Intrapartum care with existing medical conditions — structured SAQ (15 marks)

(a) The cardiac intrapartum plan (6 marks)

One mark per component; the third-stage drug and the mode-of-birth default are each worth a mark. ^[4]

• Find and follow the written multidisciplinary plan — agreed antenatally by obstetrics, cardiology and anaesthesia; the default for class III is planned vaginal birth in a centre with cardiology and intensive care on site (ROPAC found planned caesarean was not beneficial for most cardiac women).^[5][4]
• Position: left lateral, avoid supine; continuous pulse oximetry and strict fluid balance.^[4]
• Analgesia: early epidural, placed slowly with careful fluid management — it blunts the catecholamine and afterload surge of pain and is protective for most lesions.^[4]
• Second stage: assisted (operative) second stage to shorten the bearing-down effort in a fixed-output lesion.^[4]
• Third-stage drug: oxytocin, given slowly and dilute; ergometrine is contraindicated because it causes an acute afterload rise that can precipitate pulmonary oedema.^[4]
• Postpartum surveillance: high-dependency observation for 72 hours, because the postpartum fluid mobilisation is the danger window and late heart failure is the killer.^[4]

(b) Diabetes in labour (3 marks)

One mark per point. ^[6]

• Tight intrapartum capillary glucose control, monitored hourly through labour (continuous monitoring where available). The standard target range is 4 to 7 mmol per litre, the level achieved in the randomised comparison of intrapartum regimens.^[7]
• Insulin and dextrose infusion titrated to keep her in range; a rotating-fluids regimen is a reasonable alternative and was comparable to an insulin drip (mean glucose about 5.8 mmol per litre) with similar neonatal outcomes.^[7]
• Halve the insulin infusion immediately after birth — insulin requirements fall off a cliff as the placental insulinase is delivered; switch the type 1 diabetic back towards her prepregnancy regimen and arrange a neonatal hypoglycaemia alert.^[6][7]

(c) Anticoagulation and the epidural catheter (3 marks)

One mark for each timing rule; stating the rationale earns the third. ^[10]

• Catheter removal must wait 24 hours after the last therapeutic enoxaparin dose, because therapeutic-dose low-molecular-weight heparin carries a real risk of spinal epidural haematoma if the window is breached.^[10]
• The next enoxaparin dose waits 4 hours after catheter removal.^[10]
• Rationale: LMWH is only partially reversed by protamine and has a longer half-life than unfractionated heparin, which is why the timing rules exist — a systematic review found no case of obstetric spinal epidural haematoma when they are kept, and the whole point is to keep them rather than assume them away.^[9][10]

(d) Seizure in labour (3 marks)

One mark per point; treating first as eclampsia if there is doubt earns credit. ^[11]

• Airway, left lateral position, call for help, time the seizure.^[11]
• For ongoing seizure give a benzodiazepine (for example intravenous lorazepam 4 mg, repeated once after 10 minutes).^[11]
• Rule out eclampsia with the blood pressure, reflexes and urinalysis; give magnesium sulphate if eclampsia is possible — it is safer to treat first and clarify the diagnosis afterwards. Continue her antiseizure medication and arrange one-to-one care.^[11]