Elements of the Apgar score include colour, heart rate, reflexes, muscle tone, and respiration. Apgar scoring is designed to assess for signs of hemodynamic compromise such as cyanosis, hypoperfusion, bradycardia, hypotonia, respiratory depression or apnoea. Each element is scored 0 (zero), 1, or 2. The score is recorded at 1 minute and 5 minutes in all infants with expanded recording at 5-minute intervals for infants who score 7 or less at 5 minutes, and in those requiring resuscitation as a method for monitoring response. Scores of 7 to 10 are considered reassuring.

There is an association between 20 to 30% increase in the risk for developing pyelonephritis during later pregnancy and untreated cases of bacteriuria in pregnancy. This is due to the physiological changes occurring to urinary tract during pregnancy, it is also found that untreated bacteriuria can be associated with even preterm birth and low birth weight. Risk of symptomatic urinary tract infection (UTI) during pregnancy can be reduced by antibiotic treatment of asymptomatic bacteriuria

The most common pathogen associated with asymptomatic bacteriuria is Escherichia coli, which accounts to more than 80% of isolates and the second most frequently cultured uropathogen is Staphylococcus saprophyticus. Other Gram-positive cocci, like group B streptococci, are less common. Gram-negative bacteria such as Klebsiella, Proteus or other Enterobacteriaceae are the other organisms involved in asymptomatic bacteriuria.

Although the context patient is asymptomatic, her urine dipstick shows positive nitrite and leukocyte, suggestive of urinary tract infection, so oral antibiotics like cephalexin or nitrofurantoin are advisable. Normally a five day course of oral antibiotic will be sufficient for the treatment of uncomplicated UTI or asymptomatic bacteraemia in pregnant women. As the patient is currently at her 38 weeks of gestation nitrofurantoin is contraindicated so it is best to prescribe her with Oral Cephalexin. This is because nitrofurantoin is associated with an increased risk of neonatal jaundice and haemolytic anaemia, so should not be used close to delivery, that is after 37 weeks of gestation or sooner if early delivery is planned.

Acute pyelonephritis should be treated with Intravenous antibiotic treatment, guided by urine culture and sensitivity reports as soon a available. A course of minimum of 10-14 days with IV + oral antibiotics is recommended as treatment for pyelonephritis, along with an increased fluid intake as intravenous fluids in clinically dehydrated patients. Even though urinary alkalisers are safe in pregnancy, prescription of urinary alkalisers alone is not recommended due to its low effectiveness compared to antibiotics, also as it can result in a loss of treatment efficacy urinary alkalisers should never be used in combination with nitrofurantoin.

At any stage of pregnancy, if Streptococcus agalactiae, a group B streptococcus [GBS], is detected in urine the intrapartum prophylaxis for GBS is usually indicated.

Retarded skeletal growth resulting in small for gestational age babies are the usual outcomes of an untreated vitamin D deficiency in pregnancy.

Symptoms associated with maternal vitamin D deficiency during pregnancy are:
– Hypocalcemia in newborn.
– Development of Rickets later in life.
– Defective tooth enamel.
– Small for gestational age due to its effect on skeletal growth
– Fetal convulsions or seizures due to hypocalcemia.

Ultrasound has emerged as the more accurate method of assessing fetal gestational age, especially in the first trimester. Both transvaginal and transabdominal probe assessments are used to obtain a more accurate measurement of gestational age. Transvaginal is more helpful in first trimester pregnancies.

A transvaginal ultrasound exam should not be performed in a pregnant patient with vaginal bleeding and known placenta previa, a pregnant patient with premature rupture of membranes, and a patient who refuses exam despite informed discussion.

Sonographic assessment within the first 13 weeks and 6 days will provide the most accurate estimate of gestational age. Both transvaginal and transabdominal approaches may be used. However, the transvaginal approach may provide a more clear and accurate view of early embryonic structures. Although the gestational sac and yolk sac are the first measurable markers visible on ultrasound, these poorly correlate with gestational age.

The patient is presenting with classic symptoms of round ligament pain.
Round ligaments are structures which extends from the lateral portion of the uterus below to the oviduct and will travel downward in a fold of peritoneum to the inguinal canal to get inserted in the upper portion of the labium majus. As the gravid uterus grows out of pelvis during pregnancy, these ligaments will stretch, mostly during sudden movements, resulting in a sharp pain. Due to dextrorotation of uterus, which occurs commonly in pregnancy, the round ligament pain is experienced more frequently over the right side. Usually this pain improves by avoiding sudden movements, by rising and sitting down gradually, by the application of local heat and by using analgesics.

As the patient is not experiencing any symptoms like fever or anorexia a diagnosis of appendicitis is not likely. Also in pregnant women appendicitis often presents as pain located much higher than the groin area as the growing gravid uterus pushes the appendix out of pelvis.

As the pain is localized to only one side of groin and is alleviated with a heating pad the diagnosis of preterm labor is unlikely. In addition, the pain would persist even at rest and not with just movement in case of labor.

As the patient has not reported of any urinary symptoms diagnosis of urinary tract infection is unlikely.

Kidney stones usually presents with pain in the back and not lower in the groin. In addition, with a kidney stone the pain would occur not only with movement, but would persist at rest as well. So a diagnosis of kidney stone is unlikely in this case.

This is a case of a pregnant patient having vaginal bleeding. Given the patient’s presentation, the most likely cause of this patient’s antepartum haemorrhage is placenta praevia. The haemorrhage is unlikely to be due to a vasa praevia because a loss of 300mL would usually cause fetal distress or death, neither of which has occurred. Cervical malignancy is also unlikely as it typically would not have bleeding of this magnitude. A possible diagnosis would be a small placental abruption as it would fit with the lack of uterine tenderness and normal uterine size.

For the immediate management of this patient, induction of labour is contraindicated before the placental site has been confirmed. Also, induction should not be performed when the gestation is only at 33 weeks, especially after an episode of a small antepartum haemorrhage. An ultrasound examination of the uterus is appropriate as it would define whether a placenta praevia is present and its grade. It would also show whether there is any evidence of an intrauterine clot associated with placental abruption from a normally situated placenta.

If a placenta praevia is diagnosed by ultrasound, a pelvic examination under anaesthesia may be a part of the subsequent care, if it is felt that vaginal delivery might be possible. Usually it would be possible if the placenta praevia is grade 1 or grade 2 anterior in type. However, pelvic exam at this stage is certainly not the next step in care, and is rarely used in current clinical care.

A Papanicolaou (Pap) smear will be necessary at some time in the near future, but would not be helpful in the care of this patient currently.

Immediate Caesarean section is not needed as the bleeding has stopped, the foetus is not in distress, and the gestation is only 33 weeks.

Levonorgestrel, also known as the morning-after pill, is a first-line oral emergency contraceptive pill with approval from the World Health Organization to prevent pregnancy. It is FDA-approved to be used within 72 hours of unprotected sexual intercourse or when a presumed contraceptive failure has occurred.

A prescription is not needed, and it is available over the counter at local pharmacies. The FDA has also approved levonorgestrel availability for all age groups due to its lack of life-threatening contraindications and side-effect profile.

There are several contraindications for the emergency contraceptive form, including allergy, hypersensitivity, severe liver disease, pregnancy, and drug-drug interactions with liver enzyme-inducing drugs. The medication is not for use in women confirmed to be pregnant; however, there is no proof nor reports of adverse effects on the mother or foetus following inadvertent exposure during pregnancy.

In this case, induction of labour at 37 weeks of gestation was necessary due to the absence of spontaneous of labour 24 hours after rupture of membranes. High doses of Syntocin and large volume of fluids may be required particularly when induction is done before term.

Syntocin infusion can lead to uterine hypertonus and tetany which can result in fetal distress at any dosage. This is a common reason to decrease or stop the infusion and an indication for Caesarean delivery due to fetal distress

Uterine rupture can occur as a result of Syntocin infusion especially when the accompanying fluids do not contain electrolytes, which puts the patient at risk for water intoxication.

Maternal hypotension results from Syntocin infusion, not hypertension.

If the patient already has immunity (IgG positive) and if maternal rubella infection is the cause of the current symptoms (initial lgG and IgM negative, but IgM positive on a second sample 2-3 weeks later), amniocentesis may be required to confirm fetal infection.
Ultrasound may reveal growth limitation in late pregnancy, but a fetal congenital defect is rare when the infection begins at 10 weeks of pregnancy, and ultrasound testing at 12 weeks of pregnancy is unlikely to detect abnormalities, while it may discover one from 18-20 weeks. Given the well-known deleterious fetal effects of rubella infection in early pregnancy, gamma-globulin is unlikely to be beneficial at this point in the infective process, and pregnancy termination would certainly be considered by some individuals.
On the basis of prenatal rubella infection, this would not be recommended unless the infection was shown to have occurred.

The NICE guidelines on Hypertension in pregnancy define blood pressure in pregnancy as follows:
Mild hypertension: DBP=90-99 mmHg, SBP=140-149 mmHg. Moderate hypertension: DBP=100-109 mmHg, SBP=150-159 mmHg.
Severe hypertension: DBP=110 mmHg or greater, SBP=160 mmHg or greater.

Normal position of the foetus in relationship to the mother is always a longitudinal lie and a cephalic presentation. Transverse lie means that the baby is sideways. The foetus lies transverse till 26-28th week of gestation, after which it usually changes its position from transverse to a longitudinal lie with head down. A transverse lie can occur in conditions like grand multiparity, preterm foetus, placenta previa and pelvic contraction.

Analysis of presentation shows the patient has developed hyperemesis gravidarum.
She is in early shock, presented as sinus tachycardia and hypotension, with ketonuria and requires immediate fluid resuscitation and anti-emetics. The first line fluid of choice is administration of normal saline 0.9%, and should avoid giving dextrose containing fluids as they can precipitate encephalopathy and worsens hyponatremia.

The most appropriate management of a pregnant patient in this situation is administration of metoclopramide as the first line and Ondansetron as second line antiemetic, which are Australian category A and B1 drugs respectively. The following also should be considered and monitored for:
1. More refractory vomiting.
2. Failure to improve.
3. Recurrent hospital admissions.

Steroids like prednisolone are third line medications which are used in resistant cases of hyperemesis gravidarum after proper consultation.

Routine ultrasonography at around 18-22 weeks gestation has become the standard of care in many communities. Acceptance is based on many factors, including patient preference, medical-legal pressure, and the perceived benefit by physicians. However, rigorous testing has found little scientific benefit for, or harm from, routine screening ultrasonography.

If a pregnant woman develops primary herpes simplex infection after 30 weeks gestation, her risk for transmission of herpes simplex virus to the neonate leading to neonatal infection increases significantly.
Below mentioned are the most common risk factors resulting in intrapartum herpes simplex infection of the baby:
– Premature labor
– Premature rupture of membrane
-Primary herpes simplex infection near the time of delivery
– Multiple lesions in the genital area
The most appropriate management for such case includes:
– Checking for herpes simplex infection with PCR testing (cervical swab)
– Prophylactic antiviral therapy of the mother from 36th week until delivery
– Cesarean section delivery

In the case above mentioned, it is better to start antiviral therapy immediately and consider cesarean section to minimize the risk of vertical transmission of infection to the neonate.

Preeclampsia prevention
Preeclampsia is defined as a new-onset hypertension along with other features like proteinuria &/or end-organ damage at >20 weeks of gestation.
Patients with the following histories are at high risk for preeclampsia:
– Those with prior history of preeclampsia
– Those with chronic kidney disease
– Those with chronic hypertension
– Those with diabetes mellitus
– Multiple gestation
– Autoimmune disease
Patients belonging in the following criteria are at moderate risk for preeclampsia:
– Obesity
– Advanced maternal age
– Nulliparity

Preeclampsia is considered as the leading cause for maternal and fetal morbidity and mortality. This is due to its increased risk for complications such as stroke, placental abruption and disseminated intravascular coagulation. It is most likely caused due to abnormal vasoconstriction and increased platelet aggregation, which thereby results in placental infarction and ischemia. The condition can be effectively prevented by the administration of low-doses of aspirin at 12 weeks of gestation.

Patients with predisposing factors, such as chronic kidney disease, chronic hypertension and a history of preeclampsia, particularly with severe features or at <37 weeks gestation as in this patient, are at higher risk for developing preeclampsia.
In high risk patients, the only therapy proven to decrease the risk of preeclampsia is a daily administration of low-dose aspirin, as it inhibits platelet aggregation and helps in preventing placental ischemia. Treatment is initiated at 12 – 28 weeks of gestation, optimally before 16 weeks and is continued till delivery.

Betamethasone is a drug used to accelerate fetal lung maturity in patients who are prone to imminent risk of preterm delivery before 37 weeks of gestation. In this case, if the patient develops pre-eclampsia requiring an urgent preterm delivery betamethasone will be indicated.

High-doses (4 mg) of folic acid is indicated in patients with high risk for a fetus with neural tube defects, as in those who have a history of any prior pregnancies affected or those patients who use any folate antagonist medications. In the given case patient is at average risk and requires only a regular dose of 0.4 mg which is found in most prenatal vitamins.

Intramuscular hydroxyprogesterone is indicated in pregnant patients with prior spontaneous preterm delivery due to preterm prelabor rupture of membranes, preterm labor, etc to decrease the possible risk for any recurrence. In patients who underwent preterm delivery due to other indications like preeclampsia with severe features, fetal growth restriction, etc it is not indicated.

Vaginal progesterone is administered to decrease the risk of preterm delivery in patients diagnosed with a shortened cervix, which is usually identified incidentally on anatomy ultrasound scan done between 16 and 24 weeks of gestation. This patient is currently at her 14 weeks, so this is not advisable.

Patients at high risk for pre-eclampsia, like those with preeclampsia in a prior pregnancy, are advised to start taking a daily low-dose aspirin as prophylaxis for prevention of pre-eclampsia during pregnancy.

There is a high risk of developing HELLP syndrome in pre-eclamptic patients. Considering that she is complaining of right upper quadrant pain, a LFT should be done immediately.

Tamoxifen and Raloxifene are drugs which acts as selective estrogen receptor modulators.
Their mechanisms of action are competitive inhibitor of estrogen binding and mixed agonist/antagonist action respectively.
Commonly indicated in prevention of breast cancer in high-risk patients. Tamoxifen as adjuvant treatment of breast cancer and Raloxifene in postmenopausal osteoporosis.
Adverse effects include:
– Hot flashes
– Venous thromboembolism
– Endometrial hyperplasia & carcinoma (tamoxifen only)
– Uterine sarcoma (tamoxifen only)
Adjuvant endocrine therapy is commonly used option for treatment of nonmetastatic, hormone-receptor-positive breast cancer; and the most commonly used endocrine agents include tamoxifen, aromatase inhibitors, and ovarian suppression via GnRH agonists or surgery.

Tamoxifen is a selective estrogen receptor modulator which is an estrogen receptor antagonist in the breast.  It is the most preferred adjuvant treatment for pre-menopausal women at low risk of breast cancer recurrence.  Tamoxifen is also a second-line endocrine adjuvant agent for postmenopausal women who cannot use aromatase inhibitor therapy due to intolerable side effects.
Tamoxifen acts as an estrogen agonist in the uterus and stimulates excessive proliferation of endometrium. Therefore, tamoxifen use is associated with endometrial polyps in premenopausal women, and endometrial hyperplasia and cancer in postmenopausal women. These effects will continue throughout the duration of therapy and resolves once the treatment is discontinued. Even with all these possible complications, benefits of tamoxifen to improve the survival from breast cancer outweighs the risk of endometrial cancer.

In postmenopausal women, tamoxifen has some estrogen-like activity on the bone, which can increase bone mineral density and thereby reduce the incidence of osteoporosis significantly.  However, tamoxifen is generally not a first-line agent for osteoporosis in treatment due to the marked risk of endometrial cancer.

Dysplasia of the cervical transformation zone is typically caused due to chronic infection by human papillomavirus, and tamoxifen has no known effects on the cervix.

Tamoxifen is not associated with any increased risk for adenomyosis, which is characterised by ectopic endometrial tissue in the myometrium.

Intimal thickening of the coronary arteries is a precursor lesion for atherosclerosis. Tamoxifen helps to decrease blood cholesterol level and thereby protect against coronary artery disease.

Tamoxifen is an estrogen antagonist on breast tissue and is used in the treatment and prevention of breast cancer, but it also acts as an estrogen agonist in the uterus and increases the risk of development of endometrial polyps, hyperplasia, and cancer.

Cases with spontaneous rupture of membrane before the onset of labour, prior to 37 weeks of gestation is defined as preterm premature rupture of membranes(PPROM). It complicates almost 2-4% of all singleton and 7- 20% of twin pregnancies and is commonly associated with more than 60% of all preterm births.

Management of PPROM In the absence of chorioamnionitis, depends on the gestational age. That is in cases of PPROM before 23 weeks, labor may be induced or the patient be sent home for bed rest and is asked to wait until any signs of spontaneous delivery to start. Between 23 and 34 + 0/7 weeks, the patient should be transferred to a tertiary hospital and be admitted there as it is very important to administer systemic corticosteroids, for the fetal lung to attain maturity. It is also mandatory the patient gets adequate bed rest, cervical and vaginal swabs for microscopy and culture, along with prophylactic antibiotics for prevention of chorioamnionitis.
NOTE –  regardless of the gestational age, chorioamnionitis is said to be an absolute indication for the termination of pregnancy.

In the given case, patient is currently in her 28th week of gestation, so she should be immediately transferred to a tertiary hospital and given systemic steroids to promote fetal lung maturation in case preterm delivery ensues.

Cholestasis of pregnancy is associated with increased fetal morbidity and mortality and should be treated actively. The significance attached to pruritus in pregnancy is often minimal, but it is a cardinal symptom of cholestasis of pregnancy, which may have no other clinical features.

The Australasian Diabetes in Pregnancy Society recommends a 50 or 75 g glucose challenge at 26–28 weeks in all pregnant women. An OGTT should be performed if the test result is abnormal: 1 hour values after a 50 or 75 g glucose challenge exceeding 7.8 or 8.0 mmol/L respectively.

If a woman has had gestational diabetes, a repeat OGTT is recommended at 6–8 weeks and 12 weeks after delivery. If the results are normal, repeat testing is recommended between 1 and 3 years depending on the clinical circumstances.

This question is about the differential diagnoses that should be considered if a patient presents with postpartum fever. The work-up for such patients would usually involve vaginal swabs, midstream urine culture and sensitivity and an ultrasound scan of the wound to look for any presence of a haematoma. LSCS is a major surgery and one common cause of puerperal fever would be surgical site infection. It is not surprising that women who deliver via LSCS are at higher risk of developing post-partum fever compared to those who deliver vaginally. Other common causes include endometritis and UTI. Ultrasound examination of the pelvic deep venous system and the legs would also be done to look for any thrombosis. Deep vein thrombosis can occur due to immobility, however it is unlikely to present with fever.

Incidental thrombocytopenia of pregnancy is the most common cause of thrombocytopenia in an otherwise uncomplicated pregnancy. The platelet count finding in this case is of little concern unless it falls below 50×109/L.

Immune thrombocytopenia is a less common cause of thrombocytopenia in pregnancy. The anti-platelet antibodies cam cross the placenta and pose a problem both to the mother and the foetus. Profound thrombocytopenia in the baby is a common finding of this condition.

Thrombocytopenia can occur in patients with severe pre-eclampsia. However, it is usually seen concurrent with other signs of severe disease.

Maternal antibodies that target the baby’s platelets can rarely cause thrombocytopenia in the mother. Instead, it can lead to severe coagulation and bleeding complications in the baby as a result of profound thrombocytopenia.

Systemic lupus erythematosus is unlikely to explain the thrombocytopenia in this patient.

Asherman syndrome (intrauterine adhesions or intrauterine synechiae) occurs when scar tissue forms inside the uterus and/or the cervix. These adhesions occur after surgery of the uterus or after a dilatation and curettage.

Patients with Asherman syndrome may have light or absent menstrual periods (amenorrhea). Some have normal periods based on the surface area of the cavity that is affected. Others have no periods but have severe dysmenorrhea (pain with menstruation).

Although two-dimensional sonography may suggest adhesive disease, Asherman syndrome is more often evaluated initially with saline sonography or hysterosalpingography to demonstrate the adhesions.

The given case can be diagnosed as round ligament pain, which is common during pregnancy. This happens as a result to the stretching of round ligament in pelvis to occupy the growing uterus. The round ligament pain usually gets worse with movements or straining and will be relieved by rest or warm application.

As the abdominal examination of patient is unremarkable, conditions like ovarian cyst rupture, ectopic pregnancy and intestinal obstruction are a very unlikely to be the diagnosis.

Small teeth with faulty enamel is more associated with fetal alcohol syndrome (FAS).

In FAS, the most common orofacial changes are small eyelid fissures , flat facies, maxillary hypoplasia, short nose, long and hypoplastic nasal filter, and thin upper lip. The unique facial appearance of FAS patients is the result of changes in 4 areas: short palpebral fissures, flat nasal bridge with an upturned nasal tip, hypoplastic philtrum with a thin upper vermillion border, and a flat midface. Other facial anomalies include micrognathia, occasional cleft lip and/or palate and small teeth with defective enamel.

Breakthrough bleeding, breast tenderness, nausea, bloating, amenorrhea, hypertension, venous thromboembolic disease, increased risk of cervical cancer with decreased risk of ovarian & endometrial cancer, liver disorders like hepatic adenoma and increase in triglycerides due to estrogen component are the common side effects & risks of using combination oral contraceptives.

Patient in the given case mentioned symptoms of primary dysmenorrhea, which is recurrent lower abdominal pain associated with menstruation. Combination estrogen-progestin oral contraceptive pills (OCPs) are considered as the first-line treatment for dysmenorrhea in sexually active patients as OCPs help to reduce pain by thinning the endometrial lining, reducing prostaglandin release and by decreasing uterine contractions.
Nausea, bloating and breast tenderness, are considered as the early side effects of OCPs and will usually improve with continued use. The most common side effect is breakthrough bleeding which is usually associated with lower estrogen doses and other adverse effects caused by the pills include hypertension, increased risk of cervical cancer and venous thromboembolism. Although common perception considers weight gain as a side effect, several studies have shown that no significant weight gain is associated with OCPs, particularly with low-dose formulations.  Considering this, the patient should be reassured that her weight gain is not associated with regular use of OCPs.

In patients who are not sexually active, nonsteroidal anti-inflammatory drugs are considered as the first-line treatment for primary dysmenorrhea. As stopping contraception will increase this Patient’s risk of unintended pregnancy this is not advisable to her.

Switching the patient to a copper intrauterine device (IUD) will decrease systemic side effects, but as its inflammatory reaction in the uterus may increase pain symptoms, copper IUD is not recommended for patients with dysmenorrhea.

As Medroxyprogesterone will increase body fat and decrease lean muscle mass resulting in weight gain is not a good option for this patient. Also medroxyprogesterone due to its risk of significant loss of bone mineral density, is not recommended for adolescents or young women. So it can be used in this age group only if other options are unacceptable.

Presence of estrogen component is the main reason behind the side effects of combination OCPs. Progesterone-only pills have relatively fewer side effects but as they do not inhibit ovulation, they are less effective for treating dysmenorrhea and for contraception.

Combination oral contraceptive pills are the first-line therapy for primary dysmenorrhea in sexually active patients.  Its side effects include breakthrough bleeding, hypertension, and increased risk of venous thromboembolism. Researches proves that weight gain is usually not an adverse effect of OCPs.

This patient has developed deep vein thrombosis during pregnancy and required anti-coagulation as part of treatment for up to 3-6 months. Enoxaparin, which is a low molecular weight heparin, is preferred over heparin due to the once or twice a day therapeutic dosing. Also monitoring of aPTT is not required in this case.

There is an association between Enoxaparin and an increased risk for epidural hematoma in women receiving epidural anaesthesia during labour. Considering that the patient mentioned is expected to go for delivery in 4 weeks and the possibility of her needing an epidural anaesthesia or general anaesthesia in case of undergoing a cesarean section, enoxaparin should be switched to unfractionated heparin, four weeks prior to the anticipated delivery. This is because of the fact that heparin can be antidoted with protamine sulphate.

The next best line of management is immediate delivery via Caesarean section ( C section).

This is because of the change in cardiotocography (CTG). The pattern became much more severe with a virtual lack of short-term variability and prolonged decelerations. These changes indicate the necessity for an immediate C section as the cervix is not fully dilated.

As immediate delivery is indicated, another pH assessment is unnecessary as it would delay delivery and increase the likelihood of fetal hypoxia.

Delivery by ventose, in a primigravida where the cervix is only 8cm dilated is not indicated as it would allow the labour to proceed or augmenting with Syntocinon.

Hegar’s sign: softening of womb (uterus) due to its increased blood supply, perceptible on gentle finger pressure on the neck (cervix). This is one of the confirmatory signs of pregnancy and is usually obvious by the 16th week.

This patient is towards the end of the first stage of labour and is having complications. Labour is divided into 3 stages. The first stage begins at regular uterine contractions and ends with complete cervical dilatation at 10 cm. It has a latent phase and an active phase- The active phase is usually considered to have begun when cervical dilatation reaches 4 cm. So this patient is in the active phase of the first stag- The second stage begins with complete cervical dilatation and ends with the delivery of the foetus. The third stage of labour is the period between the delivery of the foetus and the delivery of the placenta and fetal membranes.

This patient’s contractions seem adequate and yet the fetal heart tone with baseline 80/min and absent variability suggests fetal distress. This is category III of the fetal heart rate pattern because the baseline rate is < 110/min with absent variability. It is usually predictive of abnormal acid-base status. The recommended actions are maternal position change and oxygen administration, discontinuation of labour stimulus such as oxytocin, treatment of possible underlying conditions, and expedited delivery.
→ Magnesium sulphate infusion is mainly used to prevent eclamptic seizures and despite no evidence of its effectiveness as a tocolytic agent, it is used sometimes to reduce risks of preterm birth.
→ Fetal scalp pH monitoring would help determine if there is indeed an acidosis and should be done before deciding whether a Caesarean section is necessary, but maternal position change and oxygen administration should be done first.
→ Ultrasonography may be used for preinduction cervical length measurement or if the active stage has already started- It is considered more accurate than digital pelvic exam in the assessment of fetal descent; however, at this point maternal position change and oxygen administration should be done first.
→ Immediate Caesarean section would be done if fetal scalp pH monitoring revealed a pH < 7.20. At this point, the best next step is maternal position change and oxygen administration.