Ten_Teachers_Obstetrics.pdf

OBSTETRICS by Ten Teachers This page intentionally left blank OBSTETRICS by Ten Teachers 19th edition Edited by Philip N Baker BMEDSCI BM BS DM FRCOG FRCSC FMEDSCI Dean of the Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada Louise C Kenny MBCHB (HONS) MRCOG PHD Professor of Obstetrics and Consultant Obstetrician and Gynaecologist The Anu Research Centre, Cork University Maternity Hospital, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland First published in Great Britain in 1917 as Midwifery Eleventh edition published in 1966 as Obstetrics Eighteenth edition published in 2006 This nineteenth edition published in 2011 by Hodder Arnold, an imprint of Hodder Education, an Hachette UK Company, 338 Euston Road, London NW1 3BH http://www.hodderarnold.com © 2011 Hodder & Stoughton Ltd All rights reserved. Apart from any use permitted under UK copyright law, this publication may only be reproduced, stored or transmitted, in any form, or by any means with prior permission in writing of the publishers or in the case of reprographic production in accordance with the terms of licences issued by the Copyright Licensing Agency. In the United Kingdom such licences are issued by the Copyright Licensing Agency Limited, Saffron House, 6-10 Kirby Street, London EC1N 8TS Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN-13 978 0 340 983 539 ISBN-13 [ISE] 978 1 444 122 305 (International Students’ Edition, restricted territorial availability) 1 2 3 4 5 6 7 8 9 10 Commissioning Editor: Joanna Koster Production Editor: Sarah Penny Production Controller: Jonathan Williams Cover Designer: Amina Dudhia Cover image © Gustoimages/Science Photo Library Typeset in 9.5/12pt Minion by MPS Limited, a Macmillan Company Printed and bound in India What do you think about this book? Or any other Hodder Arnold title? Please visit our website: www.hodderarnold.com This book is dedicated to my younger daughter, Sara (PNB) And to my sons, Conor and Eamon (LCK) This page intentionally left blank Contents The Ten Teachers ix Preface x Commonly used abbreviations xi CHAPTER 1 Obstetric history taking and examination 1 Lucy Kean CHAPTER 2 Modern maternity care 13 Lucy Kean CHAPTER 3 Physiological changes in pregnancy 20 Keelin O’Donoghue CHAPTER 4 Normal fetal development and growth 38 Gary Mires CHAPTER 5 Antenatal care 48 Alec McEwan CHAPTER 6 Antenatal imaging and assessment of fetal well-being 61 Gary Mires CHAPTER 7 Prenatal diagnosis 75 Sarah Vause CHAPTER 8 Antenatal obstetric complications 85 Louise C Kenny CHAPTER 9 Twins and higher multiple gestations 109 Grifﬁth Jones CHAPTER 10 Pre-eclampsia and other disorders of placentation 120 Louise C Kenny CHAPTER 11 Late miscarriage and early birth 132 Grifﬁth Jones CHAPTER 12 Medical diseases complicating pregnancy 144 Keelin O’Donoghue CHAPTER 13 Perinatal infections 169 Sarah Vause CHAPTER 14 Labour 185 Alec McEwan CHAPTER 15 Operative intervention in obstetrics 224 Philip N Baker CHAPTER 16 Obstetric emergencies 241 Clare Tower CHAPTER 17 The puerperium 258 Louise C Kenny viii Contents CHAPTER 18 Psychiatric disorders and the puerperium 272 Alec McEwan CHAPTER 19 Neonatology 281 Janet M Rennie CHAPTER 20 Ethical and medicolegal issues in obstetric practice 302 Philip N Baker Index 309 The Ten Teache rs Philip N Baker BMEDSCI BM BS DM FRCOG FRCSC Gary Mires MBCHB MD FRCOG FHEA FMEDSCI Professor of Obstetrics and Undergraduate Teaching Dean of the Faculty of Medicine and Dentistry, Dean, School of Medicine, University of Dundee, UK University of Alberta, Edmonton, Canada Keelin O’Donghue MB BCH BAO MRCOG PHD Grifﬁth Jones MRCOG FRCSC Senior Lecturer and Consultant Obstetrician and Assistant Professor, Division of Maternal–Fetal Gynaecologist, The Anu Research Centre, Cork Medicine, University of Ottawa, Ottawa, Canada University Maternity Hospital, Department of Obstetrics and Gynaecology, University College Lucy Kean MA DM FRCOG Cork, Cork, Ireland Consultant Obstetrician and Subspecialist in Fetal and Maternal Medicine, Department of Obstetrics, Janet M Rennie MA MD FRCP FRCPCH DCH City Campus, Nottingham University Hospitals, Consultant and Senior Lecturer in Neonatal Nottingham, UK Medicine, Elizabeth Garrett Anderson and Obstetric Hospital, University College London Hospitals, Louise C Kenny MBCHB (HONS) MRCOG PHD London, UK Professor of Obstetrics and Consultant Obstetrician and Gynaecologist, The Anu Research Centre, Clare Tower MBCHB PHD MRCOG Cork University Maternity Hospital, Department Clinical Lecture and Subspecialty Trainee in Fetal of Obstetrics and Gynaecology, University College and Maternal Medicine, Maternal and Fetal Health Cork, Cork, Ireland Research Centre, St Mary’s Hospital, University of Manchester, UK Alec McEwan BA BM BCH MRCOG Sarah Vause MD FRCOG Consultant in Obstetrics and Subspecialist in Fetal and Maternal Medicine, Department of Obstetrics, Consultant in Fetal and Maternal Medicine Nottingham University Hospitals, Nottingham, UK St Mary’s Hospital, Manchester Preface Obstetrics by Ten Teachers is the oldest and most respected English language textbook on the subject. As editors we fully appreciate the responsibility to ensure its continuing success. The ﬁrst edition was published as Midwifery by Ten Teachers in 1917, and was edited under the direction of Comyns Berkley (Obstetric and Gynaecological Surgeon to the Middlesex Hospital). The aims of the book as detailed in the preface to the ﬁrst edition still pertain today: This book is frankly written for students preparing for their ﬁnal examination, and in the hope that it will prove useful to them afterwards, and to others who have passed beyond the stage of examination. Thus, whilst the 19th edition is written for the medical student, we hope the text retains its usefulness for the trainee obstetrician and general pratitioners. The 19th edition continues the tradition, re-established with the 18th edition, of utilizing the collective efforts of ten teachers of repute. The ten teachers teach in medical schools that vary markedly in the philosophy and structure of their courses. Some adopt a wholly problem-based approach, while others adopt a more traditional ‘subject-based’ curriculum. All of the ten teachers have an active involvement in both undergraduate and postgraduate teaching, and all have previously written extensively within their areas of expertise. Some of the contributors, such as Gary Mires, have been at the forefront of innovations in undergraduate teaching, and have been heavily involved in developing the structure of courses and curricula. In contrast, other teachers are at earlier stages in their career: Clare Tower is a clinical lecturer, closely involved in the day-to-day tutoring of students. The extensive and diverse experience of our ten teachers should maximize the relevance of the text to today’s medical students. This 19th edition has been extensively revised and in many places entirely rewritten but throughout the textbook we have endeavoured to continue the previous editors’ efforts to incorporate clinically relevant material. Finally, we echo the previous editors in hoping that this book will enthuse a new generation of obstetricians to make pregnancy and childbirth an even safer and more fulﬁlling experience. Philip N Baker Louise C Kenny 2011 Commonly used abbreviat ions 2,3-DPG 2,3-diphosphoglycerate 3D three-dimensional AC abdominal circumference aCL anti-cardiolipin antibodies ACR American College of Rheumatology ACTH adrenocorticotrophic hormone AFI amniotic ﬂuid index AIDS acquired immunodeﬁciency syndrome AP anteroposterior APH antepartum haemorrhage APS antiphospholipid syndrome ARM artiﬁcial rupture of membranes ASBAH Association for spina biﬁda and hydrocephalus BMI body mass index BMR basal metabolic rate BPD biparietal diameter bpm beats per minute BPP biophysical proﬁle BV bacterial vaginosis CBG cortisol-binding globulin CDC Communicable Disease Center CEMACH Conﬁdential Enquiry into Maternal and Child Health CEMD Conﬁdential Enquiries into Maternal Death CF cystic ﬁbrosis CKD chronic kidney disease CMACE Centre for Maternal and Child Enquiries CMV cytomegalovirus CNST Clinical Negligence Scheme for Trusts CPD cephalopelvic disproportion CPR cardiopulmonary resuscitation CRH corticotrophin-releasing hormone CRL crown–rump length CRM clinical risk management CSE combined spinal–epidural CT computed tomography CTG cardiotocograph CTPA computed tomography pulmonary angiogram CVS chorion villus sampling DCDA dichorionic diamniotic DDH developmental dysplasia of the hip DHA docosahexaenoic acid DHEA dihydroepiandrosterone DIC disseminated intravascular coagulation DVT deep vein thrombosis xii Commonly used abbreviations eAg e antigen ECG electrocardiogram ECT electroconvulsive therapy ECV external cephalic version EDD estimated date of delivery EEG electroencephalography EFM external fetal monitoring EFW estimate of fetal weight EIA enzyme immunoassay ERCS elective repeat Caesarean section FBS fetal scalp blood sampling FEV1 forced expiratory volume in 1 second fFN fetal ﬁbronectin FGR fetal growth restriction FHR fetal heart rate FL femur length FRC functional residual capacity fT4 free T4 FVS fetal varicella syndrome G6PD glucose 6-phosphate dehydrogenase GBS group B streptococcus GDM gestational diabetes mellitus GFR glomerular ﬁltration rate GMH-IVH germinal matrix-intraventricular haemorrhage GnRH gonadotrophin releasing hormone GP general practitioner HAART highly active antiretroviral therapy HbF fetal haemoglobin HBIG hepatitis B immunoglobulin HBsAG hepatitis B surface antigen HBV hepatitis B virus HC head circumference hCG human chorionic gonadotrophin HCV hepatitis C virus HDFN haemolytic disease of the fetus and newborn HELLP haemolysis, elevation of liver enzymes and low platelets hGH human growth hormone HIE hypoxic–ischaemic encephalopathy HIV human immunodeﬁciency virus hPL human placental lactogen HSV herpes simplex virus IBD inﬂammatory bowel disease IDDM insulin-dependent diabetes mellitus Ig immunoglobulin IGF insulin-like growth factor IgG immunoglobulin G INR international normalized ratio IOL induction of labour IRT immunoreactive trypsin Commonly used abbreviations xiii ITP thrombocytopenic purpura IU international units IUGR intrauterine growth restriction IVC inferior vena cava IVF in vitro fertilization LA lupus anticoagulant LDH lactate dehydrogenase LIF leukaemia inhibitory factor LLETZ large loop excision of the transformation zone LMP last menstrual period LMWH low molecular weight heparin MAS meconium aspiration syndrome MCA middle cerebral artery MCADD medium chain acyl coenzyme A dehydrogenase MCDA monochorionic diamniotic MCMA monochorionic monoamniotic MI myocardial infarction MMR maternal mortality ratio; measles, mumps and rubella vaccine MRI magnetic resonance imaging MSLC Maternity Services Liaison Committee MSU midstream specimen of urine NCT National Childbirth Trust NHS National Health Service NHSLA NHS Litigation Authority NICE National Institute for Health and Clinical Excellence NIDDM non-insulin-dependent diabetes mellitus NIPE newborn and infant physical examination NK natural killer NO nitrous oxide NYHA New York Heart Association OGTT oral glucose tolerance test PAI plasma activator inhibitor PAPP-A pregnancy associated plasma protein-A PBC primary biliary cirrhosis PCA patient-controlled analgesia pCO2 partial pressure of carbon dioxide PCR polymerase chain reaction PE pulmonary embolism PEP polymorphic eruption of pregnancy PG pemphigoid gestationis PH pulmonary hypertension pO2 partial pressure of oxygen PPH postpartum haemorrhage PPHN persistent pulmonary hypertension of the newborn PPROM preterm prelabour rupture of membranes PT prothrombin time PTCA percutaneous transluminal coronary angioplasty PTH parathyroid hormone PTL preterm labour xiv Commonly used abbreviations PTU propylthiouracil PVL periventricular leukomalacia RA rheumatoid arthritis RCOG Royal College of Obstetricians and Gynaecologists RDS respiratory distress syndrome REM rapid eye movement SANDS Stillbirth and Neonatal Death Society SARS severe acute respiratory syndrome SCD sickle cell disease SFH symphysis–fundal height SGA small for gestational age SLE systemic lupus erythematosus SROM spontaneous rupture of the membranes SSRI selective serotonin reuptake inhibitors T3 tri-iodothyronine T4 thyroxine TAMBA Twins and Multiple Birth Association TCA tricyclic antidepressant drugs TENS transcutaneous electrical nerve stimulation TOF tracheo-oesophageal ﬁstula tPA tissue plasminogen activator TPHA T. pallidum haemagglutination assay TRH thyrotrophin releasing hormone TSH thyroid stimulating hormone TTN transient tachypnoea of the newborn TTTS twin-to-twin transfusion syndrome UFH unfractionated heparin UTI urinary tract infection VACTERL Vertebral, Anal, Cardiac, Tracheal, (O)Esophageal, Renal and Limb VBAC vaginal birth after Caesarean VDRL Venereal Diseases Research Laboratory VKDB vitamin K deﬁciency bleeding VTE venous thromboembolic disease VWF von Willebrand factor VZIG varicella zoster immunoglobulin VZV varicella zoster virus WHO World Heath Organization C H APT ER 1 O B S T E T R I C H I ST O R Y T AKI NG A N D E X AMI NAT I O N Lucy Kean Etiquette in taking a history.................................................................... 1 Examination...................................................................................................... 6 Where to begin................................................................................................ 1 General medical examination................................................................ 7 Dating the pregnancy................................................................................. 1 Presentation skills...................................................................................... 11 Taking the history......................................................................................... 2 History template.......................................................................................... 12 Identifying risk................................................................................................. 6 OVERVIEW Taking a history and performing an obstetric examination are quite different from their medical and surgical equivalents. Not only will the type of questions change with gestation but also will the purpose of the examination. The history will often cover physiology, pathology and psychology and must always be sought with care and sensitivity. this baseline information is established, many women Etiquette in taking a history ﬁnd it tedious to go over all this information again. Patients expect doctors and students to be well Before starting, ask yourself what you need to achieve. presented and appearances do have an enormous In late pregnancy, women will be attending the impact on patients, so make sure that your appearance antenatal clinic for a particular reason. It is certainly is suitable before you enter the room. acceptable to ask why the patient has attended in When meeting a patient for the ﬁrst time, always the opening discussion. For some women it will be introduce yourself; tell the patient who you are and say a routine visit (usually performed by the midwife or why you have come to see them. If you are a medical general practitioner), others are attending because student, some patients will decide that they do not there is or has been a problem. wish to talk to you. This may be for many reasons and, Make sure that the patient is comfortable (usually if your involvement in their care is declined, accept seated but occasionally sitting on a bed). without questioning. It is important to establish some very general facts Some areas of the obstetric history cover subjects when taking a history. Asking for the patient’s age or that are intensely private. In occasional cases there date of birth and whether this is a ﬁrst pregnancy are may be events recorded in the notes that are not usually safe opening questions. known by other family members, such as previous At this stage you can also establish whether a terminations of pregnancy. It is vital that the history woman is working and, if so, what she does. taker is sensitive to each individual situation and does not simply follow a formula to get all the facts right. Dating the pregnancy Some women will wish another person to be present if the doctor or student is male, even just to Pregnancy has been historically dated from the last take a history, and this wish should be respected. menstrual period (LMP), not the date of conception. The median duration of pregnancy is 280 days (40 weeks) and this gives the estimated date of delivery Where to begin (EDD). This assumes that: The amount of detail required must be tailored to the the cycle length is 28 days; purpose of the visit. At a booking visit, the history must be thorough and meticulously recorded. Once ovulation cycle; occurs generally on the 14th day of the 2 Obstetric history taking and examination the cycle was a normal cycle (i.e. not straight after stopping the oral contraceptive pill or soon after a unsuitable for use in deﬁning dates. It has been shown that ultrasound-deﬁned dates are more accurate than previous pregnancy). those based on a certain LMP and reduce the need for post-dates induction of labour. This may be because The EDD is calculated by taking the date of the the actual time of ovulation in any cycle is much less LMP, counting forward by nine months and adding ﬁxed than was previously thought. Therefore, the UK 7 days. If the cycle is longer than 28 days, add the National Screening Committee has recommended difference between the cycle length and 28 to that pregnancy dates are set only by ultrasound. compensate. The crown–rump length is used up until 13 weeks ⫹ In most antenatal clinics, there are pregnancy 6 days, and the head circumference from 14 to calculators (wheels) that do this for you (Figure 1.1). 20 weeks. Regardless of the date of the LMP this It is worth noting that pregnancy-calculating EDD is used. It is important that an accurate EDD is wheels do differ a little and may give dates that established as a difference of a day or two can make are a day or two different from those previously a difference in the risk for conditions such as Down’s calculated. While this should not make much syndrome on serum screening. In addition, accurate difference, it is an area that often causes heated dating reduces the need for post-dates induction of discussion in the antenatal clinic. Term is actually labour. deﬁ ned as 37–42 weeks and so the estimated time In late pregnancy, many women will have long of delivery should ideally be deﬁ ned as a range of forgotten their LMP date, but will know exactly when dates rather than a ﬁ xed date, but women have been their EDD is, and it is therefore more straightforward highly resistant to this idea and generally do want to ask this. a speciﬁc date. Almost all women who undergo antenatal care in the UK will have an ultrasound scan in the late ﬁrst Taking the history trimester or early second trimester. The purposes of this scan are to establish dates, to ensure that the pregnancy is ongoing and to determine the number of fetuses. If Social history performed before 20 weeks, the ultrasound scan can be used for dating the pregnancy. After this time, the Some aspects of history taking require considerable variability in growth rates of different fetuses makes it sensitivity, and the social history is one such area. There are important facts to establish, but in many cases these can come out at various different parts of the history and some can almost be part of normal conversation. It is important to have a list of things to establish in your mind. It is here more than anywhere that some local knowledge is helpful, as much can be gained from knowing where the patient lives. However, be careful not to jump to conclusions, as these can often be wrong. The following facts demonstrate why a social history is important: Women whose partners were unemployed or working in an unclassiﬁable role had a maternal mortality rate seven times higher than women whose partners were employed according to the Conﬁdential Enquiry into Maternal and Child Health 2003–2005 (CEMACH). Social exclusion was seen in 18 out of 19 deaths in women under 20 in the 1997–1999 Conﬁdential Figure 1.1 Gestation calculator Enquiries into Maternal Death (CEMD) (one Taking the history 3 homeless teenager froze to death in a front have some effects on the pregnancy, and all have garden). financial implications (see Chapter 8, Antenatal Married women are more likely to request amniocentesis after a high-risk Down’s syndrome obstetric complications). By the time you have ﬁnished your history and screening result than unmarried women. Husbands examination you should know the following facts that clearly have a strong voice in decision making. are important in the social history: Ifprovide a woman is unmarried, her partner cannot whether the patient is married or single and what sort of support she has at home (remember that consent for a post-mortem after stillbirth. married women whose only support is a working husband may be very isolated after the birth of a Domestic violence was reported in 12 per cent of the 378 women whose deaths were reported in baby); 1997–1999. generally whether there is a stable income coming into the house; Enquiry about domestic violence is extremely difﬁcult. It is recommended that all women are seen what sort of housing the patient occupies (e.g. a ﬂat with lots of stairs and no lift may be on their own at least once during pregnancy, so that problematic); they can discuss this, if needed, away from an abusive partner. This is not always easy to accomplish. If you whether the woman works and for how long she is planning to work during the pregnancy; happen to be the person with whom this information is shared, you must ensure that it is passed on to the whether drugs; the woman smokes/drinks or uses relevant team, as this may be the only opportunity the woman has to disclose it. Sometimes younger women ifimportant. there are any other features that may be ﬁnd medical students and young doctors much easier to talk to. Be aware of this. Smoking, alcohol and illicit drug intake also Previous obstetric history form part of the social history. Smoking causes a reduction in birthweight in a dose-dependent way. Past obstetric history is one of the most important It also increases the risk of miscarriage, stillbirth areas for establishing risk in the current pregnancy. and neonatal death. There are interventions that It is helpful to list the pregnancies in date order can be offered to women who are still smoking and to discover what the outcome was in each in pregnancy (see Chapter 8, Antenatal obstetric pregnancy. complications). The features that are likely to have impact on Complete abstinence from alcohol is advised, as future pregnancies include: the safety of alcohol is not proven. However, alcohol is probably not harmful in small amounts (less than one recurrent miscarriage (increased risk of miscarriage, fetal growth restriction (FGR)); drink per day). Binge drinking is particularly harmful and can lead to a constellation of features in the baby preterm delivery (increased risk of preterm delivery); known as fetal alcohol syndrome (see Chapter 8, Antenatal obstetric complications). early-onset pre-eclampsia (increased risk of pre-eclampsia/FGR); Enquiry about illicit drug taking is more difﬁcult. Approximately 0.5–1 per cent of women continue abruption (increased risk of recurrence); to take illicit drugs during pregnancy. Be careful not to make assumptions. During the booking visit, the congenital abnormality (recurrence risk depends on type of abnormality); midwife should directly enquire about drug taking. If it is seen as part of the long list of routine questions macrosomic diabetes); baby (may be related to gestational asked at this visit, it is perceived as less threatening. However, sometimes this information comes to FGR (increased recurrence); light at other times. Cocaine and crack cocaine are the most harmful of the illicit drugs taken, but all unexplained stillbirth (increased risk of gestational diabetes). 4 Obstetric history taking and examination The method of delivery for any previous births Previous episodes of pelvic inﬂammatory disease must be recorded, as this can have implications for increase the risk for ectopic pregnancy. This is only of planning in the current pregnancy, particularly if there relevance in early pregnancy. However, it is important has been a previous Caesarean section, difﬁcult vaginal to establish that any infections have been adequately delivery, postpartum haemorrhage or significant treated and that the partner was also treated. perineal trauma. The date of the last cervical smear should be When you have noted all the pregnancies, you can noted. Every year a small number of women are convert this into the obstetric shorthand of parity. diagnosed as having cervical cancer in pregnancy, and This is often confusing. Remember that: it is recognized that late diagnosis is more common around the time of pregnancy because smears are gravida is the total number of pregnancies regardless of how they ended; deferred. If a smear is due, it can be taken in the ﬁrst trimester. It is important to record that the woman is parity is the number of live births at any gestation or stillbirths after 24 weeks. pregnant, as the cells can be difﬁcult to assess without this knowledge. It is also important that smears are not In terms of parity, therefore, twins count as two. deferred in women who are at increased risk of cervical Thus a woman at 12 weeks in this pregnancy who has disease (e.g. previous cervical smear abnormality or never had a pregnancy before is gravida 1, parity 0. If very overdue smear). Gently taking a smear in the she delivers twins and comes back next time at ﬁrst trimester does not cause miscarriage and women 12 weeks, she will be gravida 2, parity 2 (twins). A should be reassured about this. Remember that if it is woman who has had six miscarriages and is pregnant deferred at this point, it may be nearly a year before again with only one live baby born at 25 weeks will be the opportunity arises again. If there has been irregular gravida 8, parity 1. bleeding, the cervix should at least be examined to The other shorthand you may see is where parity ensure that there are no obvious lesions present. is denoted with the number of pregnancies that did If a woman has undergone treatment for cervical not result in live birth or stillbirth after 24 weeks as a changes, this should be noted. Knife cone biopsy is superscript number. The above cases would thus be associated with an increased risk for both cervical deﬁned as: para 00, para 20 (twins), para 16. incompetence (weakness) and stenosis (leading to However, when presenting a history, it is much preterm delivery and dystocia in labour, respectively). easier to describe exactly what has happened, There is probably a very small increase in the risk of e.g. ‘Mrs Jones is in her eighth pregnancy. She has preterm birth associated with large loop excision of had six miscarriages at gestations of 8–12 weeks the transformation zone (LLETZ); however, women and one spontaneous delivery of a live baby boy at who have needed more than one excision are likely 25 weeks. Baby Tom is now 2 years old and healthy’. to have a much shorter cervix, which does increase the risk for second and early third trimester delivery. Past gynaecological history Previous ectopic pregnancy increases the risk of recurrence to 1 in 10. It is also important to know The regularity of periods used to be important in dating the site of the ectopic and how it was managed. The pregnancy (see Dating the pregnancy p. 1). Women implications of a straightforward salpingectomy for with very long cycles may have a condition known as an ampullary ectopic are much less than those after polycystic ovarian syndrome. This is a complex endocrine a complex operation for a cornual ectopic. Women condition and its relevance here is that some women who have had an ectopic pregnancy should be offered with this condition have increased insulin resistance and an early ultrasound scan to establish the site of any a higher risk for the development of gestational diabetes. future pregnancies. Contraceptive history can be relevant if conception Recurrent miscarriage may be associated with a has occurred soon after stopping the combined oral number of problems. Antiphospholipid syndrome contraceptive pill or depot progesterone preparations, increases the risk of further pregnancy loss, FGR as again, this makes dating by LMP more difﬁcult. and pre-eclampsia. Balanced translocations can Also, some women will conceive with an intrauterine occasionally lead to congenital abnormality, and device still in situ. This carries an increase in the risk cervical incompetence can predispose to late second of miscarriage. and early third trimester delivery. Also, women need Taking the history 5 a great deal of support during pregnancy if they have Major pre-existing diseases that impact on experienced recurrent pregnancy losses. pregnancy Multiple previous ﬁrst trimester terminations of pregnancy potentially increase the risk of preterm Diabetes mellitus: macrosomia, FGR, congenital delivery, possibly secondary to cervical weakness. abnormality, pre-eclampsia, stillbirth, neonatal Sometimes information regarding these must be hypoglycaemia. sensitively recorded. Some women do not wish this to Hypertension: pre-eclampsia. be recorded in their hand-held notes. Renal disease: worsening renal disease, pre-eclampsia, Previous gynaecological surgery is important, FGR, preterm delivery. especially if it involved the uterus, as this can have Epilepsy: increased ﬁt frequency, congenital abnormality. potential sequelae for delivery. In addition, the Venous thromboembolic disease: increased risk during presence of pelvic masses such as ovarian cysts and pregnancy; if associated thrombophilia, increased risk ﬁbroids should be noted. These may impact on delivery of thromboembolism and possible increased risk of and may also pose some problems during pregnancy. A pre-eclampsia, FGR. previous history of sub-fertility is also important. Four Human immunodeﬁciency virus (HIV) infection: risk of deaths occurred in CEMACH 2003–2005 of women mother-to-child transfer if untreated. with ovarian hyperstimulation syndrome following IVF. Donor egg or sperm use is associated with an Connective tissue diseases, e.g. systemic lupus erythematosus: pre-eclampsia, FGR. increased risk of pre-eclampsia. The rate of preterm delivery is higher in assisted conception pregnancies, Myasthenia gravis/myotonic dystrophy: fetal neurological even after the higher rate of multiple pregnancies has effects and increased maternal muscular fatigue in labour. been taken into account. Women who have undergone fertility treatment are often older and generally need increased psychological support during pregnancy. care received and clinical presentation, and should Legally, you should not write down in notes that a be made in a systematic and sensitive way at the pregnancy is conceived by IVF or donor egg or sperm antenatal booking visit. A good question to lead into unless you have written permission from the patient. this is ‘Have you ever suffered with your nerves?’. It is obviously a difﬁcult area, as there is an increased If women have had children before, you can ask risk of problems to the mother in these pregnancies whether they had problems with depression or ‘the and therefore the knowledge is important. Generally, blues’ after the births of any of them. Women with if the patient has told you herself that the pregnancy signiﬁcant psychiatric problems should be cared for was an assisted conception, it is reasonable to state by a multidisciplinary team, including the midwife, that in your presentation. GP, hospital consultant and psychiatric team. Medical and surgical history Drug history All pre-existing medical disease should be carefully It is vital to establish what drugs women have been noted and any associated drug history also recorded. taking for their condition and for what duration. The major pre-existing diseases that impact on You should also ask about over-the-counter pregnancy and their potential effects are shown medication and homeopathic/herbal remedies. in the box (also see Chapter 12, Medical diseases In some cases, medication needs to be changed in complicating pregnancy). pregnancy. For some women it may be possible to Previous surgery should be noted. Occasionally stop their medication completely for some or all surgery has been performed for conditions that may of the pregnancy (e.g. mild hypertension). Some continue to be a problem during pregnancy, such as women need to know that they must continue their Crohn’s disease. Rarely, complications from previous medication (e.g. epilepsy, for which women often surgery, such as adhesional obstruction, present in reduce their medication for fear of potential fetal pregnancy. effects, with detriment to their own health). Psychiatric history is important to record. These Very few drugs that women of childbearing age enquiries should include the severity of the illness, take are potentially seriously harmful, but a few are, 6 Obstetric history taking and examination and it is always necessary to ensure that drug treatment among the obstetric population is small, adherence to is carefully reviewed. Pre-pregnancy counselling is the principles of infection reduction are vital. In any advised for women who are taking potentially harmful clinical setting you must remove any wristwatches or drugs such as sodium valproate. rings with stones. You should have bare arms from the elbow down. You should ensure that you use alcohol Family history gel when moving from one clinical area to another (e.g. between wards) and always wash hands or use Family history is important if it can: gel before and after any patient contact. The patient impact on the health of the mother in pregnancy or afterwards; should see you do this before you examine them so that they are conﬁdent that you have done so. Before moving on to examine the patient, it is have implications for the fetus or baby. important to be aware of what you are aiming to Important areas are a maternal history of a achieve. The examination should be directed at the ﬁrst-degree relative (sibling or parent) with: presenting problem, if any, and the gestation. For instance, it is generally unnecessary to spend time diabetes (increased risk of gestational diabetes); deﬁning the presentation at 32 weeks unless the thromboembolic disease (increased risk of thrombophilia, thrombosis); presenting problem is threatened preterm labour. pre-eclampsia (increased risk of pre-eclampsia); Maternal weight and height serious psychiatric disorder (increased risk of puerperal psychosis). The measurement of weight at the initial examination is important to identify women who are signiﬁcantly For both parents, it is important to know underweight or overweight. Women with a body about any family history of babies with congenital mass index (BMI) [weight (kg)/height (m2)] of ⬍20 abnormality and any potential genetic problems, are at higher risk of fetal growth restriction and such as haemoglobinopathies. If any close family increased perinatal mortality. This is particularly the member has tuberculosis, the baby will be offered case if weight gain in pregnancy is poor. Repeated immunization after birth. weighing of underweight women during pregnancy Finally, any known allergies should be recorded. will identify that group of women at increased risk If a woman gives a history of allergy, it is important for adverse perinatal outcome due to poor weight to ask about how this was diagnosed and what sort of gain. In the obese woman (BMI ⬎30), the risks of problems it causes. gestational diabetes and hypertension are increased. Additionally, fetal assessment, both by palpation and ultrasound, is more difﬁcult. Obesity is also associated Identifying risk with increased birthweight and a higher perinatal mortality rate. By the time you have ﬁnished the history, you will have In women of normal weight at booking, and in a general idea of whether or not the pregnancy is likely whom nutrition is of no concern, there is no need to to be uncomplicated. Of course, in primigravid women, repeat weight measurement in pregnancy. the likelihood of later complications can be difﬁcult to Height should be measured at booking to assist predict, but even here some features such as a strong with BMI assessment. Other than this, it is only family history of pre-eclampsia may be present. relevant in pregnancy when fetal overgrowth or undergrowth is suspected, as customized charts have signiﬁcant advantages in the case of very tall Examination or short women, leading to more accurate diagnosis of growth restriction or macrosomia. Short women Basic principles of infection control are signiﬁcantly more likely to have problems in labour, but these are generally unpredictable during Hospital acquired infection has been a major problem pregnancy. Shoe size is unhelpful when height is for some groups of patients. While the incidence known. Height alone is the best indicator of potential General medical examination 7 problems in labour, but even this is not a useful At repeat visits, urinalysis should be performed. predictor. On no account should you give women This is the other proven beneﬁcial aspect of antenatal the impression that their labour will be unsuccessful care. If there is any proteinuria, a thorough evaluation because they are short. Were this always the case, the with regard to a diagnosis of pre-eclampsia should genes for being short would have disappeared from be undertaken. A trace of protein is unlikely to be the population long ago. problematic in terms of pre-eclampsia, and may point to urinary tract infection. However, if even a trace Blood pressure evaluation of protein is seen persistently, further investigation should be undertaken. The ﬁrst recording of blood pressure should be made as early as possible in pregnancy. Hypertension diagnosed for the ﬁrst time in early pregnancy (blood pressure General medical examination ⬎140/90 mmHg on two separate occasions at least 4 hours apart) should prompt a search for underlying In ﬁt and healthy women presenting for a routine causes, i.e. renal, endocrine and collagen-vascular visit there is little beneﬁt in a full formal physical disease. Although 90 per cent of cases will be due to examination. Where a woman presents with a essential hypertension, this is a diagnosis of exclusion problem, there may be a need to undertake a much and can only be conﬁdently made when other secondary more thorough physical examination. causes have been excluded. Blood pressure measurement is one of the few aspects of antenatal care that is truly Cardiovascular examination beneﬁcial. It should be performed at every visit. Routine auscultation for maternal heart sounds Measure the blood pressure with the woman in asymptomatic women with no cardiac history seated or semi-recumbent. Do not lie her in the left is unnecessary. Flow murmurs can be heard in lateral position, as this will lead to under-reading of approximately 80 per cent of women at the end of the the blood pressure. ﬁrst trimester. Studies suggest that women coming Use an appropriately sized cuff. The cuffs have from areas where rheumatic heart disease is prevalent markings to indicate how they should ﬁt. Large women and those with signiﬁcant symptoms or a known history will need a larger cuff. Using one too small will over- of heart murmur or heart disease should undergo estimate blood pressure. If you are using an automated cardiovascular examination during pregnancy. device and the blood pressure appears high, recheck it with a hand-operated device that has been recently Breast examination calibrated (every clinic should have one). Convention is to use Korotkoff V (i.e. disappearance Formal breast examination is not necessary; self- of sounds), as this is more reproducible than examination is as reliable as a general physician Korotkoff IV. Deﬂate the cuff slowly so that you can examination in detecting breast masses. Women record the blood pressure to the nearest 2 mmHg. should, however, be encouraged to report new or Do not round up or down. If the Vth sound is heard to suspicious lumps that develop and, where appropriate, near zero, give the values for the IVth and Vth sounds. full investigation should not be delayed because of pregnancy. The risk of a deﬁnite lump being cancer in Urinary examination the under 40s is approximately 5 per cent, and late-stage diagnosis is more common in pregnancy because of Screening of midstream urine for asymptomatic delayed referral and investigation. Nipple examination bacteriuria in pregnancy is of proven beneﬁt. The is not a good indicator of problems with breastfeeding risk of ascending urinary tract infection in pregnancy and there is no intervention that improves feeding is much higher than in the non-pregnant state. Acute success in women with nipple inversion. pyelonephritis increases the risk of pregnancy loss/ premature labour, and is associated with considerable Abdomen maternal morbidity. Additionally, persistent proteinuria or haematuria may be an indicator of underlying renal To examine the abdomen of a pregnant woman, place disease, prompting further investigation. her in a semi-recumbent position on a couch or bed. 8 Obstetric history taking and examination Women in late pregnancy or with multiple pregnancies late third trimester the fundal height is usually may not be able to lie very ﬂat. Sometimes a pillow approximately 2 cm less than the number of weeks. under one buttock to move the weight of the fetus a It is always important to use the chart where one little to the right or left can help. Cover the woman’s is available (Figure 1.2). Encourage women to ask legs with a sheet and make sure she is comfortable to have their abdomen measured rather than just before you start. Always have a chaperone with you to palpated at every visit and for the results to be perform this examination. plotted on the chart. Think about what you hope to achieve from the examination and ask about areas of tenderness before Fetal lie, presentation and engagement you start. Before you start to palpate, you will have an idea about any potential problems. A large SFH raises the Inspection possibility of: Assess the shape of the uterus and note any asymmetry. macrosomia; Look for fetal movements. multiple pregnancy; Look for scars (women often forget to mention polyhydramnios. previous surgical procedures if they were Rarely, a twin is missed on ultrasound! performed long ago). The common areas to ﬁnd A small SFH could represent: scars are: suprapubic (Caesarean section, laparotomy for FGR; ectopic pregnancy or ovarian masses); oligohydramnios. sub-umbilical (laparoscopy); After you have measured the SFH, palpate to right iliac fossa (appendicectomy); count the number of fetal poles (Figure 1.3). A pole is a head or a bottom. If you can feel one or two, it is right upper quadrant (cholycystectomy). likely to be a singleton pregnancy. If you can feel three Note any striae gravidarum or linea nigra (the faint brown line running from the umbilicus to or four, a twin pregnancy is likely. Sometimes large ﬁbroids can mimic a fetal pole; remember this if there the symphysis pubis) – not because they mean is a history of ﬁbroids. anything, but because obstetricians like to see that students notice these. Fundal height (cm) Weight (g) Palpation 44 5000 Symphysis–fundal height measurement 42 4500 First, measure the symphysis–fundal height (SFH). 40 4000 This will give you a clue regarding potential problems 38 3500 such as polyhydramnios, multiple pregnancy or 36 3000 growth restriction before you start to palpate. 34 Feel carefully for the top of the fundus. This 2500 32 is rarely in the midline. Make a mental note of 2000 30 where it is. Now feel very carefully and gently for 1500 the upper border of the symphysis pubis. Place the 28 1000 tape measure on the symphysis pubis and, with 26 the centimetre marks face down, measure to the 24 500 previously noted top of the fundus. Turn the tape 22 0 measure over and read the measurement. Plot the 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 measurement on an SFH chart – this will usually Gestation in weeks be present in the hand-held notes. If plotted on a Figure 1.2 Customized symphysis–fundal height chart correctly derived chart, it is apparent that in the (courtesy of the West Midlands Perinatal Institute) General medical examination 9 presentation is. It will be either cephalic (head down) or breech (bottom/feet down). Using a two-handed approach and watching the woman’s face, gently feel for the presenting part. The head is generally much ﬁrmer than the bottom, although even in experienced hands it can sometimes be very difﬁcult to tell. As you are feeling the presenting part in this way, assess whether it is engaged or not. If you can feel the whole of the fetal head and it is easily movable, the head is likely to be ‘free’. This equates to 5/5th palpable and is recorded as 5/5. As the head descends into the pelvis, less can be felt. When the head is no longer movable, it has ‘engaged’ and only 1/5th or 2/5th will be palpable Figure 1.3 Palpation of the gravid abdomen (see Figure 1.4). Do not use a one-handed technique, as this is much more uncomfortable for the woman. Now you can assess the lie. This is only necessary Do not worry about trying to determine as the likelihood of labour increases, i.e. after 34–36 the fetal position (i.e. whether the fetal head is weeks in an uncomplicated pregnancy. occipito-posterior, lateral or anterior). It makes no If there is a pole over the pelvis, the lie is difference until labour begins, and even then is only longitudinal regardless of whether the other pole is of importance if progress in labour is slow. What is lying more to the left or right. An oblique lie is where more, we do not often get it right, and women can be the leading pole does not lie over the pelvis, but just to very worried if told their baby is ‘back to back’. one side; a transverse lie is where the fetus lies directly If the SFH is large and the fetal parts very difﬁcult across the abdomen. Once you have established to feel, there may be polyhydramnios present. If the that there is a pole over the pelvis, if the gestation SFH is small and the fetal parts very easy to feel, is 34 weeks or more, you need to establish what the oligohydramnios may be the problem. 1 1 2 2 3 3 4 4 5 fifths palpable (a) 1 2 1 3 2 1 (b) Figure 1.4 Palpation of the fetal head to assess engagement 10 Obstetric history taking and examination Auscultation prelabour rupture of the membranes (increased risk of ascending infection). If the fetus has been active during your examination and the mother reports that the baby is active, it Before commencing the examination, assemble is not necessary to auscultate the fetal heart. Very everything you will need (swabs etc.) and ensure occasionally a problem is detected by auscultation, the light source works. Position the patient semi- such as a tachyarrhythmia, but this is rare. Mothers recumbent with knees drawn up and ankles together. do like to hear the heart beat though and therefore Ensure that the patient is adequately covered. If using a hand-held device can allow the mother performing a speculum examination, a Cusco to hear the heart beat. If you are using a Pinard speculum is usually used (Figure 1.5). Select an stethoscope, position it over the fetal shoulder (the appropriate size. only reason to assess the fetal position). Hearing the heart sounds with a Pinard takes a lot of practice. If you cannot hear the fetal heart, never say that you cannot detect a heart beat; always explain that a different method is needed and move on to use a hand-held Doppler device. If you have begun the process of listening to the fetal heart, you must proceed until you are conﬁdent that you have heard the heart. With twins, you must be conﬁdent that both have been heard. Pelvic examination Figure 1.5 A Cusco speculum Routine pelvic examination is not necessary. Given that as many as 18 per cent of women think that a Proceed as follows: pelvic examination can cause miscarriage, and at least 55 per cent ﬁnd it an unpleasant experience, routine Wash your hands and put on a pair of gloves. vaginal examination if ultrasound is planned has few Ifwarm the speculum is metal, warm it slightly under water ﬁrst. advantages beyond the taking of a cervical smear. Consent must be sought and a female chaperone Apply sterile lubricating gel or cream to the blades of the speculum. Do not use Hibitane cream if (nurse, midwife, etc. – never a relative) present (regardless of the sex of the examiner). However, there taking swabs for bacteriology. are circumstances in which a vaginal examination is Gently part the labia. necessary (in most cases a speculum examination is all that is needed). These include: Introduce the speculum with the blades in the vertical plane. excessive or offensive discharge; Astowards the speculum is gently introduced, aiming vaginal bleeding (in the known absence of a placenta praevia); the sacral promontory (i.e. slightly downward), rotate the speculum so that it comes to lie in the horizontal plane with the ratchet to perform a cervical smear; uppermost. to conﬁrm potential rupture of membranes. The blades can then slowly be opened until the A digital examination may be undertaken cervix is visualized. Sometimes minor adjustments to perform a membrane sweep at term, prior to need to be made at this stage. induction of labour. The contraindications to digital examination are: Assess the cervix and take any necessary samples. Gently close the blades and remove the speculum, known placenta praevia or vaginal bleeding when the placental site is unknown and the presenting reversing the manoeuvres needed to insert it. Take care not to catch the vaginal epithelium when part unengaged; removing the speculum. Presentation skills 11 Table 1.1 Bishop score Score 0 1 2 3 Dilation of cervix (cm) 0 1 or 2 3 or 4 5 or more Consistency of cervix Firm Medium Soft Length of cervical canal ⬎2 2–1 1–0.5 ⬍0.5 Position Posterior Central Anterior Station of presenting part (cm above 3 2 1 or 0 Below ischial spine) A digital examination may be performed when an Presentation skills assessment of the cervix is required. This can provide information about the consistency and effacement Part of the art of taking a history and performing an of the cervix that is not obtainable from a speculum examination is to be able to pass this information examination. on to others in a clear and concise format. It is not The patient should be positioned as before. necessary to give a full list of negative findings; it Examining from the patient’s right, two ﬁngers of is enough to summarize negatives such as: there is the gloved right hand are gently introduced into the no important medical, surgical or family history of vagina and advanced until the cervix is palpated. note. Adapt your style of presentation to meet the Prior to induction of labour, a full assessment of the situation. A very concise presentation is needed for Bishop score can be made (Table 1.1). a busy ward round. In an examination, a full and thorough presentation may be required. Be very Other aspects of the examination aware of giving sensitive information in a ward setting where other patients may be within hearing In the presence of hypertension and in women with distance. headache, fundoscopy should be performed. Signs of chronic hypertension include silver-wiring and arteriovenous nipping. In severe pre-eclampsia and some intracranial conditions (space-occupying Key points lesions, benign intracranial hypertension), Always introduce yourself and say who you are. papilloedema may be present. Oedema of the extremities affects 80 per cent Make sure you are wearing your identity badge. of term pregnancies. Its presence should be noted, Wash your hands or use alcohol gel. but it is not a good indicator for pre-eclampsia as Be courteous and gentle. it is so common. To assess pre-tibial oedema, press Always ensure the patient is comfortable and warm. reasonably ﬁrmly over the pre-tibial surface for 20 Always have a chaperone present when you examine seconds. This can be very painful if there is excessive patients. oedema, and when there is it is so obvious that testing for pitting is not necessary. More importantly, facial Tailor your history and examination to ﬁnd the key information you need. oedema should be commented upon. When pre-eclampsia is suspected, the reﬂexes Adapt to new ﬁndings as you go along. should be assessed. These are most easily checked at Present in a clear way. the ankle. The presence of more than three beats of Be aware of giving sensitive information in a public clonus is pathological (see Chapter 10, Pre-eclampsia setting. and other disorders of placentation). 12 Obstetric history taking and examination History template Previous infections and their treatment When was the last cervical smear? Was it normal? Have there ever been any that were abnormal? If Demographic details yes, what treatment has been undertaken? Name Previous gynaecological surgery Age Past medical and surgical history Occupation Make a note of ethnic background Relevant medical problems Presenting complaint or reason for attending Any previous operations; type of anaesthetic used, any complications This pregnancy Psychiatric history Gestation, LMP or EDD Dates as calculated from ultrasound Postpartum blues or depression Single/multiple (chorionicity) Depression unrelated to pregnancy Details of the presenting problem (if any) or Major psychiatric illness reason for attendance (such as problems in a previous pregnancy) Family history What action has been taken? Diabetes, hypertension, genetic problems, Is there a plan for the rest of the pregnancy? psychiatric problems, etc. What are the patient’s main concerns? Have there been any other problems in this pregnancy? Social history Has there been any bleeding, contractions or loss Smoking/alcohol/drugs of ﬂuid vaginally? Marital status Occupation, partner’s occupation Ultrasound Who is available to help at home? What scans have been performed? Are there any housing problems? Why? Drugs Were any problems identiﬁed? All medication including over-the-counter medication Past obstetric history List the previous pregnancies and their outcomes Folate supplementation in order Allergies Gynaecological history To what? Periods: regularity What problems do they cause? Contraceptive history C H APT ER 2 M O DE RN MAT ER NI T Y CAR E Lucy Kean History of maternity care in the UK................................ 13 Clinical Negligence Scheme for Trusts.......................... 16 Coordination of research: the Cochrane Library............. 14 Consumer groups......................................................... 17 Involvement of professional bodies and consumer Maternity care: the global challenge............................. 17 groups in maternity care........................................ 15 Additional reading...................................................................................... 19 OVERVIEW Modern maternity care has evolved over more than 100 years. Many of the changes have been driven by political and consumer pressure. Only recently has any good quality research been conducted into which aspects of care actually make a difference to women and their babies. In the United Kingdom, we are in the enviable position of being able to receive quality maternity care, free at the point of need. This is not so for the majority of women across the world. Despite signing up to ambitious targets for the reduction of maternal mortality, the global community is failing to achieve reductions in mortality, making pregnancy and childbirth a life-threatening challenge for millions of women. History of maternity care in the UK be inversely proportional to the number of antenatal visits. In 1963, the ﬁrst perinatal mortality study The original impetus to address the health of showed that the perinatal mortality rate was lowest for mothers and children was driven by a lack of healthy those women attending between 10 and 24 times in recruits to ﬁght in the Boer War. Up until this point, pregnancy. This failed to take into account prematurity successive governments had paid little attention to and poor education as reasons for decreased visits and maternal or child health. In 1929 the ﬁrst government increased mortality. However, antenatal care became document stated a minimum standard for antenatal established, and with increased professional contact care that was so prescriptive in its recommendations came the drive to continue to improve outcomes with that until very recently it was practised in many an emphasis on mortality (maternal and perinatal), regions, despite the lack of research to demonstrate without always establishing the need for or safety of effectiveness. all procedures or interventions for all women. The National Health Service Act 1946 came The ability to see into the pregnant uterus in into effect on 5 July 1948 and created the National 1958 with ultrasound brought with it a revolution Health Service (NHS) in England and Wales. The in antenatal care. This new intervention became introduction of the NHS provided for maternity quickly established and is now so much part of services to be available to all without cost. As part of current antenatal care that the fact that its use in these arrangements, a specified fee was paid to the improving the outcome for low-risk women was general practitioner (GP) depending on whether he never proven has been little questioned. Attending or she was on the obstetric list. This encouraged a for the ‘scan’ has become such a social part of large number of GPs to take an interest in maternity antenatal care that many surmise that it is, for many care, reversing the previous trend to leave this work women, the sole reason for attending the hospital to the midwives. antenatal clinic. Antenatal care became perceived as beneﬁcial, The move towards hospital conﬁnement began in acceptable and available for all. This was reinforced the early 1950s. At this time, there were simply not the by the ﬁnding that the perinatal death rate seemed to facilities to allow hospital conﬁnement for all women, 14 Modern maternity care and one in three were planned home deliveries. The technologies was challenged. Women, led by the more Cranbrook Report in 1959 recommended sufﬁcient vociferous groups such as the National Childbirth hospital maternity beds for 70 per cent of all conﬁnements Trust (NCT), began to question not only the need to take place in hospital, and the subsequent Peel Report for any intervention but also the need to come to the (1970) recommended a bed available for every woman hospital at all. The professional bodies also began to to deliver in hospital if she so wished. question the effectiveness of antenatal care. The trend towards hospital conﬁnement was not The government set up an expert committee only led by obstetricians. Women themselves were to review policy on maternity care and to make pushing to at least be allowed the choice to deliver recommendations. This committee produced the in hospital. By 1972, only one in ten deliveries were document Changing Childbirth (Department of planned for home, and the publication of the Social Health, Report of the Expert Maternity Group, 1993), Services Committee report in The Short Report which essentially provided purchasers and providers (1980) led to further centralization of hospital with a number of action points aiming to improve conﬁnement. It made a number of recommendations. choice, information and continuity for all women. Among these were: It outlined a number of indicators of success to be achieved within ﬁve years: An increasing number of patients should be delivered in large units; selection of patients should be improved the carriage of hand-held notes by women; for smaller consultant units and isolated GP units; home deliveries should be phased out further. midwifery-led care in 30 per cent of pregnancies; It should be mandatory that all pregnant women should be acases; known midwife at delivery in 75 per cent of seen at least twice by a consultant obstetrician – preferably as soon as possible after the ﬁrst visit to the GP in early alow-risk reduction in the number of antenatal visits for mothers. pregnancy and again in late pregnancy. Unfortunately, those targets which required signiﬁcant This report and the subsequent reports Maternity financial input, such as the presence of a known Care in Action, Antenatal and Intrapartum Care, midwife at 75 per cent of deliveries, have not been met. and Postnatal and Neonatal Care led to a policy of Nevertheless, this landmark report did provide a new increasing centralization of units for delivery and impetus to examine the provision of maternity care in the consequently care. Thus home deliveries are now UK and enshrine choice as a concept in maternity care. very infrequent events, with most regions reporting The most recent government document on less than 2 per cent of births in the community, the maternity care, Maternity Matters, aims to address majority of these being unplanned. inequalities in maternity care provision and uptake The gradual decline in maternal and perinatal and is essentially a document for commissioners to mortality was thought to be due in greater part to this assess maternity care in their area and to ensure that move, although proof for this was lacking. Indeed, safe and effective care is available to all women. the decline in perinatal mortality was least in those The pendulum has swung back, with the years when hospitalization increased the most. As government now moving towards increased choices other new technologies became available, such as for women including birth at home or in a stand- continuous fetal monitoring and the ability to induce alone midwifery unit. labour, a change in practice began to establish these as the norm for most women. In England and Wales between 1966 and 1974, the induction rate rose from Coordination of research: 12.7 to 38.9 per cent. the Cochrane Library The fact that these new technologies had not undergone thorough trials of benefit prior The study of the effectiveness of pregnancy care to introduction meant that beneﬁt to the whole has been revolutionized by the establishment of the population of women was never established. Cochrane Library. This has led to the evaluation of each During the 1980s, with increasing consumer aspect of antenatal, intrapartum and post-natal care, awareness, the unquestioning acceptance of unproven and allowed each to be meticulously examined on the Involvement of professional bodies and 15 consumer groups in maternity care basis of the available trials. Concentrating particularly its widest form. The National Screening Committee is on the randomized controlled trial design, and using responsible for developing standards and strategies for meta-analysis, obstetric practice has been scrutinized the implementation of these. The National Screening to an extent unique in medicine. Committee has uniﬁed and progressed standards for The database originally grew from the publication all aspects of antenatal screening across the United of Archie Cochrane’s Effectiveness and efﬁciency: random Kingdom. reﬂections on health services in 1972. The identiﬁcation of The provision of national standards means that controlled trials in perinatal medicine began in Cardiff new tests are critically evaluated before being offered in 1974. In 1978, the World Health Organization and to populations. Screening for additional diseases/ English Department of Health funded work at the conditions to those given below is only considered National Perinatal Epidemiology Unit, Oxford, UK, if the test is good enough and the disease/condition to assemble a register of controlled trials in perinatal meets the very stringent criteria for justiﬁcation of medicine. Now the collaboration covers all branches of screening. Conditions for which screening is currently medicine. The ﬁndings are published in the Cochrane not recommended, such as group B streptococcus Library, which is free to access for all UK healthcare carriage, are regularly reviewed against current workers via the National Library for Health at www. evidence. library.nhs.uk. It is serially updated to keep up with Antenatal screening is now offered for: published work and represents an enormous body of information available to the clinician. Down’s syndrome; fetal anomaly (by ultrasound); Involvement of professional bodies and haemoglobinopathies; consumer groups in maternity care rubella status; HIV/hepatitis B status; Maternity care is considered so important that many Tay–Sachs disease in high-risk populations. clinical, political and consumer bodies are now Newborn screening includes: involved in how it is provided. hearing; National Institute for Health and Clinical Excellence phenylketonuria; congenital hypothyroidism; As can be seen from the above, maternity care has been cystic ﬁbrosis; the subject of political debate for the last 100 years. medium chain acyl co-A dehydrogenase deﬁciency. More recently, attention has been paid to differences in standards of health care across the UK. The National Institute for Health and Clinical Excellence Royal College of Obstetricians and (NICE) has evaluated maternity care in great detail Gynaecologists and has published a number of important guidelines, covering antenatal, intrapartum and post-natal care. The Royal College of Obstetricians and Gynaecologists Trusts are judged by their ability to provide care to (RCOG) has many roles. These include developing the standards set out in these guidelines. The process guidelines, setting standards for the provision of care, of guideline development is rigorous and stakeholders training and revalidation, audit and research. are consulted at each stage of development. The Guidelines and standards guidelines are available through the NICE website The RCOG publishes a large number of guidelines (www.nice.org.uk) and provide the framework for pertinent to pregnancy with patient information leaﬂets standards of care within England and Wales. to accompany many of these. They are reviewed three- National Screening Committee yearly and are accessible to all on the college website (www.rcog.org.uk). Screening has formed a part of antenatal care since The RCOG works in partnership with other its inception. Antenatal care is essentially screening in colleges such as the Royal College of Midwives to 16 Modern maternity care set standards for maternity care. These standards section rate. It has provided interesting data for the provide important drivers to organizations such as trends in Caesarean section across the UK. the Clinical Negligence Scheme for Trusts in setting The conﬁdential enquiries are a vital source of standards for levels of care and performance by information to clinicians and service providers. These hospitals. are produced under the umbrella of the Centre for Maternal and Child Enquiries (CMACE), previously Revalidation and continuing professional known as the Conﬁdential Enquiries into Maternal development and Child Health (CEMACH). Revalidation of professionals is increasingly CMACE produce national and local audits and important. In order to be maintained on the General reports into a wide range of maternal and child Medical Council Register, all doctors will need to health issues. From an obstetric perspective, the most produce evidence that they are keeping up to date important is the triennial report on maternal mortality. within their chosen specialty. In the near future, This report has led to important improvements in failure to provide evidence of revalidation will maternity care, with signiﬁcant reductions in deaths lead to the removal of a doctor’s licence to practise from thromboembolism, hypertension and anaesthesia medicine. Part of the revalidation process involves the being seen after national recommendations made coordination and documentation of education and through this channel (Figure 2.1). professional developmental activity. The RCOG plays the major role in this important task. All practising obstetricians will need to complete a ﬁve-year cycle of Venous thromboembolism after CS

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