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Single Best Answer (SBA) Questions – Part One

Introduction This is a selection of single best answer (SBA) questions from across this book. This style of questions is increasingly favoured over the traditional multiple choice questions (MCQs) for examinations. The answers and accompanying explanations can be found in Answers to Single Best Answer (SBA) questions – part one. Questions Chapter 2 Q1 In which of the following scenarios can a woman be diagnosed as…

UK Medicolegal Issues

Introduction Health care practitioners’ priority is the provision of the highest standard of care within the constraints of the resources available to them: no obstetrician or gynaecologist goes to work with the intention of providing substandard care and causing harm to one’s patients. The nature of the practice of medicine, and obstetrics in particular, involves uncertainty. The majority of pregnancies are in healthy women who remain…

Practical Obstetrics and Gynaecology

General Advice This chapter is a practical guide to common clinical scenarios you are likely to encounter when working in obstetrics and gynaecology as a medical student or a junior doctor. Obstetrics and gynaecology is a unique specialty with its own nuances and quirks. Obstetrics in particular is the only specialty where you will care for two patients at once. Check what you don’t know, especially…

Neonatal Care

Introduction Good-quality neonatal care is extremely important and can have major implications for the rest of a baby’s life. Those born prematurely need skilled intensive support. Those born with presumed hypoxia need resuscitation, prompt assessment and appropriate subsequent care. The early neonatal period is often the time when congenital abnormalities become apparent – precise diagnosis and care can make a difference to the quality of life…

The Physiology of Pregnancy

Introduction Pregnancy is associated with substantial physiological changes. These primarily comprise adaptations that facilitate fetal growth and development as well as providing the woman with the resources required to carry the pregnancy to term and survive the process of labour. The changes are not proportional to the size of the fetus and, by the end of the first trimester, many systems are functioning at levels close…

Imaging in Obstetrics and Gynaecology

Introduction Imaging plays an important role in both obstetrics and gynaecology. Ultrasound is extremely valuable at all stages of pregnancy: early in pregnancy for viability and establishing gestation; mid-pregnancy to look for fetal abnormality; and later in pregnancy for growth, well-being, and presentation. Ultrasound is also very useful in gynaecology to assess both the uterus and the ovaries. Further information can be obtained with computed tomography…

Human Embryology

Introduction In obstetrics, it is common to use 280 days (40 weeks) from the first day of the last menstrual period (LMP) to estimate the delivery date of a full-term pregnancy. This period has also become a convenient, but inaccurate, description of the number of weeks of ‘pregnancy’. This is an obvious source of confusion, since embryologists refer to the number of gestational days (GD), that…

Global Maternal and Neonatal Health

Estimates of Global Maternal and Neonatal Mortality It is estimated that almost 300,000 women worldwide die each year from the complications of pregnancy and childbirth, with 99% of these deaths occurring in low-resource countries. Estimates from 2017 by the World Health Organization (WHO) and other partners show that two-thirds of all maternal deaths occur in sub-Saharan Africa alone and about one-fifth of all maternal deaths occur…

Neonatal Resuscitation

Physiology The fetus needs the umbilical cord and placenta for respiration. Within the first minute of life, the newborn infant has to adapt to breathing air. Various stimuli – such as hypoxia, cold air and physical contact – will encourage respiratory effort. Most newborn ‘resuscitation’ is assisting this normal transition process. The ‘healthy’ fetus will tolerate well brief periods of hypoxia (part of the normal birthing…

Stillbirth and Neonatal Mortality

Introduction The death of a baby and the loss of all the potential of a human life can be a devastating event for women, their partners, families and society. The grief and anguish is often life-changing. The human reactions to grief of disbelief, denial, negotiation and anger can all be seen by those caring for affected women and families. Care of women suffering such loss should…

Operative Birth

Introduction The term ‘operative birth’ is used to describe both instrumental vaginal delivery (also known as ‘operative vaginal delivery’ or ‘assisted vaginal birth’) and caesarean section. Operative deliveries are usually performed by obstetricians and account for a third or more of all births in most high-resource settings. Caesarean sections can be performed before the onset of labour as either elective (or scheduled) when planned, or pre-labour…

Obstetric Emergencies

Introduction Across the world, one woman dies every minute of every day from a complication of pregnancy. In high-resource settings, maternal death is rare, but the UK maternal death audit programme (MBRRACE-UK) identifies substandard care in around two-thirds of cases. Many obstetric emergencies are uncommon and can deteriorate quickly. There is an evidence base for multi-professional training that appears to be one of the most promising…

Malpresentation and Slow Labour

Introduction Labour is defined as the onset of regular uterine activity, cervical effacement and dilatation with descent of the presenting part. The duration of labour is variable and is influenced by factors including parity, gestation or whether the labour was spontaneous or induced. First labours on average last 8 hours and are unlikely to last over 18 hours. Second and subsequent labours last on average 5 hours and are…

Induction of Labour

Introduction Induction of labour is one of the most common obstetric interventions, occurring in approximately 20% of pregnancies in the United Kingdom. It is indicated in women for whom vaginal birth is planned when the risks of continuing the pregnancy are felt to be greater than the risks of induction of labour. Balancing these risks is often difficult, particularly at pre-term gestations; both fetal and maternal…

Monitoring of the Fetus in Labour

Introduction The purpose of monitoring the fetus in labour is to identify those who might be at increased risk of death or hypoxic injury so that delivery can be expedited and harm prevented. Fetal monitoring involves fetal heart rate (FHR) assessment, either by intermittent auscultation or by continuous electronic measurement (cardiotocography (CTG): ‘cardio’ meaning heart, ‘toco’ meaning labour). Intermittent auscultation of the fetal heart is appropriate…

Labour and Analgesia

Introduction Labour is a challenging time for mothers and their babies. The success of labour and the ability of the fetus to negotiate a journey through the maternal pelvis depends upon the successful interaction of three variables – the ‘power’ (contractions), ‘passen­ger’ (fetus) and ‘pelvis’ (bony pelvis and pelvic soft tissues). For women, this is often a life-changing event, with the experience that a woman has…

Multiple Pregnancy

Introduction The natural incidence of twinning has a large geographical variation, ranging from 54 in 1000 in Nigeria, 12 in 1000 in the United Kingdom, to 4 in 1000 in Japan. This difference is almost entirely due to variations in the rate of non-identical twins, while the incidence of identical twins remains remarkably constant at around 3 in 1000. However, immigration of ethnic groups with higher…

Pre-Term Birth

Introduction Pre-term birth is defined as birth before 37 weeks’ completed gestation. It occurs in around 10% of births and affects 15 million pregnancies worldwide annually. Almost one-third of pre-term births in the United Kingdom are iatrogenic (following deliberate medical intervention) when the risks of continuing the pregnancy, for either the mother or the baby, outweigh the risks of prematurity. Prematurity is the leading cause of…

Hypertension in Pregnancy

Definitions Hypertension Threshold values of ≥140 mmHg systolic or 90 mmHg diastolic blood pressure define hypertension in pregnancy ( Fig. 28.1 ), with blood pressure ≥160 mmHg systolic or ≥110 mmHg diastolic described as severe hypertension. Chronic hypertension Chronic hypertension is defined as: The presence of hypertension before 20 weeks’ gestation (in the absence of a hydatidiform mole) or Persistent hypertension beyond 6 weeks post-partum. Chronic hypertension may…

Fetal Growth and Surveillance

Introduction The focus of this chapter is on fetuses who appear to be small for their gestational age. These babies may simply be small—in other words, they are normal unborn babies who just happen to be at the lower end of a normal range (constitutionally or genetically small) or they may be small for a pathological reason. These latter fetuses are referred to as being affected…