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Question 1

Services requirements for the provision of intrapartum care

Answer 1

Timely access to - obstetric, midwifery, neonatal / paediatric, anaesthetic, operating theatre, resuscitation services, ICU consultation, haematology, blood bank
Birth centres ideally placed within (or immediately adjacent to) an appropriately resourced 24h obstetric facility
If by virtue of remote location, on-site services cannot be provided, women should be informed of the limitations of services available and implications for intrapartum and postpartum care
- Formal systems must be in place to ensure safe and timely transfer if required

Question 2

% of women developing peripartum complications requiring transfer in low risk population

Answer 2

Amongst women selected for low obstetric risk, ~25% will develop peripartum complications necessitating transfer to an obstetrician led services

Question 3

RANZCOG recommended routine labour cares

Answer 3

VE is indicated for women admitted in apparent labour unless there are contraindications - Should be done within 4h to diagnose and assess the progress of labour.
Care is optimised where there is a 1:1 midwifery support in labour in collaborative service
Involve woman and her support person in management decisions
WHO recommends maternal observations be graphically displayed on a partogram to facilitate review of progress
HR, BP, RR, temp, contraction frequency, duration, intensity, abdominal palpation, VE findings, liquor colour / presence, FHR

Question 4

Labour positioning

Answer 4

Women should be encouraged to ambulate freely according to comfort, where it does not compromise maternal and fetal observations in labour
- Cochrane 2013 - first stage of labour may be approx 1h 20m shorter for women who are upright or walk around (Better studies needed to validate these results)

Question 5

Fluids and oral intake in labour

Answer 5

Some evidence that inadequate hydration may increase the length of labour and need for oxytocin augmentation
Encourage clear fluids and light diet in active phase of labour to minimise risk of aspiration pneumonitis

Question 6

Antibiotics in labour

Answer 6

For prevention of GBS
For women at risk of chorioamnionitis or where other bacterial infection is suspected - e.g. fever >38 on one occasion or >37.4 on two occasions
Women with cardiac lesions susceptible to infective endocarditis

Question 7

Impact of ARM on labour

Answer 7

Evidence that routine ARM shortens labour is largely lacking (Cochrane review 2009)
Risk of infection increased following rupture of membranes
ARM provides useful information on fetal wellbeing (liquor volume and colour)

Question 8

Relative contraindications of ARM

Answer 8

HBV, HCV, HSV and HIV infection
- In order to minimise the risks of ascending infection
- In developing countries where incidence of HIV is high, amniotomy is developed in labour to reduce vertical transmission rates
Presenting part high and mobile

Question 9

Monitoring labour progress

Answer 9

Most trials do 2 hourly cervical assessments
- Enables dystocia to be diagnosed and correctly early
- But added maternal discomfort of more frequent exams and potential for introducing infection
Compromise: 4 hourly VE
If full dilatation not clinically apparent after a woman is 9cm, further VE beneficial to confirm full dilatation or allow diagnosis of FTP if not fully
Second stage
- Reassessment at 2h in primigravida and 1h in multigravida

Question 10

Definition of failure to progress

1st stage
Before established labour

Answer 10

No upper limit to the length of the ‘latent phase’ can be defined
Not uncommon for labour to stop and start before finally established
Recurrent or prolonged episodes of spurious labour may contribute to a legitimate decision for IOL in some women

Question 11

Definition of failure to progress

1st stage
In established labour
- primigravida

Answer 11

10th centile for progress of cervical dilatation in labour is 0.9 cm/hour (primigravida)

Threshold at which slow cervical dilatation merits a recommendation for oxytocin:

• Individualised with an informed discussion with the woman
• Commonly 1cm/hr for most women in spontaneous labour
• May be as high as 1cm / 2hr in women prioritising low intervention

Question 12

Definition of failure to progress

1st stage
In established labour
- multigravida

Answer 12

10th centile for progress of cervical dilatation is 1.2cm/hr (multigravida)

Caution for augmentation as increased risk of uterine rupture compared to primigravida

Question 13

Definition of failure to progress

2nd stage

Answer 13

Progress in includes flexion, rotation and descent
Normal for primigravida = up to 2 hours
Normal for multigravida = up to 1 hours

Question 14

When to consider episiotomy

Answer 14

Episiotomy should be considered where there is a high likelihood of severe laceration

• Soft tissue dystocia
• Requirement to accelerate birth of a compromised fetus
• Need to facilitate operative vaginal birth
• History of FGM

Question 15

When to recommend physiological third stage

Answer 15

“Expectant” or “physiological” management cannot be recommended on the basis of evidence and is associated with approximately a two-fold increase in the incidence of postpartum haemorrhage and an increased risk of blood transfusion when compared with active management

Question 16

Associations of delayed cord clamping in preterm infants

Answer 16

reduced risk of requiring transfusion, infection, NEC, and intraventricular haemorrhage

Question 17

Associations of delayed cord clamping in term infants

Answer 17

increased haematocrit and reduced iron deficiency at 3-6 months of age
However increased risk of polycythaemia and jaundice

No clear evidence to guide practitioners regarding DCC in term infants
Infants are most likely to benefit if maternal iron stores are low, or in infants who will be exclusively breast fed without iron supplementation

Question 18

Positioning for delayed cord clamping

Answer 18

~75% of available placental blood for transfusion is achieved in the first minute

Transfer of blood from placenta to newborn is facilitated by the infant being held below the level of the in situ placenta

• If infant 10cm above or below the placenta, transfusion is complete within 3 mins
• If 40cm below, transfusion time is shortened to 1 min

Question 19

Routine newborn care

Answer 19

• Assess immediately as to the need for resuscitation
• Skin-to-skin should be facilitated providing there are no maternal or neonatal complications
• Apgar scores at 1 and 5 mins of age
• Regular neonatal obs - RR, HR, colour, tone, reflex irritability
• Observe for signs of respiratory distress - grunting, nasal flaring, intercostal retraction, tachypnoea, cyanosis
• IM vitamin K recommended

Question 20

Routine maternal postpartum care

Answer 20

Regular maternal obs (HR, BP, temp)
Palpation of the uterine fundus to exclude atony
Inspection of the perineum to exclude excessive PP blood loss or development of vulval haematoma

Debriefing opportunities should be provided following an adverse outcome or experience that did not meet the expectations of the woman or her partner

Question 21

Reasons for GDM screening

Answer 21

Evidence suggests benefit of reduced perinatal mortality in screening and treating GDM

Question 22

RANZCOG GDM screening recommendation

Answer 22

75g 2h OGTT at 26-28 weeks
Earlier if high risk, and repeat at 24-28/40 if negative

Fasting: >/= 5.1 mmol/l

1h: >/- 10.0 mmol/l
2h: >/= 8.5 mmol/l

Polycose not recommended

Question 23

GDM risk factors

Answer 23

Pre-pregnancy BMI >30
Previous macrosomic baby (>4.5kg or >90th centile)
Previous GDM / hyperglycaemia in pregnancyFHx of diabetes (1st degree relative or sister with GDM)
Minority ethnic family origin with high prevalence of diabetes
- Asian, Indian, Aboriginal, Torres Strait Islander, Pacific Islander, Maori, Middle Eastern, non-white African
PCOS
Medications - corticosteroids, antipsychotics
Maternal age >40

Question 24

ADIPS diabetes mellitus in pregnancy diagnosis

Answer 24

Fasting >/= 7.0 mmol/l

2h or random >/= 11.1mmol/l

Question 25

BSL targets on treatment

Answer 25

Fasting: <5.0 mmol/L 2 hours after meals: <6.7 mmol/L If >10% of readings above targets, then reassess treatment

Question 26

Iodine supplementation recommendation

Answer 26

RDI if pregnant, planning a pregnancy, or breast feeding: 150 micrograms/day

Question 27

Definition of overt hypothyrodism

Answer 27

Overt hypothyroidism should be treated in pregnancy - TSH >reference range with decreased T4, OR - TSH >10mIU/L, irrespective of the level of FT4

Question 28

RANZCOG recommendation for screening for hypothyroidism in pregnancy

Answer 28

No studies show thyroxine influences outcome Routine screening and treatment not recommended Test if symptoms of thyroid disease or personal Hx of thyroid disease

Question 29

Main cause of hypothyroidism in NZ and Au

Answer 29

Hashimoto's thyroiditis

Question 30

Physiology of thyroid hormone production in pregnancy

Answer 30

Increase (2-fold) in serum thyroxine-binding globulin (TBG) --> increase in T4 and T3 but free T4 remains unchanged Stimulation of the thyrotropin / TSH receptor by HCG ○ HCG has weak thyroid stimulating activity as structurally similar to TSH ○ Normal increase in HCG in early pregnancy may cause a small transient increase in free T4 with subsequent TSH suppression T4 and T3 levels rise by approx 50% during the first half of pregnancy, plateau at 20/40, then new steady state is reach and overall production rate returns to prepregnancy rates Fetus is reliant on transplacental transfer of maternal thyroid hormone (T4 and T3) until the fetal thyroid starts to become functional from 12/40

Question 31

Iodine state during pregnancy

Answer 31

Relative maternal iodine deficiency - 2-fold increase in renal loss (increased GFR + decreased reabsorption) - Active transport of iodine to fetus Uptake of plasma iodide into the thyroid is increased 3-fold Insufficient dietary iodine --> cellular hyperplasia and goitre Fetus and fully breastfed infant are dependent on maternal iodine for thyroid hormone synthesis

Question 32

Risks of overt hypothyroidism

Answer 32

- Miscarriage - PET - Abruption - PPH - Anaemia - Low birth weight - Prematurity - Perinatal mortality - Stillbirth - Impaired neurological development - Low offspring IQ Adequately treated hypothyroidism is not a/w any adverse maternal, fetal or neonatal complications

Question 33

Pregnancy outcomes with subclinical hypothyroidism

Answer 33

Results for large cohorts and meta-analyses have not been consistent in demonstrating an association between SCH and adverse pregnancy outcomes High quality prospective RCTs involving >100,000 women have not demonstrated any maternal or neonatal benefits from treatment of SCH with thyroxine Associated with childhood developmental delay has not been confirmed in prospective cohort data

Question 34

Incidence of obesity / overweight

Answer 34

~50% of women who become pregnant are either overweight or obese

Question 35

Increased antenatal risks for obese women | normal BMI vs. BMI >40

Answer 35

``` Miscarriage GDM (1% vs. 7%) Fetal congenital abnormalities - E.g. increased risk of NTD - recommend high dose folate 5mg/day Stillbirth (perinatal death - 0.7% vs. 2%) PET (if BMI >35) HTN in pregnancy (2% vs. 10%) Thromboembolism (risk of PET > DVT) Abnormalities in fetal growth Obstructive sleep apnoea Preterm birth (7% vs. 11%) Maternal death ```

Question 36

Increased intrapartum risks for obese women

Answer 36

``` IOL, prolonged labour and failure to progress Rate of instrumental delivery Failed instrumental delivery Shoulder dystocia Caesarean section (33% vs. 52%) Difficulties with fetal heart rate monitoring PPH Peripartum death ```

Question 37

Increased anaesthetic risks for obese women

Answer 37

Difficulties with labour analgesia Use of GA Difficultly maintaining an adequate airway, failed intubation Increased risk of need for ICU care post-op

Question 38

Increased postpartum risks for obese women

Answer 38

``` Delayed wound healing and infection Thromboembolic disease Greater likelihood of needing support with breastfeeding establishment and continuation Postnatal depression Long term neonatal consequences - Neonatal body composition - Infant weight gain - Obesity ```

Question 39

BMI definition and WHO categorisation

Answer 39

Weight in kg / square of height in metres ``` Underweight <18.5 Normal 18.5 - 24.99 Overweight 25 - 29.99 Obese class 1 30 - 34.99 Obese class 2 35 - 39.99 Obese class 3 >40 ```

Question 40

Fetal / neonatal risks with obesity | normal BMI vs. BMI >40

Answer 40

``` Neonatal mechanism ventilation (5 vs. 10%) PTB (7 vs. 11%) Macrosomia (11 vs. 21%) SGA customised (11 vs. 19%) LGA customised (11 vs. 16%) ```

Question 41

Obesity - prepregnancy management

Answer 41

Weight management strategies: - Dietary modification - consider referral to dietician - Exercise Discuss impact of obesity on fertility and pregnancy outcomes Modest gain of 1-2 BMI units between pregnancies may increase the risk of gestational HTN, macrosomia, GDM Medications or surgery for weight management are not recommended around the time of conception or during pregnancy Advise supplement containing folate (high dose 5mg/day) and 150mcg iodine pre-conception Address psychosocial concerns Offer contraception to allow time for weight optimisation

Question 42

Prior bariatric surgery

Answer 42

Require closer monitoring of their nutritional status and fetal growth Current evidence suggests a positive outcome in reduction of maternal risks during pregnancy, such as GDM, but with an increase risk of FGR and stillbirth Pre-pregnancy counselling - Should be on lifelong vitamin supplementation - Referral to dietician, especially if malabsorptive surgery - may require additional supplementation during pregnancy - vitamin B12, iron, folate, vitamin D, calcium - Avoid pregnancy for 12-24 months after surgery and during the initial weight loss phase

Question 43

Weight loss between pregnancies:

Answer 43

``` Reduces the risk of: ○ Stillbirth ○ Hypertensive complications ○ Fetal macrosomia Increases the chances of successful VBAC ```

Question 44

Recommended weight gain in pregnancy

Answer 44

Underweight - 12.5 to 18kg Normal weight - 11.5 to 16kg Overweight - 6.8 to 11.3kg Obese (includes all classes) - 5 to 9.1kg

Question 45

Recommended weight gain for multiples

Answer 45

Normal weight 17 to 25kg Overweight 14 to 23 kg Obese (includes all classes) 11 to 19 kg

Question 46

Timing of birth in obese women

Answer 46

- No universal consensus - Observational data comparing outcomes before and after a protocol of delivery by 40/40 found a significant reduction in the risk of CS for obese women

Question 47

Intrapartum management obese women

Answer 47

IV line on admission to labour ward May need to confirm presentation with USS Awareness of increased risk of shoulder dystocia and PPH Operating theatre staff need to be altered regarding increased weight (usually >120kg) To ensure adequate staffing and equipment available

Question 48

Postpartum management obese women

Answer 48

Use of Rh(D) immunoglobulin - Some evidence to suggest IM anti-D may be associated with increased risk of lack of effect in patients with a BMI >30 - however insufficient evidence to support a change in practice Breastfeeding support - Obesity is associated with lower rates of breastfeeding initiation and maintenance - Breastfeeding has been associated with postpartum weight loss Consider VTE prophylaxis Weight management postpartum

Question 49

Benefits of exercise during pregnancy

Answer 49

Physical benefits - fitness, prevention of excessive weight gain, lifelong benefits (reduced CVD, T2DM, some cancers) Psychological wellbeing - reduced Sx of depression No evidence detrimental to fetus or woman Regular exercise during pregnancy has been a/w shorter and less complicated labour, and fewer neonatal complications (but inconclusive evidence)

Question 50

Advice for Women with a high level of fitness doing regular vigorous exercise

Answer 50

No evidence of harm to pregnancy provided they adjust routine based on changes in comfort and tolerance Athletes should be wary of excessive exertion - fetal wellbeing may be compromised about a certain (high) threshold of intensity - transient FHR decels and alterations in umbilical and uterine artery dopplers immediately post-exercise Not known if these transient changes impact neonatal outcomes Attention to adequate nutrition, hydration and avoiding overheating Pregnancy is not a time for serious competition or aiming to reach peak lifetime fitness

Question 51

Intensity of exercise recommendations in pregnancy

Answer 51

``` Pregnancy-specific heart rate zones equivalent to 60-80% of max aerobic capacity have been recommended for normal-weight women <20y - 140-155bpm 20-29y - 135-150bpm 30-39y - 130-145bpm >40y - 125-140bpm ``` If inactive overweight and obese, may be too high therefore aim for targets of 102-124bpm (if 20-29y) or 101-120bpm (if 30-39y) Intensity considered moderate if can comfortably hold a conservation Vigorous if need to pause for breath during conversation

Question 52

General exercise advice for adults, apply to pregnancy

Answer 52

Active on most, preferably all days each week Aim for 150-300 mins of moderate intensity exercise each week or 75-150 mins of vigorous exercise each week, or combination Plus muscle strengthening exercises >2 days per week Avoid prolonged sitting

Question 53

Contraindications to exercise, irrespective of pregnancy

Answer 53

CVD Poorly controlled asthma Poorly controlled diabetes Bone or joint problems

Question 54

Additional medical and obstetric issues in pregnancy that may preclude exercise (but no literature, therefore individualise recommendation)

Answer 54

``` Persistent bleeding Placenta praevia PET PIH Indicators of increased risk of PTL - multiple pregnancy, rupture membranes, premature contractions, shortened cervical length FGR Poorly controlled thyroid disease Anaemia ```

Question 55

Physiological changes of pregnancy that have implications on exercise

Answer 55

Increase in body weight - increased loading at the joints Change in weight distribution - altered centre of gravity Increase in ligament laxity - may have implications for the risk of injury Decrease in BP Increase in resting and submaximal HR Increase in metabolic rate - avoid exercising at high temperatures and humidity Enlarged uterus - improves venous return Growing fetus Weakened pelvic floor

Question 56

Incidence of smoking in pregnancy

Answer 56

Australia: 1 in 10 NZ: 1 in 8 44% of Aboriginal and Torres Strait Islander 22% of Maori women Smokers in pregnancy more likely to be younger and live in areas of SE disadvantage 3.8-fold increase in smoking cessation rate when compared to non-pregnant women Of women who cease smoking during pregnancy, 50-70% will resume in the year PP

Question 57

Pathogenesis of smoking and pregnancy outcomes

Answer 57

Smoking potentially disrupts the implantation process and interfering with the transformation of the uterine spiral arteries Studies show thickening of the villous membrane of the placenta in smokers, lessening the ability of the placenta to function Nicotine also impairs amnio acid transport across the placenta

Question 58

Obstetric complications of smoking in pregnancy

Answer 58

Miscarriage Ectopic pregnancy Preterm labour and premature rupture of membranes – two-fold increase in the risk of preterm birth with smoking Placental abruption – Two-fold increase in the risk Placenta praevia – Relative risk 1.36 Pre-eclampsia – Of pregnancies that are complicated by severe pre-eclampsia, smoking is associated with increased rates of perinatal mortality, placental abruption and small for gestational age infants Thrombotic risk Anaesthetic risks and respiratory complications

Question 59

Fetal complications of maternal smoking

Answer 59

Low birth weight (less than 2500g at birth) Fetal anomalies Perinatal death

Question 60

Child and adult complications of maternal smoking

Answer 60

``` Sudden unexpected death in infancy syndrome (SUDI) Respiratory disease ENT and other infections Childhood cancers Nicotine dependence ```

Question 61

Non-obstetric risks of smoking

Answer 61

increased rates of all- cause mortality, lung cancer, cervical pre-invasive disease and cancer, vulval cancer, bladder cancer, oropharyngeal cancer, breast cancer, cardiovascular disease, thromboembolic disease, chronic respiratory disease, reduced fertility, premature menopause and osteoporosis

Question 62

NRT and pregnancy

Answer 62

NRT may be considered when a pregnant woman is otherwise unable to quit, and when the likelihood and benefits of cessation outweigh the risks of NRT and potential continued smoking Intermittent-use forms (such as gum or spray) are preferred over continuous-delivery nicotine (patches)

Question 63

Options for testing for inherited conditions

Answer 63

1. Having child and testing after birth 2. Conceiving naturally and having diagnostic testing during pregnancy (amniocentesis or CVS) 3. IVF and testing embryos by preimplantation genetic diagnosis 4. Using donor sperm, egg or embryo from unaffected individuals 5. Adoption 6. Not having children

Question 64

If of Eastern European (Ashkenazi) Jewish descent, offer screening for:

Answer 64

- Tay Sachs disease - Niemann Pick disease type A - Fanconi anaemic group C - Familial dysautonomia - Bloom syndrome - Canavan disease Mucolipidosis type IV

Question 65

Genetic carrier screening - CF - Spinal muscular atrophy - Fragile X syndrome Carrier frequency, frequency affected Main clinical features

Answer 65

Cystic fibrosis - 1 in 35 - 1 in 4925 Recurrent lung infections, malabsorption, shortened life span Spinal muscular atrophy - 1 in 50 - 1 in 9917 - Severe muscle weakness, death usually during childhood Fragile X syndrome - 1 in 332 - 1 in 7143 - Intellectual disability, autism Australian study found that approximately 1 in 20 individuals accessing self-funded carrier screening were carriers of cystic fibrosis, spinal muscular atrophy and/or fragile X syndrome

Question 66

three most common inherited genetic conditions for which prenatal diagnosis is currently performed:

Answer 66

thalassaemia cystic fibrosis fragile X syndrome.

Question 67

Folic acid supplementation

Answer 67

Folic acid for a minimum of 1 month pre-conception and for first 3 months of pregnancy - At least 0.4mg daily If increased risk of NTD (anti-convulsant medication, pre-pregnancy diabetes, previous child or family history of NTD, BMI >35) --> 5mg daily

Question 68

Luteal phase support for IVF

Answer 68

Luteal phase support with synthetic progestogens should be provided in IVF - Associated with an improved live birth rate - Better results obtained with synthetic progestogens than micronized progesterone - No evidence to favour a specific route or duration of administration

Question 69

Progesterone in early pregnancy

Answer 69

No evidence to suggest that giving progesterone supplementation to otherwise healthy women in the first trimester reduces the risk of spontaneous miscarriage Progestogen supplementation until the second trimester in women presenting with threatened miscarriage may reduce the rate of spontaneous miscarriage - Current evidence limited by methodological inconsistencies Routine use of progestogens in those with recurrent spontaneous miscarriage does not improve pregnancy outcomes Luteal phase support with synthetic progestogens should be provided in IVF

Question 70

Progesterone use for recurrent spontaneous miscarriage

Answer 70

Routine use of progestogens in those with recurrent spontaneous miscarriage does not improve pregnancy outcomes - PROMISE trial - no difference in the rate of miscarriage in women using vaginal micronized progesterone compared to placebo - Significant heterogeneity in the clinical trials of progestogens ○ Possibility of a benefit cannot be excluded