Professional Documents
Culture Documents
Obstetrics Study Guide 2: in The Name of God
Obstetrics Study Guide 2: in The Name of God
Obstetrics Study Guide 2: in The Name of God
2008
References
1- All India Medical Pre PG. Fetal maturity &length of foetus. 2007.
See: www.aippg.net/forum/viewtopic.php?t=33005
2-Brinholz J. Gestational age.American Journal of Roentgenography. 1984. 142 (4): 849
3- Cunningham G, Gant N, Leveno K, et al. Williams Obsterics. 22nd Ed . New York : Mc Graw Hill, 2005.
4- Durham J .Transition to Parenthood: How accurate is your due date. 2004
see: www.transitiontoparenthood.com/ttp/parented/pregnancy/duedate.htm and
www.pregnancy.about.com/library/weekly/aa042197.htm
5- Friedman E. Obstetrical Decision Making. Harvard Medical School. 1981
6- Military Obstetrics and Gynecology. BrooksidePress. Estimating Gestational age. 2006
See: www.brooksidepress.org/.../Pregnancy /estimating_ gestational_age.htm
7-Mitchell P. A Comparison of Gestational Age Information Derived from the Birth Certificate, 1990 –
1998 . Alaska Vital Sign.2000. 8 (1):1-7
See: www.hss.state.ak.us/dph/bvs/PDFs/vitalsigns/avs_0801.pdf
8- Mittendorf R, Williams M, Berkey C, Cotter P. . The Length of Uncomplicated Human Gestation.
Obstetrics & Gynecology.1990 . 75(6):929-932
Pictures and material on Breech and C/S are adapted from emedicine e-Journal with permission:
9-Fischer R. Breech Presentation.emedicine.2006
10- Sehdev H. Cesarean Delivery. emedicine. 2005
Gestational Age Determination
1- Nägele’s Rule
• This was developed in the 1850’s by Dr. Nägele. To
calculate this, one should add 7 days, and then
subtract 3 months from LMP.
• ((LMP + 7 days) - 3 months) = Expected Date of
Delivery
• Example: ((the LMP on 1st April + 7 days) - 3 months) =
January 8
• This “rule” doesn’t take into account the fact that
many women are uncertain of the date of their last
menstrual period, not all women have 28 day cycles,
and not all women ovulate on day 14 of their cycle.
2- Mittendorf’s Rule
• To calculate “Mittendorf’s Rule”, one should
add 15 days for first time Caucasian women,
or add 10 days if non-white or this is not the
first baby. Then subtract 3 months.
• ((LMP + 15 days) - 3 months) = Expected Date
of Delivery for first time pregnant Caucasian
women
• Example: (( LMP on 1st April + 15 days) - 3
months) = January 16
3- Ultrasound:
Nagele Rule
Gathering other data:
1-Date of intercourse
Matches clinical 2- Date of positive
gestational age Pregnancy test
3-Signs of pregnancy
4-First heard FHR
Accepted
5-Quickening
6-Rate of uterine growth
Doesn’t match with
clinical gestational age
Ultrasound
Answer:d
Sample Chorioamnionitis Order
• General: condition/position/diet=NPO
• Lab: CBC diff, MP, WW, B/C X2, U/A ,
U/C,CXR,BUN/Cr
• IV : 1000cc Ringer +10 units of oxytocin start at
2 drops /min, add 2 drops every 15 min if FHR
and contractions are normal
Amp ampicillin 2gr iv qid +gentamicin im 80mg stat then
60 mg TDS
AMP clindamycin 900 mg iv TDS for allergic women to
penicillin(continue antibiotics after delivery until the
mother is a febrile
OTHER: Control of vital sign hourly
Induction Indications
1) Membrane rupture without spontaneous
onset of labor
2) Maternal hypertension
3) Nonreassuring fetal status
4) Postterm gestation
5) Elective induction for the convenience of
mother or the practitioner is not
recommended.
Induction contraindications
1) Classical incision or uterine surgery
2) Placenta previa
3) Appreciable macrosomia, hydrocephalus,
Mal presentations
1) Non reassuring fetal status
2) CPD
3) Active genital herpes in mother
E2 gel (dinoprostone)
• Dosage:
Intracervical gel(Prepidil ):2.5 mL/0.5 mg
Vaginal insert(cervidil) 10 mg
• The insert provides slower release of
medication
E2 administration
• An observation period ranging from 30
minutes to 2 hours for uterine activity and
FHR may be prudent.
• Oxytocin induction should be delayed for 6 to
12 hours.
• Cautions in patients with glucoma, severe
hepatic or renal impairment, or asthma are
needed.
E1 misoprostol(cytotec)
• Oral , intravaginal but not intracervical
• Possibly superior to E2 gel
Dosage:
• 25 mcg intravaginal dose
• 100 mcg oral
Bishop Scoring System
max=13, min=0
Score dil eff St. Cervical Cervical
consistency position
0 Closed 0-30 -3 Firm Posterior
1 1-2 40-50 -2 Medium Mid
position
2 3-4 60-70 -1 Soft Anterior
3 =>5 =>80 +1, ----------- ------------
+2
Oxytocin contraindications
1) ab fetal presentations
2) marked uterine over distension
3) Six or more previous pregnancies
4) Previous uterine scar and a live fetus
5) CPD
Oxytocin regimens
• Low dose: start with 0.5-1 mu/min (one drop)
add 1 mu/min every 30-40 min up to 20 mu/min
• Low dose: start with 1-2 mu/min (two drops) add
2 mu/min every 15 min up to 20 mu/min
• High dose: start with 6 mu/min (12 drops) add 6
or3 or1 mu/min (according to the presence of
recurring hyperstimulation)every 15-40 min up to
42 mu/min.
• When hyperstimulation occurs the infusion rate
is halved.
oxytocin
• Mean half life 5 min,
• 10-20 units (10000 to 20000 mu)
mixed into 1000 mL of lactated
Ringer solution which makes a
10-20 mu/mL.
Indication for forceps or vacuum
delivery
Classification of forceps or
vacuum
• Outlet: scalp is visible at the introitus without
separating the labia
• Low: leading point of fetal skull is at
station=>+2cm and not on the pelvic floor
• Mid forceps: station above +2cm but head is
engaged
• High: not included in the classification
Contraindication for vacuum delivery
1) Nonvertex presentations
2) Extreme prematurity
3) Fetal coagulopathies
4) known macrosomia
5) Above zero stations
6) Lack of experienced operator who would
abandoned the procedure if it does not proceed
easily or if the cup “pops off” more than three
times.
Vacuum technique
• The center of the cup should be over the sagittal
suture and about 3 cm in front of the posterior
fontanel.
• The full circumference of the cup should be palpated
both prior to as well as after the vacuum has been
created and prior to traction.
• The suction should be increased to a negative
pressure of 0.8 kg/cm² .
• Traction should be coordinated with maternal
expulsive efforts.
Breech Presentation
Pictures and material are adapted from :
Fischer R. Breech Presentation.emedicine.2006
with permission
Incidence
• Breech presentation occurs in 3-4% of all
deliveries.
• 25% of births prior to 28 weeks' gestation
• 7% of births at 32 weeks' gestation
• 1-3% of births at term
Predisposing factors
1) Fetus to AF ratio(prematurity,
polyhydramnios)
2) Intrauterine space(uterine malformations or
fibroids, placenta previa, multiple gestation)
3) and fetal abnormalities (eg, CNS
malformations, neck masses, aneuploidy),
Types