Adequate analgesia pethidine or morphine can be used. Epidural anaesthesia is preferable as it abolishes the bearing down desire so decreases the effort load. Shorten the second stage by forceps or ventouse. Ergometrine is better avoided as it causes sudden load of the circulation with blood from the uterus leading to acute heart failure. Oxytocin can be used instead.
Prophylactic antibiotic is essential to guard against subacute bacterial endocarditis.
Postpartum observation for 48 hours is essential as the risk of heart failure is high in this period. Although bed rest is essential, early ambulation is desirable to avoid thromboembolism. Breast feeding is allowed unless there is heart failure. Oestrogens should not be used to suppress lactation and bromocriptine or lisuride can be used. Sterilisation may be advised if decompansation occurred in this pregnancy.