Antithrombotic therapy  -The hypercoagulable state in pregnancy increases  -the risk of thromboembolic disease in women who have :  1arrhythmias  2- mitral valve stenosis  3 - who have had mechanical cardiac valve replacements.  - treatment requiring antithrombotic therapy during pregnancy

 Warfarin is commonly used as an antithrombotic  - it is teratogenic to the developing embryo/fetus  - associated with a high fetal loss rate  - it is not used in pregnancy.  - warfarin also predisposes the woman and her fetus to haemorrhage when used in the third trimester.

 - Subcutaneous low molecular weight heparins, such as enoxaparin كلكسان are useful for thromboprophylaxis  - may not be suitable for women with mechanical heart valves.  - Full-length thromboembolism deterrent (TED) support stockings should be worn ,if the woman is admitted to hospital for rest and assessment,  -should also be worn during labour and in the immediate postnatal period.

Intrapartum care: the first stage of labor  -Many women with cardiac disease have an uncomplicated labor  - there is e ff ective communication among a dedicated multidisciplinary team of midwife, obstetrician, cardiologist, neonatologist, anaesthetist and the woman and her family to optimize birth outcome.  -Vaginal birth is preferred unless there is an obstetric indication for caesarean section because vaginal birth will:

 1- improve homodynamic stability  2- there is less  chance of postoperative infection and pulmonary complications

 Intrapartum care involves:  monitoring the maternal condition 2- Continuous ECG is recommended in nearly all cases 3- pulse oximetry may be utilized to assess arterial hemoglobin saturation, which may be reduced in women with cardiac disease with impaired gas exchange between lung & heart 2- Continuous ECG is recommended in nearly all cases 3- pulse oximetry may be  4-Fluid balance should be recorded, and use of intravenous fluids may be limited.  5- Routine antibiotic prophylaxis is not recommended.  6-Continuous electronic fetal heart rate monitoring

Labor induction  -Before induction the cervix should be favorable (using the Bishop score  - artificial rupture of the membranes (ARM) is undertaken  - an IVI of oxytocin should contractions not establish.  -A prolonged induction should be avoided.  - If the cervix is unfavourable, synthetic prostaglandin is used to soften/ripen it.

 - While there is no absolute contraindication to misoprostol (prostaglandin E1) or dinoprostone (prostaglandin E2), there is a theoretical risk of coronary vasospasm and a low risk of arrhythmias.  - dinoprostone has more profound e ff ects on BP than misoprostol and is therefore contraindicated in active cardiovascular disease.

Pain relief  use the techniques that she has learned for coping with stress.  Nitrous oxide and oxygen (Entonox®) and pethidine are usually considered safe means of intrapartum analgesia for women with cardiac disease  it is important to review the labor plan with the multidisciplinary team before administration.

 epidural anesthesia may be the analgesia of choice for its effectiveness in relieving pain and decreasing cardiac output and heart rate It causes peripheral vasodilatation and decreases venous return, which alleviates pulmonary congestion. for its effectiveness in relieving pain and decreasing cardiac output and heart rate It causes peripheral vasodilatation and decreases venous return, which alleviates  an e ff ectively working epidural in situ may eliminate the need for emergency general anesthesia.

Positioning  Cardiac output is influenced by: the position of the woman during labour those with cardiac disease are particularly sensitive to aortocaval compression by the gravid uterus if adopting the supine position.  -It is recommended that midwives encourage an upright or left lateral position for women to adopt during labor and birth wherever possible

The second stage of labor  should be short without undue exertion on the part of the woman.  Prolonged pushing with held breath (the Valsalva manoeuvre ) should be discouraged as it can  further compromise the health of the woman with cardiac disease.  -Such a maneuver raises the intrathoracic pressure, forces the blood out of the thorax and impedes venous return, resulting in a fall in cardiac output.

 The midwife should therefore encourage the woman to breathe as normal and follow her natural desire to bear down giving several short pushes during each contraction.  -An instrumental birth using forceps or ventouse may be undertaken to shorten the second stage of labor.  - when the woman is in the lithotomy position, where the lower part of the body is higher than the trunk, as this produces a sudden increase in venous return to the heart, which may result in heart failure. A wedge should therefore be used to avoid aortocaval compression ( McLean et al 2013). failure. A wedge should therefore be used to avoid aortocaval compression ( McLean et al 2013).

The third stage of labour  -An active third stage of labour is usually advocated with a slow IVI of 2 U/min oxytocin administered after the birth of the placenta to avoid systemic hypotension and prevent haemorrhage.  -Prostaglandin F analogues are useful to treat PPH, unless an increase in pulmonary artery pressure (PAP) is undesirable.  - Ergometrine is contraindicated in women with cardiac disease as it can cause vasoconstriction and hypertension

Postnatal care  -The first 48 hours following the baby's birth are critical for the woman with significant cardiac disease.  - The heart must be able to cope with the extra volume of blood (autotransfusion) from the uterine circulation & increased venous return  - the total blood volume may be diminished by the amount lost at birth and during the postnatal period.  - the heart will need to compensate should the blood flow be impaired due to PPH.  - Close monitoring of haemodynamic changes

 - midwife should identify early signs of infection, thrombosis or pulmonary oedema.  - Observation of the condition of the woman's legs, the use of antiembolic stockings and early ambulation are important strategies for the midwife to adopt in order to reduce the risk of thromboembolism.  -Breastfeeding should be encouraged as cardiac output is not a ff ected by lactation  - drug therapy for specific heart conditions may need to be reviewed for safety during breastfeeding.  - support to successfully breastfeed her baby

 - emphasizing the importance of adequate rest and a dietary intake containing sufficient calories to sustain breastfeeding.  -It is important that prior to transfer from hospital, the midwife explores the help and support available in the home for when the woman returns home with her baby.  -Relatives and friends,community support services should also be considered  - the midwife should o ff er appropriate contraceptive advice and the options available to the woman who has cardiac disease