Globally the rates of induction of labour (IOL) are on the rise. The availability of prostaglandins, which act as both cervical ripening as well as inducing agent, has improved the success rates of IOL in the presence of an unfavourable cervix. Mechanical methods such as intracervical balloon catheters appear to be equally effective as compared to pharmacological agents and have fewer adverse effects. The process of IOL is associated with significant risks such as uterine hyperstimulation, fetal compromise, increased risk of operative deliveries and rarely rupture of the uterus. Hence, there should be a clear indication for IOL based on best available evidence, with benefits to either mother or fetus, which outweigh the perceived risks. The World Health Organization, the National Institute for Health and Clinical Care Excellence and various professional organisations have produced guidelines to assist clinicians in decision-making regarding IOL in various obstetric situations. The process of IOL should be tailored to meet the expectations and preferences of women in their unique circumstances.

Labour and delivery are associated with changes in maternal physiology which can impact on women with medical disorders and need to be taken into consideration when managing medications, considering mode of birth and the use of analgesia. There are relatively few conditions where caesarean section is recommended for medical indications and most women with medical problems can deliver vaginally safely at full term. Some conditions may deteriorate around delivery, such as sickle cell disease, diabetes, epilepsy, critical heart disease and restrictive lung disease requiring specific management. Others, such as asthma and arrhythmias, are not affected by delivery. Women on anticoagulation pose specific risks of haemorrhage at delivery, versus thrombosis from halting anticoagulation. Clear management plans for delivery, postnatal care and contraception should be made and agreed by both the multidisciplinary team and the woman in advance of delivery. Several medical conditions requiring multidisciplinary management plans are discussed in this chapter.

Umbilical cord prolapse is an obstetrical emergency with an incidence of 1 to 6 per 1000 pregnancies, which is associated with high perinatal mortality. This chapter addresses several important aspects of cord prolapse. The definition of cord prolapse varies in the literature, and the term ‘occult cord prolapse’ is misleading. To address this, cord prolapse, cord presentation and compound cord presentation should be classified based on their positional relationship. Urgent delivery by cesarean delivery is the main treatment, except in cases where vaginal delivery is imminent. The urgency of delivery depends on the fetal heart rate pattern, with bradycardia cases requiring the most immediate intervention. Cord arterial pH declines significantly during bradycardia-to-delivery intervals, indicating potential irreversible pathology. Various manoeuvres can be used to relieve cord compression before caesarean delivery and an algorithm was proposed to guide the acute management of cord prolapse.

Intrapartum events have resulted in maternal and perinatal morbidity and mortality and rising medico-legal claims related to maternity. Despite rapid technological advances recently, the rates of clinical incidents such as PPH, OASI and adverse fetal outcomes have not reduced significantly. Furthermore, new intrapartum incidents such as impacted fetal head, caring for mothers with high BMI and managing extreme preterm labour are on the rise. Empowering patients and their unrealistic expectations and workforce issues further complicate this issue. Many reports have indicated more than 50% of these are preventable. Various strategies at the institutional, process and clinical levels used to minimise labour risk are discussed. Some include staff numbers, fatigue, skill mix, training, guidelines, algorithms and partnership with patents. Interventions to reduce a few clinical conditions are discussed. We made suggestions based on pilot studies on how we could improve intrapartum care using modern technology, including AI.

Cerebral palsy (CP) refers to a heterogeneous group of neurological conditions appearing in early childhood, causing permanent motor dysfunction, and affecting muscle tone, posture or movement. These conditions are caused by abnormalities of the developing fetal or infant brain and are non-progressive in nature. They are often accompanied by cognitive and sensory impairments. While forms such as spastic quadriplegia and dyskinesia are notably associated with fetal hypoxia, existing evidence indicates that intrapartum events contribute to only 10–20% of all CP cases. Establishing a causal relationship between CP and events arising during labour requires multiple criteria to be met. Recent advancements in neuroimaging and diagnostic laboratory techniques have shed some light on the diverse pathways leading to brain injury. However, further research is still necessary to evaluate the impact of intrapartum fetal monitoring and obstetric interventions on the incidence of CP.

This chapter discusses the diagnosis and management of severe pre-eclampsia and eclampsia during labour and delivery. Maternal outcome has improved greatly in the last 50 years but there is much room for improvement. It emphasises the importance of accurate diagnosis, timely intervention, vigilant care prior to, during and after birth, and the use of evidence-based guidelines to reduce maternal mortality and morbidity. The chapter covers diagnostic criteria, maternal and fetal assessment and monitoring, antihypertensive therapy, seizure management, delivery guidelines and postpartum care. It emphasises the importance of lowering blood pressure and fluid management to combat the main cause of mortality and delivery on the best day in the best way.

The definition of prolonged second stage of labour varies depending on parity and use of epidural analgesia. Morbidity increases where the active second stage is more than 2 hours for nulliparous women and 1 hour for parous women. The options include oxytocin augmentation, episiotomy, assisted vaginal birth and caesarean birth, depending on the clinical circumstances. Persistent occipito-posterior position is a contributor to both prolonged second stage and operative birth. Preventative approaches include continuous support and optimal timing and position for pushing. Skilled operators and supervision are essential when intervention is required. There is randomised controlled trial evidence to support decision-making between vacuum and forceps but there are trade-offs in terms of success rates and birth-related morbidity. The decision between assisted vaginal birth and second stage caesarean relies on observational data and is more challenging. When counselling women, there needs to be transparency about short- and long-term potential outcomes and the implications for future births.

The vast majority of newborn babies require no help in adapting to their new extrauterine life. They rapidly clear lung fluid, create a functional residual capacity and breathe on their own within seconds of their birth. However, it is very difficult to predict the baby who will struggle with this transition and hence need resuscitation, and so we start this chapter with the comment that any person involved in the delivery of care to the pregnant woman should understand the principles of newborn resuscitation. This includes medical students on their obstetric attachment, student midwives in training, midwives, obstetricians and obstetric anaesthetists, neonatal nurse practitioners, physician associates, neonatologists and paediatricians.

A holistic and individualised approach to analgesia and anaesthesia is key when supporting a woman during labour and birth. This chapter discusses the options available for pain relief during labour and birth, including the evidence for and against each method. It focuses on anaesthesia employed for operative interventions that may be required to facilitate birth or in the immediate postnatal period. This chapter also provides an insight into the role of the anaesthetist on the labour ward and hopefully demonstrates that the obstetric anaesthetist is not solely a technician, but a key member of the multidisciplinary team providing peri-partum care on the labour suite.

Eighty-five per cent of women sustain perineal trauma during vaginal birth. This may occur spontaneously or intentionally when a surgical incision (episiotomy) is made. The overall risk of obstetric anal sphincter injuries (OASIs) is approximately 2% of all vaginal deliveries. The morbidity associated with perineal trauma depends on the extent of injury, the suturing technique and materials, and the skill of the person performing the procedure. Therefore, it is important that focused and intensive training is available and that practitioners ensure that procedures, such as perineal repair, are evidence-based in order to provide care that is effective, appropriate and cost-efficient. In the UK, between 2000 and 2012, the OASIs rate in England tripled from 1.8% to 5.9%, suggesting that preventive measures need to be put in place. In this chapter, we highlight safe obstetric practice and preventative strategies based on the best available evidence to minimise perineal and anal sphincter trauma.

The management of pregnant women with a previous caesarean delivery is a unique challenge. The overall success for a trial of labour after caesarean birth (TOLAC) is 60–80%, while the intrapartum uterine rupture risk is 0.5%. Although complications are rare for both TOLAC and elective repeat caesarean delivery (ERCD), the former in general poses slightly higher risk to the baby and the mother. On balance, TOLAC is preferred for most women with one prior lower transverse uterine incision. Although there remains an element of unpredictability in scar rupture, risk stratification helps to fill in the gap between safety in TOLAC, women’s preference during childbirth and resource allocation. Labour induction with previous caesarean scar is still feasible in the presence of a good indication. Other special conditions such as preterm and post-term pregnancies, fetal macrosomia, twins and breech-presenting pregnancy are also discussed in detail.

Acute Illness and Maternal Collapse is an important chapter for all healthcare professionals involved in maternity services. This chapter reviews physiological changes of pregnancy and applies these principles to recognition of maternal illness. Specific conditions that contribute to poor maternal outcomes are outlined together with a systematic approach to assessment and management of an unwell mother, including management of maternal/obstetric cardiac arrest. This chapter should enable clinicians to develop well-rounded and patient-centred skills in the recognition, assessment and management of an unwell mother.

Despite technological and scientific improvements in maternity care, mothers and babies continue to come to harm. As with other safety-critical industries, mistakes occur as a result of ‘human’ and ‘system’ errors. A sound understanding of non-technical skills can help explain past errors and prevent future errors; these skills include cognitive (situation awareness and decision-making) and social (teamwork, leadership and communication) aspects. Caring for mothers and babies is compromised by individuals and teams feeling stressed and exhausted, and it is increasingly recognised that a focus on individual/team human factors may be both ineffective and punitive. Improvements in safety culture therefore require both system redesign and compassionate leadership.

Instrumental vaginal delivery (IVD) is one of the commonest surgical operations performed in obstetric practice. The two instruments that have been used for IVDs are different forms of forceps and ventouse that help in the rotation and traction of the head along the pelvis to assist delivery. A new instrument, the ‘Odon’ device, is undergoing evaluation by clinical trials. If found to be effective and safe, it will become another instrument to help with assisted vaginal delivery. The principle with all the instruments is based on traction of a flexed head in the antero-posterior diameter along the axis of the pelvis with the flexion point of the head as the leading part. The flexion point is 3 cm anterior to the occiput along the sagittal suture. Achieving the antero-posterior direction of the head may be by digital or manual rotation with the hand, assistance with forceps specially designed for rotation or auto-rotation with vacuum. Ventouse delivery is performed by traction of the fetal scalp with a suction cup. Forceps cradle the parietal and malar bones of the fetal skull to allow application of traction. During this process it also laterally displaces maternal tissues.