Obs KS

OBG I
The chapters are according to DC Dutta’s Textbook of Obstetrics 8th Edition. Answers
have been added from an intermix of the following sources - Marrow, Textbook of
Obstetric (Sheila Balakrishnan), DC Dutta’s Textbook of Obstetrics and UpToDate.
1. Anatomy of Female Reproductive

Organs
Lower uterine segment - Definition, applied anatomy
Anatomical features
Develops from the isthmus of non-pregnant uterus
In labor, LUS boundaries
Upper → Physiological retraction ring
Lower → Fibromuscular junction of cervix and uterus
Peritoneum is loosely attached anteriorly
Size
1st trimester / Non-pregnant = 0.5 cm
Term = 5 cm
Labor = 10 cm
Wall becomes gradually thin during labor
Poor retractile property as compared to upper segment
Clinical significance
C-section : Incision is made at this segment
Placenta previa : Implantation of placenta in LUS
Poor decidual reaction : Facilitates morbid adherent placenta
Passive segment : High chances of PPH due to poor retractile property if placenta is
implanted over this area
Receptive relaxation phenomenon : Enables expulsion of fetus by formation of
complete birth canal along with fully dilated cervix
Obstructed labor : The LUS is very much stretched and thinned out, and ultimately
ruptures
2. Fundamentals of Reproduction
3. The Placenta and Fetal Membranes
Functions and clinical importance of Liquor Amnii
Functions
During pregnancy
It acts as a shock absorber, protecting the fetus from possible extraneous injury
Maintains an even temperature
The fluid distends the amniotic sac and thereby allows for growth and free
movement of the fetus and prevents adhesion between the fetal parts and amniotic
sac;
Its nutritive value is negligible because of small amount of protein and salt content;
however, water supply to the fetus is quite adequate
During labor
The amnion and chorion are combined to form a hydrostatic wedge which helps in
dilatation of the cervix;
During uterine contraction, it prevents marked interference with the placental
circulation so long as the membranes remain intact;
It guards against umbilical cord compression;
It flushes the birth canal at the end of first stage of labor and by its aseptic and
bactericidal action protects the fetus and prevents ascending infection to the uterine
cavity
Clinical Importance
Study of the amniotic fluid provides useful information about the well being and also
maturity of the fetus;
Intra-amniotic instillation of chemicals is used as method of induction of abortion;
Excess or less volume of liquor amnii is assessed by amniotic fluid index (AFI).
Maternal abdomen is divided into quadrants taking the umbilicus, symphysis pubis
and the fundus as the reference points. With ultrasound, the largest vertical pocket in
each quadrant is measured. The sum of the four measurements (cm) is the AFI. It is
measured to diagnose the clinical condition of polyhydramnios or oligohydramnios
respectively
Rupture of the membranes with drainage of liquor is a helpful method in induction
of labor
Umbilical cord: Anatomy and abnormalities.
Anatomy
Covering epithelium → It is lined by a single layer of amniotic epithelium but shows
stratification like that of fetal epidermis at term
Wharton’s Jelly → It consists of elongated cells in a gelatinous fluid formed by
mucoid degeneration of the extraembryonic mesodermal cells. It is rich in
mucopolysaccharides and has got protective function to the umbilical vessels
Blood vessels: Initially, there are four vessels — two arteries and two veins. The
arteries are derived from the internal iliac arteries of the fetus and carry the venous
blood from the fetus to the placenta. Of the two umbilical veins, the right one
disappears by the 4th month, leaving behind one vein which carries oxygenated
blood from the placenta to the fetus. Presence of a single umbilical artery is often
associated with fetal congenital abnormalities
Remnant of the umbilical vesicle (yolk sac) and vitelline duct
Allantois → A blind tubular structure may be occasionally present near the fetal end
which is continuous inside the fetus with its urachus and bladder
Obliterated extraembryonic coelom
Abnormalities
Battledore placenta → The cord is attached to the margin of the placenta. If
associated with low implantation of placenta, there is chance of cord compression in
vaginal delivery leading to fetal anoxia or even death; otherwise it has got little
significance.
Velamentous placenta → The cord is attached to the membranes. May bleed on
rupture of membranes (vasa previa)
Abnormal length →
Short cord → Less than 20 cm. May cause
Failure of external version
Prevent descent of the presenting part especially during labor
Separation of a normally situated placenta
Favor malpresentation
Fetal distress in labor
Long cord
Cord prolapse
Cord entanglement around the neck/body
Single umbilical artery
Functions of Placenta
Transfer of nutrients and waste products between the mother and fetus. In this
respect, it attributes to the following functions:
Respiratory → Intake of oxygen and output of carbon dioxide take place by simple
diffusion
Excretory → Waste products such as urea, uric acid and creatine are excreted in the
maternal blood by simple diffusion
Nutritive
Glucose → Facilitated diffusion GLUT-1
Lipids
Amino acids
Water and electrolytes
Hormones
Endocrine function: Placenta is an endocrine gland. It produces both steroid and
peptide hormones to maintain pregnancy
Hypothalamic like hormones (from syncitiotrophoblast and cytotrophoblast)
Corticotropin Releasing Hormone
Thyrotropin Releasing hormone
Gonadotropin Releasing Hormone
Growth hormone releasing hormone
Pituitary like hormones (from syncitiotrophoblast)
Adrenocorticotropic hormone
Human chorionic thyrotropin
Human chorionic gonadotropin
Human placental lactogen
Steroid hormones → Estrogens, progesterone and cortisol
Barrier function.
Immunological function.
4. The Fetus
5. Physiological Changes During
Pregnancy
Describe hematological changes of normal pregnancy. Briefly discuss
management of moderate anemia in a primigravida at 32 weeks of gestation
HEMATOLOGICAL CHANGES IN PREGNANCY
Blood volume → Increases (Max in 3rd trimester)
Plasma volume → Increases by 40-50%
RBC volume → Increases by 20-30%
Since plasma volume increase > RBC volume increase → Hemodilution → PCV
decreases
Decrease in RBC lifespan (110 days)
Hemoglobin
Total Hb mass in the body → Increases
Hb concentration → Decreases due to large increase in plasma volume
Hb can decrease up to 11 g/dL (Physiological anemia)
If less than 11 g/dL (Pathological anemia)
Leucocyte count
TLC
Normal → 6,000 - 11,000
Pregnancy → 15,000
Post-partum → 25,000
Shift from cell mediated cytotoxic immune response (Th1 cells decrease) to
humoral and innate immune response (Th2 cells increase). This shift is not seen in
PIH.
Neutrophils and T-lymphocytes increase
B- lymphocytes and CD4:CD8 ratio remain constant
Eosinophils decrease
Platelets
Decreases but within normal limits (Benign gestational thrombocytopenia)
Occurs due to hemodilution and splenomegaly
Plasma proteins
Total plasma protein mass → increases
Plasma protein concentration → decreases
Globulin → increases (due to estrogen)
Albumin → decreases
A:G ratio → 1:1 (Normal 1.7:1)
Inflammatory markers → All increase - CRP, ESR, Leukocyte ALP, C3, C4
Cytokines
Increase → IL-4, IL-10, IL-13
Decrease → IL-2, TNF, IF-alpha
Clotting factors →
All increase except XI and XIII.
Bleeding time and clotting time remains unchanged
MANAGEMENT OF MODERATE ANEMIA IN PRIMIGRAVIDA AT 32 WEEKS OF
GESTATION
Moderate Anemia → Hb 7-9.9 g/dL
Investigations
To ascertain
degree of anemia → Hemoglobin, RBC count, PCV
type of anemia
peripheral blood smear
Microcytic anemia (SITA) → Sideroblastic anemia, IDA, Thalassemia, Anemia of
chronic disease
Macrocytic anemia → B12 deficiency, Folate deficiency, Anemia of liver disease,
Thyrotoxicosis
hematological indices →
MCHC → Most sensitive RBC index for IDA (Normal : 34-37%)
MCV → Reduced in IDA. Increased in megaloblastic anemia.
cause of anemia
Iron deficiency anemia →
Parameter Normal IDA
Serum ferritin 20-200 mcg/dL < 10 mcg/dL
Serum iron < 40 mcg/dL
TIBC 325-400 mcg/dL > 410 mcg/dL
Transferrin saturation 25-50% < 10%
Serum hepcidin levels decrease in iron deficiency anemia but increase in anemia of
chronic disease
Megaloblastic anemia → B12, Folate levels
Hemoglobinopathies → Hb electrophoresis
stool examination → to look for parasitological infections
Management
Iron deficiency anemia
Expected increase in Hb → Occurs after 3 weeks of starting oral/parenteral therapy at
the rate of 0.7 g/dL per week. For practical purposes the Hb should have risen by
1g/dL at the end of one month of starting iron therapy
Oral iron preparations → Ferrous sulphate, Ferrous fumarate, Ferrous gluconate
Parenteral iron preparation → Iron sucrose, Ferric carboxymaltose
Iron sucrose 2 vials (200 mg) is infused with 100 mL normal saline (2 mg/mL)
Max 200 mg per day and 600 mg per week
Megaloblastic anemia → Vitamin B12 or Folate therapy
Parasitic infections → Deworming using Albendazole
Hematological changes in pregnancy (x4)
Blood volume → Increases (Max in 3rd trimester)
Plama volume → Increases by 40-50%
RBC volume → Increases by 20-30%
Since plasma volume increase > RBC volume increase → Hemodilution → PCV
decreases
Decrease in RBC lifespan (110 days)
Hemoglobin
Total Hb mass in the body → Increases
Hb concentration → Decreases due to large increase in plasma volume
Hb can decrease upto 11 g/dL (Physiological anemia)
If less than 11 g/dL (Pathological anemia)
Leucocyte count
TLC
Normal → 6,000 - 11,000
Pregnancy → 15,000
Post-partum → 25,000
Shift from cell mediated cytotoxic immune response (Th1 cells decrease) to
humoral and innate immune response (Th2 cells increase). This shift is not seen in
PIH.
Neutrophils and T-lymphocytes increase
B- lymphocytes and CD4:CD8 ratio remain constant
Eosinophils decrease
Platelets
Decreases but within normal limits (Benign gestational thrombocytopenia)
Occurs due to hemodilution and splenomegaly
Plasma proteins
Total plasma protein mass → increases
Plasma protein concentration → decreases
Globulin → increases (due to estrogen)
Albumin → decreases
A:G ratio → 1:1 (Normal 1.7:1)
Inflammatory markers → All increase - CRP, ESR, Leukocyte ALP, C3, C4
Cytokines →
Increase → IL-4, IL-10, IL-13
Decrease → IL-2, TNF, IF-alpha
Clotting factors →
All increase except XI and XIII.
Bleeding time and clotting time remains unchanged
Cardiovascular changes in normal pregnancy (x2)
Anatomical changes →
Enlarged uterus → Diaphragm pushed upwards → the heart is pushed upward and
outward with slight rotation to left.
May lead to palpitations
The apex beat is shifted to the 4th intercostal space about 2.5 cm outside the
midclavicular line.
Cardiac output →
Starts to increase from 5th week of pregnancy
Reaches its peak 40–50% at about 30–34 weeks.
Thereafter the CO remains static till term when the observation is made at lateral
recumbent position.
Cardiac output increases further during labor (+50%) and immediately following
delivery (+70%) over the pre-labor values
Blood Pressure →
Systemic vascular resistance (SVR) decreases (–21%) due to smooth muscle relaxing
effect of progesterone, NO, prostaglandins or ANP.
The maternal BP (BP = CO × SVR) is decreased due to decrease in SVR.
There is overall decrease in diastolic blood pressure (BP) and mean arterial pressure
(MAP) by 5–10 mm Hg
Venous Pressure → Femoral venous pressure is markedly raised especially in the later
months. It is due to pressure exerted by the gravid uterus on the common iliac veins,
more on the right side due to dextrorotation of the uterus.
Renal changes in pregnancy.
There is dilatation of the ureters, renal pelvis and the calyces.
The kidneys enlarge in length by 1 cm.
B/L hydroureter occurs, more of right side due to dextrorotation of uterus
Intravesical pressure increases and to maintain continence intraurethral pressure
increases
Renal plasma flow is increased by 50–75%, maximum by the 16 weeks and is
maintained until 34 weeks. Thereafter it falls by 25%.
Glomerular filtration rate (GFR) is increased by 50% all throughout pregnancy.
Increased GFR causes reduction in maternal plasma levels of creatinine, blood urea
nitrogen (BUN) and uric acid.
Renal tubules fail to reabsorb glucose, uric acid, amino acids and water soluble
vitamins completely
6. Endocrinology in Relation to
Reproduction
7. Diagnosis of Pregnancy
What are the clinical features of pregnancy in first trimester? Mention the most
informative test to diagnose pregnancy and list its advantages. Write the
prescription and advice // Diagnosis of pregnancy in first trimester
Clinical feature of pregnancy in the first trimester
Subjective Signs
Amenorrhea
Morning sickness → Appears soon after a missed period and rarely lasts beyond 16
weeks
Frequency of micturition → It occurs during the 8th to 12th week of pregnancy. It is
due to resting of the bulky uterus on the fundus of the bladder because of
exaggerated anteverted position of the uterus.
Breast discomfort → Feeling of fullness and prickling sensation is evident as early as
6th to 8th week especially in primigravidae
Fatigue
Objective signs
Breast changes → Valuable only in primigravidae. The nipple and areola become
more pigmented. Montgomery tubercles are prominent.
Per abdomen → Uterus remains a pelvic organ until 12th weeks, it may be just
palpable per abdomen as a suprapubic bulge
Pelvic changes
Chadwick’s/Jacquemier sign → Dusky hue of the vestibule and anterior vaginal wall
visible at about 8th week of pregnancy.
Piskacek’s Sign → Asymmetric enlargement of the uterus due to eccentric
implantation
Vaginal sign → The walls become softened. Copious non-irritating mucoid discharge
appears at around 6th week. there is increased pulsation felt around the lateral
fornices at 8th week called Osiander’s sign
Cervical signs → Cervix becomes soft as early as 6th week (Goodell’s sign)
Hegar’s sign → Bimanual palpation of uterus at 6-10 weeks
Palmer’s sign → Regular and rhythmic uterine contraction during bimanual
examination as early as 4-8 weeks
Uterine signs → The uterus is enlarged to the size of hen’s egg at 6th week, cricket
ball at 8th week and size of fetal head by 12 week.
The most important test to diagnose pregnancy is Ultrasonography.
Intra-decidual gestation sac is identified as early as 29 to 35 days of gestation
Fetal viability and gestation age is determined by
Gestation sac and yolk sac by 5 menstrual weeks
Fetal pole and cardiac activity by 6 weeks
Embryonic movement by 7 weeks
Fetal gestational age is best determined by measuring the CRL between 7 to 12
weeks
Doppler effect can pick up the heart rate reliably by 10th week
8. The Fetus-in-Utero
Define following terms LIE, PRESENTATION, ATTITUDE AND PRESENTING PART
LIE: The lie refers to the relationship of the long axis of the fetus to the long axis of
the centralized uterus or maternal spine, the most common lie being longitudinal
(99.5%).
PRESENTATION: The part of the fetus which occupies the lower pole of the uterus
(pelvic brim) is called the presentation of the fetus. Accordingly, the presentation
may be cephalic (96.5%), podalic (3%) or shoulder and other (0.5%).
PRESENTING PART: The presenting part is defined as the part of the presentation
which overlies the internal os and is felt by the examining finger through the cervical
opening. Thus, in cephalic presentation, the presenting part may be vertex (most
common), brow or face, depending upon the degree of flexion of the head
ATTITUDE: The relation of the different parts of the fetus to one another is called
attitude of the fetus. The universal attitude is that of flexion
9. Fetal Skull and Maternal Pelvis

Diameters of fetal skull.
Anteroposterior diameters
Suboccipitobregmatic → Extends from the nape of the neck to the center of bregma
Suboccipitofrontal → Extends from the nape of the neck to the anterior end of the
anterior fontanel
Occipitofrontal → Extends from the occipital eminence to the root of the nose
Mento-vertical → Extends from the midpoint of the chin to the highest point on the
sagittal suture
Submentobregmatic → Extends from junction of floor of mouth and neck to the
center of bregma
Submentovertical → Extends from the junction of floor of mouth and neck to the
highest point on sagittal suture
Transverse diameters
Biparietal diameter—9.5 cm (3 ¾"): It extends between two parietal eminences.
Whatever may be the position of the head, this diameter nearly always engages
Super-subparietal—8.5 cm (3 ½"): It extends from a point placed below one parietal
eminence to a point placed above the other parietal eminence of the opposite side.
Bitemporal diameter—8 cm (3 ¼"): It is the distance between the anteroinferior ends
of the coronal suture
Bimastoid diameter— 7.5 cm (3"): It is the distance between the tips of the mastoid
processes.
Pelvic inlet
Circumference of the inlet → The bony landmarks on the brim of the pelvis from
anterior to posterior on each side are—upper border of symphysis pubis, pubic crest,
pubic tubercle, pectineal line, iliopubic eminence, iliopectineal line, sacroiliac
articulation, anterior border of the ala of sacrum and sacral promontory
Shape → It is almost round (gynecoid) with the anteroposterior diameter being the
shortest
Plane → It is an imaginary flat surface bounded by the bony points mentioned as
those of the brim. It is not strictly a mathematical plane and is, therefore, often
referred to as superior strait.
Inclination → In the erect posture, the pelvis is tilted forward. As such, the plane of
the inlet makes an angle of about 55° with the horizontal and is called angle of
inclination.
Sacral angle → It is the angle formed by the true conjugate with the first two pieces
of the sacrum. Normally, it is greater than 90°. A sacral angle of lesser degree
suggests funnelling of the pelvis.
Axis: It is a mid-perpendicular line drawn to the plane of the inlet (Fig. 9.17). Its
direction is downward and backward
Diameters
True conjugate (Anteroposterior) → It is the distance between the midpoint of the
sacral promontory to the inner margin of the upper border of symphysis pubis
Obstetric conjugate → It is the distance between the midpoint of the sacral
promontory to prominent bony projection in the midline on the inner surface of the
symphysis pubis
Diagonal conjugate → It is the distance between the lower border of symphysis pubis
to the midpoint on the sacral promontory.
Transverse diameter → It is the distance between the two farthest points on the
pelvic brim over the iliopectineal lines.
Oblique diameter → It extends from one sacroiliac joint to the opposite iliopubic
eminence.
Moulding
It is the alteration of the shape of the fore-coming head while passing through the
resistant birth passage during labor. There is, however, very little alteration in size of
the head, as volume of the content inside the skull is incompressible although small
amount of cerebrospinal fluid and blood escape out in the process. During normal
delivery, an alteration of 4 mm in skull diameter commonly occurs.
Mechanism → There is compression of the engaging diameter of the head with
corresponding elongation of the diameter at right angle to it. Thus, in well flexed
head of the anterior vertex presentation, the engaging suboccipitobregmatic
diameter is compressed with elongation of the head in mento-vertical diameter
which is at right angle to suboccipitobregmatic
Grading: There are three gradings.
Grade-1 — the bones touching but not overlapping
Grade-2 — overlapping but easily separated
Grade-3 — fixed overlapping.
Importance
Slight molding is inevitable and beneficial. It enables the head to pass more easily,
through the birth canal.
Extreme molding as met in disproportion may produce severe intracranial
disturbance in the form of tearing of tentorium cerebelli or subdural hemorrhage.
10. Antenatal Care, Preconception

Counseling and Care
Define antenatal care. What are its objectives? Discuss details of antenatal care
when a primigravida presents to hospital at 8 weeks of gestation. Write a note
on aneuploidy and neural tube defect screening at this visit
ANTENATAL CARE
Systematic supervision (examination and advice) of a woman during pregnancy is
called antenatal (prenatal) care.
Objectives -
To assess the health status of mother and fetus
To assess the fetal gestational age and to obtain baseline investigations
To organize continued obstetric care and risk assessment
ANTENATAL CARE AT 8 WEEKS OF GESTATION
History Taking
Demographics
Name, Date of first examination, Address
Age → Extremes of age are obstetric risk factors
Obstetric history (here primigravida)
Religion
Occupation
Husband’s occupation, Married for how many years
History of present pregnancy
Period of gestation →
Ask about the first day of last menstrual period
Ask whether menstrual cycles were regular or not
Ask about any contraceptive use
Mode of conception - Natural or Assisted
Ask whether urine pregnancy test was done at home
Any symptoms → Fatigue, nausea, vomiting, breast tenderness, urinary frequency
Past history
Any underlying chronic medical conditions
Any past medical history → UTIs, TB
Any past surgical history
Family history → Family history of hypertension, diabetes, TB, bleeding disorders
Personal history → Smoking, alcohol, sleep, diet, bowel and bladder habits
Examination
General Physical Examination →
Build and nutrition
Height → Short stature is likely to be associated with short pelvis
Weight
Pallor, Jaundice
Thyroid examination
Pedal edema → Physiological, pre-eclampsia, anemia and hypoproteinemia, cardiac
failure, nephrotic syndrome
Vitals → Pulse, BP, RR, Temperature
Examination of breasts
Obstetric examination
Abdomen → Tone of abdominal muscles, any previous scards or presence of
herniation, Fundus of uterus is just palpable above the symphysis at 12 weeks of
gestation
Vaginal examination
Speculum examination
No attempt should be made for pelvic assessment at this stage
Signs
Jacquemier’s sign / Chadwick’s sign → Dusky hue of the vestibule and anterior
vaginal wall visible at about 8th week of pregnancy
Osiander’s sign → Increased pulsation, felt through the lateral fornices at 8th week
Goodell’s sign → Cervix becomes soft as early as 6th week
Hegar’s sign → Bimanual palpation of uterus at 6-10 weeks
Palmer’s sign → Regular and rhythmic uterine contraction during bimanual
examination as early as 4-8 weeks
Investigations
Blood →
Hb and Hct
ABO grouping, Rh grouping
Test for syphilis (VDRL, RPR), HBsAg, HIV testing (opt out testing), Rubella
susceptibility screening
Urine → Protein, sugars and pus cells
USG → First trimester scan helps to detect
Early pregnancy
Accurate dating
Number of fetuses
Uterine or adnexal pathologies
Gross fetal anomalies
ANEUPLOIDY AND NEURAL TUBE DEFECT SCREENING
Screening parameters are
Biophysical → USG measurement of nuchal translucency (NT), nasal bone
Biochemical → Free beta-HCG, PAPP-A
Time of test → Between 11 to 14 weeks
NT > 3 mm is abnormal
Combined tests (Dual Scan) can detect trisomy 21 in 92% cases with a false-positive
rate of 5%
A 22 years primigravida comes to antenatal clinic at 8 weeks of gestation.
Mention four routine antenatal screening tests done for infections. Briefly
discuss management of any three of them.
Four routine antenatal screening tests for infections
Syphilis (VDRL, RPR)
Confirmation by FTA-ABS (Fluorescent treponemal antibody absorption test) and
MHA-TP (Treponema pallidum micro hemagglutination) test which are specific
Treatment
Mother
Treatment started as soon as the diagnosis is established
For primary or secondary or latent syphilis (< 1 year duration) → Benzathine penicillin
2.4 million units IM single dose
When duration is more than 1 year → Benzathine penicillin 2.4 million units IM
weekly for 3 doses
If allergic to penicillin → Oral Azithromycin 2 g single dose
Tertiary disease → Neurosyphilis - Aqueous crystalline penicillin G 18-24 million units
IV daily for 10-14 days is given.
Baby born to mother with syphilis
Serological Clinical evidence of Management
Reaction disease
+ None Penicillin G 50,000 units IM single dose
+ Present Aqueous procaine penicillin G 50,000 units per kg body weight
each day for 10 days
- Absent Serological reaction should be tested weekly for the first month
and then monthly for 6 months
HIV
Antepartum care
In seropositive cases the following additional tests need to be done
Test for other STDs → hepatitis B and C, syphilis, chlamydia, herpes and rubella
Testing for TB
Serological testing for CMV and toxoplasmosis
Fungal opportunistic infections
Husband should be offered serological testing for HIV
Counselling with education
Assessment of progression of disease → CD4 counts, HIV RNA
HAART →
For newly diagnose case of HIV in a pregnant female start ART immediately without
any delay irrespective of gestational age, CD4 count, WHO clinical staging.
Recommended first line regimen
HIV-1 infection → Tenofovir (300 mg) + Lamivudine (300 mg) + Efavirenz (600 mg)
once daily. If there is previous exposure to efavirenz in any previous pregnancies
replace it with Lopinavir/ritonavir (400mg/100mg) twice daily.
HIV-2 infection or HIV-1 and HIV-2 coinfection → Tenofovir (300 mg) + Lamivudine
(300 mg) + Lopinavir/ritonavir (800mg/200mg) once daily.
Cotrimoxazole Prophylaxis
Against Pneumocystis jiroveci pneumonia, toxoplasmosis and other infections
Criteria → CD4 counts < 350 cells/cu.mm., WHO clinical stage 3 and 4
Regimen → 1 double strength tablet of cotrimoxazole (800 mg/160 mg) OD
Intrapartum care
Always opt for vaginal delivery irrespective of CD4 counts/viral loads unless obstetric
indication for C-section is present.
ART can reduce the risk of parent-to-child transmission better and with lesser risk
than C-section
Prevention of parent-to-child transmission during labor and delivery
Minimize vaginal examinations
Avoid prolonged labor, consider oxytocin to shorten labor
Avoid artificial ROM
Early cord clamping (<1 min) after it stops pulsating and after giving the mother
oxytocin
Use non-invasive fetal monitoring
Avoid routine episiotomy
Minimize the use of forceps and ventouse
Postpartum care
Breastfeeding not contraindicated in HIV positive females
Do not give mixed feeds (either exclusive breast feeding or exclusive supplementary
feeding)
Prophylaxis should be given for 6 weeks to all newborns born to HIV positive
mothers irrespective of breastfeeding or supplementary feeding decision
HIV-1 → Nevirapine prophylaxis
HIV-2 → Zidovudine prophylaxis
Duration of prophylaxis is to be increased to 12 weeks if mother decides to
breastfeed and ART is started to mother in later pregnancy, during or after delivery
or has not been on ART for an adequate period of 4 weeks to be effective for optimal
viral suppression.
Women should continue ART lifelong
HBsAg
CDC recommends that all pregnant females with HBeAg positve and viral load >
106−108106−108 copies/ml, must be given tenofovir to prevent transmission
All infants born to HBsAg positive mothers should have HBIG 0.5 mL IM within 12
hours of birth.
Active immunization with HB vaccine (0.5 mL) is also given IM at a separate site.
Repeated at 1 and 6 months
HBsAg and Anti-HBs testing at 9 months and 18 months to confirm immunity
Maternal HBV infection is not a contraindication to breast feeding or vaginal delivery.
Rubella susceptibility screening
Immunization in pregnancy (x2)
Live virus vaccines (MMR, Yellow Fever, Varicella) are contraindicated in pregnancy.
Rabies, Hepatitis A and B vaccines, toxoids can be given as in non-pregnant state
Immunization against tetanus protects not only mothers but neonates as well.
In unprotected women, 0.5 mL tetanus toxoid is given intramuscularly at 6 weeks
interval for 2 such, the first one to be given between 16-24 weeks
Women who are immunized in the past, a booster dose of 0.5 mL IM is given in the
last trimester
Excellent dating of a pregnancy: definition and significance
11. Antenatal Assessment of Fetal Well-

Being
Fetal wellbeing tests
Clinical →
Maternal weight gain
BP
Assessment of size of the uterus and height of fundus
Clinical assessment of liquor
Biochemical → Mainly done for assessment of pulmonary maturity
Biophysical → Useful for screening for uteroplacental insufficiency. The following
tests are used
Fetal movement count
USG
Cardiotocography
NST
Fetal biophysical profile
Doppler ultrasound
Vibroacoustic stimulation test
Contraction stress test
Amniotic fluid volume
Criteria for reactive NST (Non Stress Test)
In non-stress test, a continuous electronic monitoring of the fetal heart rate along
with recording of fetal movements (cardiotocography) is undertaken. There is an
observed association of FHR acceleration with fetal movements, which when present,
indicates a healthy fetus. It can reliably be used as a screening test.
Criteria: When two or more accelerations of more than 15 beats per minute above
the baseline and longer than 15 second duration are present in a 20-minute
observation window
Biophysical profile (x2)
Modified biophysical profile → NST + USG determined AFI
NST indicates acute distress in fetus whereas AFI indicates chronic distress
Modified BPP is considered abnormal if NST is non-reactive and/or AFI < 5.
A NST is said to be non-reactive is <2 accelerations in 40 minute window.
Abnormal BPP is associated with high risks of stillbirth and perinatal mortality
12. Prenatal Genetic Counseling,

Screening and Diagnosis
Screening for Down syndrome in first trimester // First trimester screening for genetic
and structural anomalies
Biochemical → Free beta-HCG, PAPP-A
Combined tests (Dual Scan) can detect trisomy 21 in 92% cases with a false-positive
rate of 5%
Once a woman is screen positive, diagnostic tests should be done early.
A targeted ultrasound examination during the second trimester and fetal
echocardiography are to be done when NT is ≥ 3 mm
Screening methods for trisomy 21
First trimester screening
Biochemical → Free beta-HCG, PAPP-A (Dual Marker Test)
Combined tests can detect trisomy 21 in 92% cases with a false-positive rate of 5%
Once a woman is screen positive, diagnostic tests should be done early.
A targeted ultrasound examination during the second trimester and fetal
echocardiography are to be done when NT is ≥ 3 mm
Second trimester screening
MSAFP (Maternal Serum Alpha Fetoprotein) → Low levels found in trisomies (Down’s
syndrome)
Triple test → It is combined biochemical test which includes MSAFP, hCG and uE3
(unconjugated estriol). In affected pregnancy levels of MSAFP and uE3 tend to be
low, while that of hCG is high.
Quadruple screening → It includes MSFP, uE3, hCG and dimeric inhibin A. In affected
pregnancy levels of MSAFP and uE3 tend to be low while that of hCG and inhibin A
are elevated.
13. Normal Labor

Difference between true and false labor pains
True labor pains
Painful uterine contractions at regular intervals,
Frequency, intensity and duration of contractions increase gradually
Associated with ‘show’,
Progressive effacement and dilatation of the cervix,
Descent of the presenting part,
Formation of the ‘bag of forewaters’
Not relieved by enema or sedatives
False labor pains
Dull in nature,
Confined to lower abdomen and groin,
May be associated with hardening of the uterus,
They have no other features of true labor pain as discussed above, and
Usually relieved by analgesic
Mechanism of labor
The series of movements that occur on the head in the process of adaptation during
its journey through the pelvis is called mechanism of labor.
In normal labor, the head enters the brim more commonly through the available
transverse diameter (70%) and to a lesser extent through one of the oblique
diameters.
Accordingly, the position is either occipitotransverse or oblique occipitoanterior. Left
occipitoanterior is little more common than right occipitoanterior as the left oblique
diameter is encroached by the rectum.
Engaging diameters
Anteroposterior →
Complete flexion → suboccipitobregmatic 9.5 cm
Slight deflexion → the suboccipitofrontal 10 cm
Transverse diameter → biparietal 9.5 cm.
As the left occipitotransverse position is the most common, the mechanism of labor
in such position will be described.
The principal movements are:
Engagement → Engagement occurs when the largest transverse diameter of the
presenting part has passed through the pelvic inlet or crossed the pelvic brim.
Engagement confirms there is no cephalopelvic disproportion at the pelvic brim.
Time for engagement →
Primigravida → 38 weeks
Multigravida → Onset of labor
Clinically engagement may be ascertained by
Per abdomen examination →
Crichton’s method → 2/5th or less palpable
Leopold 3 → Non-ballotable head
Leopold 4 → Diverging fingers
Per vaginal examination
Station → Refers to the position of fetal head with respect to ischial spine in cm. e.g.
if station is -3 head is 3 cm above ischial spine
Engaged head → Station is 0 or below it
Syncilitic vs Asyncilitic engagement
Syncilitic engagement → Sagittal suture of the head of fetus lies in transverse
diameter of pelvis. It is equidistant between pelvic symphysis and sacral promontory
Asynclitic engagement
Anterior asynclitism → Sagittal suture deflected towards sacral promontory
(Naegele’s obliquity). Anterior paritetal bone felt first on per vaginal examination.
This is most commonly seen in multiparous females.
Posterior asynclitism → Sagittal suture is deflected towards the pubic symphysis
(Litzmann’s obliquity). Posterior parietal bone is felt first on per vaginal examination.
This is seen in primigravida.
Descent → Provided there is no undue bony or soft tissue obstruction, descent is a

continuous process.
It is slow/insignificant in first stage but pronounced in second stage. It is completed
with expulsion of fetus.
Factors facilitating descent are
uterine contraction and retraction
bearing down efforts
straightening of the fetal ovoid especially after rupture of membranes
Flexion → Some degree of flexion exists at the beginning of labor. Complete flexion
is achieved when the head meets the resistance of the birth canal during descent.
Flexion is explained by the two arm lever theory with the fulcrum being
occipitoallantoid joint. The short arm of the lever extends from the condyles to the
occipital protrubrence, the long arm extends from condyles to the chin.
Internal rotation
Occurs in the anterior direction at the level of ischial spines.
Hart’s rule → Part touching the muscle will move in the direction of muscle fibres.
Occiput touches pelvic floor → Elastic recoil → Occiput rotates anteriorly → Lies
behind the pubic symphysis. Occiput rotates by 2/8 and reaches the direct occipito
anterior position.
Shoulders rotate by 1/8 in the same direction (1/8 torsion on the neck remains) and
lie in the left oblique diameter
Crowning → Head of the baby stretches the perineum and is permanently visible at
the perineum. Episiotomy is given at this time
Extension → Head of baby delivered by movement of extension with further descent.
Occiput → Vertex → Brow → Face
Restitution → It is visible passive movement of the head due to untwisting of the
neck sustained during internal rotation. Occurs due to 1/8 rotation of head in the
direction opposite to that of internal rotation.
External Rotation → It is the movement of rotation of the head visible externally due
to internal rotation of the shoulders. Occurs in the same direction as restitution. The
shoulders are now positioned along the AP diameter and the occiput points
directly towards the maternal thigh (left occiptotransverse) corresponding to the
side to which it originally directed at the time of engagement.
Expulsion → Anterior shoulder escapes below the pubic symphysis by further
descent. By a movement of lateral flexion of the spine, the posterior shoulder sweeps
over the perineum. Rest of the trunk is then expelled out by lateral flexion.
What are the signs and mechanisms of placental separation during normal
labor? Discuss active management of third stage of labor. // Active management
of third stage of labor (x3)
Signs
Per abdomen
Uterus becomes globular, firm and ballotable
The fundal height is slightly raised
Slightly bulging in the suprapubic region
Per vaginum
Slight gush of vaginal bleeding
Permanent lengthening of the cord is established
Mechanisms
Central separation (Schultze) →
Detachment starts at the center of placenta
Retroplacental clot formation
Less bleeding
Fetal side comes out first
More common method
Marginal separation (Mathews-Duncan) →
Detachment starts at the margins of placenta
No retroplacental clot formation
More bleeding
Maternal side comes out first
Less common
Active Management of Third Stage of Labor
The underlying principle in the active management is to excite powerful uterine
contractions within one minute of delivery of the baby by giving parenteral oxytocic.
This facilitates not only the early separation of placenta but also produces effective
uterine contractions following the separation.
The advantages are -
To minimize blood loss in the third stage to approximately 1/5
To shorten the duration of third stage to half
Disadvantage → The only disadvantage is slightly increased incidence of retained
placenta (1-2%) and consequently increased incidence of manual removal.
Procedure → Injection oxytocin 10 units IM (preferred) or methergine 0.2 mg IM is
given within 1 minute of the delivery of baby. The placenta is expected to be
delivered soon following delivery of the baby. If the placenta is not delivered
thereafter, it should be delivered forthwith by controlled cord traction (Brandt-
Andrews) technique after clamping the cord while the uterus still remains contracted.
If the first attempt fails, another attempt is made after 2–3 minutes failing which
another attempt is made at 10 minutes. If this still fails, manual removal is to be done
Normal labor- Criteria and stages of labor with duration // Stages of labor: duration
and events
Criteria →
Spontaneous in onset and at term
With vertex presentation
Without undue prolongation
Natural termination with minimal aids
Without having any complications affecting the health of the mother and/or the
baby
Stages of labor
First stage → The first stage is chiefly concerned with the preparation of birth canal
so as to facilitate the expulsion of fetus in second stage. Its duration is 12 hrs. in
primigravida and 6 hours in multiparae. The main events that occur in the first stage
are -
dilatation and effacement of cervix
full formation of lower uterine segment
Second Stage → The second stage begins with the complete dilatation of the cervix
and ends with the expulsion of the fetus. Its duration is two hours in primigravidae
and 30 mins in multiparae.
Third stage → The third stage of labor comprises the phase of placental separation;
its descent to the lower segment and finally its expulsion with the membranes. Its
average duration is about 15 minutes in both primigravidae and multiparae.
Fourth stage → It is the stage of observation for at least one hour after expulsion of
afterbirths. During this period maternal vitals, uterine retraction and any vaginal
bleeding are monitored.
What are the stages of labor? How do you diagnose obstructed labor? What are
the maternal complications of obstructed labor?
Stages of labor
First stage → The first stage is chiefly concerned with the preparation of birth canal
so as to facilitate the expulsion of fetus in second stage. It begins with the onset of
true labor pain and completes with full dilatation of cervix. The main events that
occur in the first stage are -
dilatation and effacement of cervix
full formation of lower uterine segment
Second Stage → The second stage begins with the complete dilatation of the cervix
and ends with the expulsion of the fetus
Third stage → The third stage of labor comprises the phase of placental separation;
its descent to the lower segment and finally its expulsion with the membranes.
Fourth stage → It is the stage of observation for at least one hour after expulsion of
afterbirths. During this period maternal vitals, uterine retraction and any vaginal
bleeding are monitored.
Obstructed labor
Clinical feature →
Patient is in agony from the continuous pain and discomfort and becomes restless
Features of exhaustion and ketoacidosis are evident
Abdominal palpation reveals
Upper segment is hard and tender
Lower segment is distended and tender
Retraction ring is felt as a groove placed obliquely
Round ligament is taut and tender
Fetal parts are not easily felt
FHS is usually absent
Maternal complications
Immediate
Exhaustion
Dehydration
Metabolic acidosis
Genital sepsis
Injury to the genital tract including rupture of the uterus
Post partum hemorrhage and shock
Remote
Genitourinary fistula or rectovaginal fistula
Variable degree of vaginal atresia
Secondary amenorrhea following hysterectomy due to rupture or due to Sheehan’s
syndrome
14. Normal Puerperium

Lochia types, clinical significance.
Types
Lochia rubra → Consists of blood, shreds of fetal membranes and decidua, vernix
caseosa, lanugo and meconium
Lochia serosa → It consists of less RBCs but more leukocytes, wound exudate, mucus
from the cervix and microorganisms. The presence of bacteria is not pathognomic
unless associated with clinical signs of sepsis.
Lochia alba → It contains plenty of decidual cells, leukocytes, mucus, cholestrin
crystals, fatty and granular epithelial cells and microorganisms
Clinical importance
The character of lochial discharge gives useful information about the abnormal
puerperal state. The vulval pads are to be inspected daily to get information of:
Amount → Scanty or absent signifies infection or lochiometra, If excessive indicates
infection (Normal for first 5-6 days = 250 mL)
Odor → if malodorous indicates infection
Color → Persistence of red color beyond the normal limit signifies subinvolution or
retained bits of conceptus.
Duration → Duration of the lochia alba beyond 3 weeks suggests local genital lesion
Discuss physiology of Lactation along with a diagram. Write names of 2 two
drugs for suppression of lactation along with their dosage. List four drugs
which are contraindicated during lactation // Physiology of lactation (x2)
The physiological basis of lactation is divided into four phases:
Preparation of breasts (mammogenesis) → Pregnancy is associated with remarkable
growth of both ductal and lobuloalveolar systems
Synthesis and secretion from the breast alveoli (lactogenesis) →
Site of milk production → alveolar cells
Although some secretory activity is evident (colostrum) during pregnancy and
accelerated following delivery, milk secretion actually starts on 3rd or 4th postpartum
day.
Around this time, the breasts become engorged, tense, tender and feel warm.
Inspite of a high prolactin level during pregnancy, milk secretion is kept suppressed
due to the effect of steroids — estrogen and progesterone, circulating during
pregnancy make the breast tissues unresponsive to prolactin.
When the estrogen and progesterone are withdrawn following delivery, prolactin
begins its milk secretory activity
Ejection of milk (galactokinesis) →
Oxytocin is the major galactokinetic hormone.
Discharge of milk from the mammary glands depends on
suction exerted by the baby during suckling
contractile mechanism which expresses the milk from the alveoli into the ducts.
Nipple and areola → Ascending impulses → Sensory T4, T5, T6 (afferent arc) →
paraventricular and supraoptic nuclei of the hypothalamus → synthesis and transport
of oxytocin to the posterior pituitary → Secretion of oxytocin into the blood (efferent
arc) → Contraction of myoepithelial cells of the alveoli and the ducts containing the
milk → Milk forced into ampulla of lactiferous duct (Milk ejection or Milk let down
reflex) → expressed by the mother or sucked out by the baby
Maintenance of lactation (galactopoiesis) → Prolactin appears to be the single most
important galactopoietic hormone. For maintenance of effective and continuous
lactation, frequency of suckling (>8/24 hours) is essential
Two drugs for suppression of lactation are → Cabergoline single dose 1mg,
Bromocriptine
Dugs contraindicated in lactation are → Lithium, oral retinoids, amiodarone, anti-
cancer drugs
Suppression of lactation
It may be needed for women who cannot breastfeed for personal or medical reasons.
Lactation is suppressed when the baby is born dead or dies in the neonatal period or
if breastfeeding is contraindicated.
Methods commonly used are:
To stop breastfeeding
to avoid pumping or milk expression
to wear breast support,
ice packs to prevent engorgement,
analgesics (aspirin) to relieve pain and
a tight compression bandage is applied for 2–3 days.
The natural inhibition of prolactin secretion will result in breast involution.
Medical methods of suppression → Dopaminergic drugs are given.
Cabergoline
Bromocriptine
Pyridoxine
High dose of estrogen → not recommended as it can lead to DVT
Care of Puerperium
Principles of management are -
To restore health of mother
To prevent infection
To take care of the breasts, including promotion of breastfeeding
To motivate the mother for contraception
Immediate attention → Immediately following delivery, the patient should be closely
observed. She should be given something to drink or eat if she is hungry. Emotional
support is essential.
Rest and Ambulance → Early ambulation is encouraged.
Hospital stay → Most women are discharged fit and healthy after two days of
spontaneous vaginal delivery with proper education and instructions.
Diet → The patient should be on a normal diet of her choice. If the patient is
lactating, high calories, adequate protein, fat, plenty of fluids, minerals and vitamins
are to be given.
Care of the bladder → The patients is encouraged to pass urine following delivery as
soon as convenient. At times the patient fails to pass urine due to unaccustomed
position and reflex pain from perineal injuries. If the patient still fails to pass urine,
catheterization needs to be one.
Care of the bowel → The problem of constipation is much less because of early
ambulation and liberalization of dietary intake.
Sleep → For both physical and mental rest.
Care of the vulva and episiotomy wound → The patient should look after personal
cleanliness of the vulval region. The perineal wound should be dressed with spirit and
antiseptic powder after each act of micturition and defecation or at least twice a day.
Care of the breasts → The nipple should be kept clean and dry after feeding is over.
Nipple soreness is avoided by frequent short feedings rather than prolonged feeding.
Rooming in → It starts from first few moments after birth. This is manifested as
bonding, kissing, cuddling and gazing at the infant. The baby should be kept in
mother’s bed or a cot beside her bed.
Immunization → Administration of anti-D-gamma globulin to unimmunized Rh-
negative mother bearing Rh-positive baby. Women who are susceptible to rubella
can be vaccinated safely with live vaccine. The booster dose of tetanus toxoid, Hep B,
Tdap should be given at the time of discharge if not given during pregnancy.
15. Vomiting in Pregnancy

Management of hyperemesis gravidarum // Hyperemesis gravidarum: investigations
& management
EVALUATION
Assess for weight loss
Vitals → PR, BP (Orthostatic hypotension)
Lab investigations
Serum electrolytes → Hypokalemia, hypochloremia, metabolic alkalosis and ketonuria
CBC → Raised Hct
Serum creatinine
Urine ketones and specific gravity
USG → To assess fetal viability, multifetal pregnancy, GTD
Assess for complications like Wernicke’s encephalopathy and Mallory Weiss
Syndrome
TREATMENT
IV Fluids for dehydration
Thiamine (Multivitamin Injections)
H2 antagonists (Ranitidine), PPIs (Omeprazole) etc. to prevent acid reflux
Correct electrolyte imbalances
Anti-emetics
if no hypovolemia → Oral drugs in the following priority order
Dimenhydrinate / Diphenhydramine
if fails
Metoclopramide / Promethazine
if fails and
pregnancy < 10 weeks → Combination of two-antiemetics orally
pregnancy > 10 weeks → Ondansetron
if hypovolemia present → IV drugs
If < 10 weeks pregnancy → Combination of two anti-emetics IV
If > 10 weeks pregnancy → Ondansetron
Ondansetron is not used prior to 10 weeks as it suspected to interfere with the

process of oraganogenesis
16. Hemorrhage in Early Pregnancy

Ectopic pregnancy -any 2 causes, criteria for medical management
Causes
Salpingitis / Pelvic Inflammatory Disease
Contraception Failure
Criteria for medical management
There should be no intra-abdominal hemorrhage (Hemodynamically stable)
Unruptured ectopic
Serum hCG level should be less than 5,000 IU/L.
Size of G-sac should be less than 4 cm
No fetal cardiac activity (not an absolute requirement)
Management of ectopic pregnancy
Management of unruptured ectopic
Expectant management → Where only observation is done hoping spontaneous
resolution
Indications
Initial serum hCG < 200 IU/L and the levels are falling
No visible sac
Patient should be hemodynamically stable
No evidence of bleeding or rupture on TVS
Medical Management →
Indications
Unruptured ectopic
Management
The drug used is Methotrexate (IM) at the dose of 50��/�250mg/m2
Day 1 → Injection methotrexate given. Baseline hCG levels measured.
Day 4 and Day 7 → hCG levels are checked again
Note: Between Day 1 and Day 4, hCG levels could rise due to the release of hCG from
shrinking sac. This is not an indication of failed medical management.
If the decrease in hCG levels between day 4 and day 7 is > 15%, patient is followed
up weekly with serum hCG until hCG is less than 10 mIU/mL
If the decrease in hCG levels between day 4 and day 7 is < 15%, repeat methotrexate
on day 7. Methotrexate can be given for a maximum of three times. If still results are
not obtained, it is an indication of surgical management.
If hCG levels increase between day 4 and day 7 it is an indication of surgical
management.
Surgical management → The procedure can be done either laparoscopically or by
microsurgical laparotomy.
Indications -
hCG levels > 5000 IU
G-sac > 4 cm
Persistent fetal cardiac activity
Hemodynamically unstable
Ruptured ectopic
Surgery done
If family complete or ruptured ectopic → Salpingectomy
If patient stable do by laparoscopic route
Stay near the ovarian ligament and cut it
Stay away from the infundibulo-pelvic ligament as it contains ovarian vessels and
nerves. If damaged it can lead to menopause like symptoms and amenorrhea at
young age
While cauterizing the tube stay away from the uterus as it can lead to uteroperitoneal
fistula
If patient unstable do by laparotomy
Ringer’s solution is started
Arrangement for blood transfusion. Even in the blood is not available, laparotomy to
be done desperately.
Abdomen is opened by infraumbilical longitudinal incision
To grasp the uterus and draw it under vision
The tubes and ovaries of both the sides are quickly inspected to find out the side of
rupture
Salpingectomy is the definitive surgery. The excised tube should be sent for
histological examination.
The ipsilateral ovary with its blood supply is preserved. Oophorectomy is done only if
the ovary is damaged beyond salvage or is pathological.
If family incomplete and unruptured ectopic → Salpingostomy or linear
salpingostomy
Steps -
Make an incision on the antimesenteric part directly over the distended tubal part
Remove ectopic by hydro-dissection
Leave the tube and incision site. No sutures required
Heals by secondary intention
Management of ruptured ectopic
Investigations
The classic history of acute abdominal catastrophe with fainting attack and collapse
associated with features of intra-abdominal hemorrhage in a woman of child-bearing
age points to a certain diagnosis of acute ectopic.
No time should be wasted for investigations other than estimation of hemoglobin
and blood grouping (ABO and Rh).
Management → As discussed in surgical method above
Clinical features investigations and management of ruptured ectopic pregnancy
Clinical presentation
Symptoms
Triad → Abdominal pain, amenorrhea, vaginal bleeding
Pain
Site of pain → Lower abdomen / pelvic area
Reason of pain → Hemoperitoneum
Pain in the middle or upper abdomen may be felt in cases where intraperitoneal
blood reaches upper abdomen.
If intraperitoneal blood reaches diaphragm → shoulder tip pain
Pooling of blood in pouch of Douglas → Pressure on rectum → Urge to defecate
Syncope / Postural hypotension
Signs
General examination → Tachycadia, hypotension
Per abdomen examination → Abdominal distension, rebound tenderness, guarding,
rigidity
Per vaginal examination → Presence of adnexal mass, cervical motion tenderness
(pain even on touching the cervix during PV examination)
Investigations
Treatment
young age
fistula
The tubes and ovaries of both the sides are quickly inspected to fund out the side of
rupture
salpingostomy
Steps -
Clinical features of ruptured ectopic pregnancy
Symptoms
Pain
Signs
rigidity
Unruptured ectopic - medical management
Indications
Unruptured ectopic
Management
management.
Clinical features and management of unruptured tubal pregnancy.
Clinical Features
Symptoms
Presence of delayed period or spotting with features suggestive of pregnancy
Uneasiness on one side of the flank which is continuous or at times colicky in nature.
Signs
Uterus is usually soft showing evidence of early pregnancy
A pulsatile small, well-circumscribed tender mass may be felt through one fornix
separated from the uterus.
Investigations
Transvaginal sonography
Signs diagnostic of ectopic pregnancy
Extra-uterine gestational sac with yolk sac / embryo with or without cardiac activity
Signs suggestive of ectopic pregnancy
Empty uterus with a positive pregnancy test
Complex adnexal mass (most common)
Increased vascularity of mass (ring-of-fire pattern)
Gestational sac in tube without yolk sac / embryo
Serial hCG estimation
Management of unruptured ectopic

resolution
Indications
No visible sac
Indications
Unruptured ectopic
Management
management.
Indications -
G-sac > 4 cm
Ruptured ectopic
Surgery done
young age
fistula
rupture
salpingostomy
Steps -
A 25 year old lady comes with bleeding per vagina and pain abdomen following
50 days of amenorrhea. Her urine pregnancy test is positive. A. Write four
differential diagnosis. Write clinical examination findings for all four
conditions. B. Write the management if on USG uterine cavity is empty with an
adnexal mass
Differential diagnosis
Ectopic pregnancy (ruptured)
Symptoms
Pain
Signs
rigidity
Hydatidiform mole
Symptoms
Vaginal bleeding (90% cases)
Lower abdominal pain → Due to overstretching of the uterus, concealed hemorrhage,
rarely perforation of uterus by invasive mole
Sick appearance
Hyperemesis
Breathlessness due to pulmonary embolization of trophoblastic cells
Expulsion of grape like vesicles per vaginum is diagnostic of vesicular mole.
Signs
Features suggestive of early pregnancy
Patient looks more ill than can be accounted for
Pallor is present unusually out of proportion to blood loss
Features of pre-eclampsia are present in about 50% cases. These include
hypertension, edema and/or proteinuria.
Per abdomen
Size of uterus is more than expected for the period of amenorrhea
Feel of uterus is firm elastic (doughy). This is due to absence of the amniotic fluid sac
Fetal parts are not felt, nor any fetal movements
Absence of fetal heart sounds
Vaginal examination
Internal ballotment cannot be elicited
Unilateral or bilateral enlargement of ovaries
Findings of vesicles in vaginal discharge is pathognomic.
Threatened abortion
Symptoms
Slight bleeding per vaginum (spotting)
Bleeding is usually painless but there may be mild backache or dull pain in lower
abdomen
Pelvic examination
Should be as gentle as possible
Closed internal os
Speculum examination reveals bleeding if any, escapes through the external os
Uterine size corresponds to period of gestation
Inevitable abortion → Patient having the features of threatened abortion, develops
the following manifestations
Symptoms
Increased vaginal bleeding
Aggravation of pain in lower abdomen which may be colicky in nature
Signs
Internal examination reveals dilated internal os of the cervix through which the
products of conception are felt
The features mentioned are suggestive of ruptured ectopic pregnancy.
Investigations
Treatment
young age
fistula
rupture
salpingostomy
Steps -
A G3 PI A1 presents pain abdomen and bleeding following 8 weeks of
amenorrhea. On examination she is pale and hypotensive. On pelvic
examination uterus is normal size and there is severe adnexal tenderness.
Ultrasound shows empty uterus and fluid in pouch of Douglas. A. Mention the
diagnosis and describe current management. B. Discuss the management if this
patient had presented 2 weeks earlier. C. What are the possible etiological
factors which can cause this condition?
Ruptured ectopic pregnancy
Investigations
Treatment
Since it is a ruptured ectopic → Salpingectomy
Since the patient is unstable do by laparotomy
rupture
If the patient had presented two weeks earlier → Unruptured ectopic
Investigations
Transvaginal sonography
Signs diagnostic of ectopic pregnancy
Extra-uterine gestational sac with yolk sac / embryo with or without cardiac activity
Signs suggestive of ectopic pregnancy
Empty uterus with a positive pregnancy test
Complex adnexal mass (most common)
Increased vascularity of mass (ring-of-fire pattern)
Gestational sac in tube without yolk sac / embryo
Serial hCG estimation
Management
resolution
Indications
No visible sac
Indications
Unruptured ectopic
Management
management.
Indications -
G-sac > 4 cm
Ruptured ectopic
Surgery done
young age
fistula
rupture
If family incomplete → Salpingostomy or linear salpingostomy
Steps -
Possible etiological factors responsible for ectopic pregnancy are -
Previous history of ectopic (highest risk factor)
Previous history of tubal surgery
Pelvic inflammatory disease / salpingitis (most common)
Highest risk if PID due to Chlamydia (Chlamydia leads to production of PROKR2
protein, which makes pregnancy more likely to implant in tubes)
Risk factors of PID
Multiple sexual partners
Cervicitis
Low socio-economic status
History of infertility
Genital TB
Endometriosis
Smoking → Leads to impaired motility of tubes
Ovulation inducing drugs → Clomiphene, Letrozole, gonadotropins
IVF/ART
Contraceptives
Progesterone containing contraceptives, progesterone only pills, progesterone IUCD
(Mirena)
Tubal ligation
Copper T
A G2 PI LI presents at 8 weeks of amenorrhea and pain abdomen. She gives
history of syncopal attack. Ultrasound does NOT reveal any intrauterine
gestational sac, but shows a mass in the adnexal region and minimal amount of
free fluid in Pouch of Douglas. A. What is the most probable diagnosis? B. Write
the reasoning for the diagnosis C. Write the investigations D. Write the
predisposing conditions for this condition. E. Briefly write the management
Acute Ectopic (Ruptured ectopic pregnancy)
Reasons -
Syncopal attack suggestive of active bleeding leading to hypovolemia
No gestational sac on ultrasonography suggestive of extra-uterine pregnancy
Mass in adnexal region
Free fluid (blood) in POD from hemorrhage
Investigations
Predisposing conditions
Previous history of ectopic (highest risk factor)
Previous history of tubal surgery
Pelvic inflmmatory disease / salpingitis (most common)
Highest risk if PID due to Chlamydia (Chlamydia leads to production of PROKR2
protein, which makes pregnancy more likely to implant in tubes)
Risk factors of PID
Multiple sexual partners
Cervicitis
Low socio-economic status
History of infertility
Genital TB
Endometriosis
Smoking → Leads to impaired motility of tubes
Ovulation inducing drugs → Clomiphene, Letrozole, gonadotropins
IVF/ART
Contraceptives
Progesterone containing contraceptives, progesterone only pills, progesterone IUCD
(Mirena)
Tubal ligation
Copper T
Treatment
Since it is a ruptured ectopic → Salpingectomy
young age
fistula
rupture
Threatened abortion: Diagnosis and management
Process of abortion has started but it is reversible
Symptoms
Slight bleeding per vaginum (spotting)
Bleeding is usually painless but there may be mild backache or dull pain in lower
abdomen
Pelvic examination
Should be as gentle as possible
Closed internal os
Speculum examination reveals bleeding if any, escapes through the external os
Uterine size corresponds to period of gestation
Management : No definitive management
USG :
Well formed gestational sac
Fetal cardiac activity visible
Empirical treatment
Avoid heavy lifting
Avoid intercourse
Rest for 48 hours
Anti-D immunoglobulin if Rh negative pregnancy > 12 weeks
Early pregnancy loss-Definition, 6 causes of spontaneous abortion
The loss of a pregnancy before 13 completed weeks is called early pregnancy loss.
Causes -
Genetic → Chromosomal anomalies
Endocrine and Metabolic factors → Luteal phase defect, deficient progesterone
secretion
Anatomical abnormalities → Cervical incompetence, congenital malformation of
uterus
Infections → TORCH infections
Immunological disorders → APLA
Maternal medical illness → Cyanotic heart disease, hemoglobinopathies
PROM
Thrombophilia → Factor V Leiden, Protein C deficiency and hyperhomocysteinemia
Clinical features and management of Molar pregnancy
Clinical Features
Symptoms
Sick appearance
Hyperemesis
Signs
Per abdomen
Vaginal examination
Internal ballottement cannot be elicited
Investigations
ABO and Rh typing
hCG titer (usually greater than the period of gestation)
Hepatic and renal function tests
Thyroid function tests (Alpha subunit of hCG is similar to alpha subunit of TSH
leading to hyperthyroidism)
Sonography →
Snow storm appearance,
Absence of fetal parts
Absence of amniotic fluid
Presence of theca lutein cysts
Definitive diagnosis made by histologic examination of products of conception
Treatment
Management of mole
Suction evacuation of the uterus
Keep packed cells ready as chances of bleeding are more
After process of evacuation begins, start oxytocin. (Giving oxytocin before suction
evacuation can lead to trophoblastic embolization)
Do sharp curettage, send the tissue for histopathological examination (gold standard
for diagnosis)
Management of theca lutein cysts
No management needed. Resolves spontaneously after evacuation
Indications for hysterectomy
Age > 40 years
Family complete
Complete mole
Uncontrolled hemorrhage or perforation during surgical evacuation
Follow up
Done using beta-hCG levels
First measured after 48 hours of evacuation.
Repeat weekly till they become undetectable (at around 7 weeks)
Repeat monthly till 6 months
Management of Molar pregnancy
Investigations
ABO and Rh typing
Sonography →
Definitive diagnosis mady by histologic examination of products of conception
Treatment
Management of mole
Suction evaculation of the uterus
evacuation can lead to trophoblastic embolisation)
for diagnosis)
Management of theica lutein cysts
Age > 40 years
Family complete
Complete mole
Follow up
Vesicular mole: Symptoms and signs
Symptoms
Sick appearance
Hyperemesis
Signs
Per abdomen
Vaginal examination
Internal ballotment cannot be elicited
Follow up of Vesicular Mole after evacuation
Routine follow-up is mandatory for all cases after complete evacuation due to
increased chances of occurrence of choriocarcinoma.
Initially the follow-ups should be at an interval of one week till beta-hCG levels
become undetectable (usually happens around 7 weeks).
After that the patient is followed up monthly for a duration of 6 months. Women
receiving chemotherapy are followed up for a period of 1 year
The patient must not become pregnant for the entire duration of follow-up
Follow up is carried out by the following two protocols
History and clinical examination
beta-hCG assay (best)
A primigravida presented to antenatal clinic at eight weeks of gestation with
vaginal bleeding and passage of vesicles. What is the most probable diagnosis?
Investigations and complications of this condition. Follow up and advice given
to this patient
Hydatidiform mole
Investigations
ABO and Rh typing
Sonography →
Definitive diagnosis mady by histologic examination of products of conception
Complications
Immediate
Hemorrhage and shock
Sepsis
Perforation of uterus
Pre-eclampsia
Pulmonary embolism
Coagulation failure
Late → Development of choriocarcinoma
Treatment
Management of mole
Suction evaculation of the uterus
evacuation can lead to trophoblastic embolisation)
for diagnosis)
Management of theica lutein cysts
Age > 40 years
Family complete
Complete mole
Follow up
Cervical encerclage // Cervical encerclage: Indications and procedure
Cervical cerclage
It is used for the management of cervical incompetence
Indication → History of cervical incompetence or USG based criteria for cervical
incompetence is met
Principle → The procedure reinforces the weak cervix by a non-absorbable tape,
placed around the cervix at the level of internal os.
Ideal time for doing cerclage is 12-14 weeks. Can be done up till 24 weeks. Not to be
done beyond 24 weeks
Transvaginal Route
Most common route
Two methods
Mc Donald cerclage →
Attempt is made to reach as close as possible to the internal os
The sutures are applied at cervicovaginal junction - purse string sutures with non-
absorbable suture material in anti-clockwise direction (2 o’ clock → 10 o’ clock → 8 o’
clock → 4 o’ clock → 2 o’ clock)
Easier to do
Shirodkar cerclage
The cervicovaginal junction is cut
Suture applied at the internal os
Non-absorbable sutures used
Less failure rate
Transabdominal Route → Only done if transvaginal cerclage fails
Progesterone → In all patients who undego cervical cerclage, supplemental
progesterone is given upto 36 weeks 6 days of gestation
Cervical insufficiency: diagnosis and management. // Cervical incompetence-
Diagnosis and management // Cervical incompetence- management (x2)
Diagnosis
History of loss of two or more pregnancies in the second trimester
Spontaneous dilation of cervix which is painless leading to expulsion of products of
conception
History of one painless second trimester abortion along with the following features
on TVS done between 18-24 weeks
Cervical length < 2.5 cm
Diameter of the internal os > 2 cm
U-shaped cervix (As the cervix shortens it changes shape from ‘T’ (normal) to ‘Y’ to ‘V’
to ‘U’)
Management
Cervical cerclage
Principle → The procedure reinforces the weak cervix by a non-absorbable tape,
placed around the cervix at the level of internal os.
Ideal time for doing cerclage is 12-14 weeks. Can be done up till 24 weeks. Not to be
done beyond 24 weeks
Transvaginal Route
Most common route
Two methods
Mc Donald cerclage →
Attempt is made to reach as close as possible to the internal os
The sutures are applied at cervicovaginal junction - purse string sutures with non-
absorbable suture material in anti-clockwise direction (2 o’ clock → 10 o’ clock → 8 o’
clock → 4 o’ clock → 2 o’ clock)
Easier to do
Shirodkar cerclage
The cervicovaginal junction is cut
Suture applied at the internal os
Non-absorbable sutures used
Less failure rate
Transabdominal Route → Only done if transvaginal cerclage fails
Progesterone → In all patients who undego cervical cerclage, supplemental
progesterone is given upto 36 weeks 6 days of gestation
Methods of first trimester MTP. Describe any one method
Medical
Mifepristone
Mifepristone and Misoprostol
Methotrexate and Misoprostol
Tamoxifen and Misoprostol
Surgical
Menstrual regulation
Vacuum aspiration (MVA/EVA)
Suction evacuation and/or curettage
Dilatation and Evacuation
Medical abortion method
Upper limit in India → 7 weeks
Carried out as on out-patient procedure
Day 1 → Tablet Mifepristone 200 mg orally
Day 3 → Tablet Misoprostol 400 mcg oral/buccal/sublingual/pervaginal
Day 15 → Patient re-examined to check whether the abortion is complete
Complete abortion is seen in 95% cases, incomplete in 2% cases and 1% cases do not
respond at all.
17. Multiple Pregnancy, Amniotic Fluid
Disorders, Abnormalities of Placenta and
Cord
Difference between monozygotic and dizygotic twins
Monozygotic Twins Dizygotic Twins
Formation Single ova is fertilized by a single sperm to Two ova are fertilized by two
form single zygote which then divides into different sperms to form two
two zygotes
Occurrence Less common More common
Sex Have same sex May have same or different sex
Genetic features (DNA Same Different
fingerprinting, Blood group)
Placenta One Two
Communicating vessels Present Absent
Intervening membranes Two (amnions) Four (Two amnion and two
chorions)
Complications of multiple gestation // Complications of multiple pregnancy //
Maternal complications of multiple pregnancy
Maternal Complications
During pregnancy
Increased nausea and vomiting
Anemia → Due to increased requirement of iron and folate.
Pre-eclampsia → Due to increased placental size
Polyhydramnios → Can lead to preterm labor and malpresentation
Ante-partum hemorrhage → Due to increased size of placenta, there are increased
chances of placenta previa.
Mechanical distress such as palpitation, dyspnea, varicosities and hemorrhoids
During labor
Early rupture of membranes and cord prolapse
Prolonged labor
Increased operative interference
Bleeding after the birth of the first baby
PPH
During puerperium
Subinvolution of uterus
Infection due to increased operative interference, pre-existing anemia and blood loss
during delivery
Fetal complications
Miscarriage rate is increased especially with monozygotic twins
Premature rate
Discordant twin growth
Intrauterine death of one fetus
Fetal anomalies → The risk of fetal anomalies like chromosomal abnormalities, neural
tube defects is increased
Asphyxia and stillbirth are more common due to increased prevalence of pre-
eclampsia, malpresentation, placental abruption and increased operative
interference.
Complications specific to Monochorionic twins.
Twin-to-twin transfusion syndrome
It is a clinicopathological state, in which one twin appears to bleed into the other
through some kind of placental vascular anastomosis.
Clinical manifestations occur when there is hemodynamic imbalance due to
unidirectional deep arteriovenous anastomoses.
Recipient twin -
Larger
Increased blood (Polycythemia) → Thrombosis → Congestive heart failure
Increased renal blood flow → Increased GFR → Polyhydramnios
Donor twin
Smaller
Decreased blood (Anemia) → High output heart failure
To maintain intravascular volume and BP → Activation of RAAS → Oliguria/Anuria →
Oligohydramnios/Anhydramnios → Stuck twin
Management
Upto 28 weeks → Fetoscopic laser ablation of vascular anastomosis
After 28 weeks → Amnioreduction from sac of polyhydramnios
Twin anemia-polycythemia sequence
It is an atypical chronic form of TTTS caused by slow transfusion of RBCs through
very small (< 1 mm) and few placental arteriovenous anastomosis
Twin reverse arterial perfusion (TRAP)
Characterized by an “acardiac perfused twin” having blood supply from a normal co-
twin via large arterio-arterial or vein to vein anastomosis
The acardiac twin recieves deoxygenated blood from the umbilical artery of normal
twin (hence the name TRAP) resulting in -
Acardiac acephalus → Abnormal development of fetus such that only the lower part
of body is developed
Acardiac amorphous → No part of acardiac twin develops and appears as an
amorphous mass
Selective IUGR
One twin is normal and the other one is growth-restricted
Smaller twin →
Fetal weight < 10th percentile of normal fetus
Difference in weight greater than or equal to 25% in comparison to normal twin
Conjoint twins
Cord entanglement → Seen in monochorionic monoamniotic twins
Twin to Twin Transfusion Syndrome (TTTS)-Diagnosis and management
Recipient twin -
Larger
Donor twin
Smaller
Criteria for diagnosis
Monochorionic diamniotic twins
One twin → Polyhydramnios
Other twin → Oligohydramnios
Early marker of TTTS on USG → Increased nuchal translucency
Management
How is chorionicity established on sonography? Discuss complications in
monochorionic twins
Chorionicity of the placenta is best diagnosed by TVS at 11-14 weeks of gestation
In dichorionic twins there is a thick septum (> 2mm) between the two gestational
sacs.
It is best identified at the base of the membrane where a triangular projection is
seen.
It is due to extension of chorionic villi into the potential inter-chorionic space.
This is known as lambda or twin peak sign and is indicative of dichorionic
placenta
Presence of one gestational sac with a thin (< 2mm) dividing membrane, and two
fetuses (T sign) suggests monochorionic diamniotic pregnancy.
COMPLCIATIONS SPECIFIC TO MONOCHORIONIC TWINS
Twin-to-twin transfusion syndrome
Recipient twin -
Larger
Donor twin
Smaller
Management
Twin anemia-polycythemia sequence
It is an atypical chronic form of TTTS caused by slow transfusion of RBCs through
very small (< 1 mm) and few placental arteriovenous anastomosis
Twin reverese arterial perfusion (TRAP)
Characterized by an “acardiac perfused twin” having blood supply from a normal co-
twin via large arterio-arterial or vein to vein anastomosis
The acardiac twin recieves deoxygenated blood from the umbilical artery of normal
twin (hence the name TRAP) resulting in -
Acardiac acephalus → Abnormal development of fetus such that only the lower part
of body is developed
Acardiac amorphous → No part of acardiac twin develops and appears as an
amorphous mass
Selective IUGR
One twin is normal and the other one is growth-restricted
Smaller twin →
Fetal weight < 10th percentile of normal fetus
Difference in weight greater than or equal to 25% in comparision to normal twin
Conjoint twins
Cord entanglement → Seen in monoamniotic twins
COMPLICATIONS OF TWIN PREGNANCY
Maternal Complications
During pregnancy
Increased nausea and vometing
Anemia → Due to increased requirement of iron and folate.
Pre-eclampsia → Due to increased placental size
Polyhydramnios → Can lead to preterm labor and malpresentation
Ante-partum hemorrhage → Due to increased size of placenta, there are increased
chances of placenta previa.
Mechanical distress such as palpitation, dyspnea, varicosities and hemorrhoids
During labor
Early rupture of membranes and cord prolapse
Prolonged labor
Increased operative interference
Bleeding after the birth of the first baby
PPH
During puerperium
Subinvolution of uterus
Infection due to increased operative interference, prexisting anemia and blood loss
during delivery
Fetal complications
Miscarriage rate is increased especially with monozygotic twins
Premature rate
Discordant twin growth
Intrauterine death of one fetus
Fetal anomalies → The risk of fetal anomalies like chromosomal abnormalities, neural
tube defects is increased
Asphyxia and stillbirth are more common due to increased prevalence of pre-
eclampsia, malpresentation, placental abruption and increased operative
interference.
Hydramnios-causes and diagnosis // Hydramnios-Causes and management //
Aetiology and management of Polyhydramnios // Causes and management of
Polyhydramnios
Causes -
Excessive urine production
Multifetal pregnancy
Twin-to-twin transfusion syndrome → One fetus : Polyhydramnios ; Other fetus :
oligohydramnios
Maternal diabetes → Maternal hyperglycemia → Fetal hyperglycemia → Polyuria
Fetal high cardiac output states → Increased renal blood blow → Increased GFR →
Polyuria. This could be due to
Hydrops fetalis → Rh isoimmunization, Parvovirus B19 infection, TORCH infections
Fetal anemia → Alpha thalassemia, G6PD deficiency
Fetal renal disorders
Bartter syndrome → X-linked recessive disorder manifesting as a congenital defect in
kidney leading to salt wasting and polyuria
Congenital mesoblastic nephroma → Hyper perfusion of kidney → Increased GFR →
Polyuria
Fetal swallowing defects
Due to GI anomalies
Duodenal atresia
Esophageal atresia
Cleft lip / Cleft palate
Neural tube defects → Anencephaly, open spina bifida
Secondary (Due to pressure effect on esophagus)
Thoracic masses
Congenital diaphragmatic hernia
Thyrotoxic goiter
Investigations
Sonography →
The following features are suggestive of polyhydramnios
Amniotic fluid index > 25 cm
Single vertical pocket > 8 cm
Absolute value of amniotic fluid > 2 L
To exclude multiple fetuses
To note the lie and presentation (Polyhydramnios can lead to unstable lie and
malpresentation)
To diagnose any fetal congenital malformations (GI, CNS, Renal, NTD etc)
Blood
ABO and Rh grouping → Rh isoimmunization can cause hydrops fetalis
Postprandial glucose and if necessary glucose tolerance test
Estimation of alpha-fetoprotein levels (elevated if neural tube defects present)
Treatment
Asymptomatic or mild symptoms → No treatment required
Severe polyhydramnios
Criteria
Symptoms → Shortness of breath which interferes with day to day life and uterine
irritability
Treatment → It is done by amnioreduction
Amnioreduction → Taking out amniotic fluid by doing therapeutic amniocentesis
Done under USG guidance
18 G spinal needle used
In one sitting 2-2.5 L fluid removed at rate of 1 L in 20 minutes
If patient goes into preterm labor the following drugs are given
< 32 weeks → Indomethacin (Tocolysis) + Corticosteroids
32-34 weeks → Nifedipine (Tocolysis) + Corticosteroids
> 34 weeks → Corticosteroids only (No tocolytics)
Polyhydramnios: Definition and causes
Definition
Absolute value of amniotic fluid > 2 L
Causes
Excessive urine production
Twin-to-twin transfusion syndrome → One fetus : Polyhydramnios ; Other fetus :
oligohydramnios
Maternal diabetes → Maternal hyperglycemia → Fetal hyperglycemia → Polyuria
Fetal high cardiac output states → Increased renal blood blow → Increased GFR →
Polyuria. This could be due to
Hydrops fetalis → Rh isoimmunization, Pravovirus B19 infection, TORCH infections
Fetal anemia → Alpha thalassemia, G6PD deficiency
Fetal renal disorders
Bartter syndrome → X-linked recessive disorder manifesting as a congenital defect in
kideny leading to salt wasting and polyuria
Congenital mesoblastic nephroma → Hyperperfusion of kidney → Increased GFR →
Polyuria
Fetal swallowing defects
Due to GI anomalies
Duodenal atresia
Oesophageal atresia
Cleft lip / Cleft palate
Neural tube defects → Anancephaly, open spina bifida
Secondary (Due to pressure effect on esophagus)
Thoracic masses
Congenital diaphragmatic hernia
Thyrotoxic goitre
Oligoamnios: Causes, assessment and management
Criteria
AFI < 5 cm
Single deepest pocket < 2 cm
Absolute value of liquor < 200 ml
Most common causes
Mild oligohydramnios : Idiopathic
Moderate oligohydramnios : Congenital anomalies of fetus
Causes of oligohydramnios
Congenital defect of renal system :
Renal agenesis
Cystic disorders of kidney
Obstructive disorders like posterior urethral valve (Keyhole sign)
Rupture of membranes
Decreased urine production due to uteroplacental insufficiency.
Cause of uteroplacental insufficiency
PIH
IUGR
Post term pregnancy
TORCH infections
Drugs : ACE inhibitors and indomethacin
Placental abruption
Consequences
Mild oligohydramnios : None
Moderate to severe :
First trimester : Pulmonary hypoplasia (most common), limb amputation
Second/Third trimester :
Limb deformities
Cord compression → Fetal distress (Variable decelerations) → Meconium aspiration
syndrome
Potter’s syndrome : Severe oligohydramnios due to kidney defect (PKD/renal
agenesis) → Lung hypoplasia, flat facies
CTEV
Management
Fetal monitoring
NST weekly
Biophysical score weekly
Doppler of umbilical vessels to monitor uteroplacental insufficiency
Others
Improve maternal hydration
Amnioinfusion
Termination of pregnancy
Mild/no complications : 39 weeks
Moderate / Severe / Complications present : 36 weeks - 37 weeks + 6 days
18. Hypertensive Disorders in Pregnancy

Imminent Eclampsia -symptoms,signs and laboratory values
Symptoms -
Headache not relieved by analgesics
Epigastric pain
Visual symptoms
Oliguria or anuria
Signs -
systolic blood pressure of 160 mmHg or more on two occasions six hours apart when
the patient is on bed rest
cerebral or visual disturbances
pulmonary edema or cyanosis
brisk deep tendon reflexes
Laboratory Values
Proteinuria > 5 g in 24 hours
Elevated creatine levels > 1.1 mg/dL
Thrombocytopenia < 1,00,000 /cu.mm
Liver transaminases > 2 times the upper limit
What is imminent eclampsia? List four symptoms and four signs for the same.
Write relevant investigations that are required in the management with
reasoning. Briefly outline the management for a 28 year old primigravida at 32
weeks of gestation with this condition
Define Preeclampsia. What are the clinical presentations of Preeclampsia? Write
in detail about laboratory and clinical evaluation of severe preeclampsia at 34
weeks of gestation in a primigravida
Mention the criteria to diagnose preeclampsia. Discuss the management of a
primigravida at 32 weeks of pregnancy with eclampsia.
Criteria for the diagnosis of pre-eclampsia
Systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg on
at least 2 occasions at least 4 hours apart after 20 weeks of gestation in a previously
normotensive patient AND the new onset of 1 or more of the following
Proteinuria ≥ 0.3 g in a 24-hour urine specimen or protein/creatinine ratio ≥0.3
(mg/mg) (30 mg/mmol) in a random urine specimen or dipstick ≥2+ if a quantitative
measurement is unavailable
Features of severe disease
Severe blood pressure elevation with systolic ≥ 160 mmHg and/or diastolic ≥ 110
mmHg on two occasions at least four hours apart while the patient is on bedrest.
New-onset and persistent headache not accounted for by alternative diagnoses and
not responding to usual doses of analgesics
New onset visual symptoms (eg, blurred vision, flashing lights or sparks, scotomata)
Platelet count <100,000/microL
Serum creatinine >1.1 mg/dL or doubling of the creatinine concentration in the
absence of other renal disease
Liver transaminases > Two times the upper limit of the normal concentrations
Severe epigastric pain not responsive to medications
Pulmonary edema
Management
Pre-eclampsia without severe features
If gestational age ≥ 37 weeks → Deliver after initial evaluation
If gestational age < 37 weeks → Expectant management until 37 weeks and then
delivery, unless features of sever disease develop
Initial Evaluation
Maternal
Complete blood count with hematocrit and platelet count
Serum creatine
Urine 24 hours protein creatine ratio
Liver enzymes
Ask history about cerebral or visual symptoms, epigastric pain, headache etc.
Fetal
Biophysical profile
Doppler studies
Based on the above evaluation it is decided whether to manage patient on
outpatient basis or admit her.
Maternal and Fetal monitoring
Maternal monitoring → The following should be done twice weekly irrespective of
admission status
BP measurement
Assessment of CBC
Liver enzymes
Creatinine
Fetal monitoring
Daily fetal movement count
Ultrasound biometry
NST and biophysical profile
Anti-hypertensive drugs
Should be started if
BP ≥ 150/100 mmHg persistently (repeated after 4 hours)
BP ≥ 160/110 mmHg on two readings 15 minutes apart (hypertensive crisis)
First line drugs
IV Labetalol → 200-1200 mg/day in 2-3 divided doses
Oral Nifedipine → 20-120 mg/day in 3-4 divided doses
For refractory hypertension → DOC is sodium nitroprusside
Intrapartum management
Delivery is the only definitive treatment
C-section to be only done if there are obstetric indications
Continuous cardiotocography monitoring is ideal during labor
Magnesium sulphate prophylaxis is not recommended if the disease is not severe
Prophylactic ergometrine should be avoided
Pre-eclampsia with severe disease
If gestational age ≥ 34 weeks → Deliver
If gestational age < viability (28 weeks) → Discuss option for termination of
pregnancy
If gestational age is viability to < 34 weeks → Expectant management if patient is
stable
Initial evaluation
Patient admitted to HDU in the first 24-48 hours for observation and to decided
whether expectant management can be continued or pregnancy has to be
terminated
Once the patient is stable and is a candidate for expectant management she can be
shifted to ward
Expectant management
Aim → To protect the fetus from consequences of disease and avoid the dangers of
prematurity. It aims at increasing birth weight and reducing neonatal complications.
If there is a worsening in condition expectant management should be abandoned
and termination of pregnancy
Anti-hypertensives → To prevent cerebral hemorrhage and maternal complications.
Same as discussed earlier.
Antenatal corticosteroids → Should be given for women receiving expectant
management between 28-34 weeks
Maternal monitoring →
BP every four to six hourly
Proteinuria by dipstick every day
Fluid intake and urinary output charts to be maintained
Lab investigations daily initially and then every two days
Fetal monitoring
Daily fetal movement count
NST daily
Biophysical profile → Twice weekly
Fetal growth scan every two weeks
Control of BP
Magnesium sulphate is given prophylactically to prevent eclampsia.
Narrow therapeutic range → 4-7 mEq/L

Monitor for signs of toxicity before giving maintenance dose
Signs of toxicity
Deep tendon reflexes absent
Urine output < 30 mL/hr
Respiratory rate < 12/min
BP falls
Chest pain, discomfort
Visual changes and disturbance
Judicious fluid management
Obstetric management →
Vaginal delivery is usually preferable
C-section to be done only for obstetric indications, failed induction, rapid worsening
of maternal or fetal conditions
Post-partum management
PPH → Prophylactic ergometrine contraindicated. Oxytocin should be used for the
active management of third stage.
Monitoring → Continue MgSO4 for another 24 hours. Monitor for oliguria,
pulmonary edema and HELLP syndrome.
Thromboprophylaxis → Due to increased risk of DVT
Anti-hypertensives → Should be continued. Dose should be reduced step wise
manner. If hypertension persists after 8 weeks, a diagnosis of chronic hypertension
should be considered.
Management of eclampsia.
General measures
The patient should be nursed in a left lateral position in a cot with railings
The immediate management includes ensuring that the airway is open,
oropharyngeal suctions as and when necessary and oxygen administration during
convulsive episode
IV line should be established
Pulse oximetry to check for saturation (can reduce to pulmonary edema)
Bladder catheterization (Maintain output charts)
During convulsions a mouth gag is kept to prevent from biting tongue
Anticonvulsant therapy
Magnesium sulphate used
Available in 2mL ampules containing 1g magnesium sulphate in each ampule
Pritchard and Zuspan regimen
Monitoring for signs of toxicity

Absent patellar reflex (first to appear)
If toxicity occurs → CaGluconate (10%) 10 mL given IV
Contraindications → Myasthenia gravis, recent MI
Anti-hypertensives
Obstetric Management
Immediate termination is advisable after controlling seizures
Mode of delivery → Vaginal delivery
If delivery does not occur within 24 hrs in patients with pre-eclampsia
C-section done
Preferred anesthesia → Neuroaxial anesthesia
Monitoring → Continute MgSO4 for another 24 hours. Monitor for oliguria,
MgSO4 in Obstetrics
Drug of choice for prevention and treatment of seizures in females with PIH
Mechanism of Action
Centrally acting drug
Blocks NMDA receptors in brain
Membrane stabilization as it is a CCB
Decreases release of acetylcholine
Brings about cerebral vasodilation
Regime

Therefore before giving maintenance dose the following signs of toxicity should be
excluded
Knee jerk or patellar reflex absent (First to manifest)
Respiratory rate < 12 / min
Antidote for toxicity → Calcium gluconate 1 g IV
MgSO4 is also used for neuroprophylaxis in preterm labor if the gestational age < 32
weeks
Define Pre-eclampsia- List any six complications
It is a multisystem disorder of unknown etiology characterized by development of
hypertension to the extent of 140/90 mm Hg or more with proteinuria after the 20th
week in a previously normotensive and nonproteinuric woman. In the absence of
proteinuria, hypertension with evidence of multisystem involvement cerebral or
visual disturbance can be considered pre-eclampsia
Complications
Eclampsia
Pre-term labor
HELLP syndrome
PPH
Cerebral hemorrhage
IUGR
Complications of Eclampsia
Injuries → Tongue bite, injuries due to fall from bed
Pulmonary complications
Edema
Pneumonia → Due to aspriation
ARDS
Embolism
Hyperpyrexia
Cardiac → Left ventricular failure
Renal failure
Hepatic → necrosis, subcapsular hematoma
Cerebral → edema, hemorrhage
Distrubed vision
Hematological → Thrombocytopenia, DIC
Postpartum → Shock, sepsis, psychosis
Pritchard regimen
Use for management of pre-eclampsia and eclampsia
Magnesium sulphate is used. It is available as 2mL ampules containing 1g
magnesium sulphate in each ampule
Loading dose → IV + IM
IV → 4 g, 20% solution (4 ampules + 12mL NS) slow IV over 3-5 mins
IM → 10 g, 50% solution (10 ampules) - 5 g in each buttock
If convulsions persist after 15 min, 2 g magnesium sulphate is given IV as a 20%
solution, rate to not exceed 1 g/min
Maintenance dose → 5 g , 50% solution to alternate buttocks every 4 hours
The loading dose is given irrespective of kidney function
Signs of toxicity have to be excluded before giving maintenance dose
Use of Magnesium sulphate in Preeclampsia.
Drug of choice for prevention and treatment of seizures in females with PIH
Mechanism of Action
Centrally acting drug
Blocks NMDA receptors in brain
Membrane stabilization as it is a CCB
Decreases release of acetylcholine
Brings about cerebral vasodilation
Regime
Therefore before giving maintenance dose the following signs of toxicity should be
excluded
Knee jerk or patellar reflex absent (First to manifest)
Antidote for toxicity → Calcium gluconate 1 g IV
MgSO4 is also used for neuro-prophylaxis in preterm labor if the gestational age <
32 weeks
A G3P2L2 at 37weeks of gestation presents to the hospital for the first time
with c/o 2 episodes of convulsion. On examination, Pulse rate- 103bpm, BP-
160/110 mmHg, Per abdomen- uterine height corresponds to 32 weeks
gestation, uterus is relaxed, liquor appears less, cephalic presentation with FHR-
130bpm. What is your diagnosis? How will you investigate and manage this
patient? List out the complications associated.
Eclampsia with IUGR/oligohydramnios
Investigations
Urine protein estimation
CBC with platelet count and hematocrit
Liver transaminases
Creatinine levels
Management
General measures
The patient should be nursed in a left lateral position in a cot with railings
The immediate management includes ensuring that the airway is open,
oropharyngeal suctions as and when necessary and oxygen administration during
convulsive episode
IV line should be established
Pulse oximetry to check for saturation (can reduce to pulmonary edema)
Bladder catheterization (Maintain output charts)
During convulsions a mouth gag is kept to prevent from biting tongue
Anticonvulsant therapy
Magnesium sulphate used
Available in 2mL ampules containing 1g magnesium sulphate in each ampule
Pritchard and Zuspan regimen
Monitoring for signs of toxicity

Absent patellar reflex (first to appear)
If toxicity occurs → CaGluconate (10%) 10 mL given IV
Contraindications → Myasthenia gravis, recent MI
Anti-hypertensives
Immediate termination is advisable after controlling seizures
Mode of delivery → Vaginal delivery
If delivery does not occur within 24 hrs. in patients with pre-eclampsia
C-section done
Preferred anesthesia → Neuroaxial anesthesia
Monitoring → Continue MgSO4 for another 24 hours. Monitor for oliguria,
19. Antepartum Hemorrhage

25 year old G2P1L1 with 32 weeks of gestation came to the hospital with 1
episode of bright red bleeding per vaginum. On examination she is pale, pulse
is 100/min and BP is 110/60 mmHg. Uterine height corresponds to 32 weeks,
relaxed. FHR is 140/min. A. What is the diagnosis? B. What are the points
favoring the diagnosis? C. Write evaluation and management of the condition
APH - Placenta previa
Placenta previa vs Abruptio placenta
Features Placenta previa Abruptio placenta
Bleeding Sudden painless bleeding Painful bleeding
Frequency of bleeding Multiple episodes Usually single bout
Color of blood Bright red Dark in color
Revealed/Concealed Always revealed Could be either revealed or concealed
Pallor Proportionate to blood loss May be out of proportion
Fundal height Corresponds to gestation May be more than gestation
Uterine consistency Relaxed Tense, tender and rigid
Fetal heart sounds Usually normal Absent or fetal distress
Evaluation and Management of APH
Resuscitation
Insert two large bore IV cannula (14 or 16 gauge)
Obtain samples for ABO, Rh type, CBC, bleeding time, clotting time, coagulation
profile
Start ringer lactate / normal saline and give oxygen by mask
Maintain airway, breathing and circulation
Blood transfusion should be started if necessary
The bladder should be catheterized and urine output should be monitored.
Vaginal exam is contraindicated
Vulval inspection is done to check whether bleeding has ceased and to confirm the
color and amount of bleeding
Once vitals are stable transabdominal ultrasound done for screening of placenta
previa
If placenta is in the lower segment, confirmation done by transvaginal sonography
(not contraindicated as the probe is 2 cm below the internal os)
Expectant Management
Prerequisites
Maternal and fetal condition good
Gestational age < 36 weeks
Patient not in labor
Fully equipped maternity hospital with facilities for emergency cesarean and blood
transfusion
McAffe and Johnson regime
Admit the patient
Give corticosteroid if the gestational age is between 24 to 34 weeks for lung maturity
If gestational age is less than 34 weeks and contraction are present give tocolytics.
Nifedipine is the drug of choice
If gestational age is < 32 weeks, give magnesium sulphate for neuro-prophylaxis
Give anti-D if patient is Rh negative
Correction of anemia
Fetal monitoring (NST weekly, biophysical profile, growth monitoring on USG)
No role for cervical cerclage
Termination of pregnancy is done at 36-37 weeks
If for a week the pregnant lady has no bleeding, transport is available within 30
minute transit time to the hospital then discharge her and ask her to follow up every
two weeks up to 36 weeks or if labor starts come to hospital immediately. Advice no
lifting heavy weight or intercourse.
When to terminate?
36-37 weeks of gestation
Onset of active labor
Fetus is dead
Profuse bleeding at any time
Maternal or fetal jeopardy
Mode of delivery → Cesarean section
A 32 year old primigravida presents with painless bleeding at 32 weeks of
gestation. On examination uterus is relaxed and fetal heart sounds are heard.
What is the cause for this antepartum hemorrhage? Write two other differential
diagnosis. Discuss further evaluation and treatment of this case.
The cause for this APH is placenta previa
Two differential diagnosis -
Abruptio placenta - painful bleeding, fetal sounds absent, tense uterus
Vasa previa
Resuscitation
profile
Once vitals are stable transabdominal ultrasound done for screening of placneta
previa
Prerequisites
transfusion
Admit the patient
If gestational age is < 32 weeks, give magnesium sulphate for neuroprophylaxis
When to terminate?
Fetus is dead
A Gravida 2, para 1, living 1 at 35 weeks presents with h/o pain abdomen and
bleeding P/V. On examination, pulse rate is 120/min and blood pressure is
90/60 mmHg; uterus is tense and tender. Fetal heart is absent. (x2) A. What is
the likely diagnosis? B. Discuss the management of the patient. C. List
complications.
APH - Abruptio placenta
Management
Resuscitation
profile, fibrinogen level (best marker for severity)
Vaginal exam is contraindicated in placenta previa
previa
If vasa previa is suspected, a sample of the blood is taken by speculum examination
to test for fetal hemoglobin using Apt test or Singer’s alkali denaturation test
Abruptio placenta is a clinical diagnosis and ultrasound is done only to rule out
placenta previa
After resuscitation
If mother is hemodynamically stable and fetal heart rate is normal then decide
according to the gestational age
gestational age < 34 weeks → Expectant management
Admit
Give corticosteroids, tocolytics are not preferred
If mother is Rh negative do Kleihauer-Betke test for dosage of anti-D
Fetal surveillance - NST, biophysical profile, USG growth monitoring
gestational age ≥ 34 weeks
Expedite delivery
Give corticosteroids and induce labor
Preferred route is vaginal delivery
if mother is hemodynamically unstable or if there is fetal distress after resuscitation
→ Emergency C-section
If there is fetal death and
DIC is present / mother unstable → Emergency C-section
DIC is absent and mother stable → Vaginal delivery
Complications
Maternal
Revealed type → Maternal risk is proportionate to the visible blood loss and maternal
death is rare
Concealed variety → The following complications may occur either singly or in
combination
Hemorrhage
Shock
Blood coagulation disorders
Oliguria and anuria - due to hypovolemia, seretonin liberated from the damaged
uterine muscle producing renal ischemia and acute tubular necrosis
Postpartum hemorrhage - due to atony of the uterus and increase in serum FDP
Fetal
Revealed type - fetal death is to the extent of 25-30%
Concealed type - fetal death risk if appreciably high, ranging from 50-100%
A 27 year old primigravida with 35 weeks of pregnancy complains of severe
pain abdomen and loss of fetal movements for 4 hours. On examination she is
pale. Uterus corresponds to 36 weeks and is tense & tender. Fetal heart could
not be heard. (2+4+4 = 10 marks) A. What is the complete diagnosis? B. Enlist
the investigations to be sent with rationale. C. Outline the management
Targeted anomaly scan
also known as a level 2 ultrasound or a detailed anomaly scan
prenatal ultrasound examination
performed between 18 and 22 weeks of pregnancy
focuses on specific areas of the fetus to assess for any abnormalities or anomalies.
assess the development of various organs and structures, including the brain, heart,
spine, and limbs.
measure the size and growth of the fetus
check the amount of amniotic fluid surrounding the fetus.
purpose → to identify any potential abnormalities or anomalies in the fetus, such as
birth defects or genetic conditions.
If any abnormalities are detected → additional testing or follow-up care.
performed in addition to the standard dating scan and the nuchal translucency scan,
which are performed earlier in pregnancy.
Abruptio placenta: Types and Grades
Types
Revealed variety → Bleeding is visible outside
Concealed variety → Blood collects behind the placenta → Enters myometrium of
uterus → Appears as if uterus is bruised → Covelaire uterus (Uteroplacental apoplexy)
Mixed → Features of both
Page classification of abruptio placenta
Grade 0 → Abruptio placenta is recognized after delivery due to retroplacental clot
Grade 1 → Bleeding + Pain with normal fetal heart sounds
Grade 2 → Bleeding + Pain with fetal distress
Grade 3 → Bleeding + Pain + Mother in shock/fetal death with or without DIC
Diagnosis and management of Abruptio placenta
Abruptio placenta is a clinical diagnosis. USG may be done to rule out placenta
previa. The diagnosis of abruptio placenta is made based on the following signs and
symptoms
Symptoms -
Severe and constant abdominal pain
Bleeding is present in the revealed and mixed types, but may be absent in concealed
type
Signs
Pallor which is usually out of proportion to bleeding
Hypertension (is there is assoicated pre-eclampsia)
Uterus will be larger than expected for the period of gestation
Uterus may be tense and tender and even rigid
Difficulty in palpating the fetal parts
Fetal distress or absent fetal heart sounds
CTG may show variable and late decelerations, poor baseline variability, prolonged
bradycardia or sinusoidal pattern
Management
Resuscitation
profile, fibrinogen level (best marker for severity)
Vaginal exam is contraindicated in placenta previa
previa
If vasa previa is suspected, a sample of the blood is taken by speculum examination
to test for fetal hemoglobin using Apt test or Singer’s alkali denaturation test
Abruptio placenta is a clinical diagnosis and ultrasound is done only to rule out
placenta previa
After resuscitation
If mother is hemodynamically stable and fetal heart rate is normal then decide
according to the gestational age
gestational age < 34 weeks → Expectant management
Admit
Give corticosteroids, tocolytics are not preferred
If mother is Rh negative do Kleihauer Betke test for dosage of anti-D
Fetal surveillance - NST, biophysical profile, USG growth monitoring
gestational age ≥ 34 weeks
Expedite delivery
Give corticosteroids and induce labor
Preferred route is vaginal delivery
if mother is hemodynamically unstable or if there is fetal distress after resuscitation
→ Emergency C-section
If there is fetal death and
DIC is present / mother unstable → Emergency C-section
DIC is absent / mother stable → Vaginal delivery
Vasa previa
It is a condition in which fetal vessels are present over the membranes covering
internal os and are ahead of the presenting part.
Three types
Type 1 → Associated with velamentous (marginal) insertion of cord (most common)
Type 2 → Associated with placenta succenturiata / bilobata
Type 3 → Associated with placenta previa (rarest)
Associated with fetal blood loss which increased perinatal mortality
In all patients of placenta previa, rule out vasa previa
Investigation of choice → TVS with doppler
Management
Fetal monitoring should start from 32 weeks
NST and Biophysical profile score (BPS) to be done weekly to rule out fetal distress
due to pressing of head onto blood vessels
Antenatal steroids to be given before 34 weeks
Plan C-section between 34-37 weeks
Most common CTG finding in vasa previa → Variable decelerations due to cord
compression
If vasa previa goes undiagnosed in pregnancy → Patient goes into labor →
Membranes rupture → Bleeding (fetal blood loss) → Fetal distress occurs out of
proportion to blood loss
Fetal blood and maternal blood can be differentiated using Singer’s alkali
denaturation test. On adding 1% KOH/NaOH if the color changes to brown it
indicates maternal blood. If the color does not change it is indicative of fetal blood.
Types of placenta previa and management of antepartum hemorrhage due to it. //
Types of Placenta Previa- Describe MacAfee and Johnson regimen
Types of placenta previa
New classification
Placenta previa → Placenta is at the level of internal os or above it (covering it)
Low lying placenta → Placenta is within 2 cm of the internal os but does not touch or
cover it
Older classification
Type 1: Low lying or lateral placenta previa → Placenta is in the lower uterine
segment but does not reach the internal os
Type 2: Marginal placenta previa → The placental edge reaches the margin of internal
os but does not cover it
Type 3: Incomplete placenta previa → The placenta covers the internal os partially
Type 4: Total, central or complete placenta previa → Placenta covers the internal os
completely
Resuscitation
profile
previa
Prerequisites
transfusion
Admit the patient
If gestational age is < 32 weeks, give magnesium sulphate for neuroprophylaxis
When to terminate?
Fetus is dead
20. Medical and Surgical Illness

Complicating Pregnancy
Define Gestational diabetes (GDM). List the risk factors for GDM. Discuss
Management of GDM at 30 weeks of gestation
GDM is defined as carbohydrate intolerance of variable severity with onset or first
recognition during the present pregnancy. Therefore it may include some women
with pre-existing but unrecognized diabetes. Risk factors
Positive family history
Having a previous birth of an overweight baby of 4kg or more
Previous stillbirth with pancreatic islet hyperplasia
Unexplained perinatal loss
Presence of polyhydramnios or recurrent vaginal candidiasis
Persistent glycosuria
Age > 30 years
Obesity
Ethnic group
Management
Aim → To maintain good glycemic control. This includes the following
Fasting blood glucose < 95 mg/dL
1 hour post-prandial glucose < 140 mg/dL
Two hours post-prandial glucose < 120 mg/dL
HbA1c < 6
Average capillary blood glucose levels < 100 mg/dL
How to?
Diet modification - Medical Nutrition Therapy (MNT)
Calories to be decided on the basis of pre-pregnant weight
The expected total weight gain during pregnancy is to be decided as follows
Pre-pregnancy weight BMI Total weight gain range (kg)
Normal weight 18.5-24.9 11.5-16 kg
Underweight < 18.5 12.5-18 kg
Overweight 25-29.9 7-11.5 kg
Obese > 30 5-9 kg
The macronutrients are to be divided as follows -
Carbohydrates → 40%
Fats → 40% (Saturated fats < 10% and cholesterol < 300 mg/day)
Proteins → 20%
Frank sugars and foods with high glycemic index should be avoided. Complex
carbohydrates should be encouraged
The MNT therapy is continued for two weeks and further management to be decided
based on the response at the end of two weeks.
If two hour PPG < 120 mg/dL
Continue MNT
No need for insulin therapy
Monitor two hour PPG
Upto 28 weeks → Biweekly
After 28 weeks → Weekly
if two hour PPG ≥ 120 mg/dL
Start insulin therapy
Monitor two hour PPG every 3rd day or more frequently till insulin dose adjusted to
maintain normal plasma glucose levels
Thereafter, monitor two hour PPG biweekly till 30 weeks and weekly thereafter.
Exercise
Moderate exercise at least 20 min daily is advised
Walking for 30 mins after a meal is also recommended and is shown to reduce
insulin requirements
Insulin therapy
Drug of choice for treating diabetes in pregnancy
Indications
GDM Patients → If two hour PPG not controlled (≥ 120 mg/dL) after two weeks of
MNT
Pre-gestational diabetes → From day 1 of pregnancy
2 hour PPG level ≥ 200 mg/dL in a pregnant female
Insulin Injection
SC route
40 IU/ml vial, human premix insulin (30:70) and insulin syringe (1 mL/40 IU) are used
One syringe can be used for a maximum of 14 times
Insulin should be stored in refrigerator between 4-8 C
Usage
Starting dose is decided as follows
Blood glucose level Dose of insulin
120-160 4U
160-200 6U
≥ 200 8U
Insulin injection to be given 30 minutes before breakfast
Every third day, fasting blood glucose level and two hour post prandial glucose levels
have to be checked
if FBS > 95 mg/dL on the third day → Add 2 U dose before breakfast
if 2 hour PPG > 120 mg/dL on the third day → Add 2 U dose before breakfast
if both are deranged → Add 4 U dose
Again on 3rd day measure FBS and two hour PPG levels. Keep titrating dose until FBS
< 95 mg/dL and two hour PPG < 120 mg/dL on third day. After that continue same
dose of insulin and MNT.
Measure FBS and two hour PPG biweekly till 30 weeks of pregnancy and every week
after 30 weeks of pregnancy
Oral hypoglycemia agents
Oral hypoglycemic agents are not used in pregnancy as they are less potent and
cross placenta causing hypoglycemia in fetus
However, metformin and glyburide can be used in pregnancy if pregnant female with
GDM refuses to take insulin (although they can’t be used in pre-gestational diabetes)
Dose
Metformin
Starting dose → 500 mg/day at bedtime
Monitor blood glucose levels and increase dose by 500 mg every week
Maximum dose → 2500 mg/day
Side effects → GI
Glyburide
Starting dose → 2.5-5 mg OD
Monitor blood glucose and increase dose weekly by 2.5-5 mg
Maximum dose is 20 mg/day
Most common side effect - maternal hypoglycemia
Antepartum management
First trimester screening for aneuploidy at 11-13 weeks and detailed anomaly scan at
18-20 weeks
Growth scans may have to be performed monthly in third trimester and macrosomia
and polyhydramnios looked for. An increased abdominal circumference with
increased fetal subcutaneous fat is highly suggestive of macrosomia
Those with poorly controlled gestational diabetes should undergo antepartum fetal
surveillance using NST and biophysical profile beginning from 32 weeks.
Doppler studies in cases complicated by pre-eclampsia or growth restriction
Timing of delivery
A1 GDM (GDM well controlled with MNT alone) → ≥ 39 weeks (up to 41 weeks)
A2 GDM (GDM treated with medications/insulin)
if well controlled → ≥ 39 weeks (up to 40 weeks)
if poorly controlled → 37-38 weeks + 6 days
Mode of delivery →
Vaginal delivery is preferred
C-section is done for obstetric reasons only
Induction of labor is important as risk of IUD and still birth increases towards the end
of pregnancy
Intrapartum glycemic control
During labor, insulin requirement decreases. So patients with GDM on insulin require
plasma glucose monitoring by a glucometer.
The morning dose of insulin is withheld on the day of induction of labor and the
patient should be started on two hourly plasma glucose monitoring
IV infusion with normal saline to be started and regular insulin to be added
according to blood glucose levels
Blood glucose levels (mg/dL) Amount of insulin added in 500 mL NS
90-120 0
120-140 4U
140-180 6U
> 180 8U
Postpartum management
Immediate postpartum care to be provided
Maternal glucose levels usually return to normal after delivery. Still, a fasting plasma
glucose and 2 hour PPG is performed on 3rd day of delivery.
Subsequently, perform 75 g GTT at 6 weeks postpartum to evaluate glycemic status
of woman.
Counseling regarding the risk of GDM in future pregnancies and developing frank
diabetes in the next 10-20 years
Write on tests performed for screening and diagnosis of gestational diabetes
(GDM). Mention the complications of GDM in Mother and Fetus. Briefly write
on pharmacological management of GDM.
IADPSG / WHO criteria
Test done at 24-28 weeks
8 hours of fasting required
Fasting blood sample is taken first
75g of oral glucose mixed in water is given then
Blood sugar levels are checked after 1 hour and 2 hours.
The diagnosis of gestational diabetes is made if at least one of the cut off values are
met
Time of sample Upper normal limit (mg/dL)
Fasting 92
1 hour 180
2 hour 153
DIPSI Guidelines (Govt. of India)
Screening at first visit and at 24-28 weeks of pregnancy
No fasting needed
Irrespective of previous meals 75 g of glucose in 300 mL water is given and the
whole solution has to be consumed in 5 minutes
If the patient vomits within 30 min of giving solution, test has to be repeated next
day
If the patient vomits after 30 mins of giving solution, continue with the test
Blood glucose levels are checked after 2 hours
Glucose levels after 2 hours if ≥ 140 mg/dL are diagnostic of gestational diabetes
mellitus, and glucose levels ≥ 200 mg/dL are indicative of pre-gestational diabetes.
Complications
Maternal →
Polyhydramnios → Due to polyuria by fetus
Preterm labor, PROM, abruptio placenta (due to polyhydramnios)
Placentomegaly
Placenta previa (due to placentomegaly)
Infections → Asymptomatic bacteriuria, UTIs and vaginal candidiasis
Birth trauma due to macrosomia
PPH due to overdistension of uterus
Type II diabetes later in life (50% risk)
Fetal
Congenital malformations (seen in overt diabetic mothers, not in GDM)
Hypoglycemia
Macrosomia
Delayed lung maturity
Necrotizing enterocolitis
Abortion, IUD, still birth
Pharmacological management
Insulin therapy
Indications
MNT
Insulin Injection
SC route
40 IU/ml vial, human premix insulin (30:70) and insulin syringe (1 mL/40 IU) are used
Usage
Blood glucose level Dose of insulin
120-160 4U
160-200 6U
≥ 200 8U
have to be checked
Dose
Metformin
Side effects → GI
Glyburide
Most common side effect - maternal hypoglycemia
A 35 year G2P1L1 at 30 weeks of gestation was diagnosed to have Gestational
Diabetes Mellitus. a) Enlist 4 each of maternal and fetal complications in her. b)
Mention the diagnostic test used for diagnosis, c) Write about the antenatal
management of this patient.
Complications
Maternal →
Polyhydramnios → Due to polyuria by fetus
Preterm labor, PROM, abruptio placenta (due to polyhydramnios)
Placentomegaly
Placenta previa (due to placentomegaly)
Infections → Asymptomatic bacteriuria, UTIs and vaginal candidiasis
Birth trauma due to macrosomia
PPH due to overdistension of uterus
Type II diabetes later in life (50% risk)
Fetal
Congenital malformations (seen in overt diabetic mothers, not in GDM)
Hypoglycemia
Macrosomia
Delayed lung maturity
Necrotising enterocolitis
Abortion, IUD, still birth
75g of oral gluocse mixed in water is given then
met
Fasting 92
1 hour 180
2 hour 153
No fasting needed
day
Gluose levels after 2 hours if ≥ 140 mg/dL are diagnostic of gestational diabetes
Management
Aim → To maintain good glycemic control. This includes the following
Fasting blood glucose < 95 mg/dL
1 hour post-prandial gluocse < 140 mg/dL
Two hours post-prandial gluocse < 120 mg/dL
HbA1c < 6
Average capillary blood glucose levels < 100 mg/dL
How to?
Diet modification - Medical Nutrition Therapy (MNT)
Calories to be decided on the basis of pre-pregnant weight
The expected total weight gain during pregnancy is to be decided as follows
Pre-pregnancy weight BMI Total weight gain range (kg)
Normal weight 18.5-24.9 11.5-16 kg
Underweight < 18.5 12.5-18 kg
Overweight 25-29.9 7-11.5 kg
Obese > 30 5-9 kg
The macronutriets are to be divided as follows -
Carbohydrates → 40%
Fats → 40% (Saturated fats < 10% and cholestrol < 300 mg/day)
Proteins → 20%
Frank sugars and foods with high glycemic index should be avoided. Complex
carbohydrates should be encouraged
The MNT therapy is continued for two weeks and further management to be decided
based on the response at the end of two weeks.
If two hour PPG < 120 mg/dL
Continue MNT
No need for insulin therapy
Monitor two hour PPG
Upto 28 weeks → Biweekly
After 28 weeks → Weekly
if two hour PPG ≥ 120 mg/dL
Start insulin therapy
Monitor two hour PPG every 3rd day or more frequently till insulin dose adjusted to
maintain normal plasma glucose levels
Thereafter, monitor two hour PPG biweekly till 30 weeks and weekly thereafter.
Exercise
Moderate exercise at least 20 min daily is advised
Walking for 30 mins after a meal is also recommended and is shown to reduce
insulin requirements
Insulin therapy
Indications
MNT
Insulin Injection
SC route
40 IU/ml vial, hman premix insulin (30:70) and isnulin syringe (1 mL/40 IU) are used
Usage
Blood gluose level Dose of insulin
120-160 4U
160-200 6U
≥ 200 8U
have to be checked
Dose
Metformin
Side effects → GI
Gylburide
Most comon side effect - maternal hypoglycemia
Antepartum management
First trimester screening for aneuploidy at 11-13 weks and detailed anomaly scan at
18-20 weeks
Growth scans may have to be performed monthly in third trimester and macrosomia
and polyhydramnios looked for. An increased abdominal circumference with
increased fetal subcutaneous fat is highly suggestive of macrosomia
Those with poorly controlled gestational diabetes should undergo antepartum fetal
surveillance using NST and biophysical profile beginning from 32 weeks.
Doppler studies in cases complicated by pre-eclampsia or growth restriction
Timing of delivery
A1 GDM (GDM well controlled with MNT alone) → ≥ 39 weeks (upto 41 weeks)
A2 GDM (GDM treated with medications/insulin)
if well controlled → ≥ 39 weeks (upto 40 weeks)
if poorly controlled → 37-38 weeks + 6 days
Mode of delivery →
Vaginal delivery is preferred
C-section is done for obstetric reasons only
Induction of labor is important is risk of IUD and still birth increases towards the end
of pregnancy
Intrapartum glycemic control
During labor, insulin requirement decreases. So patients with GDM on insulin require
plasma glucose monitoring by a glucometer.
The morning dose of insulin is withheld on the day of induction of labor and the
patient should be started on two hourly plasma glucose monitoring
IV infusion with normal saline to be started and regular insulin to be added
according to blood glucose levels
Blood gluose levels (mg/dL) Amount of insulin added in 500 mL NS
90-120 0
120-140 4U
140-180 6U
> 180 8U
Postpartum managment
Immediate postpartum care to be provided
Maternal glucose levels usually return to normal after delivery. Still, a fasting plasma
glucose and 2 hour PPG is performed on 3rd day of delivery.
Subsequently, perform 75 g GTT at 6 weeks postpartum to evaluate glycemic status
of woman.
Counseliing regarding the risk of GDM in future pregnancies and developing frank
diabetes in the next 10-20 years
Define Gestational Diabetes. A pregnant lady has an OGCT report as 160 mg%
.What would you do next? How do you interpret the results? Discuss the
antepartum management of Gestational diabetes in a patient diagnosed at 32
weeks
Gestational Diabetes: definition and diagnosis
GDM is defined as carbohydrate intolerance of variable severity with onset or first
recognition during the present pregnancy. Therefore it may include some women
with pre-existing but unrecognised diabetes.
75g of oral gluocse mixed in water is given then
met
Fasting 92
1 hour 180
2 hour 153
No fasting needed
day
Gluose levels after 2 hours if ≥ 140 mg/dL are diagnostic of gestational diabetes
Perinatal complications of Diabetes in pregnancy
Prolongation of labor due to big baby
Shoulder dystocia
Perineal injuries due to big baby
Postpartum hemorrhage due to inadequate involution of overly distended uterus
Operative interference
Indications and procedure of Glucose tolerance test as per International Association
of Diabetes and Pregnancy Study Group. // Glucose tolerance test in pregnancy
(practiced in our hospital now)
Indications
Fasting glycosuria on one occasion before 20th week and on two or more occasions
thereafter
Following a positive ‘screening test’
If fasting blood sugar exceeds 95 mg/100 mL or if that after 2 hours of ingestion of
100 g (WHO-75 g) glucose is over 120 mg/100 mL
However, if the fasting plasma glucose value is more than or equal to 126 mg/dL and
if confirmed on repeat test, there is no need to perform GTT as the woman is diabetic
Procedure
75g of oral glucose mixed in water is given then
met
Fasting 92
1 hour 180
2 hour 153
A 25 year old primigravida at 32 weeks with paroxysmal nocturnal dyspnea,
basal crepitations and mid diastolic murmur is admitted. A. What is the
complete diagnosis? B. Write the investigations and management of the
condition C. Write antenatal and obstetric management
Heart disease in pregnancy likely mitral stenosis complicated by pulmonary edema.
Investigations
ECHO → Reduction of area of mitral valve orifice, fish mouth appearance, dilatation
of left atrium
ECG → To look for atrial fibrillation
Management
Loop diuretics like furosemide to reduce the pre-load and pulmonary edema
For recurrent or intractable pulmonary edema balloon valvuloplasty may be done.
Preferably done in second trimester after 20 weeks of gestation. However if
necessary can be done at any gestational age.
Antenatal management
Goal is to avoid cardiac decompensation and to increase the cardiac output.
Limited physical activity is preferred
Sodium restriction in diet and diuretics given
If new onset A-fib develops verapamil, can be given or electro cardioversion can be
performed after adequate anti-thrombotic therapy is given for the appropriate
duration.
For chronic A-fib, digoxin of beta-blocker can be given to slow ventricular response
Obstetric management
Vaginal delivery is preferred.
First stage
Epidural analgesia is given as pain can cause tachycardia and precipitate heart failure
PGE2 may be used for cervical ripening
Induction of labor is safe and is done by oxytocin
Position → Sem recumbent position with lateral tilt (to minimize aortocaval
compression)
Monitor half hourly pulse, BP and auscultate lung bases for crepitations
Restrict IV fluid to 75 ml/hour
Infective endocarditis prophylaxis if indicated
Second stage
Cut short the second stage by forceps (preferably as they reduce maternal effort) or
vacuum
Management of third stage of labor
Oxytocin is used as the uterotonic of choice. Methyl ergometrine is contraindicated.
Give diuretics like IV furosemide
Complications of Heart disease in pregnancy - Six maternal, 2 fetal
Maternal
Congestive cardiac failure
Acute pulmonary edema
Arrhythmias
Pulmonary embolism
Infective endocarditis
Rupture of cerebral aneurysm in coarctation of aorta
Fetal
Fetal congenital cardiac disease risk in increased
FGR
Prematurity
Heart Disease in Pregnancy: NYHA classification & labor management
Management of labor in a primigravida with moderate mitral stenosis.
Vaginal delivery is preferred.
First stage
Epidural analgesia is given as pain can cause tachycardia and precipitate heart failure
PGE2 may be used for cervical ripening
Induction of labor is safe and is done by oxytocin
Position → Sem recumbent position with lateral tilt (to minimize aortocaval
compression)
Monitor half hourly pulse, BP and auscultate lung bases for crepitations
Restrict IV fluid to 75 ml/hour
Infective endocarditis prophylaxis if indicated
Second stage
Cut short the second stage by forceps (preferably as they reduce maternal effort) or
vacuum
Management of third stage of labor
Oxytocin is used as the uterotonic of choice. Methyl ergometrine is contraindicated.
Give diuretics like IV furosemide
2014 NACO guidelines for management of HIV in pregnancy
Strategies for prevention of mother to child transmission of HIV during pregnancy,
childbirth and postnatally (x2)
Pre-natal
HAART → Use of ART during pregnancy reduces the risk of mother to child
transmission drastically as it reduces viral load in the blood
For newly diagnose case of HIV in a pregnant female start ART immediately without
any delay irrespective of gestational age, CD4 count, WHO clinical staging.
Recommended first line regimen
HIV-1 infection → Tenofovir (300 mg) + Lamivudine (300 mg) + Efavirenz (600 mg)
once daily. If there is previous exposure to efavirenz in any previous pregnancies
replace it with Lopinavir/ritonavir (400mg/100mg) twice daily.
HIV-2 infection or HIV-1 and HIV-2 coinfection → Tenofovir (300 mg) + Lamivudine
(300 mg) + Lopinavir/ritonavir (800mg/200mg) once daily.
Natal
Always opt for vaginal delivery irrespective of CD4 counts/viral loads unless obstetric
indication for C-section is present.
ART can reduce the risk of parent-to-child transmission better and with lesser risk
than C-section
Prevention of parent-to-child transmission during labor and delivery
Minimize vaginal examinations
Avoid prolonged labor, consider oxytocin to shorten labor
Avoid artificial ROM
Early cord clamping (<1 min) after it stops pulsating and after giving the mother
oxytocin
Use non-invasive fetal monitoring
Avoid routine episiotomy
Minimize the use of forceps and ventose
Post-natal
Breastfeeding not contraindicated in HIV positive females
Do not give mixed feeds (either exclusive breast feeding or exclusive supplementary
feeding)
Prophylaxis should be given for 6 weeks to all newborns born to HIV positive
mothers irrespective of breastfeeding or supplementary feeding decision
HIV-1 → Nevirapine prophylaxis
HIV-2 → Zidovudine prophylaxis
Duration of prophylaxis is to be increased to 12 weeks if mother decides to
breastfeed and ART is started to mother in later pregnancy, during or after delivery
or has not been on ART for an adequate period of 4 weeks to be effective for optimal
viral suppression.
Women should continue ART lifelong
Effects of iron deficiency anemia on pregnancy and puerperium
Pregnancy
Pre-eclampsia
Increased risk of infections
Heart failure
Preterm labor
Labor
Uterine inertia
Post partum hemorrhage
Cardiac failure
Shock
Puerperium
Puerperal sepsis
Sub-invoution of uterus
Poor lactation
Increased chances of venous thromboembolism
Increased chances of pulmonary embolism
Poor wound healing
Management of Iron deficiency anemia in pregnancy
MANAGEMENT OF ANEMIA IN PREGNANCY
Investigations
To ascertain
type of anemia
chronic disease
Thyrotoxicosis
MCV
cause of anemia
Serum hepcidin levels decrease in iron deficiency anemia but increase in anemia of
chronic disease
Megaloblastic anemia → B12, Folate levels, Homocysteine levels, methylmalonic acid
levels
Management

the rate of 0.7 g/dL per week
Diagnosis and management of Iron deficiency anemia in pregnancy (x2)
Investigations
To ascertain
Severity Hb levels (g/dL)
Mild 10-10.9
Moderate 7-9.9
Severe <7
Very severe (ICMR) < 4
type of anemia
chronic disease
Thyrotoxicosis
MCV
cause of anemia
Serum hepticidin levels decrease in iron deficiency anemia but increase in anemia of
chronic disease
Management

Dose Required (Ganzoni Formula) = [2.4 x Hb deficit x Weight (kg)] + 500 mg
Parenteral iron therapy // Parenteral iron therapy -Indications, Dose calculation,
Administration // Iron sucrose therapy
Indications
Non-compliant patient
Non-tolerant patient (gastritis, nausea, vomiting)
Mild to moderate anemia at gestational age > 34 weeks
Severe anemia at gestation age < 34 weeks (except first trimester)
Contraindications
First trimester pregnancy
History of previous anaphylactic reaction
Dose calculation
Administration
The infusion rate is 15-20 drops/minute for initial 5 minutes (check for any
anaphylactic reaction)
If no reaction seen, increase the drop rate to 80-90 drops per minute
Define anemia in pregnancy. Write evaluation and treatment of iron deficiency
anemia in pregnancy. List the complications of the same.
According to WHO, anemia in pregnancy is defined as hemoglobin below 11 g/dL.
Evaluation
History
Weakness, fatigue, lethargy, light headedness
Dyspnea
Palpitations
Orthopnea and PND
Edema that is not relieved by rest
Loss of appetite
Presence of worms in stool
Bleeding tendencies
Past h/o CKD, RA, PICA
Menstrual irregularity like previous menorrhagia
Examination
Pallor → Eyes, oral mucosa, nail bed, vaginal mucosa
Shape of nails → Koilonychia, platynychia
Glossitis, cheilosis
JVP
Lymphadenopathy
Investigations
To ascertain
Severity Hb levels (g/dL)
Mild 10-10.9
Moderate 7-9.9
Severe <7
Very severe (ICMR) < 4
type of anemia
chronic disease
Thyrotoxicosis
MCV
cause of anemia
Serum hepticidin levels decrease in iron deficiency anemia but increase in anemia of
chronic disease
Management

Complications
Pregnancy
Pre-eclampsia
Increased risk of infections
Heart failure
Preterm labor
Labor
Uterine inertia
Post partum hemorrhage
Cardiac failure
Shock
Puerperium
Puerperal sepsis
Sub-invoution of uterus
Poor lactation
Increased chances of venous thromboembolism
Increased chances of pulmonary embolism
Poor wound healing
Asymptomatic bacteriuria - Definition, consequences and treatment // Asymptomatic
Bacteriuria in pregnancy
The term asymptomatic bacteriuria (ASB) is used when a bacterial count of the same
species over 105/��105/mL in midstream clean catch specimen of urine on two
occasions is detected without symptoms of urinary infection.
Consequences -
Pyelonephritis → It can further lead to
Anemia
Hypertension
Preterm labor
Treatment
Drug of choice → Nitrofurantoin 100 mg BD for 3 days or 100 mg bedtime for 10
days
For recurrent cases, nitrofurantoin 100 mg bedtime is given for 21 days
Other drugs
Ampicillin / Amoxicillin (500 mg TID)
Cephalexin (500 mg TID)
Treatment of Syphilis in pregnancy
Mother
Treatment started as soon as the diagnosis is established
For primary or secondary or latent syphilis (< 1 year duration) → Benzathine penicillin
2.4 million units IM single dose
When duration is more than 1 year → Benzathine penicillin 2.4 million units IM
weekly for 3 doses
If allergic to penicillin → Oral Azithromycin 2 g single dose
Tertiary disease → Neurosyphilis - Aqueous crystalline penicillin G 18-24 million units
IV daily for 10-14 days is given.
Baby born to mother with syphilis
Serological Clinical evidence of Management
Reaction disease
+ None Penicillin G 50,000 units IM single dose
+ Present Aqueous procaine penicillin G 50,000 units per kg body weight
each day for 10 days
- Absent Serological reaction should be tested weekly for the first month
and then monthly for 6 months
21. Gynecological Disorders in Pregnancy

22. Preterm Labor, Preterm Rupture of the
Membranes, Postmaturity, Intrauterine
Fetal Death
A primigravida at 30 weeks of pregnancy presents with painful uterine
contractions. Her cervix is 2 cm dilated. a) How do you decide about her further
management? b) Write the drugs used in treating this patient along with dose
and side effects. c) Mention four immediate problems for a preterm baby
General measures are taken
The patient is advised to lie in left lateral position
Adequate hydration
Infection to be ruled out by CBC and CRP.
Since the lady is already in labor and the period of gestation is less than 34 weeks
the main aim is to arrest pre-term labor for sufficient time so as to
Transfer the mother to tertiary care center with NICU facilities where the delivery can
be managed well
Administration of antenatal corticosteroids and their effect to come upon fetus
Administrations of magnesium sulphate for neuro-prophylaxis and their effect to
come upon fetus
Administrations of anti-biotics to prevent neonatal infection with group B
streptococci
The drugs used are -
Antenatal corticosteroids → Used if the period of gestation is < 34 weeks
Drugs used are
Betamethasone 12 mg IM 24 hours apart for two doses (preferred)
Dexamethasone 6 mg IM every 12 hours for four doses
Risks of antenatal corticosteroid use
The risk of infection in PROM may increase
Insulin dependent diabetes mellitus need insulin readjusted dose
Transient reduction in fetal breathing and movements
Magnesium sulphate → Used if the period of gestation is < 32 weeks
4 g IV over 3-5 minutes followed by 1g/hr IV infusion over 24 hours
Can lead to toxicity if proper monitoring of dose is not done. It manifests as
Chest pain, discomfort, respiratory discomfort
Visual changes, flushing
Absence of deep tendon reflexes (patellar reflex)
Urine output < 30 mL / hr
Fall in BP
Tocolytics → Effective for only 48-72 hours.
Drugs used are -
Nifedipine →
It is a calcium channel blocker
Dose → 10-20 mg every 3-6 hours
Side effects - Maternal → Hypotension, headache, flushing and nausea
Indomethacin
Prostaglandin synthetase inhibitor
Dose → Loading dose 50 mg oral or per rectum followed by 25 mg every 6 hours for
48 hours
Side effect →
Fetal → Premature closure of PDA, neonatal pulmonary hypertension
Maternal → flushing, perspiration, headache, muscle weakness
Atosiban
Oxytocin antagonist
Dose → IV infusion 300 micro-gram/min
Side effect → nausea, vomiting, chest pain
Beta-agonists
Ritodrine - IV infusion 50 micro-gram / min and is increased by 50 micro-gram every
10 mins until contractions cease. Infusion is continued for about 12 hours after
contractions cease
Terbutaline → SC injection of 0.25 mg every 3 to 4 hours is given
Side effects
Maternal → Headache, palpitaitons, tachycardia, pulmonary edema, hypotension
Fetal → Tachycardia, heart failure
Neonatal → Hypoglycemia and intraventricular hemorrhage
Penicillin
For Group B streptococcus prophylaxis if couldn’t be ruled out
IV route is used
Side effect → Anaphlaxis in people allergic to penicillin
Problem associated with pre-term baby are
Neonatal asphyxia
Hypoglycemia
Hypothermia
Anemia
Interventricular hemorrhage
Neonatal jaundice
Retinopathy of prematurity
Respiratory distress
Write four contraindications for tocolysis in Preterm labor with reasoning
Maternal
Uncontrolled diabetes, thyrotoxicosis, severe hypertension, cardiac disease
Hemorrhage in pregnancy, eg. placenta previa
Fetal
Fetal distress, fetal death, congenital malformation
Pregnancy > 34 weeks
Others
Rupture of membranes, chorioamnionitis, and cervical dilatation > 4 cm
A Primigravida aged 21yrs reported at 32 weeks gestation with preterm pre
labor rupture of membranes (PPROM). a) Explain points for diagnosis of
PPROM. b) List causes and complications of PPROM. c) Discuss in detail the
management of the patient.
Points for diagnosis
A pregnant woman presenting with history of sudden gush of fluid from vagina
leading to soaking of her clothes must warrant suspicion of PROM or PPROM
Vaginal examination is contraindicated as it can lead to infection
Sterile speculum examination is done to confirm the presence of leaking
The diagnosis is confirmed by the following findings
Visual inspection : Visualizing amniotic fluid passing from the cervical canal
Nitrazine test : Alkaline vaginal pH of more than 6-6.5 with nitrazine paper (the strip
turns blue)
Fern test : Ferning of dried amniotic fluid on a slide due to crystallization
Ultrasound : Oligohydramnios
Detection of fetal fibronectin and IGFBP-1 in cervicovaginal secretions
Causes
Infection
Primary aeteological factor leading to chorioamnionitis
Chalmydia trachomatis, Neisseria gonorrhea, Group B streptococci, Trichomonas
vaginalis are the most commonly implicated organisms
They cause PROM by increase in cytokines and imbalance of MMP and TIMP
Mechanical factors
Malpresentations
Multiple pregnancy
Polyhydramnios
Connective tissue disorders like Ehler Danlos syndrome
Iatrogenic risk factors → Cerclage, amniocentesis, cordocentesis, fetoscoy
Others →
Previous history of PROM
Low BMI
Low socioeconomic status
Maternal smoking
Complications
Choriamnionitis → It can further lead to
Sepsis
Postpartum endometritis
Septic pelvic vein thrombophlebitis
Abnormal labor
Atonic PPH
Cord prolapse
Management
Since the gestational age < 34 weeks expectant management is preferred.
Evaluation
A speculum examination is done to confirm ROM and to rule out cord prolapse and
take a cervical swab for culture and sensitivity
Expectant management
Admit the patient
A course of corticosteroid is adminstered, contraindicated if there is associated
chorioamnionitis
Drugs used are
Short term tocoytics for 48 hours to buy time for corticosteroids to act
Drugs used are -
Nifedipine →
Indomethacin
48 hours
Atosiban (not available in India)
Oxytocin antagonist
Beta-agonists (not used now)
contractions cease
Rectovagianal swab for Group B streptococci screening. Start GBS prophylaxis. The
antibiotics are stopped if screening result comes out to be negative.
The drug uses is IV penicillin
Maternal monitoring for temperature, uterine tenderness, uterine contractions.
Fetal monitoring by daily fetal movement count, NST (daily) and biophysical profile if
NST is non-reactive
Periodic USG to monitor fetal growth
If gestational age < 32 weeks, magnesium sulphate is administered for
neuroprotection.
Labor and delivery
Cardiotocography monitoring is recommended during labor to detect cord
compression and oligohydramnios.
The preferred mode of delivery is vaginal.
In case of recognized GBS infection, IV penicillin should be given
Preterm baby: Complications. Antenatal prophylaxis
Complications -
Neonatal asphyxia
Hypoglycemia
Hypothermia
Anemia
Interventricular hemorrhage
Neonatal jaundice
Respiratory distress
Antenatal prophylaxis
Antenatal corticosteroids → Used if the period of gestation is < 34 weeks
Drugs used are
Magesium sulphate → Used if the period of gestation is < 32 weeks
Tocolytics → Effective for only 48-72 hours.
Drugs used are -
Nifedipine →
Indomethacin
48 hours
Atosiban
Oxytocin antagonist
Beta-agonists
contractions cease
Penicillin
For Group B streptococcus prophylaxis if couldn’t be ruled out
IV route is used
Etiology and Management of PPROM at 34 weeks
Etiology
Infection
Primary aeteological factor leading to chorioamnionitis
Chalmydia trachomatis, Neisseria gonorrhea, Group B streptococci, Trichomonas
vaginalis are the most commonly implicated organisms
They cause PROM by increase in cytokines and imbalance of MMP and TIMP
Mechanical factors
Malpresentations
Multiple pregnancy
Polyhydramnios
Connective tissue disorders like Ehler Danlos syndrome
Iatrogenic risk factors → Cerclage, amniocentesis, cordocentesis, fetoscoy
Others →
Previous history of PROM
Low BMI
Low socioeconomic status
Maternal smoking
Management
Risk due to infection (chorioamnionitis) > Risk due to prematurity at 34 weeks
So the main management is to induce labor and delivery the baby
Corticosteroids are contraindicated after 34 weeks
The preferred mode of delivery is vaginal delivery unless there are obstetric
indications for C-section
Induction of labor with oxytocin is done.
Broad spectrum antibiotics are administered if there is prolonged PPROM (more than
18 hours)
Management of Intra uterine fetal demise. // Intrauterine Death: Causes &
Management
Diagnosis
Clinical examination
History of loss of fetal movements
Size of uterus may be less than POG if there was FGR or there may be evidence of
polyhydramnios or macrosomia in diabetic.
The fetal heart sounds will be absent
Ultrasound
Absence of fetal cardiac activity on ultrasound is diagnostic
Spalding sign (overlapping of fetal skull bones) may be seen
A large retroplacental clot may be seen in case of abruption
Radiology (used earlier)
Robert sign → Presence of gas in large vessels of fetus
Ball sign → Crumpled up spine of fetus
Spalding sign → Overlapping of fetal skull bones
Management
Breaking the bad news → Proper counselling of the parents along with their relatives
has to be done. A late IUD that is sudden and unexpected requires an empathetic
approach
In 80% cases a dead fetus is automatically expulsed from the uterus within 2 weeks.
However, most women won’t prefer to carry a dead fetus inside them due the
psychological and social aspect.
Monitoring for coagulation failure by clotting tests, platelet count and fibrinogen
levels should be done.
Women who are Rh-negative should be administered anti-D immunoglobulin.
Vaginal delivery is preferred mode.
Mode of induction
A combination of mifepristone and misoprostol is given. A single dose of
mifepristone (200 mg) is given and misoprostol is given according to the period of
gestation
If < 26 weeks → 200 microgram vaginally, sublingually or buccally every 4-6 hours
If 27-28 weeks → 100 microgram vaginally, sublingually or buccally every 4 hours
If > 28 weeks → 25 microgram vaginally every 6 hours or orally every 2 hours
Postnatal management → Dopamine agonists like cabergoline are considered best
for suppressing lactation. Cabergoline 0.25 mg twice daily for two days will suffice.
Contraceptive advice should be given. The women should be told that regainment of
fertility may be rapid due to suppression of lactation.
Evaluation of cause →
Clinical assessment and ultrasound → To look for findings as mentioned in diagnosis
Maternal investigations →
Indirect Coomb’s test if women is Rh-negative
Kleihauer Betke Test (in case of massive fetomaternal bleed)
Bile acid (obstetric cholestasis)
VDRL (syphilis)
Fasting and postprandial blood glucose and HbA1c
APLA syndrome (testing for antibodies)
Fetal testing
Chromosomal abnormalities
Autopsy (if the parents are willing) - to be done by a specialized perinatal pathologist
Postnatal visit - If a definite cause is found it should be communicated to the parents.
They should be told about the chances of recurrence and any preventive measures to
be followed preconceptionally or during next pregnancy.
23. Complicated Pregnancy

Prerequisites and factors influencing the success of a Vaginal Birth After Caesarean
Pre-requisites
Maximum 2 LSCS in the past
Adequate pelvis
No diabetes, macrosomia, post-term pregnancy (in current pregnancy)
No malpresentation in present pregnancy
Non recurring indication of C-section in previous pregnancies
Tried at higher center with facility for emergency C-section and blood transfusion
No other uterine scar of complete thickness
No history of extension of scar into upper segment (e.g.. classical C-section, Kronig
incision, T-shaped incision)
No history of uterine rupture in the past
Predictors
Prior nonrecurring indication of C- section (breech, fetal distress)
Woman having prior vaginal delivery (87% success)
Estimated fetal weight - higher the fetal weight, lower the success
Spontaneous onset of labor in the present pregnancy, higher success
Women with prior successful VBAC
Cervical dilatation (on admission) > 4 cm - higher (86%) the success
Women with previous LSCS due to breech presentation - higher success (89%)
Women who are obese and elderly - lower success
Predictors of Success in Trial of labor after Cesarean and complications
Predictors
Prior nonrecurring indication of C- section (breech, fetal distress)
Woman having prior vaginal delivery (87% success)
Estimated fetal weight - higher the fetal weight, lower the success
Spontaneous onset of labor in the present pregnancy, higher success
Women with prior successful VBAC
Cervical dilatation (on admission) > 4 cm - higher (86%) the success
Women with previous LSC due to breech presentation - higher success (89%)
Women who are obese and elderly - lower success
Complications
Maternal
Uterine wound dehiscence
Uterine rupture
Increased blood transfusion
Increased risk of hysterectomy due to uterine rupture
Infections, increased maternal morbidity
Perinatal
Low Apgar score
Admission to NICU
Hypoxic Ischemic Encephalopathy
Neonatal death
Rarely stillbirth
Prevention of Rh isoimmunization (x2)
Management
Screening by Indirect Coombs Test
All women who are Rh-negative with an Rh-positive partner should have an antibody
screen at booking.
Management is decided based on the result of this test
If test is negative → Mother not allo-immunized. Prophylaxis can be given
If test is positive → No use of prophylaxis
Management of non-immunized mother
Test repeated at 28 weeks.
If test is negative at 28 weeks, the current recommendation is to given 300
microgram of anti-D antibodies prophylactically. The antepartum prophylaxis is to
cover a small proportion of women who become immunized by silent feto-maternal
hemorrhage in pregnancy.
If the baby is Rh positive a second prophylaxis is to be given after delivery as early as
possible. (within 72 hours). The second dose is necessary because the half life of anti-
D is only 24 days and also because feto-maternal hemorrhage is more likely during
delivery.
A 26 years gravida 2 para 1 with previous neonatal death on day one due to
jaundice is referred with ICT titers of 1:16 at 26 weeks of gestation. Discuss the
investigations and treatment for this patient till delivery. Briefly describe
neonatal management at birth
Investigations
Paternal blood group genotyping →
Paternal genotyping may be done to identify if father is homzygous for D antigen or
heterozygous.
If heterozygous the chances of fetus being Rh-positive is 50%,
If homozygous the chances of fetus being Rh-positive if 100%
Fetal blood group determination
If the father is heterozygous there is a 50% chance that the fetus is Rh-negative.
Fetal blood group determination can be done in such cases by amniocentesis or
chorionic villi samling and DNA testing.
Ultrasound assessment
Accurate dating in the first trimester is essential as anemia tends to develop earlier
than in the previous pregnancy
Repeat scans are necessary to assess fetal growth and identify fetal hydrops
Middle cerebral artery doppler
Anemic fetus shunts blood preferentially to brain for adequate oxygenation
The peak MCA systolic velocity increases in fetal anemia
A threshold of 1.5 MoM identifies all fetuses with moderate or severe anemia.
Once the MCA peak systolic velocity exceeds this threshold, fetal blood sampling is
indicated to assess the need for intravascular fetal transfusions if the fetus is preterm.
If the fetus is term or near term the woman can deliver.
Usually MCA measurements are begun at 20 weeks because it may be difficult to
perform intravascular transfusions before that.
MCA doppler has almost completely replaced the need for amniocentesis and
amniotic fluid bilirubin evaluation
Management
Fetal blood sampling and intravascular transfusion
The preterm fetus should be evaluated using fetal blood sampling and intravascular
transfusions are given as needed.
Fetal blood sampling is done from the umbilical vein.
Two sites are used for intravascular transfusion. One is the umbilical vein at the site
of cord insertion into the placenta and the other is the intrahepatic portion of the
umbilical vein (ductus venosus)
The procedure is done under sterile conditions in an operation theater under
ultrasound guidance.
The movement of fetus is paralyzed using pancuronium bromide injection injected
into the fetal thigh
Then a 20 gauge needle is inserted and a sample is taken from the umbilical vein.
The fetal Hb, hematocrit, ABO and Rh type, Direct Coomb’s test and reticulocyte
count are assessed immediately.
If the hematocrit is less than 30%, transfusion can be done in the same sitting with O
negative blood. The goal is to achieve a hematocrit of 50% at the end of procedure
After the procedure the fetus is followed up with ultrasound to note the decrease in
hydrops and improvement of MCA doppler
The procedure may have to be repeated until the fetus can be delivered. The second
transfusion is usually planned for 10-14 days after the first.
Once the gestational age has reached 34 weeks the fetus can be delivered.
Antepartum corticosteroids
Betamethasone 12 mg initially and repeated after 24 hours is always given to
increase the lung maturity in the event that early delivery is necessary
Delivery
The timing of delivery depends upon severity of disease and neonatal facilities.
If the fetus is still premature, fetal blood sampling and intravascular transfusion is
indicated up to 34 weeks and then the baby is delivered.
In mild cases, delivery at 38 weeks is carried out.
C-section is only reserved for obstetric indications or if early delivery is needed in a
severely compromised fetus when the cervix is unfavourable.
Neonatal management
Cord blood is taken for Hb, hematocrit and direct Coomb’s test.
If the baby is anemic, immediate exchange transfusion may be needed with O
negative blood.
Monitor for features of pathological jaundice
Clinical jaundice appearing on the first day of life
Bilirubin levels rising > 5 mg/dL/day or > 0.2 mg/dL/hr
Jaundice on palms and soles
Signs of hepatic encephalopathy.
If features of pathological jaundice are seen then it is treated with phototherapy or
exchange transfusion
24. Contracted Pelvis

Gynecoid pelvis
It is the most common type of female pelvis. The features are as follows -
Inlet
Shape → Round
Anterior and posterior segment → Almost equal and spacious
Sacrum → Sacral angle mroe than 90 degree. Inclined backwards. Well curved from
above down and side to side
Cavity
Sacro sciatic notch → Wide and shallow
Sidewalls → Straight or slightly divergent
Outlet
Ischial spines → Not prominent
Pubic arch → Curved
Subpubic angle → Wide (85 degrees)
Bituberous diameter → Normal
Obstetric outcome
Inlet
Position → Occipitotransverse or oblique occipitoanterior
Diameter of engagement → Transverse or oblique
Engagement → No difficulty, usual mechanism
Cavity
Internal rotation → Easy anterior rotation
Outlet
Delivery → No difficulty
Munro-Kerr-Muller test
Lower bowel is emptied, preferably by enema. The patient is asked to empty the
bladder. The patient is placed in lithotomy position and the internal examination is
done taking all aseptic precautions. Two fingers of the right hand are introduced into
the vagina with the fingertips placed at the level of ischial spines and thumb is
placed over the symphysis pubis. The head is grasped by the left hand and is pushed
in a downward and backward direction into the pelvis
Inferences -
The head can be pushed down up to the level of ischial spines and there is no
overlapping of the parietal bone over the symphysis pubis — no disproportion
The head can be pushed down a little but not up to the level of ischial spines and
there is slight overlapping of the parietal bone — slight or moderate disproportion
The head cannot be pushed down and instead the parietal bone overhangs the
symphysis pubis displacing the thumb — severe disproportion
Limitations-
The method is only applicable to note the presence or absence of disproportion at
the brim and not at all applicable to elicit midpelvic or outlet contraction
The fetal head can be used as a pelvimeter to elicit only the contraction in the
anteroposterior plane of the inlet but when the contraction affects the transverse
diameter of the inlet, it is of less use.
25. Abnormal Uterine Action

Difference between retraction (Bandl’s) ring and constriction ring
Constriction ring
It is one form of incoordinate uterine action where there is localized myometrial
contraction forming a ring of circular muscle fibers of the uterus.
It is usually situated at the junction of the upper and lower segment around a
constricted part of the fetus usually around the neck in cephalic presentation.
Abdominal examination
Uterus feels normal and not tender
Ring is not palpable
FHS are heard
Fetal parts are palpable
Round ligament is not felt
Vaginal examination
Lower segment is not pressed by the presenting part
Ring is usually above the head
Features of obstructed labor are absent
Causes -
Injudicious administration of oxytocic
Premature rupture of membranes
Premature attempt of instrumental delivery
Bandl’s ring -Definition, clinical features
This type of uterine contraction is predominantly due to obstructed labor. There is
gradual increase in intensity, duration and frequency of uterine contraction. The
relaxation phase becomes less and less; ultimately, a state of tonic contraction
develops. Retraction, however, continues. The lower segment elongates and
becomes progressively thinner to accommodate the fetus driven from the upper
segment. A circular groove encircling the uterus is formed between the active upper
segment and the distended lower segment, called pathological retraction ring
(Bandl’s ring).
Clinical features:
Patient is in agony from continuous pain and discomfort and becomes restless
Features of exhaustion and ketoacidosis are evident;
Abdominal palpation reveals
Upper segment is hard and tender
Lower segment is distended and thinned out
Ring is felt obliquely
Fetal parts are not felt
Vaginal examination
Ring is not felt
Lower segment is very much pressed by the forcibly driven presenting part
Features of obstructed labor are present
Clinical features of Incoordinate uterine action
It consists of
Spastic lower uterine segment -
Per abdomen : tender uterus, difficult palpation of fetal parts, fetal distress
Per vaginum : Cervix is thick, edematous and hands loosely like a curtain,
inappropriate dilatation of the cervix
Constriction ring
Per abdomen : soft, non-tender, fetal parts are palpable, ring not palpable
Per vaginum : Ring felt above head, lower segment not pressed by the presenting
part
Cervical dystocia : Spasm of the cervix
Generalized tonic contraction
Per abdomen : Uterus smaller in size, tense and tender, fetal parts are not well
defined, FHS not audible
Per vaginum : Jammed head with big caput, dry and edematous vagina
Common clinical features -
Frequent low amplitude contractions
Elevated basal intrauterine pressure
Maternal discomfort
Pain is present before, during and after contractions
CTG : Reduced variability and late decelerations
Complications
Fetal hypoxia
Placental abruption
Extras
SPASTIC LOWER SEGMENT
The patient is in agony with unbearable pain referred to the back. There are
evidences of dehydration and ketoacidosis
Bladder is frequently distended and often there is retention of urine; distension of
the stomach and bowels are visible
There are premature attempts to bear down
Abdominal palpation reveals:
Uterus is tender and gentle manipulation excites hardening of the uterus with pain
palpation of the fetal parts is difficult;
Fetal distress appears early
Internal examination may reveal
Cervix which is thick, edematous hangs loosely like a curtain; not well applied to the
presenting part
Inappropriate dilatation of the cervix
Absence of the membranes
Meconium stained liquor amnii may be there
26. COMPLICATED LABOR-Malposition,

Malpresentation and Cord Prolapse
A primigravida in labour at term reports to labour room. Pervaginal
examination reveals cervix is 6 cm dilatated, well effaced and easily palpable
anterior fontanelle in the left anterior quadrant of pelvis. A. What is the most
probable diagnosis? What are the likely abdominal findings in this case? B.
Write steps of pelvic assessment to make sure that she is likely to have vaginal
birth. C. Write about three types of head rotation in this patient and
management of the same
Pregnant woman with fetus in right occipitoposterior position. Abdominal findings -
Inspection → Abdomen looks flat below the umbilicus
Second Maneuver (Umbilical grip) →
Fetal limbs are more easily felt near the midline on either side
Fetal back is felt far away from the midline on the flank and is difficult to outline
clearly
Anterior shoulder lies away from the midline
Fetal heart sounds more towards flank
Assessment of the pelvis
It can be done by
bimanual examination: clinical pelvimetry
imaging studies—radio-pelvimetry, computed tomography (CT) and magnetic
resonance imaging (MRI).
Clinical pelvimetry → most commonly done
Time → In vertex presentation, the assessment is done at any time beyond 37th week
but better at the beginning of labor. Because of softening of the tissues, assessment
can be done effectively during this time.
Procedures: The patient has to empty the bladder. The pelvic examination is done
with the patient in dorsal position taking aseptic precautions. The following features
are to be noted simultaneously:
State of the cervix;
To note the station of the presenting part in relation to ischial spines;
To test for cephalopelvic disproportion in nonengaged head
To note the resilience and elasticity of the perineal muscles
Steps
Sacrum → The sacrum may be smooth, short and well curved, and the sacral
promontory usually cannot be reached or the sacrum may be long or straight
Sacrosciatic notch → The notch is sufficiently wide so that two fingers can be easily
placed over the sacrospinous ligament covering the notch
Ischial spines → Spines are usually smooth (everted) and difficult to palpate. They
may be prominent and encroach to the cavity thereby diminishing the available
space in the mid pelvis
Iliopectineal lines → To note for any beaking suggestive of narrow fore pelvis
Sidewalls → Normally they are parallel or divergent. They may be convergent.
Posterior surface of the symphysis pubis → It normally forms a smooth rounded
curve
Sacrococcygeal joint → Its mobility and presence of hooked coccyx
Pubic arch → Normally, the pubic arch is rounded and should accommodate the
palmar aspect of two fingers.
Diagonal conjugate
Subpubic angle → The inferior pubic rami are defined and in female, the angle
roughly corresponds to the fully abducted thumb and index fingers
Transverse diameter of the outlet → It is measured by placing the knuckles of the first
interphalangeal joints or knuckles of the clinched fist between the two ischial
tuberosities. Normally, it accommodates four knuckles
Anteroposterior diameter of the outlet → The distance between the inferior margin
of the symphysis pubis and the skin over the sacrococcygeal joint can be measured
either with the method employed for diagonal conjugate or by external calipers.
Types of head rotation
Complete forward rotation (90% cases) → It is most favorable. Head rotates through
3/8th of circle finally arriving at direct occipitoanterior position.
Incomplete forward rotation → It occurs most commonly in android pelvis. Baby
rotates only 1/8th of circle and the position is right occipito transverse. The
management is as follows -
Android pelvis → C-section
Other pelvis →
C-section (best)
Vacuum delivery → To rotate head of baby (forceps cannot)
Manual rotation followed by forceps delivery
Kielland forceps → Only forceps which can rotate head (outdated)
Posterior rotation → It occurs most commonly in anthropoid pelvis. Occiput rotates
posteriorly and lies directly anterior to the sacral promontory (direct
occipitoposterior position / persistent occipitoposterior position). The management
is as follows -
Anthropoid pelvis → Face to pubes delivery. Vaginal delivery when face is towards
pubic symphysis and occiput towards sacral promontory. The most common
complication is complete perineal tear. Hence, it is an indication for episiotomy.
Other pelvis → Baby will not deliver and remains in that position for greater than 30
minutes (Deep sacral arrest). C-section is done for delivery of the baby.
Mechanism of labor in occipito posterior position
Engagement →
Engaging diameters of pelvis -
Right occipitoposterior position → Right oblique diameter
Left occipitoposterior position→ Left oblique diameter.
Engaging diameters of head
Transverse diameter - biparietal (9.5 cm)
Anteroposterior diameter - suboccipitofrontal (10 cm) or occipitofrontal (11.5 cm).
Descent - It is a continuous process facilitated by uterine contractions and retraction,
bearing down efforts and straightening of fetal ovoid.
Flexion: Good uterine contractions result in good flexion of the head
Internal rotation of the head: As the occiput is the leading part, it rotates 3/8th of a
circle (135°) anteriorly to lie behind the symphysis pubis. As the neck cannot sustain
such amount of torsion, the shoulders rotate about 2/8th of a circle to occupy the
right oblique diameter in ROP and the left oblique in LOP.
In other kinds of rotations of the head (incomplete forward rotation and posterior
rotation) seen in occipito-posterior position the baby is delivered using C-section
(preferably) or in some cases manual rotation may be done.
Crowning → Head of the baby stretches the perineum and is permanently visible at
the perineum. Episiotomy is given at this time
Extension → Head of baby delivered by movement of extension with further descent.
Occiput → Vertex → Brow → Face
Restitution → It is visible passive movement of the head due to untwisting of the
neck sustained during internal rotation. Occurs due to 1/8 rotation of head in the
direction opposite to that of internal rotation.
External Rotation → It is the movement of rotation of the head visible externally due
to internal rotation of the shoulders. It occurs by 1/8th of circle in the same direction
as restitution.
Expulsion → Anterior shoulder escapes below the pubic symphysis by further
descent. By a movement of lateral flexion of the spine, the posterior shoulder sweeps
over the perineum. Rest of the trunk is then expelled out by lateral flexion.
Write eight etiological factors of Breech presentation. Write the mechanism of
labor and conduct of assisted Breech delivery. Mention four fetal / neonatal
complications of Breech delivery.
Etiological Factors
Prematurity
Factors preventing spontaneous version
Breech with extended legs
Twins
Oligohydramnios
Congenital malformations of the uterus
Short cord
Intrauterine fetal demise
Favorable adaptation
Hydrocephalus - big head can be well accomodated in wide fundus
Placenta previa
Contracted pelvis
Undue mobility of fetus
Hydramnios
Multiparae with lax abdominal wall
Fetal abnormalities
Trisomies 13, 18, 21
Anancephaly
Myotonic dystrophy
Mechanism of labor
Position → Sacroanterior
Delivery of buttocks
The diameter of engagement of the buttock is one of the oblique diameters. The
engaging diameter is bi-trochanteric (10 cm) with the sacrum of the baby directed
towards the iliopubic eminence of mother. When the diameter passes through the
pelvic brim, breech is engaged
Descent of the buttocks occurs till it touches the pelvic floor
Internal rotation of the anterior buttock occurs through 1/8th of circle placing it
behind the pubic symphysis
Further descent with lateral flexion of the trunk occurs until the anterior hip hinges
under the symphysis pubis. The anterior hip is released first followed by the posterior
hip.
Delivery of the trunk from the lower limbs follow.
Restitution occurs so that the buttocks occupy original position as during
engagement in oblique diameter
Delivery of the shoulders
Bisacromial diameter (12 cm) engages in the same oblique diameter as that occupied
by the buttocks at the brim soon after the delivery of the breech.
Descent occurs with internal rotation of the shoulders bringing the shoulders to lie in
the anteroposterior diameter of the pelvic outlet. The trunk simultaneously rotates
externally through 1/8th of a circle
Delivery of the posterior shoulder followed by the anterior one is completed by
anterior flexion of the delivered trunk
Restitution and external rotation: Untwisting of the trunk occurs putting the anterior
shoulder toward the right thigh in LSA and left thigh in RSA
The fetal trunk is now positioned dorsoanterior
Delivery of the head
Engagement occurs either through the opposite oblique diameter as that occupied
by the buttocks or through the transverse diameter. The engaging diameter of the
head is suboccipitofrontal (10 cm).
Descent with increasing flexion occurs.
Internal rotation of the occiput occurs anteriorly, through 1/8th (if engaged in
oblique diameter) or 2/8th (if engaged in transverse diameter) of a circle placing the
occiput behind the symphysis pubis.
Further descent occurs until the subocciput hinges under the symphysis pubis
Head is born by flexion—chin, mouth, nose, forehead, vertex and occiput appearing
successively
Conduct of assisted breech delivery
The patient is brought to the table when the anterior buttock and fetal anus are
visible. She is placed in lithotomy position when the posterior buttock distends the
perineum.
To avoid aortocaval compression, the woman is tilted laterally (15°) using a wedge
under the back
Antiseptic cleaning is done, bladder is emptied with an “in and out” catheter
Pudendal block is done along with perineal infiltration if no epidural has been used
earlier.
Episiotomy: It should be made in all cases of primigravidae and selected multiparae.
The best time for episiotomy is when the perineum is distended and thinned by the
breech as it is “climbing” the perineum
The patient is encouraged to bear down as the expulsive forces from above ensure
flexion of the fetal head and safe descent.
The “no touch to the fetus” policy is adopted until the buttocks are delivered along
with the legs in flexed breech and the trunk slips up to the umbilicus
Soon after the trunk up to the umbilicus is born. The following are to be done:
The extended legs (in frank breech) are to be decomposed by pressure on the knees
(popliteal fossa) in a manner of abduction and flexion of the thighs
The umbilical cord is to be pulled down and to be mobilized to one side of the sacral
bay to minimize compression.
If the back remains posteriorly, rotate the trunk to bring the back anteriorly
(sacroanterior).
The baby is wrapped with a sterile towel to prevent slipping when held by the hands
and to facilitate manipulation, if required.
Delivery of the arms →
The assistant is to place a hand over the fundus and keep a steady pressure during
uterine contractions to prevent extension of the arms.
Soon, the anterior scapula is visible. The position of the arm should be noted. When
the arms are flexed, the vertebral border of the scapula remains parallel to the
vertebral column and when extended there is winging of the scapula (parallelism is
lost).
The arms are delivered one after the other only when one axilla is visible, by simply
hooking down each elbow with a finger
Delivery of the aftercoming head → This is the most crucial stage of breech delivery.
The time between the delivery of umbilicus to delivery of mouth should preferably be
5–10 minutes. The various methods of delivering the aftercoming head are
Burns-Marshall method
The baby is allowed to hang by its own weight.
The assistant is asked to give suprapubic pressure with the flat of hand in a
downward and backward direction, the pressure is to be exerted more toward the
sinciput. The aim is to promote flexion of the head so that favorable diameter is
presented to the pelvic cavity
When the nape of the neck is visible under the pubic arch, the baby is grasped by the
ankles with a finger in between the two.
Maintaining a steady traction and forming a wide arc of a circle, the trunk is swung in
upward and forward direction
Meanwhile, the left hand is to guard the perineum and slipping the perineum off
successively the face and brow.
When the mouth is cleared off the vulva, there should be no hurry.
Mucus of the mouth and pharynx is cleared by mucus sucker. The trunk is depressed
to deliver rest of the head
Forceps delivery
The head should be brought as low down as possible by allowing the baby to hang
by its own weight aided by suprapubic pressure
When the occiput lies against the back of the symphysis pubis, an assistant raises the
legs of the child as much to facilitate introduction of the blades from below
The forceps pull maintains an arc, which follows the axis of the birth canal
Ordinary forceps with usual length of shank, as in Das’s variety, is quite effective.
Piper forceps is especially designed (absent pelvic curve) for use in this condition.
The head should be delivered slowly (over 1 minute) to reduce compression-
decompression forces as that may cause intracranial bleeding.
Malar flexion and shoulder traction (Modified Mauriceau-Smellie-Veit technique)

The baby is placed on the supinated left forearm (preferred) with the limbs hanging
on either sides.
The middle and the index fingers of the left hand are placed over the malar bones on
either sides. This maintains flexion of the head.
The ring and little fingers of the pronated right hand are placed on the child’s right
shoulder, the index finger is placed on the left shoulder and the middle finger is
placed on the suboccipital region
Traction is now given in downward and backward direction till the nape of the neck is
visible under the pubic arch
The assistant gives suprapubic pressure during the period to maintain flexion.
Thereafter, the fetus is carried in upward and forward direction toward the mother’s
abdomen releasing the face, brow and, lastly, the trunk is depressed to release the
occiput and vertex.
Fetal / Neonatal complications
Intrapartum fetal death
Injury to the brain and skull - intracranial hemorrhages, minute hemorrhages,
fracture of the skull
Birth asphyxia
Birth injuries
hematoma over sternocleidomastoid
Fractures - common site are femur, humerus, clavicle
Visceral injuries - rupture of kidneys, liver, suprarenal glands, lungs etc.
Write etiology, clinical diagnosis and types of breech presentation. Describe the
mechanism of labor in breech presentation and risks to the baby during
assisted breech delivery.
Etiological Factors
Prematurity
Factors preventing spontaneous version
Breech with extended legs
Twins
Oligohydramnios
Congenital malformations of the uterus
Short cord
Intrauterine fetal demise
Favorable adaptation
Hydrocephalus - big head can be well accomodated in wide fundus
Placenta previa
Contracted pelvis
Undue mobility of fetus
Hydramnios
Multiparae with lax abdominal wall
Fetal abnormalities
Trisomies 13, 18, 21
Anacephaly
Myotonic dystrophy
Diagnosis
Head of fetus felt at fundal grip
Breech is felt in first pelvic grip
Fetal heart sounds are heard above umbilicus
Vaginal examination
Conical bag of membranes
Presenting part is high up
Sonography
Confirms the clinical examination diagnosis
Type of breech can be made out
Attitude of the head can be visualized
Placenta previa can be ruled out
Types of breech
Flexed or complete breech
Attitude of universal flexion with flexion at the thighs and knees
Less chances of vaginal delivery
Incomplete
Extended or frank breech
most common type (2/3 of breech presentations)
Flexion at the hips and extensions at the knees
Buttocks is the presenting part
Prognosis for vaginal delivery is better
Footling presentation → Both thighs and legs are partially extended bringing the legs
to present at brim
Knee presentation → Thighs are extended but knees are flexed, bring the knees down
to present at brim
Mechanism of labor
Position → Sacroanterior
Delivery of buttocks
The diameter of engagement of the buttock is one of the oblique diameters. The
engaging diamter is bitrochanteric (10 cm) with the sacrum directed towards the
iliopubic eminence. When the diameter passes through the pelvic brim, breech is
engaged
Descent of the buttocks occurs till it touches the pelvic floor
Internal rotation of the anterior buttock occurs through 1/8th of circle placing it
behind the pubic symphysis
Further descent with lateral flexion of the trunk occurs until the anterior hip hinges
under the symphysis pubis. The anterior hip is released first followed by the posterior
hip.
Delivery of the trunk from the lower limbs follow.
Restitution occurs so that the buttocks occupy original position as during
engagement in oblique diameter
Delivery of the shoulders
Bisacromial diameter (12 cm) engages in the same oblique diameter as that occupied
by the buttocks at the brim soon after the delivery of the breech.
Descent occurs with internal rotation of the shoulders bringing the shoulders to lie in
the anteroposterior diameter of the pelvic outlet. The trunk simultaneously rotates
externally through 1/8th of a circle
Delivery of the posterior shoulder followed by the anterior one is completed by
anterior flexion of the delivered trunk
Restitution and external rotation: Untwisting of the trunk occurs putting the anterior
shoulder toward the right thigh in LSA and left thigh in RSA
The fetal trunk is now positioned dorsoanterior
Delivery of the head
Engagement occurs either through the opposite oblique diameter as that occupied
by the buttocks or through the transverse diameter. The engaging diameter of the
head is suboccipitofrontal (10 cm).
Descent with increasing flexion occurs.
Internal rotation of the occiput occurs anteriorly, through 1/8th (if engaged in
oblique diameter) or 2/8th (if engaged in transverse diameter) of a circle placing the
occiput behind the symphysis pubis.
Further descent occurs until the subocciput hinges under the symphysis pubis
Head is born by flexion—chin, mouth, nose, forehead, vertex and occiput appearing
successively
Fetal / Neonatal complications
Birth asphyxia
Birth injuries
Techniques of delivering aftercoming head // Methods of delivery of aftercoming
head in breech. // Aftercoming head of breech
This is the most crucial stage of breech delivery. The time between the delivery of
umbilicus to delivery of mouth should preferably be 5–10 minutes. The various
methods of delivering the aftercoming head are
Forceps delivery

on either sides.
either sides. This maintains flexion of the head.
occiput and vertex.
Assisted Breech delivery: Pre requisites and procedure

Pre-requisites
Anesthetist - to administer anesthesia as and when required
An assistant - to push down the fundus during contraction
Instruments and suture materials for episiotomy
A pair of obstetric forceps for the aftercoming head
Appliances for resuscitation of baby
Steps
The patient is brought to the table when the anterior buttock and fetal anus are
visible. She is placed in lithotomy position when the posterior buttock distends the
perineum.
To avoid aortocaval compression, the woman is tilted laterally (15°) using a wedge
under the back
Antiseptic cleaning is done, bladder is emptied with an “in and out” catheter
Pudendal block is done along with perineal infiltration if no epidural has been used
earlier.
Episiotomy: It should be made in all cases of primigravidae and selected multipara.
The best time for episiotomy is when the perineum is distended and thinned by the
breech as it is “climbing” the perineum
The patient is encouraged to bear down as the expulsive forces from above ensure
flexion of the fetal head and safe descent.
The “no touch to the fetus” policy is adopted until the buttocks are delivered along
with the legs in flexed breech and the trunk slips up to the umbilicus
Soon after the trunk up to the umbilicus is born. The following are to be done:
The extended legs (in frank breech) are to be decomposed by pressure on the knees
(popliteal fossa) in a manner of abduction and flexion of the thighs
The umbilical cord is to be pulled down and to be mobilized to one side of the sacral
bay to minimize compression.
If the back remains posteriorly, rotate the trunk to bring the back anteriorly
(sacroanterior).
The baby is wrapped with a sterile towel to prevent slipping when held by the hands
and to facilitate manipulation, if required.
Delivery of the arms →
The assistant is to place a hand over the fundus and keep a steady pressure during
uterine contractions to prevent extension of the arms.
Soon, the anterior scapula is visible. The position of the arm should be noted. When
the arms are flexed, the vertebral border of the scapula remains parallel to the
vertebral column and when extended there is winging of the scapula (parallelism is
lost).
The arms are delivered one after the other only when one axilla is visible, by simply
hooking down each elbow with a finger
Delivery of the aftercoming head → This is the most crucial stage of breech delivery.
The time between the delivery of umbilicus to delivery of mouth should preferably be
5–10 minutes. The various methods of delivering the aftercoming head are
Forceps delivery

on either sides.
either sides. Thismaintains flexion of the head.
occiput and vertex.
Extended Breech: definition, diagnosis and intrapartum complications.
It is the most common type (2/3 of breech presentations)
It is a type of incomplete breech
Flexion at the hips and extensions at the knees
Buttocks is the presenting part
Prognosis for vaginal delivery is better
It is commonly seen in primigravidae.
Diagnosis
Clinical →
Per abdomen
Fundal grip →
Head
Irregular small part of the feet may be felt at side of head
Head is non-ballotable due to splinting action of the legs on the trunk
Lateral Grip → Irregular parts are less felt on the side
Pelvic grip → Small hard and conical mass is felt, breech is usually engaged
FHS → Located at lower level in the midline due to early engagement of breech
Per vaginum
During pregnancy → Hard feel of the sacrum is felt often mistaken for head
During labor → Palpation of ischial tuberosities, anal opening and sacrum in one line
Sonography
Confirms the clinical examination diagnosis
Type of breech can be made out
Attitude of the head can be visualized
Placenta previa can be ruled out
Intrapartum complications
Birth asphyxia
Birth injuries
Deep transverse arrest // Deep transverse arrest-Definition, causes and management
// Deep transverse arrest; Definition, Predisposing factors and Management // Deep
Transverse Arrest: Definition and management
The head is deep into the cavity; the sagittal suture is placed in the transverse
bispinous diameter and there is no progress in descent of the head even after 1/2–1
hour following full dilatation of the cervix.
The arrest in occiput transverse position may be
the end result of incomplete anterior rotation (1/8th of circle) of oblique occiput
posterior position, or
due to nonrotation of the commonly primary occiput transverse position of normal
mechanism of labor.
Causes
Faullty pelvic architecture such as prominence of ischial spines, flat scarum and
convergent side walls
Deflexion of the head
Weak uterine contractions
Laxity of the pelvic floor muscles
Diagnosis
The head is engaged
The sagittal suture lies in transverse bispinous diameter
Anterior fontanel is palpable
Faulty pelvic architecture may be detected
Management
Other pelvis →
C-section (best)
Vacuum delivery (can rotate head of baby)
Kielland forceps (only forceps which can rotate head) - outdated
Deep transverse arrest-Diagnosis and management
Diagnosis
The head is engaged
The sagittal suture lies in transverse bispinous diameter
Anterior fontanel is palpable
Faulty pelvic architecture may be detected
Management
Other pelvis →
C-section (best)
Vacuum delivery (can rotate head of baby)
Kielland forceps (only forceps which can rotate head) - outdated
Brow presentation (x2)
Least common among all cephalic presentations and the most unfavorable.
Attitude of neck : partial extension
Presenting part : Area between the anterior fontanelle (bregma) above and glabella
and orbital ridges below
Denominator : Forehead
Presenting diameter : Verticomental (13.5 cm)
Diagnosis
It is very rarely diagnosed before labor and even in diagnosis is made, there is less
significance as it may be transitory.
High mobile head, which feels large side to side
Cephalic prominence is the occiput and is on the same side as the back and the
groove between the cephalic prominence and back is less prominent than in face
presentation
Vaginal examination
Conical bag of membranes felt in early labor
Anterior fontanelle is felt at one end and the root of nose and orbital ridges are felt
at the other end of oblique or transverse diameter
Mechanism of labor → There is no mechanism of labor in brow presentation as the
verticomental diameter (13.5) is the largest diameter of fetal head
Management
Antepartum → Wait until onset of labor and hope that correction to vertex or face
occurs.
Labor → C-section should be done
27. Prolonged Labor, Obstructed Labor,

Dystocia Caused by Fetal Anomalies
A primigravida, GDM on insulin at term has been experiencing prolonged 2nd
stage of labor. Mention four causes for the delay. After some time, head is
delivered but there is no further progress. Mention the probable diagnosis at
this stage and discuss its management. Following difficult delivery, patient has
postpartum hemorrhage. Write relevant clinical examination and outline the
management.
Causes for delay in second stage of labor
Fault in the power →
Uterine inertia
Inability to bear down
Regional analgesia
Constriction ring
Fault in the passage
Cephalopelvic disproportion
Undue resistance of the pelvic floor or perineum due to spasm or old scarring
Soft tissue pelvic tumor
Fault in the passenger
Malposition
Malpresentation
Big baby
Congenital malformations
Shoulder Dystocia
Management (HELPERRZ)
Call for help; mobilize assistants, an anesthetist and pediatrician
Empty bladder. Given generous episiotomy
First maneuver → Legs maneuver (Mc. Robert’s maneuver)
Before starting the maneuver remove any pillows present
Requires one assistant at each leg
Sudden flexion (as much as possible such that the knees are near the breast) of the
thighs over mother’s abdomen and abduction
Moves the pubic symphysis in cephalad direction
Straightening of the sacrum
Available space increases
Done for 30 seconds. If fails move to next
Suprapubic pressure (Rubin manoeuvre I)
Locate the anterior shoulder
With thrusting movements, give suprapubic pressure. (Mother sould be in Mc.
Robert’s position)
This helps in pushing out anterior shoulder below the pubic symphysis
Fundal pressure is contraindicated
Enter into pelvis
Rubin Maneuver II → Take your hand above the anterior shoulder and try to bring it
below the pubic symphysis
Wood corkscrew maneuver → Two fingers anterior to the posterior shoulder and two
fingers posterior to the anterior shoulder. Rotate the shoulder of the baby in
clockwise direction. The anterior shoulder moves posteriorly and the posterior
shoulder moves anteriorly. Repeated in anti-clockwise direction if the baby is not
delivered by clockwise direction
Removal of posterior arm manually (Jacquemier maneuver)
Deliver the posterior arm → Rotate the baby → Deliver the anterior arm
Rollover maneuver ( Gaskin’s all-four-limbs maneuver)
Roll over the mother on all four limbs
Zavanelli maneuver
Push head back into the uterus and do C-section. Traumatic for both mother and
baby.
Clinical examination (PPH)
In majority of cases the vaginal bleeding is visible outside, as a slow trickle. Rarely the
bleeding is totally concealed as either vulvovaginal or broad ligament hematoma.
The patient may be hypotensive due to excessive blood loss
State of uterus
Traumatic hemorrhage → well contracted uterus
Atonic hemorrhage → uterus is found flabby and becomes hard on massaging
Management
Initial management
Massage uterus (Fundal massage)
Insert two large bore IV cannula (16 G)
Give 1000 mL crystalloids
Place foley’s catheter for fluid input-output charting
Investigations → CBC, blood grouping and Rh typing
Arrange for blood and blood products
Perform a per abdominal examination followed by a vaginal examination
Note the tone of uterus
Uterus well contracted → Traumatic PPH → Vaginal examination →
Laceration/Hematoma → Repair
Reduced uterine tone that is maintained only with massage → Atonic PPH → Vaginal
examination → Ensure entire placenta and its membranes have been expelled to
confirm atonic PPH → Uterotonics + Tranexamic Acid + Massage
Uterotonics
Oxytocin is the first choice
Dose 20 IU in 550 mL NS
If oxytocin not available - Ergometrine, carboprost/dinoprost or mesoprost can be
used
Tranexamic acid
Given within 3 hours of hemorrhage
Dose → 1 g added to 100 mL NS infused over 10 to 20 min at the rate of 1 mL/min
Mechanical methods → If bleeding still persists after uterotonics and tranexamic acid
are tried for a maximum period of 30 mins, management is done using mechanical
methods.
Bimanual compression → The abdominal hand massages the posterior aspect of the
uterus and the vaginal hand made into a fist, presses the anterior aspect of uterus
through the anterior fornix.
Aortic compression → Can either be performed manually or with the help of
Resuscitative Endovascular Balloon Occlusion of Aorta (REBOA)
Balloon Tamponade → The bulb is filled with normal saline. The inflated bulb presses
against the open venous sinuses to control bleeding. The following devices can be
used
Bakri-balloon catheter
Foley’s catheter
Sengstaken-Blakemore esophageal catheter
Condom Tamponade
Surgical methods → If mechanical methods fail to control bleeding
Compression sutures
B-Lynch or Brace sutures → Oppose the anterior and posterior wall of uterus. This will
lead to compression of the fundus and lower uterine segment, thereby controlling
hemorrhage.
Hayman suture → Utilized two vertical compression sutures placed on either side of
fundus.
Cho’s Multiple Block sutures → Block sutures involving approximation of anterior and
posterior walls with multiple squares
Stepwise devascularization → If compression sutures fails
Uterine artery ligation (Unilateral / Bilateral)
Utero-ovarian vessel ligation
Internal iliac artery ligation → Ligation of the anterior division of internal iliac artery is
another option especially in nulliparous women as uterus can be preserved.
Site → 5 cm distal to the bifurcation of common iliac artery to avoid involvement of
posterior division
MOA → Reduces pulse pressure by 85% in arteries distal to it
Hysterectomy → If all above fails hysterectomy is performed. Total hysterectomy is
ideal but may be difficult in such situations, subtotal hysterectomy is easier and
quicker to perform.
Shoulder dystocia
Shoulder dystocia is a condition characterised by delivery of the head, but the
shoulder cannot be delivered by usual methods and there is no other cause of
dystocia.
Diagnosis -
Definite recoil of the ehad back against the perineum (turtle neck sign)
Failure of spontaneous restitution of head
Fetal face becomes plethoric
Failure of shoulder to descend
Management
Call for help
Empty bladder. Generous episiotomy
First-line manoeuvers
Mc Robert’s Manoeuver
Rubin’s manoeuver (Suprapubic pressure)
Second-line manoeuvers
Jacquemier manoeuver (aka Barnum’s manoeuver)
Wood corkscrew manoeuver
Rubin’s manoeuver II
Gaskin’s manoeuver
Third-line manoeuvers
Cleidotomy
Symphysiotomy
Zavanelli manoeuver
Prevention and management of shoulder dystocia using primary maneuvers.
Prevention of shoulder dystocia is not possible accurately even with USG assessment.
Measures may be taken to minimize risk factors during the entire duration of
pregnancy like controlling diabetes, obesity etc.
Primary maneuvers for the management of shoulder dystocia
Legs maneuver (Mc. Robert’s maneuver)
Before starting the maneuver remove any pillows present
Requires one assistant at each leg
Sudden flexion (as much as possible such that the knees are near the breast) of the
thighs over mother’s abdomen and abduction
Moves the pubic symphysis in cephalad direction
Straightening of the sacrum
Available space increases
Done for 30 seconds. If fails move to next
Suprapubic pressure (Rubin maneuver I)
Locate the anterior shoulder
With thrusting movements, give suprapubic pressure. (Mother sould be in Mc.
Robert’s position)
This helps in pushing out anterior shoulder below the pubic symphysis
Fundal pressure is contraindicated
Clinical features of Obstructed labor
Clinical features (Same as Bandl’s ring / Pathological retraction ring)
Patient is in agony from the continuous pain and discomfort
Abdominal examination reveals
Uterus is tense and tender
Upper segment is tonically contracted with no relaxation
Round ligaments are taut and tender
Vaginal examination
Ring cannot be felt vaginally
Obstructed labor: diagnosis and complications
Diagnosis can be made on the basis of clinical features
Patient is in agony from the continuous pain and discomfort
Abdominal examination reveals
Uterus is tense and tender
Upper segment is tonically contracted with no relaxation
Round ligaments are taut and tender
Vaginal examination
Ring cannot be felt vaginally
Complications
Maternal
Exhaustion
Dehydration
Metabolic acidosis
Genital sepsis
Injury to genital tract (including rupture of uterus)
Post partum hemorrhage and shock
Fetus
Asphyxia
Acidosis
Intracranial hemorrhage
Infection
28. Complications of the Third Stage of

Labor
Write definition and types of Postpartum Hemorrhage. Discuss in detail the risk
factors, clinical presentation and management of Atonic Postpartum
hemorrhage
Any amount of bleeding from or into the genital tract following birth of the baby up
to the end of the puerperium, which adversely affects the general condition of the
patient evidenced by rise in pulse rate and falling blood pressure, is called
postpartum hemorrhage
Types of PPH
Primary PPH → Defined as blood loss of more than 500 mL from the genital tract
within 24 hours of childbirth. For C-section a blood loss of more than 1000 mL is
considered significant.
Secondary PPH → Secondary PPH is defined as bleeding occurring after 24 hours and
up to 6 weeks post partum.
Risk Factors and Causes
Atonic PPH
Antepartum
Grand multipara
Previous history of atonic PPH
Overdistended uterus due to multiple pregnancy, polyhydramnios or macrosomia
Uterine abnormalities or fibroids
Antepartum hemorrhage
Intrapartum
Prolonged labor
Precipitate labor
Oxytocin induced or augmented labor
Chorioamnionitis
General anesthesia
Retained placental fragments
Mismanagement of third stage of labor
Traumatic PPH
Instrumental delivery
VBAC
Face to pubis delivery
Precipitate labor
Macrosomia
Coagulopathy
Abruption
Sepsis
IUD
Severe pre-eclampsia with HELLP syndrome
Amniotic fluid embolism
Retained placenta and placental fragment
Morbidly attached placenta
Clinical features
In majority of cases the vaginal bleeding is visible outside, as a slow trickle. Rarely the
bleeding is totally concealed as either vulvovaginal or broad ligament hematoma.
The patient may be hypotensive due to excessive blood loss
State of uterus
Traumatic hemorrhage → well contracted uterus
Atonic hemorrhage → uterus is found flabby and becomes hard on massaging
Management
Initial management
Insert two large bore IV cannula (16 G)
Arrange for blood and blood products
Uterus well contracted → Traumatic PH → Vaginal examination →
Uterotonics
If oxytocin not available - Ergometrine, carboprost/dinoprost or misoprostol can be
used
Tranexamic acid
Mechanical methods → If bleeding still persists after uterotonics and tranexamic acid
are tried for a maximum period of 30 mins, management is done using mechanical
methods.
Bimanual compression → The abdominal hand massages the posterior aspect of the
uterus and the vaginal hand made into a fist, presses the anterior aspect of uterus
through the anterior fornix.
Aortic compression → Can either be performed manually or with the help of
Resuscitative Endovascular Balloon Occlusion of Aorta (REBOA)
Balloon Tamponade → The bulb is filled with normal saline. The inflated bulb presses
against the open venous sinuses to control bleeding. The following devices can be
used
Bakri-balloon catheter
Foley’s catheter
Sengstaken-Blakemore esophageal catheter
Condom Tamponade
Compression sutures
hemorrhage.
Hayman suture → Utilises two vertical compression sutures placed on either side of
fundus.
Cho’s Multiple Block sutures → Block sutures involving approximation of anterior and
Uterine artery ligation (Unilateral / Bilateral)
Utero-ovarian vessel ligation
posterior division
quicker to perform.
Two main types of PPH (Post Partum Hemorrhage) and their differentiating features.
Surgical management of Atonic postpartum hemorrhage

Compression sutures
hemorrhage.
Hayman suture → Utilised two vertical compression sutures placed on either side of
fundus.
Cho’s Multiple Block sutures → Block sutures involving approximation of nateior and
Uterine artery ligation (Unilateral / Bilateral) → The ascending branch of uterine
artery is ligated at the lateral border of the upper and lower segments.
Utero-ovarian vessel ligation→ The anastomotic branch of the uterine and ovarian
vessels is ligated additionally if the bleeding is not controlled by uterine artery
ligation.
posterior division
quicker to perform.
Medical management of Atonic Post-Partum hemorrhage
Insert two large bore IV cannulae (16 G)
Arranage for blood and blood products
Uterus well contracted → Traumatic PH → Vaginal examination →
Uterotonics
If oxytocin not available - Ergometrine, carboprost/dinoprost or mesoprost can be
used
Tranexamic acid
Secondary post partum hemorrhage
Defined as hemorrhage occuring 24 hours after delivery and within 6 weeks.
Etiology
Sepsis
Poor healing of uterine incision in previous C-section
Placental site trophoblastic tumor or choriocarcinoma
Management
Broad spectrum antibiotics are usually started immediately to control infection
Oxytocics are also given
Transvaginal sonography is extremely helpful to identify retained placental bits and if
present, they are evacuated.
Evacuation should be extremely gentle as perforation can easily occur in puerperal
uterus.
Tissue obtained should be sent for histopathological examination to rule out the
possibility of trophoblastic malignancy
Causes and management of Retained placenta // Types and management of retained
placenta
Causes and Management
Trapped placenta → Placenta is separated but not expelled. This occurs due to poor
voluntary expulsive efforts.
Management
If there is bleeding the usual methods to combat atonic PPH are employed.
Make sure the bladder is empty
If the condition is seen soon after delivery, there is no bleeding or shock, the uterus
is contracted and the internal os is closed, sublingual (400 microgram) or IV (50
microgram) glyceryl trinitrate can be tried to relax the uterus and then placenta can
be expelled by controlled cord traction.
If these measures fail, manual removal of placenta will be necessary
Placenta adherens (Simple adherent placenta) → The placenta has not-separated
from the uterine wall. It commonly occurs due to atonicity due to grand multipara,
overdistension of uterus, prolonged labor.
Management
Oxytocin promotes uterine contractions and separation of placenta. An IV infusion of
20 units can be started.
In other cases, 50 IU of oxytocin in 30 mL saline can be injected down the umbilical
cord by the Pipingas technique. This uses a nasogastric tube threaded down the
umbilical vein to the placental bed, which is then withdrawn by 5 cm and tied. This
has also been found to promote placental separation and expulsion
If this fails, manual removal has to be done
Manual Removal of placenta → done if the placenta fails to separate and is not
expelled out within 60 mins of delivery of the baby.
The operation is done under general anesthesia or regional anesthesia. If general
anesthesia is used, halothane produces effective relaxation. If the uterus is contracted
glyceryl trinitrate can be added for relaxation.
The hand is introduced into the uterine cavity and the placenta is separated from the
uterine wall by the ulnar border of the hand with a sideways slicing movement of the
fingers.
Then the placenta is peeled off its attachment to the uterus, grasped with entire hand
and slowly withdrawn
The other hand on the abdomen gives guidance and counter pressure on the uterine
fundus.
Membranes are removed using sponge holding forceps if necessary.
As soon as the placenta is delivered, an oxytocin infusion is commenced. At the same
time bimanual massage of the uterus is done to make it contract.
Morbidly adherent placenta → Placenta invades the myometrium
Management
If partial placenta accreta (focal) → remove the placental tissue as much as possible.
Effective uterine contraction and hemostasis are achieved by oxytocic if necessary. If
the uterus fails to contract, an early decision of hysterectomy may have to be taken
If total placenta accreta → hysterectomy is indicated in parous women, while in
patients desiring to have a child, conservative attitude may be taken. This consists of
incising the uterus above the placental attachment and clamping and cutting the
umbilical cord as close to its base as possible and leaving behind the placenta, which
is expected to be autolyzed in due course of time
Puerperal inversion of uterus-management and prevention
It is an extremely rare but a life-threatening complication in third stage in which the
uterus is turned inside out partially or completely
Etiology
Mismanagement of third stage, by attempts to deliver a non-separated fundally
implanted placenta by cord traction
Fundal pressure on a relaxed uterus
Spontaneous inversion can occur in atonic uterus
Placenta accreta (rare)
Classification
First degree → partial extrusion of fundus into the uterine cavity
Second degree → fundus crosses through the cervical os forming a round mass in
the vagina with no palpable fundus in the abdomen.
Third degree → Entire uterus has passed through the cervix with fundus passing out
of the vaginal introitus.
Fourth degree → Inversion of both uterus and vagina through the introitus.
Diagnosis
Shock out of proportion to bleeding
Vaginal examination → Soft, globular swelling in the vagina
Abdomen examination → Fundus not palpable.
Management
Focuses on resuscitation and replacement of the inverted uterus.
Stop oxytocin infusion
Johnson’s method of replacement
The part that came out first (fundus), should be the last to go in.
If this fails, uterine relaxants are given and manual replacement is attempted again
If still it fails, surgical methods are tried (O sullivan’s method is not used anymore)
Surgical methods-
Huntington’s method → By traction on the round ligaments with Allis forceps to pull
up the inverted uterus.
If this fails, Haultain’s method is adopted → vertically incising the posterior cervix to
relieve the constriction ring.
Once uterine replacement is done by any of the above methods, stop tocolytics,
remove placenta and start oxytocin to prevent re-inversion.
29. Injuries to the Birth Canal

Uterine scar rupture -symptoms and signs // Symptoms and Signs of rupture Uterus
Symptoms
Dull abdominal pain over the scar area with slight vaginal bleeding
Varying degrees of tenderness on uterine palpation
Feeling of something giving way accompanied by acute abdominal pain and collapse
Hematuria in case of bladder involvement
Signs
Fetal heart rate decelerations or FHS may be absent
Tachycardia
Hypotension
Vaginal examination - bleeding through the os
Abdominal examination - fetal parts may easily be palpable
30. Abnormalities of the Puerperium
A P2L2 on 10th postoperative day after cesarean delivery has excessive
bleeding per vagina. a) What is the clinical diagnosis? b) What are the causes
for the above condition? c) Write investigations and management
Secondary postpartum hemorrhage
Causes
Sepsis
Poor healing of uterine incision in previous C-section
Placental site trophoblastic tumor or choriocarcinoma
Investigations
USG to detect retained bits of placenta
CBC - anemia
Management
Principles
To assess the amount of blood loss and replace it
To find out the cause and to take appropriate steps to rectify it
Supportive therapy
Blood transfusion, if necessary
To administer methergine 0.2 mg IM if bleeding is uterine in origin
To administer antibiotics (clindamycin and metronidazole)
Conservative → If bleeding is slight and no apparent cause is detected, a careful
watch period of 24 hours or so is done in hospital
Active treatment
As the most common cause is due to retained bits of cotyledon or membranes, it is
preferable to explore the uterus urgently under general anesthesia
The products are removed by ovum forceps
Gentle curettage is done using flushing curette
Methergine 0.2 mg is given IM
The materials removed are sent for histological examination
A lady who had a vaginal delivery after a prolonged labor following premature
rupture of membranes, presents to the hospital on the 7th post natal day with
fever. Write the relevant history and examination. What are the necessary
investigations and explain the relevance of each? What is the most likely
possibility and outline the management?
History and Examination
Risk factors
Antenatal
Malnutrition
Preterm labor
PROM
Immunocompromised
Prolonged PROM > 18 hours
Diabetes
Intrapartum
Repeated vaginal examination
Dehydration and ketoacidosis
Retained bits of placenta
Prolonged labor
Obstructed labor
C-section delivery
Symptoms and Signs
Wound infections
Slight rise of temperature
Wound becomes swollen and red
Pus may form which leads to disruption of wound
Uterine infection
Mild :
Rise in temperature
lochial discharge is offensive and copious
uterus is subinvoluted and tender
Severe :
High rise in temperatures with chills and rigor
PR : Rapid
Breathlessness, cough, abdominal pain and dysuria
Lochia : Scanty and odorless
Spreading infections
Parametritis :
Onset around 7-10th day
Constant pelvic pain
Tenderness on either side of hypogastrium
Vaginal examination : Unilateral tender indurated mass
Rectal examination : Confirms the induration
Pelvic peritonitis
General peritonitis
Thrombophlebitis
Septicemia
Septic shock
Investigations
High vaginal and endocervical swabs for culture, media and sensitivity test to
antibiotics
Clean catch midstream specimen of urine for analysis and culture including sensitivity
testing
Blood for total and differential counts, hemoglobin estimation. A low platelet may
indicate septicemia or DIC. Thick blood film should be examined for malaria
Blood culture if fever is associated with chills and rigors
Pelvic USG
to detect any retained bits of conception
To locate any abscess in the pelvis
for color flow doppler study to detect venous thrombosis
X-ray chest - Koch’s lesion, atelectasis
Blood urea and electrolytes
Treatment
General care
Isolation of patient is preferred
Adequate fluid and calorie are maintained
Anemia is corrected by oral iron or if needed by transfusion
An indwelling catheter is used to relieve any urine retention
Maintain charts for pulse, respiration, temperature, lochial discharge
Antibiotic
Surgical treatment
Perineal wound - Stitches of perineal wound may have to be removed to facilitate
drainage of pus and relieve pain
Retained uterine products (if larger than 3 cm) have to be surgically evacuated after
antibiotic coverage
Pelvic abscess should be drained by colpotomy
Wound dehiscence - managed by scrubbing wound twice daily, debridement of all
necrotic tissue and then closing the wound
Necrotizing fasciitis → Rehydration, wound scrubbing, debridement, use of high dose
broad spectrum IV antibiotics
Causes of Puerperal Pyrexia
Uterine infection/Puerperal sepsis
Abdominal wound infection
Infections of perineum, vagina and cervix
Septic pelvic thrombophlebitis
Mastitis
Urinary tract infection
Pulmonary complications like atelectasis and pneumonia
Meningitis (if spinal or regional anesthesia is given)
Causes of Puerperal pyrexia and investigations (x2)
Causes
Uterine infection/Puerperal sepsis
Abdominal wound infection
Infections of perineum, vagina and cervix
Septic pelvic thrombophlebitis
Mastitis
Urinary tract infection
Pulmonary complications like atelectasis and pneumonia
Meningitis (if spinal or regional anesthesia is given)
Investigation
Hematological
Hemoglobin and Hematocrit
Leucocyte count
Platelet count
Blood urea nitrogen and creatine
Cultures of blood, urine and lochia
Ultrasound (abdominal, transvaginal, color doppler)
Chest X-ray
Causes and management of puerperal sepsis. // Puerperal sepsis-definition, causes
and management // Puerperal Sepsis: Diagnosis & Management
An infection of the genital tract which occurs as a complication of delivery is termed
puerperal sepsis
Etiology
Endometritis
Endomyometritis
Endoparameteritis
Combination of all three
Etiological agents
Aerobic → Group A beta-hemolytic Streptococcus, Group B beta-hemolytic
Streptococcus
Anaerobic - Peptococcus, Bacteroides, Fusobacterium, Mobiluncus etc
Investigations
High vaginal and endocervical swabs for culture, media and sensitivity test to
antibiotics
Clean catch midstream specimen of urine for analysis and culture including sensitivity
testing
Blood for total and differential counts, hemoglobin estimation. A low platelet may
indicate septicemia or DIC. Thick blood film should be examined for malaria
Blood culture if fever is associated with chills and rigors
Pelvic USG
to detect any retained bits of conception
To locate any abscess in the pelvis
for color flow doppler study to detect venous thrombosis
X-ray chest - Koch’s lesion, atelectasis
Blood urea and electrolytes
Treatment
General care
Isolation of patient is preferred
Adequate fluid and calorie are maintained
Anemia is corrected by oral iron or if needed by transfusion
An indwelling catheter is used to relieve any urine retention
Maintain charts for pulse, respiration, temperature, lochial discharge
Antibiotic
Surgical treatment
Perineal wound - Stitches of perineal wound may have to be removed to facilitate
drainage of pus and relieve pain
Retained uterine products (if larger than 3 cm) have to be surgically evacuated after
antibiotic coverage
Pelvic abscess should be drained by colpotomy
Wound dehiscence - managed by scrubbing wound twice daily, debridement of all
necrotic tissue and then closing the wound
Necrotizing fasciitis → Rehydration, wound scrubbing, debridement, use of high dose
broad spectrum IV antibiotics
Subinvolution: definition, causes and management
When the involution of uterus is impaired or retarded, it is called subinvolution.
Causes
Grand multipara
Overdistension of uterus in twins and hydramnios
Maternal ill health
C-section
Prolapse of uterus
Retroversion after the uterus becomes pelvic organ
Uterine fibroid
Management
Antibiotics in endometritis
Exploration of the uterus in retained products
Pessary in prolapse or retroversion.
31. The Term Newborn Infant

Advantages of breast feeding
Advantages for the baby
Nutritive value: Breast milk contains all the nutrients that a baby needs for the first 6
months of life for optimal growth and development.
Easily digestible: Breast milk contains a higher proportion of whey proteins
(lactalbumin and lactoglobulin), whereas cow's milk contains more casein.
Kidney protection: Breast milk has low sodium and mineral content.
Brain development: Breast milk has higher taurine and cystine content.
Cardio-protective: The higher PUFA content in breast milk also protects the individual
from atherosclerosis later in adult life.
Retinal development: Long-chain PUFAs are present in breast milk.
pH of breast milk is low, so organisms do not grow in it.
Anti-infective factors: Humoral (IgA, IgM) and cellular (macrophages).
No risk of milk allergy.
Protection from other allergies and diseases: Breastfed babies have a lower chance of
developing hypertension, obesity, and coronary artery disease.
Physiological adaptation: Breast milk is not just species-specific but also individually
tailored to the needs of the baby. For example, a mother who has delivered
prematurely will secrete milk that is easily digested and is nutritive for her preterm
baby.
Emotional bonding.
Risk of overfeeding is minimal.
Advantages for mother
Birth control: Lactation suppresses ovulation.
Maternal health: Breastfeeding enhances involution of the uterus and lowers the risk
of ovarian and breast cancer in the mother.
Convenience: This mode of feeding is more convenient as it does not require
cleaning the bottle and preparing the milk for artificial feeding several times during
the day and night.
Technique of Breast feeding
The mother and the baby should be in a comfortable position
Feeding in the sitting position, the mother holds the baby in an inclined upright
position on her lap
the baby’s head on her forearm on the same side close to her breasts, the neck is
slightly extended.
Good attachment means the infant’s mouth is wide open and chin touches the
breast.
The mother should guide the nipple and areola into the baby’s mouth for effective
milk transfer
The milk transfer to the infant begins with good latch on and by a peristaltic action
of the tip of the tongue to the base
The proper position for milk transfer is chest-to-chest contact of the infant and
mother.
The infant’s ear, shoulder and hip are in one line
Baby sucks the areola (lactiferous sinuses) and the nipple holding between the
tongue and the palate.
Baby Friendly Hospital Initiative
Baby Friendly Hospital Initiative
There must be a written breastfeeding policy
All healthcare staff must be trained to implement this policy
All pregnant women must be informed about the benefits of breastfeeding
Mothers should be helped to initiate breastfeeding within half an hour of birth
Mothers are shown the best way to breastfeed
Unless medically indicated, the newborn should be given no food or drink other than
breast milk
To practice ‘roomingin’ by allowing mothers and babies to remain together 24 hours
a day
To encourage demand breastfeeding
No artificial treats to babies should be given
Breastfeeding support groups are established and mothers are referred to them on
discharge
32. Low Birth Weight Baby

Write the definition, types, etiology, diagnosis and management of fetal
growth restriction
Fetal growth restriction (FGR) is said to be present in those babies whose birth
weight is below the 10th centiles of the average for the gestational age
Etiology
Maternal
Medical / obstetric causes
Teratogenic exposure to mother
Low BMI / Poor weight gain in pregnancy
High altitude
Short inter pregnancy interval
Increased maternal age
Fetal
Structural abnormalities
Intrauterine Infections
Placental
Uteroplacental insufficiency
Placenta previa
Placental abruption
Circumvallate placenta
Unknown
Diagnosis
Screening for IUGR
Measure symphysio-fundal height → Normally corresponds to weeks of gestation
Discrepancy of 3 weeks → Ultrasound → Check estimated fetal weight and amniotic
fluid
HC/AC → Ratio increases in asymmetric IUGR
FL/AC → Increased ratio
Late onset IUGR
Doppler studies →
To detect UPI. Most important vessels to show changes is umbilical artery. Normally
systolic-diastolic ratio is less than 3. A > 3 value indicates uteroplacental insufficiency
In UPI (asymmetrical IUGR) : decreased blood supply to the fetus → Redistributes
blood to brain → Brain sparing effect
In early UPI → Middle cerebral artery doppler would be normal (Brain-sparing effect)
As UPI progresses → Resistance in MCA decreases → So in late UPI → S/D ratio
decreases in the middle cerebral artery
The last vessel to show reversal of end diastolic flow is ductus venosus
To find the cause of IUGR
Chromosomal anomalies - Karyotyping
Congenital anomalies - Targeted scan
Infections - TORCH test
Treatment
Conservative
Serial USG scans for fetal growth assessment (Every 3 weeks)
Umbilical artery doppler (weekly)
Amniotic fluid assessment (weekly)
Fetal surveillance with NST or BPS
Delivery plan based on expected fetal weight
If EFW 3-9 percentile : Deliver at 38-39 weeks
If EFW <3 percentile : Deliver at 37 weeks
Mode of delivery
If fetal heart rate normal → Vaginal delivery
In other cases → C-section
Umbilical artery showing absent end diastolic flow
Consider hospitalization
Corticosteroid for fetal lung maturity
NST 1-2 times per day if hospitalized or 1-2 times/week if outpatient
UA doppler : 2-3 times/week
Fetal growth assessments every 3 weeks
Delivery at 33-34 weeks
Umbilical artery showing reversed end diastolic flow
Compulsory hospitalization
Corticosteroids for fetal lung maturity
NST 1-2 times/day
UA doppler : 2-3 times/week
Fetal growth assessments every 3 weeks
Delivery at 30-32 weeks
Diagnosis of fetal growth restriction (x2)
Diagnosis
Screening for IUGR
fluid
Late onset IUGR
Doppler studies →
Fetal growth restriction- any 4 etiological factors, any 4 fetal complications
Etiology
Maternal
High altitude
Fetal
Placental
Placenta previa
Placental abruption
Unknown
Complications
Neonatal asphxia
Meconium aspiration syndrome
Hypoglycemia
Hypothermia
Polycythemia
Diagnosis and causes of Intrauterine fetal growth restriction
Diagnosis
Screening for IUGR
fluid
Late onset IUGR
Doppler studies →
Etiology
Maternal
High altitude
Fetal
Placental
Placenta previa
Placental abruption
Unknown
Neonatal complications in Intra uterine growth restriction.
Complications
Neonatal asphyxia
Meconium aspiration syndrome
Hypoglycemia
Hypothermia
Polycythemia
Problems of premature neonate
Neonatal asphyxia
Hypothermia
Hypoglycemia
Kernicterus and intraventricular hemorrhage (<34 weeks)
Patent ductus arteriosus
Anemia
Respiratory distress syndrome
Apnea of prematurity
33. Disease of the Fetus and the Newborn

Causes and management of neonatal jaundice
Causes
Physiological jaundice
Pathological jaundice
Hemolysis
Inherited → G6PD deficiency, Hereditary spherocytosis
Acquired → Rh/ABO incompatibility
UDP-GT defects
Criggler Najjar Syndrome
Hypothyroidism
Sepsis
Increased enterohepatic circulation
Breast feeding issues
Intestinal obstruction
Extravasated blood
Cephalohematoma
Bruising
Increased conjugated bilirubin
Neonatal cholestasis
Management
Serious jaundice
It includes
Jaundice on day 1
Jaundice in palms and soles
TSB nomogram > 95th percentile for age
Signs of bilirubin encephalopathy
Management
If encephalopathy signs present → Exchange transfusion
If encephalopathy signs absent → Phototherapy
Significant jaundice
It includes
Jaundice on arms and legs
Rate of rise in bilirubin > 5mg/dL/day or >0.2 mg/dL/hr
Jaundice persisting for > 2 weeks in term babies
Jaundice persisting for > 3 weeks in preterm babies
Do serum bilirubin in nomogram
If above cut off → Phototherapy
If below cut off → Observe
Neonatal Resuscitation
Initial steps
Temperature → Needs to be maintained by putting the baby into a warmer
Stimulate the baby by gentle tactile stimulation → Rubbing the back of baby and
flicking palms and soles
Position of airway of the baby by slight extension/sniffing posture
If the baby still doesn’t cry assess HR and respiratory effort
If HR > 100/min but inadequate labored breathing
Oxygen supplementation
Using oxygen hood
Using CPAP for < 32 weeks baby
If HR < 100/min and baby is not breathing/apnea
Positive pressure ventilation
Non-invasive → Bag and mask ventilation
Invasive → ET tube
If still no response and heart rate < 60/min chest compression are indicated
Two thumb technique
Site - Lower 1/3 of sternum avoiding the xiphisternum
Depth - 1/3rd of the chest AP diameter
Combined with ventilation
In one minute give 90 compressions + 30 ventilation
If no response to chest compressions then
Adrenaline injection (1:1000)
Route - Umbilical vein (IV) or Interosseous Route or ET tube
Dose - 0.2 mL/kg for IV and Interosseous route and 1 ml/kg for ET tube
The maximum duration of resuscitation is 20 mins → After that call of resuscitation
Cephalohematoma
Neonatal head swelling
Location - Sub periosteum, Deep swelling, Localized (limited by sutures)
Reason → Instrumental delivery
Content → Blood
Appearance → Slowly increases over a period of 12-24 hours
Disappearance → 3-6 weeks
Associations → Linear skull fractures, jaundice
34. Pharmacotherapeutics in Obstetrics

Tocolytics
Nifedipine in Obstetrics
Used for treatment of hypertension
MOA → Direct arteriolar vasodilation by inhibition of slow inward calcium channels in
vascular smooth muscle
Dose → Orally 5-10 mg TID (Max 60-120 mg/day)
Side effects
Maternal hypotension, tachycardia, flushing, inhibition of labor
Contraindications → Simultaneous use of magnesium sulfate could be hazardous due
to synergistic effect
Uses of misoprostol in Obstetrics
Methyl ester of PGE1
Rapidly absorbed and more effective than oxytocin or dinoprostone for induction of
labor
Uses
Cervical ripening
Induction of labor : 25 mcg every 3-6 hours by oral or vaginal route
Used along with Mifepristone for medical termination of pregnancy
35. Induction of Labor

Define Induction of Labor (IOL). Write six indications and four methods of IOL.
Discuss the labor management for her. Write management of first stage of
labor after successful induction.
Induction of labor (IOL) means initiation of uterine contractions by any method for
the purpose of vaginal delivery
Indications
Pre-eclampsia, eclampsia
PROM
PPROM
Chorioamnionitis
Oligohydramnios
Post-maturity
IUGR
IUD
Rh-isoimmunization
Methods
Medical methods
Prostaglandins
PGE1 (Misoprostol) → Dosage is 25 mcg, can be used 4 hourly once, maximum
number of doses is 6
PGE2 (Dinoprostone)
Available as cerviprem gel (administered intra-cervically)
Dosage is 0.5 mg, can be given 6 hourly once
Maximum number of doses is 4
Mifepristone
Anti-progesterone
Dose - 200 mg per vaginally
Mechanical methods
Foleys induction
Foleys catheter is inserted into the vagina and the bulb is filled with normal saline
(30-50 mL) and pulled down till it reaches the internal os. It is also called as trans
cervical balloon catheter
Extra normal saline pushed into the catheter enters into extra amniotic space (Extra
amniotic saline infusion)
Stripping of membranes
OPD procedure
Done during per vaginal examination
Sweeping and stretching of membranes
Releases prostaglandins
Management of first stage of labor
Ambulation and maternal positioning
Early labor - ambulation is allowed
Active labor - lie down in left lateral position
Oral intake
Gastric emptying time is delayed therefore solid food is not recommended
Clear fluids should be given orally
IV fluids can be given
Should remain well hydrated
For C-section → Liquids restricted two hours and solids stopped 6-8 hours before
surgery
Bladder function → Encouraged to void frequently
Pain relief → Epidural analgesia
GBS prophylaxis recommended for all females with
Rupture of membranes > 18 hours
Intrapartum temperature > 38 C
Monitoring
Pulse and BP hourly
Temperature 4th hourly
Uterine contraction → Noted every 30 mins for 10 mins with palm of hand
PV examination → Every 4th hourly
Fetal monitoring
FHR auscultation
Partogram
Partogram -Definition, components and advantages // Partogram with diagram //
Cervical component of partogram; graphical representation and relevance
Partograph is a composite graphical record of key data (maternal and fetal) during
labor, entered against time on a single sheet of paper
Components
Patient identification
Time - Zero time for spontaneous labor is the time of admission in the labor ward
and for induced labor it is the time of induction
Fetal heart rate every 30 mins
Stage of membranes and color of liqor: to mark I for intact membranes, C for clear
and M for meconium stained liqor
Cervical dilatation and descent of head
Uterine contractions
Drugs and fluids
Blood pressure at every 2 hours, pulse at every 30 minutes
Oxytocin - concentration in the upper box and dose in the lower box
Urine analysis
Temperature record
Advantages
A single sheet of paper can provide details of necessary information at a glance
No need to record labor events repeatedly
It can predict deviation from normal progress of labor early. So, appropriate steps
could be taken in time
It facilitates handover procedure
Introduction of partograph in the management of labor (WHO, 1994) has reduced
the incidence of prolonged labor and cesarean section rate
Prostaglandins in induction of labour
PGE1 (Misoprostol) → Dosage is 25 mcg, can be used 4 hourly once, maximum
number of doses is 6
PGE2 (Dinoprostone)
Available as cerviprem gel (administered intra-cervically)
Dosage is 0.5 mg, can be given 6 hourly once
Maximum number of doses is 4
Cervidil
Slow release formulation of dinoprostone
Contains 10 mg of dinoprostone
Placed in posterior fornix of vagina
Remove it after 12 hours or before if contraction arises
Bishop Score (x2) // Bishop score- Components and interpretation
36. Population Dynamics and Control of

Conception
37. Operative Obstetrics
Lower segment Caesarean Section -Procedure // Steps of LSCS. (Lower Segment
Caesarean Section)
Before C-section
Consent
Foley’s catheterization
Antibiotic prophylaxis
Elective → 60 mins before
Emergency → ASAP
DOC → Cefazolin 2g IV single dose
In allergic patients → Clindamycin + Gentamycin
Part preparation
Shaving is not recommended
Position of patient → Supine with 15 degree lateral tilt of table (to avoid IVC
compression)
First incision → Skin incision
Lower transverse abdominal incision → Pfannenstiel incision
2 cm above pubic symphysis
Cut subcutaneous tissue
Anterior rectus sheath -
Small incision with scalpel and then extend incision with fingers/scissors (tip should
be pointed upwards)
With the back of scalpel separate the sheath from rectus abdominis muscle
Rectus abdominis muscle
Need not cut the muscle
Cut the midline aponeurosis - Muscle separates automatically
Posterior rectus sheath
Fascia transversalis easily separated with fingers
Parietal peritoneum: Cut it a little higher (lift with help of forceps and cut in center)
Retract the bladder
Visceral peritoneum
Identify the loose fold of peritoneum
Lift and incise
Extend with help of scissors (Tip upwards)
Do not go very laterally (injury to uterine vessels)
Lower uterine segment
Small incision with scalpel
Put finger and extend (to decrease chances of injury to baby)
Extend incision with the help of scissors with a finger in place
Do not go very laterally: Uterine vessels might be injured
Head of the baby visible
Remove retractor
Deliver the head of the fetus keeping in mind to maintain flexion of fetal head
Fundal pressure to help in final descent
Check cord around the neck : Remove cord (if around the neck) and then deliver the
head of the baby
Head of the baby → Anterior shoulder → Posterior shoulder → Entire baby
Delayed cord clamping
Remove placenta by controlled cord traction
Give oxytocin injection
Placenta Delivered
Baby handed over
Closing the uterus and moving upwards
Hold the angles using Allis forceps
Closure of uterine incision : Single layer / double layer
Do instrument/sponge count
Field is made clear. Hemostasis has been maintained. All suction has to be done
before closing the abdominal wall
Check tubes and ovaries are fine
Closure of abdominal wall
Peritoneum : May close (to reduce risk of adhesions) or may not
Rectus abdominis : Not closed
Subcutaneous tissue : Not closed
Skin : With interrupted/subcutaneous sutures or use staplers
Do vaginal toileting and then apply occlusive dressing over skin
Indications and Steps of caesarean section
Absolute indications
Central placenta previa
Contracted pelvis or cephalopelvic disproportion
Pelvic mass causing obstruction
Advanced Ca cervix
Vaginal obstruction
Relative indications
Antepartum hemorrhage
Bad obstetric history
Previous C-section
Dystocia
Malpresentation
Non reassuring FHR
Obstetric outlet forceps; prerequisites and complications // Outlet forceps -
Indications, complications // Indications and pre-requisites for outlet forceps delivery
// Outlet forceps: Criteria for application, complications
Indications
Maternal
Inadequate expulsive efforts
Maternal exhaustion
Where expulsive efforts are to be avoided (eg. cardiac disease)
Fetal
Non-reassuring FHR- fetal distress
Aftercoming head of breech
Suspicion of fetal compromise
Other
Prolonged second stage of labor
To cut short the second stage of labor (eg. pre-eclampsia, cardiac disease)
Prerequisites
Fetal head engaged
The cervix must be fully dilated
The membranes must be ruptured
Fetal head position is exactly known
Pelvis deemed adequate
Bladder must be emptied
Adequate maternal analgesia
Informed consent
Experienced operator
Aseptic techniques
Back up plan and facilities in case of failure
Presence of neonatologist
Willingness to abandon the procedure when difficulties faced
Complications
Facial nerve palsy
Brachial plexus injury
Corneal injury
Vacuum delivery -prerequisites and contraindications // Ventouse delivery -
Indications and prerequisites
Indications
Maternal
Inadequate expulsive efforts
Maternal exhaustion
Where expulsive efforts are to be avoided (eg. cardiac disease)
Fetal
Non-reassuring FHR- fetal distress
Aftercoming head of breech
Suspicion of fetal compromise
Other
Prolonged second stage of labor
To cut short the second stage of labor (eg. pre-eclampsia, cardiac disease)
Prerequisites
Fetal head engaged
The cervix must be fully dilated
The membranes must be ruptured
Fetal head position is exactly known
Pelvis deemed adequate
Bladder must be emptied
Adequate maternal analgesia
Informed consent
Experienced operator
Aseptic techniques
Back up plan and facilities in case of failure
Presence of neonatologist
Willingness to abandon the procedure when difficulties faced
Complications
Sixth nerve palsy
Shoulder dystocia
Cephalohematoma
Subgaleal hemorrhages
Retinal injury
External Cephalic Version // External cephalic version -Indications, contraindications
and procedure
External cephalic version (ECV) is done to bring the favorable cephalic pole in the
lower pole of the uterus
Indications
Breech presentation
Transverse lie
Contraindications
Oligohydramnios
Ruptured membranes
Active phase of labor
Twin/multifetal pregnancy
Abnormal FHR on CTG
Placenta previa/contracted pelvis
Uterus/fetal gross anomalies
Procedure
Grasp the podalic pole (the feet of the fetus) with the right hand using a Pawlik's grip
and the head with the left hand.
Exert pressure in opposite directions, pushing the head towards the pelvis and the
breech towards the top of the uterus, until the lie becomes transverse.
Change hand positions to hold the fetal poles and continue exerting intermittent
pressure until the head is brought to the lower pole of the uterus.
Types of Episiotomy and indications, structures cut // Episiotomy (x2) // Episiotomy:
Types, Indication, method of closure
A surgically planned incision on the perineum and the posterior vaginal wall during
the second stage of labor is called episiotomy (perineotomy)
TYPES
Mediolateral
Median
Lateral
J shaped
INDICATIONS
In elastic (rigid) perineum
Anticipating perineal tear:
Big baby
Face-to-pubis delivery
Breech delivery
Shoulder dystocia
Operative delivery: Forceps, ventouse delivery
Previous perineal surgery
STEPS OF MEDIOLATERAL EPISIOTOMY
Preliminary
The patient is placed in lithotomy position
The perineum is thoroughly swabbed with antiseptic (povidone-iodine) lotion and
draped properly.
Local anesthesia : 10 mL of 1% solution of lignocaine
Incision
Two fingers are placed in the vagina between the presenting part and the posterior
vaginal wall
The incision is made by a curved or straight blunt pointed sharp scissors, one blade
of which is placed inside in between the fingers and the posterior vaginal wall and
the other on the skin
The incision should be made at the height of uterine contraction
Structures cut
Posterior vaginal wall
Superficial and deep transverse perineal muscles, bulbospongiosus and part of
levator ani
Fascia covering those muscles
Transverse perineal branches of pudendal vessels and nerves
Subcutaneous tissues and skin
Repair (METHOD OF CLOSURE)
Done after expulsion of placenta
Suture material : Chromic catgut or Vicryl No. 1
Done in three layers
Vaginal mucosa and submucosal tissue
Continuous sutures used
Perineal muscles
Interrupted sutures are used
Skin and subcutaneous tissue
Mattress sutures used
38. Safe Motherhood, Epidemiology of

Obstetrics
Define Maternal Death and Maternal Mortality ratio (MMR). Discuss the
National Programmes for Maternal and Child Health
Maternal death
Death of a woman while pregnant or within 42 days of the termination of pregnancy
irrespective of the duration and the site of pregnancy, from any cause related to or
aggravated by the pregnancy or its management but not from accidental or
incidental causes.
Maternal mortality ratio
MMR is the number of maternal deaths per 100,000 live births.
Programmes
Janani Suraksha Yojana (JSY):
The National Maternity Benefit scheme has been modified into a new scheme called
Janani Suraksha Yojana (JSY). It was launched on 12th April, 2005. The objectives of
the scheme are - reducing maternal mortality through encouraging delivery at health
institutions, and focusing at institutional care among women in below poverty line
families.
Features →
It is a 100 per cent centrally sponsored scheme;
Under National Rural Health Mission, it integrates the benefit of cash assistance with
institutional care during antenatal, delivery and immediate post-partum care; This
benefit will be given to all women, both rural and urban, belonging to below poverty
line household. The eligibility of cash assistance is as follows:
In low performing states (LPS) : All women, including those from SC and ST families.
delivering in government health centres like sub-centre, primary health centre,
community health centre, first referral unit, general wards of district and state
hospitals or accredited private institutions.
In high performing states (HPS) : Below poverty line women, and the SC and ST
pregnant women delivering in Govt. health centres or accredited private institutes.
Pradhan Mantri Surakshit Matritva Abhiyan (PM-SMA): The Pradhan Mantri Surakshit
Matritva Abhiyan (PM-SMA) is a program that aims to provide free, quality antenatal
care to pregnant women through monthly camps at health facilities. The PM-SMA
focuses on providing comprehensive care to pregnant women, including services
such as antenatal check-ups, nutrition counseling, and screening for common
pregnancy-related complications.
Pradhan Mantri Matru Vandana Yojana (PMMVY): The Pradhan Mantri Matru
Vandana Yojana (PMMVY) is a program that provides financial assistance to pregnant
and lactating women to improve their health and nutrition status. Under the PMMVY,
eligible women are entitled to receive a maternity benefit of INR 5,000 (approx. $68)
in three installments, to be used for health and nutrition-related expenses during
pregnancy and lactation.
Janani Shishu Suraksha Karyakram (JSSK):
Government of India launched the Janani-Shishu Suraksha Karyakram (JSSK) on 1st
June 2011, a new national initiative, to make available better health facitlies for
women and child. The new initiatives provide the following facilities to the pregnant
women
All pregnant women delivering in public health institutions to have absolutely free
and no expense delivery, including caesarean section. The entitlements include free
drugs and consumables, free diet upto 3 days during normal delivery and upto 7
days for C-section, free diagnostics, and free blood wherever required.
This initiative would also provide for free transport from home to institution. between
facilities in case of a referral and drop back home
The scheme is estimated to benefit more than 12 million pregnant women who
access government health facilities for their delivery. Moreover, it will motivate those
who still choose to deliver at their homes to opt for institutional deliveries.
Maternal mortality-definition and causes // Definition of Maternal mortality and
causes // Causes of maternal mortality
Death of a woman while pregnant or within 42 days of the termination of pregnancy
irrespective of the duration and the site of pregnancy, from any cause related to or
aggravated by the pregnancy or its management but not from accidental or
incidental causes
Causes
Hemorrhage - mostly due to PPH. Other causes are APH, abortion complications and
ectopic pregnancy
Infection - associated with labor and puerperium
Hypertension during pregnancy - pre-eclampsia and eclampsia
Unsafe abortion
Obstructed labor - due to cephalopelvic disproportion, abnormal lie and
malpresentation
Anemia
Causes and preventive steps for maternal mortality.
Maternal Mortality Ratio - definition and strategies to reduce it.

MMR is the number of maternal deaths per 100,000 live births.
Strategies to reduce MMR
Health sector actions
Basic antenatal, intranatal and postnatal care
A skilled birth attendant
Emergency obstetric care
Good quality obstetric services
Prevention of unwanted pregnancy and unsafe abortion
Community, society and family actions
Health Planners/Policy Makers’ Actions
To organize community education, motivation and formation of safe motherhood
committee at the local level.
To strengthen the referral system for obstetric emergencies.
To develop written management protocols for obstetric emergencies in the hospital.
To improve the standard and quality of care by organizing refresher courses for the
healthcare personnel.
Periodic audit of the existing healthcare delivery system and to implement changes
as needed
Legislative and Policy actions
Girl children and adolescents should have good nutrition, education and economic
opportunities
Barriers to access of healthcare facilities should be removed
Decentralization of services to make them available or all women
Safe abortion services and postabortion care must be ensured by national policy
Social inequalities and discrimination on grounds of gender, age and marital status
are to be removed
Perinatal mortality Rate -Define and list the causes
Perinatal mortality is defined as deaths among fetuses weighing 1000 g or more at
birth (28 weeks gestation) who die before or during delivery or within the first 7 days
of delivery. The perinatal mortality rate is expressed in terms of such deaths per 1000
total births.
Janani Suraksha Yojana (JSY) - Aims and Salient features

Janani Suraksha Yojna
The National Maternity Benefit scheme has been modified into a new scheme called
Janani Suraksha Yojana (JSY). It was launched on 12th April, 2005. The objectives of
the scheme are - reducing maternal mortality through encouraging delivery at health
institutions, and focusing at institutional care among women in below poverty line
families.
Features →
It is a 100 per cent centrally sponsored scheme;
Under National Rural Health Mission, it integrates the benefit of cash assistance with
institutional care during antenatal, delivery and immediate post-partum care; This
benefit will be given to all women, both rural and urban, belonging to below poverty
line household. The eligibility of cash assistance is as follows:
In low performing states (LPS) : All women, including those from SC and ST families.
delivering in government health centres like sub-centre, primary health centre,
community health centre, first referral unit, general wards of district and state
hospitals or accredited private institutions.
In high performing states (HPS) : Below poverty line women, and the SC and ST
pregnant women delivering in Govt. health centres or accredited private institutes.
Janani Shishu Suraksha Karyakram
Janani-Shishu Suraksha Karyakram
Government of India launched the Janani-Shishu Suraksha Karyakram (JSSK) on 1st
June 2011, a new national initiative, to make available better health facitlies for
women and child. The new initiatives provide the following facilities to the pregnant
women
All pregnant women delivering in public health institutions to have absolutely free
and no expense delivery, including caesarean section. The entitlements include free
drugs and consumables, free diet upto 3 days during normal delivery and upto 7
days for Csection, free diagnostics, and free blood wherever required.
This initiative would also provide for free transport from home to institution. between
facilities in case of a referral and drop back home
The scheme is estimated to benefit more than 12 million pregnant women who
access government health facilities for their delivery. Moreover, it will motivate those
who still choose to deliver at their homes to opt for institutional deliveries.
Millennium Development Goal 5 (MDG 5)
Millennium Development Goal (MDG) 5 aims to improve maternal health and reduce
maternal mortality rates.
One of the targets of MDG 5 is to reduce the maternal mortality ratio (MMR) by
three-quarters between 1990 and 2015.
Improving access to reproductive health services, including family planning, is a key
strategy for achieving MDG 5.
MDG 5 also aims to increase the number of births attended by skilled health
personnel and to provide access to emergency obstetric care for all women.
Reducing the number of adolescent pregnancies and improving the health of
newborns and infants are also important components of MDG 5.
Achieve universal access to reproductive health was also a target under MDG 5.
39. Special Topics in Obstetrics

Causes and management of DIC in pregnancy
Triggers
Endothelial injury
Pre-eclampsia, eclampsia, HELLP syndrome
Septicemia - Septic abortion, Chorioamnionitis, Pyelonephritis
Hypovolemia
Release of thromboplastin
Hydatidiform mole
Amniotic fluid embolism
Abruptio placenta
Dead fetus syndrome
Shock
Release of phospholipids
Fetomaternal bleed
Incompatible blood transfusion
Hemolysis
Septicemia
Investigations
Bleeding time
Coagulation time
Peripheral smear
Clot observation test
Circulatory fibrinolysis test
Treatment
Volume replacement by crystalloids (Ringer’s lactate) or by colloids (hemacel or
gelofusine or albumin 5%) will reduce the amount of whole blood needed to restore
blood volume. Two large bore IV catheters are used to deliver the fluids>
Whole blood transfusion is rarely used in modern obstetrics
Fresh frozen plasma - One unit (250 mL) raised the fibrinogen by 5-10 mg/dL
Cryoprecipitate - Same fibrinogen increase but less volume (40 mL)
Platelet concentrates may be given to patients with very low platelet count
(<50,000/mL)
Packed RBCs are given when Hb < 8 mg/dL. One unit (250 mL RBC and 50 mL
plasma) increases Hb by 1 g/dL
Massive transfusion protocol → PRBC, FFP and Platelets are given in the ratio 1:1:1
Heparin should be used when the vascular compartment remains intact. In conditions
such as amniotic fluid embolism, IV heparin 5000 units repeated 4-6 hours intervals is
useful to stop DIC and may be lifesaving.
Diagnosis of fetal distress in labor (Non assuring fetal status in pregnancy)
CTG: Technique, Components and Interpretation
Intrapartum fetal monitoring
Technique
Two sensors
One to monitor fetal heart rate
Other to monitor uterine contractions
Additional button which is placed in the hand of mother, which is to be pressed by
the mother when she senses contractions.
Printed on a graph
Components
Fetal heart rate
Uterine contractions
Interpretation
Early deceleration
Due to head compression (physiological)
Onset of dip coincides with onset of uterus contraction and and ends with cessation
of contraction
Gradual dip (> 30 seconds) : Time from onset of dip to peak is greater than 30
seconds
Management : Wait and watch
Late deceleration
Most ominous type of deceleration
Gradual dip (> 30 seconds)
Onset : Uterine contraction
End : Does not end with uterine contraction (ends later)
Management
Patient in left lateral position
IV fluids
Oxygen
Stop uterotonic drugs
If persists → C-section
Variable deceleration
Cord compression
No fixed pattern between FHR dip and uterine contraction
Sudden dip (< 30 seconds)
Management
Put mother in head low position
Check for cord prolapse
IV fluids
Amnioinfusion
If persists → Persistent variable deceleration → C-section
40. Current Topics in Obstetrics

41. Imaging in Obstetrics (USG, MRI, CT,
Radiology), Amniocentesis and Guides to
Clinical Tests
Uses of Ultrasound in obstetrics-any 8 uses
First trimester
Confirmation of intrauterine pregnancy
Suspected ectopic pregnancy
Vaginal bleeding
Fetal anomalies
Suspected molar pregnancy
Gestational age
Multiple pregnancy
To confirm cardiac activity
Screening of aneuploidy
Evaluation of pelvic/adnexal masses
Second and third trimester
Gestational age
Cervical insufficiency
Suspected multiple pregnancy
Liquor volume (poly/oligohydramnios)
Placenta previa/abruption
Suspected uterine malformation
Cases with premature rupture of membranes (PROM)
Fetal growth (FGR)
Fetal presentation (breech, face)
Fetal well-being (BPP) assessment
Screening fetal anomalies
As an adjunct to: amniocentesis, chorionic villus sampling (CVS), cordocentesis, fetal
therapy, external cephalic version (ECV)
Uterine size: Either > dates or < dates
Ultrasonography in the1st trimester // 1st Trimester Ultra sound and its importance
// Ultrasound in first trimester
Confirmation of intrauterine pregnancy
Suspected ectopic pregnancy
Vaginal bleeding
Fetal anomalies
Suspected molar pregnancy
Gestational age
Multiple pregnancy
To confirm cardiac activity
Screening of aneuploidy
Evaluation of pelvic/adnexal masses
42. Practical Obstetrics

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OBG I

1. Anatomy of Female Reproductive

9. Fetal Skull and Maternal Pelvis

10. Antenatal Care, Preconception

11. Antenatal Assessment of Fetal Well-

12. Prenatal Genetic Counseling,

13. Normal Labor

Descent → Provided there is no undue bony or soft tissue obstruction, descent is a

14. Normal Puerperium

15. Vomiting in Pregnancy

Ondansetron is not used prior to 10 weeks as it suspected to interfere with the

16. Hemorrhage in Early Pregnancy

Management of unruptured ectopic

18. Hypertensive Disorders in Pregnancy

Narrow therapeutic range → 4-7 mEq/L

Monitoring for signs of toxicity

Narrow therapeutic range → 4-7 mEq/L

Monitoring for signs of toxicity

19. Antepartum Hemorrhage

20. Medical and Surgical Illness

Expected increase in Hb → Occurs after 3 weeks of starting oral/parenteral therapy at

Expected increase in Hb → Occurs after 3 weeks of starting oral/parenteral therapy at

Expected increase in Hb → Occurs after 3 weeks of starting oral/parenteral therapy at

21. Gynecological Disorders in Pregnancy

23. Complicated Pregnancy

24. Contracted Pelvis

25. Abnormal Uterine Action

26. COMPLICATED LABOR-Malposition,

Malar flexion and shoulder traction (Modified Mauriceau-Smellie-Veit technique)

Malar flexion and shoulder traction (Modified Mauriceau-Smellie-Veit technique)

Assisted Breech delivery: Pre requisites and procedure

Malar flexion and shoulder traction (Modified Mauriceau-Smellie-Veit technique)

27. Prolonged Labor, Obstructed Labor,

28. Complications of the Third Stage of

Surgical management of Atonic postpartum hemorrhage

29. Injuries to the Birth Canal

31. The Term Newborn Infant

32. Low Birth Weight Baby

33. Disease of the Fetus and the Newborn

34. Pharmacotherapeutics in Obstetrics

35. Induction of Labor

36. Population Dynamics and Control of

38. Safe Motherhood, Epidemiology of

Maternal Mortality Ratio - definition and strategies to reduce it.

Janani Suraksha Yojana (JSY) - Aims and Salient features

39. Special Topics in Obstetrics

40. Current Topics in Obstetrics

42. Practical Obstetrics

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