https://www.dropbox.com/sh/vqiptez7d95t4kc/AABQ1sN8jSEP5urWhbyLMrBOa?

dl=0
https://www.dropbox.com/sh/0pbmm85ic045wp1/AACyWqv9FeKomBqzVELBWjPya?dl=0

OSCE

Station 1:​ History taking (till HOPC, 3rd trimester)

Station 2: ​Abdominal Examination
Station3: ​Foley’s Catheterization
Pap Smear
Per Speculum/Per Vaginal Examination
Station 4: ​Instruments - 2 to 3, identification and uses. Green Armytage is important.
Station 5: ​Definitions & causes - miscarriage, antepartum (APH) and postpartum hemorrhage
(PPH), maternal mortality rate (MMR).

VIVA QUESTIONS;
Q. How do you obtain baby’s blood from the cord and what tests are done on that?
Q. Why didn’t a Rh-negative mother, whose not screened or immunized, P5 + 0, not have
Rh-positive antibodies?
Q. When will anti-D be given during the course of the pregnancy? And what does it do?
28 weeks
Prevents hemolytic disease of the fetus and newborn
Rho isoimmunisation

Q. Postpartum hemorrhage and its types. Management?

Primary Postpartum hemorrhage: Bleeding of genital tract after delivery within 24 hours
Secondary Postpartum hemorrhage: Bleeding from genital tract after 24 hours of delivery to 6
weeks.
Management: Assess airway, breathing, and circulation. Use an oxygen mask. Maintain an IV
line. Send for blood count and clotting studies. Send for renal function test. Cross match blood.
Put a foley's catheter in bladder. Transfuse blood. Investigate cause and stop bleeding. If does
not stop then send to OT.

Q. Difference between dyskaryosis and dysplasia.

Dyskaryosis is the change of appearance of cells that cover the cervix
Dysplasia is the presence of cells of an abnormal type within a tissue which may signify a stage
preceding cancer

Q. What do you do if a mother delivered Rh positive babies, in the village, and the 5th baby is…
Q. Booking investigations.
Q. What organ lies in front of the uterus?
Bladder
Q. What is Down's Syndrome? Can it be prevented? What tests can you do to find out if fetus
has it? What is harmony test? Is it available in Pakistan? (No, only UK)
Down Syndrome: Chromosomal defect where the baby contain an extra copy of the
chromosome usually trisomy 21. Test used can be amniocentesis, chorionic villus sampling. It
can be prevented by conceiving a baby earlier than 35. Harmony is a test that checks for fetal
DNA in maternal blood. The test is offered in ZU but the sample is sent to England.

Q. Test to check gestational diabetes?

OGTT, GCT

Q. Organisms causing vaginal infections?

HSV, HPV, Gonorrhea, Chlamydia

Q. Management of mother with O negative blood group.

Q. Management of Rh negative mother while she is pregnant and during labour. Or if mother is
O positive and baby is B negative.
Q. PPROM (preterm prelabour rupture of membranes) and its complications.
Q. 10 causes of abdominal pain in pregnancy.
Q. What do you know about stem cells? Where do you obtain them from?
Q. Stages of labour? 3rd stage of labour.
3 stages of labor: 1st, 2nd, 3rd
1st stage: Start of dilation of cervix to 10cm
2nd stage: Period between full dilation of cervix and expulsion of fetus.
3rd stage is between delivery of fetus to delivery of placenta. This stage if lasting more than 30
minutes is abnormal.

Q. Definition of miscarriage. What is fetal death after 24 weeks called? Antepartum hemorrhage.
Miscarriage: Expulsion or termination of pregnancy before viability. Death of fetus before 24
weeks is considered miscarriage.
Fetal death after 24 weeks is stillbirth
Antepartum Hemorrhage is bleeding from genital tract after 24 weeks of gestation and before
labor.
Causes: Placental Abruption, Placenta previa, vaginal infection

Q. Rh incompatibility.
Q. Define pap smear? What is dyskaryosis?
Cytological screening test for detecting premalignant lesions of cervix.
Define Dyskaryosis: When squamous mucosa cells next to the uterine surface show
abnormalities in their nuclei.

Q. What do you do when the pap smear is abnormal?

Class I repeat pap smear annually.
Class II repeat pap smear within 3-6 months, HPV DNA typing, colposcopic evaluation.
Class III repeat pap smear within 6 months if positive do colposcopy.
Class IV Do colposcopy.

Q. Causes of small and large for gestational age babies.

Small: Smoking, Type 1 diabetes, dec nutritional intake by mother, hypertensive mother, dec
blood flow, placenta previa, placental abruption, multiple, anemia
Large: Gestational diabetes, obesity, diabetes type 2, Genetics

Q. Maternal Mortality Rate definition.

Number of deaths from obstetric causes per 100,000 maternities.

Q. Perinatal definition.
The time period right before and after birth. Starts around 20 weeks and goes up to 1 to 4
weeks after birth.

Q. How to assess if a woman has diabetes pre-pregnancy?

GCT and OGTT

Q. Pregnancy induced hypertension (PIH) definition and symptoms? How is PIH/preeclampsia

classified? Causes? ​Gestational hypertension, also referred to as pregnancy induced
hypertension (PIH) is a condition characterized by high blood pressure during pregnancy.
Gestational hypertension can lead to a serious condition called preeclampsia, also referred to
as toxemia.

Q. Stages of pregnancy.
Q. Where is anti-D given?
Deltoid, Gluteal region is less painful but not prefered.

Q. Changes in fibroid during pregnancy?

Q. Oligohydramnios, polyhydramnios.
Q. Twin-to-twin transfusion.
Q. Down’s Syndrome testing (NT scan, AFP, PPAP-A, hCG)
Nuchal Translucency: Done at 11-14 weeks. Looks at the thickness of the neck
PPAP-A: Pregnancy associated plasma protein A.
 WEEKLY TEST QUESTIONS
(correct answers highlighted)

1ST WEEKLY TEST

Q. Term is defined as pregnancy of
a) 36 - 40 weeks
b) 37 - 41 weeks
c) 38 - 40 weeks
d) 37 - 42 weeks

Q. In the 3rd trimester history, all of the following are asked except
a) Antenatal visits
b) Gestational diabetes
c) Tetanus toxoid vaccination
d) Anomaly scan
e) History of leaking

Q. In pregnancy, all of the following increase except

a) VII
b) VIII
c) IX
d) Prothrombin
e) Von Willebrand

Q. Regarding the immune system in pregnancy, all of the following are true except
a) Pregnancy is an immunosuppressive state.
b) T-cell mediated immune responses are upregulated.
c) Innate immunity system is activated.
d) B cells are unaltered.
e) NK cells increase in early pregnancy and decrease by term.

Q. Major causes of maternal death are the following, except

a) Mild bleeding
b) Infections
c) Unsafe abortions
d) Eclampsia/Hypertension
e) Obstructed labor

Q. In past gynaecological history, all is asked except

a) Last abortion
b) Flow
c) Clots
d) Dysmenorrhea
 e) Intermenstrual bleeding

Q. Write the definition of Maternal Mortality Rate.

Number of maternal death in a given period per 100,000 women of reproductive age during the
same time period.

2ND WEEKLY TEST

Q. In a normal pregnancy, maternal physiological influences on birth weight include all of the
following except
a) Age
b) Height
c) Ethnicity
d) Blood group
e) Parity

Q. In booking visit, following should be done except

a) Confirmation of pregnancy
b) Dating scan
c) Thalassemia screen
d) Send booking investigations

Q. Almost all of the cells are produced by the bone marrow after which week?
a) 16 weeks of gestation
b) 17 weeks of gestation
c) 18 weeks of gestation
d) 20 weeks of gestation

Q. About amniotic fluid volume, which one is correct?

a) It protects the fetus from thermal injury.
b) It restricts movement of the fetus while promoting limb contracture.
c) It prevents adhesions between the fetus and amnion.
d) It prevents macrosomia.

Q. The lung first appears as an outgrowth from the primitive gut at

a) 3 - 4 weeks
b) 5 - 6 weeks
c) 8 - 9 weeks
d) 10 - 12 weeks

Q. All are instruments used for dilatation and evacuation, except

a) Uterine sound
b) Sims speculum
 c) Pippel
d) Dilator

Q. Preterm infants are more prone to

a) Hypokalemia
b) Hyponatremia
c) Hypoglycemia
d) Hyperglycemia

Q. Determinants of fetal weight are

a) Fetal genome, intrauterine environment, thyroxine, insulin
b) Thyroxine, stress, O2, CO2
c) Maternal and paternal genome
d) Only intrauterine environment

Q. Of fetal development, which statement is true?

a) In the 3rd trimester, glycogen and fat decreases and water increases.
b) In utero metabolic function is performed by the placenta.
c) The large bowel is filled with meconium in preterm fetus.
d) Surfactant is produced by 20 weeks.

Q. Prerequisite for per speculum examination is

a) Performed in left lateral position.
b) Consent.
c) Adequate light and consent.
d) Should be performed when suspecting any pathology.

3RD WEEKLY TEST

Q. In the ultrasound, high frequency sound waves used are
a) Between 2.5 - 7.0 megahertz
b) Between 3.5 - 6.0 megahertz
c) Between 2.0 - 7.0 megahertz
d) Between 1.0 - 7.0 megahertz

Q. All of the following can be diagnosed on ultrasound, except

a) Cerebral palsy
b) Achondroplasia
c) Abdominal wall defects
d) Cleft lip and palate
e) Congenital heart defects

Q. All of the following are uses of transvaginal ultrasound, except

a) Early pregnancy
 b) Measurement of cervical length
c) Measurement of distance between lower edge of placenta and internal os
d) Biparietal diameter measurement

Q. Which of the following is true?

a) Gestational sac can be visualized between 7 - 8 weeks.
b) Yolk sac can be visualized at 5 weeks.
c) Embryo is measured (CRL) between 3 - 4 weeks.
d) Heartbeat can be visualized at 8 weeks.

Q. Which of the following is true regarding chorionic villus biopsy?

a) Risk of miscarriage is 0.02%
b) This involves sampling of the amniotic fluid.
c) It can be performed soon after the screen positive result of the combined test becomes
available between 11 and 14 weeks.
d) CVS should not be performed after 15 weeks.

Q. Regarding amniocentesis, which of the following is true?

a) It can only be performed after 11 weeks.
b) It is performed under aseptic conditions, under continuous ultrasound guidance, using a
gauge 16-18 needle.
c) It increases the background miscarriage rate by 1%
d) Amniotic fluid will contain fetal blood cells, urogenital and pulmonary epithelial cells and
cells from the extraembryonic membranes.
 IMPORTANT DEFINITIONS

Antepartum Hemorrhage:​ Bleeding from the genital tract after 24 weeks and before the onset
of labor.

Primary Postpartum Hemorrhage​: Loss of more than 500ml of blood from genital tract within
24 hours of delivery.

Secondary postpartum hemorrhage​: Loss of more than 500ml of blood from genital tract after
24 hours of delivery-6 weeks.

Maternal Mortality Rate​: Number of maternal death in a given period per 100,000 women of
reproductive age during the same time period.

Miscarriage​: Spontaneous expulsion of a fetus from the womb before it can survive
independently.
 HISTORY TAKING

1. Introduction & Consent

2. Biodata
- Name
- Father/husband’s name
- Age
- Education
- Occupation
- Ethnicity
- Married since
- Address
- Date of admission
- Time of admission
- Mode of admission (OPD/ER)
- Gravida (only ask if she’s pregnant)
- Parity
- Last Menstrual Period (LMP)
- Estimated Date of Delivery (EDD = LMP + 9 months and 7 days) = 40 weeks gestation
3. Presenting Complaint
- Gestational amenorrhea since (in weeks)
- Active complaint, duration
4. History of Presenting Complaint
- Patient was in perfect/in her usual state of health till *presenting complaint*
1st trimester​:​ ​(first 12 weeks)
- Planned/unplanned pregnancy?
- Conception spontaneous/after treatment (IVF, etc)
- Booked/unbooked
- How was pregnancy first confirmed? Once/twice/more? Where?
- History of fever, per vaginal bleeding, urinary symptoms
- Any other complications?
- Routine antenatal visits throughout trimester?
- Blood tests (CBC, RBS, urine D/R, HbsAg, Anti HCV, red cell antibodies, Rubella IG) &
ultrasound, ​NT scan done at 11 - 14 weeks for Downs Syndrome;​ any problems
identified? Chorionic Villus Sampling (CVS) also done at 11 - 14 weeks
- Folic Acid intake and Calcium supplements
2nd trimester​:​ ​(12 - 24 weeks)
- Quickening? When did it start? (starts after 20 weeks)
- Routine antenatal visits throughout trimester? (every 4 weeks)
- Iron and Calcium supplements
- History of lower abdominal pain, per vaginal bleeding, discharge, increased blood
pressure, diabetes
- Blood tests (CBC, OGTT/GCT, urine D/R - every 3 weeks) & ultrasound (anomaly
scan, after 20 weeks, to check normal development)
- Chances of diabetes increase after 20 weeks
3rd trimester​:​ ​(24 - 36 weeks/delivery)
- Routine antenatal visits throughout trimester? (every 2 weeks, & then after 36th week:
every week)
- Iron and Calcium supplements
- History of lower abdominal pain, per vaginal bleeding, vaginal discharge, increased
blood pressure, diabetes - monitoring?
- 2 doses of tetanus toxoid, at 28th and 32nd weeks/7 - 8 month
- Blood tests & ultrasound (growth scan, to check normal development)
- Details about presenting complaints, any other concerns

Possible Presenting Complaints & their History:

● Hypertension:
- Associated symptoms (headache, vision)
- Tests (blood, urine, to check for proteinuria, etc)
- Medicines
- Monitoring at home, charting regularly
● Diabetes:
- Family history
- When did it start?
- Complications: macrosomia, IUGR, polyhydramnios
● Anemia
● Vaginal bleeding
- Check for low lying placenta (could be because of placenta praevia)

Complete Blood Count (CBC)

WBC 4, 000 - 10, 000/mm^3

RBC 4.2 - 5.9 million/mm^3

Hemoglobin 12 - 16 g/dL

Hematocrit 37 - 47%

MCV 56 - 95 um^3/cell

MCH 27 - 32 upg/RBC

Red Cell Distribution Width (RDW) 11.5 - 14.5

Platelet Count 150, 000 - 400, 000/mm^3

Neutrophils 40 - 75%
 Lymphocytes 15 - 45%

Monocytes 1 - 10%

Eosinophils 1 - 6%

Basophils 0 - 2%

5. Past Obstetric History

- Married since?
- Last menstrual period (LMP)
- Estimated Date of Delivery (EDD)
- Consanguineous marriage
- Gravida
- Parity
- Details of each previous pregnancy (including miscarriages)

Table:
No. Age Duration Complic Mode of Complic Weight Breast
of ations delivery ations of feeding
pregnan during during or baby/ies
cy pregnan after &
cy delivery conditio
n at birth

6. Past Gynaecological History

- Age of menarche
- Cycle length
- Regular/irregular
- Flow (number of pads used)
- Clots
- Dysmenorrhea
- Intermenstrual bleeding
- Last Menstrual Period (LMP)
- Postcoital bleeding
- Dyspareunia
- Vaginal discharge (consistency, amount, smell, colour) has
- Contraception
- Last cervical/pap smear
- Menopause
7. Past Medical History ​(diabetes, hypertension, asthma, epilepsy, Tuberculosis, blood
disorders, cancer, thyroid issues, vaginal infections)
8. Past Surgical History ​(important if any procedure with anesthetics was done and
resulted in complications; Cesarean section, ectopic pregnancy, pelvic surgery, etc)
9. Transfusion History
10. Allergy History
11. Drug History ​(regular, before or during pregnancy, treatments, contraceptives)
12. Family History ​(diabetes mellitus, ischemic heart diseases, hypertension, asthma,
Tuberculosis, history of multiple pregnancy, congenital anomalies/genetic problems,
blood disorders (Thalassemia, etc), psychiatric disorders, in patient’s first degree family:
parents & siblings, ONLY)
13. Personal History
- Diet
- Sleep
- Micturition
- Bowel habits
- Addictions
- Stress level
14. Socioeconomic History
- Number of rooms in the house
- Number of members in the house
- Number of earning members
- Ventilation
- Water source
- Help available at home
- Any housing problems?
 MODERN MATERNITY

- It should be mandatory that all pregnant women should be seen at least twice by a consultant
obstetrician preferably as soon as possible in early pregnancy and again in late pregnancy.

- Targets/Millennial Development Goals:

1) Eradicate extreme poverty and hunger
2) Achieve universal primary education
3) Promote gender equality and empower women
4) Reduce child mortality
5) Improve maternal health
6) Combat HIV/AIDS, TB, Malaria and other diseases.
7) Ensure environmental sustainability
8) Develop a global partnership for development

- Involvement of professional bodies and consumer groups in maternity care: National Institute
for Health and Clinical Excellence, National Screening Committee, Royal College of Obstetrician
and Gynecologist, SOGP.

- ​Maternal Death:​ The death of a woman while pregnant or within 42 days of termination of
pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or
aggravated by the pregnancy or its management but not from accidental or incidental causes.

- Measuring maternal death: Maternal mortality ratio, Maternal mortality rate, Adult lifetime risk
of maternal death

- ​Maternal Mortality Ratio: ​Number of maternal deaths during a given time period per 100,000
live births during the same time period.

- ​Maternal Mortality Rate: ​Number of maternal death in a given period per 100,000 women of
reproductive age during the same time period.

- ​Adult Lifetime Risk of Maternal Death: ​The probability of dying from a maternal cause during
a woman’s reproductive period.

-​ Direct Maternal Death: ​That is the result of a complication of the pregnancy, delivery, or
management of the two.
- I​ndirect Maternal Death: ​That is a pregnancy-related death in a patient with a preexisting or
newly developed health problem unrelated to pregnancy.
- Fatalities during but unrelated to a pregnancy are termed ​accidental, incidental, or non
obstetric maternal deaths.
- Major Causes:
● Direct Causes:
- Severe bleeding/hemorrhage (25%)
- Infections (13%)
- Unsafe abortions (13%)
- Eclampsia/ HTN (12%)
- Obstructed labour (8%)
- Other (8%)
● Indirect Causes: (20%)
- Cardiac disease
- Malaria, Anaemia, HIV/AIDS
- Conditions that complicate pregnancy and or are aggravated by it

- ​Perinatal Mortality Rate:​ The PNMR refers to the number of perinatal deaths per 1,000 total
births.
 PHYSIOLOGICAL CHANGES IN PREGNANCY

Why do changes occurs?

- Increased availability of precursors for hormone production and fetal – placental
metabolism.
- Improved transport capacity.
- Maternal-fetal exchange.
- Removal of Additional waste products.

Volume Homeostasis
- Rapid expansion of blood volume begins at 6-8 weeks gestation and plateaus at 32 - 34
weeks.
- Expansion of extracellular fluid results in increase of 8 - 10 kg average maternal weight.
Total body water increases 6.5 - 8.5 L by end of pregnancy.
- Increases cardiac output and renal blood flow.
- Factors contributing to fluid retention:
- Sodium retention
- Resetting of osmostat
- Decrease thirst threshold
- Decreased plasma oncotic pressure
- Consequences of fluid retention:
- Decreased haemoglobin concentration
- Decreased haematocrit
- Decreased serum albumin concentration
- Increased stroke volume
- Increased renal blood flow

Hematology
- Physiological anemia (13.3 g/dl to 10.9 g/dl)
- Increased iron demand
- Increased Absorption of iron (decrease intake can result in iron deficiency anemia)
- Renal clearance of folic acid increases
- Red cell folate concentration do not decrease.

Homeostasis and Coagulation

- Pregnancy is a hypercoagulable state.
- Factor VII, VIII. IX, X, XII, von willebrand factor and fibrinogen increases in pregnancy
- Fibrinogen increases by 50%.
- Anticoagulant factors protein S activity decreases & increase in activated protein C
resistance
- Maternal plasma D-dimer concentration increases progressively
- Venous thromboembolic complication 5 times greater during pregnancy.
 - These changes return to normal around 4 weeks after delivery.

Biochemistry
- Plasma protein (albumin) decreases - plasma oncotic pressure
- Serum creatinine, uric acid and urea concentration are reduced.
- LDH unaltered or slightly increases.

Decrease​:
- Haemoglobin concentration
- Haematocrit
- Plasma S activity
- Plasma protein concentration
- Serum creatinine
- Serum urea
- Serum uric acid

Increase​:
- ESR
- Fibrinogen concentration
- Activated protein C resistance
- Factor VII, VIII, IX, X, XII
- D-dimers
- Alkaline phosphatase

Immune System
- Pregnancy is immunosuppressive state
- T cell mediated immune responses down regulated
- Innate immune system activated
- B cell unaltered
- NK cells increase in early pregnancy and decrease by term

Maternal Brain
- Problems with attention, concentration, memory.
- Underlying mechanism not clear.
- Proposed cause lack of estrogen, elevated oxytocin
- Progesterone has sedative effect
- Greater pain tolerance

The Senses
- Changes in perception of odours.
- Decreased olfactory perception.
- Corneal sensitivity decreases.
- Decreased tear production
Respiratory Tract
- Breast engorgement and airway edema can compromise visualization larynx during
tracheal intubation.
- Vascularity to respiratory mucosa increases.
- Changes in volumes and capacity.
- Ventilation increases by 8th week.
- Diaphragm is elevated.
- Rib cage expanded
- Increase in 2,3-diphosphoglycerate
- Oxygen Hb dissociation curve shifts to right in mother and left in fetus
- Marked decrease in pCO2 Slight increase in pO2

Ventilatory Changes
- Thoracic anatomy changes
- Increase minute ventilation.
- Increase tidal volume
- Decrease residual volume
- Decrease functional residual capacity
- Vital capacity unchanged or slightly increased

Blood Gas and Acid-base Changes

- Decrease pCO2
- Increase pO2
- pH alters slightly
- Increase bicarbonate excretion
- Increase oxygen availability to tissues and placenta

Cardiovascular
- Increase heart rate (10-20 %)
- Increase stroke volume (10%)
- Increase cardiac output (30-50%)
- Decrease mean arterial pressure (10%)
- Decrease pulse pressure
- Decrease peripheral resistance (35%)
- Decrease blood pressure
- 1st heart sound is loud and sometimes split
- 3rd heart sound audible in 84 %
- Systolic murmur due to increased mammary flow

Gastrointestinal Changes
- Oral cavity
 - Erythema, oedema, hyperplasia and increased bleeding of gingival tissue
- Increased chances of gingivitis
- Increased desquamation
- Gut
- Stomach and intestine displaced upward
- Reduced upper esophageal sphincter tone due to progesterone (relaxant)
- Delayed gastric emptying
- Constipation
- Altered bioavailability

- Liver
- Hepatic function remains normal
- Difficult to examine
- Palmar erythema, telangiectasia
- Protein production increase
- Serum albumin decrease
- Increase Alpha Fetoprotein
- Increased production of fibrinogen, factor VII,VIII,X, XII
- Hypercholesterolaemia

Kidneys and Urinary System

- Increase in size by 2cm
- Hydronephrosis marked on right side in 80%
- GFR increased by 50% in 1st trimester
- GFR fall by 20 in 3rd trimester
- Renal blood flow increases (60-75%)
- Increase clearance of most substances
- Decrease plasma creatinine, urea, uric acid
- Glycosuria is normal

Reproductive Organs
- Uterus
- Uterine blood flow increases 40 fold (80 % to intervillous space, 20 % to myometrium)
- Hyperplasia and hypertrophy of myometrium
- Increased weight of uterus (50-60g to 1000g)
- Cervix
- Increased vascularity
- Swollen and softer ectropion
- Remodeling of cervical collagen
- Increase vaginal desquamation
- Acidic pH
- Breast & Lactation
- Deposition of fat around glandular tissue
 - Number of glandular ducts increased by estrogen
- Number of gland alveoli increased by progesterone and HPL
- Estrogen falls then lactation starts

Endocrinology
- Pituitary Gland
- Prolactin level increase to 15 fold (estrogen stimulatory and HPL inhibitory
- Other factors remain effective
- Prolactin may play role in insulin secretion and glucose homeostasis
- HGH suppressed by HPL
- Thyroid Function
- Thyroid binding globulin increase
- TSH response to TRH reduced in 1st trimester then returns to normal in 2nd trimester
- TSH receptors stimulated by HCG
- Order free T3,T4
- Uterus and Placenta
- Estrogen encourages hypertrophy progesterone inhibit contraction
- Progesterone also have effects on all smooth muscles
- ACTH increases 10 folds Corticosteroid concentration increase Insulin resistance
develops

Metabolism
- Energy requirements and weight gain
- Average increase of BMR 157 MJ for whole pregnancy
- Average weight gain 12.5 kg. (1.6kg in 1st trimester, 0.45 kg per week in 2nd and 0.4
kg per week in 3rd trimester)
- Water increase by around 8L
- Recommended weight gain
- Pre pregnancy BMI < 20 -----12.5 -18.0 kg
- Pre pregnancy BMI 20 - 26 ------11.5 -16.0 kg
- CHO metabolism
- During 1st half of pregnancy fasting blood glucose concentration reduced with little
change in insulin
- 2nd half of pregnancy glucose levels increased
- Insulin resistance (50-70 % decreased insulin action)
- During lactation glucose levels fall and insulin resistance returns to normal
- Lipid metabolism
- After 8th week of pregnancy triacylglycerols, fatty acid, cholesterol and phospholipids
are increased due to estrogen and insulin resistance
- By 12th week HDL cholesterol increases
- Total LDL cholesterol decreases initially and increases by 2nd and 3rd trimester
- Estrogen, progesterone and insulin promote accumulation of maternal fat stores and
inhibit lipolysis
 - In late pregnancy fat mobilization is enhanced to utilize & to preserve glucose and
amino acids.
- Calcium metabolism
- Omega - 3 fatty acids
- Skin
 ABDOMINAL OBSTETRIC EXAMINATION

1. Introduction
2. Explain procedure
3. Informed consent
4. Privacy/screen
5. Female chaperone if you’re a boy.
6. Position
7. Adequate exposure, from the xiphisternum to the pubic symphysis. Cover the above or
below with a sheet.
8. Inspection from foot end (surgical scars, abnormal bulges, pulsations, discoloration, linea
nigra/alba, striagra vaderum/gravidum, position and type of umbilicus - centrally placed &
everted, pattern of breathing, hernia).
9. Come to her right side, ask if she has pain anywhere, if yes then palpate that area last.
Throughout palpation, keep looking at the patient’s face.
10. Warm your hands.
11. Superficial palpation, with a light hand, all across the abdomen.
12. Symphysiofundal height: Measure the length of the uterus. Find the head of the fundus
with the lateral side of your left hand feeling for a resistance, start from the xiphisternum,
measure till the upper border of the pubic bone, in inches, then turn the tape over to
check in centimetres. If woman is 36 weeks pregnant, it will be around 36 cm. Height
corresponds to the weeks.
Uterus is palpable after 12 weeks.
13. Fundal grip, to figure out baby’s position, if his head or buttocks are at the top (cephalic
or breech), if lie is longitudinal. With both lateral sides of hands on top of the fundus.
14. Lateral grip to figure out which side his back is towards and curve of back. Stabilize with
one hand and feel with the other. Do both sides and move up to down while feeling.
15. Pawlick grip to check for engagement of head/buttocks (presenting part).
16. Pelvic grip to check for attitude/extension or flexion of head/buttocks (presenting part).
Done while turned away from the patient’s face.
17. Fetal heart sounds with metal cone thingy: pinards stethoscope/fetoscope. Bigger hole
on belly, paraumbilically on the side the baby’s back is, smaller hole to listen, for 1
minute (you have to listen for one whole minute). Check mother’s radial pulse along with
to make sure what you hear is not her heart sound, but the baby’s, which will be
significantly faster. 110 - 160 bpm.
18. Cover patient.
19. Thank you!
 BREAST EXAMINATION

1. Introduction
2. Explain the procedure
3. Informed consent
4. Privacy/screen
5. Chaperone
6. Ask if any pain/complaints/lump,etc in any specific place/breast
7. Exposure: whole chest
8. Inspection (asymmetry, position of nipple, scars, skin change - dimpling, any apparent
discharge, discoloration, masses, swelling, nipple changes)
9. Ask patient to stand/sit with hands on hips and then bending a little forward and inspect.
10. Ask patient to stand/sit and place hands behind the head and then bending a little
forward and inspect.
11. Position patient supine, with the hand of the side of the breast being examined, behind
the head.
12. Palpate asymptomatic breast first, using your fingers. Palpate all 4 quadrants
individually, lightly. Palpate inward, to outward in a circle. Palpate the axillary tail, near
armpit. Note any masses or tender areas. BOTH SIDES.
13. If mass palpated, examine later in more detail to figure out location, consistency, size,
borders, shape, contour, mobility, fluctuance, if it’s fixed to underlying tissue or overlying
skin, tethering, inflamed, well-circumscribed, etc.
14. Squeeze nipples between thumb and index finger to check for any discharge.
15. Palpation of axillary lymph node groups: anterior, posterior, lateral, medial, apical, while
resting the patient’s arm on your arm and then use your other hand to palpate. BOTH
SIDES.
16. Cover patient
17. Thank you!
 CATHETERIZATION

1. Introduction
2. Explain procedure: mein aapki pishaap ki nalki daal raha houn.
3. Informed consent
4. Privacy
5. Make sure there is enough light.
6. Check if all the instruments are in the tray: double-packaged Foley’s catheter, syringe
with needle, water, lubricant gel (xytocaine), 2 alcohol swabs, tape; make sure the
Foley’s catheter is connected to the tube of the urine bag and the end of the urine bag is
clipped close. Please don’t drop any of the instruments, and if you do accidentally, say
that you will discard it and use a new sterile one.
7. Position: dorsal, with legs open: lithotomy position.
8. Exposure and drape.
9. Sanitize hands and wear gloves.
10. Say that this is a sterilized procedure and I will take all aseptic measures.
11. Open labia majora with left hand, thumb and index finger.
12. Wipe the area with an alcohol swab, up to down in one swipe, discard, repeat. Don’t
move left hand, keep labia open.
13. Take the lubricated tip of the catheter (which ‘assistant’ will lubricate) and insert it into
the urethra, till urine starts coming out the tube, to the bag. Remove your left hand from
the labia now.
14. Fill the syringe with 10 cc/ml distilled water and inject it into the catheter.
15. Tug at the catheter a little to make sure the balloon has inflated and is in place.
16. Tape the catheter to the side of the thigh.
17. Cover the patient.
18. Thank you!
 GENERAL PHYSICAL EXAMINATION

Important: BMI, anemia, pedal edema.

 ANTENATAL CARE

Aims of Antenatal Care​:

- Prevent, detect, manage factors that adversely affect mother and baby
- Provide advice, reassurance, education and support
- To deal with common symptoms in pregnancy
- Antenatal screening for maternal complications
- Screening for fetal complications

Antenatal Education​:
- Provision of information
- Women and their husbands/partners have the right to be involved in all decisions
- Written information is important to help women understand the purpose of screening
tests and options that are available
- Couples should also be offered the opportunity to attend antenatal classes

Advice in Early Pregnancy​:

- Lifestyle modifications
- Information on diet, food, work during pregnancy
- Social aspects - smoking, alcohol, exercise and sexual activity
- Balanced diet - plenty of fruits, vegetables - starchy foods such as pastas, bread, rice
and potatoes, protein, fiber, diary products
- Avoid unpasteurized milk, ripened soft cheese and pate
- Avoid undercooked meat
- Take folic acid 400 microgram/day
- Limited vitamin A approx 700mg/day
- Avoid smoking
- Continuous moderate exercise, avoid contact sports, avoid scuba diving

Common Symptoms in Pregnancy​:

- Extreme tiredness​ is one of the first symptoms of pregnancy. Llasts for approx 12-14
weeks and then resolves in the majority.
- Nausea & vomiting​ is the commonest early symptom. Hyperemesis gravidarum where
fluid and electrolyte imbalance and nutritional deficiency occur is far less common.
- Constipation​ - approx one third of pregnancies. Decreasing in severity with advancing
gestation
- Heartburn​ is also a common symptom. Occurs more frequently as the pregnancy
progresses.
- Hemorrhoids​ are experienced by 1 in 10 women in the last trimester of pregnancy.
- Varicose veins​ occur more frequently in pregnancy.
- The nature of physiological ​vaginal discharge changes​ in pregnancy.
- Backache​ is another potentially debilitating symptom.
Screening for Maternal Complications​:
- Anemia
- Blood groups
- Haemoglobinopathies
- Infection
- Hypertensive diseases
- Gestational Diabetes
- Psychiatric Illnesses
- Placenta Previa (low-lying placenta)

National Screening Committee​:

- The provision of national standards means that new tests are critically evaluated before
being offered to population. Antenatal screening is now offered for:
- Down syndrome
- Fetal anomaly
- Haemoglobinopathies
- Rubella status
- HIV/hepatitis B status
- Tay Sachs Disease in high risk population

Preconception Visit​:
- Optimization of general condition
- Ideal weight
- Optimization of medical conditions
- Thalassemia screen
- Preconceptional folic acid (3 months before conception)

Booking​: (pink card in Ziauddin)

- Detailed history
- Examination
- Dating the pregnancy by dates or Dating scan (10-14 weeks)
- Lab investigations
- Start folic acid

Follow up​:
- Follow-up for fetal growth and well being, prevention of maternal complications

Recommended Schedule of Antenatal Visits:

Visits: Purpose:

Initial contact Information giving, folic acid supplementation, food hygiene

 Lifestyle issues and screening tests offered

Booking (by 10th Extensive information giving

week) Identification of women needing additional care
Offer screening tests
Offer dating scan, Down’s Syndrome screening and detailed scan
Calculate BMI. measure BP, test urine

Dating scan (10th To accurately determine gestational age, finalize EDD and to detect
- 14th week) multiple pregnancies

16th week Review test results. Offer quadruple test if not yet screened for
Down’s Syndrome

18th - 20th week Ultrasound for structural anomalies

25th week Information giving, BP/urine dip/symphysiofundal height

measurement (SFH)

28th week Information giving, BP/urine dip/SFH

Second screen for anemia and red cell antibodies
Anti-D prophylaxis for RhD-negative women

31st week Information giving, BP/urine dip/SFH

34th week Provide information with a focus on labour and birth

BP/urine dip/SFH
2nd dose of prophylactic anti-D (depending on local dosage
schedule)

36th week Provide information with a focus on breastfeeding, Vitamin K for

newborn, care of the baby, postnatal issues
Palpation for fetal presentation
BP/urine dip/SFH

38th week Provide information with a focus on prolonged pregnancy

Palpation for fetal presentation
BP/urine dip/SFH

40th week Provide further information with a focus on prolonged pregnancy

Palpation for fetal presentation
BP/urine dip/SFH

41st week Offer membrane sweep and formal induction of labour

Palpation for fetal presentation
BP/urine dip/SFH
 PAP SMEAR - PER SPECULUM

1. Introduction
2. Explain the procedure: aapkay bachaydaani kay mon kay paani ka test karna hai. Kio?
Yeh har shaadi shudda aurat ko har teen saal mein karana hotta hai, check karnay kay
liye agar cancer kay tu koi asaar nai hain, protocol kay muttabiq. Aapko dard nai houga.
3. Informed consent
4. Chaperone if you’re a boy.
5. Ask the patient if their bladder is empty, have they urinated before coming in? Need to
have an empty bladder.
6. Make sure there is adequate lighting or that your assistant has a torch.
7. Privacy/screen (actually pretend to draw the curtain).
8. Make sure your tray has everything in it: cusco's speculum, formalin/formaldehyde
whatever to fix the slide, gloves, lubricant, thingy to scrape: ayre spatula , slides, empty
bottle, card to send for cervical cytology to the lab.
9. Position - dorsal, with knees flexed and open: lithotomy position. Cover other areas with
a sheet.
10. Sanitize hands and wear gloves.
11. Fix the speculum. Warm it between your hands on in warm distilled water. And ask your
assistant to lubricate it.
12. Open the labia majora with your left hand and insert the speculum sideways/vertically,
while it is closed, slowly, all the way in. Then turn the speculum counterclockwise
horizontally, and open it sufficiently till you can see the cervix fully through it while your
assistant flashes the light into the vagina. Screw and lock the speculum into place and
then leave it.
13. Use the spatula to do a 360 degree scrape of the middle of the cervix: os, making sure
not to poke it any place else or it will get contaminated.
14. Take the spatula out carefully and swipe it front and back onto the front and back of a
slide and place it into the bottle of formaldehyde (or whatever fixing agent). Label the
bottle and fill the card to sent to the lab.
15. Unscrew the speculum, and gently take it out, turning it clockwise.
16. Cover the patient.
17. Thank you!
18. Give her instructions to go to the lab to submit the sample and card.

HIGH VAGINAL SWAB

 NORMAL FETAL DEVELOPMENT & GROWTH

Fetal growth​:
- To reach full growth potential, with adequate supply of oxygen and nutrients.
- The failure of a fetus to reach its full growth potential known as fetal growth restriction is
associated with a significant increased risk of perinatal morbidity and mortality.
- Growth restricted fetuses are more likely to suffer intrauterine hypoxia/asphyxia and as a
consequence be stillborn or have signs of hypoxic ischaemic encephalopathy.
- Growth restricted babies are more prone include neonatal hypothermia, hypoglycemia,
infection and necrotizing enterocolitis.
- Cerebral palsy is more prevalent.

Determinants of fetal birth weight are multifactorial​:

- Fetal genome
- Intrauterine environment
- Insulin
- Thyroxin

Fetal Influences​:
Genetic:
- Obvious and sometimes severe FGR is seen in fetuses with chromosomal defects such
as the trisomies, particularly of chromosomes 13 and 18.
Infection:
- Rubella
- Cytomegalovirus
- Toxoplasma
- Syphilis

Maternal Influences​:
Physiological:
- Maternal weight
- Age
- Ethnic group
Behavioral​: Smoking, alcohol
Chronic Disease​: HTN, Lung disease, cardiac disease

Placental Influences​:
- The placenta is the only way in which the fetus can receive oxygen and nutrients from
the mother from early pregnancy.
- Placental infarction secondary to maternal conditions such as chronic HTN and renal
disease or premature separation as in in placental abruption can impair this transfer and
hence fetal growth.
Fetal Development​:
Cardiovascular System and the Fetal Circulation​:
- The fetal circulation is characterized by four shunts which ensure that the best
oxygenated blood from the placenta is delivered to the fetal brain.
- These shunts are:
- Umbilical circulation
- Ductus venosus
- Foramen ovale
- Ductus arteriosus
- Prior to the birth the ductus remains patent due to the production of prostaglandin E2
and prostacyclin which act as local vasodilator.
- Premature closure can occur if cyclooxygenase inhibitors administered antenatally
Respiratory System:
- The lung first appears as an outgrowth from the primitive foregut at about 3 - 4 weeks
post conception and by 4 - 7 weeks epithelial tube branches and vascular connections
are forming.
- 20 weeks the conductive airway tree
- 26 weeks type 1 and type 2 epithelial cells differentiate
- 30 weeks surfactant production
- Dilatation of air spaces, alveolar formation and maturation of surfactant system
continues between 30 weeks to term.
- Fetal lungs are filled with fluid
- At birth production of fluid ceases and absorption of fluid occurs.
- Adrenaline plays major role. It’s sensitivity is increased at term.
- Surfactant prevents alveolar collapse after birth. Surfactant is mixture of phospholipids
and protein.
- Lecithin production enhanced by cortisol, prolonged rupture of membranes, growth
restriction. Lecithin production delayed by diabetes
- Respiratory distress syndrome occurs more common upto 28 weeks, and upto 10 %
from 34 - 36 weeks.
Gastrointestinal System:
- The primitive gut is present by the end of the fourth week, having been formed by folding
of the embryo in both craniocaudal and lateral directions.
- The primitive gut consists of three parts the foregut, midgut and hindgut.
- Foregut endoderm: Oesophagus, stomach proximal half of duodenum, liver and
pancreas
- Midgut endoderm: Distal half of duodenum, jejunum, ileum, caecum, appendix,
ascending colon.
- Hind gut endoderm: Descending colon, sigmoid colon and rectum.
- Physiological herniation occurs at 5 - 6 weeks. Returns back after rotation by 12 week.
- Failure of rotation, fistulae and atresias are common abnormalities.
- Peristalsis starts from 2nd trimester
 - The large bowel is filled with meconium at term .
- Premature and growth restricted infants have virtually no fat and a severely reduced
ability to withstand starvation.
Liver, Pancreas & Gallbladder:
- The pancreas liver and epithelial lining of the biliary tree derive from the endoderm of the
foregut.
- By 6th week the liver performs hematopoiesis
- In utero the normal metabolic functions of the liver are performed by the placenta.
- Glycogen is stored within the liver in small quantities from the first trimester, but storage
is maximal in the third trimester with abundant stores being present at term.
Kidneys & Urinary Tract:
- Pronephros (3rd week) -> mesonephros -> metanephric kidney
- In humans all of the branches of the ureteric bud and the nephron units have been
formed by 32 - 36 weeks of gestation.
- Potter's syndrome
- Common sites of abnormalities of obstructive uropathies: pyeloureteral junction,
vesicoureteric junction, posterior urethral valves.
Skin and Homeostasis:
- Fetal skin protects and facilitates homeostasis.
- The skin and it’s appendages(nails,hair) develop from the ectodermal and mesodermal
germ layers.
- The periderm eventually sloughs as the vernix a creamy protective coat that covers the
skin of the fetus.
- Preterm babies have no vernix and thin skin.
- Hair follicles begin to develop as their hair buds b/w 12 and 16th week from the basal
layer of the epidermis.
- By 24 week hair follicle produce delicate hairs lanugo.
Blood & Immune System:
- Red blood cells and immune effector cells are derived from pluripotent haematopoietic
cells first noted in the blood islands of the yolk sac.
- By 8 weeks yolk sac is replaced by the liver.
- By 20 weeks almost all of these cells are produced by bone marrow.
- Circulating monocytes are present by 16 weeks.
- Granulocytes appear in the fetal spleen and liver by 8 weeks and in the circulation by 12
- 14 weeks.
- IgG originates mostly from the maternal circulation and crosses the placenta to provide
passive immunity to the fetus and neonate.
- 90% fetal HB is |HBF till 28 weeks.
- At term HBF and HbA ratio is 80:20.
- HBF has high affinity for oxygen.
- Mean capillary HB 18g/dl.
Endocrine System;
- Major components of the hypothalamic pituitary axis are in place by 12 weeks gestation.
 - Thyrotropin releasing hormone and gonadotropin-releasing hormone have been
identified in the fetal hypothalamus by the end of the first trimester.
- Thyroid gland produces thyroxine from 10 - 12 weeks.
- Testosterone is also synthesized in the first trimester of pregnancy.
- Growth hormone also present from first trimester.

Behavioral States​:
- First activity is the beating of the heart followed by the fetal movements at 7 - 8 weeks.
- 12 weeks yawning ,sucking and swallowing.
- Four fetal behavioural states have been described, annotated 1F to 4F:
1F is quiescence.
2F is frequent and periodic gross body movements with eye movements.
3F no gross movements but eye movements.
4F vigorous continual activity again with eye movements.

Amniotic Fluid​:
- The amniotic fluid is initially secreted by the amnion but by the 10 week it is mainly a
transudate of the fetal serum via the skin and umbilical cord.
- Amniotic fluid volume increases progressively till 38 weeks:
10 weeks 30ml
20 weeks 300ml
30 weeks 600ml
38 weeks 1000ml
40 weeks 800ml
42 weeks 350 ml
- Functions:
- Protects the fetus from mechanical injury.
- Permit movement of the fetus while preventing limb contracture.
- Prevent adhesions between fetus and amnion.
- Permit fetal lung development.
 ANTEPARTUM HEMORRHAGE

Definition: ​Bleeding occurring after 24 weeks of gestation till completion of second stage of
labour.

Causes​:
1. Placental causes
- Placental abruption
- Placenta previa (partial, total)
- Vasa previa
- Marginal haemorrhage
2. Genital tract causes
- Labour (heavy show)
- Rupture of uterus
- Trauma
- Infections (vulvovaginitis, cervicitis)
- Vulvovaginal varicosities
- Tumor
3. Bleeding disorders
- Congenital (Von Willebrand's disease)
- Acquired (DIC)

History:
- Duration
- Colour
- Amount
- Association with pain
- Fetal movements
- Hypertension
- Abdominal trauma
- Rupture of membranes in polyhydramnios
- Smoking
- Chorioamnionitis
- Fibroid uterus
- Multiple pregnancy
- Snake bit

Placenta praevia​ is defined as the presence of placental tissue over or adjacent to the cervical
os.
• Type 1 (Lateral or low lying): edge of placenta encroaches on lower segment but not up to
internal os
• Type 2 (Marginal): lower edge extends to but not across the os
• Type 3 (Partial): placental edge extends asymmetrically across the os but doesn’t cover it
completely after cervical dilatation
• Type 4 (Complete or central): placenta placed over the os and likely to cover even after full
cervical dilatation
 POSTPARTUM HEMORRHAGE

Definition: ​Bleeding occurring from third stage of labour and till 42 days after delivery.

Primary PPH​: the loss of 500 ml or more of blood from the genital tract within 24 hours of the
birth of a baby.
a) Minor (500 – 1000 ml)
b) Major (more than 1000 ml)
- Moderate (1000 – 2000 ml)
- Severe (more than 2000 ml)
Secondary PPH​: abnormal or excessive bleeding from the birth canal between 24 hours and 6
weeks postnatally.

Causes​ for PPH may be considered to relate to one or more of ‘the five Ts’:
- Tone (abnormalities of uterine contraction)
- Tissue (retained products of conception)
- Trauma (of the genital tract)
- Thrombin (abnormalities of coagulation)
- Traction (uterine inversion)
Most common cause of primary PPH is uterine atony, due to:
- Retained products (placenta, membranes, clots)
- Vaginal/cervical lacerations or haematoma
- Ruptured uterus
- Broad ligament haematoma
- Extragenital bleeding (for example, subcapsular liver rupture)
- Uterine inversion

History:
- Duration
- Colour
- Amount
- Association with pain
- Smell
- Fever
- Vaginal discharge
- Obstetrical history
- Medical history
- Surgical history
- Drug history
 PER VAGINAL EXAMINATION

1. Introduction
2. Explain the procedure. Tell her exactly what you’re going to do.
3. Informed consent
4. Privacy/screen
5. Female chaperone if you’re a boy.
6. Ask if there is any pain or tenderness.
7. Position - dorsal, with legs flexed and open.
8. Proper light source.
9. Exposure and cover the rest with a sheet.
10. Sanitize hands and wear gloves.
11. Lubricate fingers.
12. Open labia with left hand’s fingers and insert index finger of right hand and then slowly
insert the middle finger too. Insert fingers vertically first, and then turn horizontally.
13. Things to check:
a) Position of cervix (anterior, central, posterior)
b) Size of os/dilation of cervix (3 cm = 2 fingers, 10 cm = fully dilated)
c) Consistency (firm, soft)
d) Length of cervix/effacement
e) Station: distance from the ischial spines laterally (-3, -2, -1, 0, +1, +2, +3)
All determine the favorability of normal vaginal delivery, and stage of labour.
 STAGES & MECHANISM OF LABOUR

Stages:
First stage of labor
- Begins with regular uterine contractions and ends with complete cervical dilatation at 10
cm
- Divided into a latent phase and an active phase
- The latent phase begins with mild, irregular uterine contractions that soften and shorten
the cervix
- Contractions become progressively more rhythmic and stronger
- The active phase usually begins at about 3 - 4 cm of cervical dilation and is
characterized by rapid cervical dilation and descent of the presenting fetal part
Second stage of labor
- Begins with complete cervical dilatation and ends with the delivery of the fetus
- In nulliparous women, the second stage should be considered prolonged if it exceeds 3
hours if regional anesthesia is administered or 2 hours in the absence of regional
anesthesia
- In multiparous women, the second stage should be considered prolonged if it exceeds 2
hours with regional anesthesia or 1 hour without it
Third stage of labor
- The period between the delivery of the fetus and the delivery of the placenta and fetal
membranes
- Delivery of the placenta often takes less than 10 minutes, but the third stage may last as
long as 30 minutes
- Expectant management involves spontaneous delivery of the placenta
- The third stage of labor is considered prolonged after 30 minutes, and active intervention
is commonly considered. Active management often involves prophylactic administration
of oxytocin or other uterotonics (prostaglandins or ergot alkaloids), cord clamping/cutting,
and controlled traction of the umbilical cord

Mechanism:
1. Descent (primi: >38 weeks, multi: labour)
2. Engagement <3/5th palpable, widest part of head into pelvis
3. Flexion
4. Internal rotation 90 degrees
5. Crowning - widest diameter of head through narrowest part, had visible at vulva, no
longer goes back, episiotomy
6. Extension
7. Restitution + external rotation
8. Downward traction
9. Upward traction
INSTRUMENTS
j
Uses:
Hegar’s Dilator: ​To dilate the os.
Right Angled Retractors: ​To retract rectus sheath.
Straight and Curved Scissors: ​To cut rectus sheath.
Plain Forceps: ​To hold soft tissue.
Toothed Forceps: ​To hold tougher tissue, like rectus sheath.
Sims Speculum: ​To hold posterior vaginal wall.
Vulsellum: ​To hold the anterior lip of cervix during ​episiotomy​, ​hysterectomy​, ​dilatation and
evacuation​ or ​dilatation & curettage​.
Cusco’s Speculum: ​To visualize cervix and vagina for ​pap smear​ and ​high vaginal swab​.
Alley’s Forceps: ​To hold tough tissue e.g. rectus sheath.
Green Armytage: ​To group & clamp tissue in the uterus and hold angle of uterus during
C-section​; To secure hemostasis over uterine incision. (To hold the lips of uterine incision- Dr
Mehreen)
Curved Artery Forceps: ​To hold bleeders or arteries.
Curved Scissors: ​To cut soft tissue.
Scalpel:​ For incision.
Doyen’s Retractor: ​Used in ​vaginal hysterectomy​ and ​laparotomy​, to retract the bladder.
Curette: ​To scrape endometrial lining in ​biopsy​, ​excision & debridement of tissue​, ​D & E​, ​D & C​.
Needle Holder: ​To hold needle during suturing.
Deavers Retractor: ​For retracting bowel.
Uterine Sound: ​To measure the length of the uterus.
Sponge Holding Forceps: ​To hold swabs or grab cervix.
D&C, D&E
 ANTENATAL IMAGING & ASSESSMENT OF FETAL WELLBEING

Diagnostic ultrasound in obstetric practice

- Ultrasound technique: high frequency sound waves of between 3.5- 7.0 megahertz
- Transducers:
- Tans-abdominal
- Trans-vaginal

TVS uses​:
- Early pregnancy
- Cervical length
- Lower edge of placenta
- Thick abdominal wall

Uses of abdominal probe​:

- Gestational age
- Size of fetus
- Growth of fetus
- Malformations/ anomalies
- Assessment of amniotic fluid
- Placental localization, presentation, lie
- Doppler studies
- Number of fetus
- Confirmation of intrauterine death

Advantages of ultrasound​:
- Safe
- Non- invasive
- Accurate
- Cost-effective

Diagnosis and confirmation of visibility in early pregnancy

- Gestational sac visualized --- 4 - 5 weeks
- Yolk sac ----- 5 weeks
- Embryo measured (CRL:Crown Rump Length) --- 5 - 6 weeks
- Heart beat visualized --- 6 weeks

TVS Diagnoses​:
- Missed miscarriage
- Incomplete miscarriage
- Ectopic pregnancy
Measurement of cervical length​:
< 2.5 cm risk of preterm delivery

Determination of gestational age, fetal size, and growth​:

- CRL up to 13+6 weeks (+/- 5 days)
- HC (Head Circumference) ---- 14 - 20 weeks
- BPD, FL ( +/- 7 days)
- AC -- HC -- BPD -- FL= EFW
- Serial measurements on growth charts

Multiple pregnancy:
- Number of fetus
- Chorionicity
Monochorionic twins:
- Two layers of amnion
- Thin inter twin membrane (T sign)
Dichorionic twins:
- Two layers of chorion two amnion
- Thicker membranes ( septum)
- Twin peak or lambda sign (9- 10) weeks

Diagnosis of fetal abnormalities​:

- Major structural abnormalities 2-3 %
- Diagnosed upto 20 weeks
- Spina bifida
- Hydrocephalus
- Achondroplasia
- Abdominal wall defects
- Cleft lip and palate
- Congenital cardiac defects
- Detection rate 40 - 90%

Soft markers​:
- For detection of chromosomal abnormalities
- Absence of fetal nasal bone
- Increased fetal nuchal translucency

Placental localization​:
- Placenta previa
- At 20 weeks low lying placenta (5%)

Amniotic fluid volume assessment​:

- AFI
 - DVP
- Oligohydramnios
- Polyhydramnios

Assessment of fetal well being​:

- Biophysical profile:
- Fetal movements
- Tone
- Breathing movements
- Doppler ultrasound
 CTG

Normal: 110 - 160 bpm. Less than 110: bradycardia (common in postdate gestation, severe
hypoxia due to: extended cold compression, cord prolapse, maternal seizures, rapid fetal
descent), more than 160: tachycardia (causes: fetal hypoxia, hyperthyroidism, fetal or maternal
anemia)

Acceleration​: abrupt increase in baseline fetal heart rate. 2 acceleration in every 30 mins is
good news. More than 15 bpm for more than 15 seconds.

Deceleration​: abrupt decrease in baseline fetal heart rate. 15 bpm for 15 sec.
Early Deceleration​: mirror image of uterine contractions, physiological, compression of head
when it passes through cervix causes parasympathetic stimulation.
Late Deceleration​: pathological, starts at peak of or towards end of uterine contraction. Means
baby was already compromised: insufficient blood flow to fetus.
Variable Deceleration​: cord compression. Change in position might help. When contractions
increase, fetal heart tone decreases. Normal variability: 8 - 10 bpm.
Causes of decreased variability: fetus sleeping, fetal tachycardia, congenital heart anomalies,
drugs, prematurity

Continuous Tracing of fetal heart rate and maternal contractions, used to assess fetal
well-being. Cardiotocograph used.

Baseline rate: 140 bpm

Baseline variability
Acceleration
Deceleration
 ANTENATAL COMPLICATIONS

1. Hemorrhoids - due to progesterone, pressure on superior rectal veins due to gravid

uterus
2. Varicose Veins - due to progesterone, venous stasis caused by weight og uterus on
Inferior Vena Cava
3. Edema
4. Abnormalities of pelvic organs:
a) Fibroid (leiomyomata)
- Types: Submucous, intramural, subserous
- Most common complication: red degeneration of fibroid.
- Differentials of red degeneration: placental abruption, acute appendicitis,
pyelonephritis/UTI, ovarian cyst accident, torsion of pedunculated fibroid.
b) Retroversion of uterus (15 % of women) - causes the base of the bladder and
urethra to stretch. Retention of urine at 12 - 14 weeks. Catheterization needed.
c) Congenital uterine abnormalities
- Fusion abnormalities
- Subseptate uterus
- Bicornuate uterus
- Double uterus
- Associated problems: miscarriage, preterm labour, PPROM,
abnormalities of lie and presentation, higher C-section rate.
d) Ovarian cysts
- Types: physiological, pathological
e) Cervical cancer - may lead to considerable bleeding and discharge at late stage
f) Urinary tract infection
- Predisposing factors: history of recurrent cystitis, renal tract abnormalities,
diabetes, bladder emptying problems
- Symptoms: low back pain, malaise, flu-like symptoms, tachycardia,
pyrexia, dehydration, loin tenderness
- Investigations: CBC, MCU for urgent microscopy, culture and sensitivity.
- Organisms: E. coli, Streptococcus, Proteus, Pseudomonas, Klebsiella
g) Pyelonephritis
- Symptoms: dehydration, high grade fever above 38.5 degrees, systemic
disturbance, shock
- Investigations: renal function test, CTG, renal scan, functional scan.
5. Abdominal pain:
a) Early pregnancy
b) Late pregnancy
c) Pregnancy unrelated
d) Uterine ovarian causes
 e) UTI
f) GIT
g) Medical causes
h) Sickle cell disease
i) DKA
j) Porphyria
k) Pneumonia
l) Malaria
6. Venous thromboembolism
- Most common cause of direct maternal death
- Pregnancy is a hypercoagulable state.
- Further exacerbated by venous stasis in lower limbs and weight of gravid uterus
7. Thrombophilia
8. Pulmonary embolism
9. Substance abuse
10. Oligohydramnios
11. Polyhydramnios
12. Fetal
 PRENATAL DIAGNOSIS

Definition​: Identification of disease prior to birth.

Why performed?
- Family history
- Past obstetric history
- Serum screening
- Ultrasound screening

Attributes​:
- Relevance
- Effect on management
- Sensitivity
- Specificity
- Predictive value
- Affordability
- Equity

Non-Invasive​:
- Ultrasound
Invasive​:
- Fetal DNA in maternal blood (screening test)
- CVB
- Amniocentesis

Diagnostic Test: Conditions:

Ultrasound diagnosis Neural tube defect, gastroschisis, cystic

adenomatoid malformation of lung, twin to
twin transfusion syndrome

Invasive test - CVB/amniocentesis Down’s Syndrome, cystic fibrosis,

thalassemia

Invasive test - cordocentesis Alloimmune thrombocytopenia

Ultrasound then invasive test Congenital diaphragmatic hernia,

exomphalos, ventriculomegaly, duodenal
atresia

Diagnosis of fetal anomaly:

 - The National Institute of Clinical Excellence (NICE) stipulates that all women should be
offered a minimum of 2 scans.
- First trimester can between 11 - 14 weeks: NT scan, done to screen Down’s Syndrome.
- Further scan offered between 18 - 22 weeks: anomaly scan, to screen any structural
anomalies.

Invasive testing:
- Pretest counselling
- Suspected condition and it’s severity
- Correct history
- Test should be available
- Sample needed and how it will be taken
- Accurate assessment of risk
- Acceptability
- Ethical

Options after diagnosis:

- Continue pregnancy
- Influence decision of termination
- Termination with full counselling for future risks

Chorionic Villus Sampling/biopsy:

- Risk of miscarriage is 2% at 11 weeks.
- Involves sampling of placental tissue.
- Performed soon after screen positive result of the combined test, available between 11 -
14 weeks.
- 2 routes: transabdominal and transvaginal.
- CVS should not be performed before 10 weeks.

Amniocentesis:
- Can only be performed after 15 weeks, when the uterus is an abdominal organ.
- Proportion of fluid to be removed is relatively small, 15 - 20 ml.
- Procedure is performed under aseptic conditions, under continuous ultrasound guidance
using a gauge 20-22 needle.
- Increases the background miscarriage rate by 1%
- Amniotic fluid will contain fetal skin, urogenital and pulmonary epithelial cells and cells
from the extraembryonic membranes

Cordocentesis
- Risk of miscarriage 2 - 5% at 20 weeks.
- Performed when rapid fall culture for karyotype is needed.
- Fetal platelet count is needed (Alloimmune thrombocytopenia)
Care after invasive test:
- Accurate labelling of sample.
- Prompt and secure transport of sample to laboratory.
- Documentation.
- Communication with referring clinician.
- Woman should be advised to avoid strenuous exercises for 24 hours.
- Woman should be warned that she might feel mild pain.
- Advise should be given if any bleeding or pain that doesn’t relieve with Paracetamol.
- Appropriate contact numbers.
- How results will be collected.
- If Rh-negative, give anti-D.
- Plan should be discussed.

Down’s Syndrome Screening

- NICE recommends all women to be screened.
- Combined test between 11 - 14 weeks.
- NT + hCG + PAPP-A
- Nuchal Translucency 11 and 13 + 6 weeks.
- Quadruple test 14 - 20 weeks.
- Combined test 10 - 14 + 1 week.
- Integrated test.
RH INCOMPATIBILITY