EVIDENCES OF PREGNANCY ABNORMAL LABOR PATTERNS

PRESUMPTIVE EVIDENCES OF PREGNANCY Labor Diagnostic Criteria Preferred Exceptional

(25% Reliability) Pattern Nullipara Primipara Treatment Treatment
Signs Symptoms Prolongation Disorder
Amenorrhea of ≥10 days Nausea Prolonged >20 >14 Bed rest Oxytocin or
Anaotomical breast changes Urinary frequency Latent hours hours CS for
Vaginal mucosa changes Fatigue Phase urgent
Skin changes Quickening problems
Thermal signs Breast tenderness Protraction Disorders
PROBABLE EVIDENCES OF PREGNANCY (50% Reliability) Protracted <1.2 <1.5
Changes (enlargement of the abdomen & uterus, cervical Active Phase cm/hr cm/hr Expectant Caesarean
changes Dilatation and delivery for
Braxton-Hicks contraction/ false labor at 28 weeks Protracted <1 cm/hr <2 cm/hr support CPD
Ballottement of the presenting part at 16 – 20 weeks Descent
Fetal outlining Arrest Disorders
Positive hCG Pregnancy Test 8 – 9 days post-ovulation with a peak Prolonged >3 hours >1 cm/hr
at about 60 – 70 days and nadir at about 14 – 16 weeks Deceleration
Phase Oxytocin Rest if
POSITIVE EVIDENCES OF PREGNANCY
Secondary >2 hours >2 hours without exhausted
Concrete evidences of fetal growth and development in-utero CPD
Arrest of
measured through the Fetal Heart Tone (FHT)
Dilatation
Doppler 10 weeks Caesarian Caesarian
Arrest of >1 hour >1 hour
Stethoscope 17 – 19 weeks delivery delivery
Descent
Echo 48 days from with CPD
Failure of No descent in
LMP
Descent deceleration phase
Fetal Heart Rate (FHR): 110 – 160 bpm or second stage
Perception of Fetal Movement (FM) by the examiner at 20 weeks
Auscultation of Funic (sharp, whistling sound produced by blood NAEGELE’S RULE
rush through the umbilical arteries, synchronous with the Fetal Get the LMP (dd/mm/yyyy)
Pulse) and Uterine (soft, blowing sound produced by blood rush Add 7 days
through the uterine arteries, synchronous with the Maternal Subtract 3 months
Pulse) Souffle Add 1 year
Demonstration of various pregnancy structures by Ultrasound *Only applicable for April – December
(Gestational Sac: 4 – 5 weeks [ave. 35 days]) and Radiograph (12 – For January – March: add 9 months and 7 days
14 weeks)
FUNDIC HEIGHT
LABOR
AOG FUNDIC HEIGHT
TRUE LABOR FALSE LABOR
12 weeks Just above the symphysis pubis
Contractions
16 weeks Halfway between the symphysis pubis &
Interval Regular Irregular the umbilicus
Frequency Progressively increasing Inconsistent 20 weeks Level of the umbilicus
Duration Progressively increasing Inconsistent 26 weeks 2 – 3 fingers above the umbilicus
Intensity Progressively increasing Unchanged 32 weeks Midway between the umbilicus & the
Cervix Progressive effacement No significant xiphoid process
and dilatation change 40 weeks 1 – 2 fingers above the costal margin
Discomfort Back and Abdomen; Mostly lower
Unrelieved by sedation abdomen;
OCCIPITAL HEAD DIAMETERS
Relieved by
sedation DIAMETER LENGTH (cm)
Occipitofrontal 11.5
Biparietal 9.5
Bitemporal 8
STAGES OF LABOR
Occipitomental 12.5
PRIMIPARA MULTIPARA Suboccipitobregmatic 9.5
First Stage Regular contractions to full cervical
dilatation
BIOPHYSICAL PROFILE
Latent Phase Irregular contractions, short, mild –
(0 – 3 cm) moderate COMPONENT SCORE
20 hours 14 hours 2 0
Active Phase Uterine contractions every 2 – 5 minutes; Non-Stress Test ≥2 accelerations of 0 – 1 acceleration
(4 – 7 cm) 40 – 60 secs, moderate - strong ≥ 15 bpm for ≥ 15 in 20 – 40 minutes
sec in 20 – 40
5 hours 4 hours
minutes
(dilatation: 1.2 (dilatation: 1.5
cm/hr) cm/hr) Fetal Breathing ≥1 episode of <30 secs of
rhythmic breathing breathing in 30
Transition Phase Uterine contractions every 1.5 – 2 minutes,
lasting for ≥30 sec minutes
(8 – 10 cm) 60 – 90 secs, moderate – strong
within 30 minutes
60 minutes 30 minutes
Fetal Movement ≥3 discrete body or <3 discrete
Second Stage Complete dilatation to delivery of the fetus
limb movements movements
60 minutes 30 minutes within 30 minutes
Affected by epidural anesthesia, maternal pushing, position of the Fetal Tone ≥1 episode of No movements
presenting part, & size of the pelvis extension of fetal No extension or
Third Stage Delivery of the fetus to delivery of the extremity with flexion
placenta return to flexion or
Fourth Stage Delivery of the placenta to 1 hour after opening or closing
delivery of hand within 30
minutes
Amniotic Fluid Single vertical Largest single
Volume pocket >2 cm vertical pocket ≤2
minutes
MODIFIED BIOPHYSICAL PROFILE SCORE, INTERPRETATION, AND TYPICAL AMNIOTIC FLUID VOLUME
PREGNANCY MANAGEMENT AOG Fetus Placenta Amniotic Percent
BIOPHYSICA INTERPRETATION MANAGEMENT (weeks) (g) (g) Fluid Fluid
L PROFILE (mL)
SCORE 16 100 100 200 50
10 Normal, Non- No fetal indication for 28 1000 200 1000 45
asphyxiated intervention; repeat test 36 2500 400 900 24
weekly except in diabeti and 40 3300 500 800 17
post-term pregnancy (2x a
week)
8 Normal, Non- No fetal indication for
Normal Fluid asphyxiated intervention; repeat testing NORMAL BLOOD LOSS AFTER DELIVERY
per protocol Vaginal Delivery 500 mL
8 Chronic fetal Deliver if ≥3 weeks; otherwise Caesarean Section 1000 mL
Oligohydram asphyxia repeat testing
nios suspected
6 Possible fetal If amniotic fluid volume is
SIGNS OF PLACENTAL SEPARATION
asphyxia abnormal, deliver
If normal fluid at ≥36 weeks Uterus becomes globular and firmer
with favourable cervix, Sudden gush of blood
deliver Uterus rises in the abdomen
If repeat test ≤6, deliver; if Umbilical cord lengthens
repeat test ≥6, observe and
repeat per protocol
4 Probably fetal Repeat testing same day, if
TYPES OF SPONTANEOUS ABORTION
asphyxia score ≤6, deliver
0–2 Almost certain Deliver Bleeding Abdominal Cervix POC
fetal asphyxia Pain
Threatened Minimal Possible Close Retained
Inevitable Profuse Severe Open Retained
Incomplete Profuse Min/Sev Open Some
BISHOP SCORING SYSTEM
expelled
Scor Dilatati Effacem Stati Cervical Cervical Complete Minimal Minimal Open All
e on ent on Consiste Position expelled
(cm) (-3 to ncy
Missed Non None Close Retained
+3)
Septic Results in uterine infection
0 Closed 0 – 30 -3 Firm Posterior
(+) fever, chills, and peritoneal signs
1 1–2 40 – 50 -2 Medium Midposte
rior
2 3–4 60 – 70 -1 Soft Anterior
3 ≥5 ≥80 +1, +2 - -
 Score of 9 – High likelihood of successful induction of labor
 Score of 4 & below – Unfavorable cervix, indication for
cervical ripening

LEOPOLD’ S MANEUVER
LM 1 Presentation Fetal Head: Hard, firm, round and
(cephalic/breec moves independently of trunk
h) Buttocks: Soft, symmetric, with
small bony processes, moves SCREENING TESTS
with the trunk
SCREENING FOR NEURAL TUBE DEFECTS
LM 2 Fetal Lie Fetal Back: Firm and smooth
Maternal Serum AFP 14 – 22 weeks AOG
(longitudinal/ Fetal Small Parts: Small
Screening Normal Upper Limit: 2.0 ng/mL
transverse) irregularities and protrusions
Multiple of Median: 2.5
LM 3 Engagement Floating: Can be gently pushed
Ultrasound Anencephaly, Major cranial defects
back and forth
Most spine defects
Engaged: Immovable presenting
part Amniocentesis Amniotic fluid AFP
Acetylcholinesterase
LM 4 Cephalic Vertex: Cephalic prominence on
Elevation – diagnostic
Prominence same side as small parts
Face: Cephalic prominence on 1ST TRIMESTER DOWN SYNDROME SCREENING
same side as back Maternal Analyte Screening with free Beta-hCG
Pregnancy-Associated Plasma Protein A (PAPP-A)
Fetal Nuchal 11 – 14 weeks AOG
Translucency NT: echolucent area seen in
longitudinal views behind the neck
2nd Trimester 15 – 20 weeks AOG
AMNIOTIC FLUID Amniocentesis 20 mL – karyotype analysis
COMPOSITION Early (1st) Trimester 11 – 14 weeks AOG
Early Pregnancy Ultrafiltrate of maternal plasma Amniocentesis 1 mL for each week of gestation
Beginning of 2nd ECF that diffuses through fetal skin Higher pregnancy loss rate
Trimester reflecting plasma Chorionic Villous 10 – 13 weeks AOG
After 20 weeks Fetal urine (Produced at 12 weeks; by 18 Sampling Same indications and complications
weeks, 7 – 14 mL is produced as amniocentesis
VOLUME (variable) Percutaneous Umbilical Cordocentesis/Fetal blood sampling
8 weeks Increases by 10 mL Cord Blood Sampling Assessment and treatment of
confirmed Red Cell or Platelet
21 weeks Increases up to 60 mL
alloimmunization, analysis of non-
33 weeks Declines gradually to a steady state
immune hydrops
 MINIMUM CRITERIA FOR DIAGNOSING PELVIC INFLAMMATORY
DISEASE (on Pelvic Examination) – CDC 2010
Cervical Motion Tenderness
Adnexal Tenderness
Abdominal Tenderness
*** Signs of lower genital tract infection in the presence of all 3
criteria increases specificity of diagnosis
DURATION OF LABOR
Additional Criteria
NULLIPARAS MULTIPARAS
 Oral temperature >101 F (>38.3 C)
 Abnormal cervical or vaginal mucupurulent discharge 1ST Stage 8 – 15 hours 5 – 11 hours
 Presence of abundant numbers of WBC on saline Latent Phase 6 – 11 hours 4 – 8 hours
microscopy of vaginal fluid Active Phase 4 – 6 hours 2 – 3 hours
 Elevated ESR (1 – 2 cm/hr) (1 – 5 cm/hr)
 Elevated CRP; and 2nd Stage 30’ – 2(50’) 5’ – 30’(20’)
 Laboratory documentation of cervical infection with N. 3rd Stage 0 – 30’(5’) 0 – 30’(5’)
gonorrheae or C. trachomatis Mean length of 1st 9 hours 6 hours
Most specific criteria for diagnosing PID include: and 2nd stages of
 Endometrial biopsy with histopathologic evidence of labor (w/o
endometritis; regional
 Transvaginal sonography or MRI showing thickened, fluid- anesthesia)
filled tubes with or without free pelvic fluid or tubo-ovarian
complex, or Doppler studies suggesting pelvic infection (e.g.
tubal hyperaemia); or
RISK OF ACIDEMIA EVOLUTION AND ACTION
 Laparoscopic abnormalities consistent with PID
VARIABLE RISK OF RISK OF ACTION
ACIDEMIA EVOLUTION
RECOMMENDED OUTPATIENT REGIMEN FOR PID – CDC 2010
Green O Very low None
Ceftriaxone + Doxycycline 250 mg IM single dose Blue O Low Conservative
With or without 100 mg orally BID for 14 days techniques &
Metronidazole 500 mg orally BID for 14 days begin
OR preparation
Cefoxitin & Probenecid + 2g IM single dose Yellow O Moderate Conservative
Doxcycline 1g oral single dose techniques &
With or without 100 mg BID for 14 days increased
Metronidazole 500 mg orally BID for 14 days surveillance
OR Orange Borderline/ High Conservative
Other 3rd generation acceptably techniques &
Cephalosporin + Doxycycline 100 mg BID for 14 days low prepare for
With or without urgent
Metronidazole 500 mg orally BID for 14 days delivery
Red Unacceptably Not a Deliver!
INDICATION FOR IN-PATIENT THERAPY FOR PID high consideration
Surgical emergencies (e.g. appendicitis) cannot be excluded
The patient is pregnant
The patient does not respond clinically to oral antimicrobial therapy
FIVE GRADES OF FETAL ACIDEMIA
The patient is unable to follow or tolerate an outpatient oral
regimen Category Definition
The patient has severe illness, nausea and vomiting, or high fever Green No acidemia
The patient has a tubo-ovarian abscess Blue No central fetal acidemia (oxygenation)
Yellow No central fetal acidemia but FHR pattern suggests intermittent
PARENTERAL TREATMENT FOR PID (CDC 2010) reductions in O2 which may result in fetal O2 debt
Orange Fetus potentially on verge of decompression
RECOMMENDED PARENTERAL REGIMEN A
Red Evidence of actual or impending damaging fetal asphyxia
Cefotetan 2 g IV q 12 hours
Or
Cefoxitin + 2g IV q 6 hours
Doxycycline 100 mg orally or IV q 12 hours BISHOP SCORING SYSTEM USED FOR ASSEESSMENT OF
RECOMMENDED PARENTERAL REGIMEN B INDUCIBILITY
Clindamycin 900 mg IV q 8 hours Scor Dilatati Effacem Statio Cervical Cervical
+ Loading Dose IV/IM: 2 mg/kg e on ent n Consisten Position
Gentamicin Maintenance: 1.5 mg/kg q 8 (cm) (%) cy
hours 0 Closed 0 – 30 -3 Firm Posterior
Single dose: 3 – 5 m/kg 1 1–2 40 – 50 -2 Medium Midpositi
ALTERNATIVE PARENTERAL REGIMEN on
Ampicillin/Sulbactam + 4g IV q 6 hours 2 3–4 60 – 70 -1 Soft Anterior
Doxycycline 100 mg oral/IV q 12 hours 3 ≥5 ≥80 +1, +2 - -
A Bishop Score of 9 conveys a high likelihood for a successful
induction while a Bishop Score of 4 or less identifies an unfavourable
cervix and may be an indication for cervical ripening.
 CURRENT CDC RECOMMENDATIONS FOR THE TREATMENT OF PID INCLUDE DIAGNOSIS OF PREGNANCY
BOTH PARENTERAL OR ORAL AMBULATORY REGIMENS PRESUMPTIVE EVIDENCES OF PREGNANCY
A. Oral Ambulatory Regimens Symptoms Signs
1. CDC-recommended regimen A 1. Nausea with or without 1. Cessation of menses
a. Ceftriaxone 250 mg IM via single dose PLUS vomiting 2. Changes in the breasts
b. Doxycycline 100 mg orally 2x a day for 14 days 2. Disturbances in 3. Discoloration of the vaginal mucosa
with or without urination o During pregnancy, the
c. Metronidazole 500 mg orally 2x a day for 14 days 3. Fatigue vaginal mucosa usually
2. CDC-recommended regimen B 4. The perception of fetal eppears dark bluis or
a. Cefoxitin 2 g IM in a signle dose, and Probenecid 1 g movement purplish-red, the so called
orally administered concurrently in a single dose PLUS Chadwick sign
b. Doxycycline 100 mg orally 2x a day for 14 days PROBABLE EVIDENCES OF PREGNANCY
c. Metronidazole 500 mg orally 2x a day for 14 days 1. Enlargement of the abdomen
3. CDC-recommended oral regimen-C 2. Changes in the shape, size, and consistency of the uterus
a. Other parenteral 3rd-generation Cephalosporin PLUS  At 12 weeks AOG: the average uterine diameter is 8 cm
b. Doxycycline 100 mg orally 2x a day for 14 days  Hegar sign
with or without  Becomes evident at about 6 – 8 weeks after the
c. Metronidazole 500 mg orally 2x a day for 14 days onset of last menstrual period
 With one hand of the examiner on the abdomen,
B. Follow-up and two fingers of the other hand placed in the
1. Patient should be re-examined within 72 hours and should vagina, the still- firm cervix is felt, with the
demonstrate substantial clinical improvement. elastic body of the uterus above the
2. Patients who do not improve within this period usually require compressible soft isthmus, which is between the
hospitalization, additional diagnostic tests, and possible surgical two
intervention. 3. Anatomical changes in the cervix
3. Some experts recommend rescreening for C. trachomatis and N.  At 6 – 8 weeks: the cervix is considerably softened
gonorrheae after completion of therapy. In women with 4. Braxton-Hicks Contractions
documented infection due to these pathogens. The optimal time  Palpable but ordinarily painless contractions at irregular
period for rescreening is 4 – 6 weeks. All women diagnosed with intervals from the early stages of gestation
acute PID should be offered HIV testing. 5. Ballottement
6. Physical Outlining of the fetus
C. Parenteral Regimens 7. Presence of chorionic gonadotropin in urine and serum
 Pregnancy Test
1. CDC-recommended parenteral regimen A
a. Cefotetan 2g IV every 12 hours, OR POSITIVE SIGNS OF PREGNANCY
b. Cefoxitin 2g IV every 6 hours, PLUS 1. Identification of fetal heart action separately and distinctly from that of
c. Doxycycline 100 mg orally or IV every 12 hours the pregnanct woman
2. CDC-recommended parenteral regimen B  By Auscultation: fetal heart beat can be detected with the
a. Clindamycin 900 mg IV every 8 hours, PLUS stethoscope by 17 weeks, on average and by 19 weeks in
Gentamicin loading dose IV or IM (2 mg/kg), followed nearly all pregnancies in non-obese women
by maintenance dose (1.5 mg/kg) every 8 hours. Single  By Doppler: fetal cardiac can be detected almost always by
daily gentamicin dosing may be substituted 10 weeks
2. Perception of active fetal movements by the examiner
3. Alternative parenteral regimens
 Detection by the examiner of the fetal movements can occur
a. Ampicillin/Sulbactam 3 g IV every 6 hours
after about 20 weeks
b. PLUS Doxycycline 100 mg orally or IV every 12 hours
3. Recognition of the embryo and fetus anytime in pregnancy by
4. It is important to continue either regimen A or B or alternative
sonographic techniques or of the more mature fetus radiographically in
regimens for at least 24 hours after substantial clinical
the latter half of pregnancy
improvement occurs and also to complete a total of 14 days
 By Abdominal sonography: a gestational sac may be
therapy with:
demonstrated after only 4 – 5 weeks
a. Doxycycline 100 mg orally twice a day or Clindamycin
 After 6 weeks: a heartbeat should be detectable
450 mg orally 4x a day
 By 8 weeks: the gestational age can be estimated quite
accurately
 By 12 weeks: the crown-rump length is predictive of
gestational age in 4 days
BACTERIAL VAGINOSIS
- Is also known as Anaerobic Vaginosis
- Is the most common diagnosis made in women complaining of abnormal
vaginal discharge
- Is a syndrome of unknown cause characterized by the decrease in the
concentration of lactobacilli and overgrowth of anaerobic organisms
associated with loss of vaginal acidity
Amsel’s Criteria
Presence of the 3 of the following four criteria is necessary for diagnosis:
1. Homogenous, milky or creamy discharge
2. Presence of clue cells on microscopic examination
3. pH of secretion of 4 -5
4. Fishy or amine odor with or without addition of KOH (Whiff’s Test)
Recommended Regimens:
 Metronidazole 500 mg orally 2x a day for 7 days
 Metronidazole 2g orally as a single dose
 Metronidazole 0.75% one full applicator (5g) intravaginally, once a day for
5 days
 Clindamycin cream 2%, one full applicator (5g) intravaginally at bed time
for 7 days
Alternative Regimens:
 Clindamycin 500 mg orally 2x a day for 7 days
 Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days
 PERINATAL SCORING
TYPICAL FEATURES OF VAGINITIS Low Risk 0–2
CONDITI SIGNS & FINDINGS ON pH WET MOUNT COMMENT High Risk 3–6
ON SYMPTOMS EXAMINATION
Severe >7
Bacterial Increased Thin, whitish >4.5 Clue cells Greatly
REPRODUCTIVE HISTORY
Vaginosi discharge gray discharge, (>20%) shift in decreased
s (white, thin)* cocci, flora. Amine lactobacilli. Age Parity Abortion
Increased odor increased odor odor after Greatly increased <16 1 0 1 2> 1
adding KOH to cocci. 16 – 35 0 1–4 0 3> 2
wet mount Small curved >35 2 >5 2
rods History of Infertility 2
Candidia Increased Thick, curdy <4.5 Hyphae or Can be mixed Post Partum Hemorrhage 1
sis discharge discharge spores infection with Manual Removal of Placenta 1
(white, thick), Vaginal bacterial HTN/Toxemia 1
Dysuria erythema vaginosis, T.
Abnormal/Difficult Labor 2
Pruritus vaginalis, or
Previous CS 2
Burning both, and have
higher pH PRESENT PREGNANCY
Trichom Increased Yellow, frothy >4.5 Motile More symptoms <20 Weeks Bleeding 1
oniasis** discharge discharge, with trichomonads at higher vaginal >20 Weeks Bleeding 3
(yellow, or without Increased pH Anemia <10G 1
frothy), vaginal or white cells HTN/Pre-Eclampsia 3
Dysuria cervical Chronic HTN 1
Pruritus erythema Getastational HTN 1
*Although these features are typical, their sensitivity and specificity are generally inadequate for Superimposed Pre Eclampsia 3
diagnosis. PROM 2
*For a diagnosis of bacterial vaginosis, a report of increased discharge has a sensitivity of 50% and Poly or Oligohydramnios 2
a specificity of 49%; odor, a sensitivity of 49% and a specificity of 20%; and pH >4.7, a sensitivity of IUGR 3
97% and a specificity of 65%, compared with the use of Gram’s stain.
Multiple Pregnancy 3
**Of patients presenting with symptoms of vaginitis, 40% report increased (white) discharge, but
Breech/Malpresentation 2
is not related to C. albicans in many studies.
*A report of yellow discharge has a sensitivity of 42% and a specificity of 80%; a frothy discharge Rh Isoimmunization 3
has a sensitivity of 8% and a specificity of 99%. Fetal Hydrops 3
Pre-term/Post Term 2
Abnormal CTG 2
TPL 2
INSTITUTE OF MEDICINE WEIGHT GAIN RECOMMENDATIONS FOR MEDICAL HISTORY
PREGNANCY
Previous Gyne Surgery 1
Pregnancy Body Mass Recommende Recommended Rates of Chronic Renal Disease 1
Weight Index* d Range of Weight Gain** in the 2nd GDM 1
Category Total Weight & 3rd Trimesters (lb) DM 3
(lb) (Mean Range [lb/wk]) Heart Disease 3
Underweight <18.5 28 – 40 1 (1 – 1.3) APAS 3
Normal Weight 18.5 – 24.9 25 – 35 1 (0.8 – 1) Pulmonary Disease/Asthma 1
Overweight 25 – 29.9 15 – 25 0.6 (0.5 – 0.7) Cancer in Pregnancy 3
Obese 30 and 11 – 20 0.5 (0.4 – 0.6) Neurological Disease 3
(including all above Other Diseases (infection) 2
classes)
*Body mass index is calculated as weight in kilograms divided by height in
meters squared or weight in pounds multiplied by 703 divided by height in
inches.
**Calculations assume a 1.1 – 4.4 lb weight gain in the first trimester
 ESTIMATING AGE DURING THE FETAL PERIOD
Menstrual Age Fertilization CRL Foot Fetal Main External Characteristics
Age (mm) Length Weight
(mm) (g)
11 9 50 7 8 Eyes closing or closed. Head more rounded. Intestines in
umbilical cord.
12 10 61 9 14 Intestines in abdomen. Early fingernail development.
14 12 87 14 45 Sex disntinguishable externally. Well-defined neck.
16 14 120 20 110 Head erect. Lower limbs well developed.
18 16 140 27 200 Ears stand out from head.
20 18 160 33 320 Vernix caseosa present. Early toenail development.
22 20 190 39 450 Head and body (lanugo) hair visible.
24 22 210 45 630 Skin wrinkled and red.
26 24 230 50 820 Fingernails present. Lean body.
28 26 250 55 1000 Eyes partially open. Eyelashes present.
30 28 270 59 1300 Eyes open. Good head of hair. Skin slightly wrinkled. Total Score: _____
32 30 280 63 1700 Toenails present. Body filling out. Testes descending. Interpretation of Results:
34 32 300 68 2100 Fingernails reach fingertips. Skin pink and smooth.  Benign: 8 and below
38 36 340 79 2900 Body usually plump. Lanugo hairs almost absent. Toenails  Borderline: 9
reach toe tips. Malignant: 10 and above
40 38 360 83 3400 Prominent chest. Breasts protrude. Testes in scrotum or
palpable in inguinal canals. Fingernails extend beyond
fingertips.

ABNORMAL LABOR PATTERNS, DIAGNOSTIC CRITERIA AND METHODS OF BODY MASS INDEX
TREATMENT
CLASIFICATION ASIAN RANGE WORLD WIDE RANGE
LABOR DIAGNOSTIC CRITERIA PREFERRED EXCEPTIONAL
PATTERN NULLIPARA MULTIPARA TREATMENT TREATMENT UNDERWEIGHT >17.50 >18.50
PROLONGATION DISORDER
NORMAL WEIGHT 17.50-22.99 18.50-24.99
Prolonged >20 hr >14 hr Bed rest Oxytocin or
Latent caesarean OVERWEIGHT 23.00-27.99 25.00-29.99
Phase delivery for
urgent problems OBESE 28.00< 30.00<
PROTRACTION DISORDERS
Protracted <1.2 cm/hr <1.5 cm/hr Expectant Caesarean
Active Phase and support delivery for CPD
Dilatation
Protracted <1 cm/hr <2 cm/hr
Descent
ARREST DISORDERS
Prolonged >3 hr >1 hr Evaluate for Rest if exhausted
Deceleration CPD: Caesarean
Phase delivery
Secondary >2 hr >2 hr CPD:
Arrest of caesaian
Dilatation delivery
Arrest of >1 hr >1 hr
Descent No CPD:
oxytocin
Failure of No descent in deceleration phase or second stage
Descent

ULTRASOUND SECTION

Transvaginal Evaluation of a New Scoring System to Ovarian Malignancy

(by SASSONE, A.M. et al)

VARIABLES VALUES
1 2 3 4 5
Inner Wall Smooth Irregularities Papillarities NA Mostly solid
Structures (<3 mm) (>3 mm)
Wall Thin Thick Mostly solid - -
Thickness (<3 mm) (>3 mm)
(mm)
Septa No septa Thin Thick - -
(mm) (<3 mm) (>3 mm)
Echogenicity Sonolucent Low Low Mixed High
echogenicity echogenicity echogenicity echogenicity
with
echogenic
core
 COMPUTATIONS
Estimated Fetal Johnson’s rule Fundic height in CM – R x S
Weight S= constant 155 if grams or .155 in KG
R= 12 if engaged or 11 if not yet engaged
Estimated Age of Mcdonald’s Gestational Fundic Height
Gestation rule age Landmarks
12 weeks Symphesis Pubis
20 weeks Umbilicus
36 weeks Xyphoid process of sternum
37-40 weeks Regression of fundal height between 36-32 cm
Estimated Date of Naegele’s rule LMP +1 year, -3 months, +7 days
Confinement *If EDC still within the year like January and February: -3 months,
+7 days

ESTIMATED FETAL WEIGHT

Engaged (FH – 11) x 0.155
Unengaged (FH – 12) x 0.155

CATEGORY 1: NORMAL
The fetal heart rate tracing shows
ALL of the following:
 Baseline FHR: 110 – 160 bpm
 Moderate FHR variability
 Accelerations may be
present or absent
 No late or variable
decelerations
Intervention:
 Strongly predictive of
normal acid-base status at
the time of observation.
routine care.
FETAL HEART RATE MONITORING
3 Tier Fetal Heart Rate Interpretation Systems
CATEGORY II: INDETERMINATE
The fetal heart tracing shows ANY of the
following:
 Tachycardia
 Bradycardia without absent variability
 Minimal variability
 Absent variability without recurrent
decelerations with minimal or moderate
variability
 Prolonged deceleration ≥ minute but less
than 10 minutes
 Variable decelerations with other
characteristics such as slow return to
baseline and/or “overshoot”
Intervention:
 Not predictive of abnormal fetal acid-base
status, but requires continued
surveillance and re-evaluation
CATEGORY III: ABNORMAL
The fetal heart rate tracing shows EITHER
of the following:
 Sinusoidal pattern OR absent
variability with recurrent late
decelerations
 Recurrent decelerations
 Bradycardia
Intervention:
 Predictive of abnormal fetal acid-
base status at the time of
observation
 Depending on clinical situation,
efforts to expeditiously resolve
underlying cause of the abnormal
fetal heart rate pattern should be
made. Need for delivery is
warranted.

EARLY DECELERATION
There is gradual decrease in the
heart rate with both onset and
recovery coincident with the
onset and recovery of the
contraction
Gradual decrease in FHR with
onset of deceleration to nadir ≥30
seconds. The nadir occurs with
the peak of a contraction.
TYPES OF DECELERATION
LATE DECELERATION
A true sign of hypoxia
A late deceleration is a smooth, gradual,
symmetrical decrease in fetal heart rate
beginning at or after the peak of the
contraction and returning to baseline only after
the contraction has ended
Gradual decrease in FHR with onset of
deceleration to nadir ≥30 seconds
VARIABLE DECELERATION
Intermittent periodic showing of FHR with
rapid onset and recovery
Vagal in origin, medical experts suggest
variable decelerations result from stimuli
such as cord or head compression
Abrupt decrease in FHR ≥15 beats per
minute measured from the most recently
determined baseline rate

Features of early heart rate Onset of the deceleration occurs after the The onset of deceleration to nadir is less
deceleration: beginning of the contraction, and the nadir of than 30 seconds. The deceleration lasts ≥15
 Drop of HR at the acme of the contraction occurs after the peak of the seconds and less than 2 minutes. A
contraction contraction shoulder, if present is not included as part
 The appearance of of the deceleration
deceleration at the height of
contraction creating a
MIRROR image
 Seen during descent of head

PROPOSED MANAGEMENT
Category Conservative OR OB Anesth Infant Location
Technique Resuscitator
Green No - - - - -
Blue Yes Available Informed - - -
Yellow Yes Available Bedside Informed Informed -
Orange Yes Immediately Bedside Present Immeiately OR
Available available
Red Yes Open Bedside Present Present OR