♀BSTETRICS & GYNECOLOGY

SECTION A: INTRODUCTION
CHAPTER AA: HISTORY-TAKING
PART AA 01: DEMOGRAPHY
1. Items to be elicited:
a) Name
b) Age
c) Address
d) Blood group
e) Occupation (patient’s & husband’s)
f) Education lvl
g) GPLA
h) LMP, EDD, POG (whether dates were confirmed)

PART AA 02: CHIEF COMPLAINT

2. State complaint & its duration

PART AA 03: HOPI

3. E.g. approach to suspected diseases:
Disease E.g. Questions

*Placenta previa diagnosed during USG?

*Previous similar episodes
Antepartum *Management
hemorrhage *Amount of bleeding (in current case)
(etc)
 *When it was diagnosed
*Management
*Control
IDDM (insulin- *Pre-pregnancy details:
dependent DM) a) Difficulty in conceiving
b) Sugar control in 1st trimester/ thruout pregnancy
(etc)

*# of episodes per day

*Presence of blood/ bile (in sputum)
Hyperemesis *Dehydration
gravida (etc)

4. H/o allergies

PART AA 04: H/O PRESENT PREGNANCY

5. 1st trimester:
Aspect Description

When it was +ve (presented as # of weeks after LMP)

Urine pregnancy test

*H/o…
a) fever with rash
b) bleeding PV
c) drug intake
d) radiation exposure
Risk factors
 *# of times
USG *Findings

Supplementations Whether taking Fe2+, folate, Ca2+ tablets (if so, their start dates & dosages)

Abnormalities Both in fetus & mother

*Dosages of supplementations:
a) Fe2+: 60 mg elemental Fe
b) Folate: 0.4 mg (4 mg in case of deficiency)
c) Ca2+: 0.5/ 1.0 g/day

6. 2nd trimester:
Aspect Description

Quickening When it was 1st felt

Whether tests were normal

BP, glucose

Anomaly scan What the findings were

Supplementations Whether still taking Fe2+, folate, Ca2+ tablets

Immunization Tetanus toxoid (# of times given, & when)

 H/o headache, blurred vision, vomiting, epigastric pain, pedal edema

Ecclampsia risk factors

7. 3rd trimester:
Aspect Description

Fetal movements

Risk factors H/o pain in abdomen/ bleeding/ leaking PV

BP Whether normal or otherwise

USG Whether done (if so, the findings)

Others If term pregnancy, ask about lightening

PART AA 05: OBSTETRIC HISTORY

8. Items to be elicited:
a) Duration of marriage
b) Consanguinity (if present, indicate degree of consanguinity)
c) OCP/ contraception usage after (previous) deliveries

9. Past pregnancies:
a) How many years ago
b) Place of supervision
c) Antenatal complications
 d) Whether BP & sugars were normal
e) Labor (vaginal/ C-section#)
f) Abortions##
g) Breastfeeding (duration, etc)
h) Immunization (of child)
i) Milestones well-attained?
j) Child alive & well?

#If C-section, ask about indication, anesthesia, intra-operative complications, blood transfusions, baby cried immediately
after birth, post-op complications (e.g. excessive bleeding PV/ fever/ etc), urinary catheter & sutures removed, wound
discharge, discharge date, etc
##Ask whether pregnancy was confirmed, POG during which abortion occurred, spontanteous/ induced, curettage

PART AA 06: PAST HISTORY

10. H/o of chronic medical illness/ epilepsies/ diabetes/ HT/ blood transfusions/ surgeries (details if present)

PART AA 07: MENSTRUAL HISTORY

11. Items to be elicited:
a) Age of attainment of menarche
b) Current duration, regularity & bleeding volume of cycles
c) Associated pains, etc

PART AA 08: FAMILY HISTORY

12. H/o of diabetes/ HT/ congenital malformations/ mutiple gestations

PART AA 09: PERSONAL HISTORY

13. Smoking/ alcohol/ other addictions
PART AA 10: DIETETIC HISTORY
14. Veg/ mixed diet

15. Daily calorie & protein intake

PART AA 11: SOCIOECONOMIC HISTORY

16. Spouse’s details: name, age, education lvl, occupation, income, etc

17. Socioeconomic status

CHAPTER AB: EXAMS
PART AB 01: GENERAL EXAM
1. Ask patient to empty bladder. Stand at right side of patient

2. General comments:
a) Patient is comfortable or not
b) Position: supine/ sitting
c) Build & nourishment: poor/ moderate/ well#.
d) Presence of any IV cannula (read the international color coding below)

#Give height, weight & BMI in long cases (for BMI, take the current weight of the pregnant patient)

3. Regional comments:
Region Description

Eyes Look for pallor & icterus

Mouth Look for pallor, sublingual icterus, oral hygiene

Neck Look for obvious swellings of thyroid & lymph nodes

Breast Look for lumps, nipple discharge and inverted nipple

 *Look for pallor in fingernails
*If pallor present, comment on koilonychia/ platonychia

Hands

Koilonychia (left) & platonychia

Test for pedal edema: press with both thumbs 2 cm above medial malleolus for 30 secs and also look
at the patient (if she grimaces with pain, ↓ pressure)

Legs

*Checked for 60 secs

Pulse rate *Comment on rate, rhythm, volume

BP Recorded from right arm in sitting position (obstetric patient)/ 45° supine

4. Systemic exam (if systemic disorder present with pregnancy, examine in detail)

PART AB 02: OBSTETRIC EXAM

SUB-PART AB 02 (A): GENERAL
5. Stand at right side of patient

6. Expose from xiphisternum  pubic hair line

SUB-PART AB 02 (B): INSPECTION

7. External appearances:
a) Abdomen distended (uniformly/ grossly)
 b) Fullness of flanks
c) Linea nigra, striae albicans & gravidarum (or dilated veins if any) visible

(L-R): linea nigra, striae albicans, striae gravidarum

d) Umbilicus centrally placed (inverted/ everted)

e) All quadrants move equally with respiration

8. Others:

1. Look for obvious fetal movements

2. Check abdomen for scars (due to previous delivery surgeries)

3. Ask the patient to cough & look for obvious hernia (inguinal/ umbilical)

Inguinal hernia (left) & umbilical hernia

SUB-PART AB 02 (C): PALPATION

9. If uterus is turned slightly to the right, correct it by dextrorotation first

10. Clinical fundal height & fundosymphyseal height:

Aspect Description
 *Determined using the flat of hand & the radial border of index finger
*Note the 1st resistance from the xiphisternum & comment
*Level of 1st resistance & the corresponding week of pregnancy:

Clinical Fundal
Height#

*Turn measuring tape to the “inches” surface

*Place metal tip of tape on public symphysis
*Measure max height of uterus & mark with fingernail
*Turn measuring tape over to “cm” surface & record the marked reading

Fundosymphyseal
Height

*Follow the 4 grips (fundal, right & left lateral, 2nd pelvic)##

*Look at amount of fifths of head palpable above pubic symphysis

Leopold
*Descriptions of the various fetal parts:
maneuvers
Part Description
 Head Hard, globular mass (usually ballotable)

Back Curved, broad surface

Limbs Irregular knob/ nodular structures

Buttocks Soft/ firm round mass (not ballotable)

#Comment the height in even numbers, maybe with a small range (e.g. 32 – 34 weeks) if required
##Reference: http://www.perinatal.org.uk/FetalGrowth/FundalHeight.aspx

11. Liquor adequacy

Oligohydramnios (left) & polyhydramnios

SUB-PART AB 02 (D): AUSCULTATION

12. Use the bell of stethoscope to auscultate fetal heart sounds (don’t panic if can’t hear FHS)

SUB-PART AB 02 (E): AFTERWORD

13. E.g. summaries of grip findings:
1. Singleton pregnancy with cephalic presentation with longitudinal lie with head (per fifths) palpable

2. Singleton pregnancy with breech presentation with longitudinal lie breech presentation

3. Twin pregnancy with 1st twin in cephalic presentation & longitudinal lie with head (per fifths) palpable

4. Singleton pregnancy with oblique lie with head more towards the right iliac fossa

5. Singleton pregnancy with transverse lie

PART AB 03: GYNECOLOGICAL EXAM
SUB-PART AB 03 (A): GENERAL
[Same as obstetric exam, except that can sit down ]

SUB-PART AB 03 (B): INSPECTION

[Same as obstetric exam, except that NO striae gravidarum & fetal movements (duh) can be seen]

SUB-PART AB 03 (C): PALPATION

14. Procedure:

1. Ask the patient for any area of tenderness# & start palpation (preferably from right iliac fossa)
Move from right iliac fossa & palpate all quadrants of abdomen clockwise with umbilicus in the last

2. If a mass is felt then describe the mass. (shape, size, consistency, surface, mobility, borders with a
special note on LOWER border)##

3. If the mass is centrally located, mention its correspondence to gravid uterus

4. Palpation for organomegaly only in indicated cases

#If tenderness occurs, start palpating the quadrant FARTHEST away (opposite) from it
##Main differences between uterine & ovarian mass:
Uterine Mass Ovarian Mass
Consistency Firm Cystic
Mobility Yes, in all directions Yes, but transverse direction only
Lower border Not palpable Palpable

Uterine mass (left) & ovarian mass

SUB-PART AB 03 (D): PERCUSSION
15. Procedure to detect shifting dullness:

Start percussion from midline (at lvl of umbilicus) --> flanks. Note any
change from resonant --> dull

Keep finger on site of dullness in the flank & ask the patient to turn to
opposite side

Pause for ≥ 10 secs to allow any ascites to gravitate

Percuss again (if that area is now resonant, it demonstrates shifting

dullness as the ascitic fluid is dependent)

SUB-PART AB 03 (E): AUSCULTATION

16. Check for bowel sounds
CHAPTER AD: TERMS
1. General terms:
Term Definition

Obstetrics Study of pregnancy & childbirth

Gynecology Study of diseases of ♀ genital tract

Gravida Pregnant state (both present & past), irrespective of POG

Nulligravida Woman who is not currently & previously pregnant

Primigravida Woman pregnant for 1st time

Multigravida Woman who had previously been pregnant (irrespective of their outcomes)

Parity State of previous pregnancy beyond period of viability

Nullipara Woman who no complete a pregnancy to the stage of viability (previous abortions may or may not be
present)

Primipara Woman who has made 1 viable delivery (not influenced by twins/ triplets)

Grand multipara Pregnant woman with h/o ≥ 4 births

Parturient Woman in labor

Labor Series of events in genital organs to expel viable products of conception out of uterus  vagina 
external environment

Delivery Expulsion/ extraction of viable fetus out of uterus

Pre-term labor Labor starting before POG of 37 weeks

Mini labor Expulsion of previable fetus in miniature form

Vis-a-tergo Final phase of dilation & retraction of cervix (achieved by downward thrust of presenting part & upward
pull of cervix over lower uterine segment

Quickening Perception of active fetal movements (≈ 18th week of gestation)

PROM Premature rupture of membranes (spontaneous rupture of membranes between 28th week of gestation
& onset of labor)

Abortion Expulsion/ extraction of embryo/ fetus from mother when it is not capable of independent survival (< 20
wks of gestation)

Antepartum hemorrhage Bleeding into/ from genital tract between period of viability & birth (70% cases due to placenta previa/
abruptio placentae)

Placenta previa Placenta is partially/ completely implanted over lower uterine segment (over & adjacent to internal
os).Is painless & has 4 types (low-lying, marginal, partial, complete)

Abruptio placentae Painful bleeding due to premature separation of normally-located placenta

Intrauterine fetal death Fetal (weighing ≥ 500 g) death occurring during pregnancy (antepartum)/ birth (intrapartum)

Post-partum hemorrhage Bleeding (> 500 mL) following birth (avrg blood loss during normal birth, C-section & hysterectomy are
 500, 1 000 & 1 500 mL respectively)

IUGR Intrauterine growth restriction (baby’s birth weight is < 10th centile for gestational age)

Episiotomy Surgical incision on perineum & posterior wall during 2nd stage of labor. Types: mediolateral, median,
lateral, J-shaped

C-section Fetus at end of 38th wk of pregnancy delivered via incision on abdominal & uterine walls

Threatened miscarriage Process of miscarriage has started but has not progressed to a state in which continuation of
pregnancy is impossible

Inevitable miscarriage Process of miscarriage has started & has progressed to a state in which continuation of pregnancy is
impossible

Complete miscarriage Products of conception expelled en masse

Incomplete miscarriage Part of products of conception remains in uterine cavity

Missed miscarriage/ fetal Dead fetus retained in uterus (for variable period)
demise
Recurrent miscarriage ≥ 3 consecutive spontaneous abortions of POG < 20 wks

Septic abortion Abortion associated with clinical evidence of infection of uterus & its contents

Ectopic pregnancy Fertilized ovum implants & develops outside endometrial cavity (usually at ampulla of Fallopian tube)

Hydatidiform mole Abnormal placenta, in which there are partly degenerative & partly proliferative changes in young
chorionic villi

Puerperium Period after childbirth, during which body tissues, revert back to pre-pregnant state

Gestational DM Carb intolerance with onset/ 1st recognition during present pregnancy. Usually presents in late 2nd/ 3rd
trimester

Pre-eclampsia Multisystem disorder of unknown etiology, characterized by development of HT (BP > 140/90) with
proteinuria (> 150 mg/day) at POG > 20th wk, in a previously normotensive & non-preoteinuric woman

Eclampsia Pre-eclampsia complicated with generalized tonic-clonic convulsions &/ or coma

Gestational HT Sustained ↑ of BP (> 140/90) on ≥ 2 occasions, ≥ 4 hrs apart beyond 20th wk of gestation (or) within
24 hrs of delivery in a previously normotensive woman

Pregnancy-induced HT HT developing as direct result of gravid state (jncluding gestational HT, pre-eclampsia & eclampsia)

Puerperal pyrexia ↑ in temperature (≥ 38°C) measured on 2 separate occasions 24 hrs apart (excluding 1st 24 hrs) within
10 days of delivery

Oligomenorrhea Menstrual bleeding occurring > 35 days apart in a constant frequency

Hypomenorrhea Unduly scanty menstrual bleeding, lasting for < 2 days

Polymenorrhea Menstrual bleeding occurring < 21 days apart in a constant frequency

Dysmenorrhea Painful menstruation sufficiently intense to incapacitate daily activities

Menorrhagia Cyclical bleeding at normal intervals, with excessive bleeding (> 80 mL)/ duration (> 7 days)/ both

Metrorrhagia Irregular, acyclical uterine bleeding

Menometrorrhagia Irregular, excessive bleeding to such an extent that periods can’t be determined

Dysfunctional uterine Abnormal frequency/ amount/ duration/ (combo of the aformentioned) uterine bleeding w/o clinically
bleeding detectable organic/ systemic/ iatrogenic cause

Sinciput Area in front of anterior fontanelle corresponding to area of brow

Occiput Area limited to occipital bone

Brow Area bounded by anterior fontanelle, coronal sutures, root of nose & supraorbital ridges

Face Area bounded by root of nose, supraorbital ridges & junction of floor of mouth with neck

2. Obstetric terms:
Term Description Possible Conditions

Lie *Relation between longitudinal axis of fetus to longitudinal axis of the *Longitudinal (subtypes:
uterus breech, cephalic)
*Longitudinal axis of fetus = cephalopodalic axis *Transverse (normal delivery
not possible)
*Oblique (unstable)

Presentation Portion of fetus which is in relation to lower pole of uterus *Cephalic (96.5%)
*Podalic @ breech (3.0%)
*Shoulder (0.5%)
*Compound
Presenting Part of the presentation which overlies internal os & is felt 1st on *In cephalic presentation:
part vaginal exam a) Vertex (96%)
b) Face (0.5)
c) Brow

*In podalic presentation:

a) Flexed (complete)
b) Extended (frank)
c) Footling (incomplete)
d) Knee

Attitude Relation of fetal parts to one another *Universal flexion

*Military
*Partial/ complete extension

Denominator An arbitrarily chosen point on presenting part of fetus used to describe *Vertex: occiput (0)
position *Face: chin (mentum)
*Brow: forehead
*Breech: sacrum
*Shoulder: acromion

Position Relation of denominator to different quadrants of maternal pelvis *Occipito-anterior

*Left/ right occipito-anterior
*Left/ right occipito-transverse
*Left/ right occipito-posterior
*Occipito-posterior
3. Fetal skull-related terms:
Region
Anterior fontanelle/bregma
Posterior fontanelle
Suboccipito-bregmatic
Submento-bregmatic
Biparietal
Suboccipito-frontal
Occipito-frontal
Mento-vertical
Submento-vertical
Super-subparietal
Bitemporal
Bimastoid
Measurement/ Definition
3 x 3 cm, diamond shape, ossify at 18th month after birth
1.2 x 1.2 cm, triangular shape, floor becomes bony at term
9.5 cm (complete flexion), vertex presentation
9.5 cm (complete extention), face
9.5 cm
10cm (incomplete flexion), vertex
11.5 cm (marked deflexion), vertex
14 cm, (partial extention), brow
11.5 cm, (incomplete extention), face
8.5 cm
8 cm
7.5 cm
 CHAPTER AE: DIAGNOSIS OF PREGNANCY
1. Pregnancy:
a) Is the period from conception  birth
b) Duration: 9 mths 7 days @ 280 days @ 40 wks

2. Calculations:
EDD Period of Gestation (POG)

*Naegele’s formula is used *Is calculated in wks

*Calculated based on LMP (last menstrual period) *E.g. patient visits on 25/11/15. Her LMP is 21/10/15.
*Formula: EDD = LMP + 9 mths 7 days *Hence, period of gestation is 35/7 = 5 wks
*E.g. LMP = 01/01/15  EDD = 08/10/15

3. Antenatal visits have to be done…

a) every 4 wks until 28 wks
b) every 2 wks until 36 wks
c) every 1 wk until delivery

4. Trimesters:
Trimester Symptoms & Signs Investigations

1 (≤ 12 wks) Symptoms *Agglutination test (using latex

*Amenorrhea particles/ sheep RBCs coated with anti-
*Morning sickness HCG)
a) Seen in 50% cases *Agglutination inhibition tests
b) Due to HCG *USG
c) If severe, is known as hyperemesis gravidarum

*↑ micturition frequency
a) Due to compression of bladder (from behind) by uterus
b) Results in bladder mucosa changes
c) Re-normalizes after 12 wks Note: these depend on presence of
HCG in maternal serum & urine
 *Breast discomfort

*Fatigue

Signs
*Enlarged, globular, soft uterus
*Palmer’s sign: uterine contractions felt during bimanual exam
*Hegar’s sign#: during bimanual exam, 2 fingers in anterior fornix can be Urine pregnancy test kit
approximated to fingers of abdominal hand (due to softening of isthmus &
emptiness of uterus)

2nd (13 – 28 Symptoms USG (to rule out anomalies)

wks) *Anemorrhea
*(Less) morning sickness & urinary symptoms
*Quickening (1st sensation of fetal movement by mother occurs at 18 –
20 wks in primigravida & 16 – 18 wks in multiparous)
*Abdominal enlargement
*Skin signs: chloasma##, linea nigra & stria gravidarum appear
 Chloasma

Signs
*Braxton-Hicks contractions (low-intensity uterine contractions)
*Internal & external ballotment

External (left) & internal ballotment

*Palpable fetal parts

*Fetal heart sounds (conclusive)

3rd (29 – 40 Symptoms

wks) *Amenorrhea
*Abdominal enlargement
*↑ micturition frequency (fetal head compresses bladder)
*↑ fetal movements

Signs
*Shelving sign (falling forward of uterus)
 *Engagement of presenting part
*↓ liquor
*↑ Braxton-Hicks contractions
*Palpable fetal parts

#Can be elicited between 6 & 10 wks. After that, growing fetus will fill the entire uterine cavity
##Temporary brown patches on skin due to hormonal changes

5. Differential diagnosis:
a) Leiomyoma (fibroids)
b) Cystic ovarian tumor
c) Distended bladder
d) Pseudocyesis (phantom pregnancy)

6. Positive, presumptive & probable signs of pregnancy:

Positive Presumptive Probable

• Palpable fetal parts • Amenorrhea • Abdominal enlargement
• Fetal heart sounds • ↑ micturition frequency • Braxton-Hicks contractions
• USG evidence of embryo • Morning sickness • External/ internal
• Fatigue ballotment
• Skin changes • Outlining the fetus
• Quickening • Changes is uterine shape,
size & consistency
• Cervical softening
• +ve immunogical tests
CHAPTER AF: PHYSIOLOGICAL CHANGES DURING PREGNANCY
PART AF 01: GENITALS
SUB-PART 01 AF (A): VULVA
1. Edematous & more vascular (superficial varicosities may appear, esp in multiparae)

2. Hypertrophied, pigmented labia minora

SUB-PART 01 AF (B): VAGINA

3. Properties:
Aspect Description

*Hypertrophy
*Edematous
*More vascular (Jacquemier’s sign = bluish discoloration of mucosa due to ↑ supply to vaginal
Vaginal wall venous plexus)
*↑ length of anterior wall

*Copious, thin, curdy white (due to ↑ exfoliated cells & bacteria)

Secretions
*Acidic:
a) pH: 3.5 – 6.0
b) Due to ↑ conversion of glycogen  lactate (by L. acidophilus)
c) Prevents multiplication of pathogens

↑ navicular cells in clusters & bacteria

Cytology
SUB-PART 01 AF (C): UTERUS
4. Properties:
Aspect Specific

*Muscle hypertrophy, hyperplasia, stretching (enlargement of fundus > body)

*↑ blood supply via uterine & ovarian arteries (detected by Doppler velocimetry)

Body

*↑ weight (due to ↑ growth of muscles, connective tissues & vessels)

*Shape: pyriform  globular (by week 12)  pyriform/ ovoid  (by week 28)  spherical (> 36 wks)
*Anteverted uterus compresses bladder  becomes erect after week 8
*Dextrorotation (turning to right, due to presence of rectosigmoid at left side)
*Braxton-Hicks contractions#

*During 1st trimester, isthmus hypertrophies, elongates & becomes softer

*After 12 wks of pregnancy, it gradually unfolds from above until it is incorporated into uterine cavity
*Its circular muscle acts as sphincter to retain fetus (otherwise, mid-trimester abortion occurs)

Isthmus
 *Marked softening (Goodell’s sign) due to…
a) hypertrophy & hyperplasia
b) fluid accumulation in & between elastic & connective tissue fibres
c) ↑ vascularity

*Marked mucosal proliferation (extends downwards beyond squamocolumnar junction; can resemble CIN)

Cervix

*Copious & tenacious secretions (physiological leukorrhea) form cervical plug

#Irregular, infrequent, spasmodic, painless contractions with no effect on cervical dilation

PART AF 02: BREAST

5. Properties:
Aspect Specific

*↑ size
*Hypertrophy & proliferation of ducts, alveoli & stroma
*↑ vascularity  appearance of bluish veins under skin
*Striation (due to stretching of cutis)
Size

*Enlarged, erectile, deeply pigmented nipples

*Montgomery tubercles (hypertrophied sebaceous glands) formation
*2° areola formation

Nipple &
areola

*Colostrum can be squeezed out of breast ≈ 12th wk

Secretions *Demo of breast secretion in a woman who no lactate before is an important sign of pregnancy

*Breast changes are best evident in primigravida. In multipara (who have lactated before, changes are not clearly
defined)

PART AF 03: SKIN

6. E.g. changes:
a) Chloasma gravidarum
b) Linea nigra, stria gravidarum, stria albicans
c) Spider nevi, palmar erythema
PART 04: WEIGHT GAIN
7. Pattern:
Trimester 1 2 3

Weight Gain (kg) 1 5 5

8. There is variable retention of electrolytes, e.g.:

a) Na+ (1 000 mEq)
b) K+ (10 g)
c) Cl-

*Na+ is retained due to ↑ estrogen, progesterone, aldosterone & (maybe) ADH

9. Factors for fluid retention in tissue spaces:

a) ↓ colloidal osmotic pressure (due to hemodilution)
b) ↑ venous pressure (of inferior extremities)

*As such, slight edema (physiological) of legs can occur during pregnancy

10. Importance of periodic/ regular weight checking:

1. Abnormality detection:
Condition Possible Abnormalities
Rapid weight gain (> 0.5 kg/wk or > 2 kg/mth) Pre-eclampsia (early manifestation)
Stagnant/ ↓ weight IUGR/ IUD

2. Obese women are at ↑ risk of pregnancy, labor & puerperal complications

3. Ideal weight gain (depends on BMI):

BMI Ideal Weight Gain (kg)
< 19 (underweight) ≤ 18
20 – 26 (normal) 11 – 16
> 30 (overweight) ≤7

4. Maternal nurtition & weight gain ∝ newborn weight

PART AF 05: WATER METABOLISM
11. Amount of water retain in body at term: 6.5 L

12. Polyuria in early pregnancy (< 8 wks):

a) Is due to ↑ water intake (as a result of ↓ osmotic threshold for thirst)
b) After 8th wk, threshold for ADH secretion resets for a new steady osmolar state (less polyuria)

PART AF 06: HEMATOLOGY

13. Properties:
Aspect Specific

*Expands:

Starts ≈ 6th wk

Blood volume Max lvl at 30th - 34th wk (↑ by 40 - 50%)

Plateaus until delivery

*↑ at 6th wk & plateaus at 30th wk

*Max ↑: 50% (↑ by 1.25 L)
Plasma volume *↑ is greater in multigravida, multiple pregnancy, large baby

*RBC mass:
a) ↑ at ≈ 10th wk & continues till term (no plateauing)
b) Max ↑: 20 – 30% (↑ by ≈ 1.25 L)
c) Fe2+ supplementation ↑ RBC mass by 30%

*↓ Hct (hemodilution):
a) ↓ by ≈ 6%
RBCs & Hb b) Due to disproportionate ↑ in plasma volume & blood volume
c) Advantages:
 1. Optimum maternal-fetal gas exchange (due to ↓ viscosity)
2. Protects mother against adverse effects of supine & erect posture
3. Protects against adverse effects of blood loss during delivery

WBCs & Immune *Neutrophilia (↑ by 8 – 20 K/mm3)

System *AMI > CMI (instead of the converse during non-pregnancy)

*Total plasma proteins ↑ from 180  230 g (at term)

Total proteins *However, due to hemodilution, plasma protein conc ↓  edema

*Hypercoagulable state:
a) Fibrinogen lvls ↑ by 50% (200 – 400  300 – 600 mg%)
Coagulation b) 4x ↑ in ESR (hence, it canNOT be used during pregnancy)
factors c) Gestational thrombocytopenia
d) However, clotting time no show significant change

PART AF 07: CVS

SUB-PART AF 07 (A): ANATOMY
14. Heart is pushed upwards, outwards & slightly rotated to the left (due to elevation of diaphragm by fundus)

15. Possible abnormal (but physiological) clinical findings:

Finding Basis

Palpitations
Heart displacement
Left axis deviation (in ECG)

Systolic murmur (at apical/ pulmonary area) ↓ blood viscosity, torsion of great vessels

Mammary murmur# ↑ blood flow thru internal mammary vessels

S3 Rapid diastolic filling

#Continuous hissing murmur audible at tricuspid area

SUB-PART AF 07 (B): CARDIAC OUTPUT (CO)
16. Changes:

Max lvl (↑ by 40 - 50%) at

↑ from 5th wk Remains static until term
30th - 34th wk

17. CO is…
a) lowest at sitting/ supine position
b) highest in left/ right lateral/ knee-to-chest position

18. Factors which ↑ CO:

a) ↑ blood volume
b) ↑ O2 demand

SUB-PART AF 07 (C): BP
19. ↓ by 5 – 10 mmHg

20. Antecubital venous pressure is unaffected

21. Femoral venous pressure:

1. Marked ↑ (esp. late in pregnancy)

2. Due to pressure exerted by gravid uterus on common iliac vein (more at

right due to dextrorotation)

3. Pressure changes:

4. Hence, physiological edema of pregnancy subsides by rest alone

22. Supine hypotension syndrome (postural hypotension):
a) During late pregnancy, gravid uterus compresses IVC when patient is supine
b) However, collateral circulation opens up via paravertebral & azygos veins (if this no occur, hypotension,
tachycardia & syncope occurs)
c) Normal BP is quickly restored by rotating patient to lateral position

PART AF 08: METABOLISM

23. Changes:
Aspect Description

*↑ insulin secretion (to provide glucose to fetus)

Carbs *↓ sensitivity of insulin receptors (in mother)

*+ve N balance thruout pregnancy (fetus + placenta, & mother each gain 500 g)
Proteins *Blood urea ↓ to 15 – 20 mg% (due to suppression of AA breakdown)

*↑ fat storage (by 3 – 4 kg)

Lipid *↑ HDL (by 15%; hence hyperlipidemia during pregnancy is not atherogenic)

*(Total requirement during pregnancy: 1 200 mg)

*↑ Fe2+ absorption from GIT & mobilization from stores (however, this is still insufficient;
Fe2+ serum Fe2+ & ferritin ↓)
*However, placenta still transfers adequate Fe2+ to fetus even if mother is severely deficient

PART AF 09: OTHER SYSTEMIC CHANGES

SUB-PART AF 09 (A): RS
24. Overall:
a) Total lung capacity ↓ by 5% (due to diaphragm elevation)
b) However, diaphragmatic excursion ↑ by 1 – 2 cm
c) Breathing becomes diaphragmatic
d) Hyperventilation (↑ tidal volume by 40%)

25. Other changes:

Aspect Description

Hyperventilation

↑ PaO2, ↓ PaCO2
Acid-base
balance ↑ O2 transfer from mother --> fetus (& vice versa for CO2)

Respiratory alkalosis (pH ↑ by 0.02)

↑ maternal excretion of HCO3-

Maternal *Is ↓, due to ↑ O2 consumption & ↓ functional residual capacity

O2 reserve *Hence, they are more susceptible to effects of apnea during intubation

SUB-PART AF 09 (B): URINARY SYSTEM

26. Changes:
Site Description

*↑ renal plasma flow & GFR

Kidney *↑ GFR  ↓ reabsorption of creatinine, N, urate, AAs & water-soluble vitamins
 *Hypertrophic (due to estrogen)
*Atonic (due to progesterone)
Ureters *Dilated (at lvl above pelvic brim) with stasis of right ureter (due to dextrorotation)

*Congestion & hypertrophy

*Mucosal edema (at late pregnancy, due to venous & lymphatic obstruction following engagement)
*↑ micturition frequency…
a) starting from 6th – 8th wk (subsides after 12th wk)
Bladder b) reappears during late pregnancy

*Stress incontinence (may be seen) in late pregnancy (due to urethral sphincter weakness)

SUB-PART AF 09 (C): SKELETAL

27. Daily Ca2+ requirement (during pregnancy & lactation): 1.0 – 1.5 g

28. Changes:
a) ↓ total Ca2+lvls
b) Unchanged serum Ca2+ & PO43- lvls
c) ↑ calcitonin lvls

29. ↑ Ca2+ absorption from intestine & kidneys (due to ↑ lvls of 1, 25-diOH-vitamin D)

30. Musculoskeletal changes:

CHAPTER AG: MENSTRUATION
PART AG 01: NORMAL MENSTRUATION
SUB-PART AG 01 (A): NORMAL MENSTRUATION
1. Phases:

Ovarian Cycle Uterine Cycle

• Follicular phase • Proliferative phase

• Ovulation • Secretory phase
• Luteal phase • Menstruation

SUB-PART AG 01 (B): OVARIAN CYCLE

SUB-PART AG 01 (B 1): FOLLICULAR PHASE
2. Hormonal regulation:
 (1, 2 & 3 apply to follicular phase)

3. Role of specific hormones:

Hormone Roles

*(Secreted by granulosa cells)

*↓ FSH release (via –ve feedback)
Inhibin •↑ androgen synthesis

*(Structurally similar to inhibin, produced in granulosa cells & pituitary)

Activin *↑ FSH binding on follicles

*Paracrine regulators
*(Lvls are highest in dominant follicle, produced by theca cells under action of LH)
*Augments LH-induced steroidogenesis
IGF-I & II *Augments effects of FSH on mitosis, aromatase activity & inhibin production
*IGF-II augments LH-induced proliferation of granulosa cells
SUB-SUB-PART AG 01 (B 2): OVULATION
4. Key events:

Follicle ruptures at Ovum is expelled into LH causes final follicular

≈ 14th day abdominal cavity growth & ovulation

FSH & progesterone lvls 36 – 48 hr before ovulation, LH surges

↑ but estrogen ↓ (due to +ve feedback from estrogen)

SUB-SUB-PART AG 01 (B 3): LUTEAL PHASE

5. Granulosa & theca interna cells proliferate

6. Angiogenesis occurs due to VEGF action

7. Corpus luteum formation:

Lutein cells (lipid-rich & Corpus luteum less sensitive to Shedding of

yellow) are formed LH & produce ↓ progesterone endometrium

Secrete copious estrogen

Luteolysis Menstruation
& progesterone

↓ FSH & LH secretions Follicle cell growth inhibited

SUB-PART AG 01 (C): UTERINE CYCLE
8. Events by phase:
Phase Events

*Deep/ thin layer of endometrium remains after menstruation

*Stromal & epithelial cells proliferate
Proliferative *Endometrial glands & new vessels form (from 5th – 14th day)
*Glands lengthen & secrete mucus (mainly in cervical region)
*Uterine epithelium is thickens rapidly (from 0.5 to 3.5 – 5.0 mm)

*Post-ovulatory events:
a) ↑ estrogen & progesterone secretions
b) Endometrium becomes edematous (thanks to progesterone)
c) Glands become tortuous, coiled & produce secretions
d) Vessels also become tortuous
Secretory e) ↑ lipid & glycogen deposits

*Thickening of endometrium:
a) Provides nutrients for early embryo (if fertilization occurs)
b) Prepares for implantation of fertilized ovum
c) Duration: 14 days (constant)

*Luteolysis  ↓ estrogen & progesterone

*PG release  vasospasm
*Foci of necrosis activated
*Spiral arteries degenerate  spotty hemorrhages
Mesntruation *Uterine contractions & blood flow begin
*↑ fibrinolysin release (which limits bleeding to 30 – 80 mL)
*Normally lasts 3 – 5 (can be 1 – 8) days
SUB-PART AG 01 (D): GENERAL
9. Values:
Parameter Value

Avrg age of menarche 13

Avrg menstrual blood loss 35 mL (may be up to 85)

Average Fe2+ loss per period 13 mg

% menstrual blood loss in 1st 2 days 70%

*Every 21 – 35 days; lasts 2 – 7 days

*Long cycles are common during1st few years after menstruation begins
Normal menstrual cycles *Cycles shorten & become more regular as woman ages

Menopause age 48 – 55

*Common symptoms of menopause: hot flashes, urinary incontinence/ burning micturition, breast & vaginal changes,
skin thinning, bone loss, cholesterol lvl changes, weight gain

10. Menstrual calendar:

a) Is used to record & predict menstruation & fertile period
b) How to use:

1. Mark start & stop dates of every menstrual cycle (to come up with a trend)

2. Describe any PMS signs/ symptoms of PMS on any particular day (e.g. bad
feelings, headache, bloated/ water retention)

3. Indicate menstrual flow (e.g. H = heavy, M = moderate, L = light)

PART AG 02: ABNORMAL MENSTRUATION
SUB-PART AG 02 (A): GENERAL
11. E.g. abnormal menstruations:
a) Dysmenorrhea
b) Menorrhagia / Hypermenorrhea
c) Metrorrhagia
d) Hypomenorrhea
e) Polymenorrhea
f) Oligomenorrhea
g) Amenorrhea
h) Dysfunctional uterine bleeding
i) Intermenstrual/ postcoital/ postmenopausal bleeding

SUB-PART AG 02 (B): DYSMENORRHEA

12. Occurs in 45 – 95% of women at reproductive age

13. Etiology:
a) Idiopathic
b) Endometriosis/ adenomyosis/ hematometra
c) PID
d) Cervical stenosis

(L-R): endometriosis, adenomyosis, hematometra

14. History & exam:

Questions to Ask Exam

• Painkillers needed? • Abdominal & pelvic exam

• Daily work/ activities affected? • (In endometriosis,) pelvic mass, fixed uterus,
endometrial nodules
15. Investigations:
Investigation Indications

High vaginal & endocervical swabs To exclude pelvic infections

*To detect endometriomas

Pelvic USG *Symptoms suggest adenomyosis

*History suggests endometriosis

*Swabs & USS normal but symptoms persist
Diagnostic laparoscopy *Patient demands a definite diagnosis

SUB-PART AG 02 (C): MENORRHAGIA

16. Etiology:

17. History & exams:

 • Frequency of change of sanitary wear
Questions to be • Passage of clots
Asked • Blood spillage
• Inability to normally execute daily activities

• Signs of anemia
Exams • Abdominal and pelvic examination (e.g. abnormal mass,
swabs, cervical smear)

18. Diagnostic criteria:

a) Long duration of flow
b) Passage of big clots
c) Use of ↑ # of sanitary pads
d) Pallor
e) ↓ Hb count

SUB-PART AG 02 (D): METRORRHAGIA

19. Etiology:
a) Dysfunctional uterine bleeding
b) Submucosal fibroids
c) Uterine polyp
d) Cervical/ endometrial carcinoma

SUB-PART AG 02 (E): HYPOMENORRHEA

20. Etiology:

Local Endocrinal Systemic

• Dilation & curettage • OCPs • Malnutrition

• Uterine synechiae • Thyroid dysfunction
• Endometrial TB • Premenopausal period

SUB-PART AG 02 (F): POLYMENORRHEA

21. Etiology:
Dysfunction Ovarian Hyperemia

*Adolescence *PID
*Pre-menopause *Ovarian endometriosis
*Following delivery/ abortion

SUB-PART AG 02 (G): OLIGOMENORRHEA

22. Etiology:
a) Age-related (e.g. adolescence, pre-menopause)
b) Weight-related (obesity)
c) Stress, exercise
d) Endocrine disorders (e.g. PCOS, hyperprolactinemia, hyperthyroidism)
e) Androgen-producing tumour (ovarian/ adrenal)
f) Tubercular endometritis
g) Drugs (e.g. phenothiazines, cimetidine, methyldopa)

SUB-PART AG 02 (H): AMENORRHEA

23. Types:
Type Definition

1° ♀ fails to menstruate by age 16

Absence of menstruation for > 6 mths in normal ♀ of reproductive age

2° that is not due to pregnancy/ lactation/ menopause

24. Etiology:
Category Etiology

*Genital tract abnormalities

*Asherman’s syndrome
Anatomical *Mullerian agenesis
disorders *Transverse vaginal septum
*Imperforate hymen

*Anovulation (PCOS)
Ovarian disorders *POF (premature ovarian failure)

*Prolactinoma
Pituitary disorders *Pituitary necrosis (Sheehan’s Syndrome)

*Excessive exercise/ weight loss/ stress (these switch off hypothalamic stimulation of pituitary)
*Hypothalamic lesions (e.g. craniopharyngioma/ glioma compress hypothalamic tissue/ block
dopamine)
*Head injuries
Hypothalamic *Kallman’s syndrome (X-linked recessive condition causing deficiency in GnRH  underdeveloped
disorders genitalia)
*Systemic disorders (e.g. sarcoidosis, TB  infiltrative lesions in hypothalamohypophyseal region)
*Drugs (e.g. progestogens, HRT, dopamine antagonists)

25. Exams:

General Inspection Visual Field Assessment Vaginal Exam

• BMI • Pituitary lesions • To detect structural outflow

• 2° sexual characteristics abnormalities & demo
• Signs of endocrine atrophic changes with hypo-
abnormalities estrogenism

26. Investigations:
Investigation Description

Pregnancy test To determine sexual activity

Blood test

LH/ testosterone assay ↑ lvls suggest PCOS

FSH assay ↑ lvls suggest POF

Prolactin assay ↑ lvls suggest prolactinoma

Thyroid function tests

USG To detect classical polycystic ovaries

MRI To detect pituitary adenoma

Hysteroscopy To detect Asherman’s syndrome/ cervical stenosis

Karyotype To detect Turner’s syndrome

SUB-PART AG 02 (J): DYSFUNCTIONAL UTERINE BLEEDING

27. Etiology:
a) Anovulation
b) Ovulatory cycles

SUB-PART AG 02 (K): AFTERWORD

28. If any abnormal uterine bleeding is present (in reproductive age group), perform PREGNANCY TEST 1st (even if
patient denied intercourse)

29. Other common causes of abnormal bleeding:

Pelvic Systemic

• Tumor • Drugs
• Infections • Endocrinal/ hematological/ renal/
liver disorders

*Other causes: uterine abnormalities, C-section scar defects, foreign bodies (IUCDs), trauma (sexual abuse)
CHAPTER AM: HIGH-RISK PREGNANCY
1. Definition:

1. Any factor which adversely affects outcome of pregnancy

2. Pregnancy which has ↑ risk for morbidity/ mortality of mother/ fetus/ neonate

2. Risk factors:
Low-risk High-risk

Age 18 – 35 < 18/ > 35

Parity index Gravida: > 5 (> 3 when GPLA ≥ 2, 2, 0, 0)

Chief complaints Bleeding PV (other than spotting)

*Bad history
Obstetric history *H/o C-section/ traumatic delivery

Menstrual history Menorrhagia (suggests leiomyoma)

*DM, HT, thyroid disorders, anemia, epilepsy, asthma, CVS diseases, etc.
*Myomectomy (for leiomyoma)
Past history *Biconvex/ septate uterus
*Vesico-vaginal fistula

Height (of mother) < 145 cm

Weight (during < 40 kg

pregnancy)
BP > 140/90

CVS exam Murmurs, rhonchi

Fundal height Symphysiofundal height </ > POG#

 *Anemia (on Hb test)
*Blood group & Rh incompatibility
*VDRL/ HIV/ HBsAg +ve
Investigations *Gestational diabetes (on GTT)
*USG/ amniocentesis/ chorionic villus sampling anomalies

Others Edema

#Conditions for…
a) symphysiofuncal height < POG: IUGR/ oligohydramnios
b) symphysiofuncal height > POG: polyhydramnios, multiple pregnancies, malpresentations

3. Management:

1. Risk-screening & referral

2. Investigations:
a) Maternal weight gain
b) Symphysiofundal height
c) USG

3. Treatment:
a) DM/ HT control
b) Anemia treatment
c) Surgeries for congenital anomalies
d) Peri-conceptual folate

4. Monitoring growth/ fetal well-being:

a) Fetal movement count
b) Non-stress test
c) Biophysical profile (determined via USG)

5. Timing delivery

6. Neonatal care
SECTION B: NATAL CARE
CHAPTER BA: PRENATAL CARE
PART BA 01: OVERVIEW
1. Definition: care given to an expected mother from time of conception  beginning of labor

2. Objective: To ensure normal pregnancy with delivery of healthy baby from healthy mother

3. Aims:
a) To ↓ maternal mortality & morbidity
b) To screen high-risk pregnancies & treat complications
c) To educate mother about physiology of pregnancy & labor
d) To prepare mother for labor & delivery
e) To prevent, identify & manage fetal complications (which can affect pregnancy outcomes)
f) To discuss (with couple) about place, time, mode of delivery & need for family planning

4. Schedule:

Every 4 wks up to 28 wks gestation

Every 2 wks up to 36 wks gestation

Every 1 wk until delivery

*More frequent visits may be required if abnormalities/ complications/ danger signs arise during pregnancy

PART BA 02: 1st TRIMESTER

4. Confirmation & registration of pregnancy via…
a) h/o present pregnancy
b) obstetric, menstrual, past, family, personal, medical & surgical history

5. Exam:
Aspect Description
 *Build, nourishment, weight, height, BMI
*Signs of PICCLE
General *Vital signs
*Thyroid & breasts

Systemic CVS, RS exams

Physical Inspection, palpation

*Hb
*HIV, HBsAg, VDRL
*Blood grouping & typing
*Urine analysis
Investigations *HbA1C
*Thyroid profile
*Dual test

*Scans:
a) Dating scan (7 – 8 wks)
b) Nuchal translucency scan (11 – 13 wks)

USG

*Site of pregnancy
*Presence of molar pregnancy
*Presence of fetal cardiac activity
*# of fetuses
*Adnexal, uterine abnormalities

6. Problems expected:
 1. Hyperemesis

2. Abortion (threatened/ missed/ incomplete/ complete)

3. UTI/ asymptomatic bacteriuria

4. ADR

5. Radiation exposure

7. Advice to mother:
a) Folate supplementation
b) Symptomatic management of complaints (if any)
c) Health education

PART BA 03: 2nd TRIMESTER

8. General things to look out for:
a) H/o of any complaints
b) Presence of quickening

9. Exams:
Aspect Description

Vital signs

Height/ weight

Height of uterus

Cardiac activity (of fetus)

At 18 – 22 wks
*Anomaly scan (for anomaly detection, placental
localization & amniotic fluid index)
Investigations At 24 – 28 wks
*Hb
*Urine protein (esp. if BP is ↑)
*GCT/ GTT

10. Problems expected:

1. Anemia

2. PIH (pregnancy-induced HT)

3. GDM

4. Low-lying placenta

5. Anomalous baby

11. Advice to mother

a) TT immunization (1st dose: 16 – 20 wks; 2nd dose after 4 wks)
b) Fe2+ & Ca2+ supplementation
c) Advice on diet, sleep, hygiene

PART BA 04: 3rd TRIMESTER

12. General things to look out for:
a) H/o any complaints
b) Appreciate fetal movements
c) Presence of pain in abdomen/ bleeding or spotting p/v/ draining p/v

13. Exams:
Aspect Description
 *Vital signs
General *Height, weight

*(Ask patient to empty bladder, & lie in supine position)

*Inspection
*Palpation (height of uterus, fundosymphyseal height, grips)
Obstetric *Scar tenderness (if previous LSCS had been done)
*Auscultation

*Cervix (effacement, consistency, position, dilation)

*Station of presenting part
Per vaginal *Pelvic exploration (usually after 37 wks)

*Hb
*Platelet count
*Coagulation tests (PT, APTT)
*USG:
Investigations a) Growth scan at 30 – 33 wks (to rule out IUGR)
b) Scan at 37 – 38 wks (for amniotic fluid index/ EFW)

*Doppler (s.o.s.)

14. Problems expected:

1. Anemia

2. PIH

3. APH (antepartum hemorrhage)

4. Malpresentations (breech/ transverse lie)

15. Advice to mother:
a) DFMC (daily fetal movement count; usually 10/day)
b) Importance of lying down in left lateral position
c) To continue Fe2+, Ca2+ supplements
d) To report in case of bleeding p/v/ draining p/v/ lower abdominal pain/ ↓ fetal movements

16. Conditions for hospital admission:

At 40 wks • For uncomplicated pregnancy

• For complications like severe PIH/ GDM/ APH/ IUGR/

At 38 wks oligamnios/ previous LSCS/ breech position/ heart disease

• For pre-term labor/ bleeding PV/ PROM/ severe anemia/ ↓

Any time fetal movements

PART BA 05: USG

17. Purpose for execution:
Trimester Purpose for USG
1 *Intrauterine pregnancy confirmation
*Multiple/ ectopic/ molar pregnancy
*Nuchal translucency at 10 – 14 wks (< 3 is normal)

Normal translucency (left) & large translucency suggestive of Down’s syndrome

*Blighted ovum (empty sac)

Normal ovum (left) & blighted ovum

*Pelvic mass/ uterine abnormalities

*Cause of vaginal bleeding & pelvic pains
*Cardiac activity
*Chorionic villus sampling

2 *Anomaly scan at 18 – 20 wks

*Fetal weight (calculated via Hadlock formula)

3 *Fetal growth (weight estimation)

*Amniotic fluid index

`
 *Placental location
*Biophysical profile

PART BA 06: ANTENATAL ADVICE

18. Advice:

1. Diet:
a) Extra requirement of 300 kcal/day
b) Supplementary Fe2+ therapy (with 60 mg elemental Fe)

2. Hygiene

3. Bowel care (avoid constipation by comsuming veggies, fruits, plenty of oral fluids)

4. Breast care

5. Exercise

6. Dressing (loose garments preferred)

7. Rest (≥ 8 hrs of sleep at night & 2 hrs at daytime)

8. Coitus (avoid during 1st trimester & last 6 wks, esp if pregnancy is of high-risk)
SECTION C: LABOR
CHAPTER CA: INTRODUCTION
1. Definition:

Series of events in genitals in order to expel viable products of

conception from uterus  vagina  external environment

2. Components:
a) Power (uterine contractions)
b) Passenger (fetus)
c) Passage

3. Normal labor:

1. Spontaneous/ induced

2. Single, live fetus

3. Cephalic presentation

4. Term (POG: 37 – 42 wks)

5. Natural termination with minimum aids (e.g. episiotomy, forceps)

6. < 12 hrs in nulliparous/ < 8 in multiparous

7. No morbidity/ mortality

*”Normal labor” is a retrospective diagnosis

CHAPTER CB: PARTURITION
PART CB 01: GENERAL
4. Phases:

Stage Definition

1 Onset of true labor pains  full dilation of cervix

2 Full dilation of cervix  complete delivery of fetus

3 Complete delivery of fetus  complete expulsion of placenta & membranes

4 Patient observed for ≈ 1 hr after complete expulsion of placenta & membranes

PART CB 02: FACTORS MAINTAINING PARTURITION

SUB-PART CB 02 (A): OVERVIEW
5. Regulation:
a) Loss of pregnancy maintenance factors
b) Synthesis of labor-inducing factors
 Factors maintaining parturition (above) & placental-fetal adrenal endocrine cascade @ fetoplacental unit

*Duration of labor:
Primigravida Multipara

Avrg Max Avrg Max

Latent phase (hrs) 8 20 6 14

Active phase (hrs) 5 12 2.5 6

Cervix dilatation rate (cm/hr) 1.2 1.5

SUB-PART CB 02 (B): PHASE 1

6. Factors maintaining parturition:
a) Tissue remodelling  compliance
 b) Structural changes in ECM
c) Change in collagen processing

SUB-PART CB 02 (C): PHASE 2

7. ↑ myometrium contractility:
a) ↑ uterine irritability & responsiveness
b) ↑ oxytocin & PGF receptors, gap junctions, connexin 43

8. Uterine myocyte contraction:

a) Actin-myosin interaction
b) ↑ intracellular Ca2+
c) ↑ myometrial gap junctions (intercellular junctional channels)
d) Cell surface receptors

9. Myometrium:
a) Retraction (contracts, becomes fixed & retains ability to further contract)

b) Plexiform arrangement of muscle fibres

c) Force exerted in multiple directions & in greater force

10. Formation of LS (lightening as fetal head descends into pelvic inlet  baby dropped)

11. Cervical ripening  dilation

12. Clinical stages of labor:

a) Effacement
b) Cervical dilation
c) Fetal expulsion
d) Placental separation & expulsion
PART CB 03: SEQUENCE OF EVENTS
SUB-PART CB 03 (A): PHASE 1
13. Bloody show (plug of cervical mucus mixed with blood)
14. True labor pains:

1. Etiology:
a) Myometrial hypoxia
b) Compression of nerve ganglia in cervix & lower uterus
c) Stretching of cervix & peritoneum overlying fundus

2. Properties to be assesed:
a) ↑ frequency of pains (ascertain # of episodes in 10 mins)
b) ↑ intensity
c) Duration
d) Intra-amniotic pressure (20 – 60 mmHg)
*Differences between true & false labor pain:
True Labor Pains False Labor Pains

*Regular *Irregular
Interval *Gradually shortens *No change

Duration & severity ↑ No change

Site Back  front Front (mainly)

Precipated by Walking

Uterine hardening <--> pain intensity Correlaion present

Show Often present -

Cervical changes Progressive effacement & dilation -

Presenting part Descends No descend

Sedation No stop pains Stops pains

Enema No relieve pains Relieves pains

15. Ominous signs:

a) Slow cervical dilation
b) Loose/ thick/ hanging cervix
c) Hypo-/ hyper-tonic contractions
d) Fetal distress
 e) Caput/ moulding
f) Meconium-stained liquor
g) Slow head descent

16. Cervical effacement (gradual uptake of cervix by uterus)

a) Cervix thins out & shortens gradually
b) Incorporation of cervical lower segment into uterus
c) Measured as % shortening (25/ 50/ 75/ 100; usually ≥ 80)
d) Anterior lip is the last to be effaced

*In primigravidas, effacement precedes dilation

17. Formation of amniotic fluid forebag (bag of waters)

18. Dilation:
Aspect Description

*Uterine contraction & retraction

*Hydrostatic action of membranes
Etiology *Ball-valve-like action of flexed head
*Mechanical stretching by fetal axis pressure

*Phase of acceleration: 3 – 4 cm
*Phase of max slope: 4 – 9 cm
*Phase of deceleration: 9 – 10 cm
Measurements

Not effaced; no dilation Fully effaced; 1 cm 5 cm dilation Fully dilated; 10 cm

*Primigravida: 1 cm/hr
Rate *Multipara: 1.5 cm/hr

Membrane rupture (May or may not be present)

SUB-PART CB 03 (B): PHASE 2

19. Contractions:
Strength Frequency (1/x min) Duration (s) Uterine Indentibility

Good 2–3 45 – 60 None

Fair 4–5 30 – 45 Slight

Poor ≥6 < 30 Easy

20. Retractions:

Physiological Pathological

• Retraction ring present on ridge on inner • Bandl ring present (in case of obstructed
surface of uterus (at junction of thickened labor)
upper segment & thinned lower segment)
21. Aspects determining route of delivery:
a) Fetal position
b) Lie
c) Presentation
d) Attitude
e) Position
f) Leopold maneuvers/ pelvic exam/ USG findings

22. Fetal descent (assessed by fifths method/ station)

23. Pelvic floor changes:

a) Stretching of levator ani
b) Thinning of central perineum
 c) Anal dilation (when perineum is distended maximally)

24. Ancillary forces in labor:

a) Maternal intra-abdominal pressure
b) Pushing (abdominal muscle contraction + foced expiratory efforts with closed glottis)

SUB-PART CB 03 (C): PHASE 3

25. Placental separation (from uterus):

1. Effects:
a) ↓ uterine area
b) Placenta buckles due to limited elasticity at decidua spongiosa (weakest layer)
c) Membranes peeled off by traction of separated placenta

2. Mechanisms:
a) Central (Schultze): retroplacental hematoma formation; placenta drags & descends

b) Marginal (Matthew Duncan): peeling off of uterine wall

c) Aided by ↑ intra-abdominal pressure

 3. Signs:
a) Fresh pains (associated with uterine contraction)
b) Sudden fresh vaginal bleeding
c) Apparent (extra-vulval) lengthening of umbilical cord
d) Uterine fundus rises above umbilicus
e) Suprapubic bulge
f) If uterine fundus is gently grasped & raised, the cord will NOT recede

*Decidua spongiosa = part of decidua basalis attached to myometrium

26. Extrusion (of placenta)

27. Bleeding control mechanisms:

1. Retraction of interlacing muscle fibres around uterine vessels (living ligatures)

2. Thrombosis & apposition of uterine wall

*Normal bleeding after delivery is < 500 mL

28. Lactation established (via oxytocin)

29. Uterine involution & repair

30. Reinstitution of ovulation:

a) Occurs 4 – 6 wks after birth
b) Depends on breastfeeding/ prolactin-mediated amenorrhea

PART CB 04: MANAGEMENT

31. Management:
a) Observation of mother for 1 – 2 hrs
b) General exam: pulse rate, BP
c) Per abdominal exam: to check whether uterus involuted normally
d) Local exam: to check for excessive PV bleeding
e) Encourage bladder emptying
f) Initiate breastfeeding
g) Ambulate mother if stable & has no other risk factors
CHAPTER CC: MECHANISM OF NORMAL LABOR
PART CC 01: GENERAL
32. Is the series of movements that occur on fetal head (as adaptive measures during its downward journey thru pelvis)

33. Fundamental principle: for fetus to maneuver its way thru curvatures & variable diameters of maternal pelvis

34. Cardinal movements:

a) Descent
b) Flexion
c) Internal rotation
d) Crowning
e) Extension
f) Restitution
g) External rotation

PART CC 02: ENGAGEMENT

35. Is the widest diameter of the presenting part (of fetus) which has passed thru pelvic inlet (of mother):
a) Biparietal diameter in case of cephalic presentation
b) Intertrochanteric length in case of breech presentation
36. Measurements:
Exam Method Measurement Recorded as…

Per abdominal 5ths of head

Per vaginal Station/ cm

37. Occurs differently in primis & multis:

Gravida Occurrence of Engagement

Primi Before onset of labor

Multi Late 1st stage (with rupture of membranes)

38. Asynclitism:

1. Is the deflection of fetal head relative to pelvis (i.e. sagittal suture is NOT strictly in sync with
transverse diameter of pelvic inlet)

2. Occurs in 75% cases

3. Types:
Sagittal suture deflection
Presenting part
Commonly seen in…
Anterior Posterior
Towards sacral promontory (posterior) Towards pubic symphysis (anterior)
Anterior parietal (bone) Posterior parietal (bone)
Multipara Primigravida

4. After passing thru promontory/ pubic symphysis, head enters pelvic brim & synclitism occurs

5. Severe degrees of asynclitism indicate CPD (cephalo-pelvic disproportion)

 (L-R): anterior asynclitism, posterior asynclitism, synclitism

PART CC 04: DESCENT

39. Is a continuous process (if no obstruction) occurring along right oblique diameter (of pelvis)

40. Occurs mainly due to…

a) uterine contractions
b) bearing-down efforts (in 2nd stage of labor)
c) gravity (minor factor)

41. Most pronounced in (deceleration phase of) 1st stage, & 2nd stage

PART CC 05: FLEXION

42. Sequence of events:
 Initial partial flexion (which is Further flexion (occurs when there's resistance to descent) -
normal attitude of fetus) posterior fontanelle lower than bregma; chin touches chest
Occipitofrontal length = 11 cm Suboccipitobregmatic length = 9.5 cm

*The ↓ of 1.5 cm is very important

Green line at (A) shows occipitofrontal length while that at (B) subocipitobregmatic length

43. Starts at pelvic inlet, & is completed when presenting part reaches pelvic floor

PART CC 06: INTERNAL ROTATION

44. Sequence of events:
Position of Fetal Head Orientation of Fetal Head

At pelvic inlet Oval (transverse)

At pelvic outlet Oval (anteroposterior)

45. If head is rotated 90°, then usually the shoulder is also rotated 45° in the same direction

PART CC 07: CROWNING

46. When head reaches underneath pubic arch, its max (biparietal) diameter stretches vulval outlet w/o recession
of head (even after uterine contractions are over)

PART CC 08: EXTENSION

47. Applies to delivery of head only

48. Forces involved:

Force Direction of Vector

Uterine contractions Downwards

Resistance (from pelvic floor) Upwards, forwards

Downwards & upwards forces (red) cancel out, so forwards force pushes fetal head towards maternal urethra (yuck!)

49. Sequence of events:

 When occiput is at pelvic outlet, fetal nape pivots on sub-pubic angle

Sinciput sweeps sacrum

Bregma, forehead, nose, mouth, chin expelled in succession over perineum

*Summary: hinge-like movement (back of head no move  front of head brushes against sacral curvature)

50. Immediately after chin is released from vulva, the head drops down & chin approximates maternal anal opening
(even more yuck!)

PART CC 09: RESTITUTION

51. Sequence of events (the last point in the flowchart defines restitution):

Neck was twisted during internal rotation

When head was at pelvic floor, shoulders entered pelvis turned obliquely
(in same direction as internal rotation)

Once head is completely outside vagina, passive untwisting occurs (head

rotates 45° in opposite direction of internal rotation, & reattains normal
relationship with shoulders)
PART CC 10: EXTERNAL ROTATION
52. Is the rotation of head (visible outside vagina) due to internal rotation of shoulder (don’t confuse this with internal
rotation of head earlier)

53. Sequence of events:

Anterior shoulder turns 45° (so that it faces pubic symphysis)

Shoulders lie in anteroposterior diameter (of pelvis)

In the process, head turns 45° more (in opposite direction as internal
rotation)

Head finally restores its original position (i.e. that BEFORE internal
rotation)

PART CC 11: LATERAL FLEXION

54. Events:
a) Anterior shoulder goes under pubis & pivots there
b) Posterior shoulder slides over perineum (via lateral flexion)
*Rest of body is born w/o special mechanisms
 CHAPTER CD: MANAGEMENT OF NORMAL LABOR
PART CD 01: INTRODUCTION
1. Occurrence of labor:
Time % Cases

EDD 4

EDD ± 1 wk 50

EDD -2 (or) +1 wk 80

Wk 42 10

Wk 43 4

2. Initiation of labor:

Labor is initiated by removal of inhibitory effects on myometrium (rather than active process governed by uterine stimulants)

3. Aims:

1. Maximal observation with minimal active intervention

2. To maintain the normalcy & to detect any deviation from normal at earliest possible moment
PART CD 02: GENERAL CONSIDERATIONS
4. General precautions:
Aspect Description

*Precautions:

Birth Attendant Patient

Antiseptics & • Scrupulous surgical cleanliness • Asepsis
Asepsis • Asepsis of delivery process • Shave vulva
• Take bath (wash vulva & perineum)
• Wear laundered gown & stay mobile

*1st exam shud be done by senior doctor

Vaginal exam *Patient shud be in dorsal position

*Proper hand washing

*Wear sterile gloves
*Vulval toileting (swab vulva with 10% Dettol or equivalent)
Preliminaries *Complete examination shud be completed before fingers are withdrawn
*Minimum vaginal examination (to ↓ infection risk)

5. Aspects to be noted in PV exam:

Aspect Description

Note degree of effacement:

Effacement
 Marked (in cm) in partograph

Cervical dilation

*Membrane status:
a) I = intacy
b) R = ruptured

Status of membranes *If ruptured, note color of liquor:

a) C = clear
b) B = blood-stained
c) M = meconium-stained

Presenting parts +
position

Posterior fontanelle

*Grading:
a) 1 = sutures apposed
b) 2 = sutures overlapped but reducible
c) 3 = sutures overlapped & not reducible
Caput/ molding of head
Station of head

Assessment of pelvis

*Photo of full partograph:

http://www.open.edu/openlearnworks/pluginfile.php/4820/mod_oucontent/oucontent/200/none/none/ldc_session4_fig1.j
pg

6. Indications for performing PV exam:

1. Onset of labor (to detect presenting part & its positions)

2. Progress of labor (to note dilatation of cervix & descent of head)

3. Following rupture of membrane (to exclude cord prolapse)

4. Whenever any interference is contemplated

5. To diagnose beginning of 2nd stage (of labor)

PART CD 03: MANAGEMENT OF 1ST STAGE

SUB-PART CD 03 (A): GENERAL
7. Overview:
a) History & exam
 b) Labor admission test
c) Prepare parts (i.e. perineum)
d) Enema
e) Ambulation
f) Diet (usually clear fluids)
g) Vitals monitoring
h) Bladder care (encourage peeing)
i) Emotional support
j) Analgesia s.o.s.

8. Principles:

1. Non-interference with watchful expectancy.

2. Encouragement, emotional support, adequate pain relief

3. Monitor progress of labor, maternal condition & fetal behavior

4. Maintain partograph recording

SUB-PART CD 02 (C): HISTORY

9. Items to be elicited:
Booked Patient Unbooked Patient#

*Menstrual history
*Past-obstetric history
*Present history

*Onset of pain
*Rupture of membranes
*Bleeding PV

#Patient whose pregnancy details/ progress has not be documented before

SUB-PART CD 02 (D): EXAM

10. Aspects to be examined (upon 1st admission & to monitor labor progress):
Aspect Items

*PicclE
*Breast, thyroid
*Pulse (check every 30 mins)
*BP: (check every 1 hr)
*Temperature: (check every 2 hrs)
*Urine output: volume, protein, acetone
*Drugs (e.g. oxytocin/ etc)

General

Systemic CVS, RS

Inspection
*Size of uterus
*Fullness of flanks
*Presence of scars

Palpation
*Size of uterus
*Lie, presenting part, fixedness, approx size, back & limbs (of fetus)
*Liquor quantity
*Uterine contractions
Per abdomen *Fetal head descent

PV (check every 4 hrs/ during
membranes rupture/ bearing
down/ FHS variations)
#< 3 cm = latient phase; > 3 cm = active phase
Auscultation
*FHS:
a) Rhythm & intensity
b) Check for 1 min every 30 mins in 1st stage; 15 mins in 2nd stage
c) Normal: 110 – 150/min
*CTG (cardiotocography):
a) ECG for fetal heart rate
b) Tocography for uterine contractions
*Presence of discharge
*Cervical position (anterior/ mid-position/ posterior)
*Effacement (partial/ full dilation)#
*Presentation
*Station of presenting part
*Membranes (intact/ ruptured)
*Pelvic assessment
SUB-PART CD 02 (E): OTHERS
11. Details:
Aspect Items

Parts preparation Enema with soap & water/ glycerin given if rectum feels loaded

*Required to…
a) ↓ duration of labor & need of analgesia
Rest & ambulation b) improve maternal comfort

*Nil per oral (to prevent Mendelson’s syndrome)

Diet *Fluids (IV fluids with Ringer solution) may be given

*Pass urine frequently (full bldder inhibits uterine contractions)

Bladder care *Catheterization done if patient fails to pass urine

*Given during active phase

*E.g. combos:
a) Inj pethidine 50 – 100 mg IM + inj metoclopromide 10 mg IM
b) Inj pethidine 50 mg IM + inj phenargan 25 mg IM

*Precautions:
Analgesia a) Repeat 4-hrly s.o.s
b) Onset of action: 1 hr; duration of action: 4 hrs
c) Adverse effect: neonatal respiratory depression

*Hence, shud NOT be given if delivery is anticipated within 2 hrs

#Aspiration of gastric contents following emergency general anesthesia  chemical pneumonitis, lung damage,
atelectasis, bronchopneumonia

SUB-PART CD 02 (E): MISC

12. Augmentation of labor:
a) Target: 3 – 5 contractions/10 min
 b) Inj oxytocin IV:

Start with 2 mIU/min (8 Augment with 2 mIU/min Max 7.5 mIU/min (60
drops/min) every 30 min drops/min)

13. Signs of distress:

Maternal Distress Fetal Distress

• Anxious look + sunken eyes • Fetal HR: < 110 (or) > 160/min
• Dehydration (dry tongue) • Fetal HR takes long time to come back to
• Acetone smell in breath normal after contraction passes off
• ↑ HR: > 100 /min • Irregularity
• Hot & dry vagina with offensive discharge
• Scanty, high-colored urine with acetone

PART CD 04: MANAGEMENT OF 2ND STAGE

SUB-PART CD 04 (A): GENERAL
14. Evidence of transition to 2nd stage:

↑ intensity of uterine contractions Urge to push/ defecate + descent of presenting part

Complete dilation of cervix (on PV exam) Bearing-down efforts

15. Principles:

1. Assist in natural expulsion of fetus slowly & steadily

2. Prevent perineal injury

16. General measures:

1. Patient shud be in bed

2. Constant supervision & fetal HR recorded at 5-min intervals

3. Administer NO2 & O2 (inhalation analgesics) to relieve pain

4. PV exam (to confirm onset of 2nd stage/ detect accidental cord prolapse)

17. Preparations for delivery:

Aspect Description

*Lateral/ squatting/ partial sitting

*Dorsal position with 15° left lateral tilt (to avoid aortocaval compression & facilitates pushing effort)
*Dorsal lithotomy (preferred position):

Pros Cons

• Asepsis • Supine hypotension syndrome

• Perineum protection • Sacroiliac pain
• ↑ vulval outlet diameter • Perineal nerve damage
• Facilitates forceps use, episiotomy • Leg cramps
Position of repair, conduction of 3rd stage
patient

Dorsal position with lateral tilt (left) & dorsal lithotomy

 *Scrub up, put on sterile gown, mask & gloves
Birth attendant *Stand at right side of table

*Swab genitalia with Dettol/ Savlon solution

Parts *1 sterile sheet is placed beneath buttocks & 1 above abdomen
preparation *Clean hands, clean surface, clean cutting & ligaturing of cords

Done if bladder is full

Catheterization

18. Duration of 2nd stage (of labor):

Duration (hr) Primigravida Multipara

Avrg 1 0.5

W/o epidural block 2 1

Max
With epidural block 3 2

SUB-PART CD 04 (B): EPISIOTOMY

19. Is a surgical cut made at opening of the vagina during to aid a difficult delivery & prevent tissue rupture

20. Drug:
a) Lignocaine (NO epinephrine) 1% (10 mg/mL), 10 mL
b) Dose: 3 – 5 mg/kg body weight

21. Indications:
 Maternal Fetal
• Prolonged 2nd stage • Pre-term baby
• Arrest of labor process by resistant • Large baby
perineum • Abnormal (face/ breech)
• Thick & heavily-muscled tissues presentation
• To prevent uncontrolled tears • Fetal distress

22. Comparison between types:

Mediolateral Midline

Extension (deep perineal tear) More common

Faulty healing More common

Post-op pain Common Minimal

Anatomical results Occasionally faulty Excellent

Blood loss More

Dyspareunia# Occasional Rare

Surgical repair More difficult

#Painful coitus
*Apart from the 1st feature above, both types are more or less the same (based on internet search results)

SUB-PART CD 04 (C): DELIVERY OF HEAD

23. Principles:
a) Maintain flexion of head to prevent early extension & to regulate its slow escape out of vulval outlet.
 b) Patient encourged to bear down during contractions (NOT during retractions)
c) When 5 cm of scalp is visible, flexion of head is maintained by pushing occiput down & backwards using thumb
& index finger of left hand, while right palm is pressed on perineum
d) Slow delivery of head between contractions is to be regulated. This is done by Ritgen’s maneuver when the
suboccipitofrontal diameter emerges out (towel-covered right hand placed over anococcyygeal region pushing
on the chin & left hand exerting pressure on the occipital region)

24. Care following delivery of head:

a) Mucus & blood in mouth & pharynx are wiped (a sucker can be used)
b) Eyelids wiped with dry cotton swabs from medial  lateral canthus (to minimize conjunctival sac contamination)
c) Neck palpated to check for presence of loop of cord (if loose, it is slid over the head. If tight, it is cut with a pair
of Kocher’s forceps)

Sucker (left) & correct way to wipe newborn’s eyelids

25. Precautions for prevention of perineal lacerations:

a) Avoid delivery by early extension
b) Avoid spontaneus forcible delivery of head by telling patient NOT to bear down during contractions
c) Deliver head between contractions.
d) Perform timely episiotomy (during crowning only)
e) Take care during delivery of shoulder when the wider bisacromial diameter emerges out of introitus (vulva)
SUB-PART CD 04 (D): DELIVERY OF SHOULDERS
26. Wait for…
a) uterine contractions, &…
b) movements of restitution & external rotation (of head)

27. If there’s delay,…

Grasp head with both hands

Draw (pull) head POSTERIORly until anterior

shoulder is released from under pubis

Draw head upwards to release posterior shoulder

SUB-PART CD 04 (E): DELIVERY OF REST OF BODY

28. After delivery of shoulders, forefingers are inserted under axillae

29. Trunk delivered gently by lateral flexion.

PART CD 05: CARE OF NEWBORN

SUB-PART CD 05 (A): IMMEDIATE CARE
30. Actions:
a) Clean & dry baby with cloth
b) Tilt head downwards (15°) to help mucus drainage
c) Oropharynx cleared by suction

d) APGAR rating done twice (1 & 5 min after delivery)

SUB-PART CD 05 (B): CORD CLAMPING & LIGATURE
31. Procedure:

Clamp cord with 2 Kocher's forceps (proximal

Cut cord between Squeeze
one at 5 cm from fetal umbilicus, distal one as
the 2 forceps cord#
close as possible to vulval outlet

Cut end covered Trim cord beyond 2nd Tie/ place 2 clamps on fetal cord (2.5
with sterile gauze ligature/clamp & 3.5 cm from umbilicus)

Cord clamping with Kocher’s forceps (left) & clamp (for step 4 above)

#Collect cord blood too, & send for Hb estimation, blood grouping & typing (in Rh –ve mother, also do Coomb’s test &
bilirubin lvls)

32. Discussion:
a) Squeezing cord prevents inclusion of embryonic remains
b) Excess cord prevents 1° hemorrhage if ligature loosens.
c) Check vessels abnormality (e.g 1 umbilical artery)
 Normal cord

d) Clamp mother’s cord too, to prevent blood loss in undiagnosed twins

33. Early & delayed cord clamping:

Early Cord Clamping Delayed Cord Clamping

Baby placed at lower level than uterus & cord clamping

General is delayed  ↑ blood flow into neonate

*Rh incompatibility (Rh -ve mother)

*Babies born asphyxiated. *Term baby
Indications *Baby of diabetic mother *Neonatal anemia/ Fe2+ deficiency

Pre-term & LBW babies (can cause hypervolemia &

Contraindications hyperbilirubinemia)

SUB-PART CD 05 (C): MISC

34. Presence of gross abnormality checked & baby wrapped warm in dry towel

PART CD 06: MANAGEMENT OF 3RD STAGE

SUB-PART CD 06 (A): GENERAL
35. Types of management:
a) Expectant (traditional)
b) Active (preferred)

SUB-PART CD 06 (B): EXPECTANT MANAGEMENT

36. Placental separation & descent into vagina are allowed to occur spontaneously
37. Placenta…
a) is separated within mins following birth
b) is expected to be expelled within 15 – 20 mins (with aid of gravity)

38. Maintain constant watch over patient.

39. Reasons for placing hand over uterine fundus:

1. To recognize signs of placental separation

2. To note the state of uterine cavity (contraction & relaxation)

3. To detect cupping of fundus (early indication of inversion of uterus)

Management of uterine inversion

40. Approach proper:

 41. Assisted placental expulsion:
Controlled Cord Traction (Modified Brandt-Andrews Method) Fundal Pressure

LEFT HAND
Palmar surface of fingers placed (above Once the uterus becomes
symphysis pubis) approx at junction of upper & hard, 4 fingers are placed
lower uterine segment behind fundus while thumb
in front of fundus

Body of uterus pushed UPwards & BACKwards Fundus pushed DOWNward &
(towards umbilicus) BACKward

Pressure withdrawn once

RIGHT HAND placenta passes thru introitus
While holding clamp, give steady tension
DOWNwards & BACKwards until placenta is expelled

*This method is only used when uterus is hard & contracted

Modified Brandt-Andrew’s method (left & fundal pressure method

SUB-PART CD 06 (C): ACTIVE MANAGEMENT

42. Principle: exciting powerful uterine contractions within 1 min of delivery by giving parenteral oxytocics
43. Facilitates early separation of placenta

44. Produces effective uterine contractions following placental separation

45. Advantages & disadvantages:

Advantages Disadvantages

• ↓ blood loss in 3rd stage (by ≈ 80%)
• ↓ duration of 3rd stage (by 50%)
• Slight ↑ incidence of retained placenta (1% -
2%)
• Consequent ↑ incidence of manual removal
• Danger to unborn 2nd baby (in case of
twins) caused by asphyxia due to tetanic
contraction of uterus

46. Procedure:

47. Inj oxytocin 5/ 10 units slowly IV/ IM (or) methergine 0.2 mg IM (for mother) to…
a) make uterus hard
b) facilitate expulsion of retained clots (if any)
SUB-PART CD 06 (D): PLACENTAL MANAGEMENT
48. Exam of placental membrane & cord:
Aspect Description

*Placenta placed on tray

Processing *Washed with running tap water to remove blood & clots

*Maternal surface (greyish decidua) inspected for completeness (missing cotyledons) & anomalies
*Membranes (chorion & amnion) inspected for completeness & presence of abnormal vessels
indicative of succenturiate lobe#:
a) Normally, chorion is shaggy while amnion shiny
b) An oval gap in chorion with torn ends of vessels running up to margin of the gap indicates
Exam proper missing succenturiate lobe
c) If cotyledon is absent/ missing succenturiate lobe/ significant missing membranes, then
EXPLORE UTERUS stat

*Cut end of cord is inspected for # of vessels (2 arteries, 1 vein)

#Accessory lobe on placenta

49. Vulva, vagina & perineum inspection:

a) Inspected for injuries (treat if any)
b) Episiotomy wound is suture
c) Vulva & adjoining part cleaned with cotton swabs soaked in antiseptic solution
d) A sterile pad is placed over vulva
PART CD 07: MANAGEMENT OF 4TH STAGE
50. Observe the following for ≥ 1 hr after delivery:
a) Pulse
b) BP
c) Uterine tone (normal: well retracted)
d) Bleeding PV
CHAPTER CE: PARTOGRAPH
PART CE 01: GENERAL
1. About:
a) Is a composite graphical record of key data (maternal & fetal) during labor against time, on a single sheet of
paper
b) Can be used for all labors in hospitals
c) Is designed to detect deviations from normal delivery which may develop as labor progresses
d) Has a different lvl of function at different lvls of healthcare

2. Principles:

1. Partogram recording starts when patient is in active phase (cervical dilation 4 cm)

2. Rate of cervical dilation should NOT be < 1 cm/hr during active labor

3. Lag time of 4 hrs between slowing of labor & the need for intervention is unlikely to compromise
fetus/ mother, & avoids unnecessary intervention

4. PV exams shud be performed as INfrequently as possible (once every 4 hrs is recommended)

3. Advantages:
a) A single sheet of paper can provide details of necessary information at a glance w/o the need for repeatedly
recording labor events
b) Can predict deviation from normal progress of labor early so that appropriate steps can be taken in time
c) Facilitates handover procedure
d) ↓ incidence of prolonged labor & C-section rate
e) ↓ maternal/ perinatal morbidity & mortality
f) As evidence in medicolegal cases
g) Offers appropriate counselling for particular situations

*Contraindication of partogram usage: CPD

4. Components:
Component Frequency of Recording (hrs)

Fetal HR 0.25/ 0.50

Cervical dilatation & descent of head 4

States of membranes & color of liquor 4

Uterine contractions 0.5

Drugs & fluids

BP & pulse 4

Oxytocin conc & dose

Urine analysis (protein, acetone, volume)

Temperature 2

PART CE 02: FETAL HR

5. General:
a) Best time to listen to fetal heart is just after strongest phase of uterine contraction
b) Listen to fetal heart for 1 min with mother in lateral position (if possible)
c) Each small square represents 0.5 hrs

6. Abnormality diagnosis:
a) Rate of < 120 bpm (bradycardia) or > 160 bpm (tachycardia) may indicate fetal distress
b) Rate of ≤ 100 bpm indicates very severe fetal distress & action should be taken stat

7. Management:
 If abnormal HR is heard, examine every 15 mins (for ≥ 1 min)
immediately after a uterine contraction

If HR remains abnormal over 3 observations, action shud

be taken UNLESS delivery is very close

PART CE 03: MEMBRANES & LIQUOR

8. Observation is made at each PV exam

9. Recording state of liquor:

Symbol Interpretation

I Membranes intact

C Membranes ruptured; liquor clear

M Membranes ruptured; liquor meconium-stained

B Membranes ruptured; liquor blood-stained

A Membranes ruptured; liquor absent

ARM = artificial rupturing of membranes

10. Management:
a) If there’s thick meconium at any time/ absent liquor at time of membrane rupture, listen to the fetal heart more
frequently, as these may be signs of fetal distress
b) If membranes have been ruptured for ≥ 12 hrs, antibiotics shud be given

PART CE 04: FETAL SKULL MOLDING

11. Is an important indication of how adequately pelvis can accommodate fetal head

12. Recording molding:

 Grade Interpretation

0 Bones are separated & sutures can be felt easily

1 Bones are just touching each other

2 Bones are overlapping, but can be easily separated

3 Bones are overlapping severely (fixed overlapping)

13. Abnormality diagnosis:

1. ↑ in molding with head high in pelvis is an ominous sign of CPD

2. When molding is at stage 2, assess clinically whether it’s due to

maternal exhaustion or pelvic/ fetal factors

*Moulding may be difficult to assess in presence of a large caput, but that in itself should alert the attendant to possible
CPD

PART CE 05: LABOR PROGRESS – UTERINE CONTRACTIONS

14. General:
a) Contractions usually become more frequent & last longer as labor progresses
b) Assessed by # of contractions in 10 mins
c) Duration = time between 1st palpable contraction & passing off of contraction
 Technically, contraction frequency can only ↑ with time (hence, there’s some error in this case)

15. Recording:

Formula for recording uterine contractions:

# of contractions/ duration of contractions’/ 10 min’’

E.g. 2 – 3/ 30 – 40’/10’’

16. Management: if uterine tachysystoles (> 5 per 10 min) are present, give tocolytics to re-establish synchrony of
uterus (i.e. # of contractions ≤ 5 per 10 min)

PART CE 06: LABOR PROGRESS – CERVICAL DILATION & FETAL DESCENT

17. Recording:
Cervical Dilation Fetal Descent

# of fingers insert-able into cervix (1 finger ≈ Abdominal palpation of 5ths of head felt above
Parameters 1.5 cm) pelvic brim

Symbol for plotting X O

18. Abnomality diagnosis:
a) “Action” line is drawn 4 hours to the right & parallel to the “alert” line
b) If cervical dilation reaches “alert” line, there shud be critical assessment of cause of delay and a decision made
for appropriate management to overcome this delay
c) If progress is satisfactory, plotting of cervical dilatation will remain on/ to the left (≤) of “alert” line

PART CE 08: OTHERS

19. Method for recording BP, pulse, drugs, urine properties:

PART CE 12: MANAGEMENT OF LABOR

SUB-PART CE 12 (A): NORMAL ACTIVE PHASE
20. Do NOT augment with oxytocin/ intervene unless complications develop

21. Artificial rupture of membranes (ARM) at any time in active phase

SUB-PART CE 12 (B): BETWEEN “ACTIVE” & “ALERT” LINES
22. In health centre:
a) Mother must be transferred to hospital with facilities for C-section, unless cervix is almost fully dilated
b) ARM may be performed if membranes are still intact, & observe labor progress for a short period before transfer

23. In hospital: perform ARM if membranes are intact, & continue routine observations

SUB-PART CE 12 (C): AT/ BEYOND “ACTION” LINE

24. Full medical assessment

25. Consider IV infusion/ bladder catheterisation/ analgesia

26. Choices of action:

Action Description

Labor termination Delivery thru C-section (if fetal distress/ obstructed labor)

Labor augmentation Oxytocin augmentation by IV infusion (if no contraindications)

Supportive therapy If satisfactory progress is established, & dilatation could be anticipated at ≥ 1 cm/hr

27. Further review (in cases whereby labor is ongoing):

1. PV exam after 3 hrs initially, then in 2-hr intervals henceforth

2. If fail to make satisfactory progress, (cervical dilatation rate of < 1 cm/hr between any
of these exams) delivery is indicated

3. Fetal heart condition while on oxytocin infusion must be checked at least every 0.5 hrs
PART CE 13: FETAL DISTRESS
28. Fetus is subjected to stress even in a normal labor due to…
a) uterine contractions which temporarily ↓ uteroplacental circulation
b) head compression (affects function of vital centres of brain)

*However, a healthy fetus can withstand the stresses of labor within physiological limits

29. Common causes:

a) Fetal hypoxia/ acidosis
b) Anemia (maternal/ fetal)
c) Infection (maternal/ fetal)
d) Drugs taken by mother (e.g. LAs, pethidine, antihypertensives)

30. Immediate management (in hospital):

a) Stop oxytocin
b) Turn patient on left side
c) PV exam (to exclude cord prolapse & observe amniotic fluid)
d) Adequate hydration (to correct maternal hypotension)
e) O2 therapy
SECTION D: COMMON PREGNANCY PROBLEMS
CHAPTER DA: GDM (GESTATIONAL DM)
PART DA 01: GENERAL
1. Screening for GDM is done between 24th & 28th week of pregnancy…
a) because of peak lvls of hormones (e.g. glucagon, prolactin, progesterone)
b) for early intervention (before significant damage sets in)

2. Even earlier screening is recommended in case of…

a) h/o GDM
b) strong family history
c) bad previous obstetric outcomes
d) obesity

PART DA 02: GCT (GLUCOSE CHALLENGE TEST)

3. General properties:
a) Is a screening test
b) No fasting required

4. Execution:

Patient drinks 50g glucose in 200 mL water 2 hr post-glucose blood

Rest for 1 hr
within 5 min sample taken

5. Interpretation:
Blood Glucose (mg%) Action

> 130 (high-normal) Repeat GCT after 1 mth

> 140 Proceed with GTT

PART DA 03: GTT (GLUCOSE TOLERANCE TEST)

6. General properties:
a) Is a CONFIRMATORY test
b) Fasting required

7. Execution & interpretation:

WHO ADA (American Diabetes Association)

Glucose given (g) 75 100

*Fasting *Fasting
Blood samples *2 hrs post-glucose *1, 2 & 3 hrs post-glucose

Sample Abnormal Lvl (mg%) Sample Abnormal Lvl (mg%)

Fasting > 100 Fasting > 95
GDM diagnostic 2-hr P-G > 140 1-hr P-G > 180
lvls 2-hr P-G > 155
3-hr P-G > 140
Any 2 abnormal readings above is +ve for GDM

PART DA 04: COMPLICATIONS

8. Complications:

Maternal Fetal Neonatal

• UTI/ vaginal infections • Macrosomia/ large-for- • Need for instrumental/

• PROM, premature labor dates surgical delivery
• 2° DM (after delivery) • Delayed surfactant • Shoulder dystocia
synthesis • Hyperbilirubinemia
• Fetal polyuria • Hypoglycemia
(polyhydramnios)
• IUD

*Complications of pre-gestational DM: congenital anomalies, miscarriage

PART DA 05: MANAGEMENT
9. Control:
a) Diet control
b) Exercise
c) Metformin (≈ 2 g/day)
d) Insulin
SECTION J: INVESTIGATIONAL EQUIPMENT
CHAPTER JA: USG
PART JA 01: TYPES
1. Types:

• Done when uterus is an abdominal organ (POG > 12 wks)

TAS (Trans-
• When uterus is a pelvic organ, it is better viewed via a full
abdominal Scan) bladder

• Generally done when uterus is an pelvic organ

TVS (Trans-vaginal • Also done (in later stages in pregnancy) to determine
Scan) cervical length/ incompetence
• Is clearer than TAS

TAS (left) & TVS

PART JA 02: USG IN OBSTETRICS

2. Uses:
Trimester Scan Description Functions

1 Dating scan *Confirmation of pregnancy

(TVS); 6th – 7th wk *Dating of pregnancy [pole (or crown-rump after 7th wk) length is measured]
*# of pregnancies
*Location of pregnancy
*Abnormal (e.g.molar) pregnancies
*Cardiac activity & rate
*Retrochorionic hemorrhage
*Fibroid uterus/ ovarian tumors
 Clockwise from top left: molar pregnancy, retrochorionic hemorrhage, ovarian
tumors, fibroid uterus

Early anomaly *To detect…

scan; 12th wk a) nuchal translucency
b) presence of nasal bone & limbs
c) megacystis (when supero-inferior height of bladder > 7 mm)
d) anencephaly (absence of cranium)
e) umbilical hernia

2 Anomaly scan; *Placenta location

18th – 20th wk *Cervical length
*To detect (among others)…
a) anencephaly
b) spina bifida
 c) gastroschisis
d) cleft lip
e) talipes

Clockwise from top left: spina bifida, gastroschisis, talipes, cleft lip

3 Growth scan; 32nd *Fetal biometry (BPD, HC, AC, FL)

– 34th wk *AFI (amniotic fluid index)#
*Fetal movements (tone, breathing, limb movements)

Serial growth
scan; 36th wk
AF scan; every 10
days after 40th wk

#Interpretation:

Category Oligohydramnios Borderline oligo- Normal High normal Polyhydramnios

AFI (cm) <5 5–8 8 – 20 20 – 24 > 24

3. Functions of doppler USG:

a) To study flow pattern of major vessels
b) To determine hypoxia (arterial doppler)/ acidemia (venous doppler)

*If acidemia is diagnosed, patient must deliver stat

4. Other uses of USG:
a) Amniocentesis/ chorionic villus sampling
b) Fetal blood transfusion

PART JA 03: USG IN GYNECOLOGY

5. Indications:

1. Lower abdominal pain

2. Abdominal mass

3. Menstrual complaints

4. Sub-fertility

5. IVF

6. IUCD positioning follow-up

ABNORMAL UTERINE BLEEDING (AUB)
Is the menstrual bleeding of abnormal quantity/ duration/ schedule

Accounts for
*15 – 20% of gynecological OPD visits
*20% gynecological surgeries