Antenatal Care Flashcards
(206 cards)
1
Q
Define gestational age
A
Duration of pregnancy from the date of the LMP
2
Q
Define gravida
A
Total number of pregnancies a woman has had
3
Q
Define Para
A
Number of times the woman has given birth after 24 weeks gestation
Regardless of whether the fetus was alive or stillborn
4
Q
First trimester
A
up to 12 weeks gestation
5
Q
Second trimester
A
13 - 26 weeks gestation
6
Q
Third trimester
A
27 weeks gestation
7
Q
When does the woman attend a booking clinic?
A
Ideally before 10 weeks
8
Q
When is the dating scan?
A
Between 10 and 13+6
For an accurate gestational age from the CRL
9
Q
When is the anomaly scan?
A
Between 18 and 20+6 weeks
10
Q
Women at risk of gestational diabetes have an oral glucose tolerance test at what date?
A
24-28 weeks gestation
11
Q
When are anti-D injections given in rhesus negative women?
A
28 and 34 weeks
12
Q
What 6 things are covered in routine antenatal appointments?
A
Symphasis-fundal height (>24wks onwards)
Fetal presentation (>36 wks onwards)
Urine dipstick for proteinurea (pre-eclampsia)
Blood pressure (pre-eclampsia)
Urine for MC&S for asymptomatic bacteriuria
13
Q
What two vaccines are offered to all pregnant women?
A
Pertussis (whooping cough) from 16 weeks gestation
Influenza (if in season)
14
Q
What dose of folic acid should be taken to reduce risk of neural tube defects?
A
400 micrograms
Ideally prior to conception to at least 12 weeks
15
Q
What dose of Vit D should be taken during pregnancy?
A
400 IU daily
16
Q
How should you position seatbelts during pregnancy?
A
Above and below the bump i.e. not across it
17
Q
Why should pregnant women avoid unpasteurised diary or blue cheese?
A
Risk of listeriosis
18
Q
Why should pregnant women avoid undercooked or raw poultry?
A
Risk of salmonella
19
Q
What can alcohol consumption result in during pregnancy? (especially in the first 3 months)
A
Fetal alcohol syndrome
20
Q
What features result in fetal alcohol syndrome?
A
Microcephaly Thin upper lip Smooth flat philtrum Short palpebral fissure Learning difficulties Behavioural problems
21
Q
What two things can result from smoking in pregnancy?
A
Fetal growth restriction (FGR)
Sudden infant death syndrome (SIDS)
22
Q
In a single uncomplicated pregnancy, what gestational age can a pregnant lady fly?
A
37 weeks
But need a note from a midwife/GP/obstetrician
23
Q
What are taken as part of the “booking bloods”?
A
- Blood group, antibodies and rhesus D status
- Full blood count for anaemia
- Screening for thalassaemia (all women) and sickle cell disease (women at higher risk)
- Offered HIV/Syphilis/Hep B screening
24
Q
Pregnant women at risk of fetal growth restriction require what?
A
Additional growth scans
25
Pregnant women at risk of VTW require what?
prophylactic LMWH (if high risk)
26
What is the first line screening for Down's Syndrome during pregnancy?
At which gestational age does this take place?
Combined test
- US for nuchal translucency (>6mm)
- Bloods i.e. high bHCG and lower PAPPA
11-14 weeks
27
At what gestational age is the triple test for Down's Syndrome performed?
14-20 weeks
28
What does the triple test for Down's syndrome entail?
Maternal bloods
1. beta-HCG (higher)
2. Alpha-fetoprotein (lower)
3. Serum oestriol (lower)
29
At what gestational age is the quadruple test for Down's syndrome undertaken?
14-20 weeks
30
What bloods are included for the quadruple test for Down's syndrome?
1. beta-HCG (higher)
2. AFP (lower)
3. Serum oestriol (lower)
4. Inhibin-A (higher)
31
What risk score during pregnancy would result in an offer of amniocentesis or chorionic villus sampling?
>1 in 150
32
Overview of chorionic villus sampling?
US guided biopsy of placental tissue
| Before 15 weeks
33
Overview of amniocentesis?
US guided aspiration of amniotic fluid
| Used in later pregnancy
34
Which blood test is an alternative to invasive testing for Down's Syndrome in high risk women?
Non-invasive Prenatal Testing
Detects fetal DNA fragments within maternal blood sample
35
If a pregnant women has hypothyroidism treated with levothyroxine (T4), how does their dose need to be adjusted for pregnancy?
Increased
Often by at least 25-50micrograms (30-50%)
Titrated based on TSH, aiming for low-normal TSH level
36
Which three anti-hypertensives need to be stopped in pregnancy due to their known harmful effects?
1. ACE inhibitors e.g. ramipril
2. ARB e.g. losartan
3. Thiazide and thiazide-like diuretics e.g. indapaminde
37
Name three classes of anti-hypertensives which are safe to use during pregnancy?
1. Labetalol (only beta blocker)
2. CCB e.g. nifedipine
3. Alpha-blockers e.g. doxazosin
38
What dose of folic acid should be taken by women on AEDs?
5mg daily from before conception
39
Name three AEDs which are safer for use in pregnancy?
1. Levetiracetam
2. Lamotrigine
3. Carbamazepine
40
Can methotrexate be used during pregnancy for those with rheumatoid arthritis?
No - teratogenic
41
Which drug is first line for treatment of rheumatoid arthritis during pregnancy?
Hydroxychloroquine
42
What medication can be used for rheumatoid arthritis flare ups during pregnancy?
Corticosteroids
43
If NSAIDs are used esp. in the third trimester what can they cause?
Closure of the ductus arteriosus
Can delay labour
NSAIDs are generally avoided in pregnancy
44
What three things can beta blockers cause in pregnancy?
1. Fetal growth restriction
2. Hypoglycaemia in the neonate
3. Bradycardia in the neonate
Labetalol most frequent used to reduce the risks
45
What is the primary side effect of using ACEi/ARB in pregnancy?
Cross placenta
Reduce production of fetal urine
Results in oligohydramnios (reduced amniotic fluid)
46
What syndrome occurs in neonates when mothers have used opiates during pregnancy?
Neonatal abstinence syndrome (NAS)
47
Can warfarin be used in pregnancy?
Teratogenic
| Try to avoid in pregnancy
48
What three things can result from Warfarin use in pregnancy?
Fetal loss
Congenital malformations
Bleeding e.g. PPH, ICH
49
During which trimester of pregnancy is it best to avoid Lithium?
First trimester
50
What can Lithium use during pregnancy result in?
Congenital cardiac abnormalities
Especially Ebstein's anomaly
51
Can Lithium be used during breastfeeding?
No, enters breast milk and is toxic to the infant
52
Can SSRIs be used during pregnancy?
Balance of risk versus benefits
53
What are the risks of SSRIs in the first trimester of pregnancy?
Congenital Heart Defects
54
What are the risks of SSRIs in the third trimester?
Persistent Pulmonary Hypertension in the neonate
55
Rubella (german measles) can cause what during pregnancy?
Congenital Rubella Syndrome
| First 20 weeks of pregnancy
56
Can the MMR vaccine be given to pregnant women?
No
| Avoid live vaccines in pregnancy
57
What four things can result in congenital rubella syndrome?
Deafness
Cataracts
Heart defects e.g. PDA, pulmonary stenosis
Learning Disability
58
What causes Chickenpox?
Varicella Zoster Virus (VZV)
59
What maternal blood test can be used to assess immunity to chicken pox??
IgG levels for varicella zoster virus
Positive result = immunity
60
If a pregnant woman who is not immune to chickenpox is exposed to VZV what treatment should be given?
IV varicella immunoglobulins
Within 10 days of exposure
61
What can result in chickenpox during pregnancy?
Congenital varicella syndrome
If infection occurs during first 28 weeks of gestation
62
What can listeriosis cause in pregnant women?
Miscarriage
Fetal death
Severe neonatal infection
63
How is cytomegalovirus often trasmitted?
Infected saliva or urine of asymptomatic children
64
What does infection with Parvovirus B19 result in?
Slapped Cheek Syndrome
65
What complications can result in pregnancy from Parvovirus B19 infection?
Miscarriage or fetal death
Severe fetal anaemia
Hydrops fetalis
66
Which mosquito spreads Zika virus?
Aedes
67
What three symptoms result in congenital zika syndrome?
Microcephaly
Fetal growth restriction
Intracranial abnormalities e.g. ventriculomegaly, cerebellar atrophy
68
What can result in a rhesus-D negative pregnant women who is carrying a rhesus-D positive child and has been sensitised to rhesus-D?
Haemolytic disease of the newborn
69
What is the main management aim in preventing HDON?
Preventing sensitisation
IM anti-D injections in rhesus-D negative women
NB Sensitisation can't be reversed once it has occured!
70
Name three occasions when anti-D should be given to prevent sensitisation to rhesus-D?
1. Antepartum haemorrhage
2. Amniocentesis procedures
3. Abdominal trauma
71
What time frame should anti-D be given from a sensitisation event?
72 hours
72
What test is used to determine if further doses of anti-D are needed in rhesus-negative pregnant women?
Kleihauer test
73
What does the Kleihauer test show?
How much fetal blood has mixed with the mothers blood during a sensitisation event
Any sensitisation event past 20 weeks gestation
Assess if further anti-D doses are required
74
Define small for gestational age
fetus <10th centile for their gestational age
75
Define low birth weight
Birth weight <2500g
76
Define severe small for gestational age
Fetus <3rd centile for their gestational age
77
What two categories can the aetiology of small for gestational age fall into?
1. Constitutionally small - growing normally, just small
2. Fetal Growth Restriction i.e. intrauterine growth restriction (IUGR) - due to pathology e.g. reduced nutrient/oxygen delivery
78
What are the two categories for the causes of fetal growth restriction?
1. Placenta mediated growth restriction
| 2. Non-placenta mediated growth restriction e.g. genetic or structural abnormality
79
Give 4 examples of placenta mediated growth restriction resulting in FGR?
Idiopathic
Pre-eclampsia
Maternal smoking/alcohol consumption
Malnutrition
80
Give 3 examples of non-placenta mediated growth restriction resulting in FGR?
Genetic abnormalities
Structural abnormalities
Fetal infection
81
What are the short term complications of fetal growth restriction?
Fetal death or stillbirth
Birth asphyxia
Neonatal hypothermia/hypoglycaemia
82
What are the long term complications of fetal growth restriction?
CVD e.g. HTN
T2DM
Obesity
83
Name 4 risk factors for small for gestational age?
Obesity
Smoking
Diabetes
Pre-eclampsia
84
What three investigations are conducting in women who are higher risk for SGA pregnancies?
Serial US measuring:
1. Estimated fetal weight (growth velocity)
2. Umbilical arterial pulsatility index (UA-PI)
3. Amniotic fluid volume
85
Outline the management of SGA pregancies
Identify the underlying cause
- Pre-clampsia? e.g. BP, proteinuria
- Uterine artery doppler scanning
- Infection screen e.g. CMV, syphilis, toxoplasmosis
Early delivery of baby
- When growth is static
- Reduces risk of stillbirth
- Corticosteroids for lung maturation
86
Define Large for Gestational Age
Newborn >4.5kg at birth
Estimated fetal weight >90th centile
87
Name 4 causes of macrosomia
1. Maternal Diabetes
2. Constitutional
3. Maternal Obesity
4. Overdue
88
Name 4 risks to the mother of a macrosomia baby
Shoulder Dystocia
Perineal tears
Instrumental delivery or c-section
Failure to progress
89
Name 3 risks to the baby when they are macrosomnic
Traumatic birth e.g. shoulder dystocia, Erbs palsy
Neonatal hypoglycaemia
Increased risk of T2DM/obesity in later life
90
What two investigations should be undertaken for large for gestational age babies?
US - exclude polyhydramnios, estimate fetal weight
Oral glucose tolerance test - for gestational diabetes
91
What sign can be seen in dichorionic diamniotic twins?
Lambda or twin peak sign
92
What sign can be seen in monochorionic diamniotic twins on US?
T sign
93
Define Twin-Twin Transfusion Syndrome
When share a placenta
Connection between the blood supplies of 2 fetuses
94
What happens in Twin-Twin Transfusion Syndrome?
Recipient receives majority of blood supply
- Fluid overloaded, heart failure and polyhydramnios
Donor is starved of blood supply
- Growth restriction, anaemia and oligohydramnios
i.e. discrepancy between sizes of the fetuses
95
What treatment can be used in Twin-Twin Transfusion syndrome?
Referral to tertiary referral centre
Laser treatment to destroy connection between the blood supplies
96
What addition monitoring is required for women with multiple pregnancies?
Anaemia screening
- booking clinic
- 20 weeks and 28 weeks
Additional USS
- Monitor for FGR, TTTS
- 4 weekly from 20wks for dichorionic twins
97
When should monoamniotic twins be delivered?
Elective c-section
32-33+6 wks gestation
98
When should diamniotic twins be delivered?
37 - 37+6 wks gestation
99
What is the main risk from UTI in pregnancy?
Preterm delivery
100
When are pregnant women tested from asymptomatic bacteriuria during pregnancy?
Why?
Booking and routinely throughout
Urine sent for MC&S
Reduce risk of preterm birth
101
What type of urine sample is sent for MC&S in pregnant women?
Midstream Urine
102
What is the commonest cause of UTI in pregnancy?
E. coli
Gram -ve rod shaped anaerobic bacteria
103
What is the antibiotic course duration for UTI in pregnancy?
7 days
104
What abx for UTI should be avoided in 3rd trimester?
Nitrofurantoin
Risk of neonatal haemolysis
105
When are women routinely screened for anaemia during pregnancy?
Booking clinic
28 weeks gestation
106
Why is it important to optimise anaemia during pregnancy?
To ensure optimal reserves in the event of significant blood loss during delivery
107
Low MCV in pregnancy can indicate what as the cause of anaemia?
Iron deficiency
108
Raised MCV in pregnancy can indicate what as the cause of anemia?
B12 or Folate deficiency
109
What dose of iron is given to pregnant women who are anaemic??
Ferrous Sulphate 200mg TDS
110
What are the treatment options for low B12 in pregnancy?
IM hydroxocobalamin
Oral cyanocobalamin
111
When should VTE prophylaxis be started in women who have 3 risk factors?
28 weeks gestation
112
When should VTE prophylaxis be started in women who have 4 or more risk factors?
First trimester
113
What is used for VTE prophylaxis in pregnancy?
How long is it continued for after pregnancy?
Low Molecular Weight Heparin
e.g. enoxaparin, dalteparin, tinzaparin
6 weeks post-partum
114
Name 4 common presenting features of DVT
Unilateral calf or leg swelling
Dilated superficial veins
Calf tenderness
Oedema
115
When measuring the leg circumference, what cm difference is significant?
>3cm
116
What is the treatment of choice to diagnose DVT?
Doppler US
117
Can you use Wells score in pregnancy?
No
Not validated for use in pregnant women
118
What do you use to treat VTE in pregnancy?
Low Molecular Weight Heparin
e.g. enoxaparin, dalteparin, tinzaparin
Dose based on weight at booking clinic
Start immediately, before confirmation of dx
119
Define pre-eclampsia
New onset hypertension in pregnancy with end-organ dysfunction
Proteinuria
Occurs after 20 weeks gestation
Due to abnormally formed spiral arteries causing high vascular resistance
120
What are the triad of features for pre-eclampsia?
Hypertension
Proteinuria
Oedema
121
Define gestational hypertension
Hypertension occuring >20 wks gestation
Without proteinuria
122
Define eclampsia
Seizures resulting from pre-eclampsia
123
Name 4 high risk factors for developing pre-eclampsia
Pre-existing hypertension
Previous hypertension in pregnancy
Diabetes
Existing autoimmune conditions e.g. SLE
124
Name 4 moderate risk factors for developing pre-eclampsia
>40 years old
BMI >35
>10 years since previous pregnancy
First pregnancy
125
What is used to treat women with risk factors for developing pre-eclampsia?
Aspirin from 12 weeks gestation until birth
If they:
- 1 high risk factor
- >1 moderate risk factor
126
Name 6 symptoms of pre-eclampsia
```
Headache
Visual disturbances
Nausea and Vomiting
Upper abdo/epigastric pain (due to liver swelling)
Oedema
Reduced urine output
Brisk reflexes
```
127
What is the diagnostic criteria for pre-eclampsia?
Systolic >140mmHg
Diastolic >90mmHg
PLUS any of:
1. Proteinuria
2. Organ dysfunction e.g. raised creatinine, elevated liver enzymes
3. Placental dysfunction e.g. FGR
128
What placental protein can be measured to rule out preeclampsia between 20-35 weeks gestation?
Placental growth factor
Low in pre-eclampsia
129
If gestational hypertension is detected during antenatal appointments, what is the target BP?
Below 135/85 mmHg
130
What is HELLP syndrome?
Haemolysis
Elevated Liver enzymes
Low Platelets
Due to complication of pre-eclampsia and eclampsia
131
What is used to treat eclamptic seziures?
IV magnesium sulphate
132
What is first line for pre-eclampsia?
Labetolol
133
What is second line for pre-eclampsia?
Nifedipine MR
134
What is third line for pre-eclampsia?
Methyldopa
135
What medication can be used in severe pre-eclampsia or eclampsia?
IV hydralazine
136
What is the definitive management of resistant pre-eclampsia?
Planned early delivery of the baby
Corticosteroids if premature
Monitor BP after delivery, which should return to normal after placenta removed
137
What is the main cause of gestational diabetes?
Reduced insulin sensitivity during pregnancy
138
What is the immediate complication of gestational diabetes?
Large for dates fetus
| Macrosomnia
139
Name 5 risk factors for gestational diabetes
Previous gestational diabetes
Previous macrosomic baby
BMI >30
Black Afro-Caribbean, Middle Eastern and South Asian
Family Hx of diabetes (1st degree relative)
140
What are the normal fasting results for an oral glucose tolerance test?
<5.6 mmol/L
141
What are the normal 2 hour results for an oral glucose tolerance test?
<7.8 mmol/L
142
What treatment for gestational diabetes should be started for fasting glucose <7 mmol/L?
Trail diet and exercise for 2 weeks
Metformin
Insulin
143
What treatment for gestational diabetes should be started for fasting glucose >7 mmol/L?
Start insulin
+/- metformin
144
What treatment for gestational diabetes should be started for fasting glucose above 6mmol/L plus macrosomia?
Start insulin
+/- metformin
145
In gestational diabetes, what is the target fasting blood glucose?
5.3 mmol/L
146
In gestational diabetes, what is the target 1 hour post-meal blood glucose?
7.8 mmol/L
147
In gestational diabetes, what is the target 2 hour post-meal blood glucose?
6.4 mmol/L
148
In women with pre-existing diabetes, what dose of folic acid is indicated?
5mg folic acid
preconception until 12 weeks gestation
149
What should be considered during delivery for mothers with T1DM?
Sliding-scale insulin regime
150
When can mothers with gestational diabetes stop their diabetic medications?
Immediately after birth
151
What are neonates of mothers with gestational diabetes at risk of?
Neonatal hypoglycaemia
Maintain blood sugars above 2 mmol/L
152
Define obstetric cholestasis
Reduced outflow of bile acids from the liver
Causes build up in the blood
Results in pruritus
153
What trimester does obstetric cholestasis tend to occur?
3rd Trimester
154
In obstetric cholestasis, where is the itching usually localised to?
Palms and soles of the feet
155
What are three differentials for obstetric cholestasis?
Gallstones
Acute fatty liver
Autoimmune Hepatitis
156
What is normally seen in obstetric cholestasis in LFTs?
Abnormal ALT, AST and GGT
Raised bile acids
157
What three strategies are used for obstetric cholestasis?
Ursodeoxycholic acid
Emollients
Antihistamines
158
Define polymorphic eruption of pregnancy
Itchy rash in 3rd trimester
Often starts on abdomen
A/w striae
159
Define atopic eruption of pregnancy
Eczema flares in pregnancy
In the 1st and 2nd trimester of pregnancy
160
Define melasma
"mask of pregnancy"
Increased pigmentation of the skin on face
Often sun-exposed areas
a/w increased female sex hormones
161
Define placenta praevia
Placenta over the internal cervical os
162
What are the three main causes of antepartum haemorrhage?
Placenta praevia
Placental abruption
Vasa praevia
163
Name three risks of placenta praevia
Antepartum haemorrhage
Emergency c-section
Emergency hysterectomy
164
Define low-lying placenta
Placenta is within 20mm of the internal cervical OS
165
Name three risk factors for placenta praevia
Previous c-section
Previous placenta praevia
Older maternal age
166
At which point during pregnancy is placenta praevia usually identified?
20 wk anomaly scan
167
For women identified as having placenta praevia at the 20 wk anomaly scan, when should repeat TV scans be arranged for?
32 wks gestation
26 wks gestation
168
In those with placenta praevia what is the safest option regarding delivery of baby?
Planned c-section
36-37 wks gestation
169
What is the main complication of placenta praevia?
Haemorrhage before, during and after delivery
170
Define vasa praevia
Fetal vessels exposed outside of the umbilical cord or placenta
Vessels travel through the chorioamniotic membranes
Travel across the internal cervical OS
2 umbilical arteries and single umbilical vein
171
Name three risk factors for vasa praevia
Low lying placenta
IVF pregnancy
Multiple pregnancy
172
What is the optimal management of vasa praevia?
Planned elective c-section at 34-36 wks
Corticosteroids for fetal lung maturation
173
Define placental abruption
Placenta separates from uterine wall during pregnancy
174
Name four risk factors for placental abruption
Pre-eclampsia
Trauma
Smoking
Increased maternal age
175
In placental abruption, what are the main three features?
Sudden onset severe abdominal pain that is continuous
PV bleeding
"Woody" abdomen on palpation
176
Define concealed placental abruption
Cervical OS remains closed
Bleeding remains in the uterine cavity
i.e. no PV bleeding
177
What prophylactic injection should be given in placental abruption in rhesus-D women?
Anti-D
178
What may be needed in placental abruption if the mother is unstable or there is fetal distress?
Emergency c-section
179
What is the main risk during delivery of baby in placental abruption?
Postpartum haemorrhage
180
Define placenta accreta
Placenta implants deeper than the endometrium in the uterus i.e. myometrium
Difficult to separate after delivery of the baby
181
Define placenta increta
Placenta attaches deeply into the myometrium
182
Define placenta percreta
Placenta invades past the myometrium and perimetrium
Can involve other organs e.g. bladder!
183
Name three risk factors for placenta accreta
Previous placenta accreta
Previous endometrial curettage
Previous c-section
184
How should placenta accreta be managed?
Discovered antenatally
Specialist MDT input for complex planning of delivery
185
What is the recommended treatment for placenta accreta?
c-section delivery of baby
Hysterectomy with placenta remaining in the uterus
186
Define Breech presentation
Presenting part of the fetus is the legs and bottom
187
Define Complete Breech presentation
Legs fully flexed at hips and knees
188
Babies that are breech before 36 weeks often do what?
Turn spontaneously
No intervention is advised
189
For babies that are breech, at what gestation is external cephalic version used?
37 weeks (term)
190
When external cephalic version fails, what two options are there for mum and baby?
Vaginal Delivery (safer for mum)
Elective c-section (safer for baby)
191
Define external cephalic version
Technique used to turn a fetus from breech to cephalic presentation
50% successful
192
External cephalic version is used at what week gestation for nulliparous women?
After 36 weeks
193
External cephalic version is used at what week gestation for woman that have given birth previously?
After 37 weeks
194
What drug is given to women to relax the uterus before ECV?
Tocolysis i.e. terbutaline
Beta-agonist (similar to salbutamol)
Reduces myometrial contractility
195
Define still birth
Birth of a dead fetus after 24 weeks gestation
196
Name three causes of stillbirth
Unexplained (50%)
Pre-eclampsia
Placental abruption
197
Name three factors that increase the risk of stillbirth
Fetal growth restriction
Smoking and Alcohol
Increased maternal age
198
What advice can be given to reduce the risk of stillbirth?
Sleep on the side (not the back)
199
Which investigation is best to diagnose intrauterine fetal death?
US looking for the fetal heartbeat
200
What is the first line management for intrauterine fetal death?
Vaginal birth
Induction of labour or expectant management
201
For intrauterine fetal death, what medications can be given to induce labour?
Oral mifepristone
| PO/PV misoprostol
202
What medication can be given to suppress lactation after stillbirth?
Dopamine agonist
e.g. cabergoline
203
Name three major causes of cardiac arrest in pregnancy
Obstetric haemorrhage
Pulmonary emobolism
Sepsis
204
Name five causes of obstetric haemorrhage
Ectopic pregnancy
Placental abruption
Placenta praevia
Placenta accreta
Uterine rupture
205
Define aortocaval compression
>20 weeks gestation the uterus is a significant size
Supine position results in compression of the IVC and aorta
Resolved by laying on the left lateral position
206
What should happen within 5 minutes of CPR commencing in a pregnant lady?
Delivery of the baby and placenta
To improve the survival of the mother
