Obstetrics: Complications

• Bleeding: Antepartum Haemorrhage | Placenta Praevia and Accreta | Placental Abruption | Vasa Praevia
• The baby's growth and wellbeing: Small for Gestational Age and Growth Restriction | Large Baby (Macrosomia) | Too Much or Too Little Fluid | Reduced Fetal Movements | Stillbirth
• Pregnancy situations: Twins and Multiple Pregnancy | Breech and Other Malpresentations | Previous Caesarean Section | Prolonged Pregnancy | Induction of Labour
• Preterm birth: Preventing Preterm Birth | Preterm Labour | Preterm Prelabour Rupture of Membranes | Chorioamnionitis
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🤰 Obstetric complications — bleeding in later pregnancy, poor fetal growth, preterm birth and malpresentation are the main reasons a pregnancy becomes "high risk". Many stillbirths are linked to growth restriction that was missed, so measuring growth, acting on reduced fetal movements, and knowing when to deliver save babies' lives.
Your four questions for every patient: How many weeks is she, and is the baby viable (24 weeks or more)? Is the mother stable — and is the baby well (CTG, movements, growth)? Where is the placenta? Does she need steroids, magnesium, antibiotics or anti-D — and when should the baby be delivered?

Antepartum Haemorrhage

• Definition: Bleeding from the genital tract from 24 weeks until birth. Affects about 3–5% of pregnancies.
• Causes:
  • Placental abruption.
  • Placenta praevia.
  • Vasa praevia (rare).
  • Local causes — cervical ectropion, polyp, infection, cervical cancer, trauma.
  • "Show" in labour; unexplained (common).
• Severity — spotting; minor (under 50 mL); major (50–1,000 mL, no shock); massive (over 1,000 mL or shock). Visible loss often underestimates bleeding (concealed abruption).
• Initial assessment:
  • ABC; maternal observations (shock).
  • Is there pain? — abruption is usually painful; praevia usually painless.
  • Abdominal examination — tense, tender womb (abruption) versus soft, non-tender (praevia); fetal lie and presentation (high or abnormal in praevia).
  • Never do a digital vaginal examination until placenta praevia is excluded by ultrasound (it can provoke massive bleeding). A gentle speculum examination is safe.
  • Fetal heart and CTG.
  • Bloods — FBC, clotting, fibrinogen, group and save/crossmatch, U&E, LFTs; Kleihauer if RhD-negative.
• Management:
  • Major or massive bleeding — two large-bore cannulas, crossmatch, major haemorrhage protocol, senior obstetrician and anaesthetist; deliver if mother or baby is compromised.
  • Corticosteroids if 24–34+6 weeks and delivery may be needed.
  • Anti-D (RhD-negative) — after any APH, with Kleihauer.

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Placenta Praevia and Accreta

• Placenta praevia — the placenta lies wholly or partly in the lower uterine segment, over or near the cervix.
  • Low-lying placenta — placental edge within 20 mm of the internal os. Placenta praevia — covers the os.
• Risk factors: Previous caesarean, previous praevia, multiple pregnancy, multiparity, older age, smoking, IVF, previous uterine surgery.
• Features:
  • Painless bright red bleeding, often recurrent, from about 28 weeks; may be triggered by sex.
  • Soft, non-tender womb.
  • High presenting part or abnormal lie (breech, transverse).
  • The baby is usually well (blood loss is maternal).
• Diagnosis: Seen on the 20-week anomaly scan as low-lying; rescan at 32 weeks (most move up as the lower segment grows); transvaginal ultrasound is safe and accurate.
• Management:
  • Bleeding — admit, resuscitate, steroids if preterm; anti-D; consider staying in hospital after repeated bleeds.
  • Advice — attend immediately with any bleeding, contractions or pain; avoid sex; correct anaemia.
  • Birth:
    • Placenta praevia or placental edge under 20 mm from the os in the third trimester — caesarean, usually planned at 36+0–37+0 weeks (earlier if bleeding).
    • Placental edge over 20 mm away — vaginal birth is possible.
    • Senior obstetrician and anaesthetist; blood available; cell salvage.
  • High risk of PPH (the lower segment contracts poorly).
• Placenta accreta spectrum — the placenta grows into (increta) or through (percreta) the womb wall and won't separate:
  • Biggest risk — placenta praevia with a previous caesarean (risk rises with each caesarean).
  • Diagnosed on specialist ultrasound or MRI.
  • Planned delivery at a specialist centre (about 35–36 weeks), often caesarean hysterectomy; massive haemorrhage risk; interventional radiology; bladder involvement (percreta).

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Placental Abruption

• What it is: The placenta separates from the womb wall before the baby is born.
• Risk factors:
  • Pre-eclampsia and hypertension.
  • Previous abruption.
  • Abdominal trauma (road accident, domestic abuse).
  • Smoking; cocaine.
  • Growth restriction; multiple pregnancy; polyhydramnios (sudden decompression after membranes rupture); PPROM; thrombophilia; older age.
• Features:
  • Abdominal pain — constant, sudden.
  • Dark vaginal bleeding — may be little or none ("concealed" abruption), so shock can be out of proportion to visible loss.
  • Tense, tender, "woody" hard womb; frequent contractions.
  • Fetal distress or fetal death; difficult to feel fetal parts.
• Diagnosis — clinical. Ultrasound often misses it (mainly used to check the baby and placental site).
• Complications:
  • Mother — haemorrhagic shock, DIC, AKI, PPH (Couvelaire uterus — blood in the womb muscle), death.
  • Baby — hypoxia, preterm birth, stillbirth.
• Management:
  • Resuscitate — large-bore access, crossmatch, clotting and fibrinogen, major haemorrhage protocol.
  • Baby alive with fetal distress — emergency caesarean (category 1).
  • Baby alive, no distress, 37 weeks or more — delivery (often induction).
  • Preterm, mild, mother and baby stable — steroids; close monitoring.
  • Intrauterine death — vaginal birth if the mother is stable (DIC is common — correct clotting).
  • Anti-D and Kleihauer if RhD-negative.
  • Prepare for PPH.

⚠️ Safety Pearl: In abruption, the amount of visible blood doesn't reflect the loss. A hard, tender womb, maternal tachycardia and fetal distress need urgent action even if there is little bleeding. Remember to ask about domestic abuse after abdominal trauma.

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Vasa Praevia

• What it is: Fetal blood vessels run through the membranes over or near the cervix, unprotected by placenta or cord. If the membranes rupture, the vessels tear — fetal blood loss.
• Risk factors: Low-lying placenta, velamentous cord insertion, bilobed or succenturiate placenta, IVF, multiple pregnancy.
• Features: Painless bleeding at rupture of membranes with sudden fetal distress (bradycardia or sinusoidal CTG); the mother is well.
• Management:
  • Emergency category 1 caesarean — fetal mortality is very high otherwise.
  • Diagnosed antenatally (transvaginal colour Doppler) — steroids, consider admission from 30–32 weeks, planned caesarean at about 34–36 weeks before labour.

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Small for Gestational Age and Growth Restriction

• Terms:
  • Small for gestational age (SGA) — estimated weight or abdominal circumference below the 10th centile. Many are constitutionally small and healthy.
  • Fetal growth restriction (FGR) — the baby is not reaching its growth potential (e.g. below the 3rd centile, or slowing growth across centiles, or abnormal Doppler). Linked to stillbirth.
• Causes:
  • Placental insufficiency (the commonest) — pre-eclampsia, hypertension, smoking, previous FGR, older age, diabetes with vascular disease, kidney disease, APS.
  • Fetal — chromosomal abnormalities (T18, T13), congenital infection (CMV, toxoplasma), structural anomalies.
  • Maternal — smoking, alcohol, drugs (cocaine), poor nutrition, low BMI, high altitude.
  • Multiple pregnancy.
• Detection:
  • Symphysis–fundal height plotted on a growth chart from 24 weeks.
  • Serial growth scans (every 2–3 weeks from 28–32 weeks) for high-risk women or when fundal height is unreliable (obesity, fibroids).
  • Saving Babies' Lives care bundle — risk assessment at booking and 20 weeks; aspirin for those at high risk.
• Monitoring a small baby:
  • Umbilical artery Doppler — the key test: absent or reversed end-diastolic flow means severe placental resistance (high risk).
  • Middle cerebral artery Doppler ("brain sparing"), ductus venosus Doppler (very preterm FGR).
  • Amniotic fluid (oligohydramnios); CTG (computerised CTG for short-term variation).
• Timing of birth — balances the risks of stillbirth and prematurity:
  • Normal Doppler SGA — often delivered at about 37–39 weeks.
  • Abnormal Doppler — earlier delivery; absent or reversed end-diastolic flow may need delivery from about 32–34 weeks (earlier with other abnormalities).
  • Steroids (under 35 weeks) and magnesium sulfate (under 30–32 weeks) before preterm delivery.
• Neonatal risks — hypoglycaemia, hypothermia, polycythaemia, jaundice, NEC; later obesity, diabetes and cardiovascular disease.

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Large Baby (Macrosomia)

• Large for gestational age — estimated weight above the 90th centile; macrosomia — birth weight over 4–4.5 kg.
• Causes: Diabetes (gestational or pre-existing), maternal obesity, excessive weight gain, previous large baby, constitutional (tall parents), post-term pregnancy, male sex, rare overgrowth syndromes (Beckwith–Wiedemann).
• Risks:
  • Shoulder dystocia and brachial plexus injury.
  • Prolonged labour, instrumental delivery, caesarean.
  • Perineal tears (OASI) and PPH.
  • Neonatal hypoglycaemia (if diabetic mother).
• Management:
  • Check for gestational diabetes (OGTT).
  • Scans estimate weight poorly (error about 10–15%).
  • Discuss options — expectant management, induction of labour (reduces shoulder dystocia slightly), or caesarean (if very large, especially with diabetes, e.g. estimated weight over 4.5 kg).
  • Senior staff present at birth; prepare for shoulder dystocia and PPH.

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Too Much or Too Little Fluid

• Polyhydramnios — too much amniotic fluid (deepest pool over 8 cm or amniotic fluid index over the 95th centile):
  • Causes:
    • Maternal diabetes (fetal polyuria).
    • Fetal swallowing problems — oesophageal atresia, duodenal atresia, neuromuscular conditions, anencephaly.
    • Twin-to-twin transfusion (recipient twin).
    • Fetal anaemia, hydrops, infection.
    • Idiopathic (most mild cases).
  • Risks — preterm labour, malpresentation, cord prolapse, abruption when membranes rupture, PPH.
  • Management — OGTT, detailed scan; amnioreduction or indometacin (before 32 weeks) for severe symptoms (specialist).
• Oligohydramnios — too little fluid (deepest pool under 2 cm):
  • Causes:
    • Ruptured membranes (the commonest).
    • Placental insufficiency (FGR, pre-eclampsia).
    • Fetal kidney problems — renal agenesis (Potter sequence), polycystic kidneys, urethral obstruction (posterior urethral valves).
    • Post-term pregnancy.
    • Drugs — NSAIDs, ACE inhibitors.
  • Risks — pulmonary hypoplasia (if early and prolonged), limb contractures, cord compression in labour.

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Reduced Fetal Movements

• Fetal movements are usually felt from 18–20 weeks (earlier in later pregnancies). There's no set "number" — the key is the baby's usual pattern. Movements don't reduce towards term.
• Why it matters: Reduced movements can be a sign of a compromised baby; about half of women who have a stillbirth notice reduced movements beforehand.
• Advice for women: Contact the maternity unit straight away (don't wait until the next day) if movements reduce or change. Don't use home Doppler devices — hearing a heartbeat can give false reassurance.
• Assessment (from 26–28 weeks):
  • History — risk factors for stillbirth (FGR, hypertension, diabetes, smoking, previous stillbirth, older age).
  • Check the fetal heart (handheld Doppler to confirm a heartbeat).
  • CTG for at least 20 minutes (from 28 weeks).
  • Ultrasound (growth, fluid, Doppler) within 24 hours if risk factors, small for dates, CTG abnormal, or recurrent reduced movements.
  • Between 24 and 28 weeks — fetal heart check and assessment; consider scan.
• Recurrent episodes — scan; consider induction of labour from 39 weeks if repeated with other concerns.
• No heartbeat — urgent ultrasound to confirm (see Stillbirth).

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Stillbirth

• Definition (UK) — a baby born dead at 24 weeks or more. About 3–4 per 1,000 births; higher in deprived areas and in Black and Asian women.
• Risk factors:
  • Fetal growth restriction.
  • Smoking; obesity; older age; first pregnancy.
  • Pre-eclampsia, diabetes, cholestasis, APS, kidney disease.
  • Abruption; infection (GBS, listeria); cord accidents.
  • Post-term pregnancy; sleeping on the back in late pregnancy.
  • Previous stillbirth.
• Diagnosis: Ultrasound to confirm absent heartbeat (second operator if possible). Break bad news compassionately, with a partner or supporter present.
• Management:
  • Check maternal wellbeing — exclude DIC (FBC, clotting, fibrinogen), infection (sepsis), pre-eclampsia, abruption.
  • Vaginal birth is usually recommended — mifepristone then misoprostol (induction); caesarean only for specific reasons (e.g. abruption with shock, previous classical caesarean).
  • Immediate induction if sepsis, pre-eclampsia, abruption or ruptured membranes; otherwise the woman can choose timing (risk of DIC rises with time).
  • Anti-D (with Kleihauer) if RhD-negative.
  • Lactation suppression — cabergoline (avoid if hypertension or pre-eclampsia).
• Investigations (with consent) — Kleihauer, infection screen (cultures, serology), bile acids, HbA1c, thyroid, thrombophilia and APS, placental histology, fetal karyotype or microarray, post-mortem (full or limited).
• Bereavement care:
  • Time with the baby; memories (photos, handprints); naming; religious and cultural needs.
  • Registration of the stillbirth (within 42 days); stillbirth certificate; funeral options.
  • Follow-up with results; counselling; plan for a future pregnancy (early booking, aspirin, growth scans, earlier delivery).
  • Support for partners and siblings; charities (Sands).

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Twins and Multiple Pregnancy

• Types:
  • Dizygotic ("non-identical") — two eggs; always dichorionic diamniotic (DCDA). Risk factors — IVF, family history (maternal), older age, Black African ancestry.
  • Monozygotic ("identical") — one egg splits; may be DCDA, monochorionic diamniotic (MCDA) or monochorionic monoamniotic (MCMA) depending on when it splits.
• Chorionicity — determined on the first-trimester scan (11–14 weeks): "lambda" (twin peak) sign = dichorionic; "T" sign = monochorionic. It sets the level of risk and care.
• Risks:
  • Mother — hyperemesis, anaemia, pre-eclampsia, gestational diabetes, VTE, PPH, caesarean.
  • Babies — preterm birth (the main risk), growth restriction, congenital anomalies, stillbirth.
  • Monochorionic twins (shared placenta):
    • Twin-to-twin transfusion syndrome (TTTS) — about 10–15% of MCDA twins: one twin (donor) becomes small with little fluid, the other (recipient) large with polyhydramnios and heart strain. Treated with fetoscopic laser of the connecting vessels.
    • Selective growth restriction; twin anaemia–polycythaemia sequence.
    • If one twin dies, the other is at risk of death or brain injury.
  • MCMA twins — cord entanglement.
• Care (NICE NG137):
  • Specialist twin clinic; aspirin if another moderate risk factor; iron and folic acid.
  • Scans — DCDA every 4 weeks from 20 weeks; monochorionic every 2 weeks from 16 weeks (TTTS).
• Timing of birth (uncomplicated):
  • DCDA — 37+0 weeks.
  • MCDA — 36+0 weeks (after steroids).
  • MCMA — 32+0 to 33+6 weeks by caesarean.
  • Triplets — about 35 weeks.
• Mode of birth — vaginal birth is possible if the first twin is cephalic; caesarean if the first twin is breech or for MCMA twins. Second twin delivery may need ECV, breech extraction or caesarean.

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Breech and Other Malpresentations

• Breech — the bottom or feet come first. About 3–4% at term (more common earlier in pregnancy).
  • Types — extended (frank) (hips flexed, knees extended — the commonest), flexed (complete), footling (feet first — highest risk of cord prolapse).
  • Causes — preterm, placenta praevia, fibroids, uterine abnormality, polyhydramnios or oligohydramnios, multiple pregnancy, fetal abnormality.
• External cephalic version (ECV) — turning the baby by hand through the abdomen:
  • Offer from 36 weeks (first pregnancy) or 37 weeks (previous births).
  • Success about 50% (higher in women who have given birth before).
  • Tocolysis (terbutaline) improves success.
  • Contraindications — APH in the last 7 days, abnormal CTG, ruptured membranes, placenta praevia, multiple pregnancy (except second twin), major uterine abnormality, caesarean needed for another reason.
  • Risks — transient fetal heart changes, small risk of abruption (theatre nearby); anti-D if RhD-negative.
• If the baby stays breech:
  • Planned caesarean (at about 39 weeks) — lower perinatal risk (Term Breech Trial).
  • Planned vaginal breech birth — an option with experienced staff in selected women (frank or flexed breech, average size, no other complications).
  • Preterm breech in labour — individual decision.
• Other malpresentations:
  • Transverse or oblique lie — at term, ECV or caesarean (risk of cord prolapse if membranes rupture); check for praevia.
  • Unstable lie — changing lie near term; admission may be considered.
  • Face and brow presentations — see the Labour, Birth and Postnatal Care chapter.

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Previous Caesarean Section

• Options for the next birth:
  • Vaginal birth after caesarean (VBAC) — successful in about 72–75% (higher if she has had a vaginal birth before).
  • Elective repeat caesarean (ERCS) — at 39 weeks.
• VBAC risks:
  • Uterine rupture — about 1 in 200 (0.5%); higher with induction or augmentation (especially prostaglandins).
  • Emergency caesarean if unsuccessful.
• Repeat caesarean risks — surgical complications, longer recovery, and with each caesarean a rising risk of placenta praevia and accreta in future pregnancies.
• VBAC is not advised after a classical (vertical upper segment) caesarean, previous uterine rupture, or with placenta praevia or other reasons for caesarean.
• Care in labour — birth in an obstetric unit; continuous CTG (fetal heart changes are often the first sign of rupture); IV access; careful use of oxytocin.
• Signs of uterine rupture — see the Obstetric Emergencies chapter.

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Prolonged Pregnancy

• Definition — pregnancy lasting 42+0 weeks or more.
• Risks — rising stillbirth risk after 41 weeks, macrosomia, meconium aspiration, oligohydramnios, need for caesarean.
• Management (NICE NG207):
  • Membrane sweep at 40 and 41 weeks (first pregnancy) or 41 weeks (later pregnancies) — increases the chance of labour starting within 48 hours.
  • Discuss induction from 39 weeks, and offer induction of labour from 41+0 weeks, so that birth happens by 42 weeks.
  • If induction is declined — increased monitoring from 42 weeks (CTG twice weekly and ultrasound of fluid depth).
• Earlier induction considered for older mothers (over 40 — offer at 39 weeks), higher BMI, IVF, and some ethnic groups at higher stillbirth risk (shared decision).

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Induction of Labour

• Common reasons: Prolonged pregnancy; pre-eclampsia; diabetes; FGR; obstetric cholestasis; prelabour rupture of membranes; reduced fetal movements; maternal request (in some situations); intrauterine death.
• Bishop score — assesses how "ready" the cervix is (dilatation, length/effacement, consistency, position, station). A score of 8 or more (or over 6) means a favourable cervix — likely to respond to amniotomy and oxytocin.
• Methods:
  • Membrane sweep — before formal induction.
  • Vaginal prostaglandin E2 (dinoprostone — gel, tablet or pessary) or oral misoprostol — to ripen the cervix.
  • Mechanical — balloon catheter (fewer hyperstimulation risks; useful after previous caesarean).
  • Amniotomy (artificial rupture of membranes) once the cervix is favourable.
  • IV oxytocin infusion after amniotomy, titrated to contractions.
• Risks:
  • Uterine hyperstimulation (too many contractions — over 5 in 10 minutes) with fetal heart changes — remove prostaglandin, stop oxytocin, tocolysis (terbutaline).
  • Failed induction (caesarean); more instrumental births; more painful labour.
  • Cord prolapse at amniotomy if the head is high.
  • Uterine rupture (previous caesarean).
• Prelabour rupture of membranes at term — 60% labour within 24 hours; offer induction or wait up to 24 hours (risk of infection rises); immediate induction if GBS positive, meconium or signs of infection.

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Preventing Preterm Birth

• Preterm birth — before 37 weeks; about 8% of UK births. Extremely preterm (under 28 weeks), very preterm (28–31+6), moderate to late (32–36+6).
• Risk factors:
  • Previous preterm birth or late miscarriage.
  • Cervical surgery (large LLETZ, cone biopsy) or a short cervix.
  • Multiple pregnancy.
  • Infection (UTI, chorioamnionitis, bacterial vaginosis).
  • Smoking; low BMI; teenage pregnancy; deprivation; short pregnancy interval.
  • Uterine abnormality; polyhydramnios; APH.
• Prevention (preterm birth clinics):
  • Transvaginal cervical length scans (16–24 weeks) for women at risk.
  • Vaginal progesterone — short cervix (25 mm or less) between 16 and 24 weeks.
  • Cervical cerclage (stitch) — previous preterm birth or mid-trimester loss with a short cervix; or history-indicated after three or more losses or preterm births. Removed at about 36–37 weeks or if labour starts.
  • Stop smoking; treat asymptomatic bacteriuria.

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Preterm Labour

• Features: Regular painful contractions, backache, pelvic pressure, show or bleeding, ruptured membranes, before 37 weeks.
• Diagnosis (NICE NG25):
  • Speculum examination (cervical dilatation, membranes).
  • Transvaginal cervical length (from 30 weeks) — over 15 mm means labour is unlikely.
  • Fetal fibronectin — negative (under 50 ng/mL) means labour is unlikely.
  • Under 30 weeks — treat as in labour if clinically suspected.
• Management:
  • Transfer to a unit with the right level of neonatal care ("in utero transfer" is better than moving the baby after birth).
  • Antenatal corticosteroids — 24+0 to 33+6 weeks (consider from 22–23 weeks after discussion, and to 35+6 weeks): betamethasone 12 mg IM, two doses 24 hours apart (or dexamethasone). Reduce breathing problems, brain bleeds, NEC and death. Best effect 24 hours to 7 days after the first dose.
  • Magnesium sulfate for fetal neuroprotection (reduces cerebral palsy) — offer at 24+0 to 29+6 weeks, consider at 30–33+6 weeks, within 24 hours of expected birth.
  • Tocolysis — nifedipine (or atosiban) to delay birth for 48 hours (to allow steroids and transfer) — between 24 and 33+6 weeks with intact membranes. Not if infection, APH or fetal distress.
  • Intrapartum antibiotics for GBS (benzylpenicillin).
  • Neonatal team at the birth; deferred cord clamping; keep the baby warm (plastic bag under 32 weeks).
• Periviable birth (22–24 weeks) — individual decisions with parents and neonatologists (BAPM framework) about active care.

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Preterm Prelabour Rupture of Membranes

• PPROM — membranes rupture before 37 weeks without labour. Causes about a third of preterm births.
• Diagnosis:
  • History of a gush or trickle of fluid.
  • Sterile speculum — pooling of fluid in the vagina (avoid digital examination — infection risk).
  • If unclear — IGFBP-1 or PAMG-1 test of vaginal fluid.
  • Ultrasound (reduced fluid supports it).
• Management:
  • Erythromycin 250 mg four times daily for 10 days (or until labour) — reduces infection and delays birth. Avoid co-amoxiclav (linked to NEC in babies).
  • Corticosteroids (and magnesium sulfate if birth is imminent and under 30–34 weeks).
  • Monitor for chorioamnionitis — temperature, pulse, CRP, white cells, CTG (fetal tachycardia).
  • Timing of birth — usually 37 weeks if no complications (offer induction from 34 weeks after discussion of risks and benefits); deliver earlier if infection or fetal compromise.
  • No tocolysis.
• Risks — chorioamnionitis, preterm birth, cord prolapse, abruption; very early PPROM (under 24 weeks) — pulmonary hypoplasia and limb deformities.

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Chorioamnionitis

• What it is: Infection of the membranes and amniotic fluid — usually after ruptured membranes or in prolonged labour.
• Features:
  • Maternal fever, tachycardia.
  • Fetal tachycardia.
  • Uterine tenderness; offensive vaginal discharge or fluid.
  • Raised CRP and white cell count.
• Management:
  • Broad-spectrum IV antibiotics (per local maternal sepsis policy).
  • Deliver — whatever the gestation (usually by induction or augmentation; caesarean for obstetric reasons).
  • Sepsis bundle if unwell; neonatal team informed (baby needs antibiotics).
• Complications — maternal sepsis, PPH, endometritis; neonatal sepsis, cerebral palsy.

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 35-year-old with two previous caesareans has painless bright red bleeding at 31 weeks. BP 118/70, pulse 92. The womb is soft and non-tender; CTG normal.
Answer: Placenta praevia (high risk of accreta).

• No digital vaginal examination; ultrasound for placental site; IV access, bloods, crossmatch.
• Steroids (24–34+6 weeks); anti-D and Kleihauer if RhD-negative.
• Specialist imaging for accreta; plan caesarean at a specialist centre with blood and senior staff.

2. A 28-year-old at 34 weeks with pre-eclampsia has sudden abdominal pain and a small dark bleed. The womb is hard; pulse 120, BP 95/60; CTG shows a prolonged bradycardia.
Answer: Placental abruption with maternal shock and fetal distress.

• Call for help; major haemorrhage protocol; large-bore access, crossmatch, clotting and fibrinogen.
• Category 1 caesarean.
• Prepare for PPH and DIC.

3. A 26-year-old at 30 weeks has regular contractions; cervix 3 cm dilated; membranes intact.
Answer: Preterm labour.

• Betamethasone 12 mg IM two doses 24 hours apart.
• Consider magnesium sulfate (30–33+6 weeks); nifedipine tocolysis if not contraindicated.
• In utero transfer to a unit with appropriate neonatal care; GBS prophylaxis in labour.

4. A 30-year-old at 33 weeks has a gush of clear fluid. Speculum shows pooling. No contractions; temperature normal.
Answer: PPROM.

• Erythromycin 250 mg four times daily for 10 days; steroids.
• Monitor for chorioamnionitis (temperature, pulse, CRP, CTG).
• Plan delivery around 37 weeks (or from 34 weeks after discussion) unless infection develops.

5. A 40-year-old in her first pregnancy is 41+0 weeks with an uncomplicated pregnancy.
Answer: Prolonged pregnancy approaching — offer induction.

• Membrane sweep; offer induction of labour (she could have been offered it at 39 weeks because of her age).
• If declined — increased monitoring from 42 weeks (CTG and fluid scans).

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Key Points

• APH: from 24 weeks — never do a digital vaginal examination until praevia is excluded.
• Praevia: painless bright red bleeding, soft womb, high or abnormal lie; caesarean at 36–37 weeks if the edge is under 20 mm from the os.
• Previous caesarean plus praevia: think placenta accreta spectrum — specialist centre.
• Abruption: painful, hard womb, shock out of proportion to visible bleeding, fetal distress — resuscitate and deliver.
• Vasa praevia: bleeding at membrane rupture with sudden fetal distress — category 1 caesarean.
• FGR: serial growth scans for high-risk women; umbilical artery Doppler guides timing.
• Reduced fetal movements: attend immediately; CTG; scan if risk factors; no home Dopplers.
• Stillbirth: exclude DIC and sepsis; vaginal birth usually; anti-D; cabergoline; investigations and bereavement care.
• Monochorionic twins: scans every 2 weeks from 16 weeks for TTTS; deliver MCDA at 36 weeks, DCDA at 37 weeks.
• Breech: ECV at 36–37 weeks; planned caesarean or selected vaginal breech birth.
• VBAC: about 75% success; uterine rupture about 0.5% — continuous CTG.
• Offer induction from 41+0 weeks; Bishop score guides method.
• Preterm labour: steroids (24–33+6), magnesium sulfate (under 30), tocolysis (nifedipine), in utero transfer.
• PPROM: erythromycin 10 days (not co-amoxiclav), steroids, watch for chorioamnionitis.

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Guidelines and Further Reading

• RCOG Green-top Guideline 63: Antepartum haemorrhage
• RCOG Green-top Guideline 27a/27b: Placenta praevia and placenta accreta
• RCOG Green-top Guideline 31: Small-for-gestational-age fetus; NHS Saving Babies' Lives care bundle
• RCOG Green-top Guideline 57: Reduced fetal movements
• RCOG Green-top Guideline 55: Late intrauterine fetal death and stillbirth
• NICE NG137: Twin and triplet pregnancy
• RCOG Green-top Guidelines 20a/20b: External cephalic version and management of breech presentation
• RCOG Green-top Guideline 45: Birth after previous caesarean birth
• NICE NG207: Inducing labour
• NICE NG25: Preterm labour and birth; BAPM framework for perinatal care at extreme preterm gestation
• BNF — for current doses

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