OBSTETRICS

DR ANIL MIRCHANDANI
M.B.B.S, M.S (OBGY),
CONSULTANT AND ASST.PROFESSOR IN OBSTETRICS
AND GYNAECOLOGY,
SETH G.S MEDICAL COLLEGE AND K.E.M HOSPITAL,
MUMBAI

1
 ANATOMY AND
FUNDAMENTALS OF
REPRODUCTION

2
FEMALE EXTERNAL GENITALIA

3
BARTHOLIN’S GLANDS
SKENE’S GLANDS
INTERNAL GENITALIA
THE UTERUS, CERVIX AND
VAGINA

7
THE FALLOPIAN TUBE
THE BLOOD SUPPLY FROM
INTERNAL ILIAC ARTERY

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10
OOGENESIS AND OVULATION

11
SPERMATOGENESIS

12
FERTILISATION

13
MOVIE

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EARLY EMBRYOLOGICAL
DEVELOPMENT
17
DECIDUA

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CHORIONIC VILLI

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20
21
22
THE TERM PLACENTA

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 Utero placental circulation
 ESTABLISHED ON 21TH DAY POST FERTILISATION (DAY 35 OF LMP)

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 Placental ageing
Villi changes:-
 Decrease in thickness of syncytium & appearance of syncitial knots

 Partial disappearance of Langhan’s cells

 Decrease in stromal tissue including hofbauer cells.

 Obliteration of some vessels and marked dilatation of capillaries

 Thickening of basement layer of fetal endothelium and

cytotrophoblast

 Deposition of fibrin on the surface of the villi.

25
 Placental ageing
Decidual changes:-
 Fibrinoid degenaration where trophoblast cells meet
the decidua.
 This zone is the Nitabuch’s layer. It limits further
invasion of decidua by the trophoblast
 This membrane is absent in placenta accreta.

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Amniotic fluid

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 Volume
Amniotic fluid volume
Weeks of gestaion

 12wks  50ml

 20wks  400ml

 36-38wks  1 litre

 Term
 600-800ml

 200ml
 43wks

 
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 Physical features

 Alkaline 7.0-7.5

 Low sp. Gravity- 1.010

 Osmolarity- 250 mosmoles/litres---fetal

maturity.

29
 Colour

 Early pregnancy- colourless

 Near term- straw coloured due to lanugo and epidermal cells
 Meconium stained or green colour- fetal distress,
 Golden colour- Rh incompatibility due to excessive haemolysis of
fetal R.B.C leading to excess production of bilirubin
 Greenish yellow or saffron- postmaturity
 Dark red coloured - concealed accidental h’ge due to contamination
with blood
 Dark brown tobacco juice- I.U.F.D due to presence of old HbA

30
 Composition

 Organic: - proteins, glucose, urea, NPN

uric acid creatinine lipids hormones such
as prolactin, insulin and rennin.
 Inorganic: - sodium280-310mg%,
potassium, chloride.

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 Umbilical cord
Development:-

 It is a band of mesoblastic tissue stretching between the embryonic

disc and the chorion.

 Initially attached to the caudal end of the embryonic disc but as a

result of cephalocaudal folding of embryo and simultaneous

enlargement of the amniotic cavity it converges on the ventral

aspect of the fetus.

32
 Umbilical cord
Structures:-
1. Covering epithelium: amniotic epithelium
2. Wharton’s jelly: ext.emb. mesoderm
3. Blood vessels: 2+1 art.+vein.
4. Remnant of umbilical vesicle (yolk sac) and its vitelline
duct (meckel’s diverticulum)
5. Allantois
6. Obliterated extraembryonic coelom (umbilical hernia)

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 Umbilical cord

Characteristics:-
 50cm long
 1.5cm in diameter
 False knots due to dilataion of umbilical veins or local collection of wharton’s
jelly
 Spiral twist from left to right due to spiral turns taken by the veins around the
arteries.
 Umbilical arteries do not posses an internal elastic lamina but have a well
developed muscular coat. This helps in effective closure of the arteries due to
reflex spasm soon after birth.
 Both arteries and veins do not posses vasavasorum

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35
 THE FETAL PHYSIOLOGY
Nutrition:

 By absorption: in the post fertilization period,

 Histotrophic transfer: after implantation

 Haematochorial: With the formation of placenta,

nutrition is by active and passive transfer.

36
 "Haase rule",
 (fetal length in centimeters during the
first 1 to 5 months of pregnancy
 correlates to the square of the age in
months,
 and during the second half of pregnancy
the age in months is MULTIPLIED by 5).

37
 HEMATOLOGY IN FETUS:
Hemopoiesis
 Yolk sac: early embryo
(14th day)
 Liver
 Bone marrow
initially nucleated RBCs
Hb 12g/dl at midpregnancy
Hb 18 g/dl at term
 Short life span: 80 days,
high reticulocyte count

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39
 Erythropoiesis: fetal erythropoietin
Fetal blood flow: fetoplacental blood volume 125 mL/
kg of fetus.
Fetal Hemoglobin: Hb F falls during latter weeks of
pregnancy. At term ¾ Hb F
Hb F bind more O2 at any given O2 tension and
identical pH
Hb A binds 2,3-DPG more avidly than Hb F
Fetal coagulation factors: decreased
platelets: normal
Fetal immunocompetence: IgG Lymphocytes,deficient

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 SKIN: lanugo appears at 16th week, horny layer is
deficient before 20th week hence the transudation
from skin occurs.

41
 Other systems

 Urinary: 650ml/day urine at term

 GIT: meconium at 20th wk
 Breathing: 11th wk
 Surfactant: 24th wk
 Ant Pitiutary hormones: 10th wk
 Post. Pitiutary hormones, insulin: 12th wk
 Glucagon: 10th wk
 Swallowing: 10-12th wk
 Sucking: 24th wk

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THE FETAL CIRCULATION

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CHANGES AT BIRTH
 THE CHANGES OF FETAL
CIRCULATION AT BIRTH:
 Closure of umbilical arteries: immediate
functional closure, obliteration at 3rd
month, forms medial umbilical ligament
and proximal part remains open as
superior vesical arteries.

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CONTINUED….
 Closure of umbilical veins: occurs little later than
the umbilical arteries, forms ductus venosus
 Closure of ductus arteriosus: happens within few
hours. PG antagonists may cause premature
closure in fetal life. Anatomical obliteration takes
1-3 months forming ligamentum arteriosum.
 Closure of foramen ovale: soon after birth but
anatomical closure takes 1 year. This causes
cyanosis in babies while crying

45
 Physiological changes in
pregnancy
 SIGNS OF PREGNANCY 
 THE FACE
• Chloasma gravidorum
 THE BREASTS
• Alveoli: e+p, ducts: only estrogen
• Montgomery’s follicles “glandular tubercles”
• Secretion

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Signs of pregnancy

 THE GENITAL TRACT

• Chadwick’s sign 8th wk
• Increased vaginal discharge
• Softening of the cervix (Goodell’s sign) 6th wk
• Hegar’s sign (6-10wks)
• Palmer’s sign (4-8wks)
• Osiander’s sign 8th wk
• Piskacek’s sign (asymmetric uterus)
• Internal ballottement

47
2. Signs
Breast changes (6-8wks)
• Breast enlargement and vascular engorgement.
• Nipple and areola become more pigmented.
• Enlargement of the accumulated sebaceous
glands of the areolas (Montgomery’s tubercles)

• Colostrum as early as 12 wks.

Fig.20-1 Breast changes. Montgomery’s glands are prominent,
and nipples and areolae are deeply pigmented. Accessory nipple
beneath left breast is also pigmented.
Changes of the reproductive organs
Per abdomen:- ut.pelvic organ till 12th wk.

Pelvic changes:-
A) Jacquemier’s or Chadwick’s sign:-
• 8th wk
• Dusky hue of vestibule & ant vaginal wall
• Cause:- local vascular congestion
• d/d pelvic tumour , uterine fibroid.
Changes of the reproductive organs
B)Vaginal sign:

• Bluish discolouration of vaginal walls,

• Walls become soft
• Copius non irritating mucoid discharge (6 th

wk)

• Osiander’s sign (8 wk)- increased pulsations

th

felt through lateral fornices.

• d/d acute pelvic infection.

Changes of the reproductive organs

• C) Cervical signs: softening of cervix due to

congestion Goodell’s sign (6thwk)
• Nonpregnant cervix- tip of nose
• Pregnant cervix- lips of mouth
• p/s examination- bluish discolouration
• d/d pts using oc pills.
Changes of the reproductive organs
•D)Uterine signs:
• Size:-enlargement and softening hen’s egg
6wk, cricket ball 8wk, fetal head 12 wks.
• Piskacek’s sign:- asymmetrical
enlargement of uterus due to lateral
implantation.
• Shape:- globular
• Consistency:- soft and elastic.
Changes of the reproductive organs
• Hegar’s sign:-
• 6-10wks.
• Upper body of ut enlarged,
• Lower part empty and soft.
• The isthmus of the uterus is also soft and
can be compressed between the fingers on
bimanual examination.
55
 Changes of the reproductive organs

 Palmer’s sign:-
 4-8 wks
 Regular and rhythmic uterine contractions
elicited on bimanual examination.

After the 12th week, the fundus of the uterus is

usually palpable above the symphysis pubis.
 WEIGHT GAIN

0.4kg

1.3kg

1.2kg
0.6kg

0.8kg
3.3kg

3.5kg
0.9kg

57
BODY WATER METABOLISM
 Total water retained: 6.5 litres.
 Cause is due to sodium(900meq) and
water retention by kidneys due to the
hormones of pregnancy.

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HEMATOLOGICAL CHANGES
 The Most significant changes are:
Physiologic anemia
Neutrophilia
Mild thrombocytopenia
Increased procoagulant factors except factor XI
and XIII
MARKED INCREASE IN FACTOR 1 AND VIII
Diminished fibrinolysis

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RBC MASS AND
HEMODILUTION
 RBC (increase in mass) and hemodilution:
 30% (250 to 450 mL) above nonpregnant, iron
supplemented
 20% above nonpregnant, not on iron supplement
 Life span slightly decreased
 Erythropoietin levels increase by 50 %
 Retic count: increases by 2%
 PLASMA INCREASES BY 50 %

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CVS CHANGES

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METABOLIC CHANGES
 BMR is increased by 30%.
 Protein: Positive nitrogen balance

 Carbohydrate:

Insulin secretion is increased due to increase in glucose and

amino acids.
Insulin sensitivity is decreased (44%).
Insulin causes fat storage. There is fasting hypoglycemia and post
prandial hyperglycemia and hyperinsulinemia. This allows
continuous supply of glucose to the fetus.
Renal threshold is same but glomerular filtration of glucose
increases. Hence there is glycosuria.

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METABOLIC CHANGES
 Fat: 3 to 4 kg fat is stored during pregnancy, plasma lipids and
lipoproteins increase
 Iron metabolism:
Iron is absorbed from duodenum and jejunum
About 10 % is absorbed
Iron is transported actively across placenta
Total iron reqd. in pregnancy is 1000mg: 300 in fetus and placenta,
400 in red cell mass, 200mg is obligatory loss through normal
route.
However there is saving from 10 months of amenorrhoea: 300 mg.

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 SYSTEMIC CHANGES IN
 PREGNANCY
RESPIRATORY
 SYSTEMIC CHANGES IN PREGNANCY
 RESPIRATORY

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URINARY SYSTEM

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URINARY SYSTEM
 Dilatation of renal pelvis
 GFR 50% increase
 Dilatation of ureters, right more than left,
above brim, max at 20-24 wks
 Frequent micturation from 6-12 wks and
after engagement

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GASTROINTESTINAL CHANGES
 Gastric motility is reduced
 Delayed gastric emptying at 12-14 weeks of gestation
 Further gastric emptying delay during labour due to
pain and anxiety
 Reduced release of CCK (due to progesterone)
--> Reduced contractility of the gallbladder
 Histological changes in liver
* Mild fatty changes
* Mild glycogen depletion
* Lymphocytic infiltration

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CENTRAL NERVOUS SYSTEM
CHANGES

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Calcium metabolism
 28gm calcium required by fetus
 Daily requirement: 1000mg
 Total serum calcium falls, ionised remains
constant
 Absorption from intestines, kidneys is increased
 No hyperparathyroidism, normal serum
phosphate
 Calcitonin up by 20%

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ENDOCRINOLOGY

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PROTEIN HORMONES
 Human chorionic gonadotropin (hCG):
“pregnancy hormone”
glycoprotein with biologic activity similar to luteinizing
hormone (LH)
Both act via the plasma membrane LH-hCG receptor
Although hCG is produced almost exclusively in the
placenta, it is also synthesized in the fetal kidneys
detection of hCG in blood or urine is almost always
indicative of pregnancy
CLINICAL IMPORTANCE
 High maternal plasma hCG levels
multifetal pregnancy
erythroblastosis fetalis associated with fetal
hemolytic anemia
gestational trophoblastic disease
trisomy 21
 Lower hCG plasma levels
early pregnancy wastage
ectopic pregnancy
HPL
 Also called “human chorionic
somatomammotropin”, or “chorionic growth
hormone”  because of its potent lactogenic
acid growth hormone-like bioactivity and
immunochemical resemblance to human
growth hormone
 The production rate of hPL near term—
approximately 1 g/day—is by far the greatest
of any known hormone in humans!
HPL
FUNCTIONS:
 Maternal lipolysis with increased levels of circulating free fatty
acids.  provides a source of energy for maternal metabolism
and fetal nutrition
 An anti-insulin or "diabetogenic" action that leads to increased
maternal insulin levels. favors protein synthesis and provides
a readily available source of amino acids to the fetus
 A potent angiogenic hormone important role in the formation
of fetal vasculature
 Breast development for lactation.
MATERNAL ENDOCRINE
 PITIUTARY: DOUBLES THE SIZE, GH, PRL,ACTH, CRH
INCREASE
 ADH, TSH: SAME
 THYROID: IODINE CLEARANCE INCREASES, SHIFTED TO
FETUS, INCREASE IN PROTEIN BOUND IODINE, TBG
INCREASES, TOTAL T3,T4 INCREASES, BUT FREE REMAIN
SAME, TSH IS NORMAL,
 ADRENALS: ALDOSTERONE, DEOXYCORTISONE, CBG,
CORTISOL(TWICE), FREE CORTISOL(THRICE): INCREASE
 DHEAS IS DECREASED
 TESTOSTERONE, ANDROSTENDIONE: INCREASE
 PARATHYROID: NO CHANGE, VITAMIN D: INCREASES

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LACTATION ENDOCRINOLOGY

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 DIAGNOSIS OF PREGNANCY
 PRESUMPTIVE: nausea, fatigue, quickening,
amenorrhoea, breast and skin and vaginal
changes, frequent urine
 PROBABLE: abdomen enlarges, hegars,
palmer’s, goodell’s, ballotment, presence of
HCG
 POSITIVE: FHS: stetho: 19wk, doppler: 10th
wk, TVS: 6th wk, FM>20wks, USG: G-sac, yolk:
5th wk, CA: 6th wk, Xray: 16th

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 Summary of pregnancy tests (B.
HCG)
Test Sensitivity Time taken Inference Positive on
AGGLUTINATION 0.5-1 IU/ML 2MIN ABSENCE OF AGGL. 2 DAYS AFTER
INHIBITION TEST (URINE) MISSED PERIOD

DIRECT AGGL. TEST 0.2 IU/ML 2MIN PRESENCE OF AGGL 2-3 DAYS AFTER
(URINE) MISSED PERIOD

TWO SITE SANDWICH 30-50 MIU/ML 4-5MIN 2 COLOUR BANDS OF DAY 1 MISSED
IMMUNOASSAY (UPT) (URINE) TEST AND CONTROL PERIOD.

ELISA 1-2 MIU/ML (SERUM) 2-4HRS 5 DAYS BEFORE

MISSED PERIOD

RADIOIMMUNO 0.002iu/ml 3-4 HRS 25TH DAY OF CYCLE

ASSAY

IMMUNO 0.05 MIU/ML 30 MIN 8 DYS AFTER

RADIOMETRIC ASSAY CONCEPTION
(IRMA)
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Estimation of fetal wt
 Fetal growth velocity:- 26.9gm/day over 32-36wks &
24gm/day over 36-40 wks
 Johnsons formula:- (ht of uterus over symphysis
pubis – 12cms) *155
 Shepard’s formula in usg:- uses BPD * AC
 Hadlock’s formula in usg:- uses BPD, AC, FL,HC

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 FETUS IN UTERO
 LIE
 PRESENTATION
 PRESENTING PART
 DENOMINATOR
 POSITION
 PALPATION BY LEOPOLD’S GRIPS

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CLINICAL OBSTETRICS
CONCEPTS:
 LIE
THE PRESENTATION AND
PRESENTING PART
ATTITUDE
DENOMINATOR AND POSITION
Understanding Fetal Head and
Maternal Pelvis

87
 The fetal skull
 Base: to protect the vital structures
---large
---ossified
---firmly united
---noncompressible
 Vault(cranium): to overlap under pressure and to
change shape to confirm to the maternal pelvis
(molding)
---thin
---weakly ossified
---easily compressible
---interconnected by membranes
88
Vertex Brow

Face

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90
91
92
 Fetal Head--- Fontanelles
 Definition: The membrane-filled space located at
the point where the sutures intersect.
 The most important of which are the anterior and
posterior fontanelles.
 More useful in diagnosing the fetal head position
than sutures

93
 Fetal Head--- landmarks
 Nasion
 Glabella
 Sinciput
 Anterior
fontanelle
 Vertex
 Posterior
fontanelle
 Occiput

94
 Fetal Head--- Diameters

 The anteroposterior diameters

---Suboccipitobregmatic diameter (9.5cm)
---Suboccipitofrontal diameter (10 cm)
---Occipital frontal diameter (11cm)
---mentovertical diameter (14cm)
---Submentobregmatic diameter (9.5cm)
 Transverse diameter

---Biparietal diameter (9.5cm)

---Bitemporal diameter (8 cm)
 Average circumference of the term fetal head(in the
occipitofrontal plane)-----------------------(34.5cm)

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Moulding

 Moulding:-It is the
changes in shape
of the head in
vertex
presentation
during labour
while passing
through the
resistant birth
canal

96
 GRADES OF MOULDING

•Grade 0:- the bones lies side by side

having an intervening membrane.
•Grade +:- the bone touching but not
overlapping
•Grade++:- overlapping but easily
separated by pressure.
•Grade+++:- fixed overlapping and cannot
be separated.

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CAPUT SUCCEDANEUM

 It is localized area
of edema on fetal
scalp on vertex
presentation due
to pressure effect
of dilating cervical
ring and vaginal
introitus.

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MATERNAL PELVIS

99
 TRUE PELVIS, FALSE
PELVIS
The Pelvic Inlet (Brim):-
Boundaries:-
• Sacral promontory,
• Ala of the sacrum,
• sacroiliac joints,
• iliopectineal lines,
• iliopubic eminences,
• upper border of the superior
pubic rami,
• pubic tubercles,
• pubic crests and
•upper border of symphysis pubis.

100
DIAMETERS OF INLET (AP)

101
DIAMETERS OF INLET
(TRANSVERSE)

TRANSVERSE

A.P OBLIQUE

102
 PELVIC CAVITY

 The pelvic cavity lies between the

inlet and outlet. It is almost round.
Its plane extends from the
midpoint of the posterior surface
of pubic symphysis to the junction
of S2–S3. It is also called the
PLANE OF GREATEST PELVIC
DIMENSIONS. It is most roomy.

103
OUTLET: OBSTETRIC

11.5 cm

10.5 cm

104
OUTLET: ANATOMICAL

105
 THE DIAMETERS

Brim Cavity Outlet :anatomical

Transverse(cm) 13.5 12.5 11

Oblique (cm) 12.5 12.5 ----

Anteroposterior(cm) 11.5 12.5 11.5 (13-14)

106
PELVIC AXIS: ANATOMICAL AND
OBSTETRIC AXIS

107
Definition of contracted pelvis: -

 Anatomical definition: - essential diameters of one

or more planes are shortened by 0.5cm

 Obstetric definition: - alteration in the size and

shape of the pelvis of sufficient degree so as to alter
the normal mechanism of labour in average size
baby.

108
CALDWELL-MOLOY’S
CLASSIFICATION

109
Gynaecoid Anthropoid

110
Android Gyanaecoid

111
CAUSES:
 RACHITIC: RENIFORM INLET
 OSTEOMALACIC : TRIRADIATE INLET
 NAEGLE’S : ONE ALA MISSING
 ROBERT’S: BOTH ALA MISSING
 KYPHOSCOLIOTIC PELVIS: EXTREME
CONTRACTION PRESENT

112
CONCEPT:
 INLET CONTRACTION: OC<10,
DC<11.5, TD<12, PSD<4
 MIDPELVIS: ISD+PSD<13
 OUTLET: ISCH.TUBEROUS DIAM< 8
 TRIAL OF LABOUR

113
 ANTE NATAL CARE
 As per WHO guidelines a woman should
have atleast 4 antenatal visits
 1st at around 16weeks
 2nd between 24-28weeks
 3rd at 32 weeks
 4th at 36weeks

114
CONCEPTS
 NAEGLE’S RULE,
 MODIFIED NAEGLE’S RULE

 NUTRITION:

CALORIES:+300, PROT: +14GM, CALCIUM:

1000MG, FOLIC ACID: 300-400MCG. VITD:
4 TIMES
IMMUNISATION WITH TT
TRAVEL: AIR TRAVEL UPTO 36WKS

115
ANTEPARTUM WELL BEING
ASSESSMENTS

116
 TRIPLE TEST( HCG, AFP, UE3)

•In Down’s syndrome, Hcg Blood is withdrawn

between 15th and 18th wk.
is high while MSAFP and
UE3 is low.
•Performed at 15th – 18th
week.
•Abnormal triple test
warrants amniocentesis
•Detection rate 69-70%

117
QUAD TEST (MSAFP and UE3
decrease, hCG and inhibin A increase)

118
Acetyl choline esterase
levels:
 Raised in open neural tube defects
 Better diagnostic value than AFP for the
same.

119
First trimester screenings:

 hCG+ MSAFP+ PAPP

(pregnancy associated plasma
proteins): 85% detection, 5% false
positive
 Combined with nasal bone
detection test(absent nasal bone):
97% detection
120
PRENATAL GENETIC DIAGNOSIS:
 To obtain fetal tissue by amniocentesis, CVS,
cordocentesis
 Doing karyotyping, dna analysis, assessing enzymes
like AFP, 17 hydroxyprogesterone etc.

121
 AMNIOCENTESIS

Performed at 14-16 wks

Invasive procedure under USG
guidance.
Amniotic fluid is processed to
get fetal cells, enzymes are
assessed
Fetal cells (fibroblasts) sent for
chromosome analysis.
Early amniocentesis is done at
12-14 wks
Complications like fetal loss,
feto maternal hemorrhage,
trauma, oligohydramnios can
occur.

122
 CHORION VILLUS
SAMPLING
 Performed at 10-12 wks
transcervically and
transabdominally from 10 wks
to term
 USG guided collection of villi
from chorionic frondosum,
tissue is sent for analysis.
 Anti D is given 50mcg in first
trimester in Rh negative mother
 Complications like fetal loss,
limb deformities and LIMB
REDUCTION DEFECTS are
known.

123
 CORDOCENTESIS:

Done after 18 wks,

invasive risky technique
22G needle is inserted
under USG guidance as
shown.
It punctures umbilical vein
near placental insertion.
Done under local
anaesthesia
Blood sent for analysis:

124
COMPONENTS OF NST

 BASAL HEART RATE

 ACCELERATIONS
 NO DECELERATIONS
 BEAT TO BEAT VARIABILITY

125
FETAL CARDIOTOCOGRAPHY:
 JUST LIKE NST BUT…
 Important difference is that
the decelerations are now
differentiated.
 EARLY DECELERATIONS:
head compression in
contraction. (nothing to worry)
 LATE DECELERATIONS:
uteroplacental insufficiency.
 VARIABLE
DECELERATIONS: cord
compression.

126
FETAL BIOPHYSICAL PROFILE
(MANNING’S SCORE)

3 <3

127
MODIFIED BIOPHYSICAL PROFILE:

 ONLY TWO COMPONENTS: AFI and

NST
 Reactive NST and AFI>5 cm means
fetus is well inside.

128
 DOPPLER
VELOCIMETRY USG
OBS
 Doppler gives an idea about the
amount of blood flowing during
systole(S), diastole (D) through the
major vessels.
 It gives an idea about the direction of
blood flow too.
 When the resistance increases, there is
decrease in blood flow through diastole
(D)
 We measure S/D ratio and we know
what is normal for that gestation.
 If resistance increases, diastolic flow
decreases, S/D ratio will increase
signifying resistance.

129
DOPPLER……

 Reversal of diastolic flow is ominous sign.

 Other ways to measure are: PULSATILITY INDEX (PI)= (S-D)/ M. (
M = {S+D}/2 )
 RESISTANCE INDEX: (S-D)/S
 VESSELS checked are: uterine and umbilical artery, Middle
cerebral artery, ductus venosus.

130
 AMNIOCENTESIS IN LATE
PREGNANCY
AMNIOCENTESIS FOR FETAL LUNG MATURITY
 Surfactant is synthesized by type II alveolar cells; it is packed in
lamellar bodies and discharged to lung alveoli and then to amniotic
fluid.
 L/S ratio is done, >2 is diagnostic of lung maturity

 Presence of lamellar bodies>30,000/microlitre

 Orange coloured cells: when desquamated fetal cells from amniotic

fluid are stained with 0.1% NILE BLUE SULPHATE, pulmonary
maturity is diagnosed if there is presence of >50% orange cells.
 Presence of phosphatidylglycerol

 AMNICENTESIS FOR ASSESSING SEVERITY OF RH

ISOIMMUNISATION.

131
AMNIOCENTESIS…

 Presence of >500ng/ml phosphatidylcholine.

 Presence of amniotic fluid turbidity.
 Amniotic fluid OPTICAL DENSITY at 650micron > 0.15.
 SHAKE BUBBLE TEST/ CLEMENT TEST: a complete ring of
bubble at meniscus after shaking suggests maturity. (bed side
test, 96 % ethanol is put in fluid)
 Foam stability index> 47.

132
 NORMAL LABOUR
 Labour which fulfils following criteria;
spontaneous in onset, at term, with
vertex presenting part, without undue
prolongation, natural termination with
minimal aids with good maternal and
fetal outcome.

133
WHY IT BEGINS AT 37-42 WKS?
 UTERINE
Uterine causes
CAUSES
 MEMBRANE
CAUSES
 CERVICAL
CAUSES LABOUR
Membrane factors Cervical causes

134
 Uterine distension:
 Increase in oestrogen:
 Increases oxytocin release
 Releases prostaglandins
 Reduction in progesterone.
 Release of prostaglandins: they help in cervical effacement and dilatation
by collagenolysis.
 Adrenergic system: alpha receptors are responsible for active uterine
contractility while beta receptors are responsible for making the uterus
relaxed.
 Increase in oxytocin receptors near term
 Ferguson’s reflex: maternal plasma oxytocin levels rise with amniotomy
and repeated vaginal examinations.

135
 STAGES OF NORMAL LABOUR:

FOURTH STAGE: ONE HOUR OBSERVATION STAGE.

136
Seven passive movements of
the baby presentation are:

1.  engagement
2.  descent
3.  flexion
4.  internal rotation
5.  extension
6.  restitution and external rotation
7.  expulsion of shoulder and rest of body.

137
 138
ENGAGEMENT
 DESCENT

 It is a continuous movement throughout

the process of delivery, however it
becomes more rapid in the second stage
of labour, it is caused by:
 -Uterine contraction and retraction,
bearing down effort – mainly in the
second stage of labour

139
FLEXION BY TWO ARM LEVER THEORY.
140
Internal rotation of the head in
LOA position.

141
DELIVERY BY EXTENSION:

DELIVERY BY EXTENSION 142

RESTITUTION

143
EXTERNAL ROTATION

144
DELIVERY OF SHOULDER AND
TRUNK:
 The ant. Shoulder delivers by slipping
below the symphysis pubis. Then the
delivery of posterior shoulder occurs.
 The rest of the body delivers by lateral
flexion.

145
MANAGEMENT
 PRESSURES:
 BASELINE TONE: 8MMHG (PRELABOUR)
 BASELINE TONE: 12MMHG (1ST STAGE)
 BRAXTON-HICKS: <20MMHG
 1ST STAGE: 25-50
 2ND STAGE: 80-100
 MONTEVIDEO UNITS (90-390MU)

146
147
EPISIOTOMY
 MIDLINE VS MEDIO-LATERAL

148
 SIGNS OF PLACENTAL
SEPARATION:
 A sudden gush of blood
 
 Lengthening of the visible portion of the umbilical cord.
 
 The uterus, which is usually soft and flat immediately after delivery,
becomes round and firm.
 
 The uterus, the top of which is usually about half-way between the
pubic bone and the umbilicus, seems to enlarge and approach the
umbilicus. There is slight bulge above the pubis.
 
 EXPULSION OF PLACENTA AND MEMBRANES.

149
MANAGEMENT OF THIRD STAGE
 EXPECTANT (WITH OR WITHOUT
CONTROLLED CORD TRACTION)
 ACTIVE MANAGEMENT

150
DEFINITION Nullipara Multipara

Prolonged latent phase >20 h >14 h

Average second stage 50 min 20 min

Prolonged second stage without >2 h (>3 h) >1 h (>2 h)

(with) epidural

Protracted dilation(ACTIVE PHASE) < 1.2 cm/h < 1.5 cm/h

Protracted descent < 1 cm/h < 2 cm/h

Arrest of dilation >2 h >2 h

Arrest of descent >2 h >1 h

Prolonged third stage >30 min >30

151 min
 PUERPERIUM

 Peurperium is the period following childbirth during

which the body tissues, especially the pelvic organs
revert back approximately to the pre pregnant state
both anatomically and physiologically.
 Except in mammary glands which show features of
increased activity.

152
 Uterus
Weight of uterus  
 Immediately postpartum: 1000g
 1 week later : 500g 
 At the end of 2nd week : 300g,
 Soon thereafter 100g or less  
 At the end of 6 weeks 60 gms

153
Multi parous Nulliparous
cervix cervix

154
Lochia

 Definition:- It is the vaginal discharge for the

first fortnight during peurperium.
 Origin:- From the uterine body, cervix and the
vagina.
 Odour and reaction:- peculiar offensive
smell. Alkaline reaction

155
 Composition

lochia rubra :

first few days after delivery

contains-
blood, shreds of fetal membranes & decidua
vernix caseosa lanugo and meconium

156
lochia serosa : after 3 or 4 days
• becomes progressively pale in color
• consists of less R.B.C’S but more leucocytes, wound
exudates, mucous from the cervix and microorganisms
(anaerobic streptococci and staphylococci)

• the presence of bacteria is not pathognomic unless

associated with clinical signs of sepsis.

157
lochia alba    : after 10th day
 white or yellowish-white color
 contains plenty of decidual cells, leucocytes,
mucous, cholesterin crystals, fatty and granular
epithelial cells and micro organisms.

158
Vaccines contraindicated in
pregnancy
 MMR,
 VARICELLA-ZOSTER,
 IPV,
 YELLOW FEVER

159
 LACTATION
COMPOSITION PER MATURE BREAST COW MILK
100ML MILK

CALORIES 75 69
PROTEINS 1.1(80/20) 3.5(18/82)
(LACTALB/CASEIN)
WATER 87 87
FAT 4.5 3.5
CARB 7.1 4.9
Na(MEQ/L) 16 50
K 53 144
CALCIUM 33 118
VITAMIN C 5MG 1MG
pH ALKALINE ACIDIC

160
ABNORMAL PUERPERIUM

161
Puerperal
Fever/Pyrexia
 Definition: -Oral temp. 38 degree C/
100.4 degree F or more recorded twice
on two separate occasions 24hrs apart
(excluding the first 24hrs) in the first 10
days after delivery.

162
 Causes of Puerperal fever

 Uterine infection
 Breast infection
 Urinary infection
 Wound infection
 Thrombophlebitis (RT. OV VEINS) (HEPARIN
CHALLENGE TEST)
 Other incidental infections
 pueperal pyrexia is considered to be due to genital
 tract infection unless proved otherwise.

163
MULTIPLE PREGNANCIES,
POLYHYDRAMNIOS

164
Varieties of twins?
 Dizygotic (70-80%): It is a fertilization of
two separate ova.
 Monozygotic (20-30%) = Identical
twins: It is a single fertilized ovum that
subsequently divides into two similar
structures.

165
TYPES OF MONOZYGOTICS

166
 First 72 H  two embryos, diamniotic,
dichorionic and two placenta or single fused
placenta.
 4-8 days  two embryos, diamniotic,
monochorionic.
 About 8 days after fertilization  two embryos,
monoamniotic and monochorionic.
 Divisions  cleavage is incomplete and
conjoined twins result.

167
INCIDENCE AND HELLIN’S RULE
 INCIDENCE: Monozygotic: 1:250
(independent) , Dizygotic: 1:80 INDIA,
1:20 African
 HELLIN’S RULE:
 TWINS 1:80
 TRIPLETS 1:802
 QUADRIPLETS 1:803
 AND SO ON 1:80n-1

168
169
INDICATIONS OF CESAREAN
SECTION:
 For other obstetric conditions associated with
twins,
 For breech presentation of first twin,
 For monoamniotic twins,
 interlocking twins,
 Conjoint twins.
 TRIPLETS AND QUADRUPLETS:
 THEY SHOULD BE KEPT FOR ELECTIVE CESAREAN
SECTION.

170
POLYHYDRAMNIOS

171
 Polyhydramnios is defined as a state
where liquor amnii exceeds 2000 ml
or when A.F.I. is more than 25 cm or a
single pocket of amniotic fluid is
greater than 8 cm by ultrasonography.
Incidence: 1% to 2 % of the cases

172
 Causes

 IDIOPATHIC
 FETAL ANOMALIES:
 Problems with swallowing and GI absorption: Oesophageal and
duodenal atresia, cleft palates
 Increased transudation of fluid: anencephaly, spina bifida
 Increased urination: anencephaly (lack of ADH, stimulation of
urination centers)
 Hydrops fetalis
 DIABETES, CARDIAC OR RENAL FAILURE IN MOTHER,
 MULTIFETAL GESTATION
 PLACENTAL HAEMANGIOMAS/CHORANGIOMAS.

173
OLIGOHYDRAMNIOS

174
 DEFINITION:
 It is the presence of scanty amount of
liquor amnii at or near term (<200ml)
(AFI<5 cm)

175
ETIOLOGY:
 FETAL CAUSES
 RENAL AGENESIS (POTTER’S Syndrome)
 Urinary tract obstruction as urethral valve or stricture or ureteric
obstruction
 Defects in amniotic membrane with chronic leak
 Post-maturity
 AMNION NODOSUM.
 MATERNAL CAUSES
 Placental insufficiency as with:
 Pre-eclampsia
 Essential hypertension
 Chronic nephritis

176
 ANTEPARTUM
HEMORRHAGE

DR ANIL MIRCHANDANI

177
DEFINITION:
 IT IS DEFINED AS BLEEDING FROM
THE GENITAL TRACT AFTER 28TH
WEEK OF GESTATION BUT BEFORE
THE BIRTH OF BABY.

178
 CAUSES OF APH:
 PLACENTA PREVIA (35%)
 ABRUPTIO PLACENTA (35%)
 LOCAL CAUSE (POLYP, CA CERVIX,
VARICOSE VEINS, TRAUMA0 (5%)
 IDIOPATHIC (25%)

179
 Classification
• TYPE IV Complete: Placenta completely
covers the os
• TYPE III Partial: Placenta partially covers the
os
• TYPE II Marginal: Placenta edge TOUCHES
of the os (ANTERIOR IIA, POSTERIOR: IIB)
• TYPE I Low lying: Placenta edge lies WITHIN
5 cm from the os

180
 INCIDENCE OF PREVIA
 1 in 200-250 live births
• Complete 20-45%, partial 30%, marginal 25-
50%
 U/S at 18 weeks shows 12-25% incidence
of low lying placenta
• Most of these (~90%) resolve by term
• “placental migration” – placenta grows towards best
blood supply located in upper uterine segment away
from cervix

181
 RISK FACTORS OF PREVIA
 Multiparity
 Multiple Gestations
 Increased maternal age
 Previous cesarean delivery
 Tobacco use
 Uterine curettage

182
DIAGNOSIS
 TVS(93-95%)
 FALSE POSITIVES AND FALSE
NEGATIVES
 MRI- MOST ACCURATE

183
MANAGEMENT:

 Women with significant vaginal bleeding are

hospitalized for resuscitation and evaluation
 Bleeding will usually resolve, but may return with the
onset of labor
 maternal/fetal status unstable → delivery by c-
section
 Maternal/fetal status stable → expected
management (MACAFEE AND JOHNSON’S
REGIMEN: EXPECTANT MANAGEMENT WITH
GOOD MATERNAL AND FETAL CONDITION WITH
AVAILABILITY OF CESAREAN SECTION)

184
 IN minor degree placenta previa, low
rupture of membranes followed by induction
of labour should be done at term.
 Cesarean is the method of delivery for
major placenta previa. HOWEVER THERE
MAY BE DIFFICULTIES IN DOING
CESAREAN SECTION IN SUCH CASES.
 PROPHYLAXIS AGAINST P.P.H.

185
ABRUPTIO PLACENTAE:

 DEFINITION: Bleeding following premature

separation of a normally situated placenta.
 AETIOLOGY
• Hypertension and severe pre-eclampsia
• Direct trauma
• High Parity
• Low socio-economic status
• Folic acid deficiency?
• Polyhydramnios
• Short umbilical cord
• Cocaine abuse

186
 CLASSIFICATION
 This is classified into three categories –
 Revealed type – the bleeding is revealed.
 Concealed type – there is no obvious
bleeding
 Mixed type – a combination of revealed
and mixed.

187
ABRUPTIO PLACENTA
 Clinical features
 Diagnosis
 Management
 Prognosis: 10% recurrence

188
 CLINICAL GRADING OF ABRUPTIO PLACENTA
 The grading of Abruptio placenta according to SHER and
STUTLAND (1985) is as below
 Grade Clinical features
 I--------- slight bleeding, irritable uterus, minimal
tenderness, DIC profile normal, FHS normal.
 II-------- bleeding is moderate; uterus is tender,
tachycardia, normotensive, no shock but fetal distress.
 III-------- Severe. The fetus is dead
 a. Without Coagulopathy
 b. With Coagulopathy

189
Hypertensive disorders in
pregnancy
 1-Gestational hypertension
 2-Pre-eclampsia (mild and severe)
 3-Eclampsia
 4-Chronic hypertension
 5-Pre-eclampsia/eclampsia
superimposed on chronic hypertension

190
Risk factors:

AGE: disease of teenage or > 35 years.

PARITY: disease of primigravidae.
presence of UNDER LYING MEDICAL DISORDER:-
 DM

 Essential hypertension.

 Chronic nephritis.

 Collagen vascular disease.

 Sickle cell anemia

 APS.

 Thrombophilia

 PCOS

191
Risk factors:
CURRENT PREGNANCY CONDITIONS:
 V.M.

 Multiple pregnancy.

 Hydrops

 Asymptomatic bacteruria.

OBESITY: BMI > 35 kg/m2

FAMILY HISTORY OF PRE-ECLAMPSIA.
PREVIOUS HISTORY OF PRE ECLAMPSIA.
BLACK RACE.
 N.B.: SMOKING ↓ Incidence

192
193
194
 THEORIES BEHIND
ETIOPATHOGENESIS OF PRE-
ECLAMPSIA

 The uteroplacental bed

 Immunological factor
 Genetic factor
 Renin- angiotensin system
 The NO theory (nitric oxide)
 Prostaglandins
 Neutrophils
195
SYMPTOMS AND SIGNS:

 ↑ BP
 Proteinuria ( TRACE, +1, +2, +3,+4)
 Edema of the face & hands ( but it has been dropped of the
definition due to poor predictive value)*****
 WEIGHT GAIN****
 Headache
 Projectile vomiting
 Visual disturbance
 Epigastric pain
 Reduced urine output
 Exaggerated reflexes

196
MANAGING ECLAMPSIA:

What is it?
it is grand mal convulsion which pass
through stages of:
 Tonic contraction

 Clonic

 Coma

 Usually take about 60-90 seconds.

197
Anti-convulsants
 PRITCHARD MGSO4 IM AND IV
 ZUSPAN MGSO4 I.V
 LYTIC COCKTAIL-KRISHNA MENON
(PETHIDINE,
LARGACTIL(chlorpromazine),
PHENARGAN(promethazine))
 LEAN DIAZEPAM
 RYAN’S PHENYTOIN

198
Imp points
 Labetolol is drug of choice
 ACE inhibitors are contraindicated
 Sr. uric acid is biochem marker
 Ergometrine is contraindicated in
hypertension
 MgSO4 levels: therapeutic: 4-7 meq/litre
 Monitor: DTR, U/O, RR

199
PRETERM LABOUR

200
Preterm labor
(PTL): Presence
of contractions
which cause
progressive
effacement and
dilatation of the
cervix between
28 and 37 weeks’
gestation.

201
CAUSES

202
DIAGNOSIS
 CONTRACTIONS (1 IN 8 MIN)
 DILATATION(>/=2CM)
 EFFACEMENT (>/+ 80%)

203
TOCOLYTICS
 B-ADRENERGICS
 CALCIUM CHANNEL BLOCKERS
(BEST)
 MAGNESIUM
 INDOMETHACIN
 ATOCIBAN (OXYTOCIN ANTAGONIST)

204
PREMATURE RUPTURE OF
MEMBRANES

205
It is rupture of
membranes before
onset of labour(PROM)
If there is rupture of
membranes before the
onset of labour in
preterm status, it is
called as PPROM
(PRETERM
PREMATURE
RUPTURE OF
MEMBRANES)
Rupture of membranes
One in 10 pts have PROM
for more than 24 hrs is
prolonged
PROM/PPROM.
206
The following factors are
incriminated:

 a. Cervical incompetence.
 b. Polyhydramnios.
 c. Multiple pregnancy.
 d. Malpresentation as the
presenting part is not fitting
against the lower uterine segment.
 e. Chorioamnionitis.
 f. Low tensile strength of the
membranes, INFECTIONS.

207
FOR DIAGNOSIS OF PROM:

 STERILE SPECULUM EXAMINATION

 FFN

208
 ….CONTD

 NITRAZINE PAPER TEST:

IF ALKALINE AMNIOTIC
FLUID IS PRESENT:
YELLOW PAPER WILL
TURN BLUE.

209
 … CONTD
 Microscopy will reveal characteristic ferning
pattern in the presence of amniotic fluid

210
 .. CONTD

 Centrifugation of fluid and staining

with NILE BLUE SULPHATE will
show orange blue colouration of
cells (exfoliated fat from sebum of
fetus)
 USG may show oligohydramnios.

211
 POST TERM PREGNANCY

 Post term pregnancy is a

pregnancy continuing beyond two
weeks of the expected date of
delivery or more than 294 days
FROM THE FIRST DAY OF THE
LAST MENSTRUAL PERIOD. It
is also called as Post maturity.
INCIDENCE: 10% of
pregnancies.

212
EFFECTS OF POST TERM
PREGNANCIES
 MACROSOMIA, CPD
 SHOULDER DYSTOCIA
 OLIGO, FETAL DISTRESS, MSAF
 OLD MAN’S LOOK

213
INDUCTION OF LABOUR
 Artificial stimulation of uterine
contractions before spontaneous
onset of labour with the purpose of
accomplishing successful vaginal
delivery.

214
 PHYSIOLOGY!
 cervical ‘ripening’

215
INDICATIONS:

 MATERNAL
 Preeclampsia, eclampsia
 PROM
 Postterm pregnancy
 Abruptio placenta
 Chorioamnionitis
 Medical conditions-DM, Heart ds,
renal ds, Chr. HT etc
216
 FETAL
 IUFD
 Fetal anomaly incompatible with life
 Severe IUGR
 Rh isoimmunisation

217
BISHOP’S SCORE

218
CONTRAINDICATIONS

219
 Severe degree CPD
 Major degree placenta praevia
 Transverse lie
 Previous classical CS,Myomectomy
 Previous>= 2 LSCS
 Grand multiparity
 Active genital herpes
 Hypersensitivity to inducing agent

220
DIFFERENT METHODS OF
INDUCTION OF LABOUR

221
 NATURAL
 Breast/nipple stimulation
 Sexual intercourse
 Membrane stripping
 Amniotomy
 Acupuncture/acupressure

222
 MECHANICAL
 Balloon catheters
 Lamineria tents
 Synthetic osmotic dilators

223
 CHEMICAL
 NONHORMONAL
 Herbs, evening primrose oil
 Homeopathic prep
 Enemas
 Castor oil
 HORMONAL
 Oxytocin
 CERVIPRIME PGE2
 Prostaglandins –PGE2, Misoprostol
 MIFEPRISTONE

224
 AUGMENTATION OF LABOUR
Time (minutes) Rate of 5U Oxy. In 500 ml normal saline

0 0.5ml/min = 8 DROPS/MIN

30 1 ml/min = 16 DROPS/ MIN

60 1.5 ml/min = 24 DROPS/MIN

90 2 ml/min = 32 DROPS/MIN

And so on And so on till 64 drops/min

225
INTRA UTERINE FETAL DEMISE

226
 Definition –
IUFD denotes death of fetus in utero after
the period of viability.

227
Etiology:

Pregnancy complications:
 Pre-eclamptic toxaemia

 Antepartum haemorrhage : placenta praevia, abruptio placentae

Pre- existing medical disease and acute illness

 Chronic hypertension

 Chronic nephritis

 Diabetes

 Severe anaemia

 Hyperpyrexia

 Syphilis, Hepatitis, toxoplasmosis etc.

228
Etiology:
Foetal
 Congenital malformation

 Rh-incompatibility

 Post maturity

External version
Idiopathic 20 –30%

229
Investigations-

Straight- X-ray abdomen

 Spalding sign: it usually appears 7
days after I.U.F.D.
 Hyper flexion of the spine

 Crowding of the ribs shadow

 Appearance of gas shadow IN

HEART (Robert’s sign) : 12 hours

230
Investigations-

 Sonography :
 (a) Lack of all foetal motions
(including cardiac)
 (b) Oligohydramnios and collapsed
cranial bones

231
 IUGR
 whose birth weight is below the tenth
percentile of the average for gestational
age.
 <2 S.D

232
Symmetrical (20%) Asymmetrical (80%)

Foetus is affected from noxious effect very Foetus is affected in the later months
early in the phase of cellular hyperplasia. during the phase of cellular hypertrophy.

Pathological process is intrinsic to the Pathological process is extrinsic to the

foetus e.g. genetic disease or infection foetus e.g. chronic placental insufficiency

Uniformly small Head larger than abdomen

Ponderal index – normal Low

HC:AC, FL:AC ratios normal Elevated

Cell number less Cell number normal

Cell size normal Cell size small

Neonatal course complicated with poor Usually uncomplicated with good

prognosis prognosis.
233
Causes: - The cause remains
unknown in 40%.
Maternal conditions associated with
placental vascular insufficiency
 Preeclampsia (most common)
 Sickle cell anaemia
 Chronic hypertension
 Cardiac disease class III class IV
 Chronic renal disease
Multiple gestation
 Diabetes with vascular lesions

234
 Maternal conditions not associated
with placental vascular insufficiency
 Constitutionally small women
 Severe malnutrition
 Smoking alcoholism
 Haemoglobinopathies

235
 Placental causes
 Abnormal placentation
 Chronic villitis (CMV, immunological)
 Placenta previa
 Abruption
 Circumvallete placenta
 Placental infarcts
 Placental haemangiomas
 Mosaicism
236
 Foetal causes
 Chromosomal abnormalities (most
common) (triploidy, aneuploidy, turners
syndrome)
 Infections mainly TORCH group
 Structural abnormalities
 Inborn errors of metabolism

237
PREGNANCY WITH PREVIOUS
CESAREAN SECTION

238
EFFECTS:
 Abortions
 Preterm labour
 Operative interventions and morbidities
 Placenta previa
 Morbidly adherent placenta
 PPH
 Obstetric hysterectomies

239
EFFECTS ON SCAR?

 SCAR
DEHISCENCE
 SCAR
TENDERNESS
 SCAR RUPTURE

240
241
Candidates For VBAC:
 The woman has had one prior low-transverse C-section delivery.
 The woman has had no other uterine scars (hysterotomy/
Myomectomy or ruptures)
 The woman has a pelvis large enough to allow a vaginal delivery.
 Delivery will be at an institution with a physician immediately
available throughout active labor who can monitor the fetus and
perform an emergency C-section if needed.
 Delivery at an institution where anesthesia and staff is also
immediately available if an emergent C-section needs to be
performed.

242
Signs of uterine rupture

 Fetal heart rate deceleration or bradycardia

 Loss of station
 Palpable fetal parts in abdomen
 Abdominal pain or uterine SCAR tenderness
 Vaginal bleeding
 Hypovolemia
 Cessation of contractions

243
MANAGEMENT:
 LABOUR MONITORING: SCAR
MONITORING AND FETAL WELL BEING
MONITORING
 CHARTING THE PARTOGRAM

244
MANAGEMENT
 OXYTOCIN IF REQUIRED FOR AUGMENTATION
OF LABOUR, THEN 2.5IU IN 500 ML IS STARTED
AT 8 DROPS PER MINUTE.
 PROPHYLACTIC FORCEPS AND VACUUM TO
CUT SHORT SECOND STAGE OF LABOUR
 To explore the scar after delivery is controversial.
 Strict monitoring in fourth stage of labour and see for
urine colour for haematuria.

245
Rhesus Isoimmunization
Dr Anil Mirchandani
MBBS, MS.

246
 The individual having the “D” antigen on
the human red cells is called Rh positive
and in whom it is not present is called Rh
negative.

247
The effects:
IN UTERO

Antigen-Antibody reaction on the RBCs

surface  Hemolysis

Anemia


 Hepatic erythropoesis & dysfunction


Portal & Umbilical Vein Hypertension … Heart
Failure


IUD  Erythroblastosis
Polyhydramni
fetalis
os 248
Pathogenesis Of Rh Iso - immunization
HAEMOLYSIS

AFTER BIRTH IN UTERO

  
Jaundice ANAEMIA BILLIRUBIN
Kernicterus
Hepatic Failure
 
 HEPATIC MAT. LIV NO
  ERYTHROPOESIS EFFECT
 DEATH IUD & DYSFUNCTION 
   
PORTAL & UMBILICAL VEIN

ERYTHROBLASTOSIS
 HYPERTNSION, HEART FAILURE 
FETALIS 

  
BIRTH OF AN AFFECTED INFANT - Wide spectrum of presentations. Rapid
deterioration of the infant after birth. May continue for few days to few months.
Chance of delayed anaemia at 6-8 weeks probably due to persistence of anti Rh
249
antibodies.
250
COOMB’S TEST

251
252
KLEIHAUER’S TEST

253
Management of Sensitized Pregnancy
Sensitized Rh Negative
mothers

… Check quantitative antibodies level @ 1st visit

… Recheck the level every 2 weeks
… Serial U/S Scan monitoring every 2 weeks
… If antibodies level continue at the same level
and no fetal compromise … deliver at term

254
Management of Sensitized Pregnancy

Sensitized Rh Negative mothers

If antibodies level start to increase

… Arrange for amniocenteses
… Spectrophotometer to study the optical density

of the amniotic fluid

( i.e. bilirubin level which reflect RBCs haemolysis
)
… U/S Scan evaluation of the fetal will beings
… Use LILEY’ s Curve to determine the fetal 255
Ultrasound scan (USS)
Help in fetal monitoring and timing of first intervention if
anti-D level is ≥ 10 IU/mL
USG DOPPLER FOR FETAL MCA-PSV which is a
marker of fetal anaemia.

USS can detect

…..…. Fetal Skin and scalp edema,
……... Fetal Ascites,
……... Fetal Pericardial or pleural effusion
…….. Polyhydramnios
…….. Fetal hepatosplenomegaly
…….. Fetal Cardiomegaly
…….. Placental hypertrophy and enlargements
…….. Abnormal fetal posture (Buddha stance)

256
Amniocentesis

Amniocentesis
Is an Indirect method to measure the degree of haemolysis of the fetal red
blood cells by measuring the Concentration of bilirubin in the amniotic fluid.

Amniotic fluid sample taken and sent for Spectrophotometer

Where optic density of the fluid changes according to the

amount of the bilirubin concentration

Increasing of the OD as pregnancy advance shows worsening

of the fetal hemolytic disease

257
1.2
1

0.8

0.4

0.1
100

200

450
300

258
 Liley’s
chart
Zone III

Zone II

Zone I

259
Management of Sensitized Pregnancy

Term pregnancy ( mild or Severely affected ) …Delive

Suitability of the place and its facility

Experience of the team

Type of
Delivery
Medication

Photo therapy

Extra uterine Blood

exchange 260
 Preterm fetus with Zone I
Cordocentesis blood sample Hb
> 10g/dl
No U / S Scan evidence of
Hydropic changes

Consider conservative management with

regular follow up of fetal and maternal
conditions till the fetal lung maturity is
assured …. Then deliver

261
 Daily maternal clinical assessments

Fetal Movements Chart

Daily C T G

Serial U / S Scan for fetal growth and amniotic fluid

Biophysical Profile

Regular cheek of the amniotic fluid bilirubin level by repeated

amniocentesis every 2 weeks until the lung maturity reached

Regular cheek of the fetal Hb and Hct values if the facilities available

262
Management of Sensitized Pregnancy

Preterm fetus with

Zone II or III

Cordocentesis blood sample Hb less than

10g/dl
Ultrasound evidence of Hydropic changes
Consider
Transfer to suitable place

Intra uterine therapy

Delivery + extra uterine mang.

263
Management of Sensitized Pregnancy

Intra uterine therapy

Intra peritoneal blood transfusion

Through the umbilical vein “ Cordocentesis
80 % of packed cell “ o “ rhesus
negative Blood Cross matched
against maternal blood group

Free of infection
Fresh
264
IMPORTANT POINTS
 ABO INCOMPATIBILITY IS MORE
FREQUENT BUT BENIGN
 COOMB’S TEST DETERMINES
PROGNOSIS
 CRITICAL TITRE IS 1:16, >10IU/ML
 IgM CANT CROSS PLACENTA
 USG SHOWS: BUDDHA’S POSITION

265
ABNORMAL POWER

266
  ABNORMAL UTERINE ACTION
  
  

NORMAL POLARITY ABNORMAL POLARITY
 (INCOORDINATE UTERINE ACTION)
  

EXCESSIVE UTERINE
 CONTRACTION INERTIA


 OBSTRUCION (-) OBSTRUCTION (+)

 PRECIPITATE TONIC UTERINE
 LABOUR CONTRACTION AND
 RETRACTION (BANDL’S RING)
  
  

HYPERTONIC UTERUS
  
  

267
  ABNORMAL POLARITY
 (INCOORDINATE UTERINE ACTION)
  
  

SPASTIC COLICKY CONSTR GENERALISED
 LOWER UTERUS RING TONIC
 SEG ASSYM CONTRACTION
 UTERINE
CERVICAL
 CONTR
DYSTOCIA
  
  

INEFFECTIVE UTERINE CONTRACTION

268
 CONSTRICTION RING RETRACTION RING

Nature Localised incordinate It is an end result of tonic

uterine contraction uterine contraction and
retraction
Cause Undue irritability of uterus Following obstructed
labour
Situation Usually at the junction of Always situated at the
upper and lower segment junction of upper and
but may occur in other lower segment. The
places. The position does position progressively
not alter. moves upwards
Uterus Upper seg contracts and Upper seg is tonically
retracts, lower seg thick contracted with no
and loose relaxation, the wall
becomes thicker. Lower
seg becomes distended and
thinned out.

269
 CONSTRICTION RING RETRACTION RING

Maternal condition Almost unaffected unless Features of maternal

labour is prolonged exhaustion and sepsis
appear early.
Abdominal Examination a) Uterus normal and non a) Uterus tense and tender
tender b) Not easily felt
b) Fetal parts easily felt c) Felt as a groove placed
c) Ring is not felt obliquely
d) Round lig not felt d) Taut and tender
e) FHS usually present e) Usually absent

Vaginal examinaton a) Lower seg is not pressed a) Lower segment is

by the presenting part pressed by the
b) Ring is felt above the presenting part
head b) Ring cannot be felt
c) Features of obstructed vaginally
labour are absent c) Features of obstructed
labour are present
270
 CONSTRICTION RETRACTION
RING RING
End result No chance of uterine Rupture of uterus in
rupture multigravidae is very
common
Principle of treatment Relax the ring To relieve the
followed by delivery obstruction
of the baby or to cut (preferably by C-
the ring during C. section) after
section excluding rupture
uterus

271
 MANAGEMENT OF SHOULDER
DYSTOCIA
 MC ROBERT’S
 SUPRAPUBIC PRESSURE
 WOOD’S
 ALL FOUR’S METHOD
 ZAVANELLI
 CLIEDOTOMY
 SYMPHYSIOTOMY

272

The woman's legs should be
maximally flexed on her abdomen McRoberts

Apply additional mild downward manoeuvre
traction on the fetal head with the
aim to deliver the impacted
anterior shoulder

McRoberts manoeuvre results in a
straightening of the lumbar spine
with consequent cephalic rotation
of the symphysis pubis

This manoeuvre is successful in
more than 40 % of cases (over 50
% when combined with supra-
pubic pressure)
273
 The accoucheur applies gentle traction
to the fetal head
 An assistant should apply continuous
downward pressure over the anterior
shoulder of the fetus in a "CPR" style
above the symphysis pubis
 The heel of the assistant's hand should
be over the back (scapula side) of the
fetus' anterior shoulder
 The aim is to push the anterior shoulder
to an oblique angle under the symphysis
 The assistant may use a rocking motion
where continuous pressure is
unsuccessful
Supra-pubic pressure

274
 The fingers of the first hand remain behind
the anterior shoulder. The accoucheur
inserts the fingers of her / his second hand
in front (chest side) of the posterior
shoulder
 Apply pressure behind the back of the
anterior shoulder so that the anterior
shoulder is displaced towards the fetal
chest in combination with additional
pressure to the front of the posterior
shoulder to rotate into the oblique.
Continue rotation throughout 180° where
unsuccessful
 Attempt delivery

Wood’s screw
manoeuvre
275

The accoucheur's hand is Delivery of the
inserted into the vagina Posterior Arm
across the fetal chest to
identify the fetal elbow

The fetal arm is flexed and
swept across the fetal chest
and maternal perineum. This
often allows the anterior
shoulder to be displaced and
delivered

If this fails, then the fetal
head and trunk can be
rotated through 180° to allow
delivery 276
Rotation onto all fours
•All fours position (rotating the pregnant woman onto her
hands and knees) increases the pelvic diameters allowing
better access to the posterior shoulder
•Consideration should be given to the time taken to
achieve this position especially if the woman is obese and /
or has an epidural

277
 Zavanelli manoeuvre
 If the above fail, then the fetal head should be
replaced back into the uterus by depressing the
posterior perineum and applying the palm of the hand
to the vertex and applying upward pressure. Once the
head is replaced, proceed to caesarean section

278
 Cleidotomy (fracture of fetal
clavicle)
 Consider cleidotomy if all other
measures have failed. It may be
considered earlier if the fetus has
succumbed
 Symphysiotomy
 Only to be considered by those with
experience with this procedure

279
POST PARTUM HEMORRHAGE

 Definition:
 It is excessive blood loss, from the
genital tract after delivery of the foetus
exceeding 500 ml or affecting the
general condition of the patient.

280
THERE ARE FOUR “T” FOR
PPH

 Tone (Uterine tone)

 Tissue (Retained tissue--placenta)
 Trauma (Lacerations and uterine
rupture)
 Thrombin (Bleeding disorders)

281
 Types:
 a.Primary postpartum haemorrhage:>
Bleeding occurs during the 3rd stage or
within 24 hours after childbirth. It is more
common.
 b. Secondary postpartum haemorrhage:>
Bleeding occurs after the first 24 hours
until 6 weeks (the end of puerperium).

282
PREDICT IN THESE CASES:
 Antepartum haemorrhage.
 Severe anaemia.
 Overdistension of the uterus.
 Uterine myomas.
 Prolonged labour exhausting the uterus.
 Prolonged anaesthesia and analgesia.
 Full bladder or rectum.
 Idiopathic.
 LARGE BABIES, BORDERLINE PELVIS
 COAGULOPATHIES

283
MANAGEMENT
 Massage of the uterus and ecbolics as:
 > Oxytocin drip: 10-20 units in 500 ml
glucose 5% or normal saline. It may be
given (5 units) directly intramyometrial in
case of C.S.
 > Ergometrine (Methergin): 1-2 ampoules
(0.25-0.50 mg) IV or IM.
 > Syntometrine 0.5 mg IV if available

284
 Prostaglandins (PGs):
 0.25 mg methyl PG F2a IM
(PROSTODIN) or
 800 mcg PGE1 (MISOPROSTOL) TO
BE PUT PER RECTALLY

285
SURGICAL T/T
 COMPRESSION
 PACKING
 U.A.E
 UTERINE ART. LIGATION
 OV. ART. LIGATION
 INT. ILIAC ART. LIGATION
 OBS. HYST.

286
UTERINE INVERSION

287
 Rare: ~1/2000 deliveries.
Causes include:
 Excessive traction on cord.

 Fundal pressure.

 Uterine atony.

288
 Blue-gray mass protruding from vagina.
 Copious bleeding.
 Hypotension worsened by vaso-vagal
reaction. Consider atropine 0.5mg IV if
bradycardia is severe.
 High morbidity and some mortality seen:
get help and act rapidly.

289
REPOSITION RULE: REPOSIT THE
PART WHICH CAME OUT LAST
DURING INVERSION

290
MX
 O’SULLIVAN METHOD
 HUNTINGTON’S
 HAULTAIN’S METHOD

291
TISSUE: RETAINED
PLACENTA

 Definition:Failure of placental delivery

within 30 minutes after delivery of the
foetus.
 Incidence: 1%.

292
293
MRP: MANUAL REMOVAL OF
PLACENTA
• Introducing one hand
into the vagina along
cord

294
Supporting the fundus while
detaching the placenta 

295
Withdrawing the hand
from the uterus with
placenta.

296
RISK FACTORS FOR MORBIDLY
ADHERENT PLACENTA

297
 placenta previa with or without previous
uterine surgery.
 previous myomectomy.
 previous cesarean delivery.
 Asherman's syndrome.
 submucous leiomyomata.
 maternal age of 36 years and older.

298
INSTRUMENTAL DELIVERY:
VENTOUSE

299
300
301
302
 - vertex presentation;
 - term fetus; 
 - cervix fully dilated(atleast >7 cm
dilated);
 - head at least at 0 station or no more
than 2/5 above symphysis pubis.

303
304
305
 create a vacuum of 0.2 kg/cm2 negative
pressure and check the application.
 Increase the vacuum to 0.8 kg/cm2 and
check the application

306
FORCEPS
The obstetric forceps is designed to grasp the
fetal head when it is in the vagina and bring
about delivery by traction and guidance without
causing injury to the mother or baby. The
forceps consists of two arms which are
movable. They somewhat resemble large
connected salad spoons. 

307
308
 Review for conditions:
 - vertex presentation or face presentation
with chin-anterior or entrapped after-
coming head in breech delivery;
 - cervix fully dilated;
 - head at +3 station or 0/5 palpable

309
 Classification of forceps
 Outlet
• Scalp visible @ introitus w/o separating labia
• Fetal skull @ pelvic floor
• Sagittal suture in AP plane (or ROA/LOA)
• Fetal head at or on perineum
• Rotation < 45 degrees
 Low
• Leading point of fetal skull > or = +2 station
• Rotation < 45 degrees
• Rotation > 45 degrees
 Mid
• Station above +2 station but the head is engaged
 High
• Not included in classification

310
311
KIELLAND’S ROTATIONAL
FORCEP

312
313
MALPOSITIONS AND
MALPRESENTATIONS

314
 Presentation

Presentation may be :
Cephalic 95%
Breech 3 - 4% at term
Oblique lie 1:200
Shoulder 1:200

315
316
When the head is present in the
lower uterine segment : “Cephalic”
the presentation may have the
following presenting parts :

Vertex 99%
Face 1:500
Brow 1:1500

317
 MALPOSITION: it refers to any position
of vertex other than flexed occipito
anterior position.

318
OCCIPITO-POSTERIOR POSITION

319
MECHANISM OF LABOUR:

320
321
322
 Fate of OPP
OPP
Engaging diameter :- occipito-frontal
11.5cm or sub-occipitofrontal 10cm.

Unfavorable (10%)
Favorable (90%)

3/8th rotation Mild deflexion Moderate deflexion Severe deflexion

occipit comes under Occiput rotate by Non-rotation Occiput rotate

symphysis pubis (rt/lt 1/8th circle posteriorly by 1/8th
occipito anterior) Oblique
posterior POPP/ occipito-
Deep
Normal vaginal delivery arrest sacral position
transverse
arrest
Face to pubis delivery Arrest

323
BREECH PRESENTATION

324
Types of breech presentation

325
326
327
Footling and kneeling

328
Causes

 Extended legs
 Preterm labour
 (COMMONEST CAUSE)
 Multiple pregnancy
 Polyhydramnios
 Hydrocephaly
 Uterine abnormalities
 Placenta praevia

329
 Types of birth
 Spontaneous
 The birth occurs with little assistance from the attendant.
 Assisted breech
 The buttocks are born spontaneously, but some
assistance is necessary for delivery of extended legs or
arms and the head.
 Breech extraction
 This is a manipulative delivery carried out by an
obstetrician and is performed to hasten the birth in an
emergency situation such as fetal compromise.

330
 Birth of the body
 Birth of the shoulders
 Birth of the head

331
Birth of head:::

332
Mauriceau–Smellie–Veit manoeuvre
(jaw flexion and shoulder traction):

333
334
Complications

 Cord prolapse
 Birth injury
 Superficial tissue damage
 Fractures
 Erb’s palsy:
 Trauma to internal organs
 Spinal cord damage or fracture of the spine
 Intracranial haemorrhage
 Fetal hypoxia
 Premature separation of the placenta
 Maternal trauma

335
 FACE PRESENTATION

Lt mento-ant Rt mento-ant Rt mento-post

Longitudinal lie. Face presentation. Left and right
anterior and rt posterior positions.
336
 Causes

 Anterior obliquity of the uterus

 Contracted pelvis
 Polyhydramnios
 Congenital abnormality
 

337
Complications

 Obstructed labour

 Cord prolapse

 Facial bruising

 Cerebral haemorrhage

 Maternal trauma

338
BROW PRESENTATION

339
 Causes
 These are the same as for a secondary
face presentation; during the process of
extension from a vertex presentation to a
face presentation, the brow will present
temporarily and in a few cases this will
persist.

340
TRASNVERSE LIE (SHOULDER
PRESENTATION)

341
 CAUSES
MATERNAL
 Lax abdominal and uterine muscles
 Contracted pelvis
 Uterine abnormality
FETAL
 Pre-term pregnancy
 Placenta praevia
 Polyhydramnios
 Macerated fetus
 Multiple pregnancy

342
Possible outcome

 There is no mechanism for delivery of a shoulder

presentation
 RARELY, THERE MAY BE SPONTANEOUS
RECTIFICATION (SHOULDER TO VERTEX) OR
SPONTANEOUS VERSION (SHOULDER TO
BREECH), SPONTANEOUS EVOLUTION (DELIVERY
OF PROLAPSED ARM-BREECH AND TRUNK- THEN
HEAD IN DEAD BABY), SPONTANEOUS EXPULSION
(DOUBLING UP OF DEAD PREMATURE BABY AND
EXPULSION: CORPUS CONDUPLICATO).

343
COMPOUND PRESENTATION

344
CORD PROLAPSE
When the umbilical cord lies alongside or
in front of the presenting part while the
fetal membranes are intact is known as
cord presentation
If the fetal membranes rupture and the
cord is felt it is called cord prolapse

345
RISK FACTORS
 Malposition
 Malpresentation
 Multiple pregnancy
 Cephalopelvic disproportion
 Polyhydramnios
 Prematurity

346
MANAGEMENT

 CESAREAN is necessarily except if:

 The cervix is fully dilated and the
presenting part is engaged: forceps or
vacuum can be performed by
experienced obstetrician.
 ◒ Dead fetus with no other indication for
C/S: allow vaginal delivery.

347
Thank you

348