524

Obstetrics

notes
My PG
Notes
MEE

M
y
PG
M
EE
N
ot
es
,1
/e
 My PG
MEE
Notes

Sperm and semen

zz Length of sperm (mature)- 55 mm

zz Fertilisable lifespan of sperm-72 hours
zz average sperm count- 60-100 million/day
zz number of sperm produced/day-100 million/
day
zz sperm remains motile for 12 hours in female
genital tract.
zz Motility is gained n epididymis
zz Gene for fusion/fertilisation- FERTILIN
zz Gene for motility of sperm- CATSPER
zz Capacitation-
occurs in female genital tract[FT>Uterus]

/e


 mainly in FT
begins in cervix

,1


 average time required- 7hours WHO parameters for semen-

final motility/maturity in female genital • Volume→ >1.5 ml

es

tract • pH → >7.2
zz main hormone for spermatogenesis— • Total sperm count → >39 million/ejaculate
ot
• Vitality→ >50% live sperms
[FSH+LH+Testosterone] > FSH
• Sperm concentratiion → >15 million/ml
receptor for sperm in Zona Pellucida-
N
zz
• total motility→ > 40%
ZPGP3[zona pellucid glycoprotein 3] • progressive motility→ > 32%
quarantine period for sperm donation is
EE

zz • Morphology(Strict Criteria) → >4% normal forms

6 MONTHS [during this period sperms are • Leukocytes → <1 million/ml
tested]
M

Implantation

Obstetrics
PG

zz implantation begins on day 6th in blastocyst form and completed on day 10

zz Endometrium of pregnancy is known as decidua
Decidua capsularis and decidua parietalis fuses by 14 to 16 weeks of gestation
y

zz

By day 8 , post fertilization Trophoblast differentiate into outer syncytiotrophoblast and inner
M

zz

cytotrophoblast
zz Cytotrophoblast further gives rise to villous trophoblast which form placental villi and extra
villous trophoblast which invades deeper into decidual Spiral arterioles of mother making it
resistant to vasopressor and maintains uteroplacental circulation
zz Polyspermy prevented by zona pellucida, also by calcium

EMBRYO → 3rd to 8th week after fertilization

FOETUS → 9 week to term

525

notes
 MEE
My PG
Notes

Fetal Membranes

Amnion Chorion
• innermost tough avascular foetal membrane It is of two types :
• Gives tensile strength to foetal membrane 1]chorion frondosum it forms placental villi.
• composed of crosslinking of in collagen 1 and 3 2]chorion laeve

zz Primary villi → formed on day 13 of fertilization

zz Secondary villi → formed on day 16 of fertilization
zz Tertiary villi → formed on Day 21 of fertilization

Human Placenta Fetal Milestones

zz Weight at term is 500 gram,
Wks Fetal Milestone
zz Diameter 20 centimetre and

/e
zz Thickness 2 to 3 centimetre 5 placental circulation established
Surface area of placental vili is 12 metre square 7 gross body movement appear first

,1
zz

zz functional unit is cotyledon 8 glucagon secretion & internal gonads

formation
Hemochorio endothelial type

es
zz
10 fetal swallowing & anterior pituitary
zz Formed from fetal parts mainly called as
hormone secretion
chorionic frondosum and maternal part called is
ot 11 female external genitalia differentiation
decidua basalis
completed
N
zz placental function starts around 10 weeks
11 respiratory movement & thyroxine
zz Placental circulation established post fertilization
secretion
EE

day 12
12 urine production, posterior pituitary
zz Fetal circulation established around Day 21 post
hormone secretion & insulin secretion
fertilization [2018]
M

14 male external genitalia differentiation

zz Ratio of mature placental weight to foetus at completed
Obstetrics

PG

term is 1:6
20 lung surfactant formed & meconium
zz Nitabuchs layer: appears
 Fibrinoid deposition in the syncytiotrophoblast.
24 hearing & sucking movement on USG
It limits further invasion of decidua by the
y


trophoblast absence of this membrane leads 28 light perception
M

to placenta accreta.
zz Placenta lacks 17-α hydroxylase enzyme therefore cannot synthesise oestrogen
zz Spiral arteriole are 120 in number and contains around 140 ml of maternal blood
zz Hofbauer cell are seen in placenta, functions as Macrophages
zz Most common mets to placenta is Melanoma and cancer breast

Placenta Variations

zz MEMBRANACEOUES PLACENTA/PLACENTA DIFFUSA-Placenta develops from both chorionn

frondosum and chorion laeve. Placenta is large and thin complication Placenta previa placenta
accreta
526 zz Fetal fibronectin also called as trophoblast glue- function migrationand attachment of trophoblast
maternal decidua

notes
 My PG
MEE
Notes

/e
Hormone Secreted by Placenta

,1
Protein hormone Steroid hormones

es
• H CG • human chorionic corticotropin • Estrogens
• HPL (Chorionic growth hormone), • human chorionic thyrotropin
ot • Progesterone
• PAPP-A
N
Human Chorionic Gonadotropin [HCG] Human placental lactogen

• It is glycoprotein , alpha subunit is similar to TSH,FSH & LH • also known as Chorionic

EE

• Carbohydrate content → 30% [highest of any human hormones] growth hormone

• Secreted by syncytio trophoblast • Produced by
M

• Maximum value at 10 weeks [60 to 80 Days] → that is one lakh IU syncytiotrophoblast

• Minimum value at 16 weeks and plateaus for the remaining pregnancy • Increases upto 36 week

Obstetrics
PG

• Half life → 24 hours & doubling time → 48 hours • concentration 5-50 μg/ml
• Post delivery start disappearing from maternal urine in 48 hours. • disappears after first
• Return to normal levels within two weeks after delivery Postpartum day
• After early abortion returns to normal level in 4 to 6 weeks • Maximum production
y

• UPT is based on sandwich ELISA method [sensitivity is 20 Mili IU/ml] throughout pregnancy
M

• HCG can be detected in maternal serum or urine as early as 8 to 9 days • highest concentration among
following ovulation by Radioimmunoassay(RIA) all protein hormones
• Most sensitive test FIA > RIA(5 IU/ml) > ELISA > RRA(20-50 mili IU/ml). • Predictor of placental
• Critical titre of HCG to visualise G sac: function
ƒƒ for transabdominal sonography → 6500 IU • Fetal growth is determined
ƒƒ for transvaginal sonography → 1500 IU by insulin hormone
• HCG levels increases in multiple pregnancy, H.mole, Choriocarcinoma, • Function of HPL
Down syndrome & Rh incompatibility ƒƒ lipolysis

• HCG levels decreases in ectopic pregnancy, abortion & trisomy 18 ƒƒ Angiogenic hormone

• Function of HCG ƒƒ fetal vasculature formation

ƒƒ Maintenance of Corpus luteum ƒƒ Anti-insulin hormone →

ƒƒ Stimulate leydig cells in male foetus to release testosterone → Responsible for Insulin
development of male external genitalia resistance
527
ƒƒ Immunosuppressive action → prevent foetus immune rejection

notes
 MEE
My PG
Notes

Alpha Fetoprotein

zz t1/2-→ 5days
zz It is secreted by yolk sac and liver in early fetal life, major source is yolk sac
zz Peak level in fetus or amniotic fluid around 13 weeks
zz Peak level in mother 32 weeks

Fetal DHEA

zz Produced from fetal adrenal gland and transfered to placenta

zz Activated by aromatase converted to oestrogen and estriol
zz Predicts about fetal well being

Umbilical Cord

/e
zz Contains → 2 arteries and 1 vein

,1
zz Wharton's Jelly is the connective tissue of umbilical cord[2018]
zz Normal length → 50 cm

es
zz short cord < 30 cm → associated with malpresentations and Abruptions
zz Long cord > 100 cm → associated with cord entanglement cord prolapse
ot
zz Single umbilical artery
 <1% incidence in singleton pregnancy
N
 3% incidence in twin pregnancy
 It is seen in:
EE

ff trisomy 18 most common

ff down syndrome
ff congenital malformation like CVS renal problems
M

ff increased risk of chromosomal abnormality

Obstetrics

Folds of Hoboken - intimal folds protruding into lumen of umbilical artery

PG

zz

zz Diameter of umbilical cord is 1 to 2 cm

zz Battledore placenta → umbilical cord inserted to margins of placenta, complications → retained
Placenta postpartum hemorrhage
y

zz Velamentous insertion of cord → umbilical cord inserted two membranes, complication → vasa
M

previa-fetal blood loss occurs

zz Loop of cord around neck seen in 25% of foetus
zz Hemangioma is most common tumor of umbilical cord

Fetal Haematopoiesis

zz Up to 8 weeks → yolk sac HB form Grover 1 Grover 2 Portland

zz After 8 weeks → mainly liver HBF
zz After 11 weeks [around 3 months] → bone marrow, lifelong HB A appears in fetal RBC
zz 30 to 32 weeks of gestation → switch from HBF to HbA begins, at birth 75 to 80% HBF while
25% HbA
528 zz Lifespan of RBC fetal type → 80 Days, Rh factor appears on fetal RBC as early as 38 days post
conception

notes
 My PG
MEE
Notes

Fetal Circulation

zz Fetal Hearts start beating from 21st day fetal heart rate 120 to 160 beats per minute
zz TVS can detect fetal → rate by 5 weeks, TAS and detect around 6 weeks
zz G sac appears on TVS around 4 and half weeks and t a s around 5 and half weeks
zz At birth first closer Umblical vessels → foramen ovale → ductus arteriosus → ductus venosus
zz closure of foramen ovale ductus arteriosus closes
zz ductus venosus obliterates and becomes ligamentum venosum
zz Umbilical vein obliterates and becomes ligamentum teres
zz Umbilical artery obliterates and become hypogastric artery obliterated

Fetal Respiratory System

zz Surfactant synthesis starts around 20 weeks, detected in amniotic fluid around 28 weeks

/e
zz Full fetal lung maturity:
Test used most common is lecithin - sphingomyelin Ratio

,1

 Best test for fetal lung maturity is phosphatidyl glycerol test

Amniotic Fluid

zz Source:
es
ot
 upto 12 weeks[1st trimester] → ultrafiltrate of maternal plasma
12 to 16 weeks → transudate of fetal skin
N


 After 20 weeks → formed by fetal urine

pH 7 to 7.5
EE

zz

zz osmolarity 260 milliosmole/litre

zz Turnover rate → replaced in every 3 hours
M

zz Increase concentration of uric acid urea creatinine and electrolytes are low sodium and chloride

Obstetrics
compared to maternal plasma
PG

zz Volume: COLOUR OF AMNIOTIC FLUID:

 16 weeks → 200 ml, • Colourless pale straw colour → Normal
• Green → meconium stained liquor(due to bile
 20 weeks → 400 ml
y

pigments like bililiverdin)

 32 weeks [highest] → 1-1.2 litres
M

• Golden colourà RH incompatibility

 At term → 800 ml
• Saffron or greenish yellow → post maturity
 Post term 42 weeksà 200 ml
• Blood stained or dark coloured → abruption
zz Amniotic fluid index • Dark brown tobacco juice → IUD
 Normal 8 to 24 • Purulent → chorioamnionitis
 Polyhydramnios more than 25 and
oligohydramnios less than 5
 Deepest vertical pocket normal 2-8 oligohydramnios less than 2 polyhydramnios > 8

529

notes
 MEE
My PG
Notes

PHYSIOLOGICAL CHANGES IN PREGNANCY

zz Weight of uterus: nonpregnant → 70 grams, weight of uterus at term → 1000 gram
zz Length of uterus: Nulligravid → 6-8 cm and multiparous → 9-10 cm
zz Volume of uterus 10 ml in non pregnant and In pregnant 5 litres
zz On vaginal cytology navicular cells seen also known as pregnancy cells or intermediate cells
zz Weight gain during pregnancy around 11 to 12 Kg-[1st trimester → 1 kg, 2nd trimester 5 kg
and 3rd trimester 5 kg]
zz water retention around 6.5 litres

Signs

TIME SIGN EXPLAINATION

/e
Hartman sign implantation bleeding

,1
Braxton Hicks contractions painless irregular spasmodic contraction without any effect
on dilation of cervix
can also be felt in pedunculated fibroid Submucous type

es
and hematometra
4-8 weeks Palmers sign regular rhythmic contraction during bimanual examination
ot
6 weeks 6oodell's sign [G looks like 6] softening of lower part of cervix
6-10 weeks Hegar's sign and by manual examination abdominal and vaginal fingers
N
opposes each other
6-8 weeks Piskacek sign asymmetric enlargement of uterus
EE

8 weeks Osiander sign [Octa-8] increased pulsation felt through lateral fornix of vagina
8 weeks Chadwick sign/Jacquemier's bluish coloration of vestibule
sign
M
Obstetrics

PG

HEMATOLOGICAL CHANGES METABOLIC CHANGES

• RBC increases by 30%, Blood volume • BMR increases by 30%
increases by 40% & Plasma volume increases • positive nitrogen balance
by 50% [RBP-30, 40, 50] • total Iron requirement in pregnancy →
y

• Physiological hemodilution occurs Approx. 1000 mg

M

• Cardiac output ↑ by 40% & oxygen demand ↑ • Iron requirement in second half of pregnancy
by 20% is 6-7 mg/day
• coagulation factors : • Calcium requirement in pregnancy thousand
ƒƒ ↓ in factor 11 & 13 and platelet counts milligram per day
ƒƒ ↑ in fibrinogen, factor 2,7,8, 9,10 and • In pregnancy calorie requirement increases by
plasminogen 300 kilo calorie for day
• Plasma protein ↓ by 10% • Folic acid requirement : non pregnant female
• Albumin ↓ by 30% 200 μgm & pregnant female 400 μgm
• Total protein ↑ by 20-30%
• BT, CT remains unchanged

530

notes

RESPIRATORY SYSTEM
• Breathing becomes diaphragmatic
• state of hyperventilation respiratory alkalosis(
progesterone acts on respiratory centre and
increases its sensitivity to hypercarcapnia)
• decreased FRC, TLC, ERV, RV & total
pulmonary resistance
• Unchanged VC, IC, IRV, RR & respiratory
rate
• Increased MV, TV by 40%, minute oxygen
uptake, depth of respiration
CARDIOVASCULAR SYSTEM
• Apex beat heard in 4th intercostal space
• systolic Murmur can be heard up to Grade 2
• heart sounds loud , splitting of S1 seen
physiological S3 heard
• left Axis deviation
• pulse rate ↑ by 10 to 15 beats per minute
• On ECG :no hypertrophy or dilatation of
heart
• Straightening of left heart border
• Heart rate↑ by 20%
• fall in blood pressure
N
• systemic vascular resistance ↓ can lead to
supine hypotension syndrome
EE
• venous pressure increases in lower limb.
Oestrogen is vasodilator
• Uterine blood flow increases to 750 ml/
M
minute at Term from 50 ml/minute in non
pregnant uterus
PG
• cardiac output maximum in Postpartum
period followed by labour followed by 28 to
32 weeks
y
M
* in Pregnancy Best parameter to ascess Thyroid function is TSH > T4 [2018]
My PG
MEE
Notes
RENAL SYSTEM
• Increased in renal size by 1 cm
• GFR by 50% renal blood flow by 80 %
creating clearance renal glycosuria
• Decrease in serum creatinine b u n plasma
osmolality serum Sodium Potassium Chloride
• Uric acid remains unchanged
• Hydroureteronephrosis more commonly seen
in right side of ureter
GIT
• Epulis of pregnancy → vascular swelling of
gums
• Liver → Alkaline phosphatase increased
/e
almost double, SGOT & SGPT decreases
• Gallbladder → increase chance of stone
,1
formation due to progesterone and increase
risk of cholestasis due to estrogen pruritis due
es
to increased bile salt
MISCELLANEOUS POINTS
ot
• Krunkenberg spindle seen on posterior surface
of cornea during pregnancy
• Anterior pituitary gland size increases→
growth hormone level increases
• Thyroid gland size increases but patient
remain euthyroid total T3 T4 increases TSH
unchanged
• Trisomy 21 [Down syndrome]
• Causes:
Obstetrics
ƒƒ most common[95%] is nondisjunction, it is
non inheritable risk is around 1%
ƒƒ Second balanced robertsonian translocation
(4%)
ƒƒ Third mosaicism (1%)
• Reference location is between 22/22 and
21/22 risk is 100%
531
notes
 MEE
My PG
Notes

Screening of Down's syndrome

Universal screening should be offered for pregnant women

First trimester screening Second trimester screening

• On USG: Nuchal translucency seen 11-13 + 6 • Triple test:

weeks period of gestation ƒƒ ß- HCG +α- fetoprotein +estriol

• Dual test → serum markers [PAPP-A + free beta ƒƒ Sensitivity 63%

HCG] ƒƒ Performed at 16 to 18 weeks

• Combined test: • Quadruple test:

ƒƒ USG [Nuchal translucency] + serum markers ƒƒ Triple test +Inhibin-A

[PAPP-A + free beta HCG] ƒƒ Detection rate 70%

ƒƒ Detection rate 85% ƒƒ Ideally done at 15 to 18 weeks[2018]

• Confirmatory test is karyotyping

• Fetal tissue sampling or invasive test

/e
zz Integrated Test :
 1st Trimester- PAPPA-A + Nuchal Translucency

,1
 2nd trimester- MSAFP + UE3 + HCG + Inhibin-A (Detection rate-94%)
*NIPT- non invasive prenatal testing– Method of detecting fetal chromosomal anomalies; Maternal

es
serum can be used[2018]

Chronic villus sampling Amniocentesis Cordocentesis

ot
N
EE
M
Obstetrics

PG

• To be done after 10 weeks.

• Should be routinely done around • Should be done after 18 to 20
• Material taken-Trophoblast cells
y

14-16 wks wks

• Risk of fetal loss 1 to 2%
M

• can be done as early as 12-14 • Material taken - fetal blood

• Disadvantage: Limb reduction
wks • Risk of fetal loss - 2- 4%
defect If performed < 10 week
• Material taken - fetal fibroblast • Best accuracy
and mosaicism (genetic disorder)
and fluid • Disadvantage:
• risk of fetal loss- 0.5 to 1% ƒƒ fetal or cord Hematoma

• highly accurate ƒƒ injury to fetal parts

• disadvantage: • Indication fetal anaemia fetal

ƒƒ PROM, infection fetal blood transfusion
ƒƒ preterm labour,

ƒƒ fetal loss,

ƒƒ RH isoimmunisation,

ƒƒ hypoplasia

• indication: Cytogenetic analysis

532
of chromosomal abnormality &
single gene disorders
notes
 My PG
MEE
Notes

USG FINDINGS
Blighted ovum Ectopic pregnancy

Live embryo outside uterus

Embryonic development arrested in fertilised ovum Free fluid in pouch of douglas
No fetal parts or yolksac in a sac >20mm Increased endometrial thickness
Adnexal mass seen
“Ring of fire appearance”
Double bleb sign Double decidual sign

/e
,1
es
ot
N
Intrauterine pregnancy
Presents in early intrauterine pregnancy
EE

Distinguishes it from pseudogestational

Empty amnion sign Tubal ring sign[bagel’s ring]
M

Obstetrics
PG
y
M

Tubal ectopic pregnancy

Pregnancy failure
Twin peak sign/lambda sign
zz Interstitial line sign :Interstitial ectopic
pregnancy
zz Ovulation :Collapse of follicle, Fluid in pouch of
douglas, Echo free zone around endometrium
zz T-sign- Monochorionic pregnancy

533
Dichorionic-diamniotic twins

notes
 MEE
My PG
Notes

Maternal Pelvis
zz Normal female pelvis: Gynaecoid pelvis
zz Least common type of pelvis: Platypelloid pelvis
zz The only pelvis with AP diameter more than
transverse diameter: AnthroPoid pelvis
zz Face to pubis delivery most common in
Anthropoid pelvis
zz Direct and Persistent occipito posterior is most
common in Anthropoid pelvis
zz Deep transverse arrest/Non rotation is most
common in Android pelvis
zz Super sub parietal diameter instead of

/e
Biparietal diameter engages in Platypelloid
pelvis

,1
zz Naegele’s pelvis: oNe ala of sacrum absent
zz rObert’s pelvis: bOth ala of sacrum absent

es
zz Rachitic pelvis → Rickets
zz triraDiate pelvis → vitamin D deficiency
ot
zz longest diameter of pelvis:transverse diameter of inlet and AP diameter of outlet (13 cm)
N
zz shortest diameter of pelvis: Interspinous diameter
zz Shortest AP diameter of Inlet:Obstetric conjugate SOLD
EE

zz Longest AP diameter of inlet: Diagonal conjugate

zz value of Obstetric conjugate: 10 cm
Value of Diagonal conjugate: 12 cm
M

zz

zz Value of true/anatomical conjugate: 11 cm

Obstetrics

PG

zz Super sub parietal diameter instead of Biparietal Diameter engages in Platypelloid pelvis

Fetal Head
y
M

zz Smallest diameter of fetal head is Bitemporal diameter (8 cm)

zz The longest diameter of fetal skull is Mentovertical diameter (14.5 cm)
zz Second longest diameter is Submentovertical = Occipitofrontal = 11.5 cm
zz Commonest type of presentation is vertex

Diameters Attitude of head Presentation Length

Suboccipito-bregmatic [SOB] Complete flexion vertex 9.5 CM

Suboccipito-frontal [SOF] Incomplete flexion Vertex 10.5 CM
Occipito-frontal [OF] Marked deflexion Vertex 11.5 CM
Mento-vertical [MV] Partial extension Brow 14 CM
Submento vertical [SMV] Incomplete extension Face 11.5 CM
534 Submento bregmatic [SMB] Complete extension Face 9.5 CM

notes
 My PG
MEE
Notes

zz Brow presentation and persistent Mento-posterior are not suitable for vaginal delivery, hence
caesarean section is mandatory

/e
,1
es
ot
LIE
N

The lie refers to the relationship of the long axis of the fetus to the long axis of the centralized
EE

zz

uterus or maternal spine, the most common lie being longitudinal (99.5%)
zz Types:
M

LONGITUDINAL LIE OBLIQUE LIE TRANSVERSE LIE

Obstetrics
PG
y
M

Transverse LIE

zz Shoulder presentation
zz Causes:
 Preterm baby [MCC].
 Placenta previa [MCC in term pregnancy]
 platypelloid pelvis
 multiparous women
zz On examination ribcage felt → called as grid iron free 535
zz Management → Elective cesarean section
notes
 MEE
My PG
Notes

Presentation
zz The part of the fetus which occupies the lower pole of the uterus (pelvic brim).
zz May be cephalic (96.5%), podalic (3%) or shoulder and other (0.5%).

Cephalic presentation
Vertex presentation Face presentation
(1 in 500 deliveries)
• Causes:
 anencephaly MCC
 Platypelloid pelvis
 Multiparous women
 preterm baby
• Complete extension of
Brow presentation
(1 in 1000deliveries)
• Causes:
 fetal anomaly
 fetal neck tumor
 placenta previa
• Partial extension of fetal head
• Military position

/e
fetal head • Engaging diameter →mento
• Presentation: left vertical (14 cm)

,1
mentoanterior • Management
• Engaging diameter:  posterior brow →

es
submentobragmatic (9.5 cesarean section
cm)  Anterior brow → face
• X-Ray → Flying foetus to pubis delivery
ot
appearance
• MC presentation
N
• Mentor anterior →
• left occipito transverse: vaginal trial
ƒƒ Most common at the time of labour • Mento posterior → LSCS
EE

ƒƒ More common in nulliparous

M

Breech Presentation
Obstetrics

PG

zz Most common malpresentation,Incidence 3% at term

zz Types
zz Causes:
y

 prematurity (MCC)
M

 oligohydramnios,
 short cord,
 congenital anomaly,
 placenta previa,
 multiparity

zz Recurrent Breech/habitual breech- recurrence in > 3 consecutive pregnancies

zz engaging diameter- Bitrochanteric (10 cm)
536 zz head born by Flexion

notes
 My PG
MEE
Notes

zz Vaginal Breech delivery→ Types:

 Spontaneous Breech Vagnial delivery →seen in very preterm deliveries (rare)
 Assisted Vaginal Breech Delivery
For Delivery of after coming head Complicated breech:
• Burn Marshall method • For delivery of extended arm → lovset/classical
• Modified mauriceau smellie veit method manual
• Prague manual fetal spine is posterior • For delivery of leg → pinard manual
• Pipers forceps
zz Duhrssen incision → for incompletely dilated cervix → incision on cervix at 2 and 10 o’clock
position
zz Stargazer fetus - fetal head is hyperextended.seen in 5% term breech
zz Zatuchni Andros scoring: for vaginal trial in breech: >4 vaginal trial and .<4 LSCS
zz External cephalic version can be attempted upto 37 weeks with use of Tocolysis.
Indication of elective cesarean section in breech:

/e
zz
 Elderly primi

,1
 Stargazer baby
 Placenta previa
Footling breech

es


 Cord prolapse
Preterm breach.


 Prev CS
ot
N
Presenting part:
EE

The presenting part is defined as the part of the presentation which overlies the internal os and is
felt by the examining finger through the cervical opening
M

Denominator

Obstetrics
PG

Bony part felt on PV examination

Malpositions
y
M

Occipito posterior
zz Causes:
 Most commonly seen in Android pelvis
 Deflexed head
 Placenta previa
 Multiparity
zz In labor :
 90% occipitoposterior rotates to occipito anterior
 Rest 10%:
ff Incomplete rotation → leads to Deep transverse arrest, mostly Seen with Android pelvis
→ needs manual rotation/ Keilland's forceps /cesarean section
ff Non rotation: leads to persistent occipito posterior, management → face to pubis vaginal
537
delivery/ cesarean section.

notes
 MEE
My PG
Notes

Miscellaneous
zz Ferguson’s reflex→ vaginal examination and amniotomy increases Oxytocin level in maternal
plasma
zz Constriction ring contraction ring shoulder sling localised Tony contraction it is physiological
because of incoordinated uterine contraction
zz Located at junction of upper segment and lower segment. Mother exertion and fetal anoxia late.
zz Pervaginal examination ring is felt between head and neck. Caput not seen
zz Treatment cesarean section

Pelvic Assessment
zz In nulliparous women done at 37 weeks in multigravida at onset of labour

/e
zz Best for pelvic assessment is MRI followed by manual assessment

,1
Contracted pelvis:

es
zz Suspected in:
Women with height < 140 cm

ot
 Abnormal spinal curvature
N
 Rickets (triradiate pelvis)
 Naegele's pelvis, Robert's pelvis
EE

zz Diagnosis of CPD by:

 Abdominal method
Abdominovaginal method(Muller Munro kerr method)
M



zz Pelvimetry findings of CPD:

Obstetrics

PG

 narrow subpubic arch

 Biischial diameter <8 cm
 Diagonal conjugate <11.5 cm
y

 Prominent ischial spine

M

zz Degree of disproportion at brim and management:

 Severe disproportion → Obstetric conjugate <7.5 → CS
 Moderate disproportion → Obstetric conjugate 7.6-9.5 → Trial of labor
 Mild disproportion → Obstetric conjugate 9.6-10 cm → Vaginal delivery
zz Best predictor of CPD is trial of labour
zz Moulding
 Grade 1 → the two parietal bone touches each other
 Grade 2 → overlapping of parietal bone but can be separated
 Grade 3 → overlapped bones and cannot be separated

538

notes
 My PG
MEE
Notes

LABOUR
zz Engagement: When biparietal diameter crosses the inlet it rules out CPD [at the level of inlet]
zz Steps of labour: engagement → decent → flexion → internal rotation [at the level of ischial spine]
→ extension → restitution → external rotation
Stages of labour
1st stage of labour: from onset of contraction to
complete dilatation of cervix
• Latent phase < 6 cm

Normal Prolonged
nulliparous 12 hours 20 hour
multiparous 8 hours 14 hours
• Active phase of first stage:

/e
Rate of Rate of Descent of
dilation head

,1
nulliparous 1.2 cm / hour 1 cm/hour
multiparous 1.5 cm / hour 2 cm/hour

es
• Epidural analgesia prolongs active phase by
1 hour
ot
• Arrest of dilatation → 2 hours with no change in
cervix
N
• Arrest of descent → 1 hour with no fetal decent
EE
M

Second stage of labour: complete dilatation of cervix

Obstetrics
PG

to expulsion of foetus

Normal Prolong ARREST

duration 2nd without with
stage
y

epidural epidural
analgesia analgesia
M

Nulli 1 hour 2 hour 3 hour 4 hour

Multi ½ hour 1 hour 2 hour 3 hour

3rd stage from expulsion of foetus to delivery of

placenta
• Duration 15 minutes up to 30 minutes
• In active management takes 5 minutes

539
4th stage – observation Duration 1 hour, risk of PPH
notes
 MEE
My PG
Notes

zz UTERINE CONTRACTION:
 Pacemaker located in cornu of uterus [right side >left side]
 10 mm Hg → uterine contraction can be palpated
 15mm Hg → pressure becomes painful and also pressure required for dilation of cervix
 40 mm Hg → the uterine wall can’t readily be depressed by the finger. i.e fundus cannot be
indented
 Adequate uterine contractions : 3 contractions in 10 minutes and each lasting for 45 seconds
or contraction generating a pressure of >200 Montevideo units
 Tachysystole → > 6 contraction in 10 minutes
 Hypertonic contraction → single contraction lasting full more than 2 minutes
zz ABNORMAL UTERINE CONTRACTIONS:
BANDL'S RING/RETRACTION RING OF BANDL’S SCHROEDER'S RING/ CONTRACTION RING
AND BARBOUR
• seen in obstructed labor • occurs due to abnormal uterine contraction

/e
• Result of tonic uterine contraction and retraction • Location: usually At junction of upper segment
• Location: Always At junction of upper segment and lower segment, but can occur in any part of

,1
and lower segment and progressive upwards uterus.
• early maternal exhaustion and fetal death • late maternal exhaustion and fetal death
• PA examination →uterus tense & tender, Ring felt • PA examination →uterus normal, FHS (+), Ring

es
as oblique groove not felt
• PV examination →LUS thinned out • PV examination →Ring felt
• Uterine rupture can occur
ot
• uterine rupture does not occur
• caput present • caput absent
N
• Treatment- cesarean section • Treatment- cesarean section

EE

Degrees of Perineal Tears

M
Obstetrics

PG
y
M

zz 3rd and 4th degree

 Should be repaired within 24 hours else will lead to Fecal incontinence
 Sequence of repair- Rectal mucosa → IAS → EAS → Episiotomy repair

540

notes
 My PG
MEE
Notes

Instrumental Delivery

Forceps Ventouse
zz Prerequisites: zz 0.8 kg/m2 vacuum is used
 F-Force(contractions) should be present zz Prerequisites:Engaged head
 O-OS fully dilated zz Indications:
 R-Ruptured membrane  DTA with adequate pelvis
 C-Contracted pelvis should not be there  Alternative to forceps except in
 E- Engaged head cases where forceps is best
 P-Presentation- Vertex zz Contraindications:
 Surrounding must be empty-bladder and bowel  non vertex presentation
zz Indications:  Fetal distress
 Prolonged 2nd stage of labor  prematurity
Conditions threatning the well being of mother

/e

 Fetal coagulation disorder ( as
Like Preclampsia, eclampsia, heart disease cephalhematoma is a complication)
Fetal indications like cord prolapse or distress

,1

 fetal macrosomia is suspected
 Forceps is best for :
ff Fetal distress

es
ff Prematurity
ff Aftercoming head of breech ot
ff Face presentation
N
EE
M

Obstetrics
PG
y
M

Cesarean Section
zz Types:
 Lower section Cesarean section (LSCS): Most commonly performed
 Classical CS(Sanger operation)
 Extraperitoneal- for chorioamnionitis (obsolete)  Cervical or Broad ligament fibroid
zz Absolute indications: done even if fetus is dead  Advanced Cervical carcinoma
 Severe contracted pelvis  Repair for VVF or stress 541
 Major degree of Placenta previa (IIb, III and IV) incontinence
 Vaginal atresia
notes
 MEE
My PG
Notes

zz Indications for Classical C.S.

 Cesarean Hysterectomy  Cervical carcinoma
 Repair of difficult or high VVF  Postmortem CS → to save time done within 4-5
hours of maternal cardiac arrest
 Deformed Kyphoscoliotic pelvis  LUS Leiomyoma

PPH
zz “any amount of bleeding from or into the genital tract following birth of the baby up to the end
of the puerperium, which adversely affects the general condition of the patient evidenced by rise
in pulse rate and falling blood pressure is called postpartum hemorrhage”.
OR
Blood loss >500 ml in vaginal delivery and >1000 ml in ceasrean delivery
zz Types:[2018]

/e
Primary Third stage haemorrhage Bleeding before placental expulsion
(Within 24 hr) True PPH [MC] Bleeding AFTER placental expulsion

,1
Secondary Endometriosis retained tissue polyp Hemorrhage beyond 24 hours and within puerperium

Causes: Atonic (80%), Traumatic, Retained tissues and Blood coagulopathy

es
zz

ot
N
EE
M
Obstetrics

PG
y
M

542

notes