Obstetrics Notes By Dr.

Kamal Deep

([email protected]™) {Only For PG

Entrance Examinations}

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1) During childbirth,the hymen is extremely lacerated and later represented by cicatrized

nodules of varying size,called the carunculae myritiformes
2) Opening of bartholin`s ducts in the groove between the hymen and the labium minus.
3) Out of 4 fornices the posterior one is deeper,the anterior one is the most shallow.
4) Vagina mucous layer is lined by stratified squamous epithelium without any secreting
glands.It is non keratinized.
5) Development from urogenital sinus. Of vagina
6) Relations of lat vaginal fornix : a)Mackendrots ligament (transverse cervical ligament)
connect lateral aspects of cervix and of the upper vaginal wall to the lateral pelvic
wall.They form a hammock that supports the uterus. b)The uterine artery (branch of ant
division of the internal iliac artery .it first runs medially towards the cervix ,crossing the
ureter above the lateral fornix of the vagina and 2 cm lateral to the cervix.The uterine
artery crosses from above and in front of the ureter.c)ureter
7) Mucous coat lining the endocervix is columnar.
8) Peritoneum in relation to the uterus when traced laterally forms the broad ligament.
9) Lymphatic drainage of the uterus : 1 Fundus and upper part of body –Aortic
nodes,partly to superficial inguinal nodes along the round ligament of the uterus. 2
Cervix—external iliac,internal iliac and sacral nodes.
10) Lymphatic drainage of vulva: superficial inguinal glands.
11) In papillary ca. of uterine cornua,lymphatic spread will ocuur to inguinal.(the
superolateral angles of the body of the uterus project outwards from the junction of the
fundus and body and is called the cornua of the uterus) cornua drains in to superficial
inguinal glands.Most of the tubal lymphatics and lymphatics from ovary drains into
paraortic nodes.The lymphatics from the isthmus drain into superficial inguinal
nodes.
12) In conditions such as primary sore and bartholin`s abscess,the horizontal inguinal
group becomes inflamed.
13) Obturator glands most frequently involved in ca cervix,drains in to external iliac nodes.
14) the squamous cells of the vagina and cervix stain a deep brown colour after being painted
with iodine ,owing to the presence of glycogen in healthy cells(positive schillers test)
15) In nulliparous women external os is circular/cervix is conical ,in the parous Ext os is
transverse slit while cervix is cylindrical.
16) Before puberty the cervix to corpus ratio : 2:1, at puberty : 1:2,durin reproductive
years 1: 3
17) Round ligament corresponds to vas in males.
18) Fallopian tube measures 4 inches or 10-12 cm .Interstitial portion is the NARROWEST
PART. Next is isthmus.Then lies laterally is ampulla,the widest and longest part.and at the
end is fimbriated extremity or infundibulum where the abdominal ostium opens into
peritoneal cavity.
19) Fallopian tubes have 3 types of cells acc to frequency1) ciliated 2) goblet cells 3) PEG
CELLS
20) MESONEPHRIC ELEMENTS 1) EPOOPHORON : CRANIAL end of wolffian body
2) PARAOOPHORON) CAUDAL end of wolffian body 3) Gartner`s duct or wolffian
duct. It passes downwards by the side of the uterus to the level of the internal os where it
passes into the tissues of the cervix.it then runs forward to reach the anterolateral aspect of
the vaginal wall and may reach as far as down the hymen.THE DUCT SOMETIMES
FORMS A CYST CALLED THE GARTNER`S CYST.(CONGENITAL CYST)
21) Female urethra measures 35MM.
22) MUSCLES OF THE PERINEUM :1) ISCHIOCAVERNOSUS
2)BULBOSPONGIOSUS 3) SUPERFICIAL TRANSVERSE PERINEI 4)
SPHINCTER URETHRAE 5) DEEP TRANSVERSE PERINEI. First thee muscles lie
in the superficial perineal space and last 2 muscles lie in the deep perineal space.last 2
muscles form the UROGENITAL DIAPHRAGM.
23) PELVIC DIAPHRAGM is formed by two pelvic muscles LEVATOR ANI and
COCCYGEUS.
24) PERINEAL BODY represented by three layers of muscles. First and superficially are
external sphincter of the anus,bulbospongiosus and superficial transverse
perinei..Deep to thi sis urogenital diaphragm enclosing the deep transverse perinei.
Deeper still is levator ani(pubococcygeus part).All these 5 muscles converge and
interlace in the perineal body to form a fibromuscular node situated in the median
plane,about 1.25 cm in front of the anal margin and close to the bulb of penis.
25) Most important structure preventing the uterine prolapse are Mackendrot`s ligament
and Uterosacral ligament.
26) Least vascular part of the uterus is in midline.
27) The uterus is supplied by both parasympathetic and sympathetic nerves through the
INFERIOR HYPOGASTRIC AND OVARIAN PLEXUSES.SYMP –T12-L1 ,
PARASYM. –S2 S3 S4. Pain sensations fronm the body of the uterus pass along the
sympathetic nerves and from the cervix along the parasympathetic nerves. Nervi ergentes
or pelvic splanchnic nerves represent the sacral outflow s2 s3 s4 of the parasympathetic
nervous system.. PUDENDAL NERVE is the chief nerve of the perineum and external
genitalia. arises from the sacral plexus S2 S3 S4. in the pelvis like pelvic splanchnic
nerves.Pudendal nerve leaves the pelvis to enter gluteal region by passing through
GREATER SCIATIC FORAMEN. The nerve leaves the gluteal region by passing
 through the lesser sciatic foramen and enters the pudendal canal .Pudendal canal present in
the lateral wall of ischiorectal fossa contains the pudendal nerve and internal pudendal
vessels.
28) The motor and sensory fibres from S2 S3 S4 ends in GANGLIA OF FRANENHAUSER
.SURROUNDING THE CERVIX.
29) Ilioinguinal nerve supplies the skin of anterior one third of scrotum and root of the
penis in males ,in females it supplies the mons ,the upper and outer aspect of labia
majora and the perineum,Rest of external genitalia and perineum supp by pudendal
nerve.Pudendal block needed in vaginal deliveries.
30) After the first meiotic division,which results in 2 daughter cells with haploid no of
chromosomes but two chromatids(2n),the two chromatids of each chromosome
separate during a second meiotic division to yield four gametes with a haploid state
(1n).when the egg is fertilized by sperm,the two haploid sets are combined,thereby
restoring the diploid state(2n) in the zygote.(diploid no of chromosomes in diploid
state,2n)
31) Primitive germ cells(oogonia) takes their origin from the yolk sac.
32) Primary oocyte is 46 XX
33) The time required for a spermatogonium to develop into mature spermatozoon is about 61
days.
34) The number of chromosomes after 1st meiotic division is haploid but in the diploid
state (2n). The secondary oocyte is 23 X with haploid no of chromosomes (but in
diploid state (2n), with two chromatids) formed after 1st meiotic division.
35) Polar bodies formed during oogenesis only.At the time of birth ova undergo first meiotic
division but arrest in prophase.Just before ovulation arrested prophase is completed to
form secondary oocyte and the first polar body.First polar body fragments and
disappears.The secondary oocyte immediately begins second meiotic division but arrest in
metaphase which is completed only when a sperm penetrate the oocyte(AFTER
fertilization.,the time when second polar body is cast off)
36) If there is no pregnancy,the corpus luteum begins to degenerate about 4 days before
the next menses(24th day of the cycle)
37) The length of secretory phase which comes after prolif phase is remarkably constant at
about 14 days,and the variations seen in the length of the menstrual cycle are due for the
most part to variations in the length of the prolif phase.Thus if a lady presents with a 29 day
cycle, ovulation occurs at 15th day,+1 is added to prolif phase as secretory phase is
mostly constant.
38) The LH SURGE STIMULATES COMPLETION OF REDUCTION DIVISION OF
THE OOCYTE. AT THE TIME OF LH SURGE(OVULATION) the steroid hormones
ratio in peripheral circulation is -----HIGH ESTROGENS TO LOW
PROGESTERONES.after LH surge both rises but ratio is more for progesterones. prolif
phase maintained by estrogens and luteal or sec phase by both hormones.
39) Morula enters the uterine cavity on 4th day after fertilization. IMPLANTATION
occurs 6 days after fertilization (or 2-3 days after entering into uterine
cavity)corresponds to 20th day of menstrual cycle.
40) Expelled products in ectopic pregnancy originate from decidua vera.The rest of the
decidua lining the uterine cavity outside the site of implantation is decidua vera or
parietalis.
41) Fibrinoid necrosis appears on the syncytiotrophoblast outside the trophoblastic shell and is
called NITABUCH`S MEMBRANE.(ZONE OF FIBRINOID DEGENERATION
WHERE THE TROPHOBLAST AND THE DECIDUA MEET)
42) Fetoplacental circulation ------21st -22nd day(Arteriocapillaryvenous system in the
mesenchymal core of each villus is completed on 21st day)
43) Blighted ovumrepresents failed development of embryo,so that a gestational sac with or
without a yolk sac is present characterised by AVASCULAR VILLI.
44) Implantation bleeding is called HARTMAN`S SIGN.
45) Def sign of pregnancy is fetal skeleton on XRAY. Radiologic evidence of fetal skeletal
shadow may be visible as early as 16th weeks.FHS is also a definite clinical sign.(120-
140 per minute)
46) Placenta weighs around 500 gm.roughly 1/6th or 20% of the weight of the baby at term.
Occupies about 30% of the uterine wall.
47) Insulin ,steroids from adrenals,thyroid,hcg,or placental lactogen cross the placenta at a
avery slow rate.Neither PARATHORMONE NOR CALCITONIN CROSSES
PLACENTA.
48) Amniotic fluid is faintly alkaline .the rate of amniotic fluid turnover is 300 cc /hr.Volume
reaches peak at 36-38 wks(1litre). 50 ml at 12 weeks.Normal amniotic fluid sodium
content at term is 320-410 mg er 100 ml.Amniotic fluid contains estradoil and
prostaglandins,prolactin ,insulin and renin.glucose,urea,protein,NPN,uric
acid,creatinine,apart from inorganic constituents like Na,k,cl
49) External genitalia develops at 8-12 weeks post conception.
50) The internal urogenital tract,In the male ,the wolffian duct -----vas
deferens,epididymis,seminal vesicles.mullerian duct disappears.In the female the mullerian
ducts----Fallopian tubes,uterus and upper vagina.wolffian duct regress.
51) The external genitalia in both sexes from common analge.The urogenital sinus gives rise to
the prostate and prostatic urethra in males ,and to the urethra and lower portion of the
vagina in the female.The genital tubercle gives rise to glans and clitoris.The urogenital
swellings----scrotum and labia majora.The urethral folds---labia minora / shaft of the penis
and male urethra.
52) Abnormal colour of liquor,Meconium is green because of the bile pigments.sugg of
fetal distress
53) Meconium contains lanugo,epithelial debris,bilirubin,mucin,salts,fats.but never bact
flora.It is a sterile mixture.
54) Red cells first appearing at about 6 weeks after conception contain the embryonic
hemoglobins Hb Portland,Hb Gower I,Hb gower II. At 10-11 weeks,fetal Hb(HbF;α2
γ2) becomes predominant. The switch to nearly exclusive synthesis of adult hemogloin
(HbA;α2β2) occurs at 38 weeks.At term about 75-80% of the total Hb is still of fetal
type HbF. Between 6-12 months after birth ,the fetal Hb is completely replaced by
adult Hb. HbF has greater affinity for oxxygen,It is also resistant to alkali.The life
span of fetal RBC is about 80 days.
55) Fetal resp movements occur earliest at 11 wks.
56) Meconium is formed when the fetus commences to swallow amniotic fluid.By the third
month of intrauterine life the upper third the small intestine has become filled with
meconium,by the 4th month the accumulation has reached the ileocecal valve.at term it is
distributed uniformly throughout the gut upto the rectum indicating the presence of
 intestinal peristalsis.In intrauterine asphyxia the anal sphincter is relaxed and the
meconium may be voided in liquor amnii.(mecomium stained liquor )indicating fetal
distress.First meconium is said to be formed during 3rd or 4th month of intrauterine
life(?????)
57) Closure of umblical veins: after obliteraton ,the umbilical vein form ligamentum teres
and ductus venosus becomes ligamentum venosum.
58) The non pregnant uterus weighs 50 gm.AT term weighs 900 -1000gm.
59) There is preponderence of navicular cells in cluster (small INTERMEDIATE CELLS
with elongated nuclei) in pregnancy in vagina nad vulva.
60) The size of ovarian vascular pedicel at term is 2.5 cm
61) Braxton`s hicks contractions: Spontaneous uterine pregnancy from very early weeks of
pregnancy,The contractions are irregular,infrequent,spasmodic and painless without any
effect on dilatation of the cervix.(uterine contractions of labour are painful).SIMILAR
TYPE OF UTERINE CONTRACTIONS ARE FELT IN 1)
HAEMATOMETRA,HAEMATOCOLPOS OR SUBSEROUS FIBROID.IN
ABDOMINAL PREGNANCY .The patient is not conscious about the contractions
but they can be felt on bimanual palpation.(not seen in submucous fibroid)
62) In 2nd trimester Breasts can be squeezed for secretion.
63) Cutaneous changes in pregnancy : 1) Pigmentation -- a) Chloasma on face b) Nipples
become deeply pigmented c) Linea nigra extending from Xiphisternum to symphysis
pubis d) Striae gravidaurum :represent scar tissue 2) OTHER CUTANEOUS
CHANGES APART FROM PIGMENTATION 1) VASCULAR SPIDER {spider
angiomata} 2)Palmar erythema 3) Falling of hairs or increase brittleness of nails.
4)“Gingivitis” the gums become congested and spongy and may bleed to touch ;[not
gingival hyperplasia]
64) In normal pregnancy ,variable amount of weight gain is a constant phenomenon
65) Haematological changes -- 1] The blood volume is markedly raised 2] Plasma volume
also increases 3] RBC volume is also increased 4] The disproportionate increase in
plasma and RBC volume produces a state of hemodilution. 5] Diminished blood
viscosity due to hemodilution. 6] Fibrinogen level is raised ,globulin is
raised,therefore ESR is also raised 7] platelet count decreases 8] increase in
plasminogen activity 9] Incraese in activities of all clotting factors X,IX,VIII,VII,II,
The level of factors XI and XII are slightly decreased.
66) Heart and circulation ---1] increase in cardiac output 2] Heart rate increases 3]
Peripheral resistance markedly decreased ;In the second trimester fall in BP
,otherwise BP unaffected 4] Uterine blood flow is increased from 50 ml per minute in
non pregnant state to about 750 ML NEAR term. 5] During late pregnancy ,the
gravid uterus produces a compression effect on inf vena cava when the patient is in
supine position ,This however results in opening up of the collateral circulation by
means of paravertebral and AZYGOUS VEINS. In 10% this may not occur leading to
postural hypotension which can be restored by turnin the patient in lateral
position.Enlargement in Azygous vein in pregnancy is due to collateral formation.
67) The oxygen consumption of the pregnant uterus at 28 weeks is 22ml/min.
68) During pregnancy serum iron conc decreases ,total iron binding capacity increases.in
the absence of exogenous iron supplementation ,the Hb conc and hematocrit falls .
Thus preg is an inevitable iron def state.
69) Æ****Total iron req durin preg is 1000 mg or average **3.5mg/day.[1000/280days]
for whole preg. (in the second half daily req. actually becomes increased to 6-7 mg
[obs dutta]) .This is the iron that should be absorbed which is provided by daily RDA
of 38mg/day acc to park or 30mg/day acc to harrison. TO BE SUPPLEMENTED “40
MG”.[apart from normal diet]
70) In pregnancy---Resp rate unaltered ,TV increased( therefore resp minute volume also
increased),VC unaltered,RV decreases.
71) Increase in GFR and Renal plasma flow.
72) MAXIMAL RISE IN PROLACTIN SEEN AT TERM.
73) Fetal growth maximally influenced by INSULIN. (Therefore in maternal diabetes
there is macrosomia),{High maternal glucose crosses the placenta but maternal
insulin doesn’t readily crosses placenta resulting in fetal islet cell hyperplasia
stimulating insulin secretion,the anabolic and growth effects of insulin results in
macrosomia. } Fetal or Maternal GH is not essential for fetal growth in utero.
74) HCG produced by syncytiotrophoblast .The doubling time of hcg concentration in
plasma is 1.4-2 days in early pregnancy.[first trimester] The maximum levels reach
between 60-70 days of pregnancy. HCG disapperas from the circulation within 2 weeks
following delivery.At 42 days of LMP level is 1.5-3.5 IU/ml ( slide test positive at 42
days of LMP,sensitivity -1.5-3.5). By radioimmunoassay the level as low as .002 can
be detected on 25th day of cycle or 8-9 days following
ovulation.RADIOIMMUNOASSAY IS THE MOST SENSITIVE METHOD OF
QUANTITATIVE MEASUREMENT OF βHCG. Early morning urine sample is
collected(First voided urine inmorning ). THE LOWEST OF SERUM βhcg at which a
gestational sac is consistently visible using transvaginal sonography Is presently 2000
IU/ML.
75) HPL/HCS ,human chorionic somatomammotropin or human placental lactogen syn.
by syncytiotrophoblast. It is lactogenic and has a small amt of growth stimulating
activity.functions as maternal growth hormone.secretion of maternal GH is not
increased durin pregnancy. level of hpl is high in maternal blood but very little
reaches fetus.It stimulates lipolysis and decrease glucose utilization in mother
,diverting glucose to the fetus.
76) A value less than 12mg/24 hours urine of Oestriol in later months of pregnancy
suggests serious fetal compromise in utero.HPL is also used for evaluating placental
insufficiency like oestriol. A value of less than 5 μg/ml of HPL after 35 weeks
indicated fetal distress.
77) Heat stable alkaline phosphatase in pregnancy derived from placenta.
78) Thyroid –There is rise in basal metabolic rate because of thyroid hyperplasia. The
serum protein bound iodine { PBI } is increased in pregnancy.This rise is thought to
reflect an increase in the concentration and binding capacity of thyroxine binding
globulin (TBG) due to estrogen stimulation.What is butanol extracted iodine???????
79) Gestational age is 280 days ,ovulatory age is 266 days{ 280-14]
80) Frequency of Micturition mostly seen in 8-12 weeks of pregnancy
81) The alveolar cells begin to show secretory activity AT MIDDLE OF PREGNANCY.
82) Pelvic changes and signs in pregnancy Æ 1) Jacquemier`s or CHADWICK`S sign
:Type of discoloration in which there is dusky hue of vestibule and anterior vaginal
wall. 2) Osiander`s sign : Increased pulsation through the lateral fornices. 3)
 Goodel`s sign : Softenin of cervix 4) Hegar`s sign : It can be demonstrated between
6-10 weeks .This sign is based on the fact that a)Upper part of the body of uterus is
enlarged by the growing ovum. b) lower part of the body is empty and extremely
soft.c) the cervix is comparatively firm.Therefore because of “softened isthmus” in
between ; the approximation of the examination fingers at the isthmic region can be
elicited. 5)Palmer`s sign : Regular and rhythmic uterine contractions can be elicited
during bimanual examnination as early as 4-8 weeks.
83) SONOGRAPHYÆ gestational ring at 5th week, cardiac pulsation at 7th week,
embryonic movements at 8th week of gestation.Earliest sign of FETAL “life” is best
detected by REAL TIME ULTRASONOGRAPHY.(CF POINT 110) Detection of
FHR by transvaginal usg Æ 40 days ,by transabdominal Æ 1 week more than
transvaginal ,by doppler Æ 10th week.
84) Quickening (perception of fetal movement by mother) Earliest at 16th week in
multipara {2 weeks earlier than primi.[18week]}
85) Uterine souffle is due to increase in blood flow through the dilated uterine vessels. The
sound is synchronous with the maternal pulse.It is a soft blowing and systolic murmur
heard low down at the sides of the uterus,best on the left side.
86) PSEUDOCYESISÆ Psychological disorder in which woman has false but firm belief
that she is pregnant although no pregnancy exists.The conspicuous feature is cessation
of menses,gradual enlargement of abdomen.inspite of these confusing features
pregnancy can be ruled out by THE ABSENCE OF POSITIVE SIGNS OF
PREGNANCY. “There is enlargement of abdomen ,not of uterus.”
87) Comonest lie-longitudinal,commonest presentation—cephalic,commonest presenting
part – vertex.Face ,brow,vertex well flexed,vertex deflexed are varieties of cephalic
presentation in different attitude. LOT is commonest type of vertex presentation.
Occipito post position is least common,it ocurs in spontaneous breech delivery .the
fetal trunk and head are rotated to bring them anteriorly. “Occurs during breech
delivery”
88) Height of the uterus: conditions where the height of uterus is more than the period of
amenorrhoea a) Mistaken date 2) Twins 3) Polyhydramnios 4) Big BABY 5) Pelvic
tumour ovarian or fibroid 6) H mole 7) concealed acc hemorrhage. Conditions
where the height of uterus is less than the period of amenorrhoea 1) Mistaken date 2)
scant liq amnii 3) Fetal growth retn 4) “Intrauterine fetal death”
89) Commonest cause of an unengaged head at term DEFLEXED HEAD PLACING THE
LARGER DIAMETER TO ENGAGE.
90) No of fontanelles at birth : 6 { 1 ANT CLOSES BY 18TH MONTH ,1 POST and 2
sphenoid closes by 2nd and 3rd months ,2 mastoid closes by 12th month.
91) Engaging Diameter of skull 1) in vertex Pt. Æ suboccipito-bregmatic 2) in face -Æ
submento-bregmatic. 3) in brow Æ Mentovertical. Longest diameter of fetal skull is
Mento-vertical in BROW Presentation[14cm].
92) The Transverse diameters of skull which are concerned in mechanism of labour are:
Biparietal(9.5cm), super-subparietal(8.5cm),bitemporal(8cm),bi mastoid(7.5cm). The
last 2 are the shortest diameters.
93) True pelvis refers to the lower part of the pelvis. Divided into inlet,cavity outlet.
INLET – shortest AP diameter in the AP plane of “INLET” is OBSTETRIC
CONJUGATE. Most important diameter of pelvic inlet is DIAGONAL
 CONJUGATE.It can be measured clinically.True conjugate is anatomical conjugate.
OUTLET – shortest diameter is Post SAGGITAL.It is bounded above by PLANE OF
LEAST PELVIC DIMENSIONS and below by the anatomical outlet.PLANE OF
LEAST PELVIC DIMENSIONS IS THE PLANE MOST IMP IN OBSTRUCTED
LABOUR.IT IS AT THIS PLANE THAT INTERNAL ROTATION OCCURS.IT IS
IRREGULARLY OVAL AND NOTCHED ON EACH SIDE BY THE ISCHIAL
SPINE.
94) Pelvic assessment is best done with the onset of labour or just before induction of
labour .Any history of vaginal bleeding contraindicates vaginal examination eg
PPH.??
95) The increased calorie req in preg is to the extent of 300kcal over the non preg state
during sec half of preg.So 2200+300=2500 kcal is needed in preg.calcium req is
1000mg. Iron is always supplemented in addition to intake of food iron from a varied
diet. Folate is also supp acc to harrison amt is 400 μg to prevent neural tube defects.
96) No treatment is req for physilogical edema or orthostatic edema .edema subsides on
rest with slight elevation of limbs.Diuretics should`nt be prescribed.
97) Amniocentesis- 15-18 weeks, CVS – 10-12 WEEKS,PUBS – during second and third
trimester.Maternal serum screenin of hormones in second trimester.
98) MSAFP elevated in OPEN NEURAL TUBE DEFECTS like spina bifida
,anencephaly etc.,IUFD, low levels are found in down`s .AFP increased in esophageal
atresia also. AFP levels are highest in fetal serum.
99) Triple test includes MSAFP, HCG and UE 3[unconjugated estriol].Inhibin can also be
measured to increase the sensitivity of down syn detection.low leavels of afp and ue3
are found in downs syn but hcg is elevated. Triple test done in second trimester
screening.
100) First trimester screening for downs syn -Maternal serum associated Plasma protein
A and the free β subunit of of HCG IN combination with ultrasonographic
measurement of nuchal translucency.(10-14 weeks of pregnancy).
101) CVS is ass with greater risk of spontaneous abortion than amniocentesis but allows
for elective abortion earlier during pregnancy.Also in CVS there is increased risk of
limb defects when the procedure is performed earlier(<10 weeks). CVS is applicable
during very narrow window of time of gestation.
102) The most specific finding in amniotic fluid to diagnose neural tube defects is Ache
elevation.It has got better diagnostic value than AFP.
103) NTDs best detected by Amniocentesis.Amniocentesis more accurate than CVS.CVS
not helpful in NTDs.
104) Culture and chromosomal studies of the desquamated fetal cells in the amniotic
fluid are carried out for women above age of “35”YEARS .
105) In practice only a small number of tissues are used for routine chromosomal
analysis : Amniocytes , or chorionic villi for prenatal testing …..For post natal studies
; Blood ,bonemarrow,or skin fibroblasts can be used. [harr 397] Q : All are used for
karyotyping except : A) lymphocytes B) Amnion cells C) fibroblasts D) Monocytes.
Ans is monocytes. Lymphocytes acc to robbins 182. ??????????
106) Ultrasound : best inv to diagnose fetal age. ,most reliable to diagnose fetal well being
,best method and most precise to diagnose placenta praevia. . *****Crown lump
length at 9-11 weeks is the best parameter measured by usg to assess fetal maturity
 and gives the best predictive value for accurate determination of gestational age
which is helpful later in pregnancy when IUGR is suspected. CRL accurate upto 14
weeks.CRL length of 120 mm means the gestational age is 14 weeks????.At 7 weeks is
10 mm. Normal CRL at birth is 33-35 cm.( CRL in cm + 6.5 =weeks of pregnancy,obs
dutta.)
107) Normal size of CBD on usg in pregnancy is 10-15 mm.
108) TESTS FOR FETAL WELL BEING--Æ Clinical- (girth of abdomen in last
trimester steadily increasing,size of uterus in earlier weeks,BP,weight gain, scanty liq
etc. ) ,biochemical (hpl,estriol-poor pred value), and biophysical assessment for fetal
well being ( fetal movement count by patient ,NST,cardiotocography,USG)……Fetal
movement count is performed 3 or 4 times a week.(less than 10 kicks in 12 hours
indicates failing placental function) .Loss of fetal movements is commonly followed by
disappearance of FHR within next 24 hrs.in either of the methods(cardif count 10 or
Daily fetal movement count,DFMC) ,if the result is ominous ,the candidate is
subjected to NST. (non stress test).
109) Non stress test for fetal well being ,it is an observed variation of FHR acceleration
with fetal movements ,which when present ,indicates a healthy fetus.(continuous
electronic monitoring of FHR along with recording of fetal movements.)
110) Manning score is a biophysical profile made up of 5 components .Apart from
standard NST,THE OTHER 4 PARAMETERS ARE observed using real time
ultrasonography. Æ 1) non stress test 2) Fetal breathing movements 3) gross fetal
movements 4) fetal tone 5) Amniotic fluid volume.
111) Fetal cardiotocography – in normal tracing ÆThere should be no deceleration or
there may be early deceleration of very short duration .Importantly there should be 2
or more accelerations during a 20 min period. Sure sign of fetal distress in fetal ECG
is Late deceleration(chronic placental insufficiency). Variable deceleration indicates
cord compression. Early deceleration is due to head compression.
112) Evidences of distress –1)An Increase in FHR to over 160/min or a decrease in rate to
less than 120/min. Fetal bradycardia is defined as less than 120 beats /min for a period
of 15 minutes continuous monitoring .2) Meconium staining of LIQ. Most sensitive
test for acute fetal distress is fresh meconium on induction of labour.?????? 3)
Excessive fetal movements may be a manifestation of fetal distress 4) Fetal blood PH
less than 7.2 is an indication for urgent interference.(sample from scalp).(due to
asphyxia or hypoxia).
113) *****Management of fetal distress during labourÆDuring labour when is the
diagnosis of fetal distress established by continuous cardiotocographic tracing
supplemented by fetal scalp blood PH estimation ,the baby should be delivered
urgently by the safest route –vaginal or abdominal. In the absence of continuous
monitoring facilities,deterioration of FHR pattern and presence of meconium stained
liquor dictates an urgent delivery.
114) Amniotic fluid volume should be assessed at least weekly,
115) Assessment of lung maturation : L :S greater than 2. , Identification of phosphatidyl
glycerolÆThe best test in diabetic mother to diagnose baby lung maturity.
116) An invasive test for assessing fetal well being : Oxytocin challenge Test : (OCT) syn
contraction stress test to detect fetal hypoxia during inducing contraction.
 Contraindication: Previous history of caesarean section , complications likely to
produce preterm labour, APH, thus its use is very selective.
117) Based on the Naegle`s formula Labour starts approximately on the expected date in
4% .
118) ( Ganong 454) Mechanism of initiation of labour : CRH -Æ ↑↑CORTISOL Æ
CORTISOL hastens the maturity of the resp systm. Thus in sense the fetus picks the
time to be born by increasing CRH secretion. Fetal adrenal also increases the DHEA`s
at the same time-Æincrease in estrogensÆ increase in prostaglandins and in oxytocin
receptors.
119) 1] First stage of labour – starts from the onset of tue labour pain and ends with Full
dilatation of the cervix; Intrauterine prssure is raised to 40-50 mm hg 2] Second
stage –starts from full dilatation of cervix and ends with expulsion of the fetus from
the birth canal;Intrauterine pressure is raised to 100-120 mm hg. 3] Third stage –
starts after expulsion of the fetus and ends with expulsion of placenta
120) With the full dilatation of cervix ,the membranes usually rupture,but rupture of
membranes is not taken for staging labour.
121) Mechanism of control of bleeding after placental seperation.: The arterioles as they
pass tortuosly through the INTERMEDIATE LAYERS OF THE MYOMETRIUM
ARE LITERALLY CLAMPED by complete retraction of these muscles. Thus
INTERMEDIATE LAYERS ARE CALLED as Lining ligature of uterus.. Also
Thrombosis occurs to occlude the torn sinuses. {facilitated by hypercoagulable state of
pregnancy}.
122) Partogram is a composite graphical record of cervical dilatation and descent of the
head against duration of labour in hours. Cervical dilatation is a sigmoid curve and
the first stage of labour has got two phases- a latent phase and an active phase. In
primi latent phase is long ,8 rs, in multi it is short only 4 hrs ,During latent
phase(.35cm/hr only) – from 0 to 3 cm dilatation.After latent phase is over cervix is 3
cm dilated. Dilatation of cervix in active phase is 1 cm per hour in primi and 1.5 cm
per hour in multi.
123) Earliest sign of placental seperation –uterus becomes globular,firm and
balottable,the fundal height is slightly raised as the seperated placenta comes down in
the lower segment. Def sign of placental seperation ---Per vaginum ,Permanent
lengthening of cord is established. There may be slight gush of free bleeding ,not free
bleeding.
124) At term uterus is 1000gm or 35 cm in height. Immediately following delivery ,the
height of uterus corresponds to 20 weeks.or 5 months / 13.5 cm or 5 & half inch above
pubic symphysis. By the end of second week or after 12-14 days the uterus becomes a
pelvic organ.
125) Vaginal examination is done in DORSAL POSITION.
126) *****Early clamping not done in - POST MATURE { beneficial for baby if there is
delay in clamping as more blood is transferred,but deleterious in premature as
hypervolemia can occur in them} . Early clamping done in Premature babies or
babies born asphyxiated AND in cases of Rh incompatibility;also includes growth
retarded fetus or one of a diabetic mother.
127) Puerperium is the period following childbirth and lasts for approx 6 weeks( 1 & a
half months). AT THE END OF 6 WEEKS UTERUS WEIGHS ABOUT 60 GM
,SIMILAR TO THAT OF NON PREGNANT STATE.
128) The ext os is most patulous in multiparous state.never reverts back to nulliparous.
129) The regn of endometrial surface uterus begins 1 week after labour.Regeneration of
epithelium is completed by 10th day. And the entire endometrium is restored durin the
3rd week except at the placental site where it takes about 6 weeks.
130) Lochia is the vaginal discharge for the first fortnight (14 days) during puerperium.
The normal duration of lochia varies from 14 – 21 days(3 weeks). Depending on the
colour : Lochia rubra Æ1-4 days Lochia serosa Æ 5-9 days Lochia albaÆ 10-15 days
*****SEQUENCE IS RUBRA –SEROSA – ALBA .Lochia rubra consists of
blood,sheds of fetal membranes, and decidua,vernix caseosa,lanugo and meconium.
****So decidua is cast off in lochia rubra.Lochia serosa consists of less RBCs,more
leukocytes ,wound exudate,mucus from cervix and microorganism(anaerobic strep
and staph) the presence of bact is not pathognomic unless ass with clinical signs of
sepsis.
131) In non lactating mothers ovulation occurs as early as 4 weeks and menstruation by
6th week. In lactating women ovulation occurs at 10 weeks{2 and a half months} after
delivery and menstruation returns by 25-30 weeks.{ THUS 100% PROTECTION
AGAINST CONCEPTION IN A “ LACTATING” MOTHER IS FOR 2 MONTHS
APPROX “ ovulation is taken into consideration” } ovulation may precede the first
menstrual period in about one third and it is possible for the patient to become
pregnant before she menstruates following her confinement.
132) Suckling is the strongest stimulus of lactation.
133) Suppression of lactation becomes necessory if the baby is born dead or dies in the
neonatal period or if breast feeding is contraindicated.
134) Retention of urine and constipation in puerperium is attributed to normal
physiology.The patient is encouraged to pas urine 6-8 hrs following delivery.
135) Hyperemesis gravidarum ( SEVERE VOMITING)is more common in first
pregnancy. Eye complications as diplopia ,dimness of vision or even blindness can
occur.The following are the indications for therapeutic termination 1) A steady
deterioration inspite of theray 2) A rising pulse of 100/mim or over 3) Temp
consisitently above 38˚ c 4) Gradually increasing oliguria and proteinuria 5) App of
jaundice 6) App of neurological comp.( wernicke`s,korsakoff,peripheral neuritis ,eye
comp etc
136) Abortion is the termination of pregnancy before the period of viability which is
considered to occur 28th week,However for international acceptance the limit of
viability is brought down to either 20th week or fetus weighing 500 gm .in MTP
termination is permitted upto *******20 weeks of pregnancy.
137) Spontaneous abortion commonly occurs during First and second months. Common
causes of abortion during 1st trimester 1) Defective germ plasm (def genes) 2) trauma
3) hormonal def 4) acute infection during mid trimester : Cervical incompetence.,
uterine malformations,low placenta,twins and polyhydramnios. Sp abortion in first
trimester is mostly due to DEFECTIVE GENES..( COMMONEST BEING
TRISOMYor MONOSOMY ???? CF HARRSION 401) acc to harr its sex chrmosome
monosomy followed by trisomy 16.
138) Intrauterine fetal death occuring before 28 th week has got a distinct etiology and if
retained inside it is called MISSED ABORTION.Thus for practical purposes
antepartum death occuring after 28 weeks is termed as intrauterine death. Diagnosis:
symptoms: -absence of fetal movements which were previously experienced by the
patient, signs :- Gradual retrogression of the height of the uterus so that it becomes
smaller than the period of amenorrohoea. Spalding`s sign : irregular overlapping
ofcranial bones on one another appearing 7 days after death . Roberts` sign :
Appearance of gas shadow in the chambers of the heart and great vessels may appear
as early as 12 hours,though difficult to interpret ,But when detected provides
conclusive evidence{ sure sign of IUD}. Complications (also of missed abortion)
:-- Blood coagulation disorders (silent DIC) –if the fetus is retained for more than 4
weeks. Infection,psychological upset,during labour uterine inertia,retained placenta and
PPH. Management (same for missed abortion more than 12 weeks): In about 80 %
of caeses ,spontaneous expulsion occurs within 2 weeks of death. If spontaneous
expulsion fails to occur within 2 weeks.,the patient is admitted. But always wait for
spontaneous expulsion even when admitted . Fibrinogen level estimated evry week. A
falling fibrinogen level should be arrested by controlled infusion of heparin.
Interference done when psychological upset,infection, Falling fibrinogen level(
fibrinogen level corrected before doin interference),tendency to be retained more than
2 weeks. Early termination is now favoured to avoid complication.
139) Septic abortion Æ Any abortion associated with clinical evidence of infection of
uterus and its contents. Acute renal failure is common in infection with Cl welchii
and Is the most life threatening complication of septic abortion.
140) The commonest chromosomal abnormality in early spontaneous abortion??????
(first trimester abortion) /still birth/live birth is Autosomal trisomy. TRISOMY 21 is
the most common chromosomal abnormality in LIVE BORN INDIVIDUALS and
STILL BIRTHS. Sex chromosome monosomy is the most common chromosomal
abnormality in early Spontaneous abortion . Non disjunction at maternal meiosis I
appears to be the most common source of TRISOMY. Acc to harrison 401 frequency
and distribution of chromosome abnormality namely sex chromosome Monosomy
followed by +16 autosomy are the highest in spontaneous abortion.
141) Threatened abortion : Clinical features : bleeding is slight and bright red in colour.
Pain appears usually following Hemorrhage. Otherwise painless bleeding.( in ectopic
bleeding is slight also but continuous and dark coloured. Amenorhoea followed by
abdominal pain and lastly vaginal bleeding.) The uterine size corresponds to the
period of amenorrhoea.( in ectopic uterus remains normal in size )
142) Inevitable abortion : Clinical features : Increased vaginal bleeding ,aggravation of
pain in lower abdomen which may be colicky in nature,INTERNAL EXAM
REVEALS DILATED INTERNAL OS OF THE CERVIX THROUGH WHICH
PRODUCTS OF CONCEPTION ARE FELT.
143) Circlage operation for cervical incompetence are SHIRODKAR and WURM and
Mc Donald`s.
144) MTP act passed in 1971. ( PREGNANCY in a minor girl {below 18 years } and
*****in lunatics even if they are older than 18 cannot be terminated without written
consent of the parents or legal gaurdians. Termination is permitted upto 20 weeks of
 pregnancy. When the pregnancy exceeds 12 weeks opinion of two medical
practitioners is required.
145) Methods of termination in first trimester (upto 12 weeks) :- - - > 1) Menstrual
Regulation is the aspiration of the endometrial cavity( employing suction with plastic
cannula and employin suction with 50 ml plastic syringe,{in suction evacuation
cannula fitted with suction apparatus}) within 14 days of missed period in a
previously normal cycle when the presence of an early pregnancy cannot be diagnosed
accurately. Done as an outdoor procedure,paracervical block anaeesthesia may be
employed. 2) suction evacuation and / or curettage : not suitable for uterus of
more than 10 weeks. The pressure of suction is 400 – 600 mmm hg. It is better to
curette the uterine cavity by a small flushing curette at the end of suction and the
cannula is reintroduced to suck out any remains. 3) Dilatation and
evacuation : slow dilatation of cervix is achieved by inserting LAMINARIA TENTS.
In rapid method tents are not used ;dilatation and evacuation done in same
sitting,while in slow method laminaria tents are introduced and further dilatation and
evacuation done after 12 hrs 4) Pharmacologic : Prostaglandins PGE 1( as
adjunct) : Before surgical methods of termination ,cervical ripening canbe achieved
by use of 1 mg PGE 1 vaginal pessary (gemeprost) in post fornix. this is done 3 hrs
before procedure . This is also used as an adjunct to mifepristone and methotrexate
therapy. Mifepristone (progesterone antagonist) :Effective upto 9 weeks. A single
dose of 600 mg orally .If abortion fails to occur PGE1 is used to complete the
abortion process. Misoprostol ( another PGE 1 analogue like gemeprost) is equally
effective and has fewer side effects.
146) Size of suction cannula 5 or 6 mm for MTP in early pregnancy.
147) Methods of termination in Mid trimester. :---- Between 13 -15 weeks—1) To
allow the pregnancy to continue so that uterus will be enlarged to about 16 weeks
when available intrauterine instillation techniques using pharmacologic agents can be
used. 2) Prostaglandins , 3) transcervical intraamniotic instillation of hypertonic
saline or extraamniotic instillation of .1% ethacrydine lactate. 4) Hysterectomy.
Between 16- 20 weeks : 1) intrauterine instillation of intraamniotic hypertonic saline
(20%) or extraamniotic instillation of ethacrydine lactate.(uterus should be atleast 16
weeks size in intramniotic instillation). DOC for MTP in a second gravida with
asthma at 16 weeks gestation (as prostaglandins are contraindicated and extraamniotic
instillation with .1% ethacrydine lactate also releases prostaglandins from decidua by
stripping the membranes) is intramniotic instillation of hypertonic saline in uterus. In
second trimester intramniotic injection of 30% or 50% glucose is unsafe .Instead 5%
of dextrose is used. DIC is comp of intraamniotic istillation,also contraindicated in
cardiovascular or renal disease or in severe anemia because of sodium load.in that
case extraamniotic ethacrydine may be used. 2) Prostaglandins –Best method
for inducing mid trimester abortion. Intravenous route is not used because of high
toxicity. It is contraindicated in asthma. Vaginal ,intramuscular,extraamniotic and
intraamniotic instillation.
148) Ectopic pregnancy : Extrauterine –Tubal ( commonest ) ,Ovarian and abdominal
(intraperitoneal, extraperitoneal{rare}) . Intrauterine – cervical ,angular ,cornual.
Most common cause of ectopic is Previous Tubal Disease.(history of PID;Salpingitis) .
Etiology : PID (Loss of cilia of the epithelium and impairment of muscular
 peristalsis), IUCD( Progestasart has got the highest rate ,cut and levonorgestrel
devices have got lowest rate of ectopic) , Use of progestin only pill or post coital
estrogen preparation,Tubal surgery, Tubal Endometriosis (Facilitating nidation in
the tube). Changes in uterus : The decidua develops all the characteristics of
intrauterine pregnancy except that it contains no evidence of chorionic villi. Arias
stella reaction is characterised by a typical adenomatous changes of endometrial
glands .This is strikingly due to progesterone influence . It is present in 10-15 % cases
of ectopic and is not specifc. Clinical features of ectopic –The classic triad of
disturbed tubal pregnancy are Amenorrhoea followed by abdominal pain aand lastly
,appearance of vaginal bleeding .Most common feature is abdominal pain .The pain
may be referred to the shoulder due to diaphragmatic irritation. On examination ->
pallor, the abdomen is tense, tumid and tender. No mass is usually felt. When
shoulder pain develops in a case of tubal pregnancy it indicates severe internal
bleeding. (peritoneal irritation) . Diagnosis :-- Laparoscopy is the best inv to
diagnose ectopic. Transvaginal Sonography is also very helpful. Next choice to
laparoscopy for the diag of unruptured ectopic. The diagnostic features are 1)
Absence of intrauterine pregnancy (characteristic finding in USG AND and most
reliable indicator ) with a positive pregnancy test . 2) Fluid in the pouch of douglas
3) Adnexal mass clearly seperated from the ovary . Combination of hcg and TVS :-
When the hcg value is greater than 2000 iu/ml AND THERE IS an empty uterine
cavity (The lowest level of serum hcg at which a gestational sac is consistently visible
using TVS is 2000 IU/ml.),ectopic preg is more likely. Also failure to double the value
of hcg by 48 hours along with an empty uterus is very much diagnostic.
Management :---- After detailed history and examination ,serum hcg ,Trasvaginal
USG ,1) if ectopic is suspected and patient in shock -resuscitation and laparotomy
and after shock treatment if rupured tubal ectopic do salpingectomy. 2) If patient
is stable do laparoscopy,in case unruptured tubal ectopic is found either conservative
medical( MTX,potassium chloride, Hyperosmolar
glucose,prostaglandins,mifepristone) or conservative surgery(toc is nullipara with an
unruptured ectopic is linear salpingectomy) is done or else extirpative management
i.e. salpingectomy. Conservative is preferred in unruptured ectopic
hemodynamically stable.
149) Abdominal pregnany – Studiford criteria is used to diagnose primary abdominal
pregnancy. Signs –fetal parts are felt easily,abnormal high position of the fetus is
commonly found in intraperitoneal pregnancy ,the fetus is lying low in
extraperitoneal(rare type). On LATERAL xray on standing position:- superimposition
of fetal skeleton with the maternal spinal shadow.(Fetus appears lateral to the lumbar
spine ) is pathognomic.
150) Hydatidiform Mole :Complete moles have 46 XX karyotype ,the molar
chromosomes are derived entirely from the father.Haploid sperm duplicates its own
chromosomes after meiosis. No trace of embryo or amniotic sac. Principally a disease
of chorion in which there is partly degenerative changes and party hypertrohic
changes in young chorionic villi ,it is a benign neoplasia with a malignant
potential.(choriocarcinoma) Ovarian changes: - Bilateral lutein cysts are present
,these are due to excessive prodn of HCG. The contained fluid is rich in chorionic
gonadotrophin. Clinical features :-- The patient gives history of Amenorrhoea 8-12
 weeks with initial features suggestive of normal preganancy but subsequently presents
with the following manifestations ( often confused with abortion) . Vaginal bleeding is
the commonest manifestation . Thyrotoxic features of tremors or tachycardia are
present on occasion(10%). Per abdomen :- the size of uterus is more than expected
for the period of Amenorrhoea. The feel of uterus is firm elastic( Doughy) . Vaginal
examination :- Most important part is examination of vagina.. Internal ballotment
can not be elicited. Finding of grape like vesicles in the vaginal discharge is
pathognomonic of hydatidiform mole. Sonography is the best method to diagnose
HMOLE. (SNOWSTORM APPEARANCE). Complications :---- Commonest is
sepsis. Treatment of Choice :-Æ Suction “Evacuation” of the uterus is done as soon
as the diagnosis is made.The immediate comp. of evacuation is bleeding.. Follow UP-
Æ Essential investigation in FU is hcg Assay.
151) Partial or incomplete mole : The karyotype is triploid. ( 69 XXY or 69 XYY)
152) Twins :- 1) Dizygotic or fraternal : From fertilization of 2 ova , 2) Monozygotic or
identical : results from fertilization of a single ovum.In thisdivision takes place after
fertilization.Mostly diamniotic –monochorionic(division between 4th to 8th day). On
rare occasions however, If the division takes place within 72 hrs after fertilization the
resulting embryo will have 2 seperate placenta .chorions and amnions( diamniotic-
dichorionic) and in extremely rare occasion division occurs after the development of
embryonic disc resulting in the formation of conjoined twins called SIAMESE TWINS. If
the division occurs after 8th day of fertilization ,when the amniotic cavity has already
formed ,a monoamniotic –monochorionic twin develops. Monoamniotic –
monochorionic twins have highest mortality. Easiest method of determining zygosity
is examination of placenta and membranes. In binovular there are two placenta and as
such the intervening membranes consists of 4 layers –amnion,chorion,chorion,amnion. In
uniovular there is single placenta. And as such the intervening membranes consists of two
layers of amnion only. Prevalence of binovular twins is related to Race : The
Frequency Is highest among Negroes., Drugs used for induction of ovulation may
produce multiple fetuses to the extent of 20-40% following gonadotrophin
therapy,although to a lesser extent (5-6%) following clomiphene citrate. In india
advancing age is not the cause of increase in incidence,Hereditary predisposition,the
incidence is also increased with increasing parity specially from 5th gravida onwards.
Complications : A} Antepartum Hemorrhage:Æ The increased incidence of Placenta
Praevia is due to the bigger size of placenta enchroachin on to the lower segment. The
separation of Normally situated placenta (causes same as of abruptio placentae in red
colour) may be due to –1) Increased incidence of PIH 2) Sudden escape of liquor
following rupture of the membranes of the hydramniotic sac, 3) Deficiency of folic
acid 4) Following delivery of the first baby due to sudden shrinkage of the uterine
wall adjacent to the placental attachment. B} During labour cord proplapse and
early rupture of membranes. Post partum hemorrhage is the most important
complication in twins because it is the cause of real danger;it is commonest during
delivery. All these were maternal complications.. Fetal comlications:-- Most
common cause of perinatal mortality in twins is premature rate(80%).
Indications of cesarean section other than associated causes( fetal causes) : --- a) Both
the babies or even the first baby with transverse lie. Imp.-Æ second twin in transverse
lie or in other noncephalic presentation is not a valid indication for CS. b) Nonvertex
 twins with estimated weight 2000 gm or less. C) Conjoined twins D) Collision of both
t he heads at brim preventing engagement of eihher head D) Monoamniotic twins.
153) Polyhydramnios :--- State where liquor amnii exceeds 2000ml/2 litres. Etiology
: 1) Fetal anomalies associated : Anencephaly( transudation from exposed
meninges,absence fetal swallowing reflex) , esophageal atresia(preventing swallowing of
liq) or tracheoesophageal fistula(esophageal atresia is ass with tracheo-esophageal fistula.
2) Chorioangioma of placenta 3) Multiple pregnancy 4) Maternal - Diabetes
(raised fetal sugar->fetal diuresis ->hydramnios)
154) Oligohydramnios - Def in amt to the extent of 100 ml or less( scanty liq should`nt be
designated as oligamnios) .Sonographic diagnosis is made when amniotic fluid index is
less than 5 cm. Etiology : often ass with a) Amnion nodosum b) Renal agenesis c)
IUGR d)postmaturity. Oligohydramnios with fetal symmetric growth retardation
is ass with increased chromosomal abnormality . Complications : “Fetal pulmonary
Hypoplasia.(may be the cause or effect)”
155) Cord abnormailities 1) BATTLEDORE PLACENTA :---- The cord is attached to
the margin of the placenta 2) Velamentous placenta :----The cord is attached to
membranes .The branching vessels traverse between the membranes for a varying distance
before they reach and supply the placenta. If the leash of blood vessels happen to traverse
through membranes overlying internal os in front of the presenting part ,the condition is
called VASA PRAEVIA. Rupture of membranes in that case leads to vaginal bleeding and
the blood is of fetal therefore in case of VASA PRAEVIA. 3)Single Umbilical
artery : It is more common in TWINS and in babies born of diabetic mothers or in
polyhydramnios. It is frequently associated with congenital malformation of the fetus .
There is ncreased chances of miscarriage ,prematurity,IUGR, and increased
perinatal mortality.
156) Preeclampsia -::: The new onset of hypertension (140 /90mmhg) , Proteinuria (>
300 mg/24hr). and pathologic edema. The end result of causes which are in known
leads to vasopspasm and injury in multiple organs. Edema : Rapid gain in weight of
more than 1 lb a week or more than 5 lb a month ( > 2 kg in one month ). The most
reliable sign in pre eclampsia is HYPERTENSION. The Earliest sign of Pre eclampsia
is excessive Weight gain/rapid. Severe preeclampsia is the
presence of new onset hypertension and proteinuria accompained by CNS dysfunction
(headaches, blurred vision, seizures, coma), marked elevations of blood pressure ( >
160/110 mmhg), severe proteinuria(> 5g per 24 hour) ,oliguria or renal
failure,pulmonary edema, hepatocellular injury,thrombocytopenia or DIC.
Eclampsia :- Preeclampsia when complicated with convulsion and / or coma is called
eclampsia. (THE FIRST THING TO DO IN A FIT IS ALWAYS TO ENSURE
AIRWAY) . Mostly seen antepartum. Antepartum eclampsia has the worst prognosis.
First AID treatment outside the hospital :the patient either at home or in the
peripheral health centre should be shifted urgently to the referral hospital.THERE IS
NO PLACE OF CONTINUING THE TREATMENT IN SUCH PLACES.THE
PATIENT MUST BE HEAVILY SEDATED BEFORE MOVING HER TO THE
HOSPITAL. Mag sulfate is DOC.Patient in labour or not ,anticonvulsant etc are
given in eclampsia. No of fits is not a prerequisite for giving mag sulfate. There should
be availability of calcium gluconate(antidote). Repeat injections are given only if the
knee jerks are present,urine output exceeds 30ml/hr and the respiration rate is more
 than 12 per minute.The therapeutic level of serum magnesium is 4-7 meq/L. At necropsy
pathognomonic lesion of eclampsia is senn in kidney?????
The HELLP (hemolysis,elevated liver enzymes,low platelets) syndrome is a special
subgroup of severe preeclampsia and is a major cause of morbidity and mortality in
this disease..Thrombocytopenia is due to intravascular platelet aggregation. Detailed
examination of ocular fundi is mandatory as fundoscopic findings provide one of the
best indicators of the duration of hypertension and prognosis.. Treatment :--
Intravenous labetalol or hydralazine are the drugs most commonly used to manage
preeclampsia.The definitive treatment of preeclamsia is delivery of the fetus and
placenta. Magnesium sulfate is the treatment of choice for the prevention and
treatment of eclamptic seizures. Given the difficulty of predicting eclamptic seizures
on the basis of disease severity,it is recommended that once the decision to proceed
with delivery is made ,all patients carrying a diagnosis of preeclampsia be treated
with magnesium sulfate. Screening test for prediction and prevention of preeclampsia
are not helpful. One such is Giant`s roll over test :-This screening test is done between
28-32 weeks. (an increase of 20 mmhg in diastolic pressure from side to back position
indicates a “positive roll over test”.)
157) Antepartum hage :--bleedin after 28th week but before the birth of the baby. Causes
of APH :-- Placenta Praevia :-The blood is almost always maternal . Painless
bleeding. First trimester bleeding is uncommon. { Stallworthy`s sign :- Slowing of
FHS on pressing the head down into the pelvis which soon recovers promptly as the
pressure is released is suggestive of the presence of low lying placenta specially of the
posterior type. } Vaginal exam must not be done outside OT as it can provoke
further separation of placenta with torrential bleeding and may be fatal. Sonography
provides the simplest ,most precise and safest method of placental localisation. In vasa
praevia detection of fetal blood ,collected from vaginal blood by singer`s test (alkali
denaturation ) is diagnostic. Malpresentation and premature labour are common in
PP. The ultimate cause of death are hemorrhage and shock. There has been a
substantial reduction of maternal deaths but the reduction of the perinatal fetal
mortality is not so gratifying as compared to that of maternal mortality. Expectant
line of treatment. The Aim is to allow the pregnancy to continue until the baby has
grown sufficient enough to survive ex utero.(carried upto 37 completed weeks) .
Expectant line of management in PP is c/I in the following( or active
interference(definitive treatment) indications) :---a) Bleeding occurs at or beyond 37
weeks of pregnancy. B) patient is in labour c) patient is exsanguinated d)baby is
dead or known to be congenitally deformed. In definitive treatment i.e. delivery :
Caesarean section is done in severe/major degrees of PP (Type II Post,Type III, and
Type IV). This is indicated for maternal interest even where the baby is dead. While
in type I ,II (ant) :- A.R.M ± Oxytocin.
158) Difference between Abruptio placenta and Placenta Praevia :--Æ a) PP is painless
,AP is painful. B) Features of preeclampsia present in one third cases of AP ,while it
is not relevant in PP. C) Malpresentation is common in PP.,While it is unrelated in
AP. D) FHS is usually absent specially in concealed type in AP. While it is present in
PP. E) general condition and anaemia isout of proportion to the visible blood loss in
concealed or mixed variety of AP,while proportional to visual blood loss.
159) Abruptio placentae also called as Accidental hemorrhage :- see point 152 For causes
of seperation of normally situated placenta : PIH, smoking(smoking also ass with IUGR)
,malnutrition, Folic acid def. Treatment(same as of PP) The first consideration always
in both PP and AP is prompt restoration of an effective circulation with IV fluids.
Couvelaire Uterus (uteroplacental apoplexy):- Association with severe form of
concealed abruptio placentae.The condition can only be diagnosed on naked eye
appearance.
160) Complications of severe anemia during pregnancy:- !) Pre-Eclampsia 2)Intercurrent
infection 3) Heart failure 4) Preterm labour During labour :- PPH, During Puerperium
:- Perperal sepsis, subinvolution , Failing lactation, Puerperal venous thrombosis,
Pulmonary thrombosis. The expected rise in Hb concentration after parenteral
therapy is 0.7 to 1 gm/100ml per week. The total elemental iron required in an
anaemic patient is calculated as follows : ( 0.3 × wt in lbs × % Hb deficit. ( to
convert pounds to 1 kg = 2.222 lb ) .
161) Heart Disease in pregnancy :--- The cardiac failure occurs soon after pregnancy
around 30 weeks, during labour, and mostly soon after delivery. Maternal
Mortality is lowest in rheumatic heart diseases ,and acyanotic heart diseases. It is
highest in cyanotic heart diseases; most of he deaths occur due to heart failure.
Presence of any of the following criteria confirms the diagnosis of organic heart
lesions :-- Presence of diastolic murmur, 2)cardiac enlargement 3) presence of loud
systolic murmur associated with a thrill 4) presence of arrythmia . GRADINGS :---
Depending upon the cardiac response to physical activity,the heart diseases are
graded according to the classification of the NYHA. GRADE/CLASS I :-No limitation
of physical activity,no symptoms with ordinary exertion GRADE II :- slight limitation
of physical activity.Ordinary physical activity causes discomfort. The patients are
comfortable at rest. GRADE III:- Marked limitation of physical activity, less than
ordinary activity causes symptoms,asymptomatic at rest. GRADE IV:- inability to
carry out any physical activity without discomfort,symptoms at rest.
{{{ The american society of anaesthesiologists classified patients into a number of
grades according to their general condition. ASA 1: -no organic,
physiological,biochemical or psychiatric or systemic disturbance.the pathological
process for which operation is to be performed is localized and does not entail a
systemic disturbance. ASA 2) mild to moderate systemic disturbance. ASA 3)
Limitation of lifestyle, severe systemic disturbance. ASA 4) Severe systemic
disorders that are already life threatening ASA 5) Moribund. little chance of
survival,but submitted to operation in desperation.little if any anaesthesia required.
}}}} Considering high maternal deaths ,cases of pulmonary hypertension
,eisenmenger`s syndrome and pulmonary venoocclusive disease are absolute
indications for termination of pregnancy. In coarctation of aorta always caesarean
section is done for termination at any time. In eisenmengers, Maternal mortality and
perinatal loss is 50%. Termination is seriously considered and suction evacuation is
the preferred method. ROLE OF ANTICOAGULANTS :- Anticoagulants are
necessary in cases of congenital heart disease who have pulmonary
hypertension,artificial valve replacements or atrial fibrillation. The patient having
warfarin should discontinue it as soon as pregnancy is diagnosed and replaced by
heparin 5000 units twice daily subcutaneously upto 12th week. This is then replaced by
 warfarin tablets 3 mg daily to be taken at the same time each day and continue upto
36 weeks .There after it is replaced by heparin upto 7 days postpartum . Warfarin is
then to be continued. WARFARIN IS NOT CONTRAINDICATED IN BREAST
FEEDING WOMEN. {Heparin doesn’t cross placenta.} Risk of thrombosis recurring
is 10-12% in a patient with history of DVT in puerperium. Warfarin therapy is
contraindindicated in the first trimester due to its association with Fetal
Chondrodyplasia Punctata. Management during labour :-- There is no place for
induction. Most patients with cardiac disease go into spontaneous labour and deliver
without any difficulty. However ,induction (vaginal PGE 2) may be employed in very
selected cases for obstetrical indications.One should guard against infection.
******Prophlactic antibiotics :-- Antibiotic prophylaxis durin labour and 48 hours
after delivery is considered appropriate. Tendency to delay in the second stage of
labour is to be curtailed by forceps or ventouse under pudendal block.Difficult
forceps it to be avoided. Ventoues is preferred. IV ergometrine with the delivery of
the anterior shoulder should be withheld . During third stage conventional
management done. Slight blood loss is beneficial but if it is in excess,oxytocin can be
given by infusion.This may be accompanied by IV furosemide. It is better to
administer oxytocin in preference to ergometrine in all casese of heart disease in third
stage. Role CS.:---In general there is no indication of caesarean section for
heart disease. It is mainly done for obstetrical indications. Tendency of prolonged
labour should be curtailed by caesarean section. However in coarctation of aorta
,elective caesarean section is indicated to prevent rupture of aorta or mycotic cerebral
aneurysm. Steroidal contraception is contraindicated. IUD is also contraindicated
for fear of infection. Barrier method of contraceptives is the best.
162) Specific heart diseases in pregnancy :--- Considering high maternal deaths ,cases of
pulmonary hypertension ,eisenmenger`s syndrome and pulmonary venoocclusive
disease are absolute indications for termination of pregnancy. In coarctation of aorta
always caesarean section is done for termination at any time. In eisenmengers,
Maternal mortality and perinatal loss is 50%. Termination is seriously considered
and suction evacuation is the preferred method. In patients with pulmonary
hypertension,vaginal delivery is less stressful hemodynamically than cesarean section.
Mitral stenosis is the commonest heart lesion met during pregnanacy and most likely
to cause death during pregnancy.MR and AR are generally well tolerated during
pregnancy.As a rule ,mitral valve proplapse doesn not present problems for pregnant
patients and aortic stenosis,unless very severe is also well tolerated. Atrial or
Ventricular septal defect is usually well tolerated durin pregnancy in the absence of
pulmonary hypertension.**** Primary pulmonary hypertension is a contraindication
to pregnancy. Corrective cardiac surgery is commonly indicated in Mitral Stenosis.
Best time of surgery is between 14-18 weeks. Open heart surgery is associated with
increase in fetal loss. {{{ Development of septal defects in the fetal heart occurs at 5-8
weeks }}}.
163) Gestational diabetes. :--The potential candidates are : A) Positive family history of
Diabetes. B) Unexplained perinatal loss. C) Presence of polydramnios D) Having a
previous birth of an overeight baby of 4 kg or more. A Typical two step strategy for
establishing the diagnosis of gestational diabetes involves administration of 50g oral
glucose challenge with a single serum glucose measurement at 60 min.if the serum
 glucose is <7.8mmol/l (<140 mg/dl) warrants administration of a 100 gm (WHO 75
gm) oral glucose challenge with serum glucose measurements obtained in the fasting
state, and at 1 ,2 and 3 h. Normal values are serum glucose concentrations
<5.8mmol/l (105 mg/dl), 10.5 mmol/l (190 mg/dl), 9.1 mmol/l (165 mg/dl), and 8.0
mmol/l (145 mg/dl), respectively. Investigation of choice in diabetic mother with a
doubtful abnormal fetus – SONAR. Ketoacidosis can be precipitated during
hyperemesis in early pregnancy , infection and fasting of labour. Shoulder dystocia
is the most common complication during vaginal delivery in a diabetic mother.
Polyhydramnios is also a common complication (25-30%). Fetal hazards :- Fetal
macrosomia (30-40%)(because of fetal hyperinsulinemia) or large of date baby
,neonatal hypoglycemia(because of relative hyperinsulinemia), congenital
malformations like VSD,Sacral agenesis(caudal regression syndrome) and neural tube
defects(anencephaly,spina bifida,microcephaly). Sacral agenesis is a characteristic
congenital anomaly in fetus of a diabetic women (williams). Estimation of glycosylated
hemoglobin A(HbA1c) can predict affection of the fetus. Note :-Large for date babies
also seen in beckwith-wiedemann syndrome
(macrosomia,macroglossia,omphalocoele),genetic predisposition.Neonatal
complications include a) hypoglycemia B) respiratory distress syndrome c)
hypocalcemia D)polycythemia e) hypomagnesemia f)cardiomyopathy g) mental
retardation. The neonatal deaths are due to hypoglycemia,respiratory distress
syndrome,polycythemia and jaundice. Management :- oral antidiabetic drugs should
not be used during pregnancy. These drugs cross the placenta and may have
teratogenic effect or produce neonatal hypoglycemia. The fact that majority of the
intrauterine deaths of the fetus occur in the last two weeks of pregnancy,the
termination should be done after 37 completed weeks. The indications for cesarean
section are 1)Elderly primigravidae 2) Multigravidae with a bad obstetric history 3)
Diabetes,difficult to control 4) obstetric complication. Barrier method of
contraceptives is ideal for spacing of births.
164) Viral infection in pregnancy:- Fulminant hepatitis seen with hepatitis E virus. In
toxoplasmosis and rubella only transplacental infection occurs.it is not transmitted to
the baby at delivery like gonococcus,HSV II (transplacental infection is not
usual,during delivery risk of transmission of mat infection to the fetus is highest in
HSV.therefore cesarean section is indiacted in an active primary genital HSV
infection.) and hepatitis B.Other infections in which transplacental infection is
important are cytomegalovirus,Chicken pox,Parvovirus.In case of HIV,The vertical
transmission to the neonates is about 30% in seropositive mothers.(the probability of
transmission of HIV from mother to infant/fetus is 30%).Maternal transmission to the
fetus occurs most commonly in the perinatal period.(out of various types of vertical
transmission :-in utero i.e. transplacentally (30-35%), during delivery (60-65%),during
breast feeding (3-10%). Transplacentally acquired HIV antibody is cleared off by
around 18 months of age.Perinatal period extends from 22nd week of gestation to less
than 7 days of life after birth.The most common cause of intrauterine infection is
cytomegalovirus. In case of toxoplasmosis, if there is no evidence of placental/fetal
infection ,single –drug treatment with spiramycin is recommended.Triple drug
therapy with spiramycin ,pyrimethamine and sulfa is recommended if there is
evidence of fetal infection (PCR of the amniotic fluid) and the woman does not wish to
 terminate the pregnancy or cannot terminate.There is essentially no risk if the mother
becomes infected ≥ 6 months before conception.if infection is acquired < 6 months
before conception,the likelihodd of transplacental infection increases as the interval
between infection and conception decreases.In pregnancy ,if the mother becomes
infected during the first trimester the incidence of transplacental infection is lowest
,but the disese in the neonate is most severe.If the maternal infection occurs durin the
third trimester ,the incidence of transplacental infection is greatest,but the infant is
usually asymptomatic at birth. But in case of rubella,percentage of fetuses infected as
well as overall risk of damage to fetus is maximum during first trimester .like
toxoplasmosis ,fetal affection is by transplacental route throughout preganancy.
165) There is no C/I for vaginal delivery in carcinoma – in – situ. Cases showing
dyskaryotic smear are subjected to COLPOSCOPIC DIRECTED BIOPSY from the
suspected site for confirmation of diagnosis. Vaginal delivery shouldn’t be allowed in
cases of invasive cancer because of cervical dystocia and injuries.classical cesarean
section should be done. In first trimester radical surgery or radiotherapy should be done
with fetus in situ. Beyond 12 weeks uterus is to be evacuated only by abdominal
hysterectomy or classical cesarean. ,after 10-14 days radical surgery is to be done. If the
pregnancy is near term, a few weeks postponement may be considered to get a viable baby.
But in most of the cases either sugery or radiotherapy is employed as in the nonpregnant
state ,the sooner the better ,irrespective of the duration of pregnancy. VAGINAL
DELIVERY SHOULD NEVER BE DONE IN INVASIVE CANCER.
166) Fibroid with pregnancy:- Commonest presentation of a large cervical fibroid is
RETENTION OF URINE IN BLADDER. Preterm labour and prematurity ae other
effects on pregnancy. Secondary PPH in puerperium. Effect of pregnancy on fibroid -
---ÆRed degeneration:-it predominantly occurs in large fibroid during the second
half of pregnancy or puerperium.the cause is not known but is probably vascular in
origin.infection doesnot play any merit.The basic principle in the management of
fibroid complicated by a fibroid is not to do anything to the fibroid whenever possible.
167) Ovarian tumour in pregnancy:- management :-the principle is to remove the
tumour as soon as the diagnosis is made. During pregnancy,the best time of elective
operation is between 14-18th week as chances of abortion is less and access to pedicel is
easy.if the diagnosis is made before this time,the patient should be kept under
observation.Beyond 36 weeks- the operation is better to be withheld till delivery and
the tumour is removed as early in puerperium as possible. In complicated –the
tumour should be removed irrespective of the period of gestation . During
puerperium :the tumour should be removed as early in puerperium as
possible.(within 48 hrs following delivery)
168) Morbid anatomic changes in retroverted uterus if left uncared for:-In the majority
spontaneous rectification of the position of the uterus occurs.In the minority and on rare
occasions,spontaneous rectification doesn’t occur between 12-16 weeks. The developing
uterus gradually fills up the pelvic cavity and becomes incarcerated. Anatomical changes :-
The cervix is pointed upwards and forwards,rarely the uterus continues to grow at the
expense of the anterior wall called anterior sacculation while the thick posterior wall lies
in the sacral hollow. Anterior sacculation is the condition where a thin walled sac develop
in myometrium often containing fetal parts. Symptoms appear between 12-16 weeks
therefore .Acute urinary retention in gravid retroverted uterus occurs in 12-16
 weeks.(after incarceration). Changes following incarceration :-The initial symptom is
frequency of urination followed by difficulty in micturition which ultimately culminates
into retention of urine.
169) Genital prolapse :- management during pregnancy:- In a young woman following
childbirth it is a great mistake to advise treatment for proplapse, if the operation is
performed within six months of delivery , there is always the posiibility of recurrence of
proplapse. Besides these women rapidly improve if well directed conservative measures are
adopted for 3 or 4 months following childbirth..Surgery is also contraindicated during
pregnancy. Ring pessary is indicated in women who is unfit for sugery or is a high risk
case for surgery on account of some medical disorders.A pregnant woman with
proplapse also needs a ring pessary in the first trimester of pregnancy. Also in a young
woman planning to concieve in the near future ,surgery is better postponed till after the
childbirth,because a good surgical result could be ruined by vaginal delivery.Surgery is
advised in women over 40 unless it is contraindicated or is hazardous on account of some
medical disorders.abdominal sling operations have been designed for young women
suffering from second or third degree uterovaginal proplapse and who are desirous of
retaining their childbirth and menstrual function.
170) Preterm labour :- high risk factors:-previous history of induced or spontaneous
abortion or preterm delivery, asympomatic bacteriuria or recurrent UTI,
smokinghabits, low socio –economic and nutritional status, bacterial
vaginosis,multiple pregnancy.
171) Prelabour rupture of membranes :- Spontaneous rupture of the membranes any time
beyond 28th week of pregnancy but before the onset of labour is called PROM.
Confirmation of diagnosis :- to examine the collected fluid from the posterior fornix
(vaginal pool) for : a) Detection of pH by litmus or nitrazine paper.The pH becomes 6-
6.2. (normal vaginal Ph during pregnancy is 4.5-5.5 whereas that of liquor amnii is 7-7.5).
BLOOD WILL INTERFERE WITH THE NITRAZINE TEST BECAUSE IT IS
ALKALINE. Centrifuged cells stained with 0.1 % nile blue sulphate showing orange blue
colouration of the cells.(stain used for maturity assesment of amniotic fluids is NILE
BLUE SULPHATE.) use of antibiotics:-prophlactic antibiotics are given to mother to
minimise maternal and perinatal risk of infection.
172) Post maturity :- A pregnancy continuing beyond two weeks of the expected date of
delivery/OR BEYOND 294 DAYS is called postmaturity or post term pregnancy. If a
patient comes with complaints of post dated pregnancy the first thing to do is review
the menstrual history once more. Accurate assesment of gestational age is the most
useful contribution of ultrasound.Estimation of fetal maturity by BPD sonic
measurements is accurate to within ± 10 days in second trimester and in third
trimester it is ± 2-3 week. There is proplongation of pregnancy in anencephaly
without polyhydramnios.there is increased chance of fetal hypoixia in Postmaturity.
173) Isoimmunization :- There is chance of feto maternal bleed in
abortion,CVS,amniocentesis,antepartum hemorrhage,attempted version.This is much more
likely to take place during third stage of labour and following caesarean section.The fetal
red cells containing Rh antigen mixes with the maternal blood.The affection of the baby
can occur due to Rh incompatibility.(detectable antibodies usually develop after 6 months
following larger volume of fetal maternal bleed.but if the fetal maternal bleed is less than
0.1 ml,the antibody may not be detected until boosted by further rh stimulus).Albumin
 agglutinin cause damage to the placenta. VARIOUS MANIFESTATIONS OF THE
HEMOLYTIC DISEASE(erythroblastosis fetalis) :- HYDROPS FETALIS :- MOST
SERIOUS FORM Of Rh hemolytic disease.(most gravely ill neonates of erythroblastosis
fetalis presents as hydrops fetalis.).Hyperplasia of the placental tissue(large placenta)
occurs in an effort to increase the transfer of oxygen but the available fetal red cells are
progressively diminshed. As a result of fetal anoxemia,there is damage to the liver leading
to hypoproteinemia which is responsible for generalised edema (hydrops fetalis),ascites
and hydrothorax. Other non immune causes (accumulation of serous fluids in tissues and
serous cavities in conditions other than rh incompatibility)of hydrops fetalis are:-
chromosomal abnormality ,congenital cardiac Lesions, renal abnormality, alfa
thalessemia, rubella, syphilis. In USG there is edema of skin ,scalp and pleural or
pericardial effusion. There is also ascites. Placenta is large pale and edematous. Earliest
in usg is skin edema???????????? Prevention of Rh immunization :-To
prevent active immunisation:- Rh anti –D immunoglobin is administered intramuscularly to
the mother following childbirth and abortionit should be administered within 72 hrs
preferably earlier following delivery or abortion.it should be given provided the baby
born is Rh positive and the direct coomb`s test become negative.if already coombs test
is positive,that means immunisation has developed already,so no use of anti-DIgG.
DOSE IS 300 μg following delivery,100 μg following abortion beyond 20 weeks and 50
μg following abortion below 20 weeks and in cases of ectopic. Approximate volume of
the fetal blood entering into the maternal blood is to be estimated by “Kleihauer
count”. The amount of anti D gamma globulin is calculated (100 μg neutralize 5 ml
of Rh positive red cells) .This constitutes a form of therapeutic titration.
Antenatal investigation protocol of Rh negative mothers:----- Rh grouping of
husband (if husband is found to be Rh neg then no problem cause baby will be Rh
negative too),coombs test, Amniocentesis:-The optical density of the liquor containing
the bilirubin pigment is observed.The O.D. difference at 450 nm wavelength gives the
prediction of the severity of fetal hemolysis. If falls in zone III (HIGH ZONE) ,the
fetus is severely affected and death is imminent.If the pregnany is beyond 34
weeks,termination is done.If the pregnancy is below 34 weeks,intrauterine fetal
transfusion may be alternative.If falls in Zone I fetus is unlikely to be affected and
pregnancy is continued to term. If falls in Zone II premature termination beyond 34 weeks
may be required..
174) Elderly primigravidae:- above the age of 30 years.
175) Grand multipara:- 4 or more viable births. Complications:- Malpresentation, Placenta
praevia ,Anemia,PPH ( ****hyperemesis is more common in primigravidae than
multigravidae,so not seen here).
176) Anatomical and obstetric features of parent pelvic tye:- Gynaecoid:- most common
type of female pelvis,ant and post segment are equal and spacious,cavity is wide and
shallow, No difficulty ,engagement in usual mechanism. Anthropoid :- associated with
negroid races & persistent posterior postions. Ant and post segments of inlet are both
increased with slight anterior narrowing,sacro sciatic notch in cavity is more wide
and shallow.,more incidence of face to pubis delivery. Android:- worst, post segment
short and anterior segment shallow,diameter of engagement is transverse or oblique like
others but engagement is delayed and difficult,associated with DEEP TRANSVERSE
ARREST. Platypelloid :-is least common,both anterior and posterior segments are
 reduced and FLAT,sacro sciatic notch in cavity is narrow and deep with side walls
convergent.
177) Osteomalacic pelvis :- triradiate shape of inlet (the promontry is pushed downwards
and forwards and the lateral pelvic walls are pushed inwards causing the ant wall to form a
beak.) Naegele`s pelvis:- it is produced due to arrested development of one ala of the
sacrum. Robert`s pelvis:- Ala of both sides are absent.
178) Cephalo Pelvic disproportion is best assessed by x ray pelvimetry??????:- The
advantages of X ray pelvimetry are:- gives precise measurements of important diameters in
accessible to clinical examination. Indications:- in clinically suspected pelvic contraction
and disproportion in primigravidae 2) Suspected pelvic contraction in multiparae with
previous history of tedious or prolonged labour ending in difficult forceps or cesarean 3)
Primigravidae with malpresentation like breech or face specially where the baby seems to
be big on clinical examination. CPD at brim :- Ultrasonographic measurement of the
biparietal diameter of head gives superior information than the X ray cephalometry. CPD
at term is best assessed by a) external pelvimetry b) internal pelvic exam c) USG d)
All. ?????????? X ray pelvimetry reveals the measurement of the obstetric conjugate
as 7.6 cm -9.5 cm--Æ moderate disproportion, less than 7.5 cm is severe disproportion.
9.6 cm -10 cm is slight.
179) Trial labour:- It is conduction of spontaneous labour in am moderate degree ( 7.6-
9.5 cm) of CPD.critical obstetric conjugate for trial labour is 9.5 cm therefore. In
breech presentation there is trial of breech. Contraindications for trial labour :-
1)Associated midpelvic and outlet contraction (2)Presence of complicating factors
like elderly primigravidae,malpresentation,postmaturity,post cesarean pregnancy,
180) Midpelvic and outlet disproportion :-Symphysiotomy as an alternative to cesarean
section in women of the underpriviliged section of the developing countries.
181) Constriction ring :- It is one form of incoordinate uterine action where there is
localised spastic contraction of a ring of circular muscle fibres 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.it is usually reversible and
complete. Its occurrence is associated with 1) injudicious administration of oxytocics 2)
premature rupure of the membranes 3) premature attempt at instrumental delivery
specially under light anaesthesia. (NOT ASSOCIATED WITH OBSTRUCTED
LABOUR).
182) Cervical Dystocia :- occurs at the level of external OS. External os fails to dilate.
183) Precipitate labour :- when the combined duration of the first and second stage is less
than 2 hours.
184) Bandl`s ring:- Pathological retraction ring,:- Due to tonic uterine contraction there
is circumferential dilatation and progressive stretching of the lower segment with
corresponding thickening of the upper segment and rise in the level of retraction ring
following obstruction.. It occurs due to tonic uterine contraction(hypertonic
dysfunctional labour) and retraction which is predominantly due to obstructed
labour.(CPD etc). Internal examination reveals that vagina is dry and hot and the
discharge is offensive. There is Exhaustion and sepsis early. Fetal death is also usually
early.
185) Commonest cause of maternal mortality is bleeding per vaginum (post natal
hemorrhage) .
186) Mechanism of normal labour :- As the Occipito-lateral position is the commonest
,the mechanism of labour in such position will be described. :--Æ Engagement Æ
Increasing flexion Æinternal rotation of occiput anteriorly to 2/8th of
circle,simultaneous rotation of the shoulders to 1/8th of circle,placing occiput behind
pubic symphysis Æ Crowning Æ Delivery of the head by extension Æ Restitution
(passive movement of the head due to untwisting of the neck caused because of the
1/8th torsion left behind during internal rotation) Æ External Rotation-(through 1/8th
of a circle in the same direction as restitution due to the internal rotation of the
shoulders placing the occiput to the side in which it was originally directed at the time
of engagement) Æ Delivery of the shoulders and trunk by lateral flexion.
Mechanism of labour in occipito-posterior position:--- Increasing flexion with
engagement Æ Long anterior internal rotation of the occiput 3/8th of
circle,simultaneous rotation of the anterior shoulder through 2/8th of circle placing
occiput behind pubic symphysis with 1/8th torsion left behind.Æ Delivery of the head
by extensionÆ Restitution(1/8th of circle)-Æ External rotation (1/8th of circle) . In
majority delivery is spontaneous or can be accomplished by low forceps or ventouse.
187) Persistent occipito posterior position:-- It is an abnormal mechanism of the occipito-
posterior position where there is malrotation of the occiput posteriorly towards the sacral
hollow (occipito sacral position). As previously mentioned delivery may occur
spontaneously as Face to pubis but arrest may occur in this position and is called occipito -
sacral arrest. In the wider sense POP also includes two other arrested positions namely
,deep transverse arrest and oblique posterior arrest. In these cases of arrest ,Manual
rotation until the occiput is behind pubic symphysis followed by forceps extraction is
done.
188) In various varieties of breech presentation engagement takes place earliest in breech
with extended legs ( Frank Breech).
189) Etiology of breech presentation:- ******Prematurity is the commonest cause of
breech presentation. 1)Preventing spontaneous version:-Septate or bicornuate
uterus, Twins, oligohydramnios 2)Favourable adaptation:- Hydrocephalus ,
Contracted pelvis 3) Undue mobility of fetus :-Hydramnios.
190) Antenatal management in breech presentation:- Perinatal mortality is much higher
in case of vaginal breech delivery,therefore External Cephalic Version is done if not
contraindicated (Sonography is particularly useful to detect congenital malformations
of the fetus,the precise location of the placenta ( PP ), and congenital malformations of
the fetus) .The success rate of version is about 70-80% The ideal time for version has
been considered to be 37 weeks but can be attempted at any time therafter upto early
labour. Contraindications of version:- suspected placenta praevia , severe
degree contracted pelvis , fetal malformations , hydrocephalus , specially valuable
baby . Successful version reduces the risk of cesarean section significantly.
Successful version is likely in cases of 1) Adequate liquor (hydramnios) , Non obese
patient , Complete breech ,non engaged breech ,sacro –anterior position. Dangers
of version :- placental seperation and bleeding ,premature onset of labour, premature
rupture of membranes , cord entaglement or formation of true knot. If version fails or is
contraindicated the pregnancy is continued ,one may find that spontaneous version has
occurred. If not two methods can be planned :- 1) Elective cesarean section:- Because of
the risk (big baby ,hyerextension of head and even footling presentation and even a slight
 complicating factor is an indication of cesarean) involved in vaginal breech delivery ,there
is tendency to liberalize the use of cesarean section 2) Vaginal breech delivery(assisted)
:- Young primigravidae with good pelvis and average size baby ,or multigravidae with
good obstetric history are the candidates for vaginal delivery. In case of vaginal breech
delivery ,there are 3 methods of delivery :- 1) spontaneous (this method should not be
encouraged 2) Assisted breech :- This method should be employed in all cases 3) Breech
extraction:- minimal aid from mother,entire body is extracted by obstetrician .Its
Indications are a) appearance of maternal and/or fetal distress, b) cord proplapse c)
extended legs arrested in the cavity or the outlet and d) following internal version . In case
of assisted breech delivery ,delivery of the aftercoming head is the most crucial stage
of delivery. The following are the methods employed for the delivery of aftercoming
head:- 1) “Burns Marshall method” 2) “Mauriceau-smellie-veit method” (malar
flexion and shoulder traction) 3) Forceps delivery. # In cases when the
vaginal delivery is contemplated in frank breech ,bringing down a leg by “pinard`s
manoeuvre” is done when the legs are extended (frank breech) . # In cases
where arms are extended along the side of the head or lie behind the neck ,arrest
occurs with the delivery of trunk upto costal margins .The delivery of arms in such
cases occuring due to faulty technique in vaginal breech delivery may be
accomplished by adopting “lovsets manoeurve” for the delivery of arm.
191) Lovsets manouvere :- Step 1:-The baby is lifted slightly to cause lateral flexion .The
trunk is rotated through 180 ˚ keeping the back anterior and maintaining a down ward
traction.this will bring the posterior arm to emerge under the pubic arch which is then
hooked out. Step 2 : The trunk is then rotated in the “ reverse direction” keeping the
back anteriore to deliver the erstwhile anterior shoulder inder the pubic symphysis.
192) Arrest of aftercoming head in breech with chin to pubis : – posterior rotation of
chin & piper`s forceps. # If the arrest of the aftercoming head is due to contracted
pelvis or hydrocephalus, perforation of the head is to be done.The usual site of
perforation is through the occipital bone.
193) Face presentation :- The cause of extreme extension of the head in face presentation is
not clear in all the cases .The commonest congenital anomaly associated with face
presentation is anencephaly . Also most common presentation in anencephaly is
FACE . There are 4 positions of face according to the relation of chin to the left and right
sacroiliac joints.:-LMA,RMA,RMP,LMP.The commonest is LMA(left mento
anterior).Most infavourable presentation is Mento-Posterior.(rt or left).There is no
possibility of spontaneous delivery in persistent mento –posterior.
194) Brow presentation:- The mechanism is more or less the same as face to pubis delivery.
195) In transverse lie there is shoulder presentation. Neglected shoulder :- The series of
complications that may arise out of shoulder presentation when the labour is left uncared
for or cesarean section was not done. Such complications are impacted shoulder Æ
obstructed labourÆ rupture uterus with clinical evidence of dehydration .Treatment is
decapitation .{Shoulder dystocia is not a complication of neglected shoulder,it is something
else. Shoulder dystocia is defined to describe a wide range of difficulty encountered in the
delivery of shoulders.Anencephaly is one of the predisposing factor,short cord or cord
tightly around the neck is another factor. Shoulder dystocia can lead to various
complications like brachial plexus injury ,increased operative delivery and morbidity.}
Management of transverse lie:-external cephalic version should be done in all cases
 beyond 32 weeks provided there are no contraindications as mentioned in breech
presentation.if version fails or c/I ,elective cesarean section is done.
196) Leopold manoeuvere refers to method of Examination of abdomen.
197) Unstable lie:- Presentation of the fetus is constantly changed even beyond 36th week
when it should have been stabilized. Causes :- The causes are those which prevent the
presenting part to remain fixed in the lower pole of the uterus .like Placenta praevia,
grand multipara,hydramnios,contracted pelvis,pelvic tumour.
198) Cord prolapse(most commonly ass with transverse lie):- Anything that interferes with
perfect adaptation of the presenting part to the lower uterine segment ,disturbing the ball
valve action may favour cord proplapse like :- The commonest malpresentation
associated is transverse and breech specially with flexed legs. .Cord roplapse is seen
least in frank type of breech.
199) Prolonged labour:- Prolonged latent phase may be worrisome to the patient but
doesnot endanger the mother or fetus . Partogram helps in detection of obstructed or
prolonged labour.
200) In obstructed labour :- Blood stained urine is a common finding. Mother is
dehydrated.rapid pulse and low BP, FHS are absent, Cervix may be fully dilated but
the presenting part is arrested due to mechanical obstruction.Vagina is dry and hot
and the discharge is offensive. (like in tonic uterine contraction and retraction,POINT
184).
201) Hydrocephalus:- The head is high up and impossible to push down in the pelvis.,
The fontanelles and sutures are wide.
202) Anencephaly :- Earliest fetal anomaly to be detected by USG, Typically there is
marked dimunition of the size of the adrenal glands probably secondary to the absence
of the pitiutary gland(not hypertrophy). Best diagnosis is at 10-12 weeks ,earliest
diagnosis at 10 weeks. Complications include:- 1) Hydramnios 2) Malpresentation 3)
Premature labour specially associated with hydramnios 4) “postmaturity”(not
prematurity) . folic acid supplementation has reduced the incidence of NTDs
considerably.
203) Post partum hemorrhage :- The amount of blood loss in excess of 500 ml. Primary
hemorrhage : -Haemorrhage occurs within 24 hours following the birth of the baby.
Primary hage is of 2 types 1) Third stage Hage :- Bleeding occurs before expulsion of
placenta 2) True PPH :- Bleeding occurs subsequent to expulsion of placenta
(majority). Secondary hemorrhage:- Hemorrhage occurs beyond 24 hours and
within puerperium,also called delayed or late puerperal hemorrhage. # Causes of
PPH:- Atonic uterus is the commonest cause of PPH . The following are the
conditions which often interfere with the retraction of the uterus as a whole and of the
placental site in particular. ---A) Grand multipara , B) overdistension of the uterus as
in multiple pregnancy,hydramnios, and large baby. Imperfect retraction and a large
placental site are responsible for excessive bleeding,C) Prolonged labour. Scheme of
management of true PPH :- Immediate measures. Treat shock with IV fluids .Feel
the uterus by abdominal palpation-Æ Uterus flabby-Æ Massage the uterus to make it
hard ,inj. Methergin 0.2 mg I.V., To add oxytocin 10 units in 500 ml of N saline at the
rate of 40 drops per minute.- Æ still flabby Æ Exploration of the uterus Æ Remains
flabby (continuing BT and oxytocin drip)Æ Administration of 15 methyl PGF2 α 250
μg I.M./intramyometrialÆ fails Æ bimanual compression Æ fails-Æ intrauterine
 pluging Æ fails Æ ligation of uterine or “anterior” division of internal iliac arteries
(bilateral).
204) Secondary PPH:- (OR PPH With retracted uterus/or LATE PPH) :- The cause of
Late PPH are :1)Retained bits of cotyledon or membranes (commonest) 2) seperation
of slough over a deep cervico –vaginal laceration following infection 3) seperation of
sloufg exposing a bleeding vessel or granulation tissue
205) Placenta Accreta :- Placenta is directly anchored to the myometrium partially or
completely without any intervening decidua.The condition is usually associated when
the placenta happens to be implanted in the lower segment (placenta praevia) or over the
previosly injured sites as in cesarean section,dilatation and curettage operation
,manual removal.Diagnosis can be made during manual removal when the plane of
cleavage cant be made out or by USG clour dopplerMRi etc. Pathological confirmattion
includes :- a) absence of decidua basalis b) absence of nitabuch`s fibrinoid layer c)
varying degree of penetration of the villi into the muscle bundles(increta) or upto the
serosal layer( percreta). Management :-Def treatment is hysterectomy ,preferable in
parous women.
206) Inversion of the uterus :- The inversion may be spontaneous or more commonly
induced . Induced :- This is due to the mismanagement of the third stage of labour .1)
Pulling the cord when the uterus specially when combined with fundal pressure .2)
Faulty technique in manual removal :- attempted shearing off the placenta from its
attachment during manual removal by pulling the partially seperated placenta or firmly
pressing on atonic uterus by the external hand or rapidly withdrawing the internal hand
thereby creating a negative pressure.
207) Perineum :- Degrees of tear ;1) First degree :- involves lacerations of the remnants of the
hymen, the fourchette , lower part of the vagina and the perineal skin but the perineal body
remains intact 2) Second degree :- involves lacerations of the posterior vaginal wall and
varying degrees of tear of the perineal body excluding the anal sphincter 3) Third degree
{ COMPLETE}:- involves major lacerations of the post vaginal wall and tear of the
perineal body including the anal sphincter with or without involvement of the anal canal or
even the rectum. Complete perineal tear should be repaired after 3 months (12 weeks)
if left delayed beyond 24 hours.
208) Cervical tear :- Left lateral tear i.e 3’ o clock position is commonest.
209) Pelvic hematoma:- Anatomical types 1) infralevator hematoma (common) :- the
commonest one is the vulval hematoma .2) supralevator hematoma (rare) Vulval
hematoma:- Etiology is improper hemostasis during repair of vaginal or perineal tears or
episiotomy wound. Treatment :- A small hematoma may be treated conservatively with
cold compresses.large hematomas detected early should be explored in OT under general
anaesthesia . The blood clots are to be scooped out and the bleeding points are to be
secured. Management of supra levator hematoma /broad ligament hematoma: -The anterior
leaf of the broad ligament is incised and blood clot is scooped out.The bleeding points,if
visible ,are to be secured and ligated .Random blind sutures shouldnot be placed to
prevent ureteric damage .if the oozing continues ,one may have to tie the anterior division
of the internal iliac artery.
210) Rupture of the uterus( obstructed labour is the commonest cause,the patient is
usually a multipara) :- 1) Spontaneous rupture(intact uterus) :- Spontaneous
rupture involves the upper segment ( body) in non obstructive type . whereas in
 obstructive type ,the rupture involves the anterior lower segment transversely. 2)
Scar rupture(scarred uterus) :- Rupture over previous scar is almost always located
at the site of the scar:-Least common in LSCS (lowersegment) type scar ,more
common in classical upper segment) one. Uterine scar following operation on
nonpregnant uterus such as myomectomy or uteroculoplasty hardly rupture as the
wound heals well because the uterus remains quiescent following operation .Uterine
scar following hysterotomy behaves like that of a classical scar and is of growing
concern.Classical or hysterotomy scar are therefore likely to give way during later
months of pregnancy. 3) Iatrogenic or traumatic:- During pregnancy:- injudicious
use of oxytocin,use of prostaglandins for induction of abortion or labour,forcible external
version,fall or blow on abdomen During labour:- Internal podalic version specially
following obstructed labour.
211) Puerperal pyrexia:- a rise of temp. above 100.4˚ f ( 38˚c) or more on 2 separate
occasions at 24 hours apart (excluding 1st 24 hours) within first 10 days following delivery
. Commonest cause predisposing to puerperal pyrexia is malnutrition. Anaerobic
streptococci is the predominant one.also staphylococcus pyogenes, non hemolytic
streptococcus,ecoli ,bacteroids Most common cause of post partum endometritis is
streptococcus α. The uterus is the most common site of puerperal infection.The
remnants of the decidua specially over the placental site are the common sites. Spread of
infection(pelvic cellulitis) can occur through direct,lymphatic and secondary to
thrombophlebitis(thrombus becomes purulent which leads to necrosis of the venous wall
and which in turn ruptures to the surrounding tissues). Hysterectomy is indicated in
gangrenous uterus or gas gangrene infection.
212) Subinvolution:- When the involution is impaired or retarded .Aggravating factors
are 1) retained products of conception 2) Uterine sepsis
213) White Leg (phlegma alba dolens) :- Retrograde extension of pelvic thrombophlebitis
to involve the ilio-femoral vein.In this interstitial tissue pressure may exceed the
capillary perfusion pressure.No lymphatic obstruction.
214) Changes durin the first week in baby :- Changes in genitalia:- vulval engorgement
,leucorrhoea or at times vaginal bleeding may occur during first week and last for 24-
48hours.It is due to “withdrawal” of maternal estrogen from the newborn .changes in
stools:- meconium is normally passed 3-4 times a day for 2-3 days.A delay in the initial
passage of meconium for more than 12 hours after birth requires observation.From the 3rd
or 4th day, “changing stools” are passed. In a baby clinic a neonate is brought with
liver 2 fingers enlarged. It is a normal phenomenon. # A healthy baby is put to
breast fed ½ - 1 hour following normal delivery. Following cesarean section a period of
4-6 hrs may be sufficient .
215) IUGR :- Symmetrical (20%) :- Thefetus is affected from the noxious stimuli very early
in the phase of cellular hyperplasia.the total cell number is less. This form of growth
retardation is most often caused by structural or chromosomal abnormalities or congenital
infection( TORCH). The pathologic process is intrinsic to the fetus and involves all the
organs including the head. Asymmetrical (80%):-fetus is affected in later months
during the phase of cellular hypertrophy.The total cell number remains the same but size is
smaller than normal.The pathologic process that too often result in this type are maternal
diseases extrinsic to the fetus.These diseases alter the fetal size by reducing uteroplacental
blood flow or by restricting the oxygen and nutrient transfer or by reducing the placental
 size.In asymmetrical IUGR brain is not affected. Etiology :- 1) Toxins :- Alcohol
,smoking, chronic renal failure , chronic urinary tract infection,propranolol(through
decreased fetal blood flow). Organ which is affected least in IUGR?????????
(****** In preterm ,Rh incompatbility or DM there is no IUGR,not at all related ).
Allyl estranol ,high protein diet,intermittent oxygen therapy, all these improve
fetoplacental function in women with IUGR except the left lateral
position.???????????
216) Head paradoxical reflex:- with inflation of lungs,there is augmentation of
respiratory effort (due to irritant receptors of the lung) . (in newborns)
217) Formation of Hyaline membrane :- Preterm,Diabetic,
Caesarean,Breech,Hypothermic,Hypovolemic. (IUGR not related )
218) There is one advantage of Formula fed that It contains Vit K. (Breast milk contains
very little vitamin K) Breast fed babies have less diarrhoea( necrotising enterocolitis)
and fewer respiratory and middle ear infections(ottitis media) than artificially fed
babies.Breast feeding also protects against neonatal hypocalcemia(due to its ideal 2:1
calcium phosphorus ratio and better calcium absorption).
219) Cephalhaematoma:- (newborn head injury)It is collection of blood in between the
pericranium and the flat bone of the skull,usually unilateral and over a parietal bone.It is
due to rupture of emissary vein from the skull and may be associated with fracture of the
skull bone.This may be caused by forceps delivery but may also be met with following a
normal labour.Ventouse application doesnot increase the incidence of cephalhaematoma.It
is never present at birth but gradually develops after 12-24 hrs.The swelling is limited
by suture lines of the skull as the pericranium is fixed to the margins of the
bone(meningocele always lies over the suture lines or fontanelle and there is impulse on
crying) .It is circumscribed,soft and fluctuant and incompressible.The blood is absorbed
in course of time(6-8 weeks) leaving an entirely normal skull.
220) Sternomastoid Hematoma(tumour):- appears about 7-10 days after birth and is usually
situated at the junction of upper and middle third of the muscle.It is caused by rupture of
the muscle fibres and blood vessels,followed by a hematoma and cicatricial contraction.It is
associated with difficult breech delivery or attempted delivery following shoulder dystocia
or excessive lateral flexion of the neck even during normal delivery. There is transient
torticollis and it is wise The swelling disappears by 6 months of age. No immediate
therapy is needed like in cephalhaematoma
221) Pharmacotherapy in obs:- Oxytocin has a half life of 3-4 minutes.Oxytocin challenge
test( contraction stress test) to detect fetal well being . contraindications:- previous
history of cesarean section 2) preterm labour 3) APH ,thus its use is very much
selective. # The indications of ergometrine or methergin is to stop the atonic uterine
bleeding following delivery ,abortion, or expulsion of Hmole. It can b used
therapeutically as well prophylactically. Contraindications when used for
prophylaxis:- 1) suspected twins 2) organic cardiac disease 3) severe pre eclampsia
and eclampsia. 4) Rh negative mother. c/I even when used therapeutic (absolute c/i) :-
Heart disease or severe hypertensive disorder ,oxytocin is a better substitute. #
oxytocin is preferred over ergometrine in induction of labour because it is short lived
and faster in action. # Tocolytic agents :-
Isoxsurpine,Ritodrine,Salbutamol,Ethanol,(progesterone and diazoxide also inhibits
 labour). Prostaglandin synthetase inhibitors not used for tocolysis because they may
cause premature closure of PDA and congestive heart failure may occur.
222) Paracervical block can only relieve the pain of uterine contraction,doesn’t relieve
pain of episiotomy.For episiotomy.perineal infiltration is done.Paracervical block is
ass. with danger of fetal bradycardia. # Most important and major cause of maternal
mortality from obstetrical anaesthesia is Aspiration of gastric contents(mendelson`s
syndrome).
223) Induction of labour :- indications :- Preeclapmsiaand eclampsia,minor degree of
Placenta Praevia.C/I :- Heart disease.(imp). The ripeness of cervix can be effectively
achieved by PGE2
224) Bishop`s pre-induction cervical scoring system:- Favourable score -6-13 (more than
6 indicates labour has begun). *****Factors include 1) CERVICAL --- a)
Dilatation(cm) b) Cervical length (effacement of cervix)(cm) c) Consistency d) Position
& 2) HEAD station.
225) Surgical induction :-The initiation of labour is attempted by sugical method and is
almost exclusively done by rupture of membranes. C/I :- IUD (IUD Is an indication
for medical induction but c/I for surgical induction).
226) Partogram :-It is a composite graphical record of cervical dilatation and descent of
head against duration in hours .It also gives information about fetal and maternal
condition that are all recorded on a single sheet of paper. Its other components are :-
1) Patient identification 2) Time 3) Fetal heart rate 4) state of membranes and colour
of liq 5) cervical dilatation and descent of head 6) uterine contractions 7) Drugs and
fluids 8) BP 9) Oxytocin(conc and dose) 10) Urine analysis 11) Temp
227) Progestasert is not so long acting like other IUDs .It should be replaced after one
year.
228) Indications of removal of IUDevice :- pregnancy occuring with the device insitu
.Best inv for detection of missing IUD is USG. Best method of post coital
contraception is Copper i.u.d. (preg rate only 0-0.1 out of various post coital
contraceptives). # Best method for a 20 yr old nulliparous is Low dose Pills. # OCPs
are also best choice for a working women with irregular and profuse bleeding. # In a
newly married couple Pill is recommended provided there is no contraindication. # In
lactating women Pill is better withheld.Minipill or injectable steroids if available,is
ideal. Alternatively IUD is to be introduced. # Also for a postpartum village woman
with onechild(lactating) Æ cu T is choice as others are not available.
229) Uterus is elevated or pushed to one side or the other by the elevator that has already
been introduced transvaginally into the uterine cavity in mini-lap .while minilap
canbe done anytime but Laparoscopic sterilization shouldnot be done within 6 weeks
following delivery.
230) Episiotomy :- Only median or mediolateral episiotomy is done commonly.1) In
median the blood loss is least, healing is superior ,dyspareunia is rare,post op comfort
is maximum “,but extension if occurs may involve the rectum.” 2) In mediolateral
relative safety from rectal extension,{blood loss,dyspareunia and post op discomfort is
comparatively more.} .TREATMENT OF EPISIOTOMY INFECTION :- to facilitate
drainage of pus,local dressing with antibiotic ointment or powder and systemic
antibiotics.
231) Forceps operations are carried according to the station of the fetal head(station of
biparietal diameter)It is the most important point of reference in the use of forceps.
Fetal indications:- Appearance of fetal distress in the second stage of labour when
prospect of vaginal delivery is safe,aftercoming head of breech .Maternal indications
:- A) Maternal distress (*********vacuum is C/I in fetal distress as it takes longer
time,forceps used in fetal distress******}. # Conditions to be fulfilled:- cervix must
be fully dilated and effaced :-temptation to apply forceps through the cervical rim is
to be checked.(cf ventouse)
232) Ventouse :- Indications :- Deep transverse arrest with adequate pelvis As an
alternative to forceps operation except :-a) Face presentation and aftercoming of
breech b) Fetal distress or prematurity ADVANTAGE OF VENTOUSE OVER
FORCEPS :- It can be used with adv in unrotated and malrotated occipito post
position of the head. # Conditions to be fulfilled:- cervix should be atleast 6 cm
dilated(preferably only cervical rim may be left behind)
233) The only indication of internal version is Transverse lie in case of the second baby of
twin.it is hardly indicated in a singleton pregnancy in present day obs.Patient should
be deeply anaesthetised(GA).
234) Caesarean section:- Absolute indications:- central placenta praeviae,severe degree
of contracted pelvis with true conjugate less than 7.5 cm,cervical or broad ligament
fibroid,vaginal atresia,advanced ca cervix(not Carcinoma in situ). Relative
indications:- Previous CS,Previous scar following classical or hysterotomy should
be dealt with elective caesarean section because of risk of scar rupture.Myomectomy
scar should be dealt with judiciously,as per se it is not an indication for
section.(described previously in rupture uterus). CS is also indicated following
successful VVF repair or difficult repair of stress incontinence. # Indications of
classical cesarean section i.e. incision made in upper segment are very much limited
such as :- 1)Big fibroid on the lower segment, 2)ca cervix, 3) repair of difficult and
high VVF ,4) severe degree of PP with engorged vessels in the lower segment.To
minimise blood loss when adequate blood is not available and the patient is in
extremes. 5) postmortem section contemplating to have a live baby. 6)lower segment
app is difficult like in dense adhesions due to previous operations and in severe
contracted pelvis with pendulous abdomen.
235) About 2/3rd of neonatal deaths are related to prematurity.(MC)
236) Most important cause of coagulation failure in obstetrics is abruptio placentae.
Other pathological conditions ass with acquired coagulopathy are:- septic abortion 2)
liq amnii embolism 3) severe pre eclampsia,eclampsia and Hellp syndrome
4)prolonged retention of dead fetus in utero 5) others like shock cesarean section.
# Treatment :- replacement of fibrinogen (massive BT{most imp} ,FFP,
cryoprecipitate & fibrinal) ,fibrinolytic inhibitors (EACA-inhibits plasminogen and
plasmin) and heparin. Dextrans should be avoided as they adversely affect platelet
function and blood cross matching tests.
237) High risk cases /factors in reproductive history(according to WHO) are:- During
pregnancy:- 1)Threatened abortion and APH 2) Twins and hydramnios 3)
Previous still birth,IUD,manual removal of placenta 4)elderly primi 5)short
statured primi 6)Malpresentations 7) Preeclampsia and eclampsia 8) Elderly grand
 multipara 9) prolonged pregnancy 10) history of previous CS and instrumental
delivery 11)Anaemia
238) 10 day rule:- No Woman should be exposed to x ray for a non urgent indication
outside 10 days from her last period during reproductive period.It means
radiography should be restricted to 1st 10 days of menstrual cycle outside from her
last period.

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