OBSTETRICS

HYPERTENSIVE DISORDERS OF PREGNANCY

HYPERTENSION:
It is defined as raised systolic BP of 140 mmHg and diastolic BP
of 90 mmHg recorded on at least two separate occasions, and at
least 4 hours apart.

TYPES OF HYPERTENSION:
● MILD HTN: systolic BP 140-149 mmHg, diastolic BP 90-99
mmHg
● MODERATE HTN: systolic BP of 150-159 mmHg, diastolic
BP of 100-109 mmHg.
● SEVERE HTN: systolic BP ≥ 160 mmHg, diastolic BP ≥ 110.

DISORDERS OF PREGNANCY:
● CHRONIC HTN: Persistent hypertension in the first half of
pregnancy (before 20 weeks). The majority will have
essential hypertension.

● PREGNANCY INDUCED HTN: Hypertension that arises for

the first time in the second half of pregnancy (after 20 weeks
of gestation) and in the absence of proteinuria in a
previously normotensive subject.

● PRE-ECLAMPSIA: Hypertension in the presence of at least

300 my protein in a 24-hour collection of urine, arising
de-novo after the 20th week of pregnancy in a previously
normotensive subject and resolving completely by the sixth
postpartum week.
Patient presents as
OBSTETRICS
-Symptoms: 36 weeks of gestational amenorrhea with frontal
headache, blurring of vision, and epigastric pain.
-Signs: Pedal edema, periorbital edema, generalized
swelling/apparent obesity.
-Risk factors: extremely obese, first pregnancy, if
pre-eclampsia in any previous pregnancy, preexisting
(diabetes, HTN, antiphospholipid antibody), Age 40 years or
more.
-COMPLICATIONS:
● ECLAMPSIA: The development of tonic-clonic convulsions in
a woman with preeclampsia. Vasospasm and cerebral
edema have both been implicated in the pathogenesis of
eclampsia.
DD: Epilepsy (rule out based on history)
● HELLP SYNDROME: Acronym for Hemolysis, elevated liver
enzymes, and low platelets. (Note that ALP is normally 3
times increased in pregnancy)
The patient presents as Pale, Yellow sclera, and disoriented.

Superimposed preeclampsia on chronic HTN: Chronic HTN

before 20 weeks of gestation, proteinuria in urine DR after 20
weeks of gestation.

INVESTIGATIONS:
● Serum uric acid decides if we should terminate the
pregnancy or continue it. Uric acid is raised in preeclampsia.
(Normal: 3.5-7.2 mg/dl). We can do a premature delivery at
37 weeks.
OBSTETRICS
● Dipstick urinalysis for testing proteinuria. (1+ = possible
significant proteinuria, ≥ 2+ = probable significant
proteinuria)
● Check reflexes: hyperreflexia (brisk reflexes, treat with
magnesium sulfate)
● CBC (emphasis on falling platelet count and rising
hematocrit)
● LFTs (deranged) If ALT is >1000 IU/L, it represents Acute
hepatic failure, and pregnancy must be terminated. Bilirubin
should always be less than 1 mg/dl.
● Check BP after the 6-hour interval.

DIFFERENTIALS:
•Acute hepatic failure: DIC, Hepatic encephalopathy, Hepatitis E.
•Thrombocytopenia: Gestational (resolves after 6th postpartum
week), ITP, TTP. Ask a hematologist for steroids in ITP since they
stop the production of antibodies however their use is not
recommended in gestational thrombocytopenia.

TREATMENT:
● For HTN:
1. Methyldopa,(Aldomat 250 mg TDS) max 500mg TDS
2. Labetalol (100 mg BD)
3. Hydralazine (25 mg TDS)

● For Eclampsia:
Magnesium Sulfate (Membrane Stabilizer for the prophylaxis of
fits)
OBSTETRICS
Loading dose: 4 g/20 min, 5mmg/10ml. In a 20 cc syringe, we
take 12 mg/cc normal saline and 8 mg/cc magnesium sulfate,
infusing 1cc/min intravenously. It takes 20 mins to complete.
Maintenance dose: 2 g/hr for 24 hours.

MODE OF DELIVERY:
depends upon BISHOP SCORE.
Induction:
1. Prostin (Per vaginal): works for 3-4 hours.
2. Transcervical Foley: The catheter falls out after the cervix is
4 cm dilated.
3. Oxytocin: Never give it before 3-4 hours of prostin. The gap
between both must be 6 hours. It will cause hypercontraction of
the uterus > 5 contractions/min. Normally there are 2-5
contractions/min.
Complications: Hypercontraction, Hyperstimulation, uterine
rupture. Fetal distress can occur after induction of labor, and for
that, we assess Fetal heart sound every 30 min.

SAVE THE MOTHER'S LIFE IN PREECLAMPSIA!

Terminate the pregnancy and deliver the PLACENTA since It is a
disease of irregular placentation.
Risk factors include Family Hx and Genetics.
Use Aspirin and folic acid for good placentation.
OBSTETRICS
FORCEPS DELIVERY

Normal delivery is a physiological phenomenon of the expulsion

of the fetus and placenta, it is assisted through:
● Forceps
● Vacuum
● C-section: if there is a problem with ith fetal heartbeat or
uterine contractions.

FORCEPS:
It is an instrument used in assisted vaginal delivery. The two most
commonly used forceps are Simpson's and Kielland's forceps.
Other types include rotational and electric.

FORCEP DELIVERY:
Assisted vaginal delivery in case of any obstruction in the normal
progress of labor.

INDICATION:
● F: the fetus is alive
● O: OS of cervix dilated (10cm)
● R: Ruplused membranes. In the case of Artificial rupture of
membrane(ARM), hemorrhage is inevitable.
● C: Cervix take up (turtle's sign)
● E: Engagement of head ( 5/5 fully engaged)
● P: Presentation suitable
● S: Sagittal suture in AP diameter (on the anterior side)
OBSTETRICS
CONTRAINDICATIONS:
● Bleeding disorders (Hemorrhagic, Thalassemia, Wilson's, or
any comorbid). Chances of postpartum hemorrhage are high
in force delivery.
● Predisposition to fractures (Patient is vit D deficient, polio,
epilepsy)
● Face presentation ( If the face is on the anterior side instead
of the sagittal suture.
● High station (+1,+2,+3)
● Gestational Age < 34 weeks (premature, aspiration, bloody
vomitus, breathing difficulties)
● CPD ( cephalopelvic disproportion, Indication of C-section)
● Incomplete dilated cervix. (less than 10 cm)

COMPLICATIONS:
MATERNAL:
● Uterine Laceration
● Extension of Episiotomy
● Urethral injury (bruises)
● Hematoma

FETAL:
● CephaloHematoma
● Bruising/ Laceration
● Facial nerve palsies
● Skull fracture
● ICH (Intracranial hemorrhage)
OBSTETRICS

VACUUM DELIVERY

VACUUM DELIVERY:
An instrumental device designed to assist delivery by applying
traction to a suction cup attached to the fetal scalp.

INDICATION:
MATERNAL:
● Exhaustion after a long labor
● Prolonged 2nd stage
● Maternal medical disorder (CVD)
● Previous C-section
● Intrapartum Infection
FETAL:
● Prolapse umbilical cord
● Premature separation of the placenta
● Fetal disorder
● Occipitoposterior position.

CONTRAINDICATION:
● Operator inexperience
● Inability to assess the fetal position
● Suspicion of CPD
● Fetal coagulopathy
● Preterm babies > 34 weeks
● Macrosomia
● Breech and face presentation
OBSTETRICS
COMPLICATION:
● CephaloHematoma
● Laceration
● Bruising
OBSTETRICS
CARDIOTOCOGRAPHY (CTG)

DEFINITION:
Graphical representation of fetal heart rate in association with
uterine contractions.

COMPONENTS:
● BASELINE HEART RATE:
Normal Fetal heart rate is 110 bpm-160 bpm.
<110= bradycardia
>160= tachycardia
Fluctuations in HR may occur in fetal distress, aspiration of
meconium, ICP (Intrahepatic cholestasis of Pregnancy), GDM,
Gestational HTN, and IUD.
-It is a technical method, which compromises its reliability when
compared to the fetoscope.

● BASELINE VARIABILITY:
Variation is usually between 5-25 bpm. Change in HR which is
noted to be more than 5 is considered saturated while less than 5
is deemed as decreased.

● ACCELERATION:
Rise in fetal HR of 15 bpm for 15 seconds. In a 10 min CTG, 2
accelerations are considered normal. It signifies that the
sympathetic system is well formed and there is no need to
intervene.

● DECELERATION:
Decrease in fetal HR of 15 bpm for 15 seconds. It is pathological.
OBSTETRICS
TYPES OF DECELERATION:
EARLY DECELERATION: Uterine contraction syncs with the nadir
of deceleration.
Cause: Head compression.

LATE DECELERATION: Difference of 15 seconds between the

nadir of deceleration and uterine contraction.
Cause: Pathology in maternal vasculature, Placental insufficiency

VARIABLE DECELERATION: No association between the nadir of

deceleration and uterine contraction.
Cause: Cord Compression.

PROBES:
U/S PROBE: For the fetal HR
TOCO PROBE: For uterine contraction.

INTERPRETATION OF CTG:
REACTIVE: All 4 assessment criteria are normal.
HR: Normal, Variability: Normal, Acceleration: more than 5,
Deceleration: not present.

NON-REACTIVE: HR, Variability, and Acceleration are normal,

but Early Deceleration is noted.

PATHOLOGICAL: Any 2 components are not normal.

(For example, HR of 100 bpm and presence of Late/Variable
Deceleration)
OBSTETRICS
MANAGEMENT:
Reassurance to non-reactive CTG.
Hydrate the patient with Ringer Lactate
Repeat the CTG
Infuse oxytocin

INDICATION:
CTG is advised after 34 weeks of gestation.
OBSTETRICS

BREECH DELIVERY

BREECH:
Any fetal presentation other than cephalic is termed breech.
Buttocks is the most common breech presentation. Baby can be
delivered through SVD in buttocks breech presentation only,
C-section is advised in all the other breech presentations.

Sacrum is the denominator of breech position, baby is delivered in

sacroanterior dimension.

TYPES OF BREECH:

● EXTENDED/FRANK BREECH:
It is the most common type of breech (70%). It presents as flexion
at the hip joint and extension at the knee joint.

● WELL-FLEXED BREECH:
It presents as flexion at both hip and knee joints.

● FOOTLING BREECH:
OBSTETRICS
On the footling limb, there is flexion at both joints. On the folding
limb, there is extension at both joints. (SVD is not recommended,
Always go for C-section)
CAUSES OF BREECH DELIVERY:
● Uterine anomaly
● Polyhydramnios
● Multiple gestations (twin pregnancy)

STEPS OF BREECH DELIVERY:

● HANDS-OFF TECHNIQUE:
Wait and watch until the buttocks descend to the perineum,
then do PV to assess if the perineum can deliver the baby,
otherwise, episiotomy is done to widen it.
● PINARD'S MANEUVER:
Well-flexed breech is delivered spontaneously. For extended
breech, Pinard's maneuver is required (Placement of middle
finger on popliteal fossa and index finger on the knee, flex
the limb and deliver the baby)
● UMBILICAL CORD:
When the baby is delivered till the umbilicus, check the cord.
If the cord is loose, wrap the baby to prevent hypothermia. If
the cord is tight, loosen it with your fingers.
● LOVSET'S MANEUVER:
When the base of the scapula is delivered, PV is done to
assess the attitude of the hands. Flexed limbs are delivered
spontaneously, for extended limbs Lovset's maneuver is
required to deliver the arm. ( Placement of middle finger on
cubital fossa and index finger on the elbow to flex the arms)
● DELIVERY OF NECK:
Wait till the nape of the neck is visible, then deliver the head.
OBSTETRICS
● DELIVERY OF HEAD:
For the delivery of the head, Piper's forceps were used, but
we don't use them now. The Burns-Marshall maneuver was
used too, but it is obsolete now (turning the baby on the
mother's abdomen). Mauriceau-Smellie-Viet's maneuver is
used these days to deliver the head of the baby. (Three
fingers are placed on the back of the neck, three are placed
on the maxilla with the central one on the philtrum, the head
is flexed and the baby is delivered)
● Wrap the baby, and prepare for the third stage of labor.

COMPLICATIONS:
● Head entrapment
● Vaginal/Cervical tears
● Postpartum Hemorrhage
● Arm fracture

PARTOGRAM
OBSTETRICS

DEFINITION:
Graphical representation of the progression of labor.

COMPONENTS:
● Maternal assessment
● Fetal assessment
● Labor progression

INDICATION:
When patient enters the active phase (dilatation of 4 cm), then
partogram is done.

WHAT IT INCLUDES:
● Biodata: Patient identification
● ROM: Rupture of membrane (yes/no, if yes then date and
time)
● Fetal heart rate: It is recorded at an interval of thirty minutes.
● Liquor moulding: moulding is overlapping of skull bones. If
there is no overlapping then it is designated by 0. If there is
approximation then it is designated by +1, overlapping is
designated by +2, +3 denotes that they do not separate, it is
assessed through PV examination.
● State of membranes and colour of liquor: "I" designates
intact membranes, "C" designates clear and "M" designates
meconium-stained liquor.
● Cervical dilatation and descent of head: PV examination
every 4 hours for descent and cervical shortening. 3-4
contractions for at least 60 seconds confirms that mother
has entered the active phase.
OBSTETRICS
● Time: It is recorded at an interval of one hour. Zero time for
spontaneous labor is time of admission in the labor ward and
for induced labor is time of induction
● Uterine contractions: Squares in vertical columns are shaded
according to duration and intensity. The are assessed by
placing hand on fundus.
● Drugs and fluids
● Blood pressure: It is recorded in vertical lines at an interval
of 2 hours.
● Pulse rate: It is also recorded in vertical lines at an interval of
30 minutes.
● Oxytocin: Concentration is noted down in upper box; while
dose is noted in lower box.
● Urine analysis
● Temperature record

ADVANTAGE:
Helps us to determine the possible fate of pregnancy and need for
intervention.

SHOULDER DYSTOCIA
OBSTETRICS
DEFINITION:
Failure to deliver the fetal shoulders using solely gentle downward
traction.

CAUSES:
● Small pelvis
● Maternal diabetes (weight of baby is increased)
● Fetal macrosomia

COMPLICATIONS:
MATERNAL:
● Genital Trauma
● Postpartum Hemorrhage
FETAL:
● Fetal distress
● Intracranial bleeding
● Clavicle trauma

MANEUVER:
● McRoberts maneuver: 1st line external maneuver.
● Suprapubic pressure: 2nd line external maneuver.
● Rubin's II: Internal maneuver (Insert fingers in the vagina
and move anterior shoulder by applying pressure on its
posterior aspect)
● Woods screw maneuver: Bi manual pressure (posterior
aspect of anterior shoulder and anterior aspect of posterior
shoulder)
● Reverse wood screw maneuver: Anterior aspect of anterior
shoulder and posterior aspect of posterior shoulder.
OBSTETRICS
● Gaskin maneuver (all-fours): Ask mother to put hands and
feet on the ground (crawling position)

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