Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) Intrapartum Care and Obstetric Emergencies Syllabus

What is the most common malposition of the fetal head and how does it typically resolve?

Occipitoposterior (OP) position is the most common malposition. About 90% rotate spontaneously to occipitoanterior; the remainder may deliver as persistent OP (face-to-pubes), undergo rotational instrumental/manual rotation, or require caesarean.

Differentiate malpresentation from malposition.

Malposition refers to an abnormal position of the vertex relative to the maternal pelvis (e.g. occipitoposterior, occipitotransverse). Malpresentation is any presenting part other than the vertex (e.g. breech, brow, face, shoulder/transverse lie, compound).

What diameters present in face and brow presentations, and what is the implication for vaginal delivery?

Face presentation: submentobregmatic diameter $\approx 9.5\ \text{cm}$ — vaginal birth possible only in mento-anterior position. Brow presentation: mentovertical diameter $\approx 13\ \text{cm}$ (largest) — incompatible with vaginal delivery unless it converts, usually requiring caesarean.

Define preterm labour and the gestational age threshold.

Preterm labour is the onset of labour (regular contractions with cervical change) before $37^{+0}$ weeks of gestation. It is subclassified as extremely preterm (<28 weeks), very preterm (28–<32 weeks), and moderate to late preterm (32–<37 weeks).

What interventions improve outcomes in threatened/established preterm labour?

Antenatal corticosteroids (e.g. betamethasone/dexamethasone) for fetal lung maturity, magnesium sulfate ($\ce{MgSO4}$) for fetal neuroprotection if <30–34 weeks, tocolysis (e.g. nifedipine) to allow steroid course/transfer, and intrapartum antibiotics if indicated (e.g. GBS).

What is the magnesium sulfate regimen for fetal neuroprotection in preterm birth?

A loading dose of $4\ \text{g}$ $\ce{MgSO4}$ IV over 15–30 minutes, followed by a maintenance infusion of $1\ \text{g/hour}$ until birth or for 24 hours. Offered when birth is expected within 24 hours before approximately $30$ weeks (consider up to $34$ weeks).

Define PPROM and outline its key management.

Preterm prelabour rupture of membranes (PPROM) is rupture of membranes before 37 weeks without labour. Management: confirm diagnosis (speculum/IGFBP-1/PAMG-1), erythromycin $250\ \text{mg}$ QDS for up to 10 days, antenatal steroids, monitor for chorioamnionitis, and avoid digital examination.

What is the recommended antibiotic for PPROM and which one is contraindicated?

Oral erythromycin $250\ \text{mg}$ four times daily for 10 days (or until labour). Co-amoxiclav is contraindicated because of an increased risk of neonatal necrotising enterocolitis.

What are the absolute contraindications to VBAC (vaginal birth after caesarean)?

Previous classical (vertical) uterine incision, previous uterine rupture, other absolute contraindications to vaginal birth (e.g. placenta praevia), and generally three or more previous caesareans. These mandate elective repeat caesarean.

Quote the approximate risks of uterine rupture and VBAC success rate counselling figures.

Risk of uterine rupture in planned VBAC is approximately $0.5\%$ ($1$ in $200$). Overall VBAC success rate is approximately $72$–$75\%$. Induction/augmentation increases rupture risk; continuous CTG monitoring is recommended in labour.

State the prerequisites for an instrumental (assisted) vaginal delivery — the mnemonic check.

Fully dilated cervix, ruptured membranes, cephalic presentation with known position, engaged head with at most 1/5 palpable abdominally and station at or below the spines, empty bladder, adequate analgesia, adequate contractions, consent, and willingness to abandon. (Mnemonic: FORCEPS.)

Compare ventouse (vacuum) versus forceps delivery outcomes.

Ventouse is more likely to fail, causes more cephalohaematoma/retinal haemorrhage and neonatal jaundice, but less maternal perineal/sphincter trauma. Forceps has higher success and less fetal scalp trauma but more maternal third/fourth-degree tears and require more analgesia.

List the classification of caesarean section by urgency (categories 1–4).

Category 1: immediate threat to life of mother or fetus (decision-to-delivery target $30$ minutes). Category 2: maternal/fetal compromise, not immediately life-threatening (target $75$ minutes). Category 3: needs early delivery but no compromise. Category 4: elective/scheduled at a time to suit.

Describe the standard technique landmarks of a lower segment caesarean section.

Pfannenstiel or Joel-Cohen transverse skin incision, dissection through subcutaneous fat, rectus sheath, separation of rectus muscles, opening of peritoneum, reflection of the bladder via a uterovesical fold incision, low transverse uterine incision, delivery of fetus and placenta, then closure of the uterus in two layers.

Give the RCOG classification of perineal (obstetric) tears.

First degree: injury to perineal skin/vaginal mucosa only. Second degree: involves perineal muscles but not anal sphincter. Third degree: involves anal sphincter complex — 3a (<50% EAS torn), 3b (>50% EAS torn), 3c (internal anal sphincter torn). Fourth degree: involves anal sphincter complex and anorectal mucosa.

What is an OASI and what care follows its repair?

Obstetric anal sphincter injury (OASI) is a third- or fourth-degree perineal tear. Care: repair in theatre by trained clinician, broad-spectrum antibiotics, laxatives, physiotherapy, follow-up, and counselling regarding mode of delivery in future pregnancies.

What are the main risk factors for obstetric anal sphincter injury?

Nulliparity (first vaginal birth), birthweight $>4\ \text{kg}$, occipitoposterior position, prolonged second stage, shoulder dystocia, instrumental delivery (especially forceps), midline episiotomy, and Asian ethnicity.

Why is a mediolateral episiotomy preferred over midline, and at what angle should it be cut?

Mediolateral episiotomy reduces the risk of extension into the anal sphincter compared with midline. It should be cut at a $60^{\circ}$ angle from the posterior fourchette when the perineum is distended, achieving roughly $45^{\circ}$ after delivery.

Compare general versus regional (spinal/epidural) anaesthesia for caesarean section.

Regional (spinal most common) is preferred: mother awake, lower maternal mortality, avoids aspiration/failed intubation, better neonatal status, allows early bonding. General anaesthesia is reserved for emergencies, regional contraindications/failure, or maternal refusal but carries airway and aspiration risks.

What measures reduce aspiration risk if general anaesthesia is needed in obstetrics?

Antacid prophylaxis (sodium citrate, $\ce{H2}$-receptor antagonist e.g. ranitidine, and metoclopramide), rapid sequence induction with cricoid pressure, and a cuffed endotracheal tube. This addresses the increased aspiration risk from a gravid uterus and reduced lower oesophageal sphincter tone.

Define primary postpartum haemorrhage and the threshold for major PPH.

Primary PPH is blood loss $\geq 500\ \text{mL}$ from the genital tract within 24 hours of birth. Minor PPH is $500$–$1000\ \text{mL}$; major PPH is $>1000\ \text{mL}$, further divided into moderate ($1000$–$2000\ \text{mL}$) and severe ($>2000\ \text{mL}$).

List the four 'T' causes of postpartum haemorrhage and which is most common.

Tone (uterine atony) — most common (~70%), Trauma (lacerations/tears/rupture), Tissue (retained placenta/products), and Thrombin (coagulopathy). Atony accounts for the majority of cases.

Outline the medical (uterotonic) management of atonic PPH in sequence.

Bimanual uterine compression and uterotonics: IV/IM oxytocin (and infusion), ergometrine $500\ \mu\text{g}$ IM/IV (avoid in hypertension), carboprost (Hemabate, $\ce{PGF2\alpha}$) $250\ \mu\text{g}$ IM every 15 min (avoid in asthma), and misoprostol $800\ \mu\text{g}$ rectally/sublingual. Add tranexamic acid $1\ \text{g}$ IV.

What surgical and mechanical options are used for refractory PPH?

Intrauterine balloon tamponade (Bakri), uterine compression sutures (B-Lynch), stepwise uterine/internal iliac artery ligation, interventional radiology uterine artery embolisation, and ultimately hysterectomy as a life-saving measure.

What is the HELPERR mnemonic for shoulder dystocia management?

H — call for Help; E — Evaluate for episiotomy; L — Legs (McRoberts position); P — suprapubic Pressure; E — Enter manoeuvres (internal rotation, e.g. Rubin/Woodscrew); R — Remove the posterior arm; R — Roll the patient onto all fours. McRoberts plus suprapubic pressure resolves the majority.

What is McRoberts' manoeuvre and why is it effective in shoulder dystocia?

Hyperflexion and abduction of the maternal hips, bringing the thighs onto the abdomen. This flattens the lumbosacral curve and rotates the symphysis pubis cephalad, increasing the functional pelvic outlet to free the impacted anterior shoulder. It is the first-line manoeuvre.

What are recognised fetal complications of shoulder dystocia?

Brachial plexus injury (Erb's palsy), fractured clavicle or humerus, hypoxic-ischaemic injury from delayed delivery, and (rarely) death. Maternal complications include PPH and third/fourth-degree perineal tears.

Describe the immediate management of umbilical cord prolapse.

Call for help, avoid handling the cord (minimise vasospasm), elevate the presenting part manually or fill the bladder with ~$500\ \text{mL}$ saline, position the woman knee-chest or in left lateral with head-down/Trendelenburg, consider tocolysis, and expedite delivery — usually emergency caesarean if not fully dilated.

Define acute uterine inversion and its initial management.

Uterine inversion is the uterine fundus collapsing into the cavity/through the cervix, often causing profound vagal shock and haemorrhage out of proportion to blood loss. Management: immediate manual replacement (Johnson manoeuvre), do not remove the placenta first, fluid resuscitation, and hydrostatic (O'Sullivan) or surgical replacement if needed.

What are the classic features and management priorities of amniotic fluid embolism?

Sudden cardiovascular collapse, hypoxia/respiratory distress, and disseminated intravascular coagulation, typically peri-delivery. It is a clinical diagnosis of exclusion. Management is supportive: high-quality CPR/resuscitation, oxygenation, circulatory and coagulation support (massive transfusion), and perimortem caesarean if cardiac arrest.

What blood pressure and proteinuria thresholds define pre-eclampsia?

New-onset hypertension after $20$ weeks: systolic $\geq 140\ \text{mmHg}$ or diastolic $\geq 90\ \text{mmHg}$, with proteinuria (urine protein:creatinine ratio $\geq 30\ \text{mg/mmol}$ or $\geq 0.3\ \text{g/24h}$) and/or maternal organ dysfunction. Severe hypertension is $\geq 160/110\ \text{mmHg}$.

What is the magnesium sulfate regimen for eclampsia and its therapeutic role?

Loading dose $4\ \text{g}$ $\ce{MgSO4}$ IV over 5–10 minutes, then maintenance $1\ \text{g/hour}$ for 24 hours (after seizure or birth). Further $2$–$4\ \text{g}$ bolus for recurrent seizures. It prevents and treats eclamptic seizures; monitor reflexes, respiratory rate, and urine output for toxicity.

What is the antidote and signs of magnesium sulfate toxicity?

Toxicity progresses with loss of deep tendon reflexes (>$5\ \text{mmol/L}$), respiratory depression (>$6$), then cardiac arrest. The antidote is calcium gluconate $1\ \text{g}$ ($10\ \text{mL}$ of $10\%$) IV over 10 minutes. Stop the infusion and support ventilation.

Which antihypertensives are used for acute severe hypertension in pregnancy?

Labetalol (oral or IV), nifedipine (oral), and hydralazine (IV) are first-line for acute control. The target is to reduce blood pressure below $160/110\ \text{mmHg}$ while avoiding precipitous falls that compromise placental perfusion. ACE inhibitors/ARBs are contraindicated.

What modifications are needed for CPR in a pregnant woman beyond ~20 weeks?

Manual left uterine displacement (or 15–30° left lateral tilt) to relieve aortocaval compression, hand position slightly higher on the sternum, early airway management (aspiration/intubation difficulty), and preparation for perimortem caesarean if no return of circulation.

When should a perimortem (resuscitative hysterotomy) caesarean be performed in maternal cardiac arrest?

It should be commenced if there is no return of spontaneous circulation within $4$ minutes of arrest, aiming to deliver by $5$ minutes. Beyond ~20 weeks it aids maternal resuscitation by relieving aortocaval compression and improving venous return and cardiac output.

Define the APGAR score and its five components.

The APGAR score assesses the newborn at 1 and 5 minutes, each component scored $0$–$2$ (max $10$): Appearance (colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration. It reflects condition and response to resuscitation, not prognosis alone.

Outline the initial steps of newborn resuscitation per Resuscitation Council.

Dry, wrap, keep warm and start the clock; assess tone, breathing, and heart rate. If not breathing/floppy: open airway (neutral position) and give $5$ inflation breaths. Reassess; if heart rate remains $<60\ \text{bpm}$ despite effective ventilation, start chest compressions at a $3:1$ ratio with ventilation.

At what newborn heart rate are chest compressions started and at what ratio?

Chest compressions are started if the heart rate remains below $60\ \text{bpm}$ despite 30 seconds of effective ventilation. The compression-to-ventilation ratio in newborn resuscitation is $3:1$, aiming for about $90$ compressions and $30$ breaths per minute.

What are the WHO/UK recommendations for initiation and exclusivity of breastfeeding?

Initiate breastfeeding within the first hour (skin-to-skin contact), feed on demand, and exclusively breastfeed for the first $6$ months, with continued breastfeeding alongside complementary foods up to $2$ years and beyond. Avoid routine supplementation that undermines establishment.

What are common lactation problems and a key management point for each?

Poor latch — review positioning/attachment. Engorgement — frequent feeding, expression, analgesia. Cracked/sore nipples — correct attachment. Mastitis — continue feeding/expressing, analgesia, antibiotics (flucloxacillin) if systemically unwell or not improving; breast abscess needs drainage.

Differentiate the baby blues, postnatal depression, and postpartum psychosis.

Baby blues: transient low mood/tearfulness in 50–80%, peaks day 3–5, resolves by ~day 10 without treatment. Postnatal depression: onset within weeks–months, persistent low mood needing treatment. Postpartum psychosis: rare (~1–2/1000), rapid onset within days, with mania/delusions/hallucinations — a psychiatric emergency requiring admission (often mother-and-baby unit).

What is secondary postpartum haemorrhage and its common causes?

Secondary PPH is abnormal/excessive bleeding from the genital tract between $24$ hours and $12$ weeks postpartum. Common causes are endometritis (infection) and retained products of conception. Management includes assessment for sepsis, antibiotics, uterotonics, and evacuation if retained tissue is present.

What are the features and management of postpartum sepsis (puerperal infection)?

Features: fever, tachycardia, lower abdominal pain, offensive lochia, uterine tenderness, with risk of rapid deterioration (notably group A streptococcus). Management follows the Sepsis Six: blood cultures, broad-spectrum IV antibiotics within 1 hour, IV fluids, lactate, oxygen, and urine output monitoring, plus source control.

What routine postnatal maternal observations and red-flag symptoms should be checked?

Monitor temperature, pulse, blood pressure, uterine involution, lochia, perineum/wound, bladder/bowel function, and mood. Red flags include heavy/secondary bleeding, signs of sepsis, severe headache/visual disturbance (pre-eclampsia), calf pain/breathlessness (VTE), and thoughts of self-harm.

Why is venous thromboembolism a key postnatal concern and how is it mitigated?

Pregnancy and the puerperium are prothrombotic (Virchow's triad: stasis, hypercoagulability, endothelial injury); VTE is a leading cause of direct maternal death. Mitigation: risk assessment, early mobilisation, hydration, mechanical prophylaxis, and LMWH thromboprophylaxis for those at risk, especially after caesarean.