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Saxena et al. Vessel Plus 2022;6:15 https://dx.doi.org/10.20517/2574-1209.2021.96 Page 9 of 17

[1]
emergency caesarean delivery and the risk of stillbirth . The obstetrician should be wary of the adverse
effects of inducing drugs such as misoprostol (arrhythmias and coronary vasospasm), oxytocin (systemic
hypotension), and prostaglandin F analogs (systemic hypotension and increase in pulmonary pressure), and
their use needs to be individualized. Mechanical methods such as artificial rupture of membranes and
cervical ripening balloon might be preferable for induction of labor in some of the patients.

Vaginal delivery, often with epidural analgesia, is the preferred mode of delivery for the majority of women
with CHD [1,36] . Vaginal delivery is associated with lesser blood loss and lesser risk of infection and venous
[1]
thromboembolism. The indications for caesarean delivery are few and listed in Table 3 . Epidural analgesia
can be used to provide anesthesia for caesarean delivery as well, but it can cause systemic hypotension and
therefore must be carefully titrated, especially in patients with left heart obstruction and diminished
[1]
ventricular function .
Mobilization of patient may facilitate fetal head descent, and a lateral decubitus position during labor can
decrease the hemodynamic impact of inferior vena cava compression. Early epidural catheter placement to
reduce labor pain can help in reducing hemodynamic load of labor. Historically, patients with significant
cardiac disease have been dissuaded from doing the Valsalva maneuver due to associated increase in oxygen
consumption and decrease in venous return. However, some studies have shown that allowing passive head
descent and assisting the second stage of labor (use of forceps/ventouse to reduce maternal effort and
epidural analgesia which suppresses Valsalva reflex due to fetal pelvic descent) can prolong labor and may
be associated with a higher risk of postpartum hemorrhage and high-degree vaginal or cervical
laceration . Therefore, it should be reserved for patients at highest risk.
[37]
Patients requiring hydration should receive intravenous crystalloids with closely monitored fluid balance.
All patients with intracardiac right-to-left shunts must have filters in intravenous lines to prevent
paradoxical air embolization. In patients with uncorrected or partially corrected complex CHD, it is vital to
maintain balance of systemic and pulmonary blood flow. A decrease in systemic vascular resistance or an
increase in pulmonary vascular resistance can lead to increased right-to-left shunting, thus increasing
hypoxemia and increasing the risk of maternal and fetal death .
[37]
No antibiotic prophylaxis is recommended against infective endocarditis (IE) for vaginal delivery. Maternal
BP, saturation, and heart rate should be monitored in all women with CHD and invasive cardiac
monitoring is rarely required. Patients with history of arrhythmias and symptomatic ventricular
dysfunction should have continuous ECG monitoring. Continuous fetal heart rate monitoring is
recommended.

Peripartum care
Although the risk of serious cardiac events was higher in the antepartum period (66%), intrapartum and
postpartum period accounted for one-third of all serious cardiac events in a recent study by Pfaller et al.
[15]
Therefore, patients with CHD should continue to receive good care in the peripartum period as well, as fatal
events are well known to occur during this period. Significant hemodynamic changes and fluid shifts in the
first 24-48 h after delivery can precipitate heart failure; hence, intensive hemodynamic monitoring should
[38]
be continued for at least 24-48 h in at-risk patients . Cardiac rhythm and saturation should be monitored
in high-risk patients. Good hydration must be maintained especially in patients with cyanotic CHD and for
this intravenous fluid administration may be necessary. Care must be taken to prevent air embolism.
Meticulous leg care, elastic support stockings, and early ambulation are important to reduce the risk of
thromboembolism. Hemoglobin values must be optimized, by blood transfusions if required. Symptoms