The incidence of listeria infection in pregnant women is estimated at 12 per 100 000 compared to 0.7 per 100 000 in the general population.

Only little volumes of urine are lost when her intra-abdominal pressure is elevated during coughing, laughing, jumping, and straining, which is the only symptom associated with real stress incontinence.
The other reactions are significantly more compatible with a detrusor instability diagnosis (also called urge incontinence).
If she had incontinence throughout pregnancy, it would have been stress in nature, which is what her current incontinence is.

Tamoxifen is an oestrogen antagonist in breast tissue but it acts as a partial oestrogen agonist on the endometrium increasing the risk of hyperplasia and has been linked to endometrial cancer. Tamoxifen improves bone density in post-menopausal women. It is an off license treatment for gynaecomastia. Reduced lactation is a potential side effect of Tamoxifen.

Twin pregnancy is associated with a number of obstetric complications, some of them with serious perinatal consequences, especially for the second twin. The rate of perinatal mortality can be up to six times higher in twin compared to singleton pregnancies, largely due to higher rates of preterm delivery and fetal growth restriction seen in twin pregnancies. Preterm birth and birth weight are also significant determinants of morbidity and mortality into infancy and childhood. More than 50% of twins and almost all triplets are born before 37 weeks of gestation and about 15–20% of admissions to neonatal units are associated with preterm twins and triplets.

Lower abdominal pain during menstrual periods and lower back or leg pain are associated with endometriosis in the uterosacral ligaments. Endometriosis can cause diarrhoea and IBS type symptoms. Note Endometriosis on the uterosacral ligament can cause tender nodules to form. These can be palpated during pelvic exam. Tender nodules are specific to endometriosis of the uterosacral ligament so if the question mentions feeling a tender nodule during PV exam think endometriosis of the Uterosacral ligaments!

The patient’s condition can be described as a normal progress of labour. The scenario shows a normal descent of the head in the pelvic cavity, with a favourable position, and occurring within an hour of the second stage of labour. A normal second stage of labour in a nulliparous individual occurs at a maximum of two hours, which is consistent with this patient. Hence, there is no delay in the second stage.

There is evident progress of labour in this patient, hence, obstructed labour or cephalopelvic disproportion is ruled out.

No signs of maternal distress such as tachycardia or pyrexia is described in this patient.

Monozygotic (MZ) twins originate when a single egg is fertilized to form one zygote, which then divides into two embryos. Although they share the same genotype they are not phenotypically identical.

The pudendal nerve is formed by sacral nerve roots S2, S3 and S4 almost immediately as they exit the spinal foramina. The pudendal nerve exits the pelvis via the greater sciatic foramen, travels behind the sacrospinous ligament before re-entering the pelvis via the lesser sciatic foramen. It is an important nerve to be aware of as it supplies sensation to the genitalia and can also be damaged/compressed at a number of places along its course. Image sourced from Wikipedia

Realignment of collagen is part of the remodelling phase. Remodelling is usually underway by week 3. Maximum tensile wound strength is typically achieved by week 12.

Urge incontinence is involuntary pee loss accompanied by a strong desire to urinate. The most common cause of urge incontinence is detrusor or bladder dyssynergia, which is characterized by an involuntary contraction of the bladder during urine distension.

Bladder training, eliminating excess coffee and fluid intake, biofeedback, and pharmacological therapy are all options for treating urge incontinence. Treatment with anticholinergic medicines (oxybutynin chloride), -sympathomimetic agonists (metaproterenol sulphate), Valium, antidepressants (imipramine hydrochloride), and dopamine agonists (Parlodel) has proven successful if conservative approaches fail.

The detrusor muscle will be relaxed by these pharmacologic drugs. Oestrogen therapy may improve urine control in postmenopausal women who are not on oestrogen replacement therapy. Kegel exercises can help women with stress urinary incontinence strengthen their pelvic musculature and improve bladder control.

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justify ed to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specific city for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral 75g glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges.

pre-eclampsia is defined as hypertension of at least 140/90 mmHg recorded on at least two separate occasions and at least 4 hours apart and in the presence of at least 300 mg protein in a 24 hour collection of urine, arising de novo after the 20th week of pregnancy in a previously normotensive woman and resolving completely by the sixth postpartum week.

According to the RCOG greentop guidelines, a women who have underdone chemotherapy for GTD are advised not to conceive for 1 years after completion of the chemotherapy.

The GI tract forms from the endoderm. The endoderm grows laterally and then ventrally finally folding on its self to form the gut tube.

NICE guidelines (CG74) advise the following regarding postoperative wound management Use sterile saline for wound cleansing up to 48 hours after surgery. Advise patients that they may shower safely 48 hours after surgery. Use tap water for wound cleansing after 48 hours if the surgical wound has separated or has been surgically opened to drain pus. Do not use topical antimicrobial agents for surgical wounds that are healing by primary intention to reduce the risk of surgical site infection

This is a case of a pregnant patient having vaginal bleeding. Given the patient’s presentation, the most likely cause of this patient’s antepartum haemorrhage is placenta praevia. The haemorrhage is unlikely to be due to a vasa praevia because a loss of 300mL would usually cause fetal distress or death, neither of which has occurred. Cervical malignancy is also unlikely as it typically would not have bleeding of this magnitude. A possible diagnosis would be a small placental abruption as it would fit with the lack of uterine tenderness and normal uterine size.

For the immediate management of this patient, induction of labour is contraindicated before the placental site has been confirmed. Also, induction should not be performed when the gestation is only at 33 weeks, especially after an episode of a small antepartum haemorrhage. An ultrasound examination of the uterus is appropriate as it would define whether a placenta praevia is present and its grade. It would also show whether there is any evidence of an intrauterine clot associated with placental abruption from a normally situated placenta.

If a placenta praevia is diagnosed by ultrasound, a pelvic examination under anaesthesia may be a part of the subsequent care, if it is felt that vaginal delivery might be possible. Usually it would be possible if the placenta praevia is grade 1 or grade 2 anterior in type. However, pelvic exam at this stage is certainly not the next step in care, and is rarely used in current clinical care.

A Papanicolaou (Pap) smear will be necessary at some time in the near future, but would not be helpful in the care of this patient currently.

Immediate Caesarean section is not needed as the bleeding has stopped, the foetus is not in distress, and the gestation is only 33 weeks.

The most common cause of maternal mortality is Cardiovascular deaths due to post partum bleeding followed by hypertensive disorders of pregnancy, sepsis and complications of labour.

The following are the most common symptoms for endometriosis, but each woman may experience symptoms differently or some may not exhibit any symptoms at all. Symptoms of endometriosis may include:

Pain, especially excessive menstrual cramps that may be felt in the abdomen or lower back
Pain during intercourse
Abnormal or heavy menstrual flow
Infertility
Painful urination during menstrual periods
Painful bowel movements during menstrual periods
Other gastrointestinal problems, such as diarrhoea, constipation and/or nausea

All options can be symptoms of endometriosis but the commonest one is dysmenorrhea.

Lamotrigine, a drug used to treat epilepsy, is less effective when taken with combined oral contraceptives. The oestrogen component of the pill decreases the circulating levels of Lamotrigine, increasing the risk of seizures. The combination is therefore classified as a UKMEC 3, as the risk of the drug combination may outweigh the benefit. As an alternative, the progesterone-only pill, depo progesterone, Mirena or the copper IUD may be considered as there is no restriction on concomitant use. Lamotrigine is not metabolised through cytochrome P450 like other antiepileptic drugs such as carbamazepine and phenytoin, neither is it an enzyme inhibitor.

Oxytocin is responsible for the let down mechanism that occurs during breast feeding in which the myothelial cells contract and push the milk into the ductules.

The pudendal nerve has its origins form S2, S3 and S4 spinal segments. It provides sensation to the clitoris and labia along with the ilioinguinal nerve.

Mature cystic teratomas of the ovary are often discovered as incidental findings on physical examination, during radiographic studies, or during abdominal surgery performed for other indications.

When symptoms are present, they may include abdominal pain, mass or swelling, and abnormal uterine bleeding. Bladder symptoms, gastrointestinal disturbances, and back pain are less frequent. When abdominal pain is present, it usually is constant and ranges from slight to moderate in intensity.

Mucinous cystadenomas are relatively common (12% to 15% of all ovarian tumours). They can become massive. These tumours usually develop in the third to fifth decades of life and typically cause vague symptoms, such as increasing abdominal girth, abdominal or pelvic pain, emesis, fatigue, indigestion, constipation, and urinary incontinence.

Corpus luteal cysts present with irregular menses, abdominal fullness due to fluid build up and pelvic pressure.

Endometriosis mainly presents with cyclic pain at site of involvement and dysmenorrhea.

Hereditary breast cancers account for 10 % of the cases. BRCA gene mutations account for 25 % of these cancers.

The ovarian artery is an artery that supplies oxygenated blood to the ovary in females. It arises from the abdominal aorta below the renal artery. It can be found in the suspensory ligament of the ovary, anterior to the ovarian vein and ureter.

While on combination oral contraceptive tablets, this patient had a migraine. After a conversation about adverse effects, stop the combo medications and prescribe her progestogen-only pills.
The following are reasons why progestogen-only pills should be your first choice:
1-Age of 45 or more years
2-Smokers who are 45 years old or older
3-Oestrogen contraindications
4-Melitus Diabetes
5-A headache (combined oral contraceptive pills have absolute contraindication)
6-Hypertension under control
7-Lactation
8-Chloasma.

Pregnancy, undetected genital tract bleeding, and concurrent use of enzyme-inducing medications are all contraindications to using progestogen-only pills.

The correct answer is reassurance after thorough examination. Most breast lesions diagnosed during pregnancy and lactation, even some specific ones such as lactation and adenoma galactocele, are benign. The diagnosis of breast cancer, which is difficult to elucidate and is less common among women who are pregnant or lactating than among those of the same age who are not, continues to be a challenge for clinicians.

Prolactin is the hormone that is responsible for the production of milk (Lactogenesis). Oxytocin is responsible for the let down reflex during suckling.

In this case, induction of labour at 37 weeks of gestation was necessary due to the absence of spontaneous of labour 24 hours after rupture of membranes. High doses of Syntocin and large volume of fluids may be required particularly when induction is done before term.

Syntocin infusion can lead to uterine hypertonus and tetany which can result in fetal distress at any dosage. This is a common reason to decrease or stop the infusion and an indication for Caesarean delivery due to fetal distress

Uterine rupture can occur as a result of Syntocin infusion especially when the accompanying fluids do not contain electrolytes, which puts the patient at risk for water intoxication.

Maternal hypotension results from Syntocin infusion, not hypertension.

The femoral triangle is bounded superiorly by the inguinal ligament which forms the base of the triangle, medially by the lateral border of the adductor longus and laterally by the sartorius muscle.

The genitofemoral nerves takes its origin from the L1 and L2 spinal segments.

Phosphate and ammonia are the major urinary buffers

The most likely cause of her postcoital bleeding is cervical ectropion as suggested by her postcoital bleeding, normal pap smears and use of oral contraceptive pills.

Cervical ectropion is a benign condition that occurs as a result of overexposure to oestrogen. Here, glandular cells (the columnar epithelium) lining the endocervix, begin to grow on the ectocervix, leading to exposure of the columnar cells to the vaginal environment.

These columnar cells are prone to trauma and bleeding during coitus.

Medical abortion is preferred from 4 to 9 weeks of gestation and in Australia, suction curettage is the most frequently used method of abortion as it is considered useful from 6 to 14 weeks of gestation.

Mifepristone is a synthetic anti-progesterone, which is found to be effective for abortion when combined with misoprostol. There are evidences which suggest the effectiveness of misoprostol and mifepristone in both first and second trimesters. It is most commonly administered as a single dose of mifepristone followed by misoprostol, a prostaglandin, given orally or vaginally two days later. Prostaglandin can be repeated at an interval of 4 hours if required.
As the vaginal use shows only few gastrointestinal side effects Misoprostol is more effective and better tolerated vaginally than orally. Misoprostol is not approved for its use in termination of pregnancy, but is available in the market due to its indications in other conditions.
Methotrexate can be used orally or as an intramuscular injection followed by misoprostol up to seven days later, but this also is not a preferred method for termination of pregnancy in Australia.

Fertilization usually occurs in the fallopian tubes after ovulation. The zygote moves through the fallopian tube and implants in the endometrium about 7-9 days after fertilisation, or 6-12 days after ovulation.

Patient’s symptoms and signs are suggestive of round ligament strain, which is a normal finding during pregnancy, especially in the 2nd trimester, and it does not require any medical intervention.

Round ligament is a rope-like fibromuscular band which extends from the anterolateral aspect of uterus anteriorly between the layers of the broad ligament, and passing through the deep inguinal ring into the inguinal canal.
A sharp, sudden spasm in the right iliac fossa which lasts for a few seconds which is usually triggered by sneezing, coughing, laughing and rolling over in bed are the common presentations of a round ligament pain.

Ectopic pregnancy and rupture of ectopic pregnancy are two unlikely diagnosis in this patient as she is in the second trimester of her pregnancy, whereas both the mentioned conditions occur during the first trimester.

Although appendicitis presents with pain in right iliac fossa, the pain is not causes by coughing or sneezing. Also, there will be other symptoms like tenderness and rebound tenderness in right iliac fossa in case of appendicitis.

The best time of the episiotomy is when the presenting part becomes visible during the contractions. If the episiotomy is performed at the proper time, less time will be required for the delivery. However, if its done too late, it causes excessive stretching of the pelvic floor and further potential lacerations.

Atosiban is a modified form of oxytocin that is administered by intravenous infusion for 2–48 hours.

This patient presents with secondary amenorrhea, most likely caused by Asherman’s syndrome- Secondary amenorrhea is defined as absence of menstruation for – 3 months in a patient who had regular menstruation previously or absence of menstruation for 9 months in a patient who had oligomenorrhea- Asherman’s syndrome as the cause of her amenorrhea is suggested by its beginning shortly after undergoing elective abortion. It is an outflow tract obstruction caused by intrauterine synechiae resulting from the procedure.

The best diagnostic test to confirm this diagnosis is hysteroscopy. It can allow visualization of the uterine cavity, the nature and extent of intrauterine synechiae.

→ Progesterone withdrawal test is one of the diagnostic studies done in the early work-up of secondary amenorrhoea- It is usually followed by the estrogen-progesterone challenge test and other tests. Progesterone withdrawal test alone would not confirm Asherman’s syndrome.
→ Pelvic ultrasound is more useful in primary amenorrhea work-up when the presence or absence of the uterus is to be confirmed- It is not very useful in the evaluation of intrauterine adhesions.
→ Brain MRI is useful in confirming the presence of pituitary tumours in patients, who are found to have high levels of prolactin. This patient’s most likely cause of secondary amenorrhea is Asherman’s syndrome.
→ TSH and prolactin levels should be the next step in the work-up of secondary amenorrhea after pregnancy has been ruled out; however, these studies cannot confirm Asherman’s syndrome.

Adenomyosis or dysfunctional uterine haemorrhage are the most likely causes of heavy periods.
Because she refuses to have a hysterectomy or endometrial ablation, hormonal therapy must be administered in addition to the iron therapy she is already receiving.
Any of the choices could be employed, but using therapy only during the luteal phase of the cycle in someone who is virtually surely ovulating (based on her typical monthly cycles) is unlikely to work.

Danazol is prone to cause serious adverse effects (virilization), especially when used for a long period of time.
GnRH agonists would cause amenorrhoea but are more likely to cause substantial menopausal symptoms, and the °fa contraceptive pill (OCP) is generally best avoided in someone using hypertension medication.

Treatment with norethisterone throughout the cycle is likely to be the most successful of the treatments available.
If a levonorgestrel-releasing intrauterine device (Mirena®) had been offered as an alternative, it would have been acceptable.

Premature menopause has been diagnosed biochemically in this patient. Menopause is considered premature when it happens without warning in a woman under the age of 40.
Follicular development is common in ultrasonography investigations of women with primary ovarian failure, but ovulation is rare. So this woman isn’t ovulating.

Exogenous oestrogen treatment in physiologic amounts does not appear to improve the rate of spontaneous ovulation.
Women with primary ovarian failure from any cause may be candidates for donor oocyte in vitro fertilisation (IVF).

Oestrogens, clomiphene citrate, and danazol are examples of treatment approaches that have been shown to be ineffective in patients with premature ovarian failure.

This patient presenting with oligohydramnios in her third trimester and had reported an episode of sudden gush of fluid secondary to ruptured membrane which she had mistaken to be “urinary incontinence”.  Hence, the most likely cause of oligohydramnios in this patient will be premature preterm rupture of membrane (PPROM).

An amniotic fluid volume which is less than expected for gestational age is called as Oligohydramnios and is typically diagnosed by ultrasound examination. This condition can be qualitatively described as reduced amniotic fluid volume and quantitatively as amniotic fluid index ≤5 cm or a single deepest pocket <2 cm. Oligohydramnios either can be idiopathic or may have a maternal, fetal or placental cause. Fetal prognosis in this case depends on several factors like the underlying cause, the severity of loss ie. reduced versus no amniotic fluid state and the gestational age at which oligohydramnios occurred. As an adequate volume of amniotic fluid is critical for the normal fetal movements, for fetal lung development and for cushioning the fetus and umbilical cord from uterine compression, so pregnancies complicated with oligohydramnios are at higher risk for fetal deformation, pulmonary hypoplasia and umbilical cord compression.
Oligohydramnios is also associated with an increased risk for fetal or neonatal death, which can either be related to the underlying cause of reduction in amniotic fluid volume or due to the sequelae caused due to reduced amniotic fluid volume. The amniotic fluid volume reflects the balance between fluid production and movement of fluid out of the amniotic sac and the most common mechanisms behind oligohydramnios are fetal oliguria/anuria or fluid loss due to rupture of membranes; also reduction in the amount of lung fluid or increased swallowing do not play major roles in this. Idiopathic cases as in idiopathic oligohydramnios, may be due to alterations in the expression of water pores like aquaporin 1 and aquaporin 3, present in fetal membranes and placenta.

Causes of oligohydramnios
a) Maternal causes includes:
– Medical or obstetric conditions associated with uteroplacental insufficiency like preeclampsia, chronic hypertension, collagen vascular disease, nephropathy, thrombophilia.
– Intake of medications like angiotensin converting enzyme inhibitors, prostaglandin synthetase inhibitors, trastuzumab.
b) Placental causes are:
– Abruption of placenta
– Twin polyhydramnios-oligohydramnios sequence which is the Twin to twin transfusion
– Placental thrombosis or infarction
c) Fetal cases leading to oligohydramnios are:
– Chromosomal abnormalities
– Congenital abnormalities which are associated with impaired urine production
– Growth restriction
– Demise
– Post-term pregnancy
– Ruptured fetal membranes
– Infections
– Idiopathic causes

During First trimester: Etiology of oligohydramnios during the first trimester is often unclear. As the gestational sac fluid is primarily derived from the fetal surface of the placenta via transamniotic flow from the maternal compartment and secretions from the surface of the body of the embryo reduced amniotic fluid prior to 10 weeks of gestation is rare.

During Second trimester: Fetal urine begins to enter the amniotic sac and fetus begins to swallow amniotic fluid by the beginning of second trimester, therefore, during this period any disorders related to the renal/urinary system of the fetus begins to play a prominent role in the etiology of oligohydramnios. Some of such anomalies include intrinsic renal disorders like cystic renal disease and obstructive lesions of the lower urinary tract like posterior urethral valves or urethral atresia. Other common causes of oligohydramnios in the second trimester are maternal and placental factors and traumatic or nontraumatic rupture of the fetal membranes.

During Third trimester: Oligohydramnios which is first diagnosed in the third trimester is often associated with PPROM or with conditions such as preeclampsia or other maternal vascular diseases leading to uteroplacental insufficiency. Oligohydramnios frequently accompanies fetal growth restriction as a result of uteroplacental insufficiency.

A rectovaginal swab taken for Group B streptococci culture should be done in women presenting with threatened preterm labour

If labour is establishes, intrapartum antibiotic prophylaxis for Group B streptococci should be commenced and continued until delivery. In cases were labour is not establish, prophylaxis for Group B streptococci should be ceased and should be re-established only if the culture is found to be positive, that too at the time of onset of labour.

Strategies acceptable for reducing early onset Group B streptococci sepsis includes universal culture-based screening using combined low vaginal plus or minus anorectal swab at 35-37 weeks gestation or a clinical risk factor based approach.

No additional prophylaxis is recommended irrespective of Group B streptococci carriage, for elective cesarean section before the commencement of labour. However, if a woman who commences labour or has spontaneous rupture of the membranes before her planned Caesarean section is screened positive for Group B streptococci, she should receive intrapartum antibiotic prophylaxis while awaiting delivery.

Although there is little direct evidence to guide this practice, consideration of the above mentioned evidences it is recommendation that, every women with unknown Group B streptococci status at the time of delivery should be managed according to the presence of intrapartum risk factors.
All women at increased risk of early onset Group B streptococci sepsis must be offered an intrapartum antibiotic prophylaxis with IV penicillin-G or ampicillin.

Squamous cell carcinoma is the most common type of vaginal cancer.

Breast development occurs from the age of 9-13 at the onset of puberty. Delayed puberty is defined as the absence of breast development after the age of 13.

Blood enters the right atrium of the fetal heart and most passes through the foramen ovale into the left atrium. From there it is pumped through the aorta. The foramen ovale is the major structure for bypassing the fetal pulmonary circulation. Some of the blood in the right atrium does enters the right ventricle and then into the pulmonary artery however most of this passes through the ductus arteriosus into the aorta thus bypassing the fetal pulmonary circulation.

Spontaneous abortion is the loss of pregnancy naturally before twenty weeks of gestation. Colloquially, spontaneous abortion is referred to as a ‘miscarriage’ to avoid association with induced abortion. Early pregnancy loss refers only to spontaneous abortion in the first trimester. In 50% of cases, early pregnancy loss is believed to be due to fetal chromosomal abnormalities. Advanced maternal age and previous early pregnancy loss are the most common risk factors. For example, the incidence of early pregnancy loss in women 20-30 years of age is only 9 to 17%, while the incidence at 45 years of maternal age is 80%. Other risk factors include alcohol consumption, smoking, and cocaine use.

Several chronic diseases can precipitate spontaneous abortion, including diabetes, celiac disease, and autoimmune conditions, particularly anti-phospholipid antibody syndrome. Rapid conception after delivery and infections, such as cervicitis, vaginitis, HIV infection, syphilis, and malaria, are also common risk factors. Another important risk factor is exposure to environmental contaminants, including arsenic, lead, and organic solvents. Finally, structural uterine abnormalities, such as congenital anomalies, leiomyoma, and intrauterine adhesions, have been shown to increase the risk of spontaneous abortion.

The tests listed can all be performed during the work-up of a woman with secondary amenorrhoea. They are useful in that they cam diagnosis the most likely cause for the amenorrhoea as well as guide the treatment required if the patient wanted to become pregnant. Of these, the hormone test best able to predict a poor response to ovulation-induction therapy is the follicle-stimulating hormone (FSH) assay. If there are high levels of FSH, most of the ovulation-induction therapies are ineffective, although the rare spontaneous pregnancy can occur.

To maximise the chance of pregnancy in patients with elevated FSH levels, the most effective technique is an ovum donation from a young woman. The ovum would be fertilised in the laboratory and transferred to the uterus of the woman with the high FSH level after administering hormonal preparation of her uterus.

If the FSH level is normal, ovulation-induction therapy is usually effective. For these patients, correction of thyroid function will be necessary if the thyroid function is not normal. Dopamine agonist therapy is indicated if the prolactin level is elevated. Clomiphene or gonadotrophin therapy can be used where the luteinising and oestradiol levels are low, normal, or minimally elevated.

Evidence is not yet of sufficient quality for there to be evidence-based guidelines or recommendations. Having excluded other causes:

Reassure patients that breakthrough bleeding is a common side-effect of CHC and usually resolves after three cycles of use.
Advise women who smoke that stopping smoking may improve cycle control.
If bleeding persists after three cycles, consider changing formulation:
Increase dose of oestrogen, particularly if on a 20-microgram ethinylestradiol (EE) preparation

All other options are not acceptable.

Call for help.
• Ensure personnel are available to ‘scribe’.
Document the time the head delivered, which shoulder is anterior (this is the arm most vulnerable to injury) and the times at which each manoeuvre is employed.
• Drop the level of the delivery bed as low as it will go, and flatten the back of the bed so the woman is completely flat. Remove the foot of the bed to allow access.
• Assess for and perform an episiotomy, if needed.
• Using one assistant on each of the mother’s legs, flex and abduct the legs at the hip (thighs to abdomen, known as McRoberts manoeuvre). This flattens the lumbosacral spine and will facilitate delivery is around 90 per cent of cases.
• If this fails, suprapubic pressure should be
applied by another assistant. This should be
applied over the posterior aspect of the anterior fetal shoulder and will act to push the shoulders together. It can be used in a constant and then rocking motion.
• If both these fail, then internal manoeuvres are necessary. The order of these will depend on the skill and experience of the person conducting the delivery and the individual case. These manoeuvres have been named after famous obstetricians, but it is the process rather than the name that is important:
• An attempt can be made to rotate the baby, so that the shoulders enter the diagonal to allow delivery. The first procedure is usually to insert a hand behind the anterior shoulder, and push it towards the chest (Rubin II). This will adduct the shoulders then push them into the diagonal. This can be combined with pressure on the
anterior aspect of the posterior shoulder
to aid rotation (Woods’ screw). If this fails,
an attempt can be made to rotate the baby
in the opposite direction (reverse Woods’
screw). Delivery of the posterior arm can be
attempted passing a hand into the vagina, in
front of the posterior shoulder and deliver
the posterior arm by swinging it in front of
the fetal chest.
If these all fail, the patient can be moved on to all fours as this increases the anterior–posterior diameter of the inlet. In this position, the posterior arm can be delivered.
After this, manoeuvres of last resort include a symphysiotomy, in which the maternal symphysis is divided, Zavanelli’s, in which the head is reduced back into the vagina and a Caesarean section performed and intentional fracture of the fetal
clavicle.

The first sign of puberty in females is the development of breasts.