CORDOCENTHESIS

Definition
It is also known as percutaneous umbilical blood sampling. It is a diagnostic prenatal test
in which a sample of the baby's blood is removed from the umbilical cord for testing
Cordocentesis, which is usually done after week 18 of pregnancy, can be used to detect certain
genetic disorders, blood conditions and infections. Cordocentesis can also be used to deliver
blood and medication to a baby through the umbilical cord. Use of cordocentesis is becoming
rare because diagnostic procedures such as amniocentesis and chorionic villus sampling, which
pose a lower risk of fetal death, can be used instead for prenatal diagnosis of disease.
Cordocentesis is most often done to test for anemia in the baby.
Indication
 Cordocentesis is used primarily to detect and treat blood conditions, such as fetal anemia.
 Cordocentesis is usually done when a diagnosis cannot be made from amniocentesis,
chorionic villus sampling, ultrasound or other methods.
 Rarely, cordocentesis might be used to check fetal chromosomes through chromosome
microarray or karyotype analysis.
 Blood obtained through cordocentesis can also potentially be used for other types of genetic
studies.
Risks
Cordocentesis carries potentially serious risks, including:
 Fetal bleeding - Bleeding from the area where the needle is inserted is the most common
complication. If life-threatening fetal bleeding occurs, your health care provider might
recommend replacement of blood products to the fetus.
 Cord hematoma - A collection of fetal blood within the cord might occur during or after a
cordocentesis. Most babies do not have signs or symptoms when this occurs. However, a few
might develop a low heart rate for a short period.
 Slowing of the baby's heart rate -The baby's heart rate might slow temporarily after
cordocentesis.
 Infection - Rarely, cordocentesis can lead to a uterine or fetal infection.
 Fetal-maternal bleeding - Fetal blood might enter maternal circulation in about 40 percent of
procedures. The amount of bleeding is usually small. This problem is more common when
the placenta lies in the front of the uterus.
 Passing maternal infection - If the mother has certain infections, such as hepatitis B, hepatitis
C or HIV, they might be passed to the baby.
 Pregnancy loss - Cordocentesis carries a higher risk of fetal death than do other prenatal
diagnostic tests, such as chorionic villus sampling and amniocentesis. The risk is about 1 to 2
percent for a fetus that appears normal and is being tested for genetic disorders.

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Procedure
A 22 gauze spinal needle 13cm in lenth is inserted through the maternal abdominal wall
under real time ultrasound guidance using curvilinear probe. The needle tip is progressed
carefully and it punctures the umbilical vein approximately. 1-2cm from the placental insertion.
Generally, 0.5 to 2ml of fetal blood is collected. It is performed under local anesthesia usually
after 18 weeks gestation.

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 AMNIOCENTESIS
Introduction
Amniocentesis (genetic) is an invasive procedure. It is the deliberate puncture of the
amniotic fluid sac per abdomen. Amniotic fluid is the fluid that surrounds and protects a baby
during pregnancy. This fluid contains fetal cells and various proteins. It is performed between 14
to 16 weeks under ultrasonographic guidance.
Indications
1. Diagnostic
Early months (14-16weeks) – antenatal diagnosis of chromosomal and genetic disorders.
 Sex-linked disorder
 Karyotyping
 Inborn errors of metabolism
 Neural tube defects
Later months –
 Fetal maturity
 Degree of fetal hemolysis in Rh sensitized mother
 Meconium staining of liquor
 Amniography or fetography
2. Therapeutic
First half –
 Induction of abortion by instillation of chemicals such as hypertonic saline, urea or
prostaglandins.
 Repeated decompression of the uterus in acute hydramnios.
Second half –
 Decompression of uterus in unresponsive cases of chronic hydramnios producing
distress or to stabilize the lie when it is not axial prior to induction.
 To give intrauterine fetal transfusionin severe hemolysis following Rh- immunization.
 Amnioinfusuion - Infusion of normal saline into the amniotic cavity is done
transabdominally or transcervically to increase the volume of amniotic fluid.
Indications for amnioinfusion – to prevent fetal lung hypoplasia, to minimize
umbilical cord compression during labor.
Procedure
 After emptying the bladder, the patient remains in dorsal position.
 The abdominal wall is prepared aseptically and draped.
 The proposed site of puncture is infiltrated with 2ml of 1% lignocaine.
 A 18-20 gauze spinal needle about 4‖in length is pierced into the amniotic cavity under
real time sonographic control, with the stiletto in. the stiletto is withdrawn and few drops
of liquor are discarded.
 About 30ml of fluid is collected in a test tube for diagnostic purposes.

3
Sites
The preferred sites for blind procedures are:
 In early months – 1/3rd of the way up the uterus from symphysis pubis.
 In later months – Transisthmic suprapubic approach after lifting the presenting part or
through the flanks in between the fetal limbs or below the umbilicus behind the neck of the
fetus.

Precautions
1. Prior sonographic localization of placenta is desirable to prevent bloody tap anf feto-maternal
bleeding.
2. Prophylactic administration of 100mf of anti-D immunoglobulin in Rh-negative non-
immunized mother.
3. Hazards are reduced significantly when it is done under direct ultrasound control compared
to the blind procedure.
Risks
Maternal complications
 Infection
 Hemorrhage (placental or uterine injury)
 Premature rupture of membranes and premature labor
 Maternal isoimmunization in Rh-negative cases.
Fetal complications
 Abortion (1%)
 Trauma
 Feto-maternal hemorrhage
 Oliogohydramnios due to leakage of amniotic fluid and that may lead to – fetal lung
hypoplasia, respiratory distress, talipes.

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 CHORIONIC VILLI SAMPLING

Introduction
Chorionic villi sampling (CVS) is performed for prenatal diagnosis of genetic disorders.
It is carried out transcervically between 10-12 weeks and transabdominally from 10 weeks to
term. Diagnosis can be obtained by 24 hours, and such , if termination is considered, it can be
done in the first trimester safely.

Indication
 If a baby has a chromosomal condition, such as Down syndrome,
 Genetic conditions, such as cystic fibrosis.
 Family history of a specific genetic condition such as Down syndrome.
 An active cervical or vaginal infection, such as herpes.
 Vaginal bleeding or spotting in the previous two weeks.
 An inaccessible placenta, due to a tilted uterus or noncancerous growths in your cervix or the
lower part of your uterus.
Procedure
A few villi are collected from the chorion frondosum under ultrasonic guidance with the help of
a long malleable polyethylene catheter introduced transcervically along the extra ovular space.
Risks
 Miscarriage - The risk of miscarriage after chorionic villus sampling is estimated to be 0.22
percent.
 Rh sensitization - Chorionic villus sampling might cause some of the baby's blood cells to
enter mothers bloodstream.
 Infection -Very rarely, chorionic villus sampling might trigger a uterine infection.
 Limb reduction defects are high when chorionic villus sampling was performed at less than
10 weeks.
 False positive results are there due to placental mosaics and maternal cell contamination.

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 ULTRASONOGRAPHY
Introduction
A fetal ultrasound (sonogram) is an imaging technique that uses sound waves to produce
images of a fetus in the uterus. The transducer converts electrical energy to mechanical energy
and vice versa.
Indication
1. Fetal
 Diagnosis of pregnancy
 Assessment of gestational age
 Diagnosis of multiple pregnancy
 Diagnosis of IUFD
 Detection of anomaly
 Assessment of growth (IUGR)
 Assessment of wellbeing (biophysical profile)
 Diagnosis of presentation (breech)
 Diagnosis of ectopic pregnancy
2. Uteroplacental
 Localization of placenta (placenta previa)
 Diagnosis of abruption placenta, molar pregnancy, uterine malformations
 Assessment of liquor volume (oligohydramnios, polyhydramnios)
 Uterine size either ˂ dates or ˃ dates
 Diagnosis of cervical incompetence
3. Maternal
 Pelvic mass diagnosis and follow up
 Others – as an adjunct to obstetric intervention
 Amniocenthesis
 Chorionic villus sampling
 Cordocenthesis
 Fetoscopy
 Intra uterine fetal therapy
 Intra uterine fetal therapy (transfusion)
Ultrasonography is performed to –
 First trimester ultrasound examination is done to evaluate the presence, size and location
of the pregnancy, determine the number of fetuses, and estimate gestational age.
Ultrasound can also be used for first trimester genetic screening, as well as screening for
abnormalities of the uterus or cervix.
 In the second or third trimester, a standard ultrasound is done to evaluate several features
of the pregnancy, including fetal anatomy. This exam is typically done between weeks 18

6
 and 20 of pregnancy. However, the timing of this ultrasound might be altered for reasons
such as obesity, which could limit visualization of the fetus.
 During the second and third trimesters, limited ultrasound evaluation might be needed
when a specific question requires investigation. Examples include the evaluation of fetal
growth and the estimation of amniotic fluid volume. A specialized or detailed exam is
done when an anomaly is suspected based on your history or other prenatal exam results.
Types
Transvaginal ultrasound - With this type of fetal ultrasound, a wand like device called a
transducer is placed in vagina to send out sound waves and gather the reflections.
Transvaginal ultrasounds are used most often during early pregnancy. This type of
ultrasound also might be done if a transabdominal ultrasound did not provide enough
information.

Transabdominal ultrasound - A Trans abdominal fetal ultrasound is done by moving a

transducer over abdomen. Various other types of transabdominal ultrasounds are
available, including:

 Specialized sonographic evaluation. This type of exam might be needed in specific

circumstances, such as when a fetal abnormality is known or suspected. In this
situation, a more detailed evaluation can provide additional information about the
abnormality.
 3D ultrasound. This exam provides a two-dimensional display of three-dimensional
data. This type of ultrasound is sometimes used to help health care providers detect
facial abnormalities or neural tube defects.

7
 Doppler ultrasound. A Doppler ultrasound measures slight changes in the
ultrasound waves as they bounce off moving objects, such as blood cells. It can
provide details about a baby's blood flow.
 Fetal echocardiography. This exam provides a detailed picture of a baby's heart. It
might be used to confirm or rule out a congenital heart defect.

8
 AMNIOSCOPY
Introduction
Examination of the amniotic fluid in the lowest part of the amniotic sac by means of an
endoscope introduced through the cervical canal. Amnioscopy is an invasive exam employed to
visualize the forebag of the amnionic sac and to look out for meconium staining. Even though
recognition of strongly stained fluid is easy, interpretation of those cases that are thinly stained is
more difficult, since in these cases which are more common to find there could be an initial
staining. On the other hand, visualization of the forebag does not necessarily depict the condition
of the rest of the amniotic fluid, especially in those cases where the fetal head is engaged.
Moreover, ascertainment that the amniotic fluid is limpid only holds a temporary significance
since it cannot predict successive release of meconium. The incidence of meconium stained fluid
prior to labor has been found to range between 6-11%.

Amnioscopy hence seems to hold a historical interest, and should only be employed in
pregnancies at term where the cervix is sufficiently dilated to permit introduction of the
amnioscope. Correlation between finding of meconium stained fluid during labour (1.5-18%
reaching 44% in post-term pregnancies) with alterations at cardiotocography and above all too
fetal acidosis or low Apgar scores at birth still remains controversial. Passage of meconium does
not seem to express fetal compromise, at least until other parameters (CTG) do not support this
suspicion. Finally, it is important to remember that amnioscopy could in some cases lead to
serious infections with chorioamnionites occasionally leading to fetal death. Accidental rupture
of the membranes could also occur, reported in 1.4% of the cases, harmful especially when far
from labour. From these considerations, and since majority of the cases especially with chronic
fetal distress, release of meconium is preceded or accompanied by reduction in the amniotic fluid
quantities, the last identifiable through ultrasound.

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 RADIOLOGICAL EXAMINATION
Introduction
With the advent of ultrasonography and MRI, the importance of radiology is declining.
Currently there are very few conditions where radiology may be of help during pregnancy.

Principles of radiation in obstetrics

 Benefits of radiation must out weight the risks of the procedure.
 Minimum radiation dose to be used
 Appropriate fetal shielding should be done
 First trimester should preferably be avoided
 Benefits and safety ultrasonography must be considered as an alternative
Indications
1. Fetal –
 Diagnosis of pregnancy – the earliest fetal skeletal shadow of vertebral dots is visible at
about 16th wek of pregnancy.
 Multiple pregnancies – to confirm the diagnosis, to note the lie of the fetuses, to exclude
skeletal malformations of the fetuses
 Hydramnios – to exclude multiple pregnancies, to detect congenital bony malformation
of the fetus like open spina bifida or anencephaly, to note the lie and presentations of the
fetus.
 Intrauterine death of the fetus
 Congenital malformation of the fetus and neonates and birth injuries –skeletal
malformations, birth injuries like fracture or dislocations
 Fetal maturity – evidenced by overall fetal shadow, thickness and density of the skull
shadow and appearance and density of the ossific centers of the upper end of the tibia and
lower end of the femur.
 Secondary abdominal pregnancy

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2. Maternal -
 Patient having cardio-pulmonary disease may require X-ray chest during pregnancy and
that should be done beyond 12 weeks.
 X –ray pelvimetry is of limited value in assessing cephalopelvic or fetopelvic
disproportion.
Radiation hazards
Risk is primarily based on the estimated dose and the period of gestation.
Teratogenicity – diagnostic range of radiation exposure is not associated with any
significant congenital malformation either in human or in animal.
Oncogenecity – dividing cells particularly in the first trimester are more sensitive to
injury from radiation. Diagnostic radiation with fetal exposure is associated with an
increased risk of malignancy.
Genetic damage – no radiation induced transmissible gene mutations have been seen in
human.
Intra uterine death – low dose radiation is not associated with any fetal death.

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 BIOCHEMICAL TEST
1. Maternal swrum alpha fetoprotein (MSAFP) –
Alfa feto protein is a oncofetal protein. It is produced by yolk sac and fetal liver. Hihest
level of alpha feto protein in fetal serum and amniotic fluid is reached around 13 weeks and
thereafter decreases. Maternal ssrtum level reaches a peak around 32 weks. Maternal Serum
Alpha Feto Prtoein (MSAFP) level is increased in number of flowing conditions:
 Wrong gestational age
 Open neural tube defect
 Multiple pregnancy
 IUFD
 Anterior abdominal wall defects
 Renal anomalies
Low levels are found in following conditions
 Trisomy (Down's syndrome)
 Gestational trophoblastic disease.
Test is done bewtweeN 15-18 weeks. MSAFP value of 2.5 multiples of the median when
adjusted withy maternal weight, is taken as cut off pint. Elevated MSAFP detects 85% of
all neural tube defects. Cases with such high values are considered for high resolution
ultrasound imaging and / or amniocenthesis.
2. Triple test –
It is a combined biochemical test which includes MSAFP, hcg and UE3 (unconjugated
oestriol). Maternal age in relation to confirmed gestsation age is also taken into account. It is
used for detection of Downs syndrome. In an affected pregnancy, level of MSAFP and UE3
tend to be low while that of hcg is high.
It is performed at 15-18 weeks. It gives a risk ratio and for confirmation, amniocenthesis
has to be done. The result is considered to be screen positive if the risk ratio is 1:250 or
greater.
3. Acetyl choline esterase (AChE) –
Amniotic fluid AChE level is elvated in most of open nural tube defects. It has got better
diagnostic value than AFP.
4. Inhibin A –
Is a diameric glycoprotein. It is produced by the corpus luteum and the placenta. Serum
level of inhibin A is raised in women carrying a fetus with Down syndrome.
5. Prenatal genetic diagnosis -
Can be made directly from fetal tissue obtained by amniocenthesis, chorion villous
sampling or by cordocenthesis.
A. Amniocenthesis – is an invasive procedure. It is conducted between 14 and 16 weeks
under ultrasonic guidance. The ftal cells obtained in this procedure are subjected for
cytogenic analysis and DNA analysis
 Cytogenic analysis – the desquamated fatal celss in the amniotic fluid, obtained
by amniocenthesis or trophoblasts cells from CVS or fetal blood cells obtained by
cordocenthesis are culture, G branded and examined to make a diagnosis of

12
 chromosomal anomalies e.g., trisomy 21 (Downs syndrome), monosomy X
(Turners syndrome) and others.
 DNA analysis – single gene disorders (cystic fibrosis, Tay-sachs disease)can be
diagnosed using specific DNA probes. DNA amplification is done by polymerase
chain reaction (PCR). The specific chromosomal region containing the mutated
gene can be identified.
B. Chorionic villi sampling - Chorionic villi sampling (CVS) is performed for prenatal
diagnosis of genetic disorders.It is carried out transcervically between 10-12 weeks
and transabdominally from 10 weeks to term. 24 hours, and such can obtain
diagnosis, if termination is considered, it can be done in the first trimester safely. A
few villi are collected from the chorion frondosum under ultrasonic guidance with the
help of a long malleable polyethylene catheter introduced transcervically along the
extra ovular space.
C. Cordocethesis - It is also known as percutaneous umbilical blood sampling. It is a
diagnostic prenatal test in which a sample of the baby's blood is removed from the
umbilical cord for testing Cordocentesis, which is usually done after week 18 of
pregnancy, can be used to detect certain genetic disorders, blood conditions and
infections. Cordocentesis can also be used to deliver blood and medication to a baby
through the umbilical cord. Use of cordocentesis is becoming rare because diagnostic
procedures such as amniocentesis and chorionic villus sampling, which pose a lower
risk of fetal death, can be used instead for prenatal diagnosis of disease.
Cordocentesis is most often done to test for anemia in the baby.
6. Flurescence In Situ Hybridisation (FISH) – structural chromosomal abnormalities
(translocations, inversions, mutations) can be detected. Chromosome specific probes can
be used to detect the unknown DNA.

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 KICK CHART
Introduction

A ‗kick chart‘ is a graph or grid printed on a piece of paper with spaces t o record the
daily movements of the baby, usually after about 28 weeks of the pregnancy. Kick charts are
mainly used for women who express concern about their baby‘s movements. They aim is to
provide a general guideline for how active a baby should be. However, there are no standard
criteria used to truly define what sufficient (or insufficient) movement is, making their use
quite controversial. Ultrasound studies of babies‘ movement patterns show they can sleep
for up to 90% of the time (often for 20 to 75 minute periods) and have active periods of up
to 40 minutes at a time. They can also have more ‗active periods‘ each day.
The charts are aimed at recording your baby‘s movements, not just kicks. This means
a flutter, elbow, roll, push, jab and stretch all count as ‗kicks‘. Also if baby has some
rigorous movements that go ‗kick‘, ‗kick‘, ‗kick‘ within a very short space of time, this is
regarded as 3 movements, not just ‗1 group‘ of movements. As a guide, the method used for
monitoring a baby‘s movements with kick charts called Cardiff count to ten.

Cardiff count 10 formula – the patient counts fetal movements starting at 9 am. The
counting comes to an end as soon as 10 movements are perceived. Mother is instructed to
report the physician if-
 Less than 10 movements occur during 12 hours on successive days
 No movement is perceived even after 12 hours in a single day.

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 FETAL MOVEMENT CHART
Introduction
Three counts each of one hour dilatation (morning, noon and evening) are recommended.
The total counts multiplied by four gives daily. (12hour) fetal movement count (DFMC). If there
is diminution of the number of kicks to less than 10 in 12 hours (or less than 3 in each hour), it
indicates fetal compromise. Mothers perceive 88% of the fetal movements detected by Doppler
imaging. The count should be performed daily starting at 28 weeks of pregnancy.
Loss of fetal movements is commonly followed by disappearance of FHR within next 24
hours. In either of the above methods, if the result is ominous, the candidate is subjected to NST.
Maternal hypoglycemia is associated with increased fetal movements. Maternal perception of
fetal movements may be reduced with fetal sleep (quiet), fatal anomalies (CNS), anterior
placenta, hydramnios, obesity, drugs (narcotics), chronic smoking and hypoxia.

15
 NON STRESS TEST (NST)
Introduction
It is a continuous electronic monitoring of the fetal heart rate along with recording of
fetal movemnts (cardiotocography) is undertaken. There is an observed association of FHR
acceleration with fetal movements, which when present, indicates a healthy fetus. It can reliably
be used as a screening test. The accelerations of the FHR associated with fetal movements are
presumably reflex mediated. It should be emphasized that the test is valuable to identify the fetal
wellness rather than illness.
Indication
NST‘s are done for several reasons. Most common is post-maturity, or going beyond the
due date. Others may include high blood pressure, maternal diabetes, toxemia, and decreased
fetal movement. These are all conditions that may be associated with decreased placental
function.
Procedure
Before an NST, mother should eat a meal or a snack to promote fetal activity. She will be
positioned comfortably and the external fetal monitors will be fastened to her abdomen with
elastic straps. She will be given a ―button‖ to push whenever she feel fetal movement. The test
takes 20-40 minutes, depending on whether the fetus is awake or asleep at the beginning of the
test.
Interpretation
1. Reactive (Reassuring) – when two or more accelerations of more than 15 beats per minute
above the base line and longer than 15 seconds in duration are present in a 20 minutes
observation. An NST is considered ―good‖ or reactive, if the fetal heart rate increases, or
accelerates, with fetal movement. Like to see at least 2-3 fetal heart rate accelerations in a 10
minute period. If the test is reactive, the NST may be repeated at weekly intervals until
delivery to monitor continued fetal well-being. If accelerations are not seen, change the
position, stimulate the baby, give a snack or ask her to walk for a while, and then re-monitor.
A borderline or non-reactive tracing may require a repeat or further testing.
2. Non-reactive (non reassuring) – absence of any fetal reactivity.
A reactive NST is associated with perinatal death of about five per 1000. However,
perinatal death is about 40 per 1000 is when the NST is nonreactive. Testing should be started
after 30 weeks and frequency should be twice weekly. The test has false negative rate of 0.5%
and false positive rate of 50%.

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 CONTRACTION STRESS TEST (CST)
Introduction
Contraction stress test is done either a dilute oxytocin solution is infused or nipple
stimulation is performed until three contractions occur within 10 minutes. There is no standard
technique for nipple stimulation. The patient gently massages the nipple of one breast through
her clothes for two minutes, stopping with onset of contractions; stimulation is resumed if
contractions are too infrequent for CST interpretation. Both nipples can be stimulated if no
contractions occur. In women who are having spontaneous contractions of adequate frequency,
oxytocin or nipple stimulation is unnecessary.
Contraindications –
Stimulating contractions for a CST are conditions that are also contraindications to labor
and vaginal delivery, such as placenta previa, vasa previa, and previous classical cesarean
delivery or extensive uterine surgery. Preterm labor, patients at high risk for preterm delivery,
and preterm premature rupture of membranes are also relative contraindications
Interpretation
 Positive – A positive (nonreassuring) test has late decelerations following ≥50 percent of
contractions. The test is positive even if the contraction frequency is less than three in 10
minutes.
 Negative – A negative (reassuring) test has no late decelerations or significant variable
decelerations.
 Equivocal – An equivocal-suspicious test has intermittent late decelerations or significant
variable decelerations, while an equivocal-tachysystolic has decelerations with contractions
occurring more frequently than every two minutes or lasting longer than 90 seconds.
 Unsatisfactory – An unsatisfactory test is uninterpretable or fewer than three contractions in
10 minutes.
The presence or absence of accelerations is also generally noted. For example, a reactive
positive CST is a FHR tracing that meets criteria for both a reactive NST and a positive CST.
Positive contraction stress test — A positive (nonreassuring) CST may indicate fetal
hypoxemia and correlates with a 20 to 40 percent incidence of intrapartum category II or III FHR
patterns (true positive). An equivocal-suspicious test with repetitive variable decelerations is also
associated with intrapartum category II or III FHR patterns, which are often related to cord
compression due to oligohydramnios, especially with postterm pregnancy. Because of the CST's
high false-positive rate (>60 percent), FHR reactivity during the test is used to differentiate false-
positive tests (an intrapartum FHR not requiring intervention) from truepositive tests (an
abnormal intrapartum FHR requiring intervention). In one study, 50 percent of reactive positive
CSTs were false positives, whereas 100 percent of nonreactive positive CSTs were true
positives.

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18
 DOPPLER ASSESSMENT
Introduction
The main use of Doppler Ultrasound in Obstetrics is to identify and monitor those fetuses
at risk of perinatal mortality or morbidity due to uteroplacental insufficiency. This is achieved by
investigating blood volume flow to the placenta; in the umbilical arteries and in the fetus.
Doppler velocimetry of the umbilical artery – is studied in pregnancies with
complications. The umbilical artery Doppler wave form is used to meaure the peak systolic (S),
peak diastolic (D) and mean (M) values. From thee values S/D ratio and the pulsatility index
(P.I) (P.I = (S-D)/M) are calculated. In a normal pregnancy the S/D ratio and the pulsatility index
decrease as the estational age advances. Higher values of S/D and P.I mean reduced diastolic
velocities and increased placental vascular resistance (IUGR, hypertension). Absence or reversal
of diastolic flow predicts academic fetus and increased perinatal morbidity and mortality (15-
30%). Absence or reversal of end-diastolic flow velocities in the umbilical artery is not an
indication for immediate delivery. But it needs immediate and intensive fetal surveillance
(biophysical profile, biometry and CTG).
Doppler velocimetry of the umbilical vein is currently studied to show pulsations
specially in fetuses with abnormal arterial velocities or with abnormal cardiac function.
Normally umbilical venous flow is monophasic. Fetuses with umbilical venous pulsations are
often associated with raised CVP and cardiac failure and increased perinatal mortality.

19
 FETOSCOPY
Introduction
Examination of the pregnant uterus by means of a fiber-optic tube. There are two types of
fetoscopes - fiberoptic scope for looking directly at the fetus within the uterus and a stethoscope
designed for listening to the fetal heartbeat. A step toward minimally invasive fetal therapy To
study the feasibility, learning curve, and safety of fetoscopy, so that fetal surgery can be
confidently performed in ongoing pregnancies. Methods Fetoscopy was performed at 12–20
weeks of gestation, in 12 women with fetal congenital malformations and/or for termination of
pregnancy, under local anesthesia using fine fetoscopes ranging from one to 2-mm diameter. The
fetal parts and placenta were examined for clarity of vision, identification, and anomalies.
Fetoscopy required great skill, patience, and extensive use of ultrasound for correct
orientation. Visualization was better with endoscope of 2-mm diameter. Laser coagulation of
placental vessels using diode laser system was possible in the last two cases. There were no
major complications. Starting fetoscopy in the department, learning and establishing the very
skillful and potentially dangerous procedure before performing fetal endoscopic surgery in
ongoing pregnancies posed unique challenges: operating theater and personnel requirements,
endoscopic techniques, fetoscopic instruments, and technical expertise in the field.

20
 PARTOGRAPH
Introduction
Friedman (1954) first devised it. Partograph is a composite graphical record of cervical
dilatation and descent of head against duration of labor in hours. It also gives information about
fetal and maternal condition, which is all recorded on a single sheet of paper.
Definition
Partograph is a composite graphical record of key data (maternal and fetal) during labor,
entered against time on a single sheet of paper.
In cervicograph (Philpott & Caste — 1972), the alert line starts at 4 cm (WHO) of
cervical dilatation and ends at 10 cm dilatation (at the rate of 1 cm/hr). The action line is drawn 4
hours to the right and parallel to the alert line. In a normal labor, the cervicograph (cervical
dilatation) should be either on the alert line or to the left of it. When it falls on Zone 2, it is
abnormal and need to be critically assessed. A senior person should reassess when it falls in
Zone 3 case. Decision is to be made either for termination of labor (cesarean section) or for
augmentation of labor (amniotomy and or oxytocin).
The Components of partograph are:
 Patient identification
 Time — recorded at hourly interval. Zero time for spontaneous labor is the time of admission
in the labor ward and for induced labor is the time of induction
 Fetal heart rate — recorded at every 30 minutes
 State of membranes and color of liquor - to mark ‗I‘ for intact membranes, ‗C‘ for clear and
‗M‘ for meconium stained liquor
 Cervical dilatation and descent of the head
 Uterine contractions — the squares in the vertical columns are shaded according to duration
and intensity
 Drugs and fluids
 Blood pressure (recorded in vertical line) at every 2 hours and pulse at every 30 minutes
 Oxytocin — concentration in the upper box and dose (m IU/min) in the lower box;
 Urine analysis
 Temperature record
Advantages of a partograph:
 A single sheet of paper can provide details of necessary information at a glance
 No need to record labor events repeatedly
 It can predict deviation from normal progress of labor early. So, appropriate steps could be
taken in time
 It facilitates handover procedure
 Introduction of partograph in the management of labor (WHO 1994) has reduced the
incidence of prolonged labor and cesarean section rate. There is improvement in maternal
morbidity, perinatal morbidity and mortality.

21
22
 DILATATION AND EVACUATION
Introduction
Dilation and evacuation (D&E) is the dilation of the cervix and evacuation of the
products of conception from the uterine cavity. The operation may be performed:
1. One stage operation – dilatation of the cervix and evacuation of the uterus are done in same
sitting.
Indication –
 Incomplete abortion
 Inevitable abortion
 Medical termination of pregnancy (6-8 weeks)
 Hydatidiform mole in the process of expulsion
Preliminaries – The steps to be followed are those mentioned earlier. The patient is put under
general anesthesia. Internal examination is done to note the size and position of the uterus and
state dilatation of the cervix.
Steps (incomplete abortion)
 If the cervix is not sufficiently dilated to admit the index finger (usually it does), it should be
dilated.
 Sims posterior vaginal speculum is introduced and an assistant is asked to hold it. The
anterior lip of the cervix is grasped by an Allis forceps to steady the cervix. Uterine sound is
not to be introduced. Sounding provides no information but risks perforation and bleeding.
 The cervical canal is gradually dilated up to the desired extent by the graduated metal
dilators.
 The products are removed by ovum forceps. The uterine cavity is finally curetted gently by a
flushing (blunt) curette. Injection methargin 0.2mg is to be given intravenously during the
procedure.
 The speculum and the allis forceps are to be removed. The uterus is to be massaged
bimanually with the help of the external hand and the internal fingers, placed inside the
vagina.
 After being satisfied that the uterus is firm and the bleeding is minimal, the vagina and
perineum are toileted, a sterile vulval pad is placed and the patient is sent back to her bed.
Post abortion care
 Emergency treatment of complications of any abortion spontaneous or induced
 Family planning counselling and referral services
 Linkage to other unproductive health services
 Male partner should be involved.
2. Two stage operation – second phase includes rapid dilation of the cervix and evacuation
Indication
 Induction of first trimester abortion
 Missed abortion (uterus 8-10 weeks)
 Hydatidiform mole with unfavorable cervix (long, firm, and closed os)

23
Procedures
A. First phase – it consist of introduction of laminaria tents or lamicel (MgSO4 sponge) into the
cervical canal to effect its slow dilatation. The same may be effective by intravaginal
insertion of misoprostol (PEG1), 400μg 3 hours before surgery. It has less side effects.
B. Second phase – the patient brought back the operation theatre usually after 12 hours. The
patient should empty her bladder beforehand.
Preliminaries
The steps to be followed are those previously mentioned. The operation may be conducted under
IV diazepam sedation, local paracervical block or under general anesthesia.
Steps in Medical termination of pregnancy
The posterior vaqginal speculum is introduced after removing the roller gauze. The tents are
removed with the help of sponge holder. The vagina and the cervix are swabbed with
antiseptic solution. The posterior vaginal speculum is removed.
Vaginal examination is done to note the size of te uterus, position of the uterus and state of
dilatation of the cervix.
Posterior vaginal speculum is reintroduced and is to be held by an assistant. The anterior lip
of the cervix to be grasped by the Allis forceps to steady the cervix.
The cervix is dilated with graduated metal dilators up to the desired extent (10/13 to 12/15) to
facilitate introduction of the ovum forceps.
The products are removed by introducing the ovum forceps, IV methargin 0.2mg is to be
given during this stag to minimize blood loss. Firm and well contracted uterus facilitates
curettage.
The uterine cavity is thoroughly curetted by a flushing curette.
The posterior vaginal speculum and the Allis forceps are removed. The uterus is massaged
bimanually and after bring satisfied, that the uterus is empty, the patient is sent to her bed
after placing a sterile vulval pad.
Oxytocic agents – injection methargin 0.2mg IM is given. Alternatively oxytocin 20 units in
500 ml of normal saline IV is given intraoperatively and continued after the operation for 30
minutes.
Prophylactic antibiotics are prescribed.
Dangers of D&E operation
a. Immediate –
 Excessive hemorrhage – may be due to incomplete evacuation, atonic uterus.
 Injury – cervical laceration of varying degree which may lead to formation of a broad
ligament hematoma, uterine perforation
 shock due to local anesthesia – convulsions,cardiorespiratory arrest, death due to
intravascular injection or over dos, excessive blood loss, cervical shock – vasovagal
syncope due to cervical stimulation.
 Perforation – injury to major blood vessels, bowel or bladder
 Sepsis – endometritis, myometritis and pelvic peritonitis.

24
  Hematometra – may cause pain.
 Increased morbidity
 Continuation of pregnancy (failure) – 1%.
b. Late –
 Pelvic inflammation
 Infertility
 Cervical incompetence
 Uterine synechiae


25
 VACCUM EXTRACTION
Introduction
Vacuum extraction (VE), also known as ventouse, is a method to assist delivery of a baby
using a vacuum device. It is used in the second stage of labor if it has not progressed adequately.
It may be an alternative to a forceps delivery and caesarean section. Ventouse is an instrumental
device designed to assist delivery by creating a vaccum between it and the fetal scalp. The
pulling force is dragging the cranium while in forceps, the pulling force is directly transmitted to
the base of the skull.
Instruments
 Suction cups with 4 sizes (30,40,50, 60mm)
 A vacuum generator
 Traction tubings

Indications
As an alternative to forceps operation
As an alternative to rotational forceps as in occipito transverse or posterior position
Delay in descent of the head in case of the second baby old twins
Delay in the first stage of labor.
Maternal exhaustion
Fetal distress in the second stage of labor, generally indicated by changes in the fetal heart-
rate (usually measured on a CTG)
Contraindications
Any presentation other than vertex
Preterm fetus (˂ 34 weeks)
Suspected fetal coagulation disorder
Suspected fetal macrosomia (≥4kg)
Conditions to be fulfilled
 There should be not be slightest bony resistance below the head.
 The head of a singleton baby should be engaged.
 Cervix should be atleast 6cm dilated.

26
Procedure
Preliminaries – the instrument should be assembled and the vaccum is tested prior to its
application.
Steps
1. Application of the cup – the largest possible cup according to the dilatation of the cervix is to
be selected. The cup is introduced after tretraction of the perineum with two fingers of the
other hand. The cup is placed against the fetal head nearer to the occiput with the knob of the
pointing towards the occiput. This will facilitate flexion of the head and the knob indicates
the degree of rotation. A vaccum of 0.2kg/cm2 is induced by the pump slowly, taking at least
2 minutes. A check is made using the fingers round the cup to ensure that no cervical or
vaginal tissue is trapped inside the cup. The pressure is gradually raised at the rate of
0.1kg/cm2 is achieved in about 10 minutes time. the scalp is sucked into the cup and an
artificial caput succedaneum (chignon) is produced. The chignon usually disappears within
few hours.
2. Traction –
 Traction must be at right angle to the cup.
 Traction should be synchronous with uterine contractions
 Traction should be made using one hand along the axis of the birth canal. The fingers of
the other hand are to be placed against the cup to note the correct angle of traction,
rotation and advancement of the head.
 Operative vaginal delivery (forceps/ventouse) should be abandoned, where there is no
descent of the presenting part with each pull or when delivery is not imminent after three
pulls with correctly applied instruments by an experienced operator. On no account,
traction should exceed 30 minutes  As soon as the head is delivered, the vacuum is
reduced by opening the screw-release valve and the cup is then detached. The delivery is
then completed in the normal way.

27
Complications:
1. Neonate:
 Superficial scalp abrasion
 Sloughing of the scalp and
 Cephalo hematoma—due to rupture of emissary veins beneath the periosteum. Usually it
resolves by one or two weeks
 Subaponeurotic (subgaleal) hemorrhage (not limited by suture line as it is not
subperiosteal)
 Intracranial hemorrhage (rare)
 Retinal hemorrhage (no long-term effect)
 Jaundice.
2. Maternal: The injuries are uncommon but may be due to inclusion of the soft tissues
such as the cervix or vaginal wall inside the cup. However, failure rate is high. The
sequential use of ventouse and forceps increases the risk of trauma to both the mother and
the neonate. Outlet forceps may be used following failure of ventouse.

28
 MEDICAL INDUCTION
Introduction
Labor induction is the process of inducing labor artificially in the pregnant woman, in
order to deliver a baby. This is a procedure done by simulating uterine contractions, before the
labor starts naturally. Labor induction is a process used to speed up the labor process sometimes
or initiate the labor, and performed mostly in the cases when the doctor is concerned about the
health of the fetus or the mother, when she is overdue for delivery. There are various methods
which help in inducing labor. Some of the prominent methods are listed below.
 By rupturing the membranes
 By using Prostaglandins
 By using Oxytocin or Pitocin
Labor Induction is a procedure performed by simulating uterine contractions, before the
labor starts naturally. The doctor will determine various factors to see if labor induction is
necessary or not. Some of the factors are as mentioned.
 Health condition of the fetus inside the womb.
 The position of the fetus in the uterus
 Gestational age and size of the baby
 The status and condition of the woman‘s cervix
There are various reasons for labor induction. Some of these reasons are listed below:
st
 When the due date of the delivery has passed and usually when the woman is in 41 and
42nd week of pregnancy.
 Any history of still birth
 In cases, when the membranes have already ruptured or the water bags have broken but and
still the labor has not started.
 If the expectant mother has some problems like hypertension (high blood pressure),
preeclampsia or diabetes. Such problems, especially, during the phase of pregnancy may be
a threat to the health of the baby.
 Uterine infections
 An increased heart rate of the fetus
 The insufficient amniotic fluid surrounding the fetus also known as oligohydramnios.
 Rh- blood problems
 The abnormal growth pattern of the fetus
 Deterioration of placenta has begun
 The abnormal or slow growth of the fetus suddenly
 Peeling off the placenta from the internal wall of the uterus, also known as placental
abruption (peeling off completely or partially).
Drugs used
1. Prostaglandins: Act locally (autocrine and paracrine hormones) on the contiguous cells.
PGE2 and PGF2α both cause myometrial contraction. But PGE2 is primarily important for
cervical ripening whereas PGF2α for myometrial contraction. PGE2 has greater collagenolytic
properties and also sensitizes the myometrium to oxytocin. Intracervical application of

29
dinoprostone (PGE2 – 0.5 mg) gel is the gold standard for cervical ripening (see p. 580). It may
be repeated after 6 hours for 3 or 4 doses if required. The woman should be in bed for 30
minutes following application and is monitored for uterine activity and fetal heart rate. Side
effects are few.
2. Misoprostol (PGE1 ) is currently being used either transvaginally or orally for induction of
labor (ACOG 2003). Oral use of misoprostol is less effective than vaginal administration. A
dose of 25 µg vaginally every 4 hours is found either superior or similarly effective to that of
PGE2 for cervical ripening and labor induction. With the above dose schedule, the risk of
uterine hyperstimulation, meconium stained liquor and fetal heart irregularities are reduced.
Total 6–8 doses are used. Buccal and sublingual use of misoprostol can avoid the first pass
hepatic circulation and can maintain the serum bioavailability similar to that of vaginal use.
Side effects are Tachysystole, meconium passage and possibly uterine rupture. It is
contraindicated in women with previous cesarean birth.
3. Oxytocinis - an endogenous uterotonic that stimulates uterine contractions. Oxytocin
receptors present in the myometrium are more in the fundus than in the cervix. Receptor
concentrations increase during pregnancy and in labor (cf. prostaglandins). Oxytocin acts by (a)
receptor mediation; (b) voltage-mediated calcium channels and (c) prostaglandin production.
Because of short half life (3–4 minutes) plasma levels fall rapidly when intravenous infusion is
stopped. Oxytocin is effective for induction of labor when the cervix is ripe. It is less effective
as a cervical ripening agent.
4. Mifepristone (progesterone receptor antagonists) blocks both progesterone and glucocorticoid
receptors. RU 486, 200 mg vaginally daily for 2 days has been found to ripen the cervix and to
induce labor. Onapristone (ZK 98299) is a more selective progesterone receptor antagonists.
Risks
 Increased risk of C-section – Even after the process of inducing labor, if the baby is not
delivered or the mother is not able to deliver the baby, and then the doctor might go for the
C-section surgery.
 Increased hospital stay – There are chances that even after the labor induction, there might
be some problem in the delivery. In such cases, the pregnant woman might have to stay for a
longer period of time in the hospital i.e. first for the labor induction but if it doesn‘t work
out, then for the C-section till the delivery is done.
 Risk of infection – Infections might happen if the delivery does not happen within a day or
two of the labor induction by breaking or rupturing the amniotic sac. In such cases, there
might be chances of infection in both fetus and the mother. This infection caused in the
uterus due to the rupturing of amniotic fluid is known as chorioamnionitis.
 Decreased heart rate – When the medicines, like prostaglandins or oxytocin, are used to
induce labor, mothers experience very strong uterine contractions. As a result, the oxygen
supply of the fetus might slow down which may further decrease the heart rate.
 Problems with umbilical cord – In the process of labor induction, there is a risk of the
umbilical cord slipping off into the woman‘s vagina before the delivery. This issue is also

30
 known as umbilical cord prolapse. In such cases, the umbilical cord might get compressed
and hence, reduce the oxygen supply to the fetus.
 Post- delivery bleeding – The labor induction process may make the muscles of the uterus
weak leading to improper functioning or contraction, after the baby is delivered. This
condition is also known as uterine atony and might result in severe bleeding after the
woman has given birth.
 Premature birth in some cases, as a serious consequence of labor induction.
 Lung problems in the fetus
 Hearing and vision issues in the baby
 Underdeveloped brain and lungs of the baby.
 In some cases, the doctors do not advise a labor induction as it might cause some serious
risks to either the mother or the fetus as mentioned below.
 Placenta previa – This is a condition in which the placenta blocks the woman‘s cervix.
 Previous major C-section surgery on the uterus with a classical incision.
 Active genital herpes infection in the pregnant woman.
 Transverse fatal lie – This is a condition in which fetus lies in a crosswise position in the
uterus.
 A very narrow birth canal which might not be able to deliver the baby out normally even if
labor induction is done.

31
 SURGICAL INDUCTION
Methods:
1. Artificial rupture of the membranes (ARM)
 Low rupture of the membranes (LRM)
 High rupture of the membranes (HRM)
Mechanism of onset of labor: May be related with
(a) stretching of the cervix
(b) separation of the membranes (liberation of prostaglandins) and
(c) reduction of amniotic fluid volume.
Effectiveness depends on:
(1) State of the cervix
(2) Station of the presenting part. Induction delivery interval is shorter when amniotomy is
combined with oxytocin than when either method is used singly.
Advantages of amniotomy:
(a) High success rate;
(b) Chance to observe the amniotic fluid for blood or meconium;
(c) Access to use fetal scalp electrode or intrauterine pressure catheter or for fetal scalp blood
sampling. Limitation: It cannot be employed in an unfavorable cervix (long, firm cervix with os
closed). The cervix should be at least one finger dilated.
Indications:
 Abruptio placenta
 Chronic hydramnios
 Severe preeclampsia
 Incombination with medical induction
 To place scalp electrode for electrode for electronic fetal monitoring.
Contraindications:
 Intrauterine fetal death
 Maternal AIDS
 Genital active herpes infection
Immediate beneficial effects of ARM
 Lowering of the blood pressure in pre-eclampsia-eclampsia.
 Relief of maternal distress in hydramnios.
 Control of bleeding in APH.
 Relief of tension in abruptio placentae and initiation of labor. These benefits are to be
weighed against the risks involved in the indications for which the method is adopted.

32
Hazards of ARM
Once the procedure is adopted, there is no scope of retreating from the decision of delivery.
Chance of umbilical cord prolapse — the risk is low with engaged head or rupture of
membranes with head fixed to the brim.
Amnionitis — Careful selection of cases with favorable preinduction score will shorten the
induction-delivery interval. Meticulous asepsis during the procedure reduces the risk.
Accidental injury to the placenta, cervix or uterus, fetal parts or vasa previa. Care taken
during rupture of the membranes minimizes the problem.
Liquor amnii embolism (rare).
Low rupture of the membranes (LRM)
It is widely practised nowadays with high degree of success. The membranes below the
presenting part overlying the internal os are ruptured to drain some amount of amniotic fluid.
Contraindication: It is preferably avoided in chronic hydramnios, as there is risk of sudden
massive liquor drainage. Sudden uterine decompression may precipitate early placental
separation (abruption). In such a case controlled ARM is done.
Procedures:
Preliminaries: It is an indoor procedure. The patient is asked to empty her bladder. The
procedure may be conducted in the labor ward or in the operation theater if the risk of cord
prolapse is high.
Actual steps
 FHR status is monitored before and after the procedure.
 The patient is in lithotomy position.
 Full surgical asepsis is to be taken.
 Two fingers are introduced into the vagina smeared with antiseptic ointment. The index
finger is passed through the cervical canal beyond the internal os. The membranes are
swept free from the lower segment as far as reached by the finger.
 With one or two fingers still in the cervical canal with the palmar surface upwards, a long
Kocher‘s forceps with the blades closed or an amnion hook is introduced along the
palmar aspect of the fingers up to the membranes.
 The blades are opened to seize the membranes and are torn by twisting movements. Amni
hook is used to scratch over the membranes. This is followed by visible escape of
amniotic fluid.
If the head is not engaged, an assistant should push the head to fix it to the brim of
the pelvis to prevent cord prolapse. If the head is deeply engaged and the drainage of

33
 liquor is insignificant, gentle pushing of the head up, facilitates escape of desired amount
of amniotic fluid.
After the membranes rupture, the following are to be assessed:
(a) Color of the amniotic fluid
(b) Status of the cervix
(c) Station of the head
(d) Detection of cord prolapse if any
(e) FHR pattern is again checked. In high-risk cases scalp electrode for fetal monitoring
is applied. A sterile vulval pad is placed. Prophylactic antibiotic may be prescribed.

Hazards:
(1) Cord prolapse
(2) Uncontrolled escape of amniotic fluid and placental abruption
(3) Injury to the cervix or the presenting part
(4) Rupture of vasa previa leading to fetal blood loss
(5) Amnionitis
2. Stripping the membranes
Stripping (sweeping) of the membranes means digital separation of the chorioamniotic
membranes from the wall of the cervix and lower uterine segment. It is thought to work by
release of endogenous prostaglandins from the membranes and decidua. Manual exploration of
the cervix triggers Ferguson reflex, which promotes oxytocin release from maternal pituitary.
Sweeping of the membranes is done prior to ARM. It is simple, safe and beneficial for induction
of labor.
As an isolated procedure, stripping the membranes off from its attachment from the lower
segment is an effective procedure for induction provided cervical score is favorable. It is used as
a preliminary step prior to rupture of the membranes. It is also used to make the cervix ripe.
Criteria to be fulfilled for membrane stripping are:
(a) The fetal head must be well applied to the cervix
(b) The cervix should be dilated so as to allow the introduction of the examiner‘s finger.

34
 PLACENTAL EXAMINATION
The placenta, at term, is almost a circular disk with a diameter of 15–20 cm and thickness
of about 3 cm at its center. It thins off toward the edge. It feels spongy and weighs about 500 gm,
the proportion to the weight of the baby being roughly 1: 6 at term and occupies about 30% of
the uterine wall. It presents two surfaces, fetal and maternal, and a peripheral margin.
Fetal surface: The fetal surface is covered by the smooth and glistening amnion with the
umbilical cord attached at or near its center. Branches of the umbilical vessels are visible beneath
the amnion as they radiate from the insertion of the cord. The amnion can be peeled off from the
underlying chorion except at the insertion of the cord. At term, about four-fifths of the placenta is
of fetal origin.
Maternal surface: The maternal surface is rough and spongy. Maternal blood gives it a dull red
color. A thin grayish, somewhat shaggy layer which is the remnant of the decidua basalis
(compact and spongy layer) and has come away with the placenta, may be visible. The maternal
surface is mapped out into 15–20 somewhat convex polygonal areas known as lobes or
cotyledons which are limited by fissures. Each fissure is occupied by the decidual septum which
is derived from the basal plate. Numerous small grayish spots are visible. These are due to
deposition of calcium in the degenerated areas and are of no clinical significance. The maternal
portion of the placenta amounts to less than one-fifth of the total placenta. Only the decidua
basalis and the blood in the intervillous space are of maternal origin.

Margin: Peripheral margin of the placenta is limited by the fused basal and chorionic plates and
is continuous with the chorion laeve and amnion. Essentially, the chorion and the placenta are
one structure but the placenta is a specialized part of the chorion.
Attachment: The placenta is usually attached to the upper part of the body of the uterus
encroaching to the fundus adjacent to the anterior or posterior wall with equal frequency. The
attachment to the uterine wall is effective due to anchoring villi connecting the chorionic plate
with the basal plate and also by the fused decidua capsularis and vera with the chorion laeve at
the margin.
Separation: Placenta separates after the birth of the baby and the line of separation is through
the decidua spongiosum.
Structures - The placenta consists of two plates. The chorionic plate lies internally. It is lined
by the amniotic membrane. The umbilical cord is attached to this plate. The basal plate lies to the

35
maternal aspect. Between the two plates lies the intervillous space containing the stem villi with
their branches, the space being filled with maternal blood.
Amniotic membrane: It consists of single layer of cubical epithelium loosely attached to the
adjacent chorionic plate. It takes no part in formation of the placenta.
Chorionic plate: From within outward, it consists of
 primitive mesenchymal tissue containing branches of umbilical vessels,
 a layer of cytotrophoblast
 syncytiotrophoblast. The stem villi arise from the plate. It forms the inner boundary of the
choriodecidual space.
Basal plate: It consists of the following structures from outside inwards.
(1) Part of the compact and spongy layer of the decidua basalis;
(2) Nitabuch‘s layer of fibrinoid degeneration of the outer syncytiotrophoblast at the junction of
the cytotrophoblastic shell and decidua;
(3) Cytotrophoblastic shell;
(4) Syncytiotrophoblast.
The basal plate is perforated by the spiral branches of the uterine vessels through which
the maternal blood flows into the intervillous space. At places, placental or decidual septa project
from the basal plate into the intervillous space but fail to reach the chorionic plate. The septum
consists of decidual elements covered by trophoblastic cells. The areas between the septa are
known as cotyledons (lobes), which are observed from the maternal surface, numbering 15–20.
Intervillous space:It is bounded on the inner side by the chorionic plate and the outer side by the
basal plate, limited on the periphery by the fusion of the two plates. It is lined internally on all
sides by the syncytiotrophoblast and is filled with slow flowing maternal blood. Numerous
branching villi which arise from the stem villi project into the space and constitute chief content
of the intervillous space.
Stem villi: These arise from the chorionic plate and extends to the basal plate. With the
progressive development — primary, secondary and tertiary villi are formed. Functional unit of
the placenta is called a fetal cotyledon or placentome, which is derived from a major primary
stem villus. These major stem villi pass down through the intervillous space to anchor onto the
basal plate. Functional subunit is called a lobule, which is derived from a tertiary stem villi.
About 60 stem villi persist in human placenta. Thus, each cotyledon (total 15–29) contains 3–4
major stem villi. The villi are the functional unit of the placenta. The total villi surface, for
exchange, approximately varies between 10 square meters and 14 square meters. The fetal
capillary system within the villi is almost 50 km long. Thus while some of the villi are anchoring
the placenta to the decidua, the majority are free within the intervillous space and are called
nutritive villi. Blood vessels within the branching villi do not anastomose with the neighboring
one.
Structure of a terminal villus: In the early placenta, each terminal villus has got the following
structures from outside inward:
(1) Outer syncytiotrophoblast;

36
(2) cytotrophoblast;
(3) basement membrane;
(4) Central stroma containing fetal capillaries, primitive mesenchymal cells, connective tissue
and a few phagocytic (Hofbauer) cells.
In placenta at term, syncytiotrophoblast becomes relatively thin at places overlying the fetal
capillaries and thicker at other areas containing extensive endoplasmic reticulum. The former is
probably the site for transfer and the latter, the site for synthesis.The cytotrophoblast is relatively
sparse. Basement membrane becomes thicker. Stroma contains dilated vessels along with all the
constituents and few Hofbauer cells. Hofbauer cells are round cells that are capable of
phagocytosis and can trap maternal antibodies crossing through the placenta (immune
suppressive). These cells can express class II major histocompatibility complex (MHC)
molecules.

37
 REPAIR OF TEARS
Timing of repair – the repair is done soon after expulsion of placenta. If repair is done prior to
that, disruption of the wound is inevitable, if subsequent manual removal or exploration of the
genital tract is needed. Oozing during this period should be controlled by pressure with a sterile
gauze swab and bleeding by the artery forceps. Early repair prevents sepsis and eliminates the
patient‘s prolonged apprehension of ―stitches‖.
Preliminaries: The patient is placed in lithotomy position. A good light source from behind is
needed. The perineum including the wound area is cleansed with antiseptic solution. Blood clots
are removed from the vagina and the wound area. The patient is draped properly and repair
should be done under strict aseptic precautions. If the repair field is obscured by oozing of blood
from above, a vaginal pack may be inserted and is placed high up. Do not forget to remove the
pack after the repair is completed.
Repair: The repair is done in three layers. The principles to be followed are:
(1) Perfect hemostasis
(2) to obliterate the dead space
(3) Suture without tension.
The repair is to be done in the following order:
(1) Vaginal mucosa and submucosal tissues
(2)perineal muscles
(3) skin and subcutaneous tissues.
Preliminaries - The vaginal mucosa is sutured first. The first suture is placed at or just above
the apex of the tear. Thereafter, the vaginal walls are apposed by interrupted sutures with
polyglycolic acid suture (Dexon) or No. ―0‖ chromic catgut, from above downwards till the
fourchette is reached. The suture should include the deep tissues to obliterate the dead space. A
continuous suture may cause puckering and shortening of the posterior vaginal wall. Care should
be taken not to injure the rectum.
Postoperative care
Dressing: The wound is to be dressed each time following urination and defecation to keep the
area clean and dry. 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).
Comfort: 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.
Ambulance: The patient is allowed to move out of the bed after 24 hours. Prior to that, she is
allowed to roll over on to her side or even to sit but only with thighs apposed. Removal of
stitches: 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. The number of stitches removed should be checked with the record of the stitches
given.

38
Complications
Immediate:
(1) Extension of the incision to involve the rectum. This is likely in median episiotomy or during
delivery of undiagnosed occipito posterior even with small mediolateral episiotomy
(2) vulval hematoma
(3) Infection: the clinical features are
 throbbing pain on the perineum
 rise in temperature
 the wound area looks moist, red and swollen
 offensive discharge comes out through the wound margins.
Treatment:
(a) To facilitate drainage of pus by cutting one or two stitches
(b) local dressing with antiseptic powder or ointment
(c) MgSO4 compression or application of infrared heat to the area to reduce edema and pain
(d) systemic antibiotic (IV).
(4) Wound dehiscence is often due to infection, hematoma formation or faulty repair. The wound
should be dressed daily until the local infection subsides and healthy granulation tissue forms in
the margins. Secondary, sutures are given under local anesthesia using cutting needle and nylon.
The margins are to be saucerized and debridement of all necrotic tissues should be done. This is
followed by through-and-through sutures taking tissues right at the bottom of the wound. Usual
postoperative dressing is to be given. Systemic (IV) antibiotic is prescribed.
(5) Injury to anal sphincter causing incontinence of flatus or feces.
(6) Rectovaginal fistula and rarely.
(7) Necrotizing fasciitis (rare) in a woman who is diabetic or immunocompromised.
Remote:
(1) Dyspareunia—this is due to a narrow vaginal introitus which may result from faulty
technique of repair or due to painful perineal scar,
(2) Chance of perineal lacerations in subsequent labor, if not managed properly and
(3) Scar endometriosis (rare).

39
 BREAST EXAMINATION IN ANTENTAL MOTHER
Introduction
Examination of the breasts helps to note the presence of pregnancy changes but also to
note the nipples (cracked or depressed) and skin condition of the areola. The purpose is to correct
the abnormality; if any, so that will be no difficulty in breastfeeding immediately following
delivery. The changes in the breasts are best evident in a primigravida. In multipara, who has
once lactated, the changes are not clearly defined.
Size: Increased size of the breasts becomes evident even in early weeks. This is due to marked
hypertrophy and proliferation of the ducts (estrogen) and the alveoli (estrogen and progesterone)
which are marked in the peripheral lobules. There is also hypertrophy of the connective tissue
stroma. Myoepithelial cells become prominent. Vascularity is increased which results in
appearance of bluish veins running under the skin. Quite often, the ―axillary tail‖ (prolongation
of the breast tissue under cover of the pectoralis major) becomes enlarged and painful. There
may be evidence of striation due to stretching of the cutis.
Nipples and areola: The nipples become larger, erectile and deeply pigmented. Variable
numbers of sebaceous glands (5–15) which remain invisible in the nonpregnant state in the
areola, become hypertrophied and are called Montgomery‘s tubercles. Those are placed
surrounding the nipples. Their secretion keeps the nipple and the areola moist and healthy. An
outer zone of less marked and irregular pigmented area appears in second trimester and is called
secondary areola.
Secretion: Secretion (colostrum) can be squeezed out of the breast at about 12th week which at
first becomes sticky. Later on, by 16th week, it becomes thick and yellowish. The demonstration
of secretion from the breast of a woman who has never lactated is an important sign of
pregnancy. In latter months, colostrum may be expressed from the nipples. For normal changes
and lactation.

40
 BREAST EXAMINATION IN POSTNATAL MOTHER
Introduction
Breastfeeding is important for the baby. The doctor will examine your breasts physically, and ask
you whether you are able to breastfeed the child without any difficulties.
Preliminaries
If physically examine women‘s breasts:
 Explain the procedure to the mother.
 Ensure privacy to help the mother feel comfortable and consider customs of modesty.
 Ask permission before breasts are exposed or touched.
 Talk with the mother and look at the breasts without touching.
 If need to touch the breasts, do so gently.
 Ask what has she noticed about her breasts – is there anything that worries her? If so, ask her
to show you.
 Talk to the mother about what examiner has found. Highlight the positive signs observed. Do
not sound critical about her breasts. Build her confidence in her ability to breastfeed.
History collection
 How did breasts change during pregnancy? If breasts become larger and the areola
become darker during pregnancy, this usually indicates that, there is plenty of milk
producing tissue.
 Has she had breast surgery at any time, which may have cut some milk ducts or nerves,
or for a breast abscess?
Inspection
 Are the breasts very large or very small? Reassure the woman those small and large
breasts all produce plenty of milk, but sometimes a mother may need help with
attachment.
 Are there any scars, which may indicate past problems with breastfeeding such as an
abscess or surgery?
 Is either breast swollen, with tight shiny skin? This suggests engorgement with edema.
Normal fullness, when the milk comes in, makes the breast larger, but not swollen with
shiny edematous skin.
 Is there redness of any part of the breast skin? If diffuse or generalized, this may be due
to engorgement. If localized, this may be a blocked duct (small area) or mastitis (larger
clearly defined area). Purple discoloration suggests a possible abscess.
 What is the size and shape of the nipples? (Long or flat, inverted, very big). Could their
shape make attachment difficult?
 Are there any sores or fissures (a linear sore)? This usually means that the baby has been
suckling while poorly attached.
 Is there a rash or redness of the nipple?

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Palpation
 Is the breast hard or soft? Generalized hardness, sometimes with several lumps, may be
due to normal fullness or engorgement. The appearance of the skin (shiny with
engorgement or normal with fullness) and flexibility of the skin (turgid) should tell which
it is.
 Talk to the mother about what the nurse have found. Highlight the positive changes
observed. Do not sound critical about her breasts. Build her confidence in her ability to
breastfeed.

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 NEONATAL RESUSCITATION
Introduction
It is a series of emergency procedures performed by a doctor to support newborn babies
who are not breathing. Are gasping or have a weak heartbeat at birth. These skills allow a doctor
to save the lives of newborn babies.
Indications
1. Asphyxia neonatrum – It is a condition that occurs when a baby doesn‘t get enough oxygen
during the birth process. It can be fatal.
2. Birth asphyxia – Is clinically defined as failure to initiate and maintain spontaneous
respiration following birth.
3. Perinatal asphyxia – Condition of impaired gas exchange or inadequate blood flow that
leads to persistent hypoxemia and hypercarbia that occurs in temporal proximity to labor
(peripartum) and delivery (intrapartum).
4. Antenatal administration of glucocorticoids to the mother.
5. Maternal hypoxic states – The maternal disease such as anemia, eclampsia, cyanotic
cardiovascular disorders, status asthmatics, dehydration, hypotension are responsible for
maternal and therefore to fetal and neonatal hypoxia.
6. The placenta, as a respiratory organ of the fetus fails functionally - Either due to
anatomical changes in the placenta or due to inadequacy of utero placental circulation.
Premature placental separation, circumvallate placenta, hypertensive disorders in pregnancy,
abnormal labor, cord compression, vascular anomalies in cord.
7. Birth trauma – Malpresentation such as breech, oblique lie, and occipito- posterior often
requires manipulative and vaginal delivery (forceps or ventouse). Prolonged second stage of
labor in contracted pelvis, often cause asphyxia. Increased intracranial tension – cerebral
edema and congestion – increased intracranial pressure – asphyxia.
8. Medication – morphine and anesthetic agents depress the respiratory centers directly and the
chance of development of asphyxia is increased.
9. Postnatal - Is secondary to pulmonary, cardio vascular and neurological abnormalities of the
neonate.
Steps of resuscitation
1. Soon after delivery immediately skin to skin contact and breast feeding (routine care)
 Only routine care is required for a baby who is crying or breathing normally;
 Even routine suctioning is not required for these normal babies.
2. If the baby is not breathing or gasping.
 Call for help
 Cut cord quickly, transfer to a firm, warm surface [under a radiant heater]
 Inform the mother that baby has difficulty breathing and you will help the baby to
breathe.
 Start newborn resuscitation

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3. Position, clear airways
4. Dry, stimulate, reposition
5. Ventilate (if still not breathing)
Selecting Bag and Mask equipment
 Size of bag: 240-750 ml
 Oxygen capability: Oxygen source, reservoir
 Safety feature: Pop off valve, pressure gauge (optional)
6. Use the correct size face mask
 The nose
 The mouth
 The tip of the chin
 but not the eyes
 Squeeze bag with 2 fingers or whole hand, 2-3 times
 Observe for rise of chest.
 If chest is not rising:
 Check seal
 Reposition the head
 Squeeze harder
 Once good seal and chest rising, ventilate at 40 squeezes per minute
 Observe chest rise
 Check heart rate after 30 seconds.
7. When to stop ventilating?
 If baby is crying;
 If breathing >30/min, and
 No chest in-drawing:
 If the skin between the ribs is ‗sucked‘ inwards and the ribs are prominent, the baby
has chest ‗in-drawing‘
8. After stopping ventilation
 Put the baby in skin-to-skin contact on mother‘s chest
 Monitor every 15 minutes for breathing and warmth
 Tell the mother the baby will probably be well
 Encourage the mother to start breastfeeding as soon as possible
 Never leave the baby alone
9. When to continue ventilating?
 If the baby
 is breathing at a rate of ˂30/min
 is gasping
 has severe chest in-drawing

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  Arrange for immediate referral
10. Referral
 Explain to the mother what happened, that her baby needs help with breathing
 Ventilate during the referral
 Record the event on a referral form and labor record
Neonatal resuscitation clinical practice guidelines (AHA 2020)
In October 2020, the AHA published their updated Recommendation for neonatal
resuscitation.
 Cord management – clamping the umbilical cord may be delayed for more than 30
seconds in term and preterm infants after an uncomplicated birth. Note that umbilical
cord milking is not recommended for preterm babies.
 Prevention of hypothermia – skin to skin contact with the mother is recommended for
healthy newborn infants because it can promote breast feeding, improve blood glucose
stability, and helps to prevent hypothermia. The infant‘s temperature should be
maintained 97.7 degree F.
 Tactile stimulation – if a newborn infant is breathing ineffectively or has apnea, drying
the infant and / or rubbing the back and soles of the feet may help stimulate breathing
 Clearing the airway – routine oral, nasal, oropharyngeal suctioning is not recommended
for newborn infants, even those who are born with meconium-stained amniotic fluid
(MSAF). However, no vigorous infants with MSAF at birth who have evidence of airway
obstruction can benefit from intubation and tracheal suction.
 Ventilator support – start positive pressure ventilation (PPV) without delay in newborn
infants who are gasping or apneic within 60 seconds after birth or who have persistent
bradycardia. Heart rate of < 100 beats/ min. A rate of 40 to 60 inflations per minute is
reasonable. Key indicator of successful ventilation is an increase in heart rate.
 Oxygen therapy – PPV may be started with air (21%) oxygen) in term and late preterm
infants up to 30% oxygen may be used in preterm infants (less than 35 weeks gestation).
Thus, use of 100% oxygen should be avoided in term and late preterm newborns because
it is associated with excess mortality.
 Heart rate assessment – electrocardiography can provide rapid and accurate
measurement of the heart rate during the resuscitation of term and preterm newborn
infants.
 Chest compression – initiate chest compressions if the heart rate is lower than 60
beats/min after at least 30 seconds of adequate PPV. Intravascular access – the umbilical
vein is the recommended route for vascular access in infants who have failed to respond
to PPV and chest compressions and who require epinephrine and / or volume expanders.
 Epinephrine administration – administer epinephrine, preferably intravenously, if the
heart rate remains lower than 60 beats/ min despite 60 seconds of chest compressions and
adequate PPV. The recommended intravenous dose of epinephrine is 0.01 to 0.03mg/ kg.

45
 Volume expansion- failure to respond to epinephrine and known or suspected blood loss
are indicators for volume expansion with normal saline or blood. The recommended
initial volume is 10ml/kg over 5 to 10 minutes.
 Care after resuscitation – newborn infants who received prolonged PPV, intubation,
chest compressions, or epinephrine should be monitored closely in an intensive care unit
or similar area after their condition has stabilized.

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 ARTIFICIAL INSEMINATION
Artificial insemination (AI)
Different methods are:
1. IUI—Intrauterine insemination
2. Fallopian tube sperm perfusion
1. Intrauterine insemination (IUI) - lUI may be either AIH (artificial insemination husband)
or AID (artificial insemination donor). Husband‘s semen is commonly used. The purpose of
IUI is to bypass the endocervical canal which is abnormal and to place increased
concentration of motile sperm as close to the fallopian tubes.
Technique: Common methods to extract sperm from the seminal plasma are washing, swim-
up and density gradient centrifugation. Swim-up method allows most motile sperm to swim-
up into the supernatant. Compared to washing method it contains no dead sperm and cellular
debris. About 0.3 ml of washed and concentrated sperm is injected through a flexible
polyethylene catheter within the uterine cavity around the time of ovulation. Washing in
culture media removes the proteins and prostaglandins from semen that may cause uterine
cramps or anaphylactoid reactions. Density gradient centrifugation recovers most highly
motile as well as morphologically normal sperm. The processed motile sperm count for
insemination should be at least 1 million. Best results are obtained when the motile sperm
count exceeds 10 million. Normal sperm survive in this female reproductive tract and can
fertilize an egg for at least 3 days but an oocyte survives only for 12–24 hours. The procedure
may be repeated 2–3 times over a period of 2–3 days. To increase sperm motility,
pentoxyphylline (phosphodiesterase inhibitor) has been used. Generally 4–6 cycles of
insemination with superovulation is advised.
Timing of IUI: In cervical insemination, timing is not so much vital because the sperm can
survive in the cervical canal for a day or two. As the reservoir function is not available in lUI,
some form of controlled ovarian hyperstimulation (COH) is required.
Results - Cumulative conception rates after 12 insemination cycles is 75–80%. The best
results are obtained in the treatment of cervical factor and unexplained infertility and in
stimulated cycle. lUI along with superovulation (induction of ovulation with hMG/ FSH
hCG) gives higher result.

47
 Artificial (therapeutic) insemination donor (aid) - When the semen of a donor is used for
insemination it is called therapeutic insemination donor.
The indications are:
Untreatable azoospermia, asthenospermia
Genetic disease
Rh-negative donor insemination—for woman with Rh-sensitization
The donor should be healthy and of the same ethnic group as husband. He should be
serologically and bacteriologically free from venereal diseases including AIDS and hepatitis.
The recipient and donor must be matched for blood grouping and Rh typing. Either fresh or
frozen semen is used. Sperm specimen should only be used when it is kept sequestered for at
least 180 days and thereafter it has been found negative for HIV. The legal, psychological
and religious aspects should be counseled before its application.
Results: A total of 3–6 cycles may have to be utilized to get a success. The success rate is
about 50–60 percent. Insemination when combined with superovulation enhances success
rate.
2. Fallopian tube sperm perfusion
Indications are same as that of lUI.
Technique: Large volume of washed and processed sperm is injected within the uterine
cavity around the time of ovulation. This causes perfusion of the fallopian tubes with
spermatozoa. In conjunction with ovulation induction, pregnancy rate is 25–30 percent per
cycle.

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 ASSISTED REDUCTIVE TECHNOLOGY (ART)
Introduction
The ART encompasses all the procedures that involve manipulation of gametes and embryos
outside the body for the treatment of infertility.
1. In Vitro Fertilization and Embryo Transfer (IVF-ET) - The field of reproductive medicine
has changed forever with the birth of Louise Brown in 1978 by IVF-ET. Patrick Steptoe and
Robert Edwards of England are remembered for their revolutionary work. The past decade
has witnessed two more dramatic changes in the technique protocol of IVF-ET. One such
change was from natural cycle to superovulation protocol and the other one was replacement
of laparoscopy by vaginal sonography for ovum retrieval.

Patient Selection (ideal)

 Age < 35 years
 Presence of ovarian reserve (D-3, serum FSH˂10IU/L)
 Husband—normal seminogram.
 Couple must be screened negative for HIV and hepatitis.
 Normal uterine cavity as evaluated by hysteroscopy/sonohysterography.
Principal steps of an ART cycle
1. Down regulation using GnRH agonist.
2. Controlled ovarian hyperstimulation (COH).
3. Monitoring of follicular growth.
4. Oocyte retrieval.
5. Fertilization in vitro (IVF, ICSI, GIFT).
6. Transfer of gametes or embryos.
7. Luteal support with progesterone.
GnRH Analogues for Down Regulation
Currently most ART procedures involve the use of GnRH agonists.
 GnRH agonist therapy used for down regulation of pituitary to prevent premature LH surge.
It gives higher pregnancy rates.

49
 GnRH agonist therapy is continued either subcutaneously or intranasally during the
gonadotropin treatment phase.
 GnRH antagonists are currently tried along with gonadotropin stimulation to prevent
premature LH surge or premature ovulation. Cetrorelix and Ganirelix are the available drugs.
Different schedules for GnRH agonist are available:
 Long follicular down regulation—when therapy is started in the follicular phase of previous
cycle.
 Long luteal down regulation (most commonly used) therapy is begun on 0–21 of the previous
cycle. Gonadotropin stimulation is started following the menses.
 Short ‗flare‘ protocol - therapy is started in the follicular phase (0-1) along with gonadotropin
stimulation. This is also called flare protocol, as gonadotropin can work over the stimulatory
effect of GnRH agonist. In short, (‗flare‘) protocol, GnRh agonist (leuprolide acetate 1.0 mg
daily) is given on cycle day 2–4, continuing thereafter at a reduced dose (0.5 mg daily).
Gonadotropin stimulation begins on cycle D3. Adjustments of gonadotropin dose are done
depending upon the response.
Natural Cycle
In the first case, Steptoe and Edwards (1978) achieved success from collecting the oocyte
from a natural cycle, 36 hours after the onset of LH surge. Compared to stimulated IVF cycles, it
has few advantages. It requires no medication, less cost, minimizes complication (multiple
pregnancy, OHSS).
Disadvantages: high cycle cancelation rates due to premature LH surge. It has a low success
rate. The other advantages of induction of superovulation are improved quality of the oocyte,
timing of ovulation can be controlled, suited to the personnel involved and extended to all cases
of ovulatory dysfunction.
Controlled Ovarian Hyperstimulation (COH) - Gonadotropin stimulation is begun once
pituitary down regulation is achieved (serum E2 < 40 pg/ml and no ovarian follicles are seen >
10 mm on TVS). Exogenous gonadotropins for (uFSH, rFSH, HMG) ovarian stimulation are
used. The drug regimens used differ in each center. Following drugs or combination of drugs is
commonly used.
Monitoring of Follicular Growth
The follicular growth response is monitored by cervical mucus study, sonographic measurement
of the follicles and serum estradiol estimation, commencing on the 8th day of treatment cycle.
The endometrial thickness (stripe) ≥ 8–9 mm (trilaminar) is optimum. When two or more
follicles are 17–18 mm in diameter and serum E2 1evels > 250 pg/ml/per follicle, 5,000–10,000
IU of hCG (250).mg of recombinant hCG) is given intramuscularly. Oocyte is retrieved 36 hours
after the hCG is given. hCG induces oocyte maturation. The individual woman may be a high
responder or a poor responder. Depending upon the response, management is done.
Oocyte retrieval
Oocyte retrieval is done aseptically through vaginal route under ultrasound guidance. With the
development of vaginal transducers, vaginal needle aspiration is done about 36 hours after hCG

50
administration but before ovulation occurs. Intravenous analgesia and sedation (propofol) is
adequate in most of the cases. The oocyte is readily recognizable as a single cell surrounded by a
mass of cumulus cells. After recovery, the oocytes are maintained in culture in vitro for 4–6
hours.
Fertilization (in vitro)
The sperm used for insemination in vitro is prepared by the wash and swim-up or density
gradient centrifugation (preferred) technique. Approximately 50,000 to 100,000 capacitated
sperm are placed into the culture media containing the oocyte within 4–6 hours of retrieval. The
eggs may demonstrate signs of fertilization when examined 16–18 hours after insemination
(presence of two pronuclei in the presence of a second polar body). Sperm density and motility
are the two most important criteria for successful IVF. The semen is collected just prior to ovum
retrieval.
Embryo transfer
The fertilized ova at the 6–8 blastomere stage are placed into the uterine cavity close to the
fundus about 3 days after fertilization through a fine flexible soft catheter transcervically. Not
more than three embryos are transferred per cycle to minimize multiple pregnancies.
The process of transfer should be accurate, a traumatic and aseptic. Small volume transfer using
soft catheter under ultrasound guidance gives the best result. Trial transfer is beneficial. The
number of embryos to be transferred depends mainly on maternal age and the embryo quality.
Excess oocytes and embryos can be cryopreserved for future use. This will reduce the cost of
ovulation stimulation as well as the risk of ovarian hyper stimulation. Luteal phase support is
maintained with progesterone. It is started on the day after oocyte retrieval. hCG is given in
supplemental doses (1,500–2,500 IU). Micronized progesterone 200 mg thrice a day oral or as
vaginal suppository (preferred) or progesterone in oil injection 50mg IM daily is continued for
about 14 days. By this time, diagnosis of pregnancy by estimation of b-hCG (quantitative value)
is possible.

Result: The overall live birth rate varies from 32.7 percent per oocyte retrieval. There is
increased risk of miscarriage (18%), multiple pregnancy (31%), ectopic (0.9%), low birth weight
baby and prematurity. The risk of congenital malformation of the baby remains similar to general
population.
Prognostic Factors for IVF-ET
1. Maternal age—there is age related decline in response to ovarian stimulation, less oocytes,
poor oocyte quality, less embryos and implantation rate.
2. Ovarian reserve—declines with age.

51
3. Indication of IVF and past reproductive success. Women with tubal or ovulatory factors,
endometriosis, or unexplained factor—have higher success rate compared to women with poor
ovarian reserve.
4. Presence of hydrosalpinges—affect the outcome adversely.
5. Fibroid uterus—especially the submucous or interstitial variety have adverse outcome.
6. Smoking—poor outcome.
Gamete Intrafallopian Transfer (GIFT)
GIFT was first described by Asch and colleagues in 1984. It is a more invasive and expensive
procedure than IVF. In this procedure, both the sperm and the unfertilized oocytes are transferred
into the fallopian tubes. Fertilization is then achieved in vivo. The prerequisite for GIFT
procedure is to have normal uterine tubes. The indications are the same as that of IVF except the
tubal factor. Best result is obtained in unexplained infertility and the result is poor in male factor
abnormality. The superovulation is done as in IVF. Two collected oocytes along with
approximately 200,000–500,000 motile sperm for each fallopian tube are placed in a plastic tube
container. It is then passed through laparoscope and inserted 4 cm into the distal end of the
fallopian tube where the combination is injected.

Result: The overall delivered pregnancy rate is as high as 27–30 percent.

Zygote Intrafallopian Transfer (zift)
Zygote intrafallopian transfer was first described by Devroey et al. (1986). The placement of the
zygote (following one day of in vitro fertilization) into the fallopian tube can be done either
through the abdominal ostium by laparoscope or through the uterine ostium under ultrasonic
guidance. This technique is a suitable alternative of GIFT when defect lies in the male factor or
in cases of failed GIFT. Results (29–30%) are similar to that of IYF. GIFT or ZIFT is avoided
when tubal factors for infertility are present. The risk of ectopic pregnancy is high for GIFT and
ZIFT compared to IVF.

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Micromanipulation
Intracytoplasmic sperm injection (ICSI) ICSI was first described by van Steirteghem and
colleagues in Belgium (1992).
Indications
 Severe oligospermia (5 million sperm/mL)
 Asthenospermia, teratospermia
 Presence of sperm antibodies
 Obstruction of efferent duct system (male)
 Congenital absence of vas (bilateral)
 Failure of fertilization in IVF
 Fertilization of cryopreserved oocytes (with hardened zona pellucida)
 Unexplained infertility.
Sperm is recovered from the ejaculate. Otherwise, sperm is retrieved by TESE (testicular
Sperm extraction) or by MESA (microsurgical epididymal sperm aspiration) procedures.
Technique: One single spermatozoon or even a spermatid is injected directly into the cytoplasm
of an oocyte by micropuncture of the zona pellucida. This procedure is carried out under a high
quality inverted operating microscope. The oocyte is stabilized at 6 or 12 O‘clock position and
entered at the 3 O‘clock position. The injecting pipette pierces the zona and oolemma and the
sperm is injected directly into the ooplasm. ICSI is found to be very effective compared to other
micromanipulation methods like subzonal insemination (SUZI). ICSl is very effective to reduce
the need of AID.
Results: Fertilization rate is about 60–70 percent. Pregnancy rate is 20–40 percent per embryo
transfer.
Embryo or oocyte donation
Ovum donation and IVF can help women with successful pregnancy. The essential requirements
for successful outcome are:
(i) Successful ovum donation and IVF.
(ii) Embryoendometrial synchronization and
(iii) Exogenous hormonal support until luteal-placental shift.
Indications
 Women with premature ovarian failure.
 Women with removed ovaries.
 Older women (poor oocyte quality).
 Failure to respond with superovulation regimen Women with repeated failure of ART
 Genetic disease.
The oocytes are collected from:
 Sister or a friend (age between 21 and 34 years).
 Those for IVF candidates, excess oocytes following retrieval and cryopreservation
(see above).
 One undergoing laparoscopic sterilization (with financial compensation). y
53
  The oocyte donor like the semen donor must be screened for infection and genetic
diseases.
Successful implantation needs a perfect coordination of embryo and the endometrium.
Estrogen therapy (in the recipient) is started at the same time when the donor gets cycle
stimulation. Progesterone treatment in the recipient generally begins on the day the donor
undergoes ovum retrieval. Generally, D3 embryos are transferred on the fourth day of
progesterone therapy.
Luteal support: As the recipient has no corpus luteum, exogenous luteal support is needed.
Exogenous estrogen and progesterone treatment should therefore be continued until 10 weeks of
gestation. Oocytes and embryos can be cryopreserved (at -196° under liquid nitrogen) for
restoration of fertility in future. Survival of cryopreserved embryo is more than that of oocytes.
Results: Live birth rate is approximately 55 percent.
Gestational surrogacy
A woman without a functional uterus (developmental or hysterectomy), can have her genetic
offspring with the help of ART. Embryos are transferred to the uterus of another woman who is
willing to carry the pregnancy on behalf of the infertile couple.
Cryopreservation of ovarian tissue
Restoration of reproductive function of a woman undergoing chemotherapy or radiotherapy is
possible these days with the help of cryobiology. Cryopreservation of ovarian tissue or auto
transplantation may allow natural pregnancy later on. With this method, ovulation using
exogenous gonadotropins can be achieved.
Oocyte cryopreservation
By freezing is an alternative method. Verification, using high concentration of cryoprotectant
can solidify cells without ice formation. Human pregnancies and deliveries from verified mature
oocytes have been recorded.
Preimplantation genetic diagnosis (PGD)
Can be performed on polar bodies removed from oocytes before fertilization. It can be done by
blastomere biopsy. Genetic screening can avoid transferring embryos with aneuploidy and
autosomal recessive or autosomal dominant gene mutation.
Health hazards of art
 Birth defects: Most of the ART procedures are not associated with any increased risk of fetal
congenital malformations or birth defects. ICSI is often done due to male factors for
infertility and it eliminates the natural process of sperm selection. It is not yet certain whether
ICSI is associated with increased chromosomal abnormalities of the offspring.
 Increased miscarriage, multiple pregnancy and ectopic and heterotrophic pregnancy have
been observed.
 Perinatal mortality and morbidity are high.
 Ovarian hyper stimulation syndrome - though rare but is a known health risk.
 Fertility drugs and cancer—no association has been found between ovulation induction drugs
and ovarian cancer.

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 Psychological stress and anxiety of the couple are severe. It is especially so when there is
failure in the treatment or with a pregnancy loss.

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 TUBAL PATENCY TEST
Introduction
Tubal patency testing is a part of female infertility evaluation. Tubal blockage acts 15%
to 20% of infertile females. Tubal patency tests are undertaken when the doctors suspect that
there are blockages or pelvic adhesions in the fallopian tubes.
Causes of tubal blockage
 Previous pelvic infection
 Tuberculosis
 Previous surgery
 Endometriosis
 IUD‘s (Intra Uterine Devices
Tests available to assess Tubal Patency
1. Gas Insufflation
This is the oldest method of assessing tubal patency and is often referred to as "blowing
the tubes". It is a simple test to carry out and does not require a general anesthetic. An
instrument is inserted into the canal of the cervix and carbon dioxide gas is "blown" into the
cavity of the uterus. The machine controlling the flow of carbon dioxide also records the
pressure of the gas as it builds up in the uterus.There will be an increase in pressure of the
gas within the uterus if the tubes are blocked. If the tubes are open, the initial rise in pressure
is followed by a sudden reduction as the gas escapes along the tubes and into the abdominal
cavity.
Result
The results of this test can be difficult to interpret and the test can be unreliable.
Furthermore, if the tubes are blocked, the test gives no information about the location or nature
of the obstruction.
2. Hysterosalpingography (H.S.G.)
A hysterosalpingogram is an X-ray of the uterus and fallopian tubes. An instrument is
gently passed into the canal of the cervix and a special radio-opaque dye is carefully injected
into the cavity of the uterus. The test is performed in the X-ray department and normally does
not require any form of general anesthetic. It can, however, causE to experience a moderate
amount of discomfort rather like period pains. The dye shows up on an X-ray screen and the
doctor is able to see the fluid filling the uterus and then passing along both tubes to enter the
cavity of the abdomen. If the dye fails to enter the tubes this may indicate an obstruction at
the junction between the uterus and the tubes or simply a temporary spasm of the tubes at this
site. Sometimes the dye can be seen to enter the tubes, which then become distended owing
to an obstruction at their outer ends. The H.S.G. can pinpoint the site of any tubal obstruction
and can also show the presence of any irregularity in the shape of the cavity of the uterus.
However, this test cannot identify the existence of pelvic adhesions, which may be
enveloping the ovaries and preventing eggs from having access to the tubes.

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 Advantages
 Helps in diagnosing uterine abnormalities too
 Some therapeutic advantage in terms of increased fertility
Disadvantages
 Flare effect
 Effective radiation dose varies
 Extremely painful
 Severe allergic reactions
3. Saline Infusion Sonohysterography (SIS)
Saline infusion sonohysterography (SIS) or saline ultrasound uterine scan uses a small
amount of saline inserted into the uterus that allows the lining of the uterus (endometrium) to
be clearly seen on an ultrasound scan. SIS helps to see if there is any thickening or small
growths (polyps) of the endometrium of the uterus that may have been seen on a prior pelvic
ultrasound scan. SIS can also be carried out to assess the postmenopausal endometrium in
patients who have postmenopausal bleeding.
Procedure
A speculum is inserted into the vagina. A soft catheter is gently inserted through the
speculum and into the uterus through the cervix. The speculum is then removed while the
catheter remains in the uterus, and a transvaginal ultrasound transducer is inserted into the
vagina. The transducer is slightly larger than a tampon and especially shaped to fit
comfortably into the vagina. A protective sterile probe cover is placed over the transducer
and lubricating gel is applied to it for ease of insertion. A small amount of saline is inserted
through the catheter into the uterine cavity. During and after the saline injection, the
transducer is then gently moved around while images of the inside of the uterus are taken.
The saline fluid within the uterus allows the lining of the uterus to be imaged clearly on the
ultrasound screen and shows any endometrial abnormality.

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 Advantages
 Less invasive and easy to administer
 No anesthesia required
 Eliminates need of iodinated contrast and ionizing radiation
Disadvantages
 Does not dierentiate between unilateral or bilateral patency
 Infection
4. Hysterosalpingo-contrast sonography (HyCoSy)
It is an ultrasound technique developed to assess whether the fallopian tubes are open or
blocked. It is an assessment of infertility or prior to treatment of infertility. The test is done
between day 5 and day 10 of the menstrual cycle.
Procedure
A speculum is inserted to into the vagina. A very thin catheter is passed through the
cervix into the uterus. The speculum is then removed and replaced by the Trans vaginal
ultrasound probe. A small balloon on the catheter is inflated to keep the catheter in place. The
first part of the test involves injecting normal saline into the catheter. Then inject a solution
of tiny bubbles, which shows up intensely white on the ultrasound image. If the fallopian
tubes are open, can see the fluid passing through the tubes and spilling around the ovaries.
The fluid /bubble mix is either normal saline mixed with air, or a fluid called ExEm foam
gel, which is specifically designed to be used for this test.

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 Advantages
 More than 90% efficacy in evaluating uterine cavity
 Minimally invasive and well tolerated.
Disadvantages
 Procedural discomfort is more
 Occasional vasovagal reaction
5. Laparoscopy and Chromopertubation
This is a much more complex procedure than the previous two tests. It is performed under
a general anesthesia and will require admission to hospital.
Procedure
A tiny incision is made at the lower border of the umbilicus. The abdominal cavity is then
distended with carbon dioxide gas in order to create more space to accurately view the pelvic
organs. A slim telescope called a laparoscope is then inserted into the abdominal cavity and the
uterus, tubes and ovaries are thoroughly inspected. The presence of adhesions either around the
tubes or tethering the ovaries can be easily detected, and their significance assessed. Other pelvic
problems such as endometriosis and fibroids will also be revealed. Tubal patency is tested by
injecting methylene blue dye into the uterus through the cervix. If the tubes are healthy, the dye
can be seen passing along them and escaping through the outer openings of the tubes.

The great advantage of laparoscopy over H.S.G. is that it allows the surgeon to have a
direct view of the pelvic organs and thereby permits a much more accurate assessment of tubal
patency and any tubal or ovarian problems. The need for further surgery can be determined
without having to resort to major abdominal surgery at that time. The majority of patients are
able to leave hospital the following day. The tiny operation scar is eventually virtually invisible.
Advantages
 Fluoroscopic/hysteroscopic selective tubal cannulation is possible.
 Confirm or exclude proximal tubal occlusion.
 Therapeutic advantage in terms of Adhesiolysis and Salpingectomy if hydrosalpinx is
detected.
Disadvantages
 Invasive procedure
 Risk of anesthesia and injury to internal organs
 Very expensive diagnostic measure

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References
1. DC Dutta. (2013). Gynecology including Contraception. Jaypee Brothers Medical Publishers
(P) LTD. Sixth edition.
2. DC Dutta. (2015). Obstetrics including Perinatology and Contraception. The Health Sciences
Publisher. Eighth edition.
3. Marie Elizabeth. (2013). Midwifery for Nurses. Second edition.
4. Nimma Bhaskar. (2019). Midwifery and Obstertical nursing. EMMESS Medical Publishers.
Third edition.
5. https://www.fortishealthcare.com/india/key-medical-procedures/labor-induction.
6. Procedures - Gynecology - UR Medicine Obstetrics & Gynecology - University of Rochester
Medical Center.
7. https://www.ncbi.nlm.nih.gov/books
8. https://www.bing.com/images
9. https://www.indianfertilitysociety.org/

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