Listen for 1 full minute with Pinard / 60-second Doppler count
Auscultate after uterine contraction in labour
Pinard vs Doppler
Feature
Pinard Horn
Hand-held Doppler
First heard
~20 weeks
~12 weeks
Battery
None needed
Required
FHR display
Auscultation only
Digital readout
Best for
Experienced midwives
Community / student use
Maternal Vital Signs in Pregnancy
Parameter
Non-Pregnant
Pregnant Changes
Clinical Note
Blood Pressure
120/80 mmHg
BP falls in T2 (nadir ~20 wks), rises back T3
Diastolic <80 common in T2; >140/90 = hypertension
Heart Rate
60–90 bpm
+10–20 bpm increase
Resting tachycardia can be normal; exclude PE if sudden
Respiratory Rate
12–16/min
Increases; tidal volume ↑40%
Dyspnoea common; exclude PE/pulmonary oedema
Temperature
36.5–37.2°C
Mild rise in T1 (progesterone)
Fever ≥38°C requires urgent assessment
SpO2
97–100%
Unchanged or slightly ↑
SpO2 <95% warrants assessment
Blood pressure should always be measured after 5 minutes of rest, in a seated position with the arm at heart level. Automated BP machines may underread in severe pre-eclampsia — use calibrated mercury or aneroid sphygmomanometer if in doubt.
Antenatal Booking Bloods
Test
Timing
Purpose
FBC
Booking & 28 wks
Anaemia (Hb <110 g/L in T1/T3, <105 g/L in T2); platelets
Blood group & Rh antibodies
Booking & 28 wks
Rh(D) status; alloantibody screen for HDFN risk
Rubella immunity
Booking
Identify susceptible women; vaccinate postnatally
Syphilis (VDRL/TPPA)
Booking
Congenital syphilis prevention
Hepatitis B (HBsAg)
Booking
Neonatal immunoprophylaxis planning
HIV
Booking (offer)
MTCT prevention; antiretrovirals if positive
Varicella titre
Booking if no history
Susceptibility — VZIG if exposed; no live vaccine in pregnancy
Thyroid function (TSH)
Booking (symptomatic/high-risk)
Hypothyroidism common; target TSH <2.5 in T1
Urine M,C&S
Booking
Asymptomatic bacteriuria — treat to prevent pyelonephritis/preterm
Cell-free fetal DNA (cfDNA / NIPT) available in GCC private hospitals. Sensitivity >99% for T21. Not routine nationally but offered privately. PPV depends on prevalence.
CVS (10–14 wks): faster result, higher loss rate (~1%)
Amniocentesis (15–20 wks): lower loss rate (~0.5%)
Anomaly Scan (18–20 Weeks)
Structures Evaluated
Head & Spine
Head shape & size (BPD/HC)
Cavum septum pellucidum
Cerebellum / cisterna magna
Nuchal fold (<6 mm)
Spine — neural tube defects
Face, Chest & Abdomen
Lips / profile (cleft lip)
4-chamber heart view
LVOT & RVOT outflow tracts
Diaphragm integrity
Stomach bubble (swallowing)
Abdominal wall / cord insertion
Limbs & Placenta
Femur / humerus length
Hands and feet (bilateral)
Kidneys & bladder
Placental site & cord vessels
Amniotic fluid index
Gestational Diabetes Mellitus (GDM) Screening
75g OGTT — IADPSG Criteria (GCC Standard)
GCC has one of the highest GDM prevalence rates globally (20–25%). Universal OGTT is recommended for all pregnant women at 24–28 weeks; high-risk women (obesity, family history, prior GDM) screened at booking.
Timepoint
GDM Diagnostic Threshold (IADPSG)
Normal
Fasting
≥ 5.1 mmol/L
<5.1 mmol/L
1-hour post-load
≥ 10.0 mmol/L
<10.0 mmol/L
2-hour post-load
≥ 8.5 mmol/L
<8.5 mmol/L
ONE abnormal value is sufficient for GDM diagnosis (IADPSG 2010). WHO 2013 aligns with IADPSG. GDM management: dietary modification, SMBG, insulin or metformin if targets not met (FBG <5.3, 1h PP <7.8, 2h PP <6.7 mmol/L).
Group B Streptococcus (GBS) Screening
Screening Protocol
Vaginal-rectal swab at 35–37 weeks
Culture on selective broth medium
GBS+ or unknown status → intrapartum IAP
IAP: Benzylpenicillin 3g IV loading, then 1.5g 4-hourly in labour
Penicillin allergy (low risk): cefazolin; high-risk allergy: clindamycin or vancomycin per sensitivities
Risk Factors for Neonatal GBS Disease
Previous infant with GBS disease
GBS bacteriuria this pregnancy
Preterm labour (<37 weeks)
Prolonged ROM (>18 hours)
Intrapartum fever ≥38°C
Blood Group, Rhesus & Anti-D Prophylaxis
Antibody Screening Schedule
ABO & Rh(D) at booking
Indirect Coombs (IAT) at booking & 28 weeks
Significant alloantibodies: serial titres, MCA Doppler for fetal anaemia
Anti-D, anti-c, anti-Kell — highest HDFN risk
Anti-D Immunoglobulin
Rh(D) negative women, non-sensitised only
Routine antenatal anti-D prophylaxis (RAADP): 1500 IU at 28 weeks (or 500 IU at 28 & 34 wks)
Anti-D if Rh−, repeat FBC & antibodies, growth USS if indicated, RAADP 1500 IU
34
34–36 Weeks
SFH, presentation check, birth plan discussion, GBS swab, USS if growth concern
38
38–40 Weeks
Bishop's score assessment, induction counselling, antenatal CTG if high-risk
Hyperemesis Gravidarum (HG)
Diagnosis & Assessment
HG affects ~1% of pregnancies but is the leading cause of first-trimester hospital admission. Defined as intractable vomiting + ≥5% weight loss + ketonuria requiring IV treatment.
PUQE Score (Pregnancy Unique Quantification of Emesis)
Hours of nausea, episodes of vomiting, episodes retching scored 1–5 each
Thiamine (Vitamin B1) deficiency risk with prolonged vomiting.
Give IV Thiamine (Pabrinex) BEFORE IV glucose / dextrose in all HG patients.
Triad: confusion, ophthalmoplegia, ataxia — irreversible if missed.
Treatment
Dosage / Route
Notes
IV Fluids
Hartmann's or NS 1L 4–6-hourly
Correct electrolytes; avoid dextrose without thiamine
Thiamine (Pabrinex)
IV Pabrinex I+II 8-hourly × 3 doses then oral thiamine 100 mg TDS
BEFORE any IV glucose
Ondansetron
4–8 mg IV/oral 8-hourly
Avoid in T1 if possible; caution cardiac QT; not first-line
Cyclizine
50 mg IV/IM/oral 8-hourly
First-line antiemetic; safe in T1
Metoclopramide
10 mg IV/oral 8-hourly
EPS risk; limit to 5 days
Promethazine
25 mg oral/IM nocte
Sedating; useful if sleep disrupted
LMWH
Enoxaparin 40 mg SC daily
Thromboprophylaxis if hospitalised; high VTE risk in HG
NG/TPN
Nasogastric/parenteral
Refractory cases; involve dietitian
Pre-Eclampsia
Diagnostic Criteria
Pre-eclampsia remains a leading cause of maternal and perinatal mortality in the GCC. ISSHP 2018 definition: new-onset hypertension ≥140/90 mmHg after 20 weeks PLUS at least one of: proteinuria, maternal organ dysfunction, or uteroplacental dysfunction.
Severe Features — escalate immediately
BP ≥160/110 mmHg sustained
Headache unresponsive to analgesia
Visual disturbances (scotomata, photopsia)
Epigastric / right upper quadrant pain (hepatic capsule)
Loading: MgSO4 4g IV over 5–10 min
Maintenance: 1 g/h IV infusion for 24h after delivery or last seizure
Monitor: RR ≥12/min, urine output ≥25 mL/h, patellar reflexes present
Toxicity antidote: Calcium gluconate 10 mL of 10% IV over 3 min
Stage 1: Umbilical Artery PI >95th centile
Stage 2: Absent/reversed EDF in UA
Stage 3: Ductus Venosus PI ↑ or absent a-wave
Stage 4: CTG decelerations — delivery usually indicated
Surveillance: 2× weekly USS + Doppler for IUGR <34 wks
Placenta Praevia
ABSOLUTE RULE: NO vaginal examination in any woman with suspected placenta praevia until placental site is confirmed by USS. Digital VE can precipitate catastrophic haemorrhage.
Classification
Grade I (Low-lying): lower edge <20 mm from internal os
Grade II (Marginal): reaches os
Grade III (Partial): partially covers os
Grade IV (Complete/Major): completely covers internal os
Suspected on 20-week scan → transvaginal USS at 32–36 weeks
Management
Major praevia (grade III/IV) → elective LSCS at 36–37 weeks
Admit if bleeding — IV access, cross-match, Rh prophylaxis if Rh-
Corticosteroids if <34 weeks and significant bleeding
MAP protocol if massive obstetric haemorrhage: call for help, 2× large-bore IV, fluid resuscitation, activate MHP, blood products 1:1:1 ratio
Antenatal CTG Interpretation
Four Features — DR C BRAVADO Framework
Feature
Normal (Reassuring)
Non-Reassuring
Abnormal
Baseline FHR
110–160 bpm
100–109 or 161–180 bpm
<100 or >180 bpm; sinusoidal ≥10 min
Variability
≥5 bpm over 1-min segments
3–4 bpm for 30–90 min
<3 bpm for >30 min; or ≥25 bpm >10 min
Accelerations
≥2 in 20 min, ≥15 bpm × ≥15 sec
None in 40–80 min
None for >90 min (at term)
Decelerations
Early decels (benign, vagal)
Variable decels; late decels <3 in 30 min
Late decels >3 in 30 min; prolonged >3 min; atypical variable
Normal CTG — All 4 features reassuring
Continue routine monitoring. Reassess as clinically indicated.
Suspicious CTG — 1 non-reassuring feature
Identify cause. Increase frequency of monitoring. Consider further evaluation (BPP, Doppler).
Pathological CTG — ≥2 non-reassuring OR ≥1 abnormal feature
Urgently assess fetal wellbeing. Position left lateral. IV fluids. Oxygen only if hypoxaemic. Stop oxytocin. Prepare for emergency delivery. FBS or expedite delivery.
Biophysical Profile (BPP)
Five Parameters — Score /10
Parameter
Score 2 (Normal)
Score 0 (Abnormal)
NST (CTG)
≥2 accelerations in 20–40 min
<2 accelerations
Fetal Breathing
≥1 episode ≥30 sec in 30 min
Absent or <30 sec
Fetal Movement
≥3 discrete movements in 30 min
<3 movements
Fetal Tone
≥1 extension + return to flexion (limb or trunk)
Slow extension, no return, absent
Amniotic Fluid
≥1 pocket ≥2 cm in 2 perpendicular planes
Absent / largest pocket <2 cm
Score 8–10/10
Normal — repeat in 1 week (or per indication)
Score 6/10
Equivocal — reassess in 6 hours; consider delivery if ≥36 weeks or oligohydramnios
Score ≤4/10
Deliver regardless of gestational age
Fetal Movement Monitoring
Cardiff Count-to-Ten Method
Count from 9 am daily in left lateral position after meal
Record time to reach 10 movements
<10 movements in 12 hours → urgent assessment
Normal: most women reach 10 by midday
Do not use alcohol / cold drinks to provoke movement
Inform all women to report reduced movement from 24 weeks
Reduced Fetal Movement — Assessment Pathway
History: duration, gestation, risk factors
Auscultation / Doppler FHR immediately
CTG ×20–30 min (term); BPP if CTG concerns
USS: AFI, growth, Doppler if <28 wks or IUGR
Reassure if normal, and advise to re-attend if recurrence
Second episode RFM: MCA Doppler, Kleihauer test, consider LSCS timing
In-hospital delivery with CTG monitoring, anaesthesia and surgical team available
Uterine Rupture — Red Flags in VBAC
Sudden severe abdominal pain (scar pain between contractions)
Fetal bradycardia / pathological CTG
Vaginal bleeding
Loss of fetal station / presenting part retracts
Maternal shock → immediate laparotomy
VBAC success rate: ~72–75%. ELRCS risk vs VBAC risk — individualised counselling. In GCC, high elective LSCS rate limits VBAC uptake.
IV access (large-bore) + preload 500 mL crystalloid
Continuous CTG during insertion and 30 min after each top-up
BP monitored q5 min × 15 min after each bolus
Hypotension (SBP <100 or >20% drop): IV fluid bolus, left lateral tilt, ephedrine/phenylephrine
Consent must be obtained when not in active severe pain — if patient requests before active labour, document when able to consent
Contraindications to Epidural
Patient refusal
Coagulopathy / platelets <75 × 10⁹/L
Local / systemic infection at insertion site
Raised ICP
Haemodynamic instability
Uncooperative patient
LMWH within 12 h (UFH within 4 h)
Birth Planning — GCC Cultural Considerations
Culturally Sensitive Planning
Female-only birth attendants — request documented and honoured where possible per local policy
Husband/mahram presence — standard in GCC; discuss preferences
Ramadan fasting — see GCC Context tab for specific guidance
Umbilical cord care per cultural/religious preference (delayed cutting, placenta disposal)
Islamic birth rites — Adhan in ear, tahneeq; coordinate with family
Language concordance — Arabic interpreter available if needed
Water Birth & Home Birth
GCC Water Birth Availability
Limited availability — select private hospitals (e.g., Mediclinic, Aster). Not widely available in public sector. Suitable for low-risk at-term women. Hydrotherapy in labour widely available even where water birth is not.
Home Birth — GCC Context
NOT recommended. All GCC governments mandate hospital-based delivery. Community/home birth not supported by healthcare systems. Advise all women on timely hospital attendance in early labour.
Pre-Eclampsia Risk Stratifier (FIGO/NICE)
Risk Category—
Aspirin Recommendation—
Aspirin Dose—
Start From—
GCC-Specific Epidemiology
GDM Epidemic
GCC prevalence: 20–25% of pregnancies
UAE, Saudi Arabia, Qatar ranked globally highest
High baseline T2DM rates (15–20% adult population)
Contributing: obesity, sedentary lifestyle, consanguinity, high multiparity, late childbearing
Universal 75g OGTT mandated in most GCC antenatal guidelines
Fasting is an individual religious duty. Islam permits pregnant and breastfeeding women to break the fast if there is genuine harm risk (hardship / darar). The nurse's role is to provide evidence-based information and support informed decision-making — not to direct religious practice.
Risks to Discuss
GDM / existing DM: hypoglycaemia risk, glucose fluctuations; if on insulin or sulphonylurea — advise breaking fast; frequent SMBG
Dehydration: especially in summer months (GCC: 45°C+, >16 h fast)
Reduced fetal movements reported in some studies during Ramadan fasting — reassure but advise to monitor and report
Ketonaemia with prolonged fasting — fetal neurotoxic potential (observational data)
First trimester fasting & NTD — folic acid absorption concern
Iron / supplement absorption on empty stomach — advise timing with Iftar/Suhoor
Practical Recommendations
Low-GI, complex carbohydrates at Suhoor (pre-dawn meal)
Adequate hydration between Iftar and Suhoor
Avoid overcompensation with high-sugar Iftar foods (GDM risk)
Folic acid and iron at Suhoor or Iftar
Insulin regimens must be adjusted with diabetologist if fasting
If unwell, dizzy, contractions, reduced movements — break fast immediately
Increased kick count vigilance recommended
Third trimester fasting: more physiological stress — individualise counselling
Healthcare Access & Social Context
Nationals vs Expatriates
GCC nationals: free comprehensive antenatal care in government hospitals
Expatriates (majority of GCC population in UAE/Qatar/Kuwait): employer-sponsored or self-funded insurance; many use private hospitals
Undocumented/uninsured women: a vulnerable population — access to emergency obstetric care protected legally but routine care gaps exist
Cultural differences in disclosure of domestic violence, substance use — sensitive enquiry essential
Consanguinity common in some GCC populations — genetic counselling referral pathways important
Leading GCC Maternity Hospitals
Hospital
Country
Specialty
Latifa Hospital
UAE (Dubai)
High-risk obstetrics, NICU
Corniche Hospital
UAE (Abu Dhabi)
Largest delivery centre in Arab world
Al Ain Hospital (Tawam)
UAE
Tertiary referral, genetics
KFMC (King Fahad Medical City)
Saudi Arabia
National referral, MFM
Hamad Medical Corp
Qatar
Corniche Hospital Doha
Mubarak Al-Kabeer
Kuwait
Ministry, tertiary
Teenage & Adolescent Pregnancy
In some GCC regions, marriage and pregnancy in girls aged 15–18 (or younger in some jurisdictions) occurs, particularly in less urbanised areas. Legal age of marriage varies by GCC country (typically 15–18 with judicial consent). Nurses must be aware of increased obstetric risk and safeguarding obligations.
Obstetric Risks in Adolescent Pregnancy
Pre-eclampsia risk higher in young primiparas
Cephalopelvic disproportion / obstructed labour in girls with immature pelvis
Anaemia, nutritional deficiency
Preterm birth, SGA, low birthweight
Postpartum depression and social isolation
Nursing Responsibilities
Non-judgmental, culturally respectful communication
Assess for signs of coercion — document and escalate per local safeguarding policy
Additional psychosocial support referral
Nutritional optimisation — folate, iron, calcium
Senior obstetric review for all teenage pregnancies under 16
Practice MCQs — Antenatal Care
1. A woman's LMP was 1 January. Using Naegele's Rule, what is her EDD?
2. At 30 weeks gestation, what is the expected symphysis-fundal height range?
3. According to IADPSG criteria for the 75g OGTT, which fasting glucose value confirms GDM?
4. What is the antidote for magnesium sulphate toxicity?
5. A biophysical profile score of 4/10 should prompt which action?
6. Which Bishop's score indicates a cervix favourable for induction of labour?
7. In hyperemesis gravidarum, which treatment must be given BEFORE intravenous glucose to prevent Wernicke's encephalopathy?
8. What does the Cardiff Count-to-Ten method instruct a pregnant woman to do?
9. At what gestational age is GBS vaginal-rectal swab recommended?
10. A woman with placenta praevia presents with fresh vaginal bleeding at 32 weeks. What is the most important IMMEDIATE nursing action to avoid?