Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
Document title:
Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
Publication date:
October 2009
Document number:
MN09.9-V3-R14
Replaces document:
MN09.9-V2-R11
Author:
Queensland Maternity and Neonatal Clinical Guidelines Program Adapted from RBWH Clinical Guideline 06582/GUID
Audience:
Health professionals in Queensland public and private maternity services
Exclusions:
Management of diagnosed venous thromboembolism
Review date:
October 2014
Endorsed by:
Statewide Maternity and Neonatal Clinical Network QH Patient Safety and Quality Executive Committee
Contact:
Queensland Maternity and Neonatal Clinical Guidelines Program Email:
[email protected] URL: www.health.qld.gov.au/qcg
Disclaimer These guidelines have been prepared to promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach. Information in this guideline is current at time of publication. Queensland Health does not accept liability to any person for loss or damage incurred as a result of reliance upon the material contained in this guideline. Clinical material offered in this guideline does not replace or remove clinical judgement or the professional care and duty necessary for each specific patient case. Clinical care carried out in accordance with this guideline should be provided within the context of locally available resources and expertise. This Guideline does not address all elements of standard practice and assumes that individual clinicians are responsible to: • Discuss care with consumers in an environment that is culturally appropriate and which enables respectful confidential discussion. This includes the use of interpreter services where necessary • Advise consumers of their choice and ensure informed consent is obtained. • Provide care within scope of practice, meet all legislative requirements and maintain standards of professional conduct • Apply standard precautions and additional precautions as necessary, when delivering care • Document all care in accordance with mandatory and local requirements
This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 2.5 Australia licence. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/2.5/au/ © State of Queensland (Queensland Health) 2010 In essence you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the authors and abide by the licence terms. You may not alter or adapt the work in any way. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email
[email protected] , phone (07) 3234 1479. For further information contact Queensland Maternity and Neonatal Clinical Guidelines Program, RBWH Post Office, Herston Qld 4029, email
[email protected] phone (07) 3131 6777.
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
Flowchart: Postnatal prophylactic management
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
Abbreviations ACHS
Australian Council on Healthcare Standards
APCR
Activated protein C resistance
APLS
Antiphospholipid syndrome
B2GP1
Beta 2 Glycoprotein 1
bd
Twice daily
BMI
Body mass index
DVT
Deep vein thrombosis
GECS
Graduated elastic compression stockings
HITS
Heparin induced thrombocytopenia
kg
Kilograms
INR
International normalised ratio
IV
Intravenous
LMWH
Low molecular weight heparin
mg
Milligram
MTHFR
Methylene tertrahydrofolate reductase mutation
PE
Pulmonary embolism
Subcut
Subcutaneous
stat
Immediately
VTE
Venous thromboembolism
Terminology Local facilities may as required, differentiate the roles and responsibilities assigned in this document to an “Obstetrician” according to their specific practitioner group requirements; for example to General Practitioner Obstetricians, Specialist Obstetricians, Consultants, Senior Registrars and Obstetric Fellows.
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
Table of Contents Introduction.....................................................................................................................................6 1.1 Definition ................................................................................................................................6 1.2 Risk factors for VTE in pregnancy .........................................................................................6 2 Assessment ....................................................................................................................................7 2.1 Previous VTE .........................................................................................................................7 2.2 Pre-existing medical conditions .............................................................................................8 2.3 Transfer of Care.....................................................................................................................8 3 Methods of thromboprophylaxis .....................................................................................................8 3.1 Pharmacological ....................................................................................................................8 3.1.1 Drug dosage and administration........................................................................................8 3.2 Non-pharmacological.............................................................................................................8 3.2.1 Graduated elastic compression stockings .........................................................................8 4 Prophylactic management of VTE..................................................................................................9 4.1 Antenatal prophylactic management .....................................................................................9 4.2 Intrapartum prophylactic management ..................................................................................9 4.3 Postnatal prophylactic management .....................................................................................9 4.3.1 Epidural management........................................................................................................9 4.3.2 Post caesarean section ...................................................................................................10 4.3.3 Post vaginal delivery........................................................................................................10 5 Management of specific patient groups........................................................................................11 5.1 Previous VTE and thrombophilia .........................................................................................11 5.1.1 Receiving long term anticoagulation prior to pregnancy .................................................11 5.1.2 Not receiving long term anticoagulation prior to pregnancy ............................................11 5.2 Previous VTE without documented thrombophilia...............................................................12 5.3 History of thrombophilia without previous VTE....................................................................12 References ..........................................................................................................................................13 Appendix A: Drug Information .............................................................................................................14 Appendix B: Warfarin Guidelines.........................................................................................................15 Appendix C: Decision support for heparin intravenous infusion order ................................................17 Appendix D: Example heparin intravenous infusion order form ..........................................................18 Appendix E: Acknowledgements .........................................................................................................19 1
List of Tables Table 1. Risk assessment...................................................................................................................... 7 Table 2. Antenatal prophylactic management ....................................................................................... 9 Table 3. Prophylactic management post caesarean section............................................................... 10 Table 4. Prophylactic management post vaginal delivery ................................................................... 10 Table 5. Management with anticoagulation prior to pregnancy........................................................... 11 Table 6. Management without long term anticoagulation prior to pregnancy...................................... 11 Table 7. Management of history of VTE without thrombophilia........................................................... 12 Table 8. Management of thrombophilia without previous VTE............................................................ 12
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
1
Introduction
Pregnancy places women at an increased risk of developing a venous thromboembolism (VTE), in comparison to non-pregnant women.1,2 Identification of risk and adequate prophylaxis can decrease the incidence of VTE.1 There is limited high level evidence from randomised trials. This guideline summarises current information and makes consensus recommendations on best practice.
1.1
Definition
Pulmonary embolism and deep vein thrombosis are the two components of a single disease called venous thromboembolism.3
1.2
Risk factors for VTE in pregnancy • Personal history of VTE* • Family history of VTE* • Thrombophilia:* o Congenital or o Acquired • Antiphospholipid syndrome (APLS)* • Extended major pelvic or abdominal surgery* • Paralysis of lower limbs* • Age greater than 35 years • Weight greater than 80 kg and / or BMI greater than or equal to 30 • Parity of four or more • Gross varicose veins • Current infection • Prolonged immobility/hospitalisation (greater than 4 days) • Caesarean delivery: o Increased risk with emergency caesarean in labour • Labour longer than or equal to twelve hours • Assisted birth • Excessive blood loss • Dehydration • Pregnancy related medical illness: o Ovarian hyper-stimulation syndrome o Preeclampsia o Hyperemesis • Pre-existing medical illness, for example: o Nephrotic syndrome o Cardiac disease o Cancer o Inflammatory bowel disease o Sickle cell disease
*Australian Council on Healthcare Standards (ACHS) High Risk Factors4
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
2
Assessment • Assess all women for VTE risk factors in early pregnancy or before conception. • Repeat the assessment at each antenatal visit and when there is a change in risk status, for example with hospitalisation2,5 or preeclampsia • Determine the level of risk by assessing for risk factors identified in [section 1.2] • Refer to [section 5] for specific patient group management if identified risk factor(s) include any of the following: o significant personal history of VTE o thrombophilia or o antiphospholipid syndrome
Table 1. Risk assessment
Level of Risk
Criteria
Low risk
• • •
No identified risk factors Uncomplicated pregnancy Elective caesarean section
Moderate risk
•
1-2 identified risk factors
•
greater than or equal to 3 risk factors (not including VTE, thrombophilia or APLS)
• • •
Significant personal history of VTE Thrombophilia APLS
High risk Specific patient group management Refer to [Section 5]
2.1
Previous VTE
Refer all women with significant personal or family history of VTE, to an obstetrician or physician experienced in VTE prophylaxis management.2,6 All women with previous VTE should have a full thrombophilia screen including2,6,7: • activated protein C resistance (APCR) • factor V Leiden mutation will be done if APCR is detected • prothrombin gene mutation • antithrombin III deficiency • protein C deficiency • protein S deficiency • antiphospholipid antibodies: o lupus anticoagulant o anticardiolipin antibodies o B2GP1 • consider testing for Hyperhomocysteinaemia or MTHFR mutation (methylene tertrahydrofolate reductase mutation) Note: High risk thrombophilias including: Homozygous Factor V Leiden mutation, Antithrombin III deficiency and the presence of multiple thrombophilia are associated with a higher risk for VTE.1
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
2.2
Pre-existing medical conditions • Liaise with an obstetrician and physician experienced in prophylactic management of VTE in woman with a history of: o cerebral haemorrhage o gastrointestinal haemorrhage o heparin induced thrombocytopenia (HITS) o thrombocytopenia o renal insufficiency • Ensure a multidisciplinary approach to care7 • Thromboprophylaxis may need to be individualised • Ensure referral to anaesthetics team to discuss management plan peripartum
2.3
Transfer of Care
Consultation with or referral or transfer to higher level services may be appropriate. Facilities should have documented processes for referral and transfer to higher level services.
3
Methods of thromboprophylaxis
3.1
Pharmacological • Low molecular weight heparin (LMWH): o the agent of choice for antenatal thromboprohylaxis2,6,8 • Unfractionated heparin • Warfarin: o is contraindicated antenatally for thromboprophylaxis2 o should only be considered postnatally for prolonged thromboprophylaxis
These medications are safe to use with breastfeeding mothers.2 3.1.1 Drug dosage and administration Refer to [Appendix A] for pharmacological information.
3.2
Non-pharmacological • • • •
3.2.1
Early mobilisation Avoidance of dehydration Graduated elastic compression stockings (GECS)2 Intermittent pneumatic compression device
Graduated elastic compression stockings • • • • •
Should be worn continuously5 Patient compliance is essential5 Contraindicated in critical limb ischaemia5 Should be measured and fitted for each woman5 A health professional trained in garment prescription can assist with GECS selection and fitting
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
4
Prophylactic management of VTE • Regardless of risk for VTE, immobilisation and dehydration should be minimised2,5 • If anticoagulation is required peripartum a multidisciplinary team approach is essential: o Develop a plan for the peripartum management of anticoagulation (prophylactic or therapeutic) • If identified risk factor(s) include any of the following, refer to [section 5] for management: o significant personal history of VTE o thrombophilia or o antiphospholipid syndrome
4.1
Antenatal prophylactic management • Clinical surveillance at each antenatal visit or hospital review is required:9 o assess if risk factors for VTE have changed and ask about VTE symptoms
Table 2. Antenatal prophylactic management
Level of Risk
Antenatal Management
Low risk
• Clinical surveillance6
Moderate or high risk
• Clinical surveillance6 • Consider prophylactic LMWH if immobilised • Liaise with a treating team experienced in prophylactic management
4.2
Intrapartum prophylactic management
If receiving anticoagulation, cease during labour.
4.3
Postnatal prophylactic management • Refer to the flow chart on [page 3] • Postpartum prophylaxis should begin as soon as possible after delivery • Sodium Heparin may be substituted for enoxaparin at the obstetrician/physician’s discretion • Consider precautions regarding epidural management. Refer to [section 4.3.1]
4.3.1 Epidural management Management of moderate or high risk women with an epidural includes2,3,7: • Formulation of a plan for removal • Discussion with the anaesthetic team 4.3.1.1 Commencement of anticoagulation • Anticoagulation (prophylactic or therapeutic) may commence 2 hours AFTER insertion of spinal or epidural catheter10 4.3.1.2 Timing of catheter removal • Remove catheter10: o at least 2 hours PRIOR or 6 hours AFTER unfractionated heparin dose (sodium heparin) o at least 2 hours PRIOR or 12 hours AFTER low molecular weight heparin prophylactic dose (enoxaparin) o at least 2 hours PRIOR or 24 hours AFTER low molecular weight treatment dose (enoxaparin)
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
4.3.2 Post caesarean section The risk of VTE is higher after caesarean section than after vaginal delivery11 Table 3. Prophylactic management post caesarean section
Level of Risk
Management
Low risk
• Early mobilisation • Avoid dehydration • GECS
Moderate risk
• Prophylactic enoxaparin: o commence within 6 hours after giving birth o continue therapy until discharge or until fully mobile review by medical staff if hospitalised more than 5 days • GECS
High risk
• Liaise with obstetric team • Prophylactic enoxaparin: o commence within 6 hours after giving birth o continue prophylaxis until 5th post operative day (or until fully mobile if longer) • Consider GECS with pneumatic device until mobilising.8,9 Then GECS
4.3.3 Post vaginal delivery Although the risk of VTE is greater after caesarean section than after vaginal delivery,11 women with multiple risk factors giving birth vaginally may still require specific VTE prophylaxis. Table 4. Prophylactic management post vaginal delivery
Level of Risk
Management
Low risk
• Early mobilisation • Avoid dehydration
Moderate risk
EITHER • Prophylactic enoxaparin: o commence within 6 hours after giving birth o continue therapy until discharge or until fully mobile review by medical staff if hospitalised more than 5 days OR • GECS
High risk
• Liaise with obstetric team • Prophylactic enoxaparin: o commence within 6 hours after giving birth o continue prophylaxis until 5th day postpartum (or until fully mobile if longer) • Consider GECS with pneumatic device until mobilising. Then GECS
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
5
Management of specific patient groups • A multidisciplinary team consisting of an obstetrician, physician, anaesthetist and midwife is essential for peripartum management: o Develop a plan for the peripartum management of anticoagulation (prophylactic or therapeutic) • Refer to [section 4.3.1] for the management of epidurals
5.1
Previous VTE and thrombophilia
5.1.1
Receiving long term anticoagulation prior to pregnancy
Table 5. Management with anticoagulation prior to pregnancy
Period
Management
Antenatal
• Clinical surveillance • Therapeutic LMWH1,2,9: o women greater than 100 kg: liaise with an obstetrician and physician experienced in VTE prophylaxis management regarding dose • Consider change to intravenous therapeutic unfractionated heparin close to delivery • Requires regular review and monitoring in a high risk pregnancy clinic • GECS11
Intrapartum
• Cease anticoagulation prior to established labour/planned delivery1,2 • Liaise with multidisciplinary team re: management plan for delivery
Postnatal
• Discuss timing for resumption of anticoagulation with obstetrician, physician and anaesthetist • Resume therapeutic anticoagulation with warfarin • Administer therapeutic intravenous unfractionated heparin or LMWH until INR level is therapeutic1 • GECS11 • Referral to local medical officer and usual treating specialist
5.1.2 Not receiving long term anticoagulation prior to pregnancy Higher dose prophylaxis may be required if there are multiple risk factors for VTE or multiple thrombophilias. Table 6. Management without long term anticoagulation prior to pregnancy
Period
Management
Antenatal
• Clinical surveillance8 • Prophylactic LMWH8 • Consider changing to prophylactic subcutaneous unfractionated heparin close to delivery at obstetrician’s discretion • GECS11
Intrapartum
• Cease anticoagulation prior to established labour/planned delivery • Liaise with multidisciplinary team re: management plan for delivery
Postnatal
• Prophylactic subcutaneous unfractionated heparin, LMWH or warfarin • Thromboprophylaxis for 6 weeks post partum2 • GECS11
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
5.2
Previous VTE without documented thrombophilia
Table 7. Management of history of VTE without thrombophilia
Period
Management
Antenatal
• Clinical surveillance8 • Thromboprophylaxis with LMWH if: o multiple risk factors for VTE o previous VTE in pregnancy o previous VTE while on oral contraceptives o previous idiopathic VTE o liaise with obstetrician and/or physician experienced in VTE in pregnancy • GECS11
Intrapartum
• Cease anticoagulation prior to established labour/planned delivery • Liaise with multidisciplinary team re: management plan for delivery
Postnatal
• Prophylactic subcutaneous unfractionated heparin, LMWH or warfarin • Thromboprophylaxis for 6 weeks post partum8 • GECS11
5.3
History of thrombophilia without previous VTE
There is limited evidence to determine best practice. Each patient should be assessed on an individual basis and referred to a physician experienced in this area Table 8. Management of thrombophilia without previous VTE
Period
Management
Antenatal
• Clinical surveillance • Liaise with a physician experienced in VTE in pregnancy • Consider thromboprophylaxis with: o high risk thrombophilia o multiple thrombophilia risks o multiple risk factors for VTE • GECS11
Intrapartum
• Cease anticoagulation during labour if on thromboprophylaxis • Liaise with multidisciplinary team re: management plan for delivery
Postnatal
• Thromboprophylaxis is recommended with known thrombophilias2 • Thromboprophylaxis with subcutaneous unfractionated heparin, LMWH or warfarin for 6 weeks • GECS11
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
References 1. Kent N, Leduc L, Crane J, Farine D, Hodges S, Reid GJ, et al. Prevention and treatment of venous thromboembolism (VTE) in obstetrics. J Sogc. 2000; 22(9):736-749. 2. Royal College of Obstetricians and Gynaecologists. Thromboprophylaxis during pregnancy, labour and after vaginal birth. Guideline No.37. 2004. 3. Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med. 2008; 359(19):2025-33. 4. The Australian Council on Healthcare Standards. Obstetric indicators: clinical indicators users' manual version 6. 2008. 5. Prevention of venous thromboembolism: best practice guidelines for Australia and New Zealand. 4th ed: Baulkham Hills, NSW: Health Education & Management Innovations; 2007 [cited 2009 July 15]. Available from: http://www.surgeons.org/Content/NavigationMenu/FellowshipandStandards/Resourcesforsurgeons/V TE_Guidelines.pdf. 6. Scottish Intercollegiate Guidelines Network. Prophylaxis of venous thromboembolism: a national clinical guideline. [online]. 2002 [cited 2009 June 22]; No. 62. Available from: http://www.sign.ac.uk/guidelines/fulltext/62/index.html. 7. Duhl AJ, Paidas MJ, Ural SH, Branch W, Casele H, Cox-Gill J, et al. Antithrombotic therapy and pregnancy: consensus report and recommendations for prevention and treatment of venous thromboembolism and adverse pregnancy outcomes. Am J Obstet Gynecol. 2007; 197(5):457 e1-21. 8. Bates SM, Greer IA, Pabinger I, Sofaer S, Hirsh J. Venous thromboembolism, thrombophilia, antithrombotic therapy, and pregnancy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133(6 Suppl):844S-886S. 9. James AH. Prevention and management of venous thromboembolism in pregnancy. Am J Med. 2007; 120(10 Suppl 2):S26-34. 10. Horlocker T, Wedel D, Benzon H, Brown D. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA consensus conference on neuraxial anesthesia and anticoagulation). Reg Anesth Pain Med. 2003; 28(3):172-197. 11. Bates SM, Greer IA, Hirsh J, Ginsberg JS. Use of antithrombotic agents during pregnancy: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126(3 Suppl):627S-644S. 12. Nelson-Piercy C. Handbook of Obstetric Medicine. 3rd ed: Informa Health Care; 2007.
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
Appendix A: Drug Information Note: There is limited data on the dosing of LMWH in pregnant women, obese women and women with renal impairment. The current dose is determined on standard practice worldwide. Liaise with Obstetric Medicine team and/or pharmacologist regarding LMWH dosing and monitoring for women: • greater than 100 kg (actual weight), • with renal impairment Prophylactic LMWH Enoxaparin Standard dose Enoxaparin Intermediate dose
Dose 40 mg daily
Route subcut
40 mg bd
subcut
Therapeutic LMWH Enoxaparin
Dose 1 mg/kg bd
Route subcut
Prophylactic Unfractionated Heparin (Sodium Heparin)12 Standard dose Intermediate dose High dose Therapeutic Unfractionated Heparin (Sodium Heparin) Loading Dose Infusion
Dose
Route
Consider this dose for patients: o greater than 100 kg o with multiple risk factors Comments • Check renal function prior to initiating LMWH • Greater than 100 kg liaise with experienced physician regarding dose Comments
5000 Units bd 7500 Units bd 10000 Units bd Dose
subcut subcut subcut Route
Comments
80 units/kg 18 units/kg/hour
IV stat IV infusion
Postnatal Warfarin
Dose Variable dose
Route oral
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Comments •
•
Monitor with regular APTT as per hospital guideline • Refer to Appendix D & E for decision support information and example administration form Comments Aim for INR 2-3
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
Appendix B: Warfarin Guidelines Source: http://qheps.health.qld.gov.au/medicines/documents/warfarin/warfarin_guidelines.pdf
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
Appendix C: Decision support for heparin intravenous infusion order Source: http://qheps.health.qld.gov.au/medicines/documents/heparin/heparin_form.pdf
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
Appendix D: Example heparin intravenous infusion order form Source: http://qheps.health.qld.gov.au/medicines/documents/heparin/heparin_form.pdf
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Queensland Maternity and Neonatal Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium
Appendix E: Acknowledgements The Queensland Maternity and Neonatal Clinical Guidelines Program gratefully acknowledge the contribution of Queensland clinicians and other stakeholders who participated throughout the guideline development process particularly: Working Party Clinical Lead Dr Karin Lust, General and Obstetric Physician, Royal Brisbane and Women’s Hospital Working Party Members Ms Karen Baker, Midwife, Mackay Base Hospital Ms Penelope Dale, Midwife, Royal Brisbane and Women’s Hospital Associate Professor Rebecca Kimble, Obstetrician, Royal Brisbane and Women’s Hospital Dr Justin Nasser, Obstetrician, Gold Coast Hospital Ms Jody Paxton, Nurse Educator, Mater Health Services, Brisbane Ms Carol Reid, Registered Nurse, Safe Medication Practice Unit Dr Liana Tanda, Obstetrician, Caboolture Hospital Ms Mary Tredinnick, Pharmacist, Royal Brisbane and Women’s Hospital Dr Danny Tucker, Obstetrician, Townsville Hospital
Program Team Associate Professor Rebecca Kimble, Director, Queensland Maternity and Neonatal Clinical Guidelines Program Ms Joan Kennedy, Principal Program Officer, Queensland Maternity and Neonatal Clinical Guidelines Program Mr Stephen Aitchison, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines Program Ms Jacinta Lee, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines Program Ms Catherine van den Berg, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines Program Steering Committee, Queensland Maternity and Neonatal Clinical Guidelines Program
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