A woman presents in threatened preterm labour well before term. Which intervention most improves neonatal outcome? A. Tocolysis to stop the contractions B. Antenatal corticosteroids C. Immediate caesarean section D. Bed rest ANSWER: B — antenatal corticosteroids. Why: given to the mother, they cross the placenta and accelerate fetal LUNG MATURATION, reducing neonatal death, respiratory distress and bleeding into the immature brain. This is the single largest available gain. THE ROLE OF TOCOLYSIS (A): it does NOT by itself improve neonatal outcome. Its purpose is to buy a window of HOURS in which steroids can act and transfer can be arranged. Understanding that relationship is what the question is testing.

A district hospital expects to deliver a very preterm baby and has no neonatal intensive care. Should the baby be delivered and then transferred, or should the mother be transferred first? ANSWER: TRANSFER THE MOTHER, before delivery, if there is time. WHY: a sick preterm newborn tolerates transfer far worse than the pregnant woman carrying it. In utero, the baby has stable temperature, oxygenation and circulation — the mother is the best incubator and transport system available. CAVEAT: the window is short, and transfer must not be attempted if delivery is imminent or the mother is unstable. But where there is time, in utero transfer is clearly preferable. DO BOTH IF POSSIBLE: give steroids AND arrange transfer — they are not alternatives.

A woman with ruptured membranes remote from term develops fever, uterine tenderness and offensive-smelling liquor. The fetal heart rate is elevated. What should be done? ANSWER: DELIVER. This is CHORIOAMNIONITIS. The usual balance in prelabour rupture of membranes — waiting to gain fetal maturity versus delivering to avoid infection — no longer applies. The uterus is already infected. CONTINUING THE PREGNANCY NOW RISKS: - maternal sepsis - fetal infection and death So delivery is indicated regardless of gestation, alongside treatment of the infection. RELATED PREVENTIVE POINT: avoid repeated digital vaginal examination after membranes rupture — each one carries organisms upward. Use a sterile speculum where examination is needed.

Two fetuses measure below the expected size for gestation. How do you distinguish the healthy one from the one at risk? ANSWER: by the GROWTH TREND, not a single measurement. CONSTITUTIONALLY SMALL Small parents, small baby. Growing STEADILY along its own line. Healthy; needs recognition, not intervention. GROWTH RESTRICTED Not receiving what it needs, usually a placental problem. Growth SLOWING, or crossing downward across centiles. At real risk of STILLBIRTH. A single measurement below average means little. A falling trajectory means a great deal — which is why SERIAL measurement exists and one scan cannot answer the question. AND LOOK FOR THE CAUSE: growth restriction and pre-eclampsia share a placental origin. Check her blood pressure and urine.

A woman telephones at 34 weeks reporting that the baby has been moving less for a day. She has no pain or bleeding. What is the correct response? A. Reassure her; movements often reduce in late pregnancy B. Advise her to lie down, drink something cold and count movements for two hours, then call back C. Ask her to attend now so the fetal heart can be assessed D. Bring her routine appointment forward by a week ANSWER: C — she must be SEEN. WHY: a fetus short of oxygen conserves energy by MOVING LESS. Reduced movement may be the ONLY warning before stillbirth. THE TRAP: most women reporting reduced movements have a healthy baby. That reassuring base rate is exactly what makes telephone reassurance feel reasonable — and it is not. The cost of seeing many well women is small; the cost of missing one compromised fetus is a preventable death. COUNSELLING POINT: tell every woman what to report, at every visit. A woman who has not been told will wait for her next appointment.

What is the strongest predictor of preterm birth, and name three other risk factors. ANSWER: a PREVIOUS PRETERM BIRTH is the strongest predictor. Such a woman should be identified early and followed more closely, because she is the one most likely to benefit from planning. OTHER RISK FACTORS (any three): - multiple pregnancy - infection, particularly urinary tract infection - smoking - short interpregnancy interval - heavy physical work with poor nutrition PREVENTIVE POINT: treating ASYMPTOMATIC urinary infection in pregnancy is one of the few clearly effective measures, which is why it forms part of routine antenatal care.