Thromboprophylaxis during labour and delivery, including the use of regional analgesia.
When should thromboprophylaxis be interrupted for delivery?
Women receiving antenatal LMWH should be advised that if they have any vaginal bleeding or once
labour begins they should not inject any further LMWH.
Regional techniques should be avoided if possible until at least 12 hours after the previous
prophylactic dose of LMWH.
LMWH should not be given for 4 hours after use of spinal anaesthesia or after the epidural catheter
has been removed and the catheter should not be removed within 12 hours of the most recent
injection.
When a woman presents while on a therapeutic regimen of LMWH, regional techniques should be
avoided if possible for at least 24 hours after the last dose of LMWH.
The first thromboprophylactic dose of LMWH should be given as soon as possible after delivery
provided there is no postpartum haemorrhage and regional analgesia has not been used.
Women at high risk of haemorrhage with risk factors including major antepartum haemorrhage,
coagulopathy, progressive wound haematoma, suspected intra-abdominal bleeding and postpartum
haemorrhage may be managed with
anti-embolism stockings (AES), foot impulse devices or
intermittent pneumatic compression devices.
Unfractionated heparin (UFT) may also be considered.
If a woman develops a haemorrhagic problem while on LMWH the treatment should be stopped and
expert haematological advice sought.
Thromboprophylaxis should be started or reinstituted as soon as the immediate risk of haemorrhage
is reduced.
If LMWH is routinely prescribed at 6 p.m.,
this allows for an elective caesarean section the next morning,
removal of the epidural catheter before 2 p.m. and
a first postnatal dose of LMWH at 6 p.m. the same day.
If LMWH precludes regional techniques (in, for example, the woman who presents
in spontaneous labour within 12 hours of taking a LMWH dose), alternative analgesia such as
opiate-based intravenous patient-controlled analgesia can be offered.
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