NICE 121: Intrapartum Care for women with Medical Conditions — Part 1

Post #1
This blogpost is Post #1 of Summary of NICE guideline “NG 121: Intrapartum Care for Women with Existing Medical Conditions or Obstetric Complications and their Babies” released in March 2019. As this is an extensive and lengthy guideline, so I will be covering it in two posts. 

This post covers intrapartum care in Heart Disease, Asthma, Long-term Systemic Steroids, Bleeding Disorders, SAH / AV Malformation of Brain, Acute Kidney Injury (AKI) or Chronic Kidney Disease (CKD) and Obesity

I have extracted the main points only. You must read the original guideline to have complete understanding. Original guideline can be downloaded here: NG 121

This guideline should be read along with NICE intrapartum Care for Healthy Women CG190 (N.B: In this summary when it is written “to manage as low risk /like normal/follow routine intrapartum care” refers to CG 190)

Kindly let me know in comments below if anything needs to be modified in this post and suggestions to improve future posts are welcome.

Thanks

NICE 121: INTRAPARTUM CARE FOR WOMEN WITH EXISTING MEDICAL CONDITIONS

Information for women with existing medical conditions

• Clarify with women whether and how they would like their birth companions(s) involved in discussions about care during labour/birth
• Offer information about Intrapartum care including
• General information
• How medical condition affect care
• How labour & delivery affect medical condition 
• How medical condition and its management affect baby
• Offer this information in pre-conception consultations or as early as possible during pregnancy & Allow extra time to discuss
• Information delivered by a member of multidisciplinary team (MDT)

Planning for intrapartum care with women with existing medical conditions – involving a multidisciplinary team

• MDT led by named healthcare professional to prepare individualized plan involving woman
• Plan should be:
• Based on → shared decision making principles
• Reviewed with woman and her birth companions(s) → as soon as possible  throughout pregnancy & on admission for birth
• Updated → if change in medical condition
• Shared with → GP & teams providing Antenatal/ Intrapartum care
• MDT may include:
• Midwife, Obstetrician, Obstetric Anesthetist, Obstetric Physician or Clinician with Expertise in care of pregnant women with medical condition, Clinician with Expertise in Medical Condition, Speciality Surgeon, Critical Care Specialist, Neonatologist, woman’s GP, Allied Health Professionals 

HEART DISEASE

Risk Assessment

• Follow principles of MDT working
• Include a Cardiologist
• Heart disease diagnosed intrapartum→ urgent multidisciplinary discussions & take woman’s preferences into account
• Some women may be low risk→ follow routine intrapartum care 

Module 9: Maternal Medicine

This blogpost is the outline of Module 9: Maternal Medicine. It is one of the most important and lengthy module. There is an extensive list of topics to cover and a lot of facts to memorize. To make it simple, this module can be outlined according to the Systems e.g. Neurology, Endocrinology etc

• The first step is to have a look in to details of core module on the RCOG website which provides a mental road map to cover it under appropriate headings
• One of a very important and standard resource for this module is “Handbook of Obstetrics Medicine” by Catherine Nelson Piercy. The module is well covered in this book. It is recommended to at least go through the differential diagnosis tables given at the end of the book
• Remember that management of patient starts from pre-conception period and it is important to make sure that she enters pregnancy in optimal health condition
• Most of the Medical Disorders are chronic conditions and a woman may have to live with it for the rest of her life, which can be frustrating 
• There is need of Multidisciplinary Team and involvement of Specialists
• As the pregnancy may become high risk, so patient needs Close Monitoring, Extra Antenatal Visits and Consultant-led Care
• Once she delivers, there should be appropriate postpartum care, contraception plan and advice regarding next pregnancy
• The following tables may be used to organise the study material in one place

Module 10-11: Labour & Delivery - Module 12: The Puerperium

This blogpost provides the outline of three (3) Modules in obstetrics “Module 10 & 11: Management of Labour & Delivery” AND “Module 12: Postpartum Problems (The Puerperium)”. I decided to cover these in a single post as all these modules are closely interlinked

• It is important to develop understanding of a particular problem as it may start in antenatal period and has to be dealt till the postpartum period (and may even effect the management of next pregnancy)
• Kindly have a look at the details of modules on RCOG website which will clarify what are you expected to demonstrate under these modules
• Module 10 & 11 are covered under a Single Main Heading as it is difficult to clearly distinguish it in a given scenario
• Some of the topics to be covered in these modules are already outlined in posts covering Module 8: Antenatal Care Click Here: Post#1 Post#2
• Specially in the postpartum module, you may notice that there is repetition of some topics which were already outlined under antenatal care module. The main purpose to repeat these is to give a clear idea how all these modules are connected. Some of the problems are more relevant in postpartum period e.g. mental health issue, Sepsis or VTE to name a few
• Following tables may help you to collect and organize your study material in one place
• If you use gadgets (iPad/Laptop/Smartphone) its easier to arrange but if you prefer hard copies, you can get the printouts and arrange it according to your convenience

Module 8: Antenatal Care — Part 2

This post is the second part of outline of “Module 8: Antenatal Care” and it covers the remaining topics in this module. As this is a lengthy module so, it was decided to cover the reading resources and outline in two posts. 

• The first part of this module can be accessed by clicking here: Module 8: Antenatal Care—Part 1
• The first post of this module included the topics of “the routine antenatal care” along with preterm labour and stillbirth
• This post mainly covers topics which are NOT routine care and they require additional care
• Study outline for two main topics of obstetrics (Infections in Pregnancy and Obstetrical Emergencies) is added which may occur in antenatal period and effect the intrapartum/ postpartum care
• Again it is evident that it is not possible to prepare any module separately
• We need to develop the deep understanding of the topic and apply it on a given scenario
• Following tables provide an outline of the module which might be helpful to collect and organize your study material
• You can make a BIG folder “Antenatal Care” and add subfolders based on the following tables
• Make your own NOTES and keep adding points as you come along new ones