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The six elements considered to be reflective of good care are:
 Consultant obstetrician planning and directly supervising delivery.
 Consultant anaesthetist planning and directly supervising anaesthesia at delivery.
 Blood and blood products available.
 Multidisciplinary involvement in preoperative planning.
 Discussion and consent, including possible interventions (such as hysterectomy, leaving the placenta in situ, cell
salvage and interventional radiology).
 Local availability of a level 2 critical care bed.

According to the RCOG- Any lack of compliance with the care bundle by the clinical team for a woman with either placenta praevia or accreta
should be investigated.

According to MBBRACE-UK 2014 to 2016- Women who have had a previous caesarean section who also have either placenta praevia or an anterior placenta underlying the old caesarean section scar at 32 weeks of gestation are at increased risk of placenta accreta and should be managed as if they have placenta accreta, with appropriate preparations for surgery made.

The likelihood of maternal GBS carriage in this pregnancy is 50%.
What should be done?- Discuss the options- a. Intrapartum antibiotic prophylaxis ( IAP).
b. Bacteriological testing in late pregnancy and the offer of IAP if still positive. ( This is the only group of women who are eligible for GBS screening funded by NHS)

Cord presentation is the presence of the umbilical cord between the fetal presenting part and the cervix, with or without intact membranes. ( i.e if the cord  is present ABOVE the cervix, with ruptured membranes- this is cord PRESENTATION)

Cord prolapse is descent of the umbilical cord through the cervix  in the presence of ruptured membranes.

Cord prolapse can be occult ( Alongside the presenting part) or OVERT (Past the presenting part)

A dose of 250 IU anti-D immunoglobulin should be sufficient to cover up to five adult therapeutic doses of D positive platelets given within a 6-week period.

In severely thrombocytopenic patients with platelet count of?30 × 10^9/L, anti-D Ig should be given subcutaneously, or IV.

Planned VBAC is contraindicated in women with previous uterine rupture or classical caesarean scar.

Women who have had two or more prior lower segment caesarean deliveries may be offered VBAC after counselling by a senior obstetrician. This should include the risk of uterine rupture and maternal morbidity, and the individual likelihood of successful VBAC.

This is GBS bacteruria. GBS bacteriuria is associated with a higher risk of chorioamnionitis and neonatal disease. Women with GBS bacteriuria should be offered IAP.

Women with GBS urinary tract infection (growth of greater than 10^5 cfu/ml) during pregnancy should receive appropriate treatment at the time of diagnosis as well as IAP. 

Systemic chemotherapy is contraindicated in the first trimester because of a high rate of fetal
abnormality,but is safe from the second trimester.

If the placenta is thought to be low lying (less than 20 mm from the internal os) or praevia
(covering the os) at the routine fetal anomaly scan, a follow-up ultrasound examination
including a TVS is recommended at 32 weeks of gestation to diagnose persistent low-lying
placenta and/or placenta praevia.

Use of TVS- to accurately see the placental edge. Also, cervical length is a predictor of antepartum bleeding and emergency preterm caesarean section in placenta praevia. Women with a cervical length of less than 31 mm have a 16 times higher risk of emergency
caesarean section due to massive haemorrhage.

• IAP( Intrapartum antibiotic prophylaxis)  is recommended for women in confirmed preterm labour.  The risk of GBS infection is higher with preterm delivery and the mortality rate from infection is increased (20–30% versus 2–3% at term). For this reason, IAP is recommended for women in confirmed preterm labour.
• There is no evidence that intrapartum vaginal cleansing will reduce the risk of neonatal GBS disease.
• Polymerase chain reaction or other near-patient testing at the onset of labour is not recommended.

The recommended dose is - 3 g intravenous benzylpenicillin be given as soon as possible after the onset of labour  and 1.5 g 4 hourly until delivery.
The first dose should be given at least 4 hours prior to delivery.

Routine ultrasound screening is not useful. Selective ultrasound screening can be considered for women with breech presentation at term who are considering vaginal birth.

Successful VBAC is more likely among women with previous caesarean for
fetal malpresentation (84%) compared with women with previous caesarean for either labour dystocia (64%) or fetal distress (73%) indications.

- For pregnancies at more than 16 weeks of gestation the term low-lying placenta should be used when the placental edge is less than 20 mm from the internal os on transabdominal or transvaginal scanning (TVS).

• The term placenta praevia should be used when the placenta lies directly over the internal os.

The algorithm suggested by RCOG for low lying placenta can be accessed HERE