Drugs used during pregnancy can have temporary or permanent effects on the fetus. Anything (including drugs) that can cause permanent deformities in the fetus are labeled as teratogens. In the U.S., drugs were classified into categories A, B, C, D and X based on the Food and Drug Administration (FDA) rating system to provide therapeutic guidance based on potential benefits and fetal risks. Drugs, including some multivitamins, that have demonstrated no fetal risks after controlled studies in humans are classified as Category A. On the other hand, drugs like thalidomide with proven fetal risks that outweigh all benefits are classified as Category X.

Both expectant management (watchful waiting) and an induction of labor (artificially stimulating labor) are considered in this case. 90% of women start labor on their own within 24 hours, and therefore it is reasonable to wait for 12–24 hours as long as there is no risk of infection. However, if labor does not begin soon after the rupture of membranes, an induction of labor is recommended because it reduces rates of infections, decreases the chances that the baby will require a stay in the neonatal intensive care unit (NICU), and does not increase the rate of cesarean sections. If a woman strongly does not want to be induced, watchful waiting is an acceptable option as long as there is no sign of infection, the fetus is not in distress, and she is aware and accepts the risks of prolonged PROM. There is not enough data to show that the use of prophylactic antibiotics (to prevent infection) is beneficial for mothers or babies at or near term. Because of the potential side effects and development of antibiotic resistance, the use of antibiotics without the presence of infection is not recommended in this case.

There are four common methods of starting contractions. The four most common are stripping the membranes, breaking the mother's water, giving the hormone prostaglandin, and giving the synthetic hormone pitocin. Stripping the membranes doesn't work for all women, but can for most. A doctor inserts a finger into the mother's cervix and moves it around to separate the membrane connecting the amniotic sac, which houses the baby, from the walls of the uterus. Once this membrane is stripped, the hormone prostaglandin is naturally released into the mother's body and initiates contractions. Most of the time doing this only once will not immediately start labor. It may have to be done several times before the stimulant hormone is released, and contractions start. The next method is breaking the mother's water, which is also referred to as an amniotomy. The doctor uses a plastic hook to break the membrane and rupture the amniotic sac. Within a few hours labor usually begins. Giving the hormone prostagladin ripens the cervix, meaning the cervix softens, thins out, or dilates. The drug Cervidil is administered by mouth in tablet form or in gel form as an insert. This is most often done in the hospital overnight. The hormone oxytocin is usually given in the synthetic form of Pitocin. It is administered through an IV throughout the labor process. This hormone stimulates contractions. Pitocin is also used to "restart" labor when it's lagging.

The use of misoprostol is also allowed, but close monitoring of the mother is required.

A number of medications may be useful to delay delivery including: NSAIDs, calcium channel blockers, beta mimetics, and atosiban. Tocolysis rarely delays delivery beyond 24–48 hours. This delay however may be sufficient to allow the pregnant woman to be transferred to a center specialized for management of preterm deliveries and give administered corticosteroids to reduce neonatal organ immaturity. Meta-analyses indicate that calcium-channel blockers and an oxytocin antagonist can delay delivery by 2–7 days, and β2-agonist drugs delay by 48 hours but carry more side effects. Magnesium sulfate does not appear to be useful and may be harmful when used for this purpose.

Inducing labor artificially starts the labor process by using medication and other techniques. Labor is usually only induced if there is potential danger on the mother or child.

There are several reasons for labor induction; the mother's water breaks, and contractions have not started, the child is post-mature, the mother has diabetes or high blood pressure, or there is not enough amniotic fluid around the baby. Labor induction is not always the best choice because it has its own risks. Sometimes mothers will request to be induced for reasons that are not medical. This is called an elective induction. Doctors try to avoid inducing labor unless it is completely necessary.

The routine administration of antibiotics to all women with threatened preterm labor reduces the risk of the baby to get infected with group B streptococcus and has been shown to reduce related mortality rates.

When membranes rupture prematurely, obstetrical management looks for development of labor and signs of infection. Prophylactic antibiotic administration has been shown to prolong pregnancy and reduced neonatal morbidity with rupture of membranes at less than 34 weeks. Because of concern about necrotizing enterocolitis, amoxicillin or erythromycin has been recommended, but not amoxicillin + clavulanic acid (co-amoxiclav).

When the fetus is premature (< 37 weeks), the risk of being born prematurely must be weighed against the risk of prolonged membrane rupture. As long as the fetus is 34 weeks or greater, delivery is recommended as if the baby was term (see above).

Nutrition during pregnancy is important to ensure healthy growth of the fetus. Nutrition during pregnancy is different from the non-pregnant state. There are increased energy requirements and specific micronutrient requirements. Women benefit from education to encourage a balanced energy and protein intake during pregnancy. Some women may need professional medical advice if their diet is affected by medical conditions, food allergies, or specific religious/ ethical beliefs.

Adequate periconceptional (time before and right after conception) folic acid (also called folate or Vitamin B) intake has been shown to decrease the risk of fetal neural tube defects, such as spina bifida. The neural tube develops during the first 28 days of pregnancy, a urine pregnancy test is not usually positive until 14 days post-conception, explaining the necessity to guarantee adequate folate intake before conception. Folate is abundant in green leafy vegetables, legumes, and citrus. In the United States and Canada, most wheat products (flour, noodles) are fortified with folic acid.

DHA omega-3 is a major structural fatty acid in the brain and retina, and is naturally found in breast milk. It is important for the woman to consume adequate amounts of DHA during pregnancy and while nursing to support her well-being and the health of her infant. Developing infants cannot produce DHA efficiently, and must receive this vital nutrient from the woman through the placenta during pregnancy and in breast milk after birth.

Several micronutrients are important for the health of the developing fetus, especially in areas of the world where insufficient nutrition is common. Women living in low and middle income countries are suggested to take multiple micronutrient supplements containing iron and folic acid. These supplements have been shown to improve birth outcomes in developing countries, but do not have an effect on perinatal mortality. Adequate intake of folic acid, and iron is often recommended. In developed areas, such as Western Europe and the United States, certain nutrients such as Vitamin D and calcium, required for bone development, may also require supplementation. Vitamin E supplementation has not been shown to improve birth outcomes. Zinc supplementation has been associated with a decrease in preterm birth, but it is unclear whether it is causative. Daily iron supplementation reduces the risk of maternal anemia. Studies of routine daily iron supplementation for pregnant women found improvement in blood iron levels, without a clear clinical benefit. The nutritional needs for women carrying twins or triplets. are higher than those of women carrying one baby.

Women are counseled to avoid certain foods, because of the possibility of contamination with bacteria or parasites that can cause illness. Careful washing of fruits and raw vegetables may remove these pathogens, as may thoroughly cooking leftovers, meat, or processed meat. Unpasteurized dairy and deli meats may contain "Listeria," which can cause neonatal meningitis, stillbirth and miscarriage. Pregnant women are also more prone to "Salmonella" infections, can be in eggs and poultry, which should be thoroughly cooked. Cat feces and undercooked meats may contain the parasite Toxoplasma gondii and can cause toxoplasmosis. Practicing good hygiene in the kitchen can reduce these risks.

Women are also counseled to eat seafood in moderation and to eliminate seafood known to be high in mercury because of the risk of birth defects. Pregnant women are counseled to consume caffeine in moderation, because large amounts of caffeine are associated with miscarriage. However, the relationship between caffeine, birthweight, and preterm birth is unclear.

The first step in management of uterine atony is uterine massage. The next step is pharmacological therapies, the first of which is oxytocin, used because it initiates rhythmic contractions of the uterus, compressing the spiral arteries which should reduce bleeding. The next step in the pharmacological management is the use of methylergometrine, which is an ergot derivative, much like that use in the abortive treatment of migraines. Its side effect of hypertension means its use should not be used in those with hypertension or pre-eclampsia. In those with hypertension, the use of prostaglandin F is indicated (but beware of its use in patients with asthma).

Another option Carbetocin and Carboprost where Oxytocin and ergometrin is inappropriate.

An initial assessment to determine the status of the mother and fetus is required. Although mothers used to be treated in the hospital from the first bleeding episode until birth, it is now considered safe to treat placenta previa on an outpatient basis if the fetus is at less than 30 weeks of gestation, and neither the mother nor the fetus are in distress. Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement (to maintain blood pressure) and blood plasma replacement (to maintain fibrinogen levels) may be necessary.

Corticosteroids are indicated at 24–34 weeks gestation, given the higher risk of premature birth.

The method of delivery is determined by clinical state of the mother, fetus and ultrasound findings. In minor degrees (traditional grade I and II), vaginal delivery is possible. RCOG recommends that the placenta should be at least 2 cm away from internal os for an attempted vaginal delivery. When a vaginal delivery is attempted, consultant obstetrician and anesthetists are present in delivery suite. In cases of fetal distress and major degrees (traditional grade III and IV) a caesarean section is indicated. Caesarian section is contraindicated in cases of disseminated intravascular coagulation. An obstetrician may need to divide the anterior lying placenta. In such cases, blood loss is expected to be high and thus blood and blood products are always kept ready. In rare cases, hysterectomy may be required.

Principles of management are to treat the shock and replace the uterus. The patient should be moved rapidly to the OR to facilitate anesthesia monitoring during this procedure. Usually this complication is only recognized after delivery of the placenta, wherein pitocin has already been started, which just exacerbates the problem. The uterus clamps down around the inversion making it very difficult to perform a replacement. This is a true obstetrical emergency, so extra doctors, nurses, anesthesiologists should be summoned to the room to assist. The pitocin should be turned off immediately. Giving tocolytics such as terbutaline or magnesium sulfate have a lower success rate. Halothane and Nitroglycerine (100mcg to 200 mcg intravenously) have a higher success rate.

Once you have achieved uterine relaxation, place your fist into the vagina. Find the biggest part of the inversion and push with your fist cephalward to replace the uterus. This takes firm steady force, so keep your fist in the vagina if you need to rest your hand. Then continue more force toward the fundus to replace the uterus. You can use your left hand on the outside of the abdomen to help you feel where the fundus should be replaced. This helps guide the angle of your fist in replacing the uterus. Once it is replaced, give the patient Misoprostol 1000 mcgs rectally to help with increasing uterine tone. Other medications such as Methergine and Hemabate can be used. If you have heavy bleeding, consider inserting a Bakri balloon into the uterine cavity to tamponade the bleeding.

These patients have usually sustained heavy blood loss, and should be monitored in the ICU postoperatively. If you have given nitroglycerine, they must have cardiac monitoring postoperatively.

Other personnel should be monitoring vital signs, ordering blood products, assisting the anesthesiologist, drawing labs, and stabilizing the patient. Remember that nitroglycerine can cause hypotension, which can be reversed with ephedrine.

If external replacement fails, a laparotomy may be required, in which the uterus is gently pulled the right way round using forceps.

Antibiotic Treatment consists of:

- Standard: Ampicillin 2g IV every 6 hours + Gentamicin 1.5 mg/kg every 8 hours

- Alternative: Ampicillin-Sulbactam 3g IV every 5 hours, Ticarcillin-Clavulanate 3.1g IV every 4 hours, Cefoxitine 2g IV every 6 hours

- Cesarean Delivery: Ampicillin 2g IV every 6 hours + Gentamicin 1.5 mg/kg every 8 hours + Clindamycin 900 mg every 8 hours or Metronidazole 500 mg IV every 6 hours

- Penicillin-Allergy: Vancomycin 1g IV every 12 hours + Gentamicin 1.5 mg/kg every 8 hours

Completion of treatment/cure is only considered after delivery.

Instead of referring to "fetal distress" current recommendations hold to look for more specific signs and symptoms, assess them, and take the appropriate steps to remedy the situationthrough the implementation of intrauterine resuscitation. Traditionally the diagnosis of "fetal distress" led the obstetrician to recommend rapid delivery by instrumental delivery or by caesarean section if vaginal delivery is not advised.

Perineal pain after childbirth has immediate and long-term negative effects for women and their babies. These effects can interfere with breastfeeding and the care of the infant. The pain from injection sites and possible episiotomy is managed by the frequent assessment of the report of pain from the mother. Pain can come from possible lacerations, incisions, uterine contractions and sore nipples. Appropriate medications are usually administered. Routine episiotomies have not been found to reduce the level of pain after the birth.

No studies demonstrate the effectiveness of hypnosis, biofeedback, sterile water injection, aromatherapy, and TENS in reducing pain during labor and delivery.

Once RLP has been diagnosed, there are many ways to reduce the pain without jeopardizing the pregnancy.

- Analgesics. Acetaminophen or paracetamol is safe to take during pregnancy, thus is the most commonly prescribed pain reliever for pregnant women with RLP.

- Heat application. Applying a hot compress to the area of pain may give some relief. Hot soaks and hot baths may also help.

- Modifications in movements and position. Triggering factors that can cause RLP are sudden movements, (e.g. sitting up and down, standing up, sneezing, coughing), physical exertion, and long periods in the same resting position. A change in daily activities can help find relief and prevent worsening of the condition. Avoid sudden movements that can cause spasms of the ligament. When about to sneeze or cough, brace yourself by bending and flexing the hips to minimize the pull on the ligaments.

- Rest. Resting is one of the best remedies against RLP. When lying down, changing position slowly and regularly is recommended.

- Physical exercises Daily stretching exercise may be recommended by a gynecologist. An example of such an exercise is kneeling with hands and knees on the floor, then lowering your head to the floor, and keeping your bottom up in the air. The so-called pelvic (hip) tilt exercise also appears to help in reducing pain intensity and duration.

- Surgery. In RLP pathologies involving endometriosis and ademyosis, surgery may be necessary to perform resection of the ligament or removal cysts and myoma.

Precipitate delivery may cause intracranial hemorrhage resulting from a sudden change in pressure on the fetal head during rapid expulsion.

It may cause aspiration of amniotic fluid, if unattended at or immediately following delivery.

There may be infection as a result of unsterile delivery.

Emergency exploratory laparotomy with cesarean delivery accompanied by fluid and blood transfusion are indicated for the management of uterine rupture. Depending on the nature of the rupture and the condition of the patient, the uterus may be either repaired or removed (cesarean hysterectomy). Delay in management places both mother and child at significant risk.

Miscarriage is the loss of a pregnancy prior to 20 weeks. In the UK miscarriage is defined as the loss of a pregnancy during the first 23 weeks.

Upon diagnosis, many providers will prescribe Ursodeoxycholic Acid. While there is no cure for ICP, and no way to guarantee a successful outcome, studies have shown a slightly better fetal and maternal outcome from administration of Ursodeoxycholic Acid, whereas Cholestyramine appears to only relieve itching.

If additional blood tests to check clotting function identify a problem, giving Vitamin K may help avoid the risk of hemorrhage at delivery.

Delivery by 35–37 completed weeks may be important to fetal outcome as a recent study demonstrated that in severe ICP (defined as bile acids greater than 40 umol/L) the risk of stillbirth was 1.5% compared to 0.5% of uncomplicated pregnancies. This risk rose further if bile acids doubled,

Some disorders and conditions can mean that pregnancy is considered high-risk (about 6-8% of pregnancies in the USA) and in extreme cases may be contraindicated. High-risk pregnancies are the main focus of doctors specialising in maternal-fetal medicine.

Serious pre-existing disorders which can reduce a woman's physical ability to survive pregnancy include a range of congenital defects (that is, conditions with which the woman herself was born, for example, those of the heart or , some of which are listed above) and diseases acquired at any time during the woman's life.

The goal of antiretroviral use during pregnancy is to reduce the risk of transmission of HIV from mother to child. It is important to choose medications that are safe for the mother and the fetus and which are effective at decreasing the total viral load. Some studies have shown an increase in stillbirths, preterm delivery, and delayed fetal growth in women using high doses of antiretroviral drugs during pregnancy. However, the overall benefits of ART are believed to outweigh the risks and all women are encouraged to use ART for the duration of their pregnancy.

Due to physiological changes in the body during pregnancy, it may be necessary to alter the dosing of medications so that they remain effective. Generally, the dose or the frequency of dosing are increased to account for these changes.

The recommended ART regimen for HIV-positive pregnant women consists of drugs from 4 different classes of medications listed below. In the United States, the favored regimen is a three-drug regimen where the first two drugs are NRTIs and the third is either a protease inhibitor, an integrase inhibitor, or an NNRTI.

- Nucleoside reverse transcriptase inhibitors (NRTIs) are considered the "backbone" of ART and 2 medications are generally used in combination. Due to its known safety profile and extensive use in pregnant patients, zidovudine-lamivudine (ZDV/3TC) is the preferred choice as the NRTI backbone. Zidovudine may worsen anemia, so patients with anemia are advised to use an alternative agent. For women who are coinfected with Hepatitis B, tenofovir with either emtricitabine or lamivudine is the preferred NRTI backbone. NRTI use may cause lactic acidosis in some women, so it is important to monitor patients for this complication. Deaths from lactic acidosis and liver failure have been associated with the use of two NRTIs, stavudine and didanosine (Zerit and Videx, respectively); therefore, combinations involving these drugs should be avoided in pregnancy.

- Protease inhibitors (PIs) have been studied extensively in pregnancy and are therefore the preferred third drug in the regimen. Atazanavir-ritonavir and darunavir-ritonavir are two of the most common PIs used during pregnancy. There is conflicting data regarding their association with preterm births, so women who are at a high risk for premature delivery are advised not to use PIs. Some PIs have been associated with hyperglycemia but is unclear whether they add to the risk of developing gestational diabetes. Some PIs have been noted to cause hyperbilirubinemia and nausea, so these side effects should be monitored for closely.

- Integrase inhibitors (IIs) are generally the third drug in the regimen when a PI cannot be used. They rapidly reduce the viral load and for this reason, they are often used in women who are diagnosed with HIV late in the pregnancy. Raltegravir is the most common II used.

- Non-nucleoside reverse transcriptase inhibitors (NNRTIs), the most popular being efavirenz and nevirapine, may be used during pregnancy. However, there are significant toxicities associated with their use, making them a less desirable option.

- Efavirenz (brand name Sustiva, and a component of the combination drug Atripla) is classified as a category D drug by the US Food and Drug Administration indicating there are risks associated with its use during pregnancy. In a study analyzing the use of the drug in pregnant women, 2.3% of births were associated with birth defects. However, a systematic review of the safety of efavirenz use in humans during the first trimester found no increase in birth defects among women using the drug. Given the uncertain potential for risk the U.S. DHHS recommends against using efavirenz in the first trimester of pregnancy or in women who may become pregnant. They instead recommend a protease inhibitor based regimen with lopinavir or atazanavir. However, to simplify regimens and provide a uniform recommendation for HIV-infected individuals during pregnancy, the WHO continues to recommend efavirenz as a first line agent for HIV positive women. Women using efavirenz prior to their pregnancy may continue with the drug as it is more dangerous to stop or change medications during pregnancy because this can result in improper control of the viral load.

- Nevirapine (trade name Viramune) increases the risk of very serious liver damage in women with CD4 counts greater than 250 cells/mm . It is generally avoided in pregnant women. Women taking nevirapine safely prior to pregnancy may continue with the medication because nevirapine-related liver damage has not been seen in women previously using the medication.

The delivery of the second twin in a transverse lie with a shoulder presentation represents a special situation that may be amenable to a vaginal delivery. As the first twin has just been delivered and the cervix is fully dilated the obstetrician may perform an internal version, that is inserting one hand into the uterus, find the baby’s feet, and then bring the baby into a breech position and deliver the baby as such.

While a transverse lie prior to labor can be manually versed to a longitudinal lie, once the uterus starts contracting the uterus normally will not allow any version procedure. A shoulder presentation is an indication for a caesarean section. Generally, as it is diagnosed early, the baby is not damaged by the time of delivery. With the rupture of the membranes, there is an increased risk of a cord prolapse as the shoulder may not completely block the birth canal. Thus the caesarean section is ideally performed before the membranes break.