Obs Card 19

Question 3
A patient came to you at her 3rd day of puerperium with fever
and pain in breast. What is your probable diagnosis? Outline
the management.
Probable diagnosis: Breast engorgement.
Outline of management:
Onset: It usually manifests after the milk secretion starts (third or
fourth day postpartum).
Symptoms include—
(a) Considerable pain and feeling of tenseness or heaviness in both
the breasts,
(b) Generalized malaise or even transient rise of temperature and
(c) Painful breastfeeding.
Prevention includes—
(i) To avoid prelacteal feeds,
(ii) To initiate breastfeeding early and unrestricted,
(iii) Exclusive breastfeeding on demand,
(iv) Feeding in correct position,
(v) Correct latch on.
Treatment:
(1) To support the breasts with a binder or brassiere,
(2) Frequent suckling,
(3) Manual expression of any remaining milk after each feed,
(4) To administer analgesics for pain,
(5) The baby should be put to the breast regularly at frequent
intervals,
(6) In a severe case, gentle use of a breast pump may be helpful.
This will reduce the tension in the breast without causing excess
milk production.
OBSTETRIC card no:19

Question no:01
what is liquor amnii?what are the functions of liquor amnii?
Liquor amnii:It is the faintly alkaline, clear watery fluid with low
specific gravity of about 1.010 of amniotic cavity.
FUNCTION:Its main function is to protect the fetus.

-During pregnancy:
 1. It acts as a shock absorber, protecting the fetus from
possible extraneous injury.
2. It Maintains an even temperature.
3. The fluid distends the amniotic sac and thereby allows for
growth and free movement of the fetus and prevents adhesion
between the fetal parts and amniotic sac.
4. Its nutritive value is negligible because of small amount of
protein and salt content, however, water supply to the fetus is quite
adequate.
-During labour:
1.The amnion and chorion are combined to form a hydrostatic
wedge which helps in dilatation of the cervix.
2. During uterine contraction, it prevents marked interference
with the placental circulation so long as the membranes remain
intact.
3. It flushes the birth canal at the end of first stage of labour
and by its aseptic and bactericidal action protects the fetus and
prevents ascending infection to the uterine cavity.
4.It guards against umbilical cord compression.

Subject- Obstetrics Card No- 02

Question no- 02
What are the criteria of normal delivery? How will you manage
the first stage of labour?

Answer:
Criteria of normal delivery:
1. Spontaneous in onset & at term
2. Without any undue prolongation
3. With vertex presentation
4. Natural termination with minimal aids
5. Without having any complications affecting the health of the
mother and/or the baby

Management of first stage of labour:

Clinical features:
Symptoms :
True labour pain
Show
Sudden gush of liquor amnii (late part)

Signs :
1) Per abdominal examination :
▪ Evidence of true labour pain
▪ Intermittent uterine contraction
▪ FHR: 120-140 beats/min which increases by 10 beats during
contraception

2) Per-vaginal examination :
▪ Gradual dilatation of cervix from 2 to 10 cm
▪ Gradual effacement of the cervix
▪ Rupture of the membrane at the last part of first stage
▪ Bulging of the membrane during contraction( if membrane
is not ruptured)

Monitoring : By modified WHO partograph

Treatment of the first stage of labour:

1) Reassurance and encouragement

2) Constant supervision is must
3) Strict maintenance of asepsis/hygiene throughout the delivery
process
4) Company & privacy
5) Position : Lithotomy/ left lateral/ any position the woman prefers
6) Diet : Liquid
7) Rest & ambulation : If the membrane is ruptured, patient should
be in bed and otherwise she's allowed to walk
Place of delivery : On the basis if patient choice,comfort,availability
of health care facilities. High risk pregnancy- hospital
9) Bladder care : Patient is encouraged to pass urine by herself &
routine use of catheter is a harmful practice
10) Bowel care : An enema with soap & water or glycerin
suppository
11) Relief of pain : In a normal,uncomplicated labour analgesics are
not used routinely & are not a part of essential care for normal
childbirth.
12) Special care during labour:
a) Progress of labour: By partograph and it is
 achieved by-
-Per abdominal examination :
✔ Number of uterine contraction in 10
minutes & duration of each contraction
✔ Fetal heart rate( Normal 110-150/min)

-Per vaginal examination :

✔ Cervical dilatation
✔ Descent of the head
✔ Formation of caput
✔ Degree of molding
✔ Station of the head in realtion to ischial
spine

-Assessment of maternal well being : Pulse, BP,temperature,

respiration, state of hydration ( in tongue), urine output
13) Should exclude cephalo-pelvic disproportion
14) Augmentation should only be done if there is slow progress
Obstetrics Card 19
Question 5
What is caput succedaneum?
Mention the difference between caput succedaneum &
cephalohaematoma.

Answer:
Caput succedaneum :
It is the formation of swelling due to stagnation of fluid in the layers
of the scalp beneath the girdle of contact.
Difference between Caput succedaneum & Cephalohaematoma :
Traits Caput Cephalohaematoma
succedaneum
Definition It is the formation of It is the collection of
swelling due to blood in between
stagnation of fluid pericranium and the
in the layers of the flat bone of the
scalp beneath the skull.
girlde of contact.
Pathogenesis Stagnation of fluidRupture of emissary
in the layers of the
veins in between the
skull. pericranium and the
flat bone of the
skull.
At birth Usually present at Never present at
birth. birth
Disappearance Within 24hours Within 4-8weeks
Boundary Not limited by Limited by suture
suture line (diffuse) lines, so it is
localized
Tenderness Non-tender Tense and tender
Significance Signifies static Associated with
position of the head fracture of the skull.
for a long period of May be caused by
time. forceps delivery.
Hyperbilirubinaemia No It can cause
Hyperbilirubinaemia Hyperbilirubinaemia
when extensive and
may need blood
transfusion.

Obstetrics q:4 card 19

Antepartum death occurring beyond 28 weeks of pregnancy is
termed as intrauterine fetal death.
Causes of IUFD
A. Idiopathic 25 to 35%
B. Maternal causes 5 to 10%
1) hypertensive disorder: preeclampsia, eclampsia, chronic
hypertension
2) medical disorders: GDM severe anaemia, SLE
3) hyperpyrexia
4) abnormal labour: prolonged labour obstructed labour,ruptured
uterus.
5) post dated pregnancy
6) maternal infections
7) antiphospholipid syndrome
C) fetal causes 25 to 40%
1.Fetal chromosomal abnormalities and malformation.
2. Fetal infections: rubella,CMV, parvovirus b19
3. R h incompatibility
4. Non immune hydrops
5. Placental insufficiency
D) placental 20-35 %
1. APH
2. Placental insufficiency
3. Cord accidents
4. Twin twin transfusion syndrome
E.iatrogenic:
External version
Post term pregnancy placental infection
Investigation to confirm IUFD:
1 ultrasonography: confirmatory (reveals no fetal movement no fetal
heart rate and collapsed cranial bones)
2. Straight x ray abdomen:
spalding sign: irregular overlapping of cranial bones
Hyperflexion of the spine
Crowding of the ribs shadow
Appearance of gas shadow(Robert's sign) in the Chambers of the
heart and great vessels.
3) estimation of fibrinogen level and partial thromboplastin time in
the foetus which is written for more than 2 weeks
4) hematological examination (to find out causes)
CBC
ABO blood grouping and RH typing
VDRL
RBS
Hba1c

Obs Card 20
✳Question 1(a) :What are the stages of labour with duration?

Ans::

1)First stage:starts from onset of true labor pain and ends with full
dilatation of cervix.

Duration:Primi-12hrs

Multi-6hrs
2)Second stage:starts from full dilatation of cervix and ends with
expulsionof fetus from birth cannal.

2 phase:Propulsive and Expulsive.

Duration:Primi- 2hrs

Multi- 30 min

3)Third stage:begins after expulsion of fetus and ends with

expulsion of placenta and membranes.

Duration- 15 min both primi and multiparae.

By active mx- 5 min duration.

4)Fourth stage:

Observation for at least 1 hr after expulsion of the afterbirths.

✳Question 1(b):What are the components of active management of

3rd stage of labour?

Ans::

(Principle)::The underlying principle in active management is to

excite powerful uterine contraction within 1 minute of delivary of
the baby by giving parenteral oxytocic.

(Procedure)::

Injection oxytocin 10 units IM or injection methergine .2mg IM to

the mother within 1 min of delivary of the baby---) Clamp,divide and
ligate the cord---) To deliver the placenta by controlled cord traction
soon after the delivary of the baby availing first uterine contraction-
--)if fails---)Repeat after 2-3 minutes---)if fails---)Wait for 10
minutes and repeat the precedure---)if fails ---) Manual removal
Oxytocic maybe given with crowning of head,delivary of anterior
shoulder or after the delivary of the placenta.If the administration
is mistimed as might happen in a busy labour room ,one should not
be panicky but conduct the 3rd stage with conventional watchful
expectancy.

(Advantage):

1)To minimize blood loss in 3rd stage approximately to one fifth

2)to shorten the durationof 3rd stage to half.

(Disadvantage):

1)slight increased incidence of retained placenta and consequent

increased incidence of manual removal.

2)In case of accidental administration in undiagnosed twin

pregnancy ---)asphyxia of 2nd baby tetanic contraction of uterus.

✳Question 2:: A primi lady came at her 34 wks of

pregnancy with the complaints of blurring of vision,headache and
epigastric pain.

On examination-BP 160/110mmHg.

✳Question 2(a) dx?

2(b) how will u manage the case??

Ans 2(a)::My diagnosis: Pre- eclamsia.

Ans 2(b)::

Management of Pre-eclamsia::

A)Hospitalization

1)Rest
2)BP check(4 times/day)

3)Inv: CBC,platelet count,coagulation profile,if platelet count

<100,000/ml then -uric acid,creatinine,LFT,24hrs urine for protein

4)Opthalmoscopy

5)Fetal well being assessment- Daily fetal movement

count,NST,CTG,biophysical profile,USG dopplar.

B)Antihypertensive::if DBP>110mmHg(Labetalol Iv,hydralazine Iv or

nifedipine Po)

❇ If complete control

1)preterm(discharge,to attend antenatal clinic)

2)Term (to stay in hospital-preg >37 wks delivary by induction or

c/s)

3)Postpartum monitoring

❇If BP persistantly high-(try to continue the pregnancy till 37

completed wk/ at least 34 wks then delivary)

❇If persistantly increasing BP to severe level despite the use of

antihypertensive And addition of ominous symptom like (visual
disturbance,restlessness,SaO2
<95%,tachycardia >100bpm,tachypnea >26/min)

then 1)couple councelling

2)transfer to a tertiary care center

3)prophylactic antihypertensive therapy

4)Delivary irrespective of duration of gestation

5)steroid therapy if preg <34 wk..

Delivary by induction(PGE2,ARM,Oxytocin) or by c/s.

❇Postpartum monitoring....

✔Answer to the question no :03

🔸def:

GDM is defined as carbohydrate intolerance of variable severity with

onset or first

recognition during the present pregnancy.

🔸Dx of a case of GDM:

(a)the fasting plasma glucose exceeds 126 mg/dl,

(b)the 2 hours

post glucose (75 gm) value exceeds 200 mg/dl and

(c)HbA1C ≥ 6.5%

🔸Complications of diabetes:

Maternal-

▪During pregnancy:

Abortion:

Preterm labor

Infection: Urinary tract infection and vulvovaginitis.

 Increased incidence of preeclampsia

Polyhydramnios,large baby, large placenta, fetal hyperglycemia.

Maternal distress

Diabetic retinopathy

Diabetic nephropathy

Coronary artery disease

Ketoacidosis

▪During labor:

There is increased

incidence of:

(1) Prolongation of labor due to big baby.

(2)shoulder dystocia

(3) Perineal

injuries.

(4) Postpartum hemorrhage.

(5) Operative interference.

▪Puerperium:

(1) Puerperal sepsis.

(2) lactation failure.

Effect on fetus-
1.fetal macrosomia

2.congenital anomalies

3.birth injuries

4.unexplained fetal death

Neonatal complications -

1.Hypoglycaemia

2.RDS

3.Polycythaemia

4.hypocalcaemia

5.cardiomyopayhy

✔Answer to the question no:04

🔸Congenital anomalies of newborn :

1.clefts lip

2.cleft palate

3.club foot

4congenital anomalies of skull :hydrocephalus,macro or microsomia

5.tetralogy of Fallot

6.Atrial septal defect

7.ventricular septal defect

8.imperforated anus
9.hypospadias

10.congenital diaphragmatic herniae

✔Answer to the question no :05

🔸def-clinical purposes, a pregnancy continuing beyond 2 weeks of

the expected date of delivery (> 294 days) is called postmaturity or
post-term pregnancy.

🔸assessment of fetal well being-

▪clinical assessment for 1st visit -

1.history taking

2.General examination

3.systemic examination

-a)search for maternal systemic ds

-b)per abdominal examination

-c)per vaginal examination

▪clinical assessment for the subsequent visit -

1.history

2.maternal weight gain

3.blood pressure

4.assessment the size of uterus and height of fundus

5.clinical assessment for excess liquor

6.document of grith of abdomen in late trimester

7.leg oedema

▪Biochemical assessment -

aminocentesis

▪Biophysical -

1.fetal movement count (FMC)

2.fetal heart rate (FHR)

3.non stress test (NST)

4.cardiotocography (CTG)

5.vibro acoustic stimulation test

6.contraction stress test (CST)

7.biophysical profile (BPP)

8.USG of pregnancy profile

9.Doppler USG

10.amniotic fluid index (AFI)

🔸features of post mature baby-

(1) General appearance: Baby looks thin and old. Skin is wrinkled.
There is absence of vernix caseosa. Body and the cord are stained
with greenish yellow color. Head is hard without much evidence of
molding. Nails are protruding beyond the nail beds;

(2) Weight often more than 3 kg and length is about 54 cm. Both
are variable and even an IUGR baby may be born.
 Obs Card 21
Answer to the question no 1
A. Define induction of labour.
Answer:
Induction of of labour : Induction of labour means initiation of
uterine contraction (after the period of viability) by any method
(medical surgical for combined) for the purpose of vaginal delivery.

B. What are the methods of induction of labour?

Answer:
Methods of induction of labour:
1. Medical induction:
-Prostaglandins
a. PGE2 (Dinoprostone)
b. PGE1 (Misoprotol)
c. PGF2α (Dinoprost)
-Oxytocin
-Mifepristone (steroid receptor antagonist)
2.Surgical induction:
-Artificial rupture of membranes
a. low rupture of the membrane
b.high rupture of the membrane
-Stripping of the membranes
3.Combined: by both medical and surgical induction.

C. How will you give induction in a prigravida at 41 weeks

pregnancy?
Answer:
Induction in a prigravida at 41 weeks pregnancy:
A.Uncomplicated case (without any risk factor):
1.Ripe cervix :induction of labour by ARM (low rupture membrane)
-Liqour clear: oxytocin infuition/drip -expectant vaginal delivery.
-Liquor meconium stained:LUCS
2. Unripe cervix: repairing of cervix by vaginal PGE2 gel followed by
ARM
-Liqour clear: Oxytocin infusion/drip -expectant vaginal delivery.
-Liqour meconium stained:LUCS
B. Complicated case (associated to with risk factors): elective
cesarean section
.Answer to the question no 2 :
Management of breech delivay:Diagnosed:
1.clinical:after 32 weeks
Perabdominal examination:A. Hard,round,well circumscribed at
fundal grip
B.soft,broad,irregular mass at pelvic grip
C.irregular node oneside and back another side at lateral grip
D.fetal heart sound above or at the umbilicus
2.pervaginal examination
Pregnancy:soft, broad,irregular at fornics
Labour:buttock,anus,scrum,feet external genetalia can be feel
Treatment :
A .external cephalic version at or above 36 weeks
B.B.if external cephalic version fails then elective cesarean section
at or above 38 weeks or assisted vaginal breech delivery can be
done

Complications of breech :
1 Maternal
A. Trauma to genital tract
B. Operative vaginal delivary
C. Cesarean section
D. Sepsis
E. Maternal death
2 Fetal
A. Birth injury
B. Birth asphyxiation
C. Injury to brain and skull
D. Congenital anomalies such as anencephaly, hydrocephalus and
dislocation of hip

Answer to the question no 3 :

mx of APH:
1.Expectant mx
2.Active mx
Expectant mx: is given when-.hb% is greater than or equal to 10%
.haematocrit is greater than 30 %
.less than 37 weeks pregnency
.active vaginal bleeding absent
.fetal well being assured by usg,ctg
Conduction of expectant rx:
1)Bed rest with bathroom toilet privilage.
2)inv:hb%,usg,urinary protein,blood grouping, rh typing
3)haematinic supplementation
4)blood transfusion if needed
5)a gentle speculam ex is done to exclude cervical,vaginal lesion for
bleeding
6)periodic ex:vulval pad,fsh,fetal surveillance
7)tocolytics (mgso4) if bleeding is associated with uterine
contraction
8)cervical circlage to reduce bleeding, to prolong pregnency is not
helpful
9)Rh immunoglobulin in Rh negative mother(unsensitized)
10)pregnency is carried upto 37 weeks
11)preterm delivary have to be done-reccurence of brisk hge which
is continuing
If Dead fetus
If congenitally malformed fetus
If delivary is done bellow 34 weeks then betamethasone is given for
lung maturation.

Active rx:.
if bleeding continues
Pregnancy more than 37 weeks
Pt in labour
Exsanguinated
Fhs:absent or nonreassuring

Conduction of active rx:(sonography based)

1)If placental edge is 2-3 cm away from the internal cervical os then
vaginal delivary is done
2)if placental edge is within 2 cm of the internal os c/s is done

Answer to the question no 4 :

What is Bishop's score and mention It's component.

Bishop's score:It can be defined as pre labour scoring system to

assess of predicting whether the induction will be required or not.
Component:
Parameters Score
0 1 2 3

Cervix

Dilatation
(cm)

Closed, 1–2, 3–4, 5 +

* Effacement

(%)

0-30 40-50 60-70 ≥ 80

Consistency
Firm Medium Soft –

Position
Posterior Midline Anterior

Head:
Station: –3 –2 –1,0 + 1, + 2

Total score = 13;

Favorable score = 6-13; Unfavorable score

= 0-5

* Cervical

length (cm)
> 4, 2-4, 1-2, < 1

Answer to the question no 5 :

Postnatal care :
postnatal care included systemic examination of mother and baby
and appropriate advice given to mother during postpartum period

Advice during discharge :

1.extra nutritious diet and continuation of iron folic acid
supplementation. 2. vaccination from 6th
week 3. postnatal check up after 6 weeks.
4. abstinence from intercourse for 6 weeks 5.exclusive breast
feeding upto 6 month. 6. Norplant after 6 weeks
7. Cu T inserted after 6 weeks

Obs Card 22
Q no 1 ans:
#Multiple pregnancy:
When more than one fetus simultaneously
develops in the uterus,it is called multiple pregnancy.

#complication of multiple pregnancy in antenatal period:

Maternal complication:
During pregnancy:
Hyperemesis gravidarum
Anaemia
Miscarriage
Pre-eclamsia
Polyhydramnios
Antepartum haemorrhage
Malpresentation
Pre term labour
Increased mechanical distress

During labour:
PROM
Cord prolapse
Prolonged labour
Bleeding
Post partum haemorrhage
Increased offensive interference

Fetal complication:
Abortion
IUGR
Congenital malformation
Asphyxia & stillbirth.

Q no 2ans:
Probable causes:
1)preterm labour
2)abruptio placenta
3)ruptured uterus
4)torsion of uterus
5)acute fulminating pre eclampsia
6)surgical ***acute appendicitis ***UTI ***intestinal
obstruction
7)Gynaecological : ***red degeneration of fibroid
***torsion of ovarian cyst

Confirmation of true labour pain/not::

by characteristics of true labour
pain :
1)painful uterine contraction at regular
inyerval
2)pain is colicky in nature, starts in back
and radiatesto lower abdomen and medial aspect of thigh
3)frequency of contractions increases
gradually
4)intensity and duration of contractions
increases progressive ly
5)associated with ''show"
6)progressive effacement and dilatation of
cervix
7)descend of presenting part
8)formation of "bag of fore-waters"
 9)not relieved by enema or sedatives...

If it is not true labour pain then it will be false labour pain..

Characteristics of false labour pain are:
1)dull in nature
2) confined to lower abdomen and groin
3)not associated with hardening of uterus
4)absence of true labour pain features
5) usually relieved by enema and sedatives

Q no 3 ans:

2
This is a case of moderate anaemia
Investigation :
1)Hb estimations, total RBC count,PCV /Hct to see
degree of anaemia
2)CBC with PBF, reticulocyte count
3)RBC indices:MCV,MCHC,MCH,serum iron profile
4)For IDA :serum iron,serum ferritin,percent saturation
and total iron binding capacity
5)For megaloblastic anaemia :serum folate,serum vit b
12 assay,bone marrow examination

Complications of anaemia in pregnancy :

A)Maternal complications :
1)During pregnancy : Pre eclampsia intercurrent infection
heart failure preterm labour
2)during labour uterine inertia
cardiac failure shock post partum hemorrhage
3)during puerperium Puerperal
sepsis sub involution poor lactation puerperal venous thrombosis
Pulmonary embolism.
B)fetal complications :
a)increase incidence of LBW
b)IUFD
c)Increase perinatal loss

***Special complications of megaloblastic anaemia :

1)abortion
2)dysmaturity
3)pre maturity
4)abruptio placenta
5)fetal malformations: Neural
tube defect Cleft palate Harelip

1
Q no 4 ans:
(a)Episiotomy:
A surgically planned incision on the perineum and the
posterior vaginal wall during the second stage of labor is called
episiotomy.

(b) The ideal time to give episiotomy:

Bulging thinned perineum during contraction just prior to crowning
( when 3-4 cm of head is visible ) is the ideal time to give
episiotomy.

(C) Following advices are to be given to take care of episiotomy

wound :
1)keep the wound clean and dry
By regular dressing. The dressing is done by swabbing with cotton
swabs soaked in antiseptic solution ( povidone-iodine ) followed by
application of antiseptic powder or ointment (furacin or neosporin).
 2)Antibiotic is given, Cap
amoxicillin 500 mg 8 hourly for 7 days.
3)To relieve pain in the area,
MgSO4 compression or application Of infrared heat may be used.Ice
packs reduce swelling and pain also.Analgesic drugs(ibuprofen)may
be given when required.
4)The patient is allowed to move
out of the bed after 24 hours.Prior to that,she is allowed to roll over
onto her side or even to sit but only with thighs apposed.
5)When the wound is sutured
by catgut or Dexon which will be absorbed,the sutures need not be
removed. But if nonabsorbable material like silk or nylon is
used,the stitches are to be cut on 6th day.

Q no 5 ans:
PPH:
Quantitative definition:
When bleeding occur from or into the
genital tract mora than 500 ml in a normal vaginal delivery or
more than 100 ml in a caesarean section delivery or any amount of
significant bleeding in a previously anaemic mother which adversely
affects the general condition of the mother after the delivery of the
fetus upto the end of the puerperium , is called post-partum
haemorrhage(PPH).
Qualitative/Clinical definition:
Any amount of bleeding from or into
the genital tract following birth of the baby upto the end of the
puerperium which adversely affects the general condition of the
patient evidenced by rise in pulse rate & falling blood pressure is
called PPH.

Causes of primary PPH:

Atonic uterus(80%)
Grand multiparae
Over distension of the uterus in multiple
pregnancy,polyhydramnios & large baby
Malnutrition & anaemia
Antepartum haemorrhage
Prolonged labour
Anaesthetic drugs: Ether,halothane & cyclopropane
Initiation or augmentation of delivery by oxytocin/injudicious use of
oxytocin
Persistent uterine contraction
Malformation of the uterus
Mismanaged third stage of labour
Constriction ring
Precipitate labour
Uterine fibroid

Traumatic(20%):
Trauma to the genital tract during delivery:cervix,vagina,perineum,
paraurethral region, & rarely rupture of the uterus
Bleeding during C/S
Episiotomy
Mixed;
Combination of atonic uterus &trauma
Coagulopathy:
Bleeding & coagulation disorder
HELLP syndrome
IUD
Abruptio placenta
Jaundice in pregnancy.

Obs Card 23
--------------------Answer to question no. 1--------------------

Antenatal care (ANC)/prenatal care:

Regular and periodic systematic supervision (examination and

advice) of a woman in according to need during pregnancy is called
antenatal (prenatal) care.

Antenatal advices:

A. Dietary advices: Pregnancy diet ideally should be light,

nutritious, easily digestible and rich in
protein, vitamins and minerals. Dietetic advice should be given with
due consideration to socio-
economic condition, food habit and taste of individual woman.
Supplementary iron and folic acid therapy should be included..

Diet during pregnancy should be adequate to provide:

a)To maintain good maternal health.

b). To meet optimum needs of growing fetus.
c)To provide strength and vitality required during labor.
d)For successful lactation.

B. Antenatal hygiene: In otherwise uncomplicated cases, following

advices should be given:
1. Rest: Patient may continue usual activity, but should avoid
excessive and strenuous work
especially in 15 trimester and last 4 wks.
2. Sleep: Patient should be in bed for 10 hr on average (8 hr at night
and 2 hr at noon)
especially in last 6 wk.
3. Bowel: Regular bowel movement may be facilitated by taking
plenty of fluids.
vegetables, and milk or by stool softener (at bed time).
4. Bathing: Patient should take daily bath but be careful about
slipping in bathroom.
5. Clothing, shoes and belt:
Patient should wear loose but comfortable garments.High heel
shoes should better be avoided.Constricting belt should be avoided.
6. Dental care: Good dental and oral hygiene should be maintained.
7. Care of breasts:
-Nipple is to be cleaned.
-Retracted nipple, if any, to be corrected by manipulation.
-A well fitted brassiere can give relieve from breast engorgement
which cause discomfort in late pregnancy.

8. Coitus: Coitus should be avoided during Ist trimester and last 6

weeks if HO preterm
labor and abortion present.

9) Travel:
-Travels by vehicles having jerks are better to be avoided specially
in 15 trimester and
last 6 wks.
-Long journey is preferably be limited to 2nd trimester.
-Rail route is preferable to bus route.
-Travel in pressurized aircraft is safe up to 36 weeks. [Air travel is
contraindicated in
placenta previa, pre-eclampsia, severe anemia and sickle cell
diseases.]
-Prolong sitting in car or aero plane should be avoided due to risk of
venous stasis and
thromboembolism.
-Seat belt should be under the abdomen.

10. Smoking and alcohol: It is better to stop smoking and alcohol

consuming.
Hazards of smoking: Smaller baby and increase chances of
abortion.
Hazards of alcohol; IUGR and fetal mal-development

C. Immunization:
1. TT immunization: Not only protects mother but also neonates.
-If patient is not previously immunized: 2 doses, IM, 0.5 mL each,
first one between
16-24 wk and second dose 6 wk latter
-If patient is previously immunized: Booster dose of 0.5mL IM in
last trimester.

2. Rabies, hepatitis A & B vaccines, toxoids can be given as in non-

pregnant state.
3)But, live vaccines (MMR, varicella, yellow fever) are
contraindicated.
D. Drugs: Medicine is to be prescribed cautiously as some drug can
cross placenta and cause fetal
abnormality. Possibility of pregnancy should be kept in mind while
prescribing drugs to any
woman of reproductive age.
E. Mental preparation: Sufficient time and opportunity must be
given to expectant mother to have a free and frank talk on all
aspects of pregnancy and delivery.

F. Child care: Mother has to be educated about hygiene, rearing of

child and breast feeding.

G. Birth plan: Mother is to be counseled about birth plan. High risk

mother has to be delivered in an
institution

H. Family planning: Mother has to be educated and motivated

during antenatal period for FP. Is she
is multi-para, she should be motivated for sterilization .

I. General advices:

1. Advice to attend for antenatal check-up positively on schedule

date of visit.
2. Patient should be instructed to report even at early date some
untoward symptoms arise.
3. Advice to come to hospital for consideration of admission:
a. Painful uterine contraction at interval of about 10 minutes or
earlier and continued for
at least an hour (suggestive of onset of labor).
b. Sudden gush of watery discharge per vagina (suggestive of
PROM).
c. Active per-vaginal bleeding, however slight it may be
.......................... ******...............................
--------------------Answer to question no. 2--------------------

i) this is a case of pregnancy with 1st stage of labor

ii) Management:
Clinical features:
Symptoms:
1. True labour pain
2. Show
3. Sudden gush of liquor amni
 Signs::
a) Per abdominal examination.
1. Evidence of true labor pain.
2. Intermittent uterine contraction.
3. FHR : 120-160 beats/min. Which is
increase by 10 beats during
contraction
4. Maternal pulse, BP, Temperature and
other vital sign.

b) per- vaginal examination:

1.Cervix become dilated.
2.Gradual effacement of the cervix.
3. Status of membrane may or may not
ruptured

Treatment:
1. Reassurance and encouragement
2. Constant supervision is must
3. Strict maintenance of hygiene
4. Company and privacy
5. Diet : usually liquid
6. Ppace of delivery : hospital
7. Position: lithotomy / left lateral
8. Bladder care : Patient encouraged to pass urine.
9. Relief of pain
10. Special care during labor. :
a) progress of labor: by partograph and it is achieved by :
* Per abdominal examination.
ii) number of uterine contraction in 10 min. and duration of each
contraction.
iii) Fetal heart rate ( 110-150)/min.
* per vaginal examination.
i) cervix is dilated
ii) decent of the head
iii) formation of caput
iv) degree of moulding.
v) station of the head in relation to ischial spine.
vi) color of the liquor
* assessment of maternal well being:
Pulse. BP. Respiration. Temperature.
States of hydration ( in tongue)
Urine output

b) should exclude cephalo-pelvic disproportion

c) augmentation should only be done if there is slow progress
.......................... ******...............................

--------------------Answer to question no. 3-------------------

(i) My Diagnosis is PROM ( Premature Rupture Of Membrane)

(ii) Management of PROM

[A] Clinical Features :
1. Symptoms :
a) history of a gush fluid from the vagina or watery vaginal
discharge
b) lower abdominal pain
c) In case of chorioamnionitis : Rise of temperature
2. Signs :
a) The smell is characteristically sweet
Maybe meconim stained
b) In case of chorioamnionitis : Rise of temperature, tachycardia,
hypotension, & foul smelling P/V discharge
c) Patient maybe presented at toxic & irritated state
d) Sterile speculum examination with aseptic precaution : Liquor
escaping out through the cervix. (P/V/E is relatively
contraindicated in PROM)

[B] Investigations :
a) Ferning test : Fluid from the posterior fornix is placed on a slide
and allowed to dry. Amniotic fluid will form a fernlike pattern of
Crytallinzation.
b) Nitrazine test : A sterile cotton- tipped swab should be used to
collect fluid from the posterior fornix and apply it to Nitrazine
( Phenolphthalein) paper
c) Complete blood count : Neutrophilic Leukocytocis in case of
chorioamnionitis
d) Urine R/E
e) High vaginal swab for C/S
f) Ultrasonography for assessment of fetal well being

[C] Treatment of PROM :

1. Medical management
a) Preterm pregnancy without chorioamnionitis :
i) Bed rest
ii) Antibiotic
- 1st 48hrs : Inj. Ampicillin ( 2gm I/v every qds) plus inj.
Erythromycin (250 mg iv every qds)
- Next 5 days : Cap. Amoxacillin(250mg tds) plus cap. Erythromycin
(500mg tds)

iii) Corticosteroids : Inj.Dexamethasone( 12.5mg iv) are given stat &

repeat the same dose after 8 hrs
iv) Tocolytics : If the gestational age is >= 34 to <= 37 weeks &
labour is not started within 48 hours after the Prom, induction of
labour should be done by oxytocin.

b) Term pregnancy without chorioamnionitis :

- bed rest
- antibiotics
- steroid has little or no role
- obstreric mgmt is the main management
c) chorioamnionitis : broad spectrum antibiotics

[B] Obstreric management :

1. Assessment of gestational age and fetal weight
2. Patient is not in labour
3. Absence of infection and fetal distress
4. Satisfactory biophysical profile and non-stress tests
.......................... ******...............................
--------------------Answer to question no. 4 --------------------

# Pre- eclampsia :
Pre-eclampsia is a multi-system disorder of
unknown etiology characterized by development of hypertension to
the extent of 140/90 mm Hg or more with proteinuria after the 20th
week of pregnancy in a previously normotensive and non-
proteinuric patient.

#INVESTIGATIONS OF PRE-ECLAMPSIA

(A) Urine Examination:

(1) Heat Coagulation test to detect proteinuria : Proteinuria is
the last feature of pre-eclampsia to appear. Urine becomes solid on
boiling (10-15 g/L). It is done the the bed side for rapid detection.

(2) Urine R/M/E

(3) 24 hours urine collection for protein measurement.

(B) Opthalmoscopic examination : In severe cases retinal

edema ,constriction of arterioles & alterations of normal ratio of
vein : arteriolar diameter from 3:2 to 3:1

(C)Blood examination:
(1) serum uric acid level : Raised serum uric acid level (>4.5
mg/dl) indicates pre-eclampsia

(2) Serum creatinine :may be >1mg/dl

(3) Thrombocytopenia or abnormal coagulation profile of

varying degree may be present

(4) Hepatic enzyme: may be raised

(5) Blood urea may be normal or slightly raised.

(D) Antenatal fetal monitoring : By USG

#COMPLICATIONS OF PRE-ECLAMPSIA

(1) IMMEDIATE
(A) Maternal Complications:
 (a)During Pregnancy:
i) Eclampsia
ii) Antepartum haemorrhage (placental
abruption)
iii)Oliguria & anuria (Acute renal failure)
iv) Cardiac failure
v) HELLP Syndrome
vi) Dimness of vision and even blindness.
vii) premature labour

(b) During labour:

i) Eclampsia
ii) PPH & shock

(c) Puerperium :
i) Eclampsia (within 48 hrs)
ii) puerperal sepsis & septic shock

(B) Fetal Complications:

i) Intrauterine death ( IUD)
ii) Intrauterine growh retardation (IUGR)
iii) Birth asphyxia
iv) Prematurity

(2) Remote Complications:

i) Residual hypertension
ii) Recurrent pre-eclampsia

.......................... ******...............................

--------------------Answer to question no. 5 --------------------

a)Preterm labour is defined as the one where the labor starts before
37th completed week(<259 days), counting from the first day of last
menstrual period.
Causes of preterm labor:
*Idiopathic:50%
*High risk factors:
1) History:
i)previous history of induced or spontaneous abortion or preterm
delivery.
ii) Pregnancy following assisted reproductive technologies.
iii) Asymptomatic bacteriuria or recurrent UTI.
iv) Smoking habits.
v)Low socio-economic and nutritional status.
vi)Maternal stress.

2) Complications in present pregnancy: Maternal,Fetal, Placental.

a)Maternal:
i) Pregnancy complications:Preclamsia,PROM
ii)Uterine :Cervical incompetence, Malformations of uterus.
iii)Medical and surgical history:Acute fever,acute appendicitis.
iv) Genital tract infections: Bacterial vaginosis,beta hemolytic
streptococcus.

b)Fetal: Multiple pregnancy, congenital malformations.

c) Placental: Infraction, Thrombosis,previa,abruption.

3) Iatrogenic:
Indicated preterm delivery due to medical or obstetrics
complications.

4) Idiopathic.

Features of preterm baby are:

i) Weight:2500gm or less
ii) Length:Less then 44cm.
iii)Head and abdomen is relatively larger.
iv)Skull bone is soft with wide suture and posterior fontanel.
v)Head circumference disproportionately exceeds that of
chest.(Normal HC is greater then CC at birth and the difference is
about 1.5cm)
vi)Pinnae of the ear are soft and flat.
vii)Eyes are kept closed.
viii) Skin thin red and shiny due to lack of subcutaneous fat and
covered by plentiful lanugo and vernix caseosa.
ix)Muscle tone: poor.
x)Planter deep creases not visible before 34 weeks.
xi) Testicals undecended and labia minora exposed because labia
Majora are not in contact.
xii) Tendency of herniation.
xiii)Nail are not grown upto finger tips.

Obs Card 24
Answer to the question number 1

Labor: Series of events that take place in the genital organs in an

effort to expel the viable products of conception out of the womb
through the vagina into the outer world
Trait True Labor Pain False Labor Pain

1 Site Back and in front of Lower Abdomen and

abdomen Groin
2 Radiation Towards thigh Localized
3 Character Colicky Dull
4 Duration Intermittent Continuous
5 Intensity Severe Less Severe
6 Progression Increasing Intensity Continuous and non-
and Duration progressive
7 Relieving None Sedatives, Analgesics and
Factor Enema Simplex
8 Associated #Progressive No such association
Factors effacement and
dilatation of the cervix
#Show
#Formation of Bag of
Waters

Answer to the question number 2

Dx: 3rd stage bleeding of true PPH

Management:

Clinical features:
Symptoms: Per-vaginal bleeding with or without visible blood clot
after the delivery of the fetus but before the expulsion of the
placenta.

Signs / clinical examination:

A) General examination:
1) Patient may be exhausted after a stressful delivery. Lethargic or
even impaired consciousness & mentation in case of profound
2)hypovolemia or shock.
3) Face: Pallor or even paper white (due to severe anaemia)
4) Eyeball: Sunken.
5) Tongue: Dry.
6 Skin: Dry, cold & clammy.
7) Hypotension, tachycardia (bradycardia in late stage & is a poor
prognostic sign).
8) Respiratory distress & tachypnoea.
9). Urine output or even anuria & ARF due

B) Per-abdominal examination:
In atonic uterus : Uterus is soft & flabby and becomes hard on
massaging.
In traumatic case : Uterus is well contracted or hard.

C) Per-vaginal examination:
1) Active bleeding may be seen on inspection. 2) Clotted blood may
be found. 3) Signs of laceration in the genital tract &/or perineum
may be present.

Investigations:

1) Blood grouping & Rh typing and cross matching with the donor
blood for urgent blood transfusion
2) Hb%.
3) Coagulation profile: Bleeding time, Clotting time. Prothrombin
time. Bedside clot observation test.
Investigations should be done adequate resuscitation of specific
obstetric management
4) Ultrasonography: For any remnant of placenta, after settlement
of patient or emergency baia

Treatment:
A) Principles of treatment:
> To empty the uterus of its contents & to make it contract
> To replace the blood.
> To ensure the effective haemostasis traumatic bleeding.

B) Immediate treatment/resuscitation:
1) Palpation of the fundus & massage the uterus to make it hard
2) Inj. Ergometrine (0.25 mg) or Inj. Methergine (0.2 mg) is given
intravenously.
3) Wide bore IV cannula is to opened & IV fluids is to be started
upto blood transfusion (Ringer's lactate, Hartmann's solution or
Normal saline). contracted
4) Blood transfusion.
5) Catheterization: To monitor urine output.
6) Sedation: May be given by Morphine (15 mg) IM.
7) Monitoring: Maternal PPT, respiration, skin, tongue, urine output
etc.

C) Specific treatment:
Manual removal of placenta.
1) During the resuscitation period, if features of placental
separation are evident, expression of placenta is to be done either
by fundal pressure or control cord traction (CCT) method.
2) If the placenta is not separated, manual removal of placenta is to
be done under GA 3) If the patient is in shock, she has to be
resuscitated first before undertaking manual removal
4) Manual removal of the placenta is done after the delivery of the
baby when two attempts of CCT fail & IV Methergine or Ergometrine
is used.
5) Crede's expression of the placenta is abandoned.

Answer to the question number 3

A pregnancy continuing beyond 2 weeks of expected date of
delivery(>294 days) is called post term pregnancy.

Complications of post term are:

i)Fetal:
a) During pregnancy:
There is diminished placental function, oligohydramnios and
meconium stained liquor.This leads to fetal hypoxia and fetal death.

b)During labour:
i)Fetal hypoxia and acidosis.
ii)Labour dysfunction.
iii) Meconium aspiration.
iv)Risk of cord compression due to oligohydramnios.
v) Shoulder dystocia.
vi) Increase incidence of birth trauma due to big size baby and non
moulding of head due to hardening of skull bones.
vii) Increase incidence of operative delivery.

c) Following birth:
i)Chemical pneumonitis, atelectasis and pulmonary hypertension
due to meconium aspiration.
ii)Hypoxia(low APGAR score) and respiratory failure.
iii) Hypoglycemia and polycythemia.
iv) Increased NICU admissions.

Answer to the question number 4

4.a. My probable diagnosis is gestational diabetes mellitus.

b. Further investigations;

Non-challenge blood glucose test

Fasting glucose test
2-hour postprandial (after a meal) glucose test
Random glucose test
Screening glucose challenge test
Oral glucose tolerance test (OGTT)

Answer to the question number 5

Instrumental deliveries in obs :

1. Forceps delivery
2. Ventouse delivery.
.
Prerequisite full filled before ventouse :
1.The cervix must be fully dilated.
2.The membranes must be ruptured.
3.The position & station of the featal head must be known with
certainty & fetal head must be engaged.
4.Evidence of CPD must be excluded.

Obs Card 25

1). Define labour.What are the stages of labour.

Mention the active management of 3rd stage of labour.
Ans- Labour: Series of events that take
place in the genital organs in an
effort to expel the viable products of
conception out of the womb through
the vagina into the outer world is
called labour.

Stages of labour:

1st stage /cervical stage of labour:

It starts from the onset of true
labour pain and ends with full
dilatation of the cervix.
primigravidae-12 hrs
Multiparae-6 hrs

2nd stage of labour:lt starts from the

full dilatation of cervix and ends with
the expulsion of fetus from birth
canal.Duration:
primigravidae-2hrs
Multiparae-30 min.
Phases of 2nd stage
propulsive phase-It starts from the
full dilatation of the cervix upto the
descent of presenting part to the
pelvic floor.
Expulsive phase: It is distinguished
by maternal bearing down efforts
3rd stage of labour:
It begins after expulsion of the fetus
and ends with the expulsion of the
placenta & membranes.
Duration:
both in primi & multiparae-15 min.
in case of active management-5 min
Active management of 3rd stage of
labour:
Principle: Ensuring powerful uterine
contractions within 1 min. of delivery
of the baby by giving parenteral
oxytocin
Procedure:*Injection oxytocin(110
units 1/M) is given within 1 minute of
delivery of baby
*The placenta is expected to be
delivered soon following delivery of
the baby
*if the placenta is not delivered it
should be delivered by controlled
cord traction technique
*if the first attempt miss then
another attempt made after 2/3
minutes failing which another
attempt should made at 10 min.

2) (i)What are the common causes of lower abdominal pain during

3rd trimester of pregnancy
 (ii) How wll you treat a case of UTI during pregnancy
Ans-Common causes of low er abdominal pain in 3rd trimester of
of pregnancy
1) Labour pain true or false labour pain.
2) UTI
3) Abruptio placenta.
4) Pre-term Iabour.
5) Rupture uterus
6) Acute fulminating pre-eclampsia
7) Torsion of uterus.
8)Conslipation.

(ii)Treatment of UTI in pregnancy:

A) General treatment:
1)Bed rest
2) Plenty of water intake
3)Maintenance of personal hygiene
B)Specific treatment:
l)Appropriate antibiotic:Cap. Amoxicillin( 500 mg tds)/ Cap.
Ampicillin (500 mg tds
Or qds)/Cap. Co-amoxiclav (625 mg or 1.2 gm tds)/Cap.
Cefuroxime(250/500
mg bd)/ Cap. Cefixime (200 or 400 mg bd)
2)Antispasmodic: Tab. H-N butyl bromide (10 or 20 mg bd or tds)
/Tab. Tiemoium
methyl sulphate (50 mg bd or tds)
3) Anti-pyretic: Tab. Paracetamol (500-1000 mg tds).
4)Anti-emetic (if vomiting present): Tab. Ondansetron (8 mg od or
bd)/tab.
prochlorperazine (12.5 mg bd or tds)/Tab. Metoclopramide (10 mg
bd or tds)/ Tab.
Meclizine (50 mg bd or tds).
C)Obstetric treatment:
1) Should avoid unnecessary catheterization.
2) Careful monitoring of the fetal wellbeing & maternal physical
condition.

3) A lady came to you at 34 weeks pregnancy with sudden painless

pervaginal bleeding.
(i)What is your diagnosis? (ii) How will you manage this lady?
Ans-
Diagnosis : 34 weeks of pregnancy with APH due to placenta
praevia.

(2)management of a case of placenta praevia:

Clinical features:
Symptom: The only symptom of placenta praevia is P/V bleeding
which is
Sudden onset
Painless
Apparently causeless &
Recurrent (characteristics of P/V/B is discussed above).
Signs:
A) General examination: (Mostly haemodynamic changes due to
bleeding)
General condition &anaemia are proportionate to the visible blood
loss (but in
tropics the picture is often confusing due to pre-existing oedema).
Patient is exhausted.
Cold, clammy skin.
Tachycardia & hypotension.
Rapid respiration (tachypnoea).
Decreased urine output.
B) Per-abdominal examination:
1) Size of the uterus: Proportionate/ corresponds to the period of
gestation.
2) Feelings of uterus: Relaxed soft. & elastic without any localized
area of
tenderness.
3) Presentation: Breech, transverse or unstable lie is common.
4) Fetal head:
Fetal head is floating in contrast to the period of gestation.
Persistent displacement of the fetal head is very suggestive.
The head cannot be pushed down into the pelvis.
5) FHS: Usually present.
Pér-vaginal examinations
P/V/E is contraindicated
2) Only inspection is to be done to note whether the.bleeding is still
occurring or has
ceased. Blood is bright red.
Investigations: (mostly clinical diagnosis)
1) Ultrasonography for confirmation of the diagnosis.
2) Blood: Hb% (to detect degree of anaemia).
3) Blood grouping & Rh typing.
Treatment: All cases of APH even if the bleeding is slight or absent
by the time the patient reaches in
the hospital should be admitted & regarded as due to placenta
praevin unless proven otherwise.
A) Espectant treatment: <37 weeks
1) Bed rest with bathroom privileges.
2) Periodic inspection: Vulval pad, FHS, fetal surveillance (by USG
at 2-3 weeks
interval).
3) Iron. folic acid, Zn supplementation.
4)Use of tocolytics & cervical circlage are not helpful.
B) Definitive treatment: call fort help.
General treatment:
1) Nothing by mouth.
2) Wide bore I/V cannula.
3)IV fluid: Hartman' s solution, Normal saline, plasma
4) Blood transfusion (at least 2-4 unit of blootransfusion be
transfused as early as
possible after cross-matching & donor should be readied for further
transfusion.
5) Inj. 10% Calcium gluconate (10 m) iv very slowly ovef 10-
20,minutes after
each 3 units of blood transfusion
6) Catheterization: To monitor urine output.
7) Monitoring: Pulse, BP, temperature, respiration, urine output &
FHR
b) Obstetric treatment
1) Without internal examination: C/S section
2) PVE in OT followed by low rupture of membrane.
weeks
1) Bed rest with bathroom privileges.
2) Periodic inspection: Vulval pad, FHS, fetal surveillance (by USG
at 2-3 weeks
interval).
3) Iron. folic acid, Zn supplementation.
4)Use of tocolytics & cervical circlage are not helpful.
B) Definitive treatment: call fort help.
General treatment:
1) Nothing by mouth.
2) Wide bore I/V cannula.
3)IV fluid: Hartman' s solution, Normal saline, plasma
4) Blood transfusion (at least 2-4 unit of blootransfusion be
transfused as early as
possible after cross-matching & donor should be readied for further
transfusion.
5) Inj. 10% Calcium gluconate (10 m) iv very slowly ovef 10-
20,minutes after
each 3 units of blood transfusion
6) Catheterization: To monitor urine output.
7) Monitoring: Pulse, BP, temperature, respiration, urine output &
FHR
b) Obstetric treatment
1) Without internal examination: C/S section
2) PVE in OT followed by low rupture of membrane.

4) A primi came at her 41 weeks of pregnancy with cephalic

presentation.How will you assess her for normal vaginal delivery?
Ans- 1) Reassurance & encouragement.
2) Constant supervision is must.
3) Strict maintenance of hygiene / asepsis throughout the delivery
process.
Company & privacy: To whom woman feels comfortable.
5) Diet: Usually diet is liquid.
4)
6) Rest & ambulation: If the membrane ruptured, patient should be
in bed and otherwise she is
allowed to walk.
7) Place of delivery: High risk pregnancies should be delivered at
hospital; otherwise place of
delivery depends on the patients choice, comfort & availability of
health care facilities
8) Position: Lithotomy / left lateral/ any position the woman
prefers.
9) Bladder care: Patient is encouraged to pass urine by herself &
routine use of catheter is a harmful
9)
practice.
10) Relief of pain: In a normal, uncomplicated labour, analgesics
are not used routinely & are not a part
of essential care for normal childbirth (please see below for details).
11) Special care during labour:
Progress of labour: By partograph & it is achieved by -
a)
Per abdominal examination:
Number of uterine contraction in 10 minutes & duration of each
contraction.
Fetal heart rate (Normal 110-150 /minute).
Per vaginal examination:
Cervical dilatation.
Descent of the head.
Formation of caput.
Degree of molding.
Station of the head in relation to ischial spines.
Color of the liquor (If the membranes are ruptured).
Assessment of maternal wellbeingE Pulse, BP, respiration,
temperature, state of
hydration (in tongue), urine output (2 hourly).
b) Should exclude cephalo-pelvic disproportion (CPD).
c) Augmentation should only be done if there is slow progress.

We will do pelvimetry and Bishop's scoring. If favourable then

induction is done by Oxytocin drip.
Then see if the cervix is favourable or not.
If not, then give Prostaglandin and then again give Oxytocin drip
and go for normal vaginal delivery.

5) What is post natal care?What would you advice to a woman who

comes to you at 06 weeks after vaginal delivery?
Ans: Post Natal Care: Postnatal care includes systemic examination
of the
mother and baby and appropriate advices for care of both during
postpartum period. It is a multidisciplinary activity including an
obstetrician,
a neonatologist and a medicine specialist.
Advice to a mother after 6 weeks after vaginal delivery:
i) Diet: High nutritious diet containing adequate vitamins, minerals
including iron, folic acid, vitamin-C, calcium etc.
ii) Should not bear heavy weight for at least 3 months.
iii)Contraception: -Progesterone only pill/mini pill for 1st 6 months
-Barrier method for next 2 years
iv) Coitus:-Abstinence in 1st 1 and half months
-With caution for next 1 and half months
v) Birth spacing: For at least 2 years

vi) Breast feeding and care of new born: -Exclusive breast feeding
for
1st 6 months.
- Weaning from 7h month till 2 years
vii)Immunization: Immunization of the baby properly according to
EPI
schedule.
viii) Sunlight exposure of the baby: By covering the mouth and
genitalia.
ix)If any sign symptoms of jaundice appear- contact a pediatrician.
x)If episiotomy given: Care of the wound, regular dressing and
antibiotic.

Obs Card 26
ANS TO THE QUESTION NO. 1
Puerperium is the period following childbirth during which the
body tissues specially the pelvic organs revert back
approximately to the pre-pregnancy state both Anatomically
and physiologically.

ABNORMALITIES OF PUERPERIUM:
1. Puerperal pyrexia
2. Puerperal sespsis
3. Subinvolution
4. Breast complication
- breast engorgement
- cracked and retracted nipple leading to difficulty in breastfeeding
-mastitis and breast abscess
-lactation failure
5. Urinary complications
- UTI
- retention of urine
- incontinence of urine
- suppression of urine
6. Puerperal venous thrombosis and
pulmonary embolism
7. Obstetric palsies ( Postpartum traumatic neuritis)
8. psychiatric disorders
- Puerperal Blues
- Postpartum depression
- Postpartum psychosis (schizophrenia)

LOCHIA :
depending upon the variation of the colour of the discharge lochia
can be of 3 type :
🔴 Lochia rubra
🖊 red in colour
🖊 persist for 1-4 days
🖊 consist of blood, shreads of fetal membranes and decidua,
vernix caseosa, Lanugo and meconium

🔴 Lochia serosa
🖊yellowish or pink or pale brownish in colour
🖊Persist for 5-9 days
🖊consists of less RBC but more leukocytes,
wound exudates, mucus from the cervix
and microorganisms
(anaerobic streptococci and staphylococci)
🖊The presence of bacteria is not pathognomic
Unless associated with clinical signs of sepsis.

🔴 Lochia alba
🖊Pale white in color
🖊Persists for 10-15 days
🖊contains plenty of decidual cells, leukocytes, cysts, mucous,
cholesterin crystals, fatty and granular epithelial cells and the
micro-organisms.
IMPORTANCE :
the valuable pads are to be inspected Daily to get information of -
🖊odor :
if malodorous - indicates infections.
retained plug or cotton piece inside the vagina should be kept in
mind.
🖊amount :
scanty or absent - signifies infection or
lochiometra.
if excessive indicates infection.
🖊colour :
persistence of red colour beyond the normal limits signifies Sub
involution or retained bits
of conceptus.
🖊 duration :
duration of the lochia Alba beyond 3 weeks suggest local genital
lesion.

Ans to the Question no. 2

When the placenta is implanted partially or completely over
the lower uterine segment (over and adjacent to the internal os)
it is called placenta previa.
Ans to the Question No. 3
I) My probable diagnosis is puerperial sepsis with wound infection
II) Management of puerperal sepsis :
✔ History :
- low socioeconomic condition
- poor personal hygiene
- H/O exhausted normal or operated delivery

✔ Clinical Feature :
▶Symptoms:
- Rise of temperature
- constitutional symptoms - malaise, weakness, loss of appetite,
vomiting
- Lower abdominal pain
- Foul smelling p/v discharge

▶Signs:
- patient may be toxic
- Temperature is raised (>100°F) , in severe infection there is high
rise of temperature associated with chills and rigor
- P/A examination :
Tender may be present with subinvolution of uterus
In case of C/S local wound may be tender and there may be
purulent discharge with disruption of the wound
-P/V examination : offensive and copious P/V discharge may be
present.

✔ Investigations:
- TC, DC, ESR, Hb% : neutrophilic leucocytosis, raised ESR,
reduced Hb.
- Urine R/M/E: To detect any pus cell mainly and culture &
sensitivity
- High vaginal & endocervical swab: For culture in aerobic &
anaerobic media and sensitivity test to antibiotics.
- USG of pelvic cavity
- Blood culture
- Serum creatinine
- RBS
- For malaria: thick blood film/ immune chromatographic strip test
(ICT test) for malaria

✔ Treatment :
▪General :
- Isolation of the patient
- Adequate fluid and calorie intake
- Anaemia should be corrected
- Maintenance of temperature chart
- Maintenance of inatke output chart

▪ Antibiotics :
- Ideal antibiotic regimen should be depend on the culture and
sensitivity report
- Gentamicin ( 2mg/kg IV loading dose followed by 1.5mg / kg 8
hourly) plus Ampicillin (1 g IV 6 hourly) / Clindamycin (900 mg IV
8 hourly)
- Cefotaxim 1g IV 8 hourly is another alternative

- Metronidazole 500 mg IV 8 hourly is given to control anaerobic

group
- The treatment is continued untill the infection is controlled or for
at least 7-10 days

▪Anti-pyretic :
Paracetamol 1 gm tds or 500mg qds or 15 mg/kg/wt

▪Surgical treatment :
- management of the perineal wound, pelvic abscess, wound
dehiscence, necrotizing fascitis etc
- sometimes uterine exploration is needed

▪ Management of septic shock:

- Fluid and electrolyte balance (to monitor CVP)
- Respiratory support ( to maintain arterial PO2 and PCO2)
- Circulatory support (noradrenalin)
- Control of infection ( invasive antibiotic therapy &/or surgical
removal of the septic foci)
- specific management : hemodialysis for ARF

Ans to the Question No. 4

Methods of antenatal fetal monitoring :
CLINICAL: symphysio-fundal height, abdominal girth.
BIOCHEMICAL: Biochemical tests are mainly done for assessment
of pulmonary maturity.
BIOPHYSICAL: Biophysical profile is a screening test for utero–
placental insufficiency.

The following biophysical tests are used:

(1) Fetal movement count :
- Cardif “count 10” formula: patient counts fetal movements
starting at 9 am. counting comes to an end as soon as 10
movements are perceived.
- Daily fetal movement count (DFMC): three counts each of 1
hour duration (morning, noon and evening) are recommended. total
counts multiplied by four gives daily (12 hour) fetal movement
count.
- Mothers perceive 88% of the fetal movements detected by Doppler
imaging.

(2) Non-stress test (NST): In non-stress test, a continuous

electronic monitoring of the fetal heart rate along with recording of
fetal movements (cardiotocography) is undertaken.

Interpretation:
- Reactive (reassuring)—When two or more accelerations of more
than 15 beats per minute above the baseline and longer than 15
seconds in duration are present in a 20 minute observation.
- Non-reactive (Non-reassuring)—Absence of any fetal reactivity.

(3) Fetal Biophysical Profile (BPP)—considers several parameters.

BPP using real time ultrasonography has a high predictive value.
Indication:
Non-reactive NST, high-risk pregnancy. Test frequency weekly after
a normal NST and twice weekly after an abnormal test.

Modified Biophysical Profile consists of NST and

ultrasonographically determined amniotic fluid index (AFI).
Modified BPP is considered abnormal (nonreassuring) when the
NST is non-reactive and/or the AFI is < 5.

Parameters:
-Non-stress Test
-Fetal breathing movements
-Gross body movements
-Fetal muscle tone
-Amniotic fluid

(4) Fetal Cardiotocography (CTG) : A normal tracing after 32

weeks, would show baseline heart rate of
110-160 beats per minute (bpm) with an amplitude of baseline
variability 5–25 bpm. There should be no deceleration or there may
be early deceleration of very short duration. there should be two or
more accelerations during a 20-minute period.

(5) Ultrasonography : IUGR can be diagnosed accurately with serial

measurement of BPD, AC, HC, FL and amniotic fluid volume.

(6) Amniotic fluid volume (AFV) : Amniotic fluid volume is

primarily dependent upon the fetal urine output, pulmonary fluid
production and fetal swallowing.
A vertical pocket of amniotic fluid > 2 cm is considered normal.
Amniotic fluid index (AFI) is the sum of vertical pockets from four
quadrant of uterine cavity. AFI < 5 is associated with increased risk
of perinatal mortality and morbidity.

(7) Doppler Ultrasound Velocimetry :

Doppler flow velocity waveforms are obtained from arterial and
venous beds in the fetus.
-Arterial Doppler (umbilical artery, middle cerebral artery)
waveforms are helpful to assess the downstream vascular
resistance.
-Venous Doppler (Ductus Venosus, Umbilical Vein) parameters
provide information about cardiac forward function (cardiac
compliance, contractility and after-load).

Role of USG in obstetrics:

Fetal:
- diagnosis of pregnancy
- assessment of gestational age
- diagnosis of multiple pregnancy
- diagnosis of IUD
- detection of anomalies
- assessment of growth (IUGR)
- assessment of wellbeing (biophysical profile)
- diagnosis of presentation
- diagnosis of ectopic pregnancy

Utero-placental:
- localisation of placenta (placenta praevia)
- diagnosis of abruptio placenta
- diagnosis of molar pregnancy
- diagnosis of uterine malformation
- assessment of liquor volume (polyhydramnios & oligohydramnios)
- uterine size (either increased dates or decrease dates)
- diagnosis of cervical incompetence

Maternal:
-pelvic mass diagnosis & follow up
- obstetrical intervention
- amniocentesis
- chorion villus sampling
- cordocentesis
- fetoscopy
- intrauterine fetal therapy

Ans to the Question no. 5

Advice given to the mother during discharge:

Advice after c/s section
1) Diet: High nutritious diet containing vitamins, minerals
including iron, folic acid, vitamin-C,
calcium etc.
2)Should not bear heavy weight for at least 6 months.
3) Should wear abdominal binders for at least 2-3 months
4) Coitus : Abstinence in 1st 3 months;
With caution in next 3 months.
5) Birth spacing : For at least 2 years.
6) Breast feeding : Exclusive breast feeding for 6 months.
7) Immunization: immunization of the baby at 1.5 month(6week)
8)Come for check-up at 6th of puerperium

Obs Card 27
Question no:1

Clinical course of 2nd stage of labour:

Second stage begins with full dilatation of the cervix and ends with
expulsion of the fetus.
1.Pain:

Increase intensity, at 2- 3 min interval for 1-2 min.

2.Breaking down efforts:

Additional voluntary expulsive efforts that appear during the 2nd

stage of labour. It is initiated by Ferguson reflex.

3.Membrane status:

May rupture with gush of liquor per vagina.

4.Descent of the fetus:

Abdominal examination- progressive descent of the head, assessed

in relation to the brim, rotation of ant shoulder to midline and
change in position of fetal heart rate.( fifth formula)

Internal examination- descent of head in relation to ischial spines

and gradual rotation of head evidenced by position of sagittal
suture and occiput in relation to quadrants of pelvis.
5.Vaginal signs:

The maximum diameter of the head stretches the vulval outlet and
there is no recession even after the contraction passes off, this is
called ‘crowning’ of the head. The head is born by extension. Then
by further bearing down efforts the shoulders and the trunk is
delivered.

6.Maternal signs:

Features of exhaustion, respiration slowed with increased

perspiration. During bearing down face is congested, neck veins
prominent.

7.Fetal effects:

Slowing of FHR during contraction.

Question 2:

(a).Caesarean section : An operative procedure whereby the

fetus/fetuses are delivered after the end of 28 th week through an
incision on the abdominal and uterine walls.
(B). INDICATIONS OF C/S:

Absolute indications:

1.Central placenta praevia(type-IV)

Cephalopelvic disproportion(absolute)

Pelvic mass causing obstruction (cervical or broad ligament fibroid)

Advanced cervical carcinoma

Vaginal obstruction (atresia, stenosis)

1.Cephalopelvic disproportion(relative)

Previous C/S :

Previous 2 C/S

Features of scar dehiscence

Previous classical C/S

When primary C/S was due to recurrent indiction

Fetal distress

Cervical dystocia : Due to_

Large fetus

Small pelvis
Inefficient uterine contractions

Ante-partum haemorrhage:

Placenta praevia

Abruption placenta

Malpresentation :

Breech

Shoulder

Brow

Failed surgical induction of labour

Failure to progress in labour

Bad obstetric history

Hypertensive disorders:

Eclampsia

Severe pre-eclampsia

Medical disorders:

Uncontrolled DM

Coarctation of aorta

Marfan's syndrome
Gynaecological disorders:

Benign/malignant pelvic tumor

Following repair of VVF

(C). COMPLICATIONS OF C/S:

Maternal complications:

(A).Pre-operative:

Extension of uterine incision to one or both sides which may cause:

Severe haemorrhage

Broad ligament haematoma

Uterine laceration

Uterine atony and primary PPH

Morbid adherent placenta

Rare complications:

Urinary bladder injury

Ureteral injury

GIT injury
(B).Post-operative:

IMMEDIATE:

PPH -> hypovolemia -> Shock

Non-haemorrhagic shock due to prolonged labour

Anaesthetic hazards:

Aspiration pneumonitis

Lung collapse

Infection

Secondary PPH

Intestinal obstruction

Thromboembolic disorder

Septic thrombo-phlebitis

Wound complications:

Frank pus

Haematoma formation

Dehiscence

Burst abdomen
LATE:

Gynaecological:

Menstrual irregularity

Chronic pelvic pain

Backache

General surgical:

Incisional hernia

Intestinal obstruction

Wound dehiscence

Excessive scar formation

For future pregnancy:

R/O scar rupture

R/O rupture of uterus

Fetal complications:

Iatrogenic prematurity

RDS

Birth injury

Birth asphyxia.
Question 3:

(A).My diagnosis is it is a case of primigravida, 34 weeks pregnancy

with antepartum haemorrhage most probably due to abruptio
placenta.

(B). As the baby was born at 34th week, the infant is at risk of many
complications due to immaturity of various organs and also for the
cause of preterm birth. Possible complications are:

Asphyxia

Hypothermia

Pulmonary syndrome that includes pulmonary oedema, intra-

alveolar haemorrhage, idiopathic respiratory distress syndrome,
bronchopulmonary dysplasia

Cerebral haemorrhage

Neonatal shock

Hypoglycaemia

Heart failure

Oliguria, Anuria
Infection

Jaundice

Patent ductus arteriosus

Dehydration and acidemia

Anaemia

Apnoea and sudden infant death syndrome

Retinopathy of prematurity

Increased length of hospital stay

Question 4

Calculation of EDD(Expected date of delivery ) :

1- 9 calendar months plus 7 days from LMP(- first day of last

menstrual period) or

2-10 lunar months plus 7 days from LMP or

3-280 days or 40 weeks from LMP
Question 5

➡ peurperium is the period following childbirth during which the

body tissues, especially the pelvic organs revert back approximately
to the prepregnant state both anatomically and physiologically.

Types of peurperium are:

Normal peurperim

Abnormal peurperium

Steps of management of normal peurperium after vahinal

delivery are:

1). Immediate attention/management of 4th stage

-close observation of the patient

-emotional support

2). Rest and early ambulation

3). Hospital stay: patient should be discharged within 24-

48 hrs and 3-5 days for those who have perineal stitches

Diet: high calorie diet with adequate fat,vitamin,minerals

Bladder care: encouraging the patient to pass urine as soon as
convenient

Care of bowel:

-sufficient amount if vegetable and fluid should be included in dietary

plan

-if constipation 2 tsf ispagula husk at bed time

Adequate sleep

Care of vulva and episiotomy wound: proper cleanliness, wound

dressing, antibiotics and analgesics

care of breast:

-Nipple should be washed with sterile water before feeding

-It should be cleaned and kept dry after feeding baby

10)Rooming in/ maternal-infant bonfing

11)Asepsis and antiseptics

Immunization

Advice for family planning and contraception

Obs Card 28

Card:28 Quest ion:1

Obst ructed labor:
Obst ructed labor is the one where,in spit e of good uterine contractions,t he
progressive descent of the present ingpart isarrest ed due to mechanical
obst ruct ion.
Causes:
Fault in passage :
Bony:
- Cephalopelvic disproport ion
- Cont racted pelvis
- Secondary contracted pelvisin mult iparous women. 2)Soft t issue obst ruct
ions:
- Cervical dyst ocia due to prolapse
- Previousoperative scarring
- Cervical or broad ligament fibroid
- Impact ed ovarian tumor
- The non- gravid horn of a bicornuate uterusbelowthe present ingpart.

Fault in the passenger :

1)Transverse lie 2)Browpresent at ion
Congenit al malformat ion of the fetus:
- Hydrocephalus (commonest )
- Fetal ascit es
- Double monst ers
Big baby, occipito- post erior posit ion 5)Compound present at ion
6)Locked t win

Prevention:
Ant enatal:
Detection of the factorslikely to produce prolonged labor:
- Bigbaby
- Small women
- Malpresent at ion and posit ion.

Int ranatal:
- Cont inuousvigilance
- Use of pantograph
- Timely intervention of a prolonged labor due to mechanical factorscan
prevent obst ructed labor.
* Obs:Card 28
Ques 2

It isa case of 37 week of pregnancy wit h premat ure rupture of membrane

(PROM)

Mx:
Medical -
Bed rest
Ant ibiot ic not needed
Steroid haslittle role Obst et ric -
Wait for spont aneous onset of labour for 24 hrs, if failsthen Induct ion of
labour wit h Oxyt ocin.

Obs Card 28
Qst n 3:

* primary PPH: Any amount of bleeding fromor into genital t ract following
birt h of the baby upto the end of puerperiumwhich adversely affectsthe
general condition of the patient evidenced by rise in pulse rate and falling
blood pressure iscalled post partumhaemorrhage.

** causes of primary PPH:

At onic uterus:
grand mult iparae
over dist ension of uterus( in mult iple pregnancy, polyhydraminos, large baby)
malnut rit ion and anaemia
antepartumhaemorrhage
prolonged labour
anaest het ic drugs
init iat ion or augment at ion of delivery oxytocin/injudicioususe of oxytocin
persist ent uterine dist ension
malformat ion of uterus
mismanaged 3rd sat ge of labour
const rict ion ring
precipitate labour
uterine fibroid

Traumat ic:
t rauma to the genit al t ract during delivery( cervix, vagina, perineum,
paraurethral region and rarely rupture of the uterus
bleeding during c/s
episiot omy
C.Mixed: combinat ion of atonic uterusand t rauma D.Coagulopat hy:
bleeding and coagulation disorder
HELLP syndrome
IUD
abruptio placenta
j aundice in pregnancy Obst et rics
Card:28 Quest ion :4

Ant enatal care

Syst emic supervision (examinat ion and advice) of a woman during
pregnancy.

Routine invest igat ion during 1st ante natal checkup a). Hb%
b). Blood groupingand Rh typing c). Randomblood sugar (RBS)
Urine rout ine examinat ion for protein, sugar and Puscells
VDRL
HbsAg
Cervical cytology by papanicolaou st ain isroutine in many clinics

Ant enatal advice

Dietary advice : Diet should be light , nutrit ious,easily digest ible and rich
in protein vitamins and minerals.
Ant enatal hygiene:
Adequat e sleep and rest
Bowel care by preventing const ipat ion
Bathingbe careful about slipping
woman should wear loose and comfort able clothesand prevent t ight clothing
like belts
Maint ain good dental hygiene
Proper care of breast
Avoid coitusin the first t rimest er
Avoid smoking and alcohol
Immunizat ion:
TT immunizat ion
1st dose- 5th mont h 2nd dose- 7th mont h
Rabies,hepat it isA&B vaccine toxoids asin non pregnant st ate
Precaution while using drugsas some drugsare teratogenic
General advice:
Advice to at tend antenatal checkup as scheduled
Inst ructed to report s as soon as possible in case of serious sympt oms like
P/V bleeding or discharge, absent or less fetal movement , urinary t roubles,
abdominal pain etc.
Advice for hospit al admission if:
If sudden hush of wat ery discharge per vagina
Act ive per vaginal bleeding despit e howsmall it might be
Painful uterine contraction at interval of about 10 mins.
Obst et rics CARD NO : 28
QUESTIONNO : 05
Lie : The lie refers to the relat ionship of the long axis of the fetus to the
long axis of the centralized uterusor mat ernal spine .

Present at ion : The part of the fetus which occupiesthe lower pole of the
uterusor may be related to the pelvic brimiscalled the present at ion of the
fetus.
Posit ion : It isthe relat ion of the denominat or to the different quadrantsof
the pelvis. Present at ionsof the longitudinal lie :
Cephalic Present at ion (96.5%)
Present ingpartsof Cephalic present at ion :
Vert ex ( most common - 96%)
brow
face

Obs Card 29
1. i)What is birth asphyxia?
ii)Name the common causes of birth asphyxia?

Birth asphyxia :
Birth asphyxia can be defined as non-establishment of satisfactory
pulmonary respiration at birth.
It’s literal meaning is “stopping of pulse”.

Common causes of birth asphyxia :

Continuation of the intrauterine hypoxia:
a) Inadequate utero-placental circulation:
1) Premature separation of placenta.
2) Circumvallate placenta.
3) Hypertensive disorders of pregnancy.
4) Cord compression
5) Vascular anomalies the cord.

b) Maternal hypoxic state:

1) Maternal severe anaemia.
2) Eclampsia
3) Cyanotic heart diseases.
 4) Status asthmaticus
5) Dehydration
6) Hypotension

B) Maternal medication during prenatal & antenatal period:

1) Anaesthetic drug.
2) Morphine
3) Pethidine
4) Induction by oxytocin, ergometrine & prostaglandin

C) Birth trauma to the neonatal: Birth trauma>

increased intracranial tension > cerebral oedema &
congestion > increased intracranial pressure > asphyxia.
1) Breech presentation.
2) Oblique lie
3) Occipito posterior position
4) Forceps & Ventouse delivery
5) Prolong stage labour due to CPD or contracted pelvis

D) Postnatal factors:
1) Severe anaemia: Haemorrhagic or haemolytic diseases
2) Shock: Severe infection, massive blood loss, intracranial or
adrenal haemorrhage.
3) Failure to breathe adequately: Trauma, narcosis, cerebral
defect.
4) Failure to oxygenation: In congenital heart diseases, pulmonary
diseases.

2. i)What do you mean by augmentation of labour?

ii)Tell the methods of augmentation of labour?

Augmentation of labour:
Augmentation of labour is the process of stimulation of uterine
contractions (both in frequency & intensity) that are already present
but found to be inadequate.

Methods of augmentation of labour:

A) Medical induction: Induction of labour by drugs is called medical
induction.
Example: Induction by oxytocin, prostaglandin, mifepristone
etc.
 B) Surgical induction: Induction of labour by surgical procedure
is called surgical induction.
Example: Induction by artificial (low) rupture of
membrane ( ARM/LRM), Stripping the membranes
C) Mixed: By both medical & surgical methods.

3. A patient came to you at 39 weeks of pregnancy with labour pain for

20 hours. On examination uterus is contracted, fetal heart sound
present. Per vaginal examination shows cervix fully dilated, membrane
ruptured.
Diagnosis: Obstructed labour

Mode of Delivery: There is no place of “wait and watch” neither any

scope of using oxytocin to stimulate uterine contraction. Internal
version is also prohibited. Most of the cases delivery is done by
caesarean section.
Caesarean section: Desperate attempt to do a C/S to save the
moribund baby more often leads to disastrous consequences.
Vaginal delivery:
Vaginal delivery is the treatment of choice.
If the head is low down, FHR is good and vaginal delivery is not risky→
Forceps Delivery.
Dead baby→ Destructive operation

Complications:
Effects on the mother:
Immediate:
Exhaustion: due to constant agonizing pain & anxiety
Dehydration: due to increased muscular activity without adequate fluid
intake
Metabolic acidosis: due to accumulation of lactic acid & ketones.
Genital sepsis: due to repeated P/V/E or attempted manipulation
outside.
Rupture of the uterus (common in multiparae) & other injury to the
genital tract.
PPH & shock
Increased rate of operative manipulation.
Remote:
Genitourinary(VVF) fistula or recto vaginal fistula
Variable degree of vaginal atresia
Secondary amenorrhoea following hysterectomy(due to rupture of
uterus) & Sheehan’s syndrome
Effects on the fetus:
Asphyxia due to tonic uterine contractions or due to cord prolapse
specially in shoulder presentation (so there is utero-placental
circulation compromise)
Acidosis due to fetal hypoxia and maternal acidosis
Intra-cranial haemorrhage due to duper-moulding of the head leading
to tentorial tear or due to traumatic delivery
Infection
4. A patient came to hospital 16 days after C/S with H/O profuse P/V
bleeding 2 hrs back.
i) What is your diagnosis?
ii) How will you manage her?
i) Diagnosis: It is a case of 16th day of puerperium with secondary
PPH
ii) Management:
Symptoms: Per-vaginal bleeding.
Signs:
General examination -
Signs of anaemia,dehydration present.
Signs of sepsis may present.

P/A examination-
1) Subinvolution of uterus may be present.
2) Patulous cervical os.
3) CS wound: Evidence of infection.

P/V examination-
1) Signs of bleeding are on inspection.
2) Clotted blood may be found.
3) Signs of laceration in the genital tract or perineum may be present.

Investigations:
1) Blood grouping & Rh typing and cross matching with the donor
blood.
2) Blood routine examination: TC (raised in sepsis).DC, Hb%
3) Ultrasonography: For bits of placenta inside the uterine cavity.

Treatment:
Conservative treatment:
If the bleeding is slight & no apparent cause is detected,a careful watch
for a period of 24 hours or so is done in the hospital.
Supportive treatment:
1) Bed rest.
2) Nutritious diet.
3) Blood transfusion.
4) Antibiotic: Broad spectrum, preferably injectable. Inj.
Cephradine(500mg,I/V 6 hourly) or Ceftriaxone (2g ,I/V daily)
with/without
Inj. Metronidazole.
5) Inj. Ergometrine (0.5 mg)I/M: If the bleeding is uterine in origin.

Specific treatment:
1) If retain bits of cotyledon or membranes-Exploration of the uterus
urgently under G/A.The products are removed by ovum forceps.Gentle
curettage is done by using flushing curette. Ergometrine(0.5mg) is
given I/M.
2) Secondary PPH following C/S-May require Laparotomy.
3) Wound of cervico-vaginal canal: Haemostatic sutures.
4) The bleeding from uterine wound can be controlled by haemostatic
sutures.
5) May require ligation of the internal iliac arterv or may end in
hysterectomy.

5. What is MMR? What are the common causes of MMR in our

country? How can we reduce MMR globally?
MMR- Maternal mortality rate or MMR indicates the number of
maternal deaths divided by the number of women of reproductive age
(15-49). It is expressed per 100000 women of reproductive age per
year.
Causes in our country:
Hemorrhage: antepartum hemorrhage due to abruption placentae or
placenta previa, retained placenta, abortion etc.
Infections due to premature rupture of the membranes, prolonged or
obstructed labor etc.
Hypertension during pregnancy : preeclampsia, eclampsia
Unsafe abortion
Obstructed labor
Anaemia
Other indirect causes such as viral hepatitis ( HEV )
Specific actions to reduce MMR are discussed under the following
groups:
Health Sector actions:
Basic antenatal Intranatal and postnatal care . Risk assessment is a
continued procedure throughout and is not once only
A skilled attendant should be present at every birth. Functioning
referral system is essential for integration of domiciliary and
institutional services.
Emergency obstetric care (EmOC) is to be provided either by a field
staff at the doorstep of pregnant woman or preferably at the first
referral unit FRUL
Good quality obstetric services at the referents are to be ensures
Facilities transfusion, laparotomy and cesarean section must be
available at the FRU level
Prevention of unwanted pregnancy and unsafe abortion. All couples
and individuals should have access to effective, client oriented and
confidential family planning services
Frequent joint consultation among specialists in the management of
medical disorders in pregnancy particularly anemia, diabetes cardiac
disease, viral hepatitis, and hypertension
Maternal mortality conferences to evaluate the cause of death and the
avoidable factors.
Periodic refresher courses for continuing education of obstetricians,
general practitioners, midwives and ancillary staff and to highlight the
preventable factors.

Community, Society and Family Actions:

These are essential to safe motherhood. Wide range of groups
(women's groups), health care professionals, religious leaders and safe
motherhood committees (regional, district) can help the woman to
obtain the essential obstetric care.

Health Planners/ Policy Makers Actions:

To organize community education, motivation and formation of safe
motherhood committee at the local level.
To strengthen the referral system for obstetric emergencies. To develop
written management protocols for obstetric emergencies in the
hospitals
To improve the standard and quality of care by organizing refresher
courses for the health care personnels.
Periodic audit of the tiny health care delivery system and to implement
changes as needed

Legislative and Policy Actions

Girl children and adolescents should have good nutrition, education
and economy opportunities. They are to be educated about the age of
sex and the risks of unprotected sex.
Barriers to the access of health care facilities should be removed.
Policies should increase women's decision making power of respond to
their own health and reproduction.
Decentralization of services to make them available to all the women,
Safe abortion services and postabortion care must be ensured by
national policy.
Social inequalities and discrimination on trends of gender, age and
marital status are to be removed.

Obs Card 30
Answer to question 1)
Puerperal pyrexia: A rise of temperature reaching 100.4°F(38°C) or
more (measured orally) on two separate occasions at 24 hours
apart(excluding first 24 hours) within first 10 days following delivery is
called puerperal pyrexia.
Causes of puerperal pyrexia:
a. Puerperal sepsis.
b. Urinary tract infections-Cystitis, pyelonephritis.
c. Breast complications-mastitis, breast abscess, breast engorgement.
d. Wound infections- caesarean section wound or episiotomy wound.
e. Pulmonary infections- atelectasis, pneumonia.
f. Septic pelvic thrombophlebitis.
g. A recrudescence of malaria or pulmonary tuberculosis.
h. Others- pharyngitis, gastroenteritis.
Investigations:
a. High vaginal and endocervical swabs for culture in aerobic and
anaerobic media and sensitivity test to antibiotics.
b. Urine R/M/E of clean catch midstream urine specimen for culture &
sensitivity test.
c. Blood for TC, DC of WBC, Hb%, platelet count, ESR.
d. Thick blood film for malaria parasite
e. Blood culture-if fever is associated with chills and rigor.
f. Pelvic USG- to detect any retained bits of conception in uterus ,to
locate any abscess within the pelvis, to collect sample (pus, fluid) from
the pelvis for culture & sensitivity, colour flow doppler study for venous
thrombosis.
g. CT and MRI- if doubt of pelvic vein thrombosis.
h. X-ray chest - in suspected pulmonary Koch's lesion, lung collapse,
atelectasis.
i. Blood urea and electrolyte - to have baseline record (renal failure)
Answer to question 2)
Provisional diagnosis is a case of 5thgravida para 4 with 39weeks pg
with transverse lie.
Management:
O Clinical features & clinical examination findings:
1. Abdominal examination:
a. Inspection: The uterus looks broader and often asymetrical,not
maintaining the pyriform shape.
b. Palpation:
➡Fundal height: Less than the period of amenorrhea.
➡Fundal grip: Fetal pole is not palpable( empty fundal grip)
➡Pelvic grip: The pelvic grip is found empty.
➡ Lateral grip:
- Soft, broad & irregular breech is felt to one side of the midline and
smooth,hard & globular head is felt on other side.
- The back is felt anteriorly across the long axis in dorso- anterior or
irregularly small parts are felt anteriorly in dorso- posterior.
c. Auscultation of fetal heart sound:
➡Dorso- anterior position:FHS is heard easily much below the
umbilicus.
➡Dorso- posterior position: FHS is located at a higher level & often
indistinct.
2. Per vaginal examination:
a. During pregnancy: Presenting part is so high that it cannot be
identified properly.
b. During labour:
➡ Elongated bag of membranes can be felt if it doesn't rupture
prematurely.
➡The shoulder is identified by palpating acromion process,the scapula,
clavicle & axilla.
➡The characteristic landmarks are the feeling of the ribs & intercostal
space.
➡The arm may be found prolapsed.
➡It should be remembered that findings of a prolapsed arm is
confirmed not only transverse lie but also is may be associated with
compound presentation.
➡In complicated cases a leg may be prolapsed.
O Investigation:
1. Ultrasonography
2. Plain X-ray abdomen (not done commonly nowadays)
O Treatment:
1. Antenatal care and treatment:
a. External cephalic version: External cephalic version should be done
in all cases beyond 35 weeks provided there is no contraindication.
b. If version fails or is contraindicated:
Caesarean section delivery after 37 weeks.
☑️Dead or congenitally maldormed baby: Vaginal delivery.
2. Treatment during labour:
a. Early labour:
➡ External cephalic version should be tried in all cases if there is no
contraindications or there is good amount of liquor present.
➡If external cephalic version fails or contraindicated: Caesarean
section.
b. Late labour:
➡If baby is alive and fetal condition is good: caesarean section.
➡If baby is dead: Destructive operation( decapitation, evisceration)
followed by exploration of uterine cavity to exclude ruptured uterus.If
destructive operations cannot be done caesarean section is the
treatment of choice.
Answer to question 3)
Preeclampsia: It is a multisystem disorder of unknown etiology
characterized by development of hypertension to the extent of 140/90
mm Hg or more with proteinuria after the 20th week in a previously
normotensive and normoproteinuric woman.
Baseline investigations done in a case of preeclampsia:
1. Urine: Proteinuria present which may be trace or copious (10 - 15
g/L). There maybe few hyaline casts, epithelial cells or even few red
cells. 24 hour urine collection for protein measurement is done.
2. Ophthalmologic examination: In severe cases, there maybe retinal
oedema, constriction of the arterioles, alteration of normal ration of
vein:artery from 3:2 to 3:1 and nicking of veins where crossed by
arterioles. There maybe haemorrhage.
3. Serum urea and creatinine: Not specific and inconsistent. S. uric
acid level greater than 4.5 mg/dL indicates the presence of eclampsia.
S. creatinine level maybe more than 1 g/dL.
4. CBC: There maybe thrombocytopenia
5. LFT: Hepatic enzyme levels maybe increased
6. Coagulation profile: Abnormal Coagulation profile
7. Antenatal fetal monitoring: By clinical examination, daily fetal kick
count, USG for foetal growth and AFI, CTG, Umbilical artery Doppler
flow velocimetry and biophysical profile
Complications of preeclampsia:
1. Immediate:
A. Maternal:
- During pregnancy: Eclampsia (2%), Accidental hge,
Oliguria and anuria, Dimness of vision and even blindness, Preterm
labour, HELLP syndrome, Cerebral hge, ARDS
- During labour: Eclampsia, PPH,
- During puerperium: Eclampsia, Shock, Sepsis
B. Fetal:
- Intrauterine death
- IUGR
- Asphyxia
- Prematurity
2. Remote:
- Residual HTN: It may persist even after 6 months following
delivery in 50% cases
- Recurrent preeclampsia: Thre is a 25% chance of preeclampsia
to recur in subsequent pregnancies
- Chronic renal disease- High incudence of glomerulonephritis
- Risk of placental abruption
Answer to question 4)
Management of obstructed labour:
Clinical presentation:
History:
H/O prolongation of labour inspite of onset& continuation of true
labour pain(which is the evidence of good uterine contraction)
Failure in progress of labour inspite of good uterine contractions for a
reasonable period (2-4hours) is an impending sign of obstructed
labour.
Previous H/O prolonged labour.
H/O C/S due to obstructed labour.
Short stature
Hypertension, DM.
General examination:
1. Height: Short stature.
2. Patient may be exhausted.
3. Hypotension, tachycardia.
4. Tachypnoea.
5. Signs of dehydration: Dry tongue, dry skin, hypotension,
tachycardia, low urine output etc maybe present.
6. Ketoacidosis may be present.
7. Signs of shock( haemorrhagic): May be present in case of ruptured
uterus.
Pre-abdominal examination:
1. Fetal heart sound: Signs of fetal distress or even absent FHS.
2. Height of Uterus: Decreased(as there is rupture of membrane)
3. Lateral grip: Fetal head& back maybe palpated.(transverse lie).
4.Fundal grip: Head is palpated(breech presentation)
5.Feeling of uterus: Hard(i.e contracted).
6. Abdominal findings of CPD maybe found.
Per-vaginal examination:
1. Inspection: Vagina is found to be oedematous& dry.
2. Palpation:
Membranes are ruptured.
Dry, hot& oedematous vagina.
Oedematous cervix is loosely applied tothe presenting part.
Cervix is fully dialated.
Investigation:
1) USG: No role in current, but a previous USG may confirm the cause
of obstructed labour( tranverse lie, big baby, hydrocephalus, any
ovarian or uterine pathology etc)
2) Blood: Hb%, TC, DC.
3) RBS
4) Blood grouping & Rh typing.
Treatment:
A) Principles of treatment:
1) Correction of dehydration & ketoacidosis.
2) Control of infection & sepsis.
3) Blood transfusion in case of severe anaemia & ruptured uterus.
4) To relieve the obstruction (obstetric management) at the earliest by a
safe delivery procedure.
B)General treatment:
1) Nothing by mouth.
2) Oxygen inhalation: if maternal respiratory distress and fetal distress.
3)I/V fluid: Hartman's solution, Normal saline, Ringer's lactate, 5% DA
& 5% DNS. At least 3litres of fluid are required to correct correct
clinical dehydration..
4)Correction of acidosis: 25% sodium bi carbonate I/ V tds.
5) Antibiotic: Injection Ceftriaxone( 2gm, I/V od) or Cepradine( 500mg,
I/V qds) or Cefepime(2gm, I/V bd) + Inj Metronidazole(500mg, I/V tds)
6) Analgesic: Inj Pethidine 100mg, I/V or I/M which also reduces
anxiety.
7) Catheterization: To monitor the urine output for 14-21 days to rest
the bladder & urethra & to prevent VVF.
C) Specific/ obstetric treatment: There is no place of 'wait & watch'
neither any scope of using oxytocin to stimulate uterine contraction.
Internal version is also prohibited. Most of the cases delivery is done by
caesarean section.
a) Vaginal delivery:
If the head is low down, FHR is good & vaginal delivery is not risky:
Foceps delivery
In neglected cases even with audible FHS: vaginal delivery is the
treatment of choice.
Dead baby:destructive operation.
b) Caesarean section:
In case of early detection with good fetal condition: C/S gives the best
result.
But in late & neglected cases, even with audible FHS, desperate
attempt to do a C/S to save the moribund baby more often leads to
disastrous consequences.
Answer to question 5)
Advantages of Breastfeeding :
I. Breast milk is an ideal food with easy digestion and low osmotic
load.
II. Protection against infection and deficiency states:
1. Vitamin D promotes bone growth, protects the baby against
rickets
2. Leukocytes, lactoperoxidase prevents growth of infective agents
 3. Lysozyme, lactoferrin, interferon protect against infection
4. Long-chain omega-3 fatty acids essential for neurological
development
5. Immunoglobulins IgA (secretory), IgM, IgG protect against
infection
6. Supply of nutrients and vitamins.
III. Breast milk is a readily available food to the newborn at body
temperature and without any cost.
IV. Acts as a natural contraception to the mother
V. Additional advantages:
(i) It has laxative action
(ii) No risk of allergy
(iii) Psychological benefit of mother-child bonding
(iv) Helps involution of the uterus and
(v) Lessens the incidence of sore buttocks, gastrointestinal
infection and atopic eczema. The incidence of scurvy and rickets is
significantly reduced.
Composition:
I. Carbohydrate: Mainly lactose, stimulates growth of intestinal flora,
produces organic acids needed for synthesis of vitamin B
II. Fat: Smaller fat globules
III. Protein: Rich in lactalbumin and lactoglobulin, less in casein
VI. Minerals: K+, Ca2+, Na+, Cl–
V. Vitamins: Vitamin B12 and Vitamin D