Conditions

Question 1

What is pelvic organ prolapse?

Answer 1

Pelvic organ prolapse refers to the descent of pelvic organs into the vagina. Prolapse is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.

Question 2

What are the types of pelvic organ prolapse?

Answer 2

1. Cystocele
   Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele). Prolapse of both the bladder and the urethra is called a cystourethrocele.
2. Uterine Prolapse
   Uterine prolapse is where the uterus itself descends into the vagina.
   –Vault Prolapse
   Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina.
3. Enterocele
   Bulges of the upper posterior vaginal wall may contain loops of intestine from the pouch of douglas
4. Rectocele
   Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. Rectoceles are particularly associated with constipation. Women can develop faecal loading in the part of the rectum that has prolapsed into the vagina. Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina. Women may use their fingers to press the lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels.

Question 3

What are the risk factors for pelvic organ prolapse?

Answer 3

Pelvic organ prolapse is the result of weak and stretched muscles and ligaments. The factors that can contribute to this include:

-Multiple vaginal deliveries
-Instrumental, prolonged or traumatic delivery
-Advanced age and postmenopause status
-Obesity
-Chronic respiratory disease causing coughing
-Chronic constipation causing straining

Question 4

How does pelvic organ prolapse typically present?

Answer 4

Typical presenting symptoms are:

-A feeling of “something coming down” in the vagina
-A dragging or heavy sensation in the pelvis
-Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
-Bowel symptoms, such as constipation, incontinence and urgency
-Sexual dysfunction, such as pain, altered sensation and reduced enjoyment

Women may have identified a lump or mass in the vagina, and often will already be pushing it back up themselves. They may notice the prolapse will become worse on straining or bearing down.

Question 5

How is pelvic organ prolapse examined?

Answer 5

Ideally, the patient should empty their bladder and bowel before examination of a prolapse. When examining for pelvic organ prolapse, various positions may be attempted, including the dorsal and left lateral position.

A Sim’s speculum is a U-shaped, single-bladed speculum that can be used to support the anterior or posterior vaginal wall while the other vaginal walls are examined. It is held on the anterior wall to examine for a rectocele, and the posterior wall for a cystocele.

The women can be asked to cough or “bear down” to assess the full descent of the prolapse.

Question 6

How is a pelvic organ prolapse graded?

Answer 6

1st degree: The lowest part of the prolapse descends halfway down the vaginal axis to the introitus
2nd degree: The lowest part of the prolapse extends to the level of the introitus, and through the introitus on straining
3rd degree: The lowest part of the prolapse extends through the introitus and outside the vagina

Question 7

How is a uterine prolapse graded?

Answer 7

The severity of a uterine prolapse can be graded using the pelvic organ prolapse quantification (POP-Q) system:

Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina

A prolapse extending beyond the introitus can be referred to as uterine procidentia

Question 8

What are the three options for management of a pelvic organ prolapse?

Answer 8

1. Conservative management
2. Vaginal pessary
3. Surgery

Question 9

How might a pelvic organ prolapse be conservatively managed?

Answer 9

Conservative management is appropriate for women that are able to cope with mild symptoms, do not tolerate pessaries or are not suitable for surgery. Conservative management involves:

-Physiotherapy (pelvic floor exercises)
-Weight loss
-Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
-Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
-Vaginal oestrogen cream

Question 10

What are vaginal pessaries and what are the types?

Answer 10

Vaginal pessaries are inserted into the vagina to provide extra support to the pelvic organs. They can create a significant improvement in symptoms and can easily be removed and replaced if they cause any problems. There are many types of pessary:

-Ring pessaries are a ring shape, and sit around the cervix holding the uterus up
-Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
-Cube pessaries are a cube shape
-Donut pessaries consist of a thick ring, similar to a doughnut
-Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina.

Women often have to try a few types of pessary before finding the correct comfort and symptom relief. Pessaries should be removed and cleaned or changed periodically (e.g. every four months). They can cause vaginal irritation and erosion over time. Oestrogen cream helps protect the vaginal walls from irritation.

Question 11

What are the possible complications of pelvic organ prolapse surgery?

Answer 11

-Pain, bleeding, infection, DVT and risk of anaesthetic
-Damage to the bladder or bowel
-Recurrence of the prolapse
-Altered experience of sex

Question 12

What are the types of kidney stones?

Answer 12

Renal stones as also referred to as renal calculi, urolithiasis and nephrolithiasis. They are hard stones that form in the renal pelvis, where the urine collects before travelling down the ureters. They may be asymptomatic until they irritate or get stuck in the ureters. They might get stuck at any point along the ureters, but commonly at the vesico-ureteric junction.

Two key complications are:
1. Obstruction leading to acute kidney injury
2. Infection with obstructive pyelonephritis

Types
- Calcium-based stones are the most common type of kidney stone (about 80%). Having a raised serum calcium (hypercalcaemia) and a low urine output are key risk factors for calcium collecting into a stone. There are two types of calcium stones:
*Calcium oxalate (more common)
*Calcium phosphate

Other types of kidney stones include:
- Uric acid – these are not visible on x-ray
- Struvite – produced by bacteria, therefore, associated with infection
- Cystine – associated with cystinuria, an autosomal recessive disease

Question 13

What is a staghorn calculus?

Answer 13

A staghorn calculus is where the stone forms in the shape of the renal pelvis, giving it a similar appearance to the antlers of a deer stag. The body sits in the renal pelvis with horns extending into the renal calyces. They may be seen on plain x-ray films.

Most commonly, this occurs with stones made of struvite. In recurrent upper urinary tract infections, the bacteria can hydrolyse the urea in urine to ammonia, creating the solid struvite.

Question 14

What are the presenting features of renal stones?

Answer 14

Renal stones may be asymptomatic and never cause an issue.

Renal colic is the presenting complaint in symptomatic kidney stones. Renal colic is:
Unilateral loin to groin pain that can be excruciating (“worse than childbirth”)
Colicky (fluctuating in severity) as the stone moves and settles

Patients often move restlessly due to the pain.

There may also be:
Haematuria
Nausea or vomiting
Reduced urine output
Symptoms of sepsis, if infection is present

Question 15

How are kidney stones investigated?

Answer 15

1. Urine dipstick usually shows haematuria in cases of kidney stones. A normal urine dipstick does not exclude stones. Urine dipsticks are also helpful to exclude infection.
2. Blood tests help establish signs of infection and also kidney function. Checking the serum calcium helps identify hypercalcaemia that may have caused the kidney stone.
3. An abdominal x-ray can show calcium-based stones, but uric acid stones will not show up (they are radiolucent).
4. Non-contrast computer tomography (CT) of the kidneys, ureters and bladder (CT KUB) is the initial investigation of choice for diagnosing kidney stones. The NICE guidelines (2019) recommend a CT within 24 hours of the presentation.
5. Ultrasound of the kidneys, ureters and bladder (ultrasound KUB) is a less preferred alternative to CT scan. A negative result does not exclude kidney stones. It is less effective at identifying kidney stones but is helpful in pregnant women and children.

Stones can be analysed to determine the type, which can help establish the cause and reduce the risk of recurrence.

T***Remember hypercalcaemia as a cause of kidney stones. You can remember the presentation of hypercalcaemia with the mnemonic “renal stones, painful bones, abdominal groans and psychiatric moans”. The three causes to remember are calcium supplementation, hyperparathyroidism and cancer (e.g., myeloma, breast or lung cancer).

Question 16

How are kidney stones managed?

Answer 16

NSAIDs are the most effective type of analgesia, for example, intramuscular diclofenac. IV paracetamol is an alternative, where NSAIDs are not suitable. Opiates are not very helpful for pain management and are not routinely used.

Antiemetics are used for nausea and vomiting (e.g., metoclopramide, prochlorperazine or cyclizine).

Antibiotics are required if infection is present.

Watchful waiting is usually used in stones less than 5mm, as there is a 50-80% chance they will pass without any interventions. It may also be suitable for patients with stones 5-10mm, depending on individual factors. It can take several weeks for the stone to pass.

Tamsulosin (an alpha-blocker) can be used to help aid the spontaneous passage of stones.

Surgical interventions are required in large stones (10mm or larger), stones that do not pass spontaneously or where there is complete obstruction or infection.

Question 17

What surgical therapies can be used for renal stones?

Answer 17

Extracorporeal shock wave lithotripsy (ESWL):
ESWL involves an external machine that generates shock waves and directs them at the stone under x-ray guidance. The shockwaves break the stone into smaller parts to make them easier to pass.

Ureteroscopy and laser lithotripsy:
A camera is inserted via the urethra, bladder and ureter, and the stone is identified. It is then broken up using targeted lasers, making the smaller parts easier to pass.

Percutaneous nephrolithotomy (PCNL):
PCNL is performed in theatres under a general anaesthetic. A nephroscope (small camera on a stick) is inserted via a small incision at the patient’s back. The scope is inserted through the kidney to assess the ureter. Stones can be broken into smaller pieces and removed. A nephrostomy tube may be left in place after the procedure to help drain the kidney.

Open surgery:
Open surgery can be used to access the kidneys and remove the stones. This is rarely needed as other, less invasive, methods are usually effective.

Question 18

How should recurrent kidney stones be managed?

Answer 18

One episode of renal stones predisposes patients to further episodes. NICE guidelines (2019) recommend advising patients to:
- Increase oral fluid intake (2.5 – 3 litres per day)
- Add fresh lemon juice to water (citric acid binds to urinary calcium reducing the formation of stones)
- Avoid carbonated drinks (cola drinks contain phosphoric acid, which promotes calcium oxalate formation)
- Reduce dietary salt intake (less than 6g per day)
- Maintain a normal calcium intake (low dietary calcium might increase the risk of kidney stones)

Other common recommendations include:
- For calcium stones – reduce the intake of oxalate-rich foods (e.g., spinach, beetroot, nuts, rhubarb and black tea)
- For uric acid stones – reduce the intake of purine-rich foods (e.g., kidney, liver, anchovies, sardines and spinach)
- Limit dietary protein

Two medications that may be used to reduce the risk of recurrence are:
- Potassium citrate in patients with calcium oxalate stones and raised urinary calcium
- Thiazide diuretics (e.g., indapamide) in patients with calcium oxalate stones and raised urinary calcium

Question 19

What are the types of vaginal fistulas?

Answer 19

There are several types of vaginal fistula, which are defined by the location of the opening and the connection that is formed.

Types of vaginal fistulas can include:

Vesicovaginal – opening between the vagina and the bladder

Rectovaginal – opening between the vagina and rectum/lower part of the large intestine, which carries stool out of the body

Colovaginal – opening between the vagina and colon

Enterovaginal – opening between the vagina and small intestine

Ureterovaginal – opening between the vagina and the tubes (ureters) that carry urine from your kidneys to your bladder

Urethrovaginal – opening between the vagina and urethra, a part of the bladder

Question 20

What are the features of vaginal fistulas?

Answer 20

Common symptoms of a vaginal fistula include (symptoms may depend on the specific type of fistula):
Urinary and fecal leakage
Abnormal vaginal discharge
A foul odour in urine or vaginal discharge
Recurrent infection including recurrent UTIs
Abdominal pain
Rectal or vaginal bleeding
Tissue damage
Kidney infections
Fever
Weight loss
Nausea
Vomiting
Diarrhoea
Other irritative type symptoms

Question 21

What are the risk factors for vaginal fistulas?

Answer 21

Common causes of a vaginal fistula include:
Childbirth, especially prolonged or obstructed childbirth
Complications from pelvic surgery
Cancer/radiation treatment
Crohn’s Disease or ulcerative colitis
Infection
Other pelvic injury
Retained foreign material in the vaginal (e.g., vaginal pessary)

Question 22

How are vaginal fistulas diagnosed?

Answer 22

Examination

Additional diagnostic testing may include:
- Dye Test – inserting dye in the bladder and or the rectum to check for leakage of dye into the vagina
- Imaging studies - such as ultrasound, CT scan or MRI
- Colonoscopy - using a camera to look into the colon to screen for other potential causes of fistulas, including inflammatory bowel disease
- Cystourethroscopy - using a camera to look into the bladder and urethra to potentially identify the location of the fistula

Question 23

How are vaginal fistulas treated?

Answer 23

Treatment can vary depending on the location and type of vaginal fistula. In some cases, a fistula may be small enough to heal on its own with the use of a bladder catheter, but frequently, surgical repair either from the abdomen or through the vagina may be required to close the opening.

Your doctor may also recommend working with a physical therapist as part of your care.

Question 24

What are the maternal and foetal risks with obesity in pregnancy?

Answer 24

Obese women, and their unborn children, are at an increased risk of a number of complications during pregnancy and labour. Obesity is usually defined as a body mass index (BMI) >= 30 kg/m² at the first antenatal visit.

Maternal risks
miscarriage
venous thromboembolism
gestational diabetes
pre-eclampsia
dysfunctional labour, induced labour
postpartum haemorrhage
wound infections

There is also a higher caesarean section rate.
Fetal risks
congenital anomaly
prematurity
macrosomia
stillbirth
increased risk of developing obesity and metabolic disorders in childhood
neonatal death

Question 25

How is obesity in pregnancy managed?

Answer 25

Dieting and weight loss is not recommended
- obese women should take 5mg of folic acid, rather than 400mcg
- all obese women should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks
- if the BMI >= 35 kg/m² women should give birth in a consultant-led obstetric unit
- if the BMI >= 40 kg/m² should have an antenatal consultation with an obstetric anaesthetist and a plan made

(those with a BMI>35 and another risk factor eg first pregnancy, >40, twins, FH of PET will be started on aspirin prophylaxis from 12 weeks)

Question 26

What are the risks of gonorrhoea in pregnancy?

Answer 26

During pregnancy, gonorrhoea can cause:
- miscarriage
- premature labour and birth
- the baby being born with conjunctivitis
- It is also associated with ectopic pregnancy

If the baby is not promptly treated with antibiotics, there’s a risk of progressive and permanent vision damage. These babies need hospitalisation and evaluation for disseminated disease. Hourly saline lavage is recommended to remove the discharge (qds). The recommended treatment is ceftriaxone 25-50 mg/kg IV or IM in a single dose, not to exceed 125 mg. The mother and partner should be treated for sexually transmitted infection.

(positive women are treated as per normal management - IM ceftriaxone)

Question 27

What are the complications of chlamydia in pregnancy? How is it managed?

Answer 27

If you have chlamydia that’s not treated while you’re pregnant, there’s a chance you could pass the infection on to your baby. If this happens, your baby may develop an eye infection (conjunctivitis) and lung infection (pneumonia).

The recommended treatment is erythromycin 50 mg/kg/day orally divided into 4 doses daily for 14 days. The alternative is azithromycin 20 mg/kg/day orally, 1 dose daily for 3 days. In either regime, monitor for signs of infantile hypertrophic pyloric stenosis, which is reportedly more common in infants given either of these agents under the age of 6 weeks. Follow-up and a second course may be needed, as efficacy is about 80%. Topical treatment alone is not sufficient (and is not felt to be necessary when systemic treatment is taken). The presence of chlamydia in the eyes invariably indicates its presence in the respiratory tract too, which is a further reason for systemic therapy. The mother and her sexual partner(s) will also need treating.

Untreated chlamydia in pregnancy may also increase the risk of problems such as premature labour and birth (before 37 weeks of pregnancy) or your baby being born with a low birthweight.

Doxycycline is CI in pregnancy and breastfeeding so these women are given azithromycin (1 g orally as a single dose for 1 day, followed by 500 mg orally once daily for 2 days)

Erythromycin is an alternative if this is CI.

Question 28

How is syphilis managed in pregnancy?

Answer 28

IM Benzathine penicillin

Amoxicillin alternative

Question 29

Risks of syphilis in pregnancy?

Answer 29

Transmission causing congenital syphilis. Some babies with CS have damaged bones and teeth or problems with their sight or hearing. Presents shortly after birth or later in infancy with a rash on the palms/soles of feet, mucous patches/lesions in the mouth/nose/genitals, fever, hepatosplenomegaly, anaemia, bone developmental abnormalities (‘saber shins’), neurological sequalae (seizures, developmental delay).

Miscarriage and stillbirth

Question 30

What is postpartum endometritis?

Answer 30

Endometritis refers to inflammation of the endometrium, usually caused by infection. It can occur in the postpartum period, as infection is introduced during or after labour and delivery. The process of delivery opens the uterus to allow bacteria from the vagina to travel upwards and infect the endometrium.

Endometritis occurs more commonly after caesarean section compared with vaginal delivery. Prophylactic antibiotics are given during a caesarean to reduce the risk of infection.

Endometritis can be caused by a large variety of gram-negative, gram-positive and anaerobic bacteria. It can also be caused by sexually transmitted infections such as chlamydia and gonorrhoea.

Question 31

How does postpartum endometritis present?

Answer 31

Postpartum endometritis can present from shortly after birth to several weeks postpartum. It can present with:

Foul-smelling discharge or lochia
Bleeding that gets heavier or does not improve with time
Lower abdominal or pelvic pain
Fever
Sepsis

Question 32

How is postpartum endometritis managed?

Answer 32

Investigations to help establish the diagnosis include:

Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
Urine culture and sensitivities

Ultrasound may be considered to rule out retained products of conception (although it is not used to diagnose endometritis).

Septic patients will require hospital admission and the septic six, including blood cultures and broad-spectrum IV antibiotics (according to local guidelines). A combination of clindamycin and gentamicin is often recommended. Blood tests will show signs of infection (e.g. raised WBC and CRP).

Patients presenting with milder symptoms and no signs of sepsis may be treated in the community with oral antibiotics. A typical choice of broad-spectrum oral antibiotic might be co-amoxiclav, depending on the risk of chlamydia and gonorrhoea.

Question 33

What are the sepsis 6?

Answer 33

Give
-Oxygen
-IV abx
- Fluid challenge

Take
-Lactate
-Urine output
-Blood cultures

Question 34

What are the options for induction of labour?

Answer 34

Membrane sweep involves inserting a finger into the cervix to stimulate the cervix and begin the process of labour. It can be performed in antenatal clinic, and if successful, should produce the onset of labour within 48 hours. A membrane sweep is not considered a full method of inducing labour, and is more of an assistance before full induction of labour. It is used from 40 weeks gestation to attempt to initiate labour in women over their EDD.

Vaginal prostaglandin E2 (dinoprostone) involves inserting a gel, tablet (Prostin) or pessary (Propess) into the vagina. The pessary is similar to a tampon, and slowly releases local prostaglandins over 24 hours. This stimulates the cervix and uterus to cause the onset of labour. This is usually done in the hospital setting so that the woman can be monitored before being allowed home to await the full onset of labour.

Cervical ripening balloon (CRB) is a silicone balloon that is inserted into the cervix and gently inflated to dilate the cervix. This is used as an alternative where vaginal prostaglandins are not preferred, usually in women with a previous caesarean section, where vaginal prostaglandins have failed or multiparous women (para ≥ 3).

Artificial rupture of membranes with an oxytocin infusion can also be used to induce labour, although this would only be used where there are reasons not to use vaginal prostaglandins. It can be used to progress the induction of labour after vaginal prostaglandins have been used.

Oral mifepristone (anti-progesterone) plus misoprostol are used to induce labour where intrauterine fetal death has occurred.

Question 35

How is failure to progress managed?

Answer 35

Experienced midwives and obstetricians will manage failure to progress. The main options for managing failure to progress are:

Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes
Oxytocin infusion
Instrumental delivery
Caesarean section

Oxytocin is used first-line to stimulate uterine contractions during labour. It is started at a low rate and titrated up at intervals of at least 30 minutes as required. The aim is for 4 – 5 contractions per 10 minutes. Too few contractions will mean that labour does not progress. Too many contractions can result in fetal compromise, as the fetus does not have the opportunity to recover between contractions.

The condition of the fetus needs to be monitored throughout labour and delivery. Fetal compromise may mean delivery needs to be expedited, or example, with emergency caesarean section.

Question 36

How are face presentations managed?

Answer 36

With adequate pelvic size, and rotation of the head to the mento-anterior position, vaginal delivery should be achieved after a long labour.
Backwards rotation of the head to a mento-posterior position requires a caesarean section.

Question 37

How are brow presentations managed?

Answer 37

The fetal head stays between full extension and full flexion so that the biggest diameter (the mento-vertex) presents.
Brow presentation occurs in 0.14% of deliveries[5].
Brow presentation is usually only diagnosed once labour is well established.
The anterior fontanelle and super orbital ridges are palpable on vaginal examination.
Unless the head flexes, a vaginal delivery is not possible, and a caesarean section is required.

Question 38

What are the key stages of labour?

Answer 38

Descent: In the primigravida this is likely to occur from 38 weeks gestation onwards, in a multigravida woman, this may not occur until labour is established.Descent is encouraged by:
Increased abdominal muscle tone
Braxton hicks in the late stages of pregnancy
Fundal dominance of the uterine contractions during labour
Increased frequency and strength of contractions during labour
As the head descends, it moves towards the pelvic brim in either the left or right occipito-transverse position (this means the occiput can be facing the left side or right side of the mother’s pelvis).

Engagement: This is when the largest diameter of the fetal head descends into the maternal pelvis.
The term engagement is referring to the widest part of the fetal head successfully negotiating its way down deep into the maternal pelvis. Engagement is identified by abdominal palpation, where the fetal head is 3/5th palpable or less.

Neck flexion: As the fetus descends through the pelvis, fundal dominance of uterine contraction exerts pressure down the fetal spine towards the occiput, forcing the occiput to come into contact with the pelvic floor. When this occurs the fetal neck flexes (chin to chest) allowing the circumference of the fetal head to reduce to sub-occipitobregmatic (9.5cm).
In this position, the fetal skull has a smaller diameter which assists passage through the pelvis.

Internal rotation: The pelvic floor has a gutter shape with a forward and downward slope, encouraging the fetal head to rotate from the left or right occipito-transverse position a total of 90-degrees, to an occipital-anterior (occiput facing forward) position, to lie under the subpubic arch. With each maternal contraction, the fetal head pushes down on the pelvic floor. Following each contraction, a rebound effect supports a small degree of rotation. Regular contractions eventually lead to the fetal head completing the 90-degree turn. This rotation will occur during established labour and it is commonly completed by the start of the second stage. Further descent leads to the fetus moving into the vaginal canal and eventually, with each contraction, the vertex becomes increasingly visible at the vulva.

Crowning: When the widest diameter of the fetal head successfully negotiates through the narrowest part of the maternal bony pelvis, the fetal head is considered to be ‘crowning’. This is clinically evident when the head, visible at the vulva, no longer retreats between contractions. Complete delivery of the head is now imminent and often the woman, who has been pushing, is encouraged to pant so that the head is born with control.

Extension of the presenting part: The occiput slips beneath the suprapubic arch allowing the head to extend. The fetal head is now born and will be facing the maternal back with its occiput anterior.

Restitution and External rotation: Because the shoulders at the point of the head being delivered are only just reaching the pelvic floor they are often still negotiating the pelvic outlet and the fetus may naturally align its head with the shoulders. This is called restitution and visually you may see the head externally rotate to face the right or left medial thigh of the mother.
During the next contraction, the shoulders, having reached the pelvic floor, will complete their rotation from a transverse position to an anterior-posterior position. Evidence of this manoeuvre happening inside can be visualised by seeing the head externally rotating as the fetus keeps its spine aligned.

Delivery of the shoulders: Downward traction by the healthcare professional will assist the delivery of the anterior shoulder below the suprapubic arch.
This is followed by upward traction assisting the delivery of the posterior shoulder.
The fetal body will be delivered by the contractions, the health professional’s role is only to assist safe negotiation of this last stage.

Question 39

What are the transverse and antero-posterior diameters of the pelvic inlet?

Answer 39

Transverse - 13cm
Antero-posterior - 11cm

Since the transverse diameter is greater than the antero-posterior (AP) diameter in the pelvic inlet, the widest circumference of the fetal head descends in a transverse position.

Question 40

What are the transverse and antero-posterior diameters of the pelvic outlet?

Answer 40

Transverse - 11cm
Antero-posterior - 13cm

Since the transverse diameter is greater than the antero-posterior (AP) diameter in the pelvic inlet, the widest circumference of the fetal head descends in a transverse position. However, when it gets closer to the pelvic outlet, the nature of the pelvic floor muscles encourages the fetal head to rotate from a transverse position to an anterior-posterior position, as the AP diameter is greater than the transverse diameter.

Question 41

What is the suboccipitobregmatic fetal head diameter?

Answer 41

(vertex, flexed)

9.5cm

Question 42

What is the occipitofontal fetal head diameter?

Answer 42

(vertex, neutral flexion)

11cm

Question 43

What is the submentobregmatic fetal head diameter?

Answer 43

Face

9.5cm

Question 44

What is the verticomental fetal head diameter?

Answer 44

Brow

13.5cm

Question 45

What is uterine rupture and what are the risk factors?

Answer 45

Uterine rupture is a complication of labour, where the muscle layer of the uterus (myometrium) ruptures. With an incomplete rupture, or uterine dehiscence, the uterine serosa (perimetrium) surrounding the uterus remains intact. With a complete rupture, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.

Uterine rupture leads to significant bleeding. The baby may be released from the uterus into the peritoneal cavity. It has a high morbidity and mortality for both the baby and mother.

Risk factors
The main risk factor for uterine rupture is a previous caesarean section. The scar on the uterus becomes a point of weakness, and may rupture with excessive pressure (e.g. excessive stimulation by oxytocin). It is extremely rare for uterine rupture to occur in a patient that is giving birth for the first time.

The risk factors to consider are:
Vaginal birth after caesarean (VBAC)
Previous uterine surgery
Increased BMI
High parity
Increased age
Induction of labour
Use of oxytocin to stimulate contractions

Question 46

What are the features of uterine rupture and how is it managed?

Answer 46

Uterine rupture presents with an acutely unwell mother and abnormal CTG. It may occur with induction or augmentation of labour, with signs and symptoms of:
Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardia
Collapse

Management
Uterine rupture is an obstetric emergency. Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).

Question 47

What are the types of rupture of membranes?

Answer 47

Rupture of membranes (ROM): The amniotic sac has ruptured.

Spontaneous rupture of membranes (SROM): The amniotic sac has ruptured spontaneously.

Prelabour rupture of membranes (PROM): The amniotic sac has ruptured before the onset of labour.

Preterm prelabour rupture of membranes (P‑PROM): The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm).

Prolonged rupture of membranes (also PROM): The amniotic sac ruptures more than 18 hours before delivery.

Question 48

What is the prophylaxis of preterm labour?

Answer 48

Vaginal Progesterone
Progesterone can be given vaginally via gel or pessary as prophylaxis for preterm labour. Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery. This is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation.

Cervical Cerclage
Cervical cerclage involves putting a stitch in the cervix to add support and keep it closed. This involves a spinal or general anaesthetic. The stitch is removed when the woman goes into labour or reaches term.

Cervical cerclage is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation, who have had a previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy).

“Rescue” cervical cerclage may also be offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery.

Question 49

How is preterm prelabour rupture of membranes managed?

Answer 49

Prophylactic antibiotics should be given to prevent the development of chorioamnionitis. The NICE guidelines (2019) recommend erythromycin 250mg four times daily for ten days, or until labour is established if within ten days.

Induction of labour may be offered from 34 weeks to initiate the onset of labour.

Question 50

How can preterm labour with intact membranes be managed?

Answer 50

• Fetal monitoring (CTG or intermittent auscultation)
• Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour
• Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
• IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain
• Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth

Question 51

What is tocolysis and when is it used?

Answer 51

Tocolysis involves using medications to stop uterine contractions. Nifedipine, a calcium channel blocker, is the medication of choice for tocolysis. Atosiban is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated.

Tocolysis can be used between 24 and 33 + 6 weeks gestation in preterm labour to delay delivery and buy time for further fetal development, administration of maternal steroids or transfer to a more specialist unit (e.g. with a neonatal ICU). It is only used as a short term measure (i.e. less than 48 hours).

Question 52

When are antenatal steroids given in preterm labour?

Answer 52

Giving the mother corticosteroids helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery. They are used in women with suspected preterm labour of babies less than 36 weeks gestation.

An example regime would be two doses of intramuscular betamethasone, 24 hours apart.

Question 53

When is magnesium sulphate given in preterm labour?

Answer 53

Giving the mother IV magnesium sulfate helps protect the fetal brain during premature delivery. It reduces the risk and severity of cerebral palsy. Magnesium sulphate is given within 24 hours of delivery of preterm babies of less than 34 weeks gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth.

Mothers need close monitoring for magnesium toxicity at least four hourly. This involves close monitoring of observations, as well as tendon reflexes (usually patella reflex). Key signs of toxicity are:

Reduced respiratory rate
Reduced blood pressure
Absent reflexes

Question 54

What are the risks of instrumental delivery?

Answer 54

Having an instrumental delivery increases the risk to the mother of:

Postpartum haemorrhage
Episiotomy
Perineal tears
Injury to the anal sphincter
Incontinence of the bladder or bowel
Nerve injury (obturator or femoral nerve)

The key risks to remember to the baby are:
Cephalohaematoma with ventouse
Facial nerve palsy with forceps

Rarely there can be serious risks to the baby:
Subgaleal haemorrhage (most dangerous)
Intracranial haemorrhage
Skull fracture
Spinal cord injury

Question 55

What nerves may be injured during instrumental delivery?

Answer 55

Rarely an instrumental delivery may result in nerve injury for the mother. This usually resolves over 6 – 8 weeks. The affected nerves may be:

Femoral nerve
Obturator nerve

The femoral nerve may be compressed against the inguinal canal during a forceps delivery. Injury to this nerve causes weakness of knee extension, loss of the patella reflex and numbness of the anterior thigh and medial lower leg.

The obturator nerve may be compressed by forceps during instrumental delivery or by the fetal head during normal delivery. Injury causes weakness of hip adduction and rotation, and numbness of the medial thigh.

Question 56

When is crown rump length measured?

Answer 56

At the dating scan to give an accurate gestational age.

Cardiac activity should be present in an embryo with a CRL ≥7 mm

Usually 6-6.5 weeks

Question 57

What is the fetal pole?

Answer 57

The fetal pole is the first direct imaging manifestation of the fetus and is seen as a thickening on the margin of the yolk sac during early pregnancy. It is often used synonymously with the term “embryo”.

The fetal pole is usually identified at ~6.5 weeks with transabdominal ultrasound imaging and at ~6 weeks 2 with transvaginal ultrasound imaging, although it may not be seen until ~9 weeks in some cases.

a fetal pole should be seen when mean gestation sac diameter is ≥25 mm

When the fetal pole measures ≥7 mm (crown rump length), a fetal heartbeat should be detected.

Question 58

What is antiphospholipid syndrome?

Answer 58

Antiphospholipid syndrome is an autoimmune disorder caused by antiphospholipid antibodies. These antibodies target the proteins that bind to the phospholipids on the cell surface, causing inflammation and increasing the risk of thrombosis (blood clots). It can occur in isolation or associated with another autoimmune condition, particularly systemic lupus erythematosus.

Antibodies
The specific antiphospholipid antibodies are:

Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta-2 glycoprotein I antibodies

Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder or secondary to other conditions, most commonly systemic lupus erythematosus (SLE). Around 30% of patients with SLE have positive antiphospholipid antibodies.

A key point for the exam is to appreciate that antiphospholipid syndrome causes a paradoxical rise in the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade.

Question 59

What are the features of antiphospholipid syndrome?

Answer 59

Features
venous/arterial thrombosis
recurrent miscarriages
livedo reticularis
other features: pre-eclampsia, pulmonary hypertension

Question 60

How is antiphospholipid syndrome investigated and managed?

Answer 60

Management - based on EULAR guidelines

primary thromboprophylaxis
low-dose aspirin

secondary thromboprophylaxis
initial venous thromboembolic events: lifelong warfarin with a target INR of 2-3
recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin then consider adding low-dose aspirin, increase target INR to 3-4
arterial thrombosis should be treated with lifelong warfarin with target INR 2-3

Question 61

What is balanitis?

Answer 61

Balanitis is inflammation of the glans penis and sometimes extends to the underside of the foreskin which is known as balanoposthitis. There are a number of causes of balanitis and the most common causes are infective (both bacterial and candidal) although there are a number of other autoimmune causes that are important to know. Simple hygiene is a key part of the treatment of balanitis and both improper washing under the foreskin and the presence of a tight foreskin can make balanitis worse. The presentation can either be acute or more chronic and children and adults are affected by the causes differently.

Question 62

How is balanitis managed?

Answer 62

There are three things which form the basis of management of all causes of balanitis; gentle saline washes, ensuring to wash properly under the foreskin, and in the case of more severe irritation and discomfort then 1% hydrocortisone can be used for a short period.
When the cause is not clear, these measures can often resolve the condition alone.

In the case of candidiasis the treatment is with topical clotrimazole which has to be applied for two weeks to fully treat the infection.
Bacterial balanitis is most often due to Staphylococcus spp. or Group B Streptococcus spp. and can be treated with oral flucloxacillin or clarithromycin if penicillin allergic.
Anaerobic balanitis is managed with saline washing and can also be managed with topical or oral metronidazole if not settling.
Dermatitis and circinate balanitis are managed with mild potency topical corticosteroids (e.g. hydrocortisone)
Lichen sclerosus and plasma cell balanitis of Zoon are managed with high potency topical steroids (e.g. clobetasol).
Circumcision can help in the case of lichen sclerosus.

Question 63

What is chancroid? how is it managed?

Answer 63

Chancroid is a tropical disease caused by Haemophilus ducreyi. It causes painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border.

A single IM dose (250 mg) of ceftriaxone, a single IM dose (1gram) of azithromycin or an oral (500 mg) of erythromycin four times a day for seven days.

Sexual partners of a patient who has chancroid should be examined and treated for chancroid if they have had sexual contact with the patient during 10 days preceding the onset of symptoms in the patient. This is done even if the partners do not have any symptoms.

Question 64

How is pubic lice managed?

Answer 64

treat with permethrin 5% cream or malathion 0.5% aqueous solution.

Question 65

What endocrine therapies are available for trans women?

Answer 65

For trans women, or for women following genital change surgery, the goal is to suppress androgens and provide oestrogen therapy.

Traditionally cyproterone acetate or spironolactone have been used, but as these have been associated with risks and side-effects.

Increasingly depot injections of gonadotrophin-releasing hormone (GnRH) analogues are used. These include goserelin and leuprorelin.
This would be stopped if gonads were removed surgically.

Oestrogen supplementation can be delivered orally or subcutaneously with an optimum dose achieved by monitoring of plasma levels. Lipids, liver function and blood pressure should also be monitored. Contra-indications and cautions for oestrogen use should be considered (thromboembolic disease, migraine, cerebrovascular disease, coronary heart disease, etc)

Question 66

What endocrine therapies are available for trans men?

Answer 66

For trans men, or men following genital change surgery, the goal is to suppress oestrogens and provide testosterone therapy.

Long-acting GnRH analogues eg goserelin and leuprorelin are used to suppress ovarian function, and stopped if ovaries are removed.

Testosterone replacement may be given in the form of depo injection or by transdermal gel. Contra-indications and cautions should be considered (eg, breast cancer, uterine cancer, severe liver disease). Haemoglobin and haematocrit levels should be monitored as polycythaemia may occur.