Triage may be defined as the assessment of patients to determine both nature of and need for urgency of treatment required. While it is commonly thought of as identifying a hierarchy of priority within multiple patients, in labour ward it is the system by which the medical needs and management requirements of specific patients within a particular clinical area are categorised to ensure appropriate allocation of resources, both for individual patients and in the context of the whole ward and the resource pool. In an obstetric setting, triage is not only the principal gateway into labour ward for emergency attenders who require unscheduled attention in a maternity unit but it also remains key to the ongoing management of all patients on the labour ward itself. Effective and efficient triage is considered a key competency for labour ward clinicians and, indeed, prioritisation of the ‘Labour Ward Board’ is a favourite examination question for trainees about to become specialists.

The twin birth rate has increased over the last four decades due to rising maternal age at conception and the use of assisted reproductive technology. Compared to singletons, twins, especially the second twin, are more susceptible to perinatal complications. However, current evidence suggests that in well-selected patients under skilled obstetricians’ care, planned vaginal delivery can be just as safe as planned caesarean delivery. This chapter elaborates on evidence-based information about selection criteria for vaginal twin delivery, timing of delivery and intrapartum management. Techniques for delivering vertex and nonvertex second twins and intertwin delivery intervals will also be discussed, along with addressing the associated controversies. Given the tendency of twin pregnancies to have preterm delivery, this chapter will also delve into the decision-making process for the mode of delivery in preterm twin gestations.

Peripartum rupture of the uterus is rare, but is a life-threatening complication leading to maternal and perinatal morbidity and mortality. There is wide variation in the reported incidence of rupture of the uterus, with high incidence and more morbidity and mortality among the developing countries compared to the developed world. In the high-income countries uterine rupture is mainly due to scar rupture, while in the developing world, rupture due to prolonged and obstructed labour is still happening in spite of the progress made in the field of antenatal and intrapartum care. Caesarean section rates are increasing all over the world, and women with prior caesarean section are at higher risk of uterine rupture during subsequent pregnancy. Women with a previous lower segment caesarean section can opt for an elective caesarean delivery or a vaginal delivery after caesarean (VBAC). The most feared complication of VBAC is uterine rupture with its associated maternal and fetal consequences.

Caesarean delivery is one of the most frequently performed operations. It is indicated in situations where the benefits associated with the procedure outweigh those of vaginal delivery. With appropriate indications, caesarean deliveries can be life-saving for both the mother and the fetus. The use of a correct surgical technique is essential to improve safety and reduce the risk of complications. As with most surgical procedures, different surgeons have different operating skills, technical difficulties may vary from case to case, and operating room conditions also differ in different parts of the world, so it is difficult to standardise the technique and to carry out research comparing different technical variations. Nevertheless, in this chapter, the published evidence is reviewed and summarised for the individual steps of caesarean delivery.

The causes of postpartum haemorrhage are well established and there is growing awareness of the important risk factors. The immediate treatments tend to be directed at the most common causes. Identification of risk factors in women allows optimisation to mitigate their effects. Over the past years there has been growing evidence about how to optimise the diagnosis of postpartum haemorrhage and which treatment strategies are likely to be the most effective. Objective measurements of blood loss are encouraged as they are more accurate than visual estimation and bundled treatments are essential in avoiding treatment delays when dealing with this time-critical emergency. If initial approaches to management are unsuccessful, then there is escalation to more extensive treatments which include surgery.

Hypoxic-ischemic injury during labour is a leading cause of perinatal mortality, severe neonatal and longer-term morbidity globally. It leads to brain damage, cerebral palsy and premature death in adult survivors. Hypoxia during labour causes fetal distress which often occurs in women without obvious risk factors. When it happens, emergency operative birth (caesarean section or instrumental vaginal birth) is frequently required. Identification of infants at risk of fetal distress or other adverse outcomes is difficult – the current approach using maternal risk factors and/or clinical assessment of fetal size is poor at detecting small or vulnerable infants. Furthermore, although the association between some risk factors and adverse outcomes is known, the actual predictive utility for a specific risk factor is often relatively poor and more accurate tests are urgently required. There is currently no treatment to prevent fetal hypoxia in labour and we have limited ability to identify vulnerable fetuses before labour commences. Timely, accurate identification of this at-risk cohort with effective intervention represents one of the great challenges in perinatal medicine.

Labour or parturition is a physiologic process culminating in expulsion of fetus, amniotic fluid, placenta and membranes from the gravid uterus of a pregnant woman involving sequential and integrated changes in the myometrium, decidua and cervix. In a woman with a regular 28-day cycle, labour is said to take place 280 days after the onset of the last menstrual period. However, the length of human gestation varies considerably among healthy pregnancies, even when ovulation is accurately measured in naturally conceiving women. Initiation of labour may be best regarded as a withdrawal of the inhibitory effects of pregnancy on the tissue of the uterus, rather than as an active process mediated by the release of uterine stimulants. Successful labour passes through three stages: the shortening and dilatation of the cervix; descent and birth of the fetus; and the expulsion of the placenta and membranes. Efficient uterine contractions (power), an adequate roomy pelvis (passage) and an appropriate fetal size (passenger) are key factors in this process.

The third stage of labour is defined as the time from the birth to the delivery of the placenta, which in the majority of cases is uneventful but unexpected complications can arise that can lead to significant morbidity and mortality. This chapter describes the normal physiology and how haemostasis is achieved. Expectant (physiological) and active management are described. Details of the dose and route of administration of the uterotonics are discussed. The importance of inspection of the perineum, delayed cord clamping and the correct technique for controlled cord traction is outlined. Pathological conditions such as retained placenta, its causes, management and mismanagement are discussed. The chapter concludes describing the benefits of immediate provision of postpartum long-acting reversible contraception.

Antepartum haemorrhage (APH) is a frequent reason for presentation to maternity units in the antenatal period. APH most commonly arises from placenta previa or placental abruption; placenta previa is typically associated with painless bleeding while in the latter, patients usually present with abdominal pain or uterine contractions. It is important to recognise that bleeding may be concealed especially in placenta abruption and therefore the actual blood loss may supersede that found on clinical examination. It is therefore paramount to accurately assess and interpret the haemodynamic circulation of the patient presenting with APH. The initial management of APH is the same regardless of the underlying cause and includes obtaining intravenous access, sending blood for group and crossmatch, full blood count and a Kleihauer test in Rhesus-negative patients. Scenarios that will require more aggressive resuscitation with intravenous fluids and blood products include massive obstetric haemorrhage more than 1000ml, placental abruption with early-onset coagulopathy and clinical manifestations of hypovolemic shock.

Placenta accreta spectrum (PAS) is a disorder that describes the pathological attachment of the placenta to the myometrium. The continuously rising PAS rates combined with its significant association with a history of caesarean delivery increase the likelihood of encountering women with PAS in obstetric practice. This multifactorial disorder could be associated with serious maternal and fetal morbidity and mortality. Therefore, it is critical to recognise women at risk and provide tailored antenatal care. This chapter discusses the aetiology, impact and known risk factors for PAS. It lists the available diagnostic tools, based on antenatal sonographic and magnetic resonance imaging, and provides recommendations for optimal management of women suspected to have PAS. It summarises the surgical options such as the classical peripartum hysterectomy and compares it to other conservative options using the best available evidence. This chapter provides a comprehensive literature review followed by key learning points for appropriate management.

The fetus receives its oxygen and nutrition from the placenta through the umbilical cord that floats in the amniotic fluid. The placenta receives oxygen and nutrition from the maternal blood and excretes its waste products into the maternal side. Uterine contractions of labour reduce or intermittently cut off the blood perfusion into the retro-placental area, thus reducing the exchange of gases and essential nutrition to the fetus. Contractions may also compress the umbilical cord and prevent or reduce gas and nutrition exchange by reducing or obstructing the flow of blood from and to the placenta.

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.