9.5 Routine Antenatal Care, Labour & Obstetric Emergencies
Key Takeaways
Gestational diabetes is diagnosed by a 75 g OGTT at 24–28 weeks with a fasting glucose of 5.6 mmol/L or more or a 2-hour glucose of 7.8 mmol/L or more (NICE NG3).
Rhesus D-negative women without anti-D antibodies are offered routine antenatal anti-D prophylaxis in the third trimester, usually from 28 weeks (NICE TA156).
Shoulder dystocia is managed by calling for help and performing McRoberts manoeuvre with suprapubic pressure; fundal pressure must be avoided.
In cord prolapse, avoid handling the cord, relieve compression by elevating the presenting part (knee-chest position or filling the bladder) and arrange immediate delivery.
Under the Abortion Act 1967, termination is lawful up to 24 weeks on health grounds, and beyond 24 weeks only for serious maternal risk or a substantial risk of serious fetal abnormality.
Routine Antenatal Care, Labour & Obstetric Emergencies
Routine Antenatal Care (NICE NG201)
- Booking ideally by 10 weeks: history, BMI, blood pressure, urine culture for asymptomatic bacteriuria, blood group and antibodies, full blood count, and risk assessment (pre-eclampsia, gestational diabetes, VTE, mental health, domestic abuse).
- Supplements: folic acid 400 micrograms daily until 12 weeks (5 mg if higher risk of neural tube defects: previous affected pregnancy, diabetes, BMI 30 or more, antiepileptic drugs, sickle cell disease); vitamin D 10 micrograms daily.
- Screening: infectious diseases (HIV, hepatitis B, syphilis), sickle cell and thalassaemia, the dating scan (10+0 to 13+6 weeks), the combined test for Down's, Edwards' and Patau's syndromes (nuchal translucency, PAPP-A and hCG, 11+2 to 14+1 weeks) or the quadruple test (from 14+2 weeks), with non-invasive prenatal testing offered after a higher-chance result, and the anomaly scan (18+0 to 20+6 weeks).
- Vaccines in pregnancy: pertussis (from 16 weeks, ideally around 20–32 weeks), influenza in season, RSV from 28 weeks, and COVID-19.
- Rhesus D-negative women: routine antenatal anti-D prophylaxis in the third trimester (usually starting at 28 weeks); cell-free fetal DNA testing of the baby's RhD group avoids anti-D when the fetus is RhD-negative.
- Aspirin 75–150 mg from 12 weeks for women at high risk of pre-eclampsia (see section 9.2).
Gestational Diabetes (NICE NG3)
Risk factors (offer a 75 g OGTT at 24–28 weeks): BMI above 30, previous baby weighing 4.5 kg or more, previous gestational diabetes (test early), first-degree relative with diabetes, and family origin with a high prevalence of diabetes.
- Diagnosis: fasting glucose 5.6 mmol/L or more, or 2-hour glucose 7.8 mmol/L or more.
- Management: diet and exercise; metformin if targets are not met within 1–2 weeks; insulin if fasting glucose is 7.0 mmol/L or more at diagnosis (or 6.0–6.9 with complications such as macrosomia). Targets: fasting 5.3, 1 hour after meals 7.8, or 2 hours 6.4 mmol/L.
- After birth: stop treatment, check fasting glucose at 6–13 weeks (or HbA1c after 13 weeks), then annual HbA1c because of the high lifetime risk of type 2 diabetes.
Labour
| Stage | Definition | Key Points |
|---|---|---|
| First stage | Onset of regular contractions to full dilatation (latent phase to 4 cm, then active phase) | Suspect delay if less than 2 cm dilatation in 4 hours in the active phase |
| Second stage | Full dilatation to birth of the baby | Delay if birth is not imminent after about 2 hours of active pushing in a first labour (1 hour if parous); consider instrumental birth |
| Third stage | Birth of the baby to delivery of the placenta | Active management (oxytocin 10 IU IM, controlled cord traction) reduces PPH; prolonged if more than 30 minutes (active) or 60 minutes (physiological) |
Induction of labour (NICE NG207): offer induction from 41+0 weeks for uncomplicated pregnancies (a membrane sweep may be offered first). Methods include vaginal prostaglandin (dinoprostone), oral misoprostol, mechanical balloon catheters, amniotomy and oxytocin. The Bishop score assesses cervical favourability; watch for uterine hyperstimulation (stop prostaglandin or oxytocin, consider tocolysis with terbutaline).
Intrapartum fetal monitoring: a normal baseline fetal heart rate is 110–160 beats/min with variability of 5 beats/min or more. Persistent late decelerations, a rising baseline, reduced variability or prolonged bradycardia require escalation and expedited birth.
Rupture of Membranes & Preterm Labour
- Term prelabour rupture of membranes: offer induction or expectant management for up to 24 hours. Give intrapartum antibiotics if group B streptococcus (GBS) is known.
- Preterm prelabour rupture of membranes (PPROM): confirm with speculum examination; give oral erythromycin for 10 days (or until labour), antenatal corticosteroids, and monitor for chorioamnionitis (fever, tachycardia, tender uterus, offensive discharge), which requires delivery and IV antibiotics.
- Preterm labour: corticosteroids (for example two doses of IM betamethasone 24 hours apart) between 24 and 34+6 weeks to improve neonatal lung maturity; magnesium sulfate for fetal neuroprotection before 30 weeks; tocolysis (nifedipine or atosiban) to allow steroids and transfer to a unit with neonatal intensive care.
- Intrapartum benzylpenicillin is offered for GBS carriage, previous baby with GBS disease, preterm labour, or intrapartum fever.
Obstetric Emergencies
Shoulder Dystocia
The anterior shoulder impacts behind the symphysis pubis after the head is delivered (the head retracts against the perineum, the "turtle sign"). Risks: macrosomia, diabetes, maternal obesity, previous shoulder dystocia, instrumental birth.
- Call for help (senior obstetrician, midwife, neonatologist) and note the time.
- McRoberts manoeuvre (hyperflexing the mother's legs onto her abdomen) with suprapubic pressure: resolves most cases.
- Internal manoeuvres (delivery of the posterior arm, rotational manoeuvres) or all-fours position.
- Avoid excessive or downward traction on the head and never use fundal pressure (risk of uterine rupture and brachial plexus injury). Complications: Erb's palsy (C5–C6), fetal hypoxia, PPH and perineal tears.
Umbilical Cord Prolapse
The cord descends below the presenting part after membrane rupture (risks: malpresentation, polyhydramnios, artificial rupture with a high head).
- Call for help; avoid handling the cord (it causes vasospasm); keep it moist and inside the vagina if possible.
- Relieve compression: push the presenting part up manually, place the mother in the knee-chest or left lateral head-down position, or fill the bladder with about 500 mL of saline.
- Immediate delivery: category 1 caesarean section, or instrumental birth if fully dilated and birth is imminent.
Maternal Collapse & Other Emergencies
- Maternal collapse: follow ABCDE and ALS with manual left uterine displacement to relieve aortocaval compression. If there is no return of circulation after 4 minutes in a woman beyond about 20 weeks, perform a resuscitative hysterotomy (perimortem caesarean section), aiming for delivery within 5 minutes. Causes include haemorrhage, thromboembolism, amniotic fluid embolism, sepsis, cardiac disease and eclampsia.
- Uterine rupture: mainly with a previous caesarean scar; abdominal pain, fetal heart abnormalities, loss of station, vaginal bleeding and shock; immediate laparotomy.
- Maternal sepsis: follow the Sepsis Six and NICE NG255 (pregnant or recently pregnant women); chorioamnionitis and endometritis are common sources.
Breech Presentation
Breech affects about 3–4% of babies at term. Offer external cephalic version (ECV) from 36 weeks in nulliparous and 37 weeks in multiparous women (success about 50%) unless contraindicated (for example recent antepartum haemorrhage, ruptured membranes, abnormal CTG or another indication for caesarean section). Planned caesarean section reduces perinatal risk compared with planned vaginal breech birth.
Termination of Pregnancy
- Abortion Act 1967 (as amended in 1990), England, Wales and Scotland: two registered doctors must agree in good faith that a legal ground applies (one doctor in an emergency). Up to 24 weeks: continuing the pregnancy would risk the woman's physical or mental health (or that of her existing children) more than termination. No time limit if termination is needed to prevent grave permanent injury or to save her life, or if there is a substantial risk of serious fetal abnormality. Northern Ireland has a separate legal framework.
- Early medical abortion (mifepristone followed by misoprostol) can be taken at home up to 9 weeks and 6 days in England, Scotland and Wales after a telemedicine or in-person consultation. Surgical options include vacuum aspiration and, later, dilatation and evacuation.
- Anti-D is offered to RhD-negative women having an abortion from 10+0 weeks (NICE NG140).
- Conscientious objection is permitted except in an emergency, but the doctor must ensure the patient can access another doctor without delay (GMC).
Other Pregnancy Complications
- Intrahepatic cholestasis of pregnancy: itching (especially palms and soles) without a rash in the third trimester, with raised bile acids and often raised transaminases. Exclude other liver disease. The risk of stillbirth rises with very high bile acids (100 micromol/L or more), so the RCOG (2022) advises planned birth timed by the peak bile acid level; ursodeoxycholic acid does not reduce adverse perinatal outcomes, and its benefit for itch is uncertain. Symptoms resolve after birth.
- Vasa praevia: fetal vessels run through the membranes over the cervix. Rupture of membranes causes painless bleeding with sudden fetal bradycardia (the blood is fetal), requiring emergency caesarean section. When diagnosed antenatally on ultrasound, planned caesarean section before labour is arranged.
- Multiple pregnancy: higher risks of pre-eclampsia, anaemia, preterm birth, growth problems and (in monochorionic twins) twin-to-twin transfusion syndrome; care is consultant-led with serial scans.
- Obesity in pregnancy (BMI 30 or more): 5 mg folic acid, screening for gestational diabetes, assessment for VTE prophylaxis and aspirin, and anaesthetic review.
A 32-year-old woman whose previous baby weighed 4.6 kg has a 75 g oral glucose tolerance test at 26 weeks. Fasting glucose is 5.8 mmol/L and the 2-hour value is 7.2 mmol/L. What is the correct interpretation and first step?
Gestational diabetes; diet, exercise and glucose self-monitoring
Pre-existing type 2 diabetes; start gliclazide 40 mg daily
Normal result; repeat the oral glucose tolerance test at 34 weeks
Gestational diabetes; start insulin immediately at diagnosis
During a vaginal birth, the baby's head delivers and then retracts against the perineum. The next contraction with gentle traction does not deliver the shoulders. After calling for help, what is the most appropriate next step?
Strong downward traction on the fetal head
Apply firm fundal pressure
Immediate symphysiotomy
McRoberts manoeuvre with suprapubic pressure
A woman at 39 weeks has spontaneous rupture of membranes and the midwife sees and feels the umbilical cord at the introitus. The fetal heart rate is 90 beats/min. What should be done while preparing for delivery?
Gently replace the cord into the uterus with a gloved hand
Knee-chest position and elevate the presenting part
Clamp and cut the cord to prevent fetal haemorrhage
Start an oxytocin infusion to speed up delivery of the baby
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