Fetal production of immunoglobulin begins early on at about 10 weeks gestation with the production of IgM antibodies. Maternal IgG, which is a key component of fetal immunity is passed on to the foetus through the placenta from 12 weeks of gestation. Secretory IgA is not produced until after birth, through breast milk.

The 1st stage of wound healing is haemostasis. Even in incised wounds a small haematoma forms. Here the clotting cascade is activated by tissue factor and endothelial cells resulting in activation of platelets. This results in platelet aggregation and the laying down of a fibrin mesh that is cross linked and holds the platelets in place.
Wound healing is typically divided into phases:
1. Haemostasis Phase
2. Inflammatory phase
3. Proliferation phase
4. Remodelling phase

Woman in the given case is taking a full bottle of Whisky every day. As per standards, a small glass of Whisky (1.5 Oz) is equivalent of a standard drink and a bottle definitely exceeds 12 standard drinks. This makes her fetus at significant risk for fetal alcohol syndrome (FAS) which is associated with many congenital malformations. Low-set ears, midfacial hypoplasia, elongated philtrum, upturned nose and microcephaly along with skeletal and cardiac malformations are the congenital malformations commonly associated with fetal alcohol syndrome.

Health risks of benzodiazepines during pregnancy has not been clearly established, but there are inconsistent reports of teratogenic effects associated with fetal exposure to benzodiazepines. Neonatal abstinence syndrome of delayed onset can be associated with regular use of benzodiazepine in pregnancy.

Use of Amphetamine in controlled doses during pregnancy is unlikely to pose a substantial teratogenic risk, but a range of obstetric complications such as reduced birth weight and many these outcomes which are not specific to amphetamines but influenced by use of other drug and lifestyle factors in addition to amphetamine are found commonly among women who use it during pregnancy. Exposure to amphetamines in utero may influence prenatal brain development, but the nature of this influence and its potential clinical significance are not well established.

3,4- methylenedioxymetham phetamine(MOMA), which is an amphetamine derivative and commonly known as ecstasy, have existing evidences suggesting that its use during first trimester poses a potential teratogenic risk. So it is strongly recommended to avoided the use of ecstasy during 2-8 weeks post conception or between weeks four to ten after last menstrual period as these are the considered periods of organogenesis.

Role of cocaine in congenital malformations is controversial as cases reported of malformations caused by cocaine are extremely rare. However, it may lead to fetal intracranial haemorrhage leading to a devastating outcome.

Opiate addictions carry a significant risk for several perinatal complications, but it has no proven association with congenital malformation.

During fertilization, a sperm must first fuse with the plasma membrane and then penetrate the female egg cell to fertilize it. Fusing to the egg cell usually causes little problem, whereas penetrating through the egg’s hard shell or extracellular matrix can be more difficult. Therefore, sperm cells go through a process known as the acrosome reaction, which is the reaction that occurs in the acrosome of the sperm as it approaches the egg. The acrosome is a cap-like structure over the anterior half of the sperm’s head. Upon penetration, if all is normally occurring, the process of egg-activation occurs, and the oocyte is said to have become activated. This is thought to be induced by a specific protein phospholipase c zeta. It undergoes its secondary meiotic division, and the two haploid nuclei (paternal and maternal) fuse to form a zygote. To prevent polyspermy and minimize the possibility of producing a triploid zygote, several changes to the egg’s cell membranes render them impenetrable shortly after the first sperm enters the egg.

A fundal height measurement is typically done to determine if a baby is small for its gestational age. The measurement is generally defined as the distance in centimetres from the pubic bone to the top of the uterus. The expectation is that after week 24 of pregnancy the fundal height for a normally growing baby will match the number of weeks of pregnancy — plus or minus 2 centimetres.

A fundal height that measures smaller or larger than expected — or increases more or less quickly than expected — could indicate:
– Slow fetal growth (intrauterine growth restriction)
– A multiple pregnancy
– A significantly larger than average baby (fetal macrosomia)
– Too little amniotic fluid (oligohydramnios)
– Too much amniotic fluid (polyhydramnios).

The arcuate line is a smooth rounded border on the internal surface of the ilium just inferior to the iliac fossa. It forms the boundary of the pelvic inlet.

According to the WHO, active management of the third stage of labour has been shown to decrease the risk of postpartum haemorrhage in vaginal births worldwide. Per the guidelines from the International Federation of Gynaecologists and Obstetricians (FIGO), the active management of the third stage is summarised as follows:
1. The administration of a uterotonic (oxytocin, ergometrine or misoprostol), within one minute of fetal delivery,
2.Controlled cord traction with manual support to the uterus until placental delivery
3. Fundal massage immediately after placental delivery.

The correct answer is Obstetric Cholestasis.
The characteristics (elevated bile acids, conjugated bilirubin, and alkaline phosphatase (ALP) levels) are typical with obstetric cholestasis, which affects roughly 3-4 percent of pregnant women in Australia. Obstetric cholestasis is diagnosed when otherwise unexplained pruritus occurs in pregnancy and abnormal liver function tests (LFTs) and/or raised bile acids occur in the pregnant woman and both resolve after delivery. Pruritus that involves the palms and soles of the feet is particularly suggestive.
Liver function tests and bile acid levels measurements are used to validate this diagnosis.
All of the other diagnoses are theoretically possible, but unlikely.
On liver function tests, hepatitis A and acute fatty liver of pregnancy (which is frequently associated with severe vomiting in late pregnancy) usually show substantially worse hepatocellular damage.
Pre-eclampsia is connected with hypertension and proteinuria (along with changes in renal function and, in certain cases, thrombocytopenia), while cholelithiasis is associated with obstructive jaundice and pale stools due to a stone in the CBD.

The period from attaining a complete cervical dilation of 10 cm to fetal delivery is considered as the second stage of labor. In the given case patient have achieved an excellent fetal descent to +3 due to her average-sized infant of 3.4 kg, suitable pelvis (no fetal molding or caput, suggesting no resistance against the bony maternal pelvis), and a favorable fetal position of left occiput anterior. 
But with no further fetal descent the patient fulfills the following criterias suggestive of second-stage arrest like:
≥3 hours of pushing in a primigravida without an epidural or ≥4 hours pushing with an epidural, as in this patient
OR
≥2 hours of pushing in a multigravida without an epidural or ≥3 hours pushing with an epidural.

As continued pushing without any effect will lead to complications like postpartum hemorrhage, limiting the chances of spontaneous vaginal delivery, it is better to manage this case by operative vaginal delivery procedures like vacuum-assisted delivery, to expedite delivery. maternal exhaustion, fetal distress, and maternal conditions like hypertrophic cardiomyopathy, in which the Valsalva maneuver is not recommended are the other indications for performing an operative vaginal delivery.

Fundal pressure is the technique were external pressure is applied to the most cephalad portion of the uterus, were the applied force is directed toward the maternal pelvis. The maneuver was not found to be useful in improving the rate of spontaneous vaginal deliveries.

Epidurals will not arrest or affect spontaneous vaginal delivery rates, instead they just lengthen the second stage of labor. Also an appropriate analgesia is a prerequisite to use in operative vaginal delivery.

Manual rotation of an infant to a breech presentation for breech vaginal delivery is called as internal podalic version. It is contraindicated in singleton deliveries due to the high risk associated with breech vaginal delivery in regards to neonatal mortality and morbidity.

The ideal fetal head position in vaginal delivery is occiput anterior (OA) as the flexed head in this provides a smaller diameter and facilitates the cardinal movements of labor. The occiput posterior (OP) position, in contrast to OA, presents with a larger-diameter head due to the deflexed position. So the chance for spontaneous vaginal delivery will be decreased if fetal head is rotated to OP position.

A lack of fetal descent after ≥4 hours of pushing in a primigravida with an epidural (≥3 hours without) or ≥3 hours in a multigravida with an epidural (≥2 hours without) is defined as second stage arrest of labor.  The condition is effectively managed with operative vaginal delivery procedures like vacuum-assisted delivery. Other common indications for operative vaginal delivery are maternal exhaustion, fetal distress, and maternal conditions where the Valsalva maneuver is not recommended.

According to the RCOG greentop guidelines, a women who have underdone chemotherapy for GTD are advised not to conceive for 1 years after completion of the chemotherapy.