Continuous CTG produces a paper recording of the baby’s heart rate and the mother’s labour contractions. Although continuous CTG provides a written record, mothers cannot move freely during labour, change positions easily, or use a birthing pool to help with comfort and control during labour. It also means that some resources tend to be focused on the need to constantly interpret the CTG and not on the needs of a woman in labour.

Continuous CTG was associated with fewer fits for babies although there was no difference in cerebral palsy; both were rare events. However, continuous CTG was also associated with increased numbers of caesarean sections and instrumental births, both of which carry risks for mothers. Continuous CTG also makes moving and changing positions difficult in labour and women are unable to use a birthing pool. This can impact on women’s coping strategies. Women and their doctors need to discuss the woman’s individual needs and wishes about monitoring the baby’s wellbeing in labour.

Future research should focus on events that happen in pregnancy and labour that could be the cause of long term problems for the baby.

In Cushing’s syndrome there is excess cortisol. Causes are broadly divided into 2 types: ACTH dependent disease: excess ACTH from the pituitary (Cushing’s disease), ectopic ACTH-producing tumours or excess ACTH administration. Non-ACTH-dependent: adrenal adenomas, adrenal carcinomas, excess glucocorticoid administration. The recommended diagnostic tests for the presence of Cushing’s syndrome are 24-hour urinary free cortisol, 1 mg overnight dexamethasone suppression test and late-night salivary cortisol. There are several other tests that may also be performed to find the cause. ACTH and cortisol measured together may show if this is ACTH dependent or not. MRI pituitary and CT abdo and pelvis may show if tumour is the cause.

Squamous cell carcinoma is the most common type of vaginal cancer.

Vulvovaginal candidiasis is the most common genital infection and it is caused by candida albicans in 80-92% of the cases. Other non albicans species include C.tropicalis, C.glabrata, C.krusei and C.parapsilosis. 20% of women of childbearing age are asymptotic colonisers of Candida species as part of their normal vaginal flora. This increases to 40% in pregnancy.

Ladd’s bands are the most common form of peritoneal bands in malrotation of the intestine.

Congenital infections can be the cause of various congenital abnormalities. Infection with the Rubella virus, part of the TORCH infections (toxoplasmosis, other organisms, rubella, cytomegalovirus, and herpes simplex), can lead to cardiac abnormalities, ophthalmic defects, sensorineural deafness and neurodevelopmental delays. At birth congenital rubella syndrome presents with a petechial rash characteristically dubbed a blueberry muffin rash, and hepatosplenomegaly with jaundice. Immunization of the mother against measles is an effective way of reducing the occurrence of congenital rubella syndrome.

Twin pregnancies are at risk for iron deficiency due to significant maternal, fetal, and placental demands. Recommendations regarding the optimal iron dose in twin pregnancies are based on clinical expert opinions, advocating doubling the dose of iron from 30 mg of elemental iron to 60 mg routinely during the second and third trimester, regardless of maternal iron stores.

If pregnant with twins, patient should take the same prenatal vitamins she would take for any pregnancy, but a recommendation of extra folic acid and iron will be made. The additional folic acid and extra iron will help ward off iron-deficiency anaemia, which is more common when patient is pregnant with multiples.

If a cervical screening test reveals invasive squamous cell carcinoma or adenocarcinoma, refer the patient to a gynaecologist at a tertiary hospital right once for further treatment.
Colposcopy at a GP practice is not appropriate in these situations. When it comes to the prospect of cancer, reassurance isn’t enough.

CDC urges all women of reproductive age to take 400 micrograms (mcg) of folic acid each day, in addition to consuming food with folate from a varied diet, to help prevent some major birth defects of the baby’s brain (anencephaly) and spine (spina bifida).

Women who are at high risk of having babies with neural tube defects and who would benefit from higher doses of folic acid include those with certain folate-enzyme genotypes, previous pregnancies with neural tube defects, diabetes, malabsorption disorders, or obesity, or those who take antifolate medications or smoke. Such women should take 5 mg/d of folic acid for the 2 months before conception and during the first trimester.

it is imperative to elucidate the patient’s risk for current pregnancy and time within her current menstrual cycle prior to IUD insertion. A negative urine pregnancy test is a prerequisite to placement of an IUD. Pregnancies occurring with IUDs in place have an increased incidence of complications, including spontaneous abortion and septic abortion.

For this reason, many providers prefer to time IUD insertion within the first 5-7 days of the menstrual cycle, further assuring that the patient is not newly pregnant.

All other options take risk of the patient being pregnant.

HELLP syndrome stands for haemolysis, elevated liver enzyme levels, and low platelet levels and is a very severe condition that can happen during pregnancy. Management of this condition requires immediate delivery of the baby.

The broad ligament is one of the secondary supporting structures of the uterus which attaches the lateral portion of the uterus to the pelvic sidewall. The broad ligament primarily serves a protective layer for important structures including the fallopian tubes, the ovaries, the ovarian arteries, and the uterine arteries, the round and ovarian ligaments, and the infundibulopelvic ligaments.

This patient is above 35 and smokes more than 15 cigarettes per day, which is an absolute contraindication to using a combined oral contraceptive pill. A BMI of greater than 35 is a relative contraindication to the usage of the combined oral contraceptive pill.
Progestogen-only contraception, such as etonogestrel implant, levonorgestrel intrauterine device, and depot medroxyprogesterone, should be offered to her.
Without initially attempting lifestyle changes, a referral for weight loss surgery is not required. Also, nicotine replacement therapy may aid in quitting smoking, but it may take time.

The bladder is supplied by branches of the internal iliac artery, including the superior vesical artery, branches of the gluteal and obturator arteries and the inferior vesical artery in males and the vaginal and the uterine arteries in females.

The rectus sheath is formed by the decussation and interweaving of the aponeuroses of the fl at abdominal muscles. The external oblique aponeurosis contributes to the anterior wall of the sheath throughout its length. The superior two thirds of the internal oblique aponeurosis splits into two layers (laminae) at the lateral border of the rectus abdominis; one lamina passing anterior to the muscle and the other passing posterior to it. The anterior lamina joins the aponeurosis of the external oblique to form the anterior layer of the rectus sheath. The posterior lamina joins the aponeurosis of the transversus abdominis to form the posterior layer of the rectus sheath.

This lady should be admitted to hospital for early surgical exploration. Taking into account her age, mild abdominal discomfort and a palpable lower abdominal mass, it is imperative that ovarian malignancy be ruled out as soon as possible. Patients with ovarian malignancy often present in advanced stages of cancer as the symptoms tend to be occult and non-specific. Other things to include in her workup would be her CA125 level. Any form of hormonal therapy is contraindicated until ovarian malignancy has been ruled out. A pap smear is not relevant here since we are suspecting an ovarian malignancy rather than cervical. Evaluation of her mass takes priority over an assessment for osteoporosis.

The best time of the episiotomy is when the presenting part becomes visible during the contractions. If the episiotomy is performed at the proper time, less time will be required for the delivery. However, if its done too late, it causes excessive stretching of the pelvic floor and further potential lacerations.

The fetal head is engaged when the head of the foetus or the presenting part enters the pelvic inlet or pelvic brim. It usually occurs at 38 weeks of gestation.
The Spalding sign refers to the overlapping of the fetal skull bones caused by collapse of the fetal brain. It appears usually a week or more after fetal death in utero.
In brow presentation the scalp is deflexed as the foetus is looking upward. Normally the head is inflexed such that the chin is touching the chest.

The patient most likely suffered a uterine rupture. It occurs most often in multiparous women and is less often associated with external haemorrhage. Shock develops shortly after rupture due to the extent of concealed bleeding.

Uterine inversion rarely occurs when after a spontaneous and normal third stage of labour. Although it can lead to shock, it is usually associated with a history of controlled cord traction or Dublin method of placenta delivery before the uterus has contracted. This diagnosis is also strongly considered when shock is out of proportion to the amount of blood loss.

An overwhelming infection is unlikely in this case when labour occurred for a short period of time. Uterine atony and amniotic fluid embolism are more associated with excessive vaginal bleeding, which is not evident in this case.

Patient’s presentation is classic for uterine rupture, were she developed sudden abdominal pain followed by cessation of contractions, termination of urge to push and vaginal bleeding.
Abdominal examination shows no fetal cardiac activity and signs of fluid collection like fluid thrill and shifting dullness. The fluid collected will be blood, which usually enters the peritoneum after the rupture of the uterus. In such patients vaginal examination will reveal a range of cervical dilatation with evidences of cephalopelvic disproportion.
Anterior lower transverse segment is the most common site for spontaneous uterine rupture. Patient in the case presenting with tachycardia and hypotension is in shock due to blood loss and will require urgent resuscitation.

Placenta previa presents with painless bleeding from the vagina and Placental abruption will present with painful vaginal bleeding with tender and tense uterine wall, however, in contrary to that of uterine rupture, uterine contractions will continue in both these cases.

Shoulder dystocia is more likely to present in a prolonged labour with a significant delay in the progress of labour. However, in this case, there is no mention of shoulder dystocia.

Disseminated intravascular coagulation (DIC) is a condition which is causes due to abnormal and excessive generation of thrombin and fibrin in the circulating blood which results in bleeding from every skin puncture sites. It results in increased platelet aggregation and consumption of coagulation factors which results in bleeding at some sites and thromboembolism at other sites. Placental abruption, or retained products of conception in the uterine cavity are the causes for DIC.

On reflex liquid-based cytology, this patient had a cervical screening test that revealed HPV non-16 and 18 kinds, as well as a low-grade squamous intraepithelial lesion. In a year, she should be provided a cervical screening test. If HPV non-16/18 kinds are discovered in 12 months, she will need a colposcopy.

Threatened abortion:
– Vaginal bleeding with closed cervical os during the first 20 weeks of pregnancy
– Occurs in 25% of 1st-trimester pregnancies
– 50% survival
More than half of threatened abortions will abort. The risk of spontaneous abortion, in a patient with a threatened abortion, is less if fetal cardiac activity is present.

The biophysical profile is a composite test that collects 5 indicators of fetal well-being, including fetal heart rate reactivity, breathing movements, gross body movements, muscular tone, and quantitative estimation of amniotic fluid volume. The assessment of fetal heart rate is accomplished by performing a nonstress test, whereas the latter 4 variables are observed using real-time ultra-sonography.

This patient is presenting with a low-lying placenta at 18 weeks of gestation. This is a common finding on ultrasound at 18-20 weeks. If there is not bleeding, there is an 80-90% chance that by late pregnancy, the placenta will have moved and is no longer occupying the lower uterine segment. For this reason, the repeat ultrasound examination is usually performed at 32-34 weeks of gestation. Further discussions about management can then be made after obtaining those results.

Leaving the repeat ultrasound until term would be inappropriate as intervention would be needed prior. If the placenta praevia is still present, it is typically advisable to deliver prior to term.

Cardiotocographic (CT) fetal heart rate monitoring is not required in the absence of bleeding or other symptoms.

Delivery by Caesarean section would not be necessary if the placenta was no longer praevia by the time the repeat ultrasound is done.

Repeat ultrasound examination at 22 weeks of gestation would also unnecessary and inappropriate as it is too close in time for the change to occur.

Occipitomental diameter is the greatest diameter of the fetal scalp and runs from chin to the prominent portion on the occiput. It measure about 12.5cm in diameter.

Rheumatoid arthritis and its prognosis during pregnancy are highly unpredictable, as the disease can improve in 75% of the cases and gets worse in 25%. During conception and pregnancy, it is advisable to avoid those rheumatoid arthritis medications which possess high risk in causing congenital disabilities. Most common such contraindicated remedies include methotrexate and leflunomide.
Drugs like Prednisone, Non-steroidal anti-inflammatory drugs and TNF inhibitors are also not considered safe during pregnancy, so if required these should be used under specialist supervision.

Sulfasalazine and Antimalarials such as hydroxychloroquine are safe and can be used without much complications during pregnancy. In this given case, the patient should be advised to stop methotrexate and to continue sulfasalazine during pregnancy.

Shortly after the morula enters the uterus, around the 4th day after fertilization, a clear cystic cavity starts forming inside the morula. The fluid passes through the zona pellucida from the uterine cavity and hence forms the blastocyst.

The biochemical and mechanical effects of progesterone and the enlarging uterus are responsible for some changes in lung function during pregnancy.

Progesterone increases the sensitivity of the respiratory centre to arterial carbon dioxide while also causing hyperaemia in the airway leading to nasal obstruction. As a result, minute ventilation and tidal volume increase by 50% to allow greater arterial oxygen saturation.

The enlarging uterus displaces the diaphragm upwards, and also limits the movement of the thoracic cage, thereby decreasing the functional residual capacity (FRC) and the expiratory reserve volume (ERV) by 20%.

Functional Expiratory Volume in 1 second (FEV1) and Forced Vital Capacity (FVC) remain unchanged in pregnancy.

The uterine and vaginal arteries branch from the internal iliac artery. The ovarian artery branches direct from the aorta.

Labour induction is indicated as no fetal movements have been felt for 24 hours, with a normal cardiotocograph (CTG) and the pregnancy is at near/full term with a favourable cervix.

Amniotic fluid volume assessment would have been indicated 24 hours earlier as, if it was low, induction would have been indicated then, despite a normal CTG.

Ultrasound examination of the foetus is not indicated as it is necessary to expedite delivery.

Carrying out another CTG, with or without oxytocin challenge, is not indicated, although MG monitoring during induced labour would be mandatory.

Delivery immediately by Caesarean section is not indicated unless the lack of fetal movements is due to fetal hypoxia. This can result in fetal distress during labour, necessitating an emergency Caesarean section if the cervix is not fully dilated.