should be called.  In these circumstances switchboard should be requested 
to urgently page the duty consultant and if out-of-hours to also phone the consultant at 
home informing the consultant that their immediate presence is required on LDRP.  The 
switchboard should be asked to confirm to LDRP that the consultant is on his / her way. 
 
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28.7 MATERNAL 
ADVICE 
 
It is helpful to warn mothers that some otherwise healthy babies will usually be taken to 
Special Care for a period of assessment: 
 
•  Gestation <34 weeks 
•  Weight < 1.8 kg 
•  Term babies with weight under the 3rd centile (not all admitted to SCBU) 
 
28.8  ROUTINE MANAGEMENT OF THE BABY 
 
The baby should be labelled and weighed in the delivery room and may be put to the 
breast at an opportune time according to the mother’s wishes. 
 
28.9  DELIVERY IN THEATRE 
 
If birth takes place in the operating theatre, parental interests should not be neglected.  
When spinal / epidural anaesthesia is used, both parents may have the opportunity to 
see and touch the baby.  If general anaesthesia is given the father should see the baby 
as soon as possible. 
 
28.10  MANAGEMENT OF BABY AT BIRTH WITH MECONIUM STAINED 
LIQUOR 
 
Most babies born from meconium stained liquor have not inhaled any particulate 
material into the lower respiratory tract.  If they have not done so as a result of anoxic 
gasping before birth, they will very rarely do so at birth.  However, be aware that 
participate material in the trachea can cause obstruction and may need removing. 
 
If thick meconium is present at birth and the baby makes no respiratory effort 
 
•  Avoid tactile stimulation 
•  Inspect the larynx using neonatal laryngoscope 
•  Under direct vision aspirate the trachea to confirm they have not aspirated any 
meconium below the cords. 
 
Material thick enough to cause obstruction cannot be sucked up by a catheter small 
enough to pass down an ET tube; if possible whole ET tube should be used as the 
suction catheter. 
 
There is no evidence to suggest that upper airway suction during delivery reduces the 
number of babies with symptomatic aspiration pneumonia needing Oxygen after birth 
and some evidence to show it can do more harm. 
 
A BABY BORN SCREAMING HAS AN OPEN AIRWAY 
 
A FLOPPY BABY ------------ HAVE A LOOK 
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28.11  SKIN-TO-SKIN & HYPOTHERMIA GUIDELINES  
 
♦  All mothers should be actively encouraged to hold their babies in skin-to-skin contact 
as soon after delivery as is practical, regardless of intended method of feeding.  
 
♦  Skin-to-skin contact must be offered within an unhurried environment with no 
pressure to cease as long as both mother and baby are well.  (Literature suggests 
this could last 90 minutes.)  
 
♦  The baby should be dried with a pre-heated towel. 
 
♦  When skin-to-skin contact is initiated both mother and baby should be covered 
together.  The baby can also wear a hat if the room temperature is sub optimal or if 
the baby is small.  
 
♦  According to the parent’s wishes the baby should be weighed either immediately 
post delivery or after skin-to-skin contact has ceased.  In this way the contact 
between the mother and the baby is not interrupted. 
 
♦  Early feeding should be encouraged. 
 
♦  Most babies are particularly alert and want to feed within the first two hours after 
delivery.  Signs that he/she is ready for a feed can be pointed out. 
 
♦  The midwife should offer help with this first feed. 
 
♦  Special attention needs to be addressed with regards to the safety of the infant if the 
mother has recently been sedated, received opiate analgesia or general 
anaesthesia.  In this situation either the birth partner or a Health Care Professional 
should remain with the pair whilst the baby is in bed with the mother.  This is an ideal 
time for positive family interaction. 
 
♦  When the mother has decided to cease skin-to-skin contact, the baby can be 
identified, checked over, weighed and washed.  The baby’s father can be offered 
skin-to-skin contact.  If he declines or is unable, the baby can be wrapped in a pre-
heated blanket until the mother is able to have the baby back skin-to-skin. 
 
♦  The baby and mother will be transferred to Maternity Ward skin-to-skin.  A blanket 
should be wrapped around them both.  
 
♦  If the mother wishes she can keep the baby skin-to-skin on Maternity Ward, ensuring 
she is not too sedated (see above) 
 
♦  The mother should be offered assistance again with feeding during this early 
postnatal period. 
 
♦  All help and skin contact will be documented on the Audit Sheet and the care plan. 
 
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♦ During the postnatal period, regardless of the chosen feeding method, women 
should be encouraged to retry skin-to-skin contact as a way of settling their babies.  
 
♦ Should the baby’s temperature be low at any time skin-to-skin contact must be 
encouraged as the optimum method of bringing it up to normal levels.  (See 
attached Appendix 1 – Flow chart)
 
 
Benefits of Skin-to-Skin Contact  
 
♦  Maintains / regulates the baby’s body temperature.   
 
♦  Calms the baby thus teaching the mothers a way to soothe their baby, making 
rooming in easier.  
 
♦  If left undisturbed in skin-to-skin contact with their mothers after delivery babies 
exhibit such behaviour as:- 
 
ƒ Salivating 
ƒ Rooting 
ƒ  Crawling to the breast 
 
All of which enable the first feed.  
 
♦  Early contact leading to an early feed boosts maternal confidence, which leads to 
easier subsequent feeds. 
 
♦  Early breastfeeding can increase uterine activity so reducing the risk of post-partum 
haemorrhage.   
 
♦  Early breastfeeding appears to help promote gut maturity and aids the passage of 
meconium in the baby and so lessens the incidence of mucousy babies and 
neonatal jaundice.   
 
♦  Mothers are overwhelmingly positive about their experiences of skin-to-skin contact 
and often claim that the sight, feel and smell of their baby encouraged powerful 
feelings of love and protectiveness.   
 
♦  Demand feeding is encouraged, it can be used to stimulate the sleepy baby. 
 
♦  Settling the fractious baby is easier making the need for soothers less likely. 
 
Benefits for the Pre-term Baby 
 
♦  Regulates heartbeat and breathing  
♦  Helps maintain temperature  
♦  Promotes longer more restful sleep  
♦  Encourages breastfeeding  
♦  May enhance weight gain and possibly lead to a shorter hospital stay  
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Flowchart for Management of Hypothermia 
 

S.G.A. & Pre-term 
Term 
 
 
 
  Temperature 36.5 & below 
Temperature 36.2 & below 
 
 
 
♦  Skin to skin contact with 
♦  Skin to skin contact with 
mother 
mother 
♦  Ensure both are covered 
♦ 
Ensure both are 
with a blanket 
covered with a blanket 
♦ Ensure the baby feeds 
♦  Ensure the baby feeds 
adequately 
adequately 
♦  The baby will need a hat 
 
♦  Ensure a warm thermal 
environment 
Check temperature after 1 hour 
If no improvement 
♦  Check blood glucose 
♦  Inform Paediatrician 
If improved 
If improved 
♦  Encourage skin to skin 
♦  Encourage skin to skin 
as much as possible 
as much as possible 
♦  Monitor temperature 2-4 
♦  Monitor temperature 4-6 
hourly until stable 
hourly until stable 
♦ Monitor 
feeds 
♦ Monitor  feeds  until 
temperature stable 
When in cot 
When in cot 
♦ Extra 
clothes 
♦ Extra 
clothes 
♦ Extra 
blankets 
♦ Extra 
blankets 
♦ Extra 
mattress 
♦ Hat 
♦ Sheepskin 
Page 294 of 302 

North Cumbria Delivery Suite Guidelines  
28.12  HYPOGLYCAEMIA OF THE NEWBORN  -  
 
GUIDELINES FOR PREVENTION AND MANAGEMENT 
 
Well Term Babies 
 
Infants born at term (>37 completed weeks) who are appropriate for gestational age 
and who are well do not require routine glucose monitoring. These babies are able to 
produce alternative fuels in the form of ketone bodies so the blood glucose level per se 
is less relevant and harder to interpret (1). The healthy term newborn does not develop 
“symptomatic” hypoglycaemia as a result of simple underfeeding (2). If there are 
symptoms to suggest low blood glucose, the infant must be reviewed to look for an 
underlying cause. 
 
Hypoglycaemia and hypothermia are often associated and although there is no 
established causal link it is important that the baby’s temperature is maintained from 
birth.  
 
There is little data on how often a newborn infant needs to feed but feeding early after 
delivery is recommended. It may be four times or less in the first day of life increasing in 
frequency from day two (3).If a baby is unwilling to feed or has not woken up for a feed 
within twelve hours of birth he or she may be ill in this case the baby should be clinically 
assessed “feed – check – review” see below. Clinical observation and physical 
examination are more valuable than isolated blood glucose monitoring in establishing 
whether there is an underlying problem. These infants will then have appropriate 
investigations and treatment without delay. 
 
If there are no signs of illness, but the infants feeding pattern is causing concern, 
guidelines recommend a policy of  “feed – check – review” (4), and compliance with the 
Healthy Term Baby flow chart management. 
 
♦  Feed - Offer milk frequently either breast or E.B.M. or formula if the infant is 
artificially fed. Initiate Skin-to-Skin contact and encourage feeding by massage and 
stimulation. 
 
♦  Check - Observation of vital signs – temperature, heart rate and respirations. 
 
♦  Review - Well baby = continue: Symptoms or concern = need medical review. 
 
Jitteriness is a rapid symmetrical tremor of the limbs. It is common in the first few days 
and can be stopped by handling the baby and flexing it’s limbs. It is never accompanied 
by physiological changes e.g. heart rate or apnoea – this could be indicative of a 
seizure. Jitteriness in a healthy term baby is often a benign finding. In a high risk baby 
hypoglycaemia should be considered. 
Page 295 of 302 

North Cumbria Delivery Suite Guidelines  
Well Term Baby (Flowchart) 
 

At Birth 
 
 
Feeding is not initiated 
 
♦ Dry the baby well 
 
♦ Establish  Skin-to-Skin 
♦ 
Maintain or re-establish 
♦ Offer a feed as soon as the 
skin-to-skin 
baby is ready
♦ Observe for infant cues and 
offer feeds 
♦ Teach hand expressing
Feeding is initiated 
 
Well baby but feeding not 
♦ Baby is a symptomatic 
initiated or woken up by 12 
♦ Offer  2nd feed within 6 hours 
If cause for 
hours
♦ 
Continue with demand feeding 
concern 
unless any clinical cause for 
concern 
Follow policy of 
♦ Teach hand expressing within 1st 
“Feed, Check, Review” 
and 24 hours if breastfeeding 
 
♦ Exclude 
clinical signs of 
Hypoglycaemia see below 
Normal examination and 
♦  Monitor vital signs 
A symptomatic 
 
♦ Continue 
Feed-Check-Review 
♦ Encourage 
Skin-to-Skin 
Abnormal examination 
and / or Symptomatic 
 
♦ Blood Glucose estimation 
Blood Glucose 
2.6 mmol/l or Ç above 
 
♦ Continue  Feed-Check-Review 
Blood Glucose 
♦ Repeat blood glucose prior to next 
2.6 mmol/l or below 
feed only if concerned. 
 
♦ Feed – breast, EBM or 
formula if A/F or no EBM 
Any Baby 
♦ Repeat Blood Glucose 1 
Who is Symptomatic 
hour after feed 
 
♦ Must be referred to a paediatrician 
immediately 
♦ Blood glucose must be done 
Blood Glucose 
Blood Glucose 
♦ Keep the baby warm 
2.6 mmol / l or above 
Below 2.6mmol/l 
 
 
 
Symptoms Include 
♦  Offer 3 hourly feeds 
♦  Inform the staff 
• Jitteriness 
♦  Repeat pre feed blood 
on NNU 
• Irritability, 
Cold 
glucose until 2 consecutive 
• Apnoea 
readings are Ç 2.6mmol/l 
• Colour 
Changes ♦  Then demand feeding 
• Hypotonia 
• Convulsions 
Jitteriness is rapid generalised symmetrical tremor of the limbs.  
• 
Altered 
It is common in the first few days and can be stopped by 
Consciousness 
handling the baby and flexing the limbs.  It is never accompanied 
 
by physiological changes, e.g. raised heart rate or apnoea this 
Any Baby  
would be indicative of a seizure.  Jitteriness in a healthy baby is 
  
often a benign finding.  In a high risk baby hypoglycaemia should 
Whose Blood Glucose is È 1 
be considered.  (Textbook of Neonatology Eds., Robertson & 
mmol/ l  refer immediately to 
Bernie, 3rd Edition, Churchill Livingston, 1999) 
paediatrician 
Page 296 of 302 

 
High Risk Babies 
 
All babies in the at risk group (see over) should be identified clearly at birth and the 
Hypoglycaemia Guidelines flow chart followed, feed chart commenced and subsequent 
care documented and discussed with the parents. 
 
Hypoglycaemia is a low blood sugar concentration, which may result in permanent 
neurological dysfunction. A “normal” range for the neonate has not yet been properly 
defined and values are influenced by birth weight, gestational age, feeding method and 
postnatal age. 
 
At Risk babies have an increased incidence of hypoglycaemia, and an appropriate 
metabolic response may be absent placing them at greater risk. Infants in these at risk 
groups should be fed early and reviewed frequently as they may have an impaired 
counter regulatory response i.e. be unable to synthesise glucose adequately or mobilise 
alternative cerebral fuels. Therefore blood glucose monitoring is appropriate for such 
babies even when asymptomatic. 
 
Consensus is that for at risk neonates who do not show abnormal clinical signs the 
blood glucose concentration should be maintained above 2.5 mmol/l. 
 
 
In at risk neonates hypoglycaemia is more likely to occur in the first 24 hours of life 
hypoglycaemia that presents after this time, is recurrent, or persistent, does not 
necessarily mean inadequate feeding, but could be a sign of illness. 
 
Colostrum or breast milk appears to promote ketogenesis. There is evidence that 
suggests formula fed babies have lower blood glucose measurements than those who 
are breastfed. Therefore colostrum or breastmilk should be given when available. 
 
If at any stage any infant develops symptoms of hypoglycaemia, becomes unwell or has 
a blood glucose of less than 1.0 mmol/l urgent referral must be made to the 
Paediatrician. If more than 2 blood glucose measurements are less than 2.6 mmol/l 
conformation by the lab is indicated. 
   
Symptoms of hypoglycaemia include jitteriness, apnoea, pallor, abnormal cry, 
floppiness, tachyapnoea, feeding difficulties, coma and convulsions. 
Page 297 of 302 

 
High Risk Babies (Flowchart) 
 
At Risk Babies 
 
♦ Weight  È 3rd centile 
i.e. 37 weeks – 2220 g 
At birth 
At birth 
38 weeks – 2400 g 
39 weeks – 2600 g 
The baby who is able to feed 
The baby who is  
40+ weeks – 2790 g 
 
unable to feed 
♦ Look “wasted” e.g. loose skin folds on upper 
♦  Dry the baby well 
 
arms, thighs, abdomen and scapular 
♦  Keep the baby warm, skin-to-
♦  Dry the baby well 
regions 
skin 
♦  Keep the baby warm, as 
♦  Encourage an early feed on 
much skin-to-skin as baby’s 
♦ Pre-term less than 37 weeks 
labour ward (within 1 hour).  
condition will allow 
♦ Baby of a diabetic / gestational mother 
Give E.B.M. if a breastfeeding 
♦  Transfer the baby to NNU 
♦ Baby who is hypothermic 
baby will not feed. 
 
♦ Baby who has apgar È 7 at 5 mins 
♦ Low cord pH 
♦ Baby who is clinically ill 
The Second Feed 
If the Blood Glucose is Low 
If the Blood Glucose 
♦ Maternal medication e.g. beta blockers 
2-3 hours after first 
È 2.6 mmol/l 
is still low 
 
 
È 2.6 mmol/l or the baby is 
Any Baby Who Is 
♦ Keep the baby warm 
♦ Feed the baby quickly, at 
symptomatic 
Symptomatic 
♦ Encourage the baby to have a 
the breast or give EBM or 
 
 
good feed,  (if the baby is to 
high calorie formula if the 
♦  Inform the paediatrician 
♦  Must be referred to a paediatrician 
be breastfed and will not feed, 
mother is formula feeding 
♦  Admit to NNU and follow 
immediately 
give E.B.M. as much as can 
♦  Check a post feed blood 
their guidelines 
♦  Blood glucose must be done 
be hand expressed, by cup or 
glucose 1 hour after the feed 
♦  Keep the baby warm 
syringe) 
is completed 
 
♦ 
Check a pre-feed blood 
Symptoms Include 
glucose 
If the Blood Glucose 
If at any time the blood glucose is low 
 
is Normal 
- Jitteriness 
- Colour changes 
2.6 mmol/l or Ç 
- Irritability 
- Hypnotonia 
- Cold 
- Convulsions 
Third and Subsequent Feeds 
Jitteriness is rapid generalised symmetrical tremor of the limbs.  It is common 
- Apnoea 
- Altered consciousness 
 
in the first few days and can be stopped by handling the baby and flexing the 
 
♦  Feed in 2-3 hours with pre-feed blood 
limbs.  It is never accompanied by physiological changes, e.g. raised heart 
Any Baby 
rate or apnoea this would be indicative of a seizure.  Jitteriness in a healthy 
glucose for this feed 
 
baby is often a benign finding.  In a high risk baby hypoglycaemia should be 
♦  Monitor blood glucose prior to feeds until 
Whose blood glucose is È 1 mmol/l refer 
considered.  (Textbook of Neonatology Eds., Robertson & Bernie, 3rd Edition, 
there are 3 consecutive pre-feed blood 
immediately to paediatrician 
Churchill Livingston, 1999) 
glucose readings of 2.6 mmol/l or Ç 
Page 298 of 302 

 
 
 
28.13  UNEXPECTED ABNORMALITY OR DEATH 
 
In cases of unexpected major fetal abnormality the duty paediatrician should always be 
informed.  After stillbirth or early neonatal death, senior medical staff should be informed as 
soon as possible in order to investigate the cause of death, begin bereavement counselling 
and complete certification.  Under all of these circumstances the consultant obstetrician 
responsible for the cause should be informed at the earliest opportunity. 
 
28.14  HAEMOLYTIC DISEASE OF THE NEWBORN 
 
In HDN, the attending midwife should take cord blood at delivery.  The role of the duty 
paediatrician is to: 
 
•  Meet the parents prior to delivery and outline a plan of management 
•  Ensure that blood is available in the transfusion laboratory in case it is needed 
•  Ensure that cord blood is sent urgently for Hb, group and Coombs + cross match 
•  Ensure that results are retrieved 
•  Take part of the cord blood sample to measure PCV and Bilirubin 
 
28.15  GROUP B STREPTOCOCCUS INFECTION 
 
This topic has been dealt with in Chapter 19. 
 
28.16  CHILD ABDUCTION – PROCEDURE FOR STAFF 
 
When any baby has a legal status then that baby cannot be moved from the hospital by a 
parent or unauthorised person, therefore all staff at ward level will need to know. 
 
Order of Procedure 
 
1.  CIC - Ring 3434 to close all exits and check CCTV 
2.  WCH – Ring switchboard to close all exits and check CCTV 
 
3.  Inform midwife / nurse in charge of ward area 
 
4.  Contact the police as they are the only people who have got detaining power, Tel 9999 
 
5.  Immediately search the entire unit.  Time is critical (do a head count of all infants).  
Question the mother of the infant suspected to be missing as to other possible 
locations of the child within the facility. 
 
6.  The Social Services to be contacted.  Outside 0900 hrs – 1700 hrs there is an 
emergency service.  Switchboard have the number. 
 
7.  Inform the Midwifery Manager bleep holder and Head of Midwifery and Supervisor of 
Midwives. 
 
8.  Inform the Business Manager – Maternity, Obstetrics & Paediatrics Services. 
 
Page 299 of 302 

 
9.  Ask switchboard to inform the Chief Executive and / or Director of Nursing and Quality, 
and Security Officer. 
 
10. Midwife / nurse to move mother to a single room and stay with her. 
 
11. Mother’s belongings not to be moved.  The area where abduction occurred must be left 
untouched as the police may require forensic evidence from the area. 
 
12. Midwife / nurse in charge of ward should explain the situation to each mother while the 
mother and infant are together.  (Mothers should not hear the news from the media or 
the police). 
 
NOTE: 
“Legal Status” implies – An Emergency Protection Order or a Ward of Court 
order.  Both can be placed on the baby and confer legal status. 
 
NB:  Midwifery or nursing staff must not liaise with press or public. 
 
Nurse Managers / Supervisors should be sensitive to the fact that the nursing staff may suffer 
post-traumatic stress disorder (PTSD) as a result of the abduction and hold a group 
discussion session in which all hospital personnel affected by the abduction are required to 
attend.  Such a session will allow health care personnel a forum for expressing their emotions 
and help them deal with the stress resulting form the abduction. 
 
 
Page 300 of 302 

 
 
References: 
 
Besch NJ, Perlstein PH, Edwards NK, Keenan WJ, Sutherland JM (1971) The transparent 
baby bag.  A shield against heat loss.  NEJM 284: 121-124 
 
Lyon AJ, Stenson B (2004) Cold comfort for babies.  Arch Disease Childhood: Fetal & 
Neonatal Edition 
89 
 
Vohra S, Frent G, Campbell V, Abbott M, Whyte R (1999) Effect of polyethylene occlusive skin 
wrapping on heat loss in very low birth weight infants at delivery: a randomised trial.  
Pediatrics
 134: 547 - 551 
 
Ashmore S. Implementing skin-to-skin contact in the immediate postnatal period.  MIDIRS 
Midwifery Digest, vol. 11, no. 2, June 2002, pp 247-250. 
 
Children in Need and Bloodborne Viruses 
(http://www.dh.gov.uk/assetRoot/04/08/21/43/04082143.pdf) 
(http://www.dh.gov.uk/assetRoot/04/09/35/12/04093512.pdf) 
 
Christensen K. et al Temperature, metabolic adaptation and crying in healthy full term 
newborns cared for skin-to-skin or in a cot.  Acta Paediatr 1992; 81: pp 488-493. 
 
www.babyfriendly.org.uk  BFI Website 
 
Chua S. et al.  Influence of breastfeeding and nipple stimulation on postpartum uterine activity. 
 British Journal of Obstetrics and Gynaecology 1994; 101: pp 804-805. 
 
Ingram J Johnson D and Greenwood R.  Why are some babies’ mucousy after birth?  British 
Journal of Midwifery, Feb 2002, vol 10, No 2, pp 94-98. 
 
Lawrence Ruth A. Breastfeeding, A Guide for the Medical Professional Fifth Edition 1999 
 
Fohe K, Kropf S, Avenarius S.  Skin-to-skin contact improves gas exchange in premature 
infants. Journal of Paediatrics 2000; 20 (5): 311-315 
 
Bauer J et al. Metabolic rate and energy balance in very low birth weight infants during 
kangaroo holding by their mothers and fathers.  Journal of Paediatrics 1996; 129 (4): 608-611 
 
Messmer R, Rodriguez S, Adams J et al. Effect of kangaroo care on sleeptime for neonates.  
Paediatric Nursing 1997; 23 (4): 408-414 
 
Wahlberg V, Affonso DD, Persson B.  A retrospective comparative study using the kangaroo 
method as a complement to the standard incubator care.  Eurpopean Jounal of Public Health  
1992; 2 (1): 34-37 
 
Kambarami RA, Chidede O, Kowo DT.  Kangaroo care versus incubator care the 
management of well pre-term infants.  Annals of Tropical Paediatrics 1998; 18 (2) 81-86 
Hawdon JM, Ward Platt MP, Aynsley Green A (1992) Patterns of metabolic adaptation for 
term and preterm infants in the neonatal week. Archives of Diseases in Childhood; 67:357-365 
 
Page 301 of 302 

 
Hypoglycaemia of the Newborn – A Review of the Literature. Bulletin of the World Health 
Organisation. Geneva 1997. 
 
Yamauchi Y, Yamanouchi I, (1990) Breastfeeding frequency during the first 24 hours after 
birth in full term neonates. Paediatrics; 86: 171-175 
 
Hypoglycaemia of the Newborn – Guidelines for appropriate blood glucose screening and 
treatment of breastfed and bottle-fed babies in the United Kingdom. 
The British Association of 
Perinatal Medicine, N.C.T. et al. Glasgow 1997. 
 
Textbook of Neonatology. Eds. Robertson & Bernie. 3rd edition, Churchill Livingstone, 1999. 
 
Resuscitation Council UK (2001).  Resuscitation at Birth.  The Newborn Life Support Provide 
Course Manual. 
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