If a baby loses more than 10% of its birth weight, it is necessary to refer the mother and baby to a midwife for assistance in increasing the baby’s weight.

Breastfeeding Problems and Their Management

Breastfeeding is a natural process, but it can come with its own set of challenges. Some of the minor problems that breastfeeding mothers may encounter include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These issues can be managed by seeking advice on proper positioning, trying breast massage, and using appropriate medication.

Mastitis is a more serious problem that affects around 1 in 10 breastfeeding women. It is characterized by symptoms such as fever, nipple fissure, and persistent pain. Treatment involves the use of antibiotics, such as flucloxacillin, for 10-14 days. Breastfeeding or expressing milk should continue during treatment to prevent complications such as breast abscess.

Breast engorgement is another common problem that causes breast pain in breastfeeding women. It occurs in the first few days after birth and affects both breasts. Hand expression of milk can help relieve the discomfort of engorgement. Raynaud’s disease of the nipple is a less common problem that causes nipple pain and blanching. Treatment involves minimizing exposure to cold, using heat packs, and avoiding caffeine and smoking.

If a breastfed baby loses more than 10% of their birth weight in the first week of life, it may be a sign of poor weight gain. This should prompt consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight should continue until weight gain is satisfactory.

A woman at 12 weeks gestation is seeking Down syndrome screening. Although her age increases the likelihood of her fetus having Down’s syndrome, it will not affect the initial screening process. The standard screening method involves an ultrasound to evaluate nuchal translucency and serum testing to measure levels of β-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein A (PAPP-A). This combined screening can also detect Edward’s (trisomy 18) and Patau (trisomy 13) syndromes. The triple test, which includes α-fetoprotein, unconjugated oestriol, and β-hCG, is conducted between 15-20 weeks gestation to assess for Down’s syndrome. The quadruple test is also an option for women who have missed the window for combined antenatal screening. A biophysical profile, which evaluates fetal wellbeing through ultrasound detection of heart rate, breathing, movement, tone, and amniotic fluid volume, is used to determine the need for rapid induction of labor.

NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A). The quadruple test is offered between 15-20 weeks for women who book later in pregnancy. Results are interpreted as either a ‘lower chance’ or ‘higher chance’ of chromosomal abnormalities. If a woman receives a ‘higher chance’ result, she may be offered a non-invasive prenatal screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities. Private companies offer NIPT screening from 10 weeks gestation.

PPH, which is the loss of 500ml or more from the genital tract within 24 hours of giving birth, is primarily caused by uterine atony. It can be classified as minor (500-1000ml) or major (>1000ml) and has a mortality rate of 6 deaths/million deliveries. The causes of PPH can be categorized into the ‘four T’s’: tone, tissue (retained placenta), trauma, and thrombin (coagulation abnormalities).

Understanding Postpartum Haemorrhage

Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.

In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.

Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.

Women with a history of gestational diabetes should be offered an OGTT immediately after booking and at 24-28 weeks to screen for gestational diabetes in subsequent pregnancies. No screening test is not recommended. OGTT at 24-28 weeks is the screening strategy for those with risk factors but no previous history of gestational diabetes.

Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.

Pregnancy Complications: Placental Abruption, Uterine Rupture, Placenta Previa, and Placenta Accreta

During pregnancy, there are several complications that can occur, including placental abruption, uterine rupture, placenta previa, and placenta accreta.

Placental abruption happens when part of the placenta separates prematurely from the uterus. Symptoms include abdominal or back pain, vaginal bleeding (although there may be no bleeding in concealed abruption), a hard abdomen, and eventually shock. Treatment involves hospitalization, resuscitation, and delivery of the baby.

Uterine rupture is rare and usually occurs during labor, especially in women who have had previous uterine surgery. Symptoms include abdominal pain and tenderness, vaginal bleeding, fetal heart rate deterioration, and hypovolemic shock. Emergency exploratory laparotomy with Caesarean section and fluid resuscitation is necessary.

Placenta previa occurs when the placenta attaches to the lower uterine segment and often presents with painless vaginal bleeding after the 28th week. However, severe pain is not a typical symptom. The location of the placenta can be determined through scans.

Placenta accreta happens when the placenta attaches to the myometrium instead of just the endometrium. This can lead to failure of the placenta to separate after delivery, resulting in significant postpartum bleeding.

1: The occiput posterior (OP) position during delivery is feasible, but it may result in a longer and more painful labor.
2: If labor progress is slow, augmentation should be considered.
3: The use of Kielland’s forceps is linked to the most favorable outcomes, but it requires specialized skills.
4: Typically, women in the OP position will feel the urge to push earlier than those in the occiput anterior (OA) position.

Labour is divided into three stages, with stage 2 being from full dilation to delivery of the fetus. This stage can be further divided into two categories: passive second stage, which occurs without pushing, and active second stage, which involves the process of maternal pushing. The active second stage is less painful than the first stage, as pushing can mask the pain. This stage typically lasts around one hour, but if it lasts longer than that, medical interventions such as Ventouse extraction, forceps delivery, or caesarean section may be necessary. Episiotomy, a surgical cut made in the perineum to widen the vaginal opening, may also be required during crowning. However, this stage is associated with transient fetal bradycardia, which is a temporary decrease in the fetal heart rate.

Category 2 caesarean sections are performed when there is a non-immediate life-threatening emergency concerning the mother or the baby. This may include an abnormality detected by cardiotocography that requires an emergency caesarean section within 75 minutes of the decision being made. It is not immediately life-threatening to either the mother or the baby.

Category 1 caesarean sections are performed in immediately life-threatening situations, such as haemodynamic instability of the mother.

Category 3 caesarean sections are not immediately life-threatening to the mother but are necessary for the non-immediate life-threatening condition of the baby, such as distress.

Category 4 caesarean sections are elective and may be chosen by the mother or recommended based on past medical history.

Caesarean Section: Types, Indications, and Risks

Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.

C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.

It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.

Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.

Pregnant women experiencing severe hyperemesis gravidarum before their dating scan should receive an early pregnancy ultrasound scan to detect abnormal trophoblastic disease, such as molar pregnancy or choriocarcinoma. Women with pre-existing diabetes or gestational diabetes are offered fetal growth scans every two weeks from 28 to 36 weeks’ gestation to monitor the baby’s growth and amniotic fluid levels. All pregnant women in the UK are offered a minimum of two antenatal scans, including the dating scan between 10+0 and 13+6 weeks’ gestation and the anomaly scan between 18+0 and 20+6 weeks’ gestation. The anomaly scan assesses the baby’s organs, growth, and placenta position, and can detect congenital abnormalities and small-for-gestational age babies. The first antenatal ultrasound scan can be offered as early as nine weeks’ gestation to confirm the pregnancy and determine the gestational age. The combined test, which includes nuchal translucency, PAPP-A, and hCG, can also be performed during the dating scan to assess the risk of Down syndrome.

The first step in managing chickenpox exposure during pregnancy is to confirm the patient’s immunity by checking her varicella-zoster antibodies. If the woman is unsure about her past exposure to chickenpox, this test will determine if she has antibodies to the virus. If the test confirms her immunity, no further action is necessary. Administering the varicella-zoster vaccine or IV immunoglobulin is not appropriate in this situation. Neglecting to check the patient’s immunity status can put her and her unborn child at risk.

Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral acyclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.

Differentiating between types of miscarriage: A case study

A patient presents with vaginal bleeding and cramping at 8 weeks gestation. An ultrasound shows a viable pregnancy with fetal cardiac activity and a gestational sac within the uterus. The cervical os is closed. What type of miscarriage is this?

Threatened miscarriage is the most likely diagnosis in this case. The patient can be reassured with precautions, as over 75% of pregnancies with threatened miscarriage do not abort. However, there is an increased risk of growth restriction and abnormal placentation in the third trimester.

Ectopic pregnancy can be ruled out as the ultrasound has established the gestational sac within the uterus, not within the adnexa. Septic miscarriage is also unlikely as the patient does not demonstrate signs of infection, such as fever, and the cervical os is closed.

A missed miscarriage can be ruled out as fetal cardiac activity was seen on ultrasound. In a complete miscarriage, the uterus would not have a gestational sac.

In conclusion, differentiating between types of miscarriage is important in determining appropriate management and counseling for patients. In this case, a diagnosis of threatened miscarriage allows for reassurance and monitoring of potential complications later in pregnancy.