OBSTETRIC CASE

Mrs. ———————, —— years of age, is educated upto ———— and works as a —————. She is the
wife of Mr. ———————, —— years of age and working as a —————. She resides at
—————— and belongs to class ———— of socioeconomic status according to modified BG Prasad
scale. Her nearest health facility is ————— which is ——— (time) away from her house by —————
(mode of travel) and JIPMER is ——— (time) away from her home.

Obstetric index and period of gestation in months.

(She is a gravida ——, para ——, with —— living issue(s) and —— abortions/ she is a primi gravida) at her
—— month of gestation.

Last menstrual period

Regularity of cycles, h/o OCPs before conception (at least 3 months)

Expected date of delivery (calculated by you) is —————— by Naegele’s formula

Expected date of delivery (given by 1st trimester scan, also mention whether the 2 EDDs coincide or are
different)

Period of gestation (in weeks+ days)

She is booked and immunised.

Her blood group is ———

Blood group of husband (if the patient is Rh -ve)

Chief complaints: to be mentioned in the chronological order

(Common complaints)
• Excessive vomiting
• Swelling of feet
• Bleeding per vaginum
• Leaking per vaginum
• Pain abdomen
• Decreased foetal movements
• Breathlessness
• White discharge per vaginum
• Burning micturition
• Any other complaints diagnosed incidentally on antenatal visit
• Or for safe confinement

If no complaints and patient is in 3rd trimester,

No history of pain abdomen, bleeding p/v, leaking p/v

History of present illness

Specific to each condition- rule out the causes, complications of each condition

Hypertensive disorders in pregnancy

• Swelling of feet- onset, duration, relieved by rest or not, swelling of other parts (face, abdomen, vulva,
whole body)
• When was G HTN diagnosed- at what weeks or months and where, monitoring of BP done when, how and
where, any scans done, urine tests done, values of BP at the time of diagnosis
• Any drugs for HTN
• History of hospital admission
• Perception of foetal movements
• History of anaemia and cardiac disease
• History of imminent symptoms - headache, blurring of vision, epigastric pain/ right hypochondriac pain,
nausea and vomiting
• History to rule out complications (complications of HTN on pregnancy)
• History of bleeding per vaginum (Abruptio placentae)

Diabetes in pregnancy
Gestational diabetes mellitus
• When was diagnosed- in which trimester- in months or weeks
• How was diagnosed- screening or diagnostic tests done (when, where, how)- detailed history, values of
blood sugar at the time of diagnosis
• How was she managed after diagnosis- diet+ exercise or insulin
• If insulin- dosage, who gives injections
• Are sugars monitored, are sugars under control
• History of complications (rule out UTI, Vaginal Candidiasis)- burning micturition, itching of private parts

Overt diabetes mellitus

• Duration of DM
• Drugs- oral drugs or insulin
• Were sugars under control at the time of conception
• Was anomaly scan done, was it normal
• History of burning micturition
• History of itching of private parts
• History of increased weight gain
• History of high BP recordings
• If high BP recordings present, symptoms of pre eclampsia

Rh incompatible pregnancy
• Blood groups of patient and husband
• History of any intramuscular injection given within 1-2 days of delivery of first delivery
• History of repeated blood tests during antenatal period (indirect Coombs test)
• History of any intramuscular injection other than vaccine given in mid pregnancy
• Any history of bleeding per vaginum

Oligohydramnios
• History of reduced perception of foetal movements
• History of high BP recordings (complication of GHTN)
• History of leaking per vaginum
• Anomaly scan- when was it done, was it normal (anomalies cause small baby)
• 3rd trimester scans were done, baby said to have adequate weight
• Any other comorbidities in the patient (undernourished, anaemic, multipara without space between
subsequent pregnancies)

Polyhydramnios
• History of difficulty breathing, pedal oedema (due to over distended abdomen)
• Rule out Rh isoimmunisation
• History of GDM
• Rule out congenital anomalies, multiple pregnancy
• 3rd trimester scans- whether baby was told to be big

Foetal growth restriction

• History of maternal malnutrition, low socioeconomic status of mother
• Check for reliability of LMP- correlate with dating scan
• History of high BP recordings and/or imminent symptoms (FGR is a foetal complication of GHTN)
• History of bleeding or leaking per vaginum
• History of reduced perception of foetal movements
• History of recurrent (>=2) first trimester abortions (APLA Syndrome)
• History of chronic diseases- type 2 DM, CKD, SLE, CVS disorders- in the mother
• History of low birth weight in previous pregnancies (constitutional causes)
• Pre pregnancy weight less than 45kg

Multiple pregnancy (m/c Twin gestation)

• History of excessive vomiting
• History of breathlessness and easy fatiguability
• History of difficulty walking and backache
• History of high BP recordings and/or imminent symptoms of eclampsia
• History of pedal oedema, varicosities, haemorrhoids
• History of bleeding per vaginum (Abruption placentae)
• History of pain abdomen (preterm labour)
• History of infertility/ ovulation induction drugs/ IVF
• History of previous twin pregnancy or twin pregnancy in family

Cardiac disorders in pregnancy

• History of breathlessness- onset, duration, progression (NYHA classification), aggravating and relieving
factors, associated factors, medications taken
• History of chest pain, palpitation, syncope, orthopnoea, PND, cough with haemoptysis- elaborate
• If known case of cardiac disease- age of diagnosis, treatment history, previous cardiac surgery, previous
hospital admissions, history of recurrent lower respiratory tract infections, urinary tract infections, dental
problems, history of rheumatic fever in childhood, history of cyanotic spells
• History of fever, cough with expectoration, burning micturition
• History to rule out complications of cardiac disease- failure, infective endocarditis
• History of cardiac problems in previous pregnancy
• History of symptoms of preeclampsia, high blood sugar values and bleeding per vaginum (abruption)

Anaemia in pregnancy
• History of easy fatiguability, tiredness, weakness, lethargy, breathlessness, palpitations, swelling of feet
(anaemia in failure)
• History of bleeding per rectum, melena, haematuria, hematemesis, haemoptysis (anaemia due to blood
loss)
• History of worms in stool
• History of fever with chills and rigor
• History of symptoms of preeclampsia
• Whether iron and folate supplements are taken regularly
• History of bleeding per vaginum
• Spacing between pregnancies (if multipara)
• History of blood transfusion or iron injections in previous pregnancy
• History of postpartum haemorrhage
• History of fever, foul smelling lochia postpartum
• History of low birth weight baby
• Whether postnatal iron supplements were taken
• History of chronic illnesses like CKD

History of present pregnancy

1st trimester
• Conception: spontaneous/ post infertility treatment
• Pregnancy detected at —— days/ weeks of amenorrhea by urine pregnancy test (UPT) and confirmed by
ultrasound (USG) at ——— weeks of amenorrhea at ————— (place)
• Any complaints in 1st trimester
• No of antenatal visits
• History of excessive vomiting
• History of fever with rashes (TORCH)
• History of bleeding per vaginum
• History of exposure to radiation
• History of teratogenic drug intake (valproate, phenytoin, ACE inhibitors and ARBs, Tetracyclines,
Chloramphenicol, warfarin, Chemotherapy drugs)
• History of burning micturition (UTI)
• History of folate tablets taken
• History of immunisation
• 1st trimester investigations: CBC- Hb, blood grouping, urine- RME/ culture, TSH, glucose screening,
serological tests (HIV, HbSAg, VDRL)
• 1st trimester scan- dating scan (when/ where)
• 1st trimester screening (for high risk pregnancy/ elderly primigravida)

2nd trimester
• No of antenatal visits
• Months/weeks when quickening was felt
• History of immunisation
• History of iron and folate (IFA) and calcium supplements
• History of bleeding per vaginum
• History of high BP recordings (if yes, elaborate)
• History of imminent symptoms- headache (occipital), blurring of vision, epigastric pain, nausea and
vomiting, pedal oedema, decreased urine output
• History of screening done for high blood sugars
• History of high blood sugar values (if yes, elaborate)
• History of anomaly scan- interpretation of the scan
• 2nd trimester screening

3rd trimester
• No of antenatal visits
• Perception of foetal movements
• History of high BP recordings/ imminent symptoms
• History of increased weight gain
• History of IFA and calcium supplements
• History of bleeding per vaginum
• History of leaking per vaginum
• History of pain abdomen

She is not a known case of Diabetes or Hypertension.

Pre pregnancy weight ——
Current weight——
Total weight gain in pregnancy ——

Menstrual history
Age at menarche
Menstrual cycle
• Regular/ irregular
• Once in —— days
• Lasts for —— days
• Flow is moderate/ profuse/ scanty
• History of clots/ dysmenorrhea
LMP

Marital history
Married for —— years
Consanguineous/ non consanguineous marriage
Degree of consanguinity (pedigree)

Past obstetric history

• Birth order
• Delivered on ——— (month/ year)
• Antenatal health (briefly mention antenatal trimester history with any major events)
• Whether booked and immunised

• Details of delivery (elaborate each previous pregnancy)

- Term/ pre term/ post term
- Place of delivery
- Induction done or not
- Vaginal delivery : spontaneous/ instrumental

- Caesarean section
At what period of gestation
Elective/ emergency section
Duration of labour (if emergency)
History of prolonged rupture of membranes
Section done in first/ second stage of labour: history of bearing down
Indication for section
Type of anaesthesia given

• Baby details
- Live/ still born
- Birth weight
- Sex of baby
- Cried immediately after birth
- History of NICU admission
- History of congenital anomalies
- Breastfed after —— (time)
- Present age and health of child
- If dead, cause of death

• Postnatal history
- Puerperium eventful/ uneventful

- In case of C section
History of fever, pus discharge from wound, foul smelling lochia
History of blood transfusion
When was catheter removed
When were sutures removed
History of secondary suturing
Duration of stay in hospital
When was the routine activities resumed
History of contraception after delivery

• History of use of contraceptive in between pregnancies

• Method of contraception and duration
• Inter-pregnancy interval

- in case of previous abortion or intrauterine death

Period of gestation
Induced or spontaneous
Cause of abortion or intrauterine death (if spontaneous)
Symptoms of patient
Any procedure done following abortion
Any evaluation/ treatment for cause of abortion done

Past history
History of TB/ asthma/ cardiac disease/ epilepsy/ jaundice/ thyroid disorders
History of surgery
History of blood transfusion

Personal history
Sleep and appetite
Addictions
Bowel and bladder habits

Dietary history
Mixed/ veg diet
24 hour recall method- in GDM/ overt DM, Anaemia, FGR

Family history
DM/ HTN/ TB
Multiple pregnancy/ congenital anomalies
Summary
Mrs——————, —— years of age, GPLA (obstetric score), at ——— weeks of gestation presented with
complaints of —————— diagnosed as —————— at —— weeks of gestation and was admitted in
view of —————. There is no other history suggestive of any complications. She is booked and
immunised. She has well perceived foetal movements. There is no history of bleeding or leaking per
vaginum, abdominal pain, high BP recordings or high blood sugar values. There is previous history of NVD/
CS/ any other antenatal medical condition. There is no significant past/ personal/ family history.

Examination

General examination
• Comfortable at rest
• Built
• Nourishment
• Height
• Weight
• BMI (using pre pregnancy weight)
• Pallor/ icterus/ cyanosis/ clubbing/lymphadenopathy/ pedal oedema
• Gait and any spine abnormalities
• Thyroid (any thyromegaly)
• Breast (lumps, nipple discharge, cracking or retraction)

Vitals
• Temp
• Pulse: rate, rhythm, volume, character, vessel wall, peripheral pulses
• BP: sitting (or semi recumbent)/ supine (left lateral- false lowering of BP)
• Respiratory rate

Systemic examination
• CVS
• RS
• CNS

Obstetric abdominal examination

Explain the procedure to patient. Get consent. Ask the patient to empty bladder. Ensure privacy. Stand on
right side. Cover the lower limbs with a blanket. Expose the abdomen from xiphisternum to pubic symphysis.

Inspection
• Abdominal distension: uniform/ non- uniform
• Flanks- full or not
• All quadrants move equally with respiration
• Umbilicus: inverted/ everted/ flushed to surface and in midline/deviated
• Linea nigra
• Striae gravidarum
• Scars/ sinuses/ dilated veins
• Hernial orifices

Palpation
Ask the patient to flex and slightly abduct her hip. Correct the dextrorotation of uterus with right hand.
Palpate with the ulnar border of left hand to determine the fundus (upper border) of uterus from below
upwards till disappearance of resistance of uterus. Before taking away the palpating hand, ask the patient for
permission and mark the fundal height on her abdomen.
• Fundal height: in weeks

Ask the patient to extend her legs. Place one end of the measuring tape on the pubic symphysis and take it up
along the midline to the marked point of fundal height, with the inch side of the tape facing upwards. Turn
the tape to check the symphysiofundal height in cms.
• Symphysiofundal height: in cm (mention whether it corresponds to the period of gestation)

• Abdominal girth: in inches

Obstetric grips

• Fundal grip
Ask the patient to flex and slightly abduct her hip. The grips are performed only in a relaxed uterus. The
examiner faces the head end of the patient and palpates the fundus with both the hands.
- A broad, soft, irregular, non ballotable part is felt, suggestive of foetal breech. (OR)
- A smooth, hard, globular, ballotable part is felt, suggestive of foetal head.

• Lateral/ umbilical grip

Face the head end of the patient. Steady one side of the uterus with palm of one hand while palpating the
other side and vice versa.
- A smooth curved, uniform resistance is felt, suggestive of foetal back
- Small, knobby, irregular parts are felt suggestive of foetal limbs

• First pelvic/ Pawlik’s grip

Face the head end of the patient. Place the ulnar border on pubic symphysis and palpate the foetal part
between your stretched thumb and fingers.
- A smooth, hard, globular, ballotable part is felt suggestive of foetal head. (OR)
- A broad, soft, irregular, non ballotable part is felt, suggestive of foetal breech
- If presenting part is freely ballotable, it is not engaged.
- If presenting part is fixed or non ballotable, it may be engaged.

• Second pelvic/ Leopold grip

Face the foot end of the patient. Place hands on either side of abdomen parallel to inguinal ligament.
Palpate simultaneously with both hands starting from ASIS and move medially and downwards.
- Confirms the findings of 1st pelvic grip, whether the presenting part is engaged or not.
- Attitude of head (if cephalic presentation): well flexed/ deflexed/ extended head

Uterine activity: relaxed/ irritable/ contractions

Liquor: average/ excessive/ reduced
Scar tenderness (in case of previous CS)
The suprapubic region is gently palpated with the palm of the fingers, simultaneously observing the patient’s
face for any wincing or discomfort due to pain.

Auscultation
Foetal heart sounds (on the side of foetal back, along the spinoumbilical line)
Rate- normal: 120- 160 bpm

Estimated foetal weight

- by Johnson’s formula

EFW= (SFH- 11 or 12) X 155 g

Summary

Diagnosis
—— years of age, GPLA (obstetric score), at —— weeks of gestation, diagnosed with ——————— on
—————— (mention treatment) with/without previous NVD/ CS, without any other known
comorbidities, with a single/ twin live foetus in cephalic/ breech presentation, not in labour.
Elderly primigravida
According to FIGO, women having their first pregnancy at-or above 35 years of age.
Complications of pregnancy in elderly
During pregnancy
- miscarriage
- preeclampsia
- abruption
- fibroid
- GDM, HTN, IUGR
- post maturity
During labour
- preterm labour
- prolonged labour- pelvis is not as pliable (due to more calcification) as reproductive age group, CPDs are
common
- uterine inertia, increased C section
Foetal risks- preterm, prematurity, aneuploidy (m/c: trisomy 21- Down’s syndrome)
Puerperium risks: failure of lactation, increased morbidity

Management- Preconception counselling, genetic screening, Elective C section, contraceptive advice post
delivery

Teenage pregnancy
Pregnancy in a woman 19 years of age or younger.
Causes: low socioeconomic status, maternal illiteracy, mother who gave birth before 20 years

Risks associated with teenage pregnancy can be:

Antenatal risks
- Anaemia
- Malnutrition
- Abortion
- Preterm labour
- IUGR
- Preeclampsia
Intrapartum risks
- Contracted pelvis
- CPD
- Increased C section
- Perineal injuries
Postpartum risks
- Failed lactation
- Postpartum depression

Socioeconomic Scales
Modified BG Prasad’s classification- based on per capita income
Modified Kuppuswamy classification- based on education, occupation and income scores are made

Complications associated with low socioeconomic status

- Anaemia and malnutrition
- RHD
- TB
- STDs
- Hookworm infestation

Complications associated with higher socioeconomic status

- Obesity
- Postdated pregnancy
- GDM
- Gestational hypertension

Obstetric index/ score

Obstetric indices include gravida, parity, live (no of living children) and abortion.

Gravida- number of pregnancies including the present pregnancy, irrespective of the period of gestation and
the outcome of pregnancy
- Primigravida: increased risks of Preeclampsia, preterm labour, CPD
Parity- number of pregnancies that have crossed the period of viability (28 weeks) excluding the present
pregnancy
Live- number of living children at present
Abortion- expulsion of products of conception before the period of viability (<28 weeks)

Terminologies used in obstetrics-

Primigravida: woman who is pregnant for the first time
Multigravida: a woman who is or has been pregnant for at least second time
Nulliparous: a woman who has never carried a previous pregnancy upto the period of viability
Primiparous: a woman who has had one previous viable pregnancy
Multiparous: a woman who has had two or more previous viable pregnancies
Nulligravida: a woman who has never been pregnant so far
Puerperium: refers to the period of 42 days or 6 weeks after childbirth
Grand multigravida: a woman who has had 5 or more previous viable pregnancies

Complications of grand multigravida:

Antenatal
- Anaemia
- Malpresentation (pendulous abdomen)
- Multiple pregnancy
- Placenta previa

Intrapartum
- incoordinate uterine action
- Rupture uterus
- Postpartum haemorrhage

Postpartum
- Sub-involution of uterus
- Failed lactation

Calculation of Expected Date of Delivery

Naegele’s rule:
EDD= LMP+ 7days + 9 months (for a woman with 28 day cycles)
If LMP is not known, ask the woman to correlate it to some festivals, ask when was the UPT positive, ask for
date of quickening or ask for any details of IUI/ IVF if treated for infertility.

Prerequisites for Naegele’s rule: regular menstrual cycles, no history of OCP intake 6 months prior to
conception

For cycle length >28 days: add upto extra 14 days to the EDD calculated by Naegele’s rule
For cycle length <28 days: deduct the number of days from the EDD calculated by Naegele’s rule
If cycle length >45 days or for irregular cycles: Dating scan

Dating scan
- uses crown- rump length
- Done between
- Date discrepancy: 5-7 days

Anomaly scan
- done between 18- 20 weeks of gestation
- Parameters used: head circumference, abdominal circumference, femoral length, biparietal diameter
- Date discrepancy: 10-14 days

Growth scan
- done after period of viability to term/ delivery
- Parameters used: head circumference, abdominal circumference, femoral length, biparietal diameter
- Date discrepancy: 3 weeks
- Other parameters for assessment of EDD: ossification centres

Date of quickening
In primigravida, EDD= Quickening + 20 weeks
In multigravida, EDD= Quickening + 22 weeks

Documentation of FHR
By TVS- as early as 5 weeks
By TAS- 7 weeks
Handheld Doppler- 10 weeks
Auscultation- 20 weeks

Excellent vs Good vs Poor dates

Excellent dates
- Woman with adequate clinical information (LMP, 28 day cycle, no recent use of OCP, uterine size
correlates to period of gestation) and one USG done between 16- 24 weeks corresponding to the EDD and
POG.
- Woman with inadequate clinical information and two USGs done between 16- 24 weeks showing similar
EDD and linear growth
Good dates
- Woman with adequate clinical examination and one USG after 24 weeks of gestation that corresponds to
POG
- Woman with inadequate clinical examination and with two or more USGs done after 24 weeks of
gestation showing linear growth and similar EDD
Poor dates: any situation other than above mentioned ones

What is a booked pregnancy?

Booking refers to the number of antenatal visits made by the pregnant woman to the doctor.
Ideal no of visits: 13
1st trimester: 1 visit
2nd trimester: once in 4 weeks
3 rd trimester: once in 2 weeks for 28- 36 weeks, once a week after 36 weeks

Minimum no of visits: 4
Timing of registration: 1st visit (within 12 weeks)
2nd visit: from 24- 28 weeks (2nd trimester)
3rd visit: between 28- 34 weeks
4th visit: 36 weeks- term

A woman is said to be booked if

- she has had a minimum of 3 antenatal visits after registration of pregnancy, out of which 2 are in the 3rd
trimester.
- She has been provided with iron and calcium supplements
- She has been immunised with 2 doses of Td vaccine

Pedal oedema and pregnancy

Pedal oedema in pregnancy can be physiological or pathological.

Physiological: occurs to pressure on inferior vena cava by the gravid uterus which in turn causes increased
femoral venous pressure, decrease in albumin can also cause decreased oncotic pressure leading to oedema

Pathological: preeclampsia, anaemia, hypoproteinemia, renal failure, cardiac causes, hypothyroidism

Physiological edema Pathological edema
Usually develop in 3rd trimester Can develop anytime during pregnancy
Dependent edema- only pedal Non dependent oedema- face, hands, abdominal wall,
vulva, etc
Subsides on rest within 12 hours Does not subside after rest
Not associated with raised BP Can be associated with raised BP

Bleeding per vaginum in pregnancy

Causes of bleeding p/v in 1st trimester
- implantation bleeding
- Abortion
- Ectopic pregnancy
- Molar pregnancy
- Cervical lesions like erosion, polyp, carcinoma

Causes of bleeding p/v in 2nd trimester

- abortion
- Molar pregnancy
- Cervical lesions

Causes of bleeding p/v in 3rd trimester

- physiological: “show”- passage of blood stained discharge with onset of labour
- Antepartum haemorrhage: abruption placentae, placenta previa
- Scar rupture in previous C section
- Cervical lesions

Leaking per vaginum

Leaking implies rupture of membranes causing leakage of amniotic fluid.

History of continuous gushing of fluid from vagina.

Differential diagnosis: urinary incontinence, Hydrorrhoea gravidarum

Most common causes- Pre-labour rupture of membranes (PROM) or ROM.

PROM can be at term or preterm (before the completion of 37 weeks)
Diagnosis of PROM: history of leaking, speculum examinations show leaking, valsalva/cough impulse
shows leaking, sterile vulval pad to demonstrate leaking.

Sometimes involuntary passage of urine or vaginal discharge can be mistaken for leaking.
Confirmation tests for liquor maybe done to distinguish these.
- Nitrazine paper test: paper turns yellow to blue due to alkaline pH of liquor
- Fern test: fluid collected from the posterior fornix via examination is examined under microscope and it
shows a fern pattern or arborisation.
- Nile blue sulphate test: liquor stained with nile blue sulphate shows orange blue cells indicating foetal fat
cells

Pain abdomen
Causes of pain abdomen in pregnancy can be broadly obstetric and non obstetric causes-
Obstetric causes Non- obstetric causes
Early Late Medical Surgical Gynaecological
- Abortion - Labour pain - Pyelitis - Appendicitis - Torsion of ovarian
- Disturbed ectopic - Preterm labour - Pyelonephritis - Intestinal cyst
- Hydatidiform - Abruptio placentae - Pneumonia perforation - Red degeneration
Mole - Rupture uterus - Cystitis - Intestinal of fibroid
- Acute - Polyhydramnios - Hepatitis obstruction - Urinary retention
Polyhydramnios - Severe - Acute fatty liver - Volvulus
preeclampsia - Peptic ulcer - Cholecystitis
- Eclampsia - Choledocholithiasis
- HELLP Syndrome - Biliary colic
- Torsion of uterus - Renal/ ureteric
calculi
- Malignant disease

Causes of abdominal pain the 3rd trimester include-

Obstetric causes Non obstetric causes
Labour pain Medical: PUD, UTIs
Abruption Surgical: appendicitis, cholecystitis
Scar dehiscence in previous C section Gynaecological: red degeneration, twisted cyst
 True labour pain False labour pain
Increase in frequency, duration and intensity of Irregular contractions
contractions with time
Pain in lower back radiating to lower abdomen and thighs Lower abdominal pain
Associated cervical dilatation and effacement No associated cervical changes
Does not subside with enema or sedation Subsides with enema or sedation

Decreased foetal movements

Causes of decreased foetal movements include:
• Intrauterine Growth Restriction or FGR
• Post external cephalic version
• Intrauterine death
• Trauma
• Abruptio placentae
• Oligohydramnios

Dyspnoea or breathlessness in pregnancy

Causes of breathlessness in pregnancy can be physiological or pathological

Physiological: hyperventilation (progesterone causes decreased CO2 threshold)

Pathological
- Anaemia
- Respiratory causes
- Cardiac causes
- Obstetric causes like: Polyhydramnios, multiple pregnancy

mMRC grading for breathlessness

Grades Degree of breathlessness related to activities
0 Breathlessness only on strenuous exercise
1 Short of breath when hurrying on a level ground or walking up a slight hill
2 Walks slower than most people of same age, stops for breath when walking at own pace on level ground
3 Stops for breath after walking 100 yards or after a few minutes on level ground
4 Too breathless to leave the house, or breathless when dressing- undressing

NYHA classification of breathlessness

Class Description
I Uncompromised and no limitation of physical activity
II Slightly compromised with slight limitation of physical activity. The patients are comfortable at rest but
ordinary physical activity causes discomfort
III Markedly compromised with marked limitation of activity. The patients are comfortable at rest but
discomfort occurs with less than ordinary activity
IV Severely compromised with discomfort even at rest
Trimesters in pregnancy
1st- from the time of conception to 13+6 weeks of pregnancy
2nd- from the 14th week upto 28 completed weeks of gestation
3rd- from the 29th week upto delivery

Infertility
Infertility is defined as the failure of a couple to conceive within 1 or more years of regular unprotected inter
course.
It can be primary or secondary infertility.
Causes- male, female, combined

Causes of infertility in females include-

Ovarian Tubal Uterine Cervical Peritoneal
Anovulation, Corpus Pelvic infection, Congenital anomalies Cervical stenosis and Adhesions, Tubal
luteum Insufficiency, Tubal pregnancy, of Mullerian duct, scarring- LEEP, obstruction, kinking,
premature ovarian Endometriosis, Pelvic Polyps, Fibroid, Dilatation, Tubo ovarian mass
failure, Turner’s surgeries Intrauterine Amputation,
syndrome, PCOS adhesions Conization

• Ovulation induction
Drugs used include:
- Letrozole (Aromatase inhibitors)
- Clomiphene citrate
- Gonadotropin (FSH or hMG- given as IM on day 2 or 3)
They are taken for 5 days from day 3 to day 7 of cycle.

Drugs used for facilitation of induction- Dexamethasone, Metformin, Bromocriptine

Disadvantages: Ovarian hyper stimulation, Multiple pregnancy

Diagnosis of pregnancy
1st trimester
Symptoms
- Amenorrhea (D/D: anovulatory cycles)
- Nausea and vomiting
- Sudden onset bleeding (D/D: refer)
- Fatigue
- Increased micturition

Signs
I. Breast
- tenderness
- Increased vascularity causing engorged veins
- Hyperpigmentation of areola (4-6 weeks)
- Secondary areola (>8 weeks)
- Montgomery tubercles

II. Cervix/ Vagina

- Jacquemier’s/ Chadwick’s sign: bluish discolouration due to increased vascularity (D/D: PID)
- Osiander’s sign: pulsations in the greater fornix of vagina (D/D: PID, Fibroid)
- Goodell’s sign: softening of cervix like the lips of mouth

III. Uterus
- size increases: hen’s egg at 8 weeks, orange at 10 weeks, coconut size/ foetal head size at 12 weeks
( abdominal organ)
- Consistency: soft on one side harder on other indicating site of implantation
- Palmer’s sign: uterine contractions felt on bimanual examination (6-8 weeks)
- Hegar’s sign: compressibility and softening of cervical isthmus (6-12 weeks)

IV. External os
- Pin pointed (primigravida)
- Slit shaped and open (multigravida)

Investigations
I. UPT: beta HCG
II. Serum beta HCG
III. USG- TVS upto 12 weeks
- Confirmation of pregnancy
- Site of implantation
- Chorionicity
- Gestational age: CRL
- NT scan
- Any other uterine pathologies

Earliest TVS signs

- Presence of G sac: 4.5 weeks
- Yolk sac: 5 weeks
- Embryo: 5.5 weeks
- Cardiac activity: 6 weeks

Abnormal findings in TVS

- G sac> 25mm: Anembryonic sac/ Blighted ovum
- Pseudo G sac: ectopic pregnancy
- 5mm long without Cardiac activity: Missed abortion

2nd trimester
Symptoms
- Nausea and vomiting may continue
- Quickening
- Perception of foetal movements
- Braxton- Hicks contractions

Signs
- Uterine size increases (lower border of umbilicus: 22 weeks, upper border: 24 weeks)
- Palpation of foetal parts
- Foetal heart sounds

Investigations
- Anomaly scan
- Umbilical artery doppler (Preeclampsia, FGR)

3rd trimester
Symptoms
- Perception of foetal movements
- Lightning crotch> 36 weeks

Signs
- Flank fullness with fully distended abdomen
- Palpable foetal parts
- Foetal heart sounds

Investigations: Growth scan

Hyperemesis gravidarum
Nausea and vomiting in pregnancy can be simple vomiting or hyperemesis gravidarum.
In late pregnancy- it can be due to severe preeclampsia.

Causes of nausea and vomiting in pregnancy

Medical Surgical Gynaecological
Intestinal infestation Appendicitis Twisted ovarian tumour/ cyst
UTIs Peptic ulcer Red degeneration of fibroid
Hepatitis Intestinal obstruction
Diabetic ketoacidosis Cholecystitis
Pyelonephritis Pancreatitis

Hyperemesis gravidarum is defined as a severe type of vomiting in pregnancy which has deleterious effect
on the health of mother with or without incapacitation of her day- to-day activities characterised by:
- dehydration
- electrolyte imbalance
- >5% loss of pre pregnancy weight

Risk factors: 1st pregnancy, young age, low BMI, migraine, motion sickness, multiple pregnancy
Causes- due to increased beta HCG, estrogen and progesterone levels
Seen commonly in - multiple pregnancy, ectopic pregnancy, molar pregnancy

PUQE: Pregnancy Unique Quantification of Emesis- scoring for assessment of hyperemesis

Complications in mother
- Neurological
- Gastric ulcers
- Mallory Weiss syndrome
- Hepatic failure, renal failure
- Convulsions
Foetal complications: low birth weight, Preterm birth
Management: hospitalisation, iv fluids, antiemetics, prevention of
complications
Infections in pregnancy
Infections in pregnancy in general are ruled out by history of fever with rashes.
High grade fever can lead to abortion, IUD, preterm delivery
Causes- TORCH infections
T- Toxoplasmosis
O- others: Syphilis, Hepatitis B, Varicella, HIV,
R- Rubella
C- Cytomegalovirus
H- Herpes Simplex

Risks of foetal anomalies are 50%, 25% and 10% respectively if Rubella infection occurs in the 1st, 2nd and
3rd trimesters. But it is the opposite in case of CMV infection- the risks are higher in the 3rd trimester and
least in the 1st trimester.

Congenital Rubella syndrome

- Triad: Sensorineural hearing loss, congenital cataract, cardiac defects (PDA, ASD, VSD)
- Hepatosplenomegaly, osteopenia, chromosomal anomalies
- MTP is advised if active Rubella infection occurs in the 1st trimester, in a non immunised woman
- Rubella vaccine can be given to non immunised, non pregnant women- they are advised to conceive after
3 months of vaccination only (live vaccine).

Congenital Varicella syndrome

- limb hypoplasia and deformity, chorioretinal scarring, microcephaly, cutaneous scarring
- Varicella zoster immunoglobulin is given to exposed newborns within 5 days of delivery

Congenital Syphilis
- Hutchinson’s triad (late Syphilis): Hutchinson teeth (notched incisors), interstitial keratitis, sensorineural
hearing loss
- Early Syphilis: salt and pepper chorioretinopathy, congenital glaucoma, snuffles, optic neuritis, skin
rashes, low birth weight

• Radiation exposure in pregnancy

Radiation exposure >= 5 rad is teratogenic
Radiation exposure in the 1st trimester- increased risk of childhood malignancy
No woman should be exposed to radiation 10 days outside her LMP.

• Drugs in pregnancy
Teratogenic drugs include:
- Anti-epileptics: valproate (neural tube defects), phenytoin (foetal hydantoin syndrome)
- Antihypertensives: ACE inhibitors, ARBs
- Antibiotics: Tetracyclines, Chloramphenicol
- Warfarin (foetal warfarin syndrome)
- Chemotherapy drugs
- Methotrexate, lithium, mifepristone, atorvastatin

Foetal Warfarin syndrome/ Warfarin embryopathy/ Conradi syndrome

- skeletal and facial anomalies, optic atrophy, microcephaly, chondrodysplasia punctata
Drugs safe in pregnancy include-
Anti-epileptics: levetiracetam, carbamazepine
Antibiotics: penicillins, cephalosporins
Antihypertensives: labetolol, nifedipine

• Folate
Folate- periconceptional intake (from 1st trimester- till 6 months post delivery)
Dosage: 0.5mg OD oral
It is given to decrease the incidence of neural tube defects.

Folate is needed for the conversion of dihydrofolate to tetrahydrofolate, (a form which is used by the cells for
DNA replication) by the enzyme dihydrofolate reductase. Absence or deficiency of folate causes abnormal
DNA synthesis in the neural cells.

Immunisation in pregnancy
Td vaccine- protection against maternal and neonatal tetanus and diphtheria.
0.5ml of vaccine contains- Tetanus and Diphtheria toxoids
A dosage of 0.5ml is given IM in deltoid or upper outer quadrant of buttocks

1st dose of vaccine is usually given at the 3rd month visit. It should ideally be given in the 2nd trimester but
Second dose is administered 4 weeks after 1st dose or 4 weeks prior to EDD
If the duration between subsequent pregnancies is within 3 years and the mother has received 2 doses in the
last pregnancy, she can get a booster dose alone.
Alternately Tdap can also be given at 27-36 weeks of gestation. It has protection against pertussis as well.

Other vaccines that can be safely administered during pregnancy are

- Rabies inactivated
- Hepatitis A and B inactivated
- Vaccinations against Pneumococcus, Meningococcus, Haemophilus (inactivated)

Immunoglobulins for post exposure prophylaxis that can be administered

- Hepatitis A and B
- Rabies
- Varicella
- Measles
Vaccines contraindicated in pregnancy - live viral vaccines
Eg: Mumps, Measles, Varicella

Why UTIs are common in pregnancy?

Vaginal pH increases- increased alkalinity

Dilation of pelvicalyceal system (mild hydronephrosis on Urinary retention Infection
right side)
Increased vesicoureteric reflex
Urinary incontinence due to urethral hyper-mobility

UTIs can be complicated- upper UTI or uncomplicated- lower UTI and Asymptomatic bacteriuria.
Asymptomatic bacteriuria is diagnosed by > 10 to the power 5 colony forming units (CFU) on culture of
midstream clean catch urine in the absence of symptoms.
In a sterile catheter sample: >10 to the power 4 CFUs
Suprapubic aspiration sample: >10 to-the power 3 CFUs

Symptoms
Lower UTI: fever, abdominal pain, burning micturition, increased frequency and urgency
Upper UTI: loin to groin pain, renal angle tenderness, vomiting, pus in urine

Antenatal screening: urine routine microscopic examination, urine culture and sensitivity, leukocyte esterase
strips

Treatment
Personal hygiene and Antibiotics
Uncomplicated UTI: Nitrofurantoin 100mg QID x 3-5 days
Complicated UTI: Nitrofurantoin 100mg (Sustained Release) BD x 14 days
If persistent, culture specific drugs.

Investigations in 1st trimester

CBC- Hb, total counts
Blood grouping and Rh typing (ABO, Rh)
Serum TSH levels
Screening for Diabetes in pregnancy- DIPSI: 75g GTT
Urine- routine microscopy and culture
Serology: HIV, VDRL, HbSAg
USG- Dating scan, NT scan
High risk women- 1st trimester screening

Screening of Diabetes in pregnancy

Ideally, screening for Diabetes in pregnancy is done between 24-28 weeks.
Pregnancy is associated with increased insulin resistance leading to normoglycaemic woman becoming
diabetic. The hormones responsible for increased insulin resistance are human placental lactogen, oestrogen,
progesterone, prolactin and cortisol.
Significant insulin resistance happens from 24- 28 weeks of gestation.

Why screening of Diabetes is done during pregnancy?

In pregnancy, the blood glucose levels are not stable due to impaired insulin activity caused by
human placental lactogen, oestrogen, progesterone and cortisol. Thus, the insulin requirement during
pregnancy increases as pregnancy advances. There is rapid activation of lipolysis even with short period of
fasting. So keto acidosis can be precipitated during hyperemesis in early pregnancy, infection and fasting of
labor. Also vascular changes, especially retinopathy, nephropathy, coronary artery disease and neuropathy
may be worsened during pregnancy.
Also, Diabetes can lead to a lot of complications in the mother and the foetus. They include:
Maternal complications
- Abortion
- Preterm labour
- Infections
- Increased preeclampsia
- Polyhydramnios
- Diabetic retinopathy and nephropathy
- Coronary artery disease
- Prolonged labour
- Shoulder dystocia
- Postpartum haemorrhage
- Puerperal sepsis
- Lactation failure
Foetal complications
- Macrosomia
- Congenital malformations (due to teratogenic effects in the first trimester affecting organogenesis)

Major birth defects in infants of Diabetic mother

Neural Cardiovascular Renal Gastrointestinal Others
Neural tube defects ASD, VSD Renal agenesis Duodenal atresia Single umbilical
Anencephaly TGA Hydronephrosis Anorectal atresia artery
Microcephaly TOF Double ureter Omphalocoele
Sacral agenesis Coarctation of aorta PKD Tracheo oesophageal
Caudal regression syndrome Situs inversus fistula

Methods of screening of Diabetes in pregnancy

Criteria for screening of Gestational Diabetes
- IADPSG (75g GTT- diagnostic test)
- DIPSI (75g GTT- diagnostic test)
- ACOG (50g GCT- screening test, 100g GTT- diagnostic test)
- WHO (same as IADPSG)
- ADA

IADPSG- International Association of Diabetes in Pregnancy Study Groups

Based on HAPO study (Hyperglycaemia and Adverse Pregnancy Outcomes)
1st trimester- FBS, RBS or HbA1c is done to rule out overt Diabetes. If it’s negative, further screening is
needed.
- test done from 24- 28 weeks of gestation
- The patient is asked to take unrestricted carbohydrate diet before the test
- 8 hours of fasting
- Fasting blood glucose sample is taken
- If the fasting blood glucose value is more than the cut off, abandon the test
- 75 oral glucose is given in 300 ml of water, asked to take in 10- 20 min
- Postprandial values are taken at 1hr and 2hr.
- Any one value among the 3 above the recommended cut off is diagnostic of GDM
Cut off values: according to ADA criteria (can be used for diagnosis in ACOG step 2)
Fasting blood glucose: =>92 mg/dl
1hr post prandial: =>180mg/dl
2hr post prandial: =>153 mg/dl

DIPSI (Diabetes in Pregnancy Study group India) guidelines

- 2 (or 3) screening in antenatal period: once in 1st trimester, if negative, then from 24- 28 weeks and 32-34
weeks
- No fasting required, no restriction of diet
- 75g oral glucose is given in 300ml of water
- Blood glucose levels are checked after 2 hrs
Blood glucose levels 140- 199: Gestational Diabetes
Blood glucose >=200: Pre- gestational Diabetes/ overt Diabetes

If the patient vomits within 30 mins of the test- repeat testing the next day
If the patient vomits after 30 minutes of the test- continue with the same test
If patient’s first antenatal visit is >28 weeks, only 1 test needs to be done.

ACOG criteria (American College of Obstetrics and Gynaecology)

Early screening in high risk patients: 1st antenatal visit
Repeat at 24- 28 weeks of pregnancy
2 step criteria: Glucose challenge test followed by a Glucose Tolerance test
1st step: GCT/ Glucose Challenge Test
- It’s a screening test
- Done at 1st visit, if negative repeated at 24- 28 weeks
- Fasting is not required
- Irrespective of diet and fasting status, 50g of oral glucose is given
- Blood sugar levels are checked after 1hr
Cut off: >= 200 mg/dl: confirm overt Diabetes
140- 199 mg/dl: do the 2nd step (GTT)
120- 139 mg/dl: repeat GCT after 2 weeks
2nd step: 100g 3hr GTT/ Glucose Tolerance Test
- Diagnostic test, done to confirm GDM after step 1
- 8 hours (ideal) of fasting (not more than 14 hrs) and unrestricted carbohydrate diet
- Fasting blood glucose sample is taken
- 100g of oral glucose is given in water
- Post prandial 1hr, 2hr and 3hr values are taken
- Any 2 abnormal value is suggestive of GDM
- If any 1 abnormal value, repeat the test after 1-2 weeks
- If GCT is abnormal and GTT is normal, repeat GTT at 24- 28 weeks and 32- 34 weeks
Cut off : according to Carpenter and Coustan criteria (must know)
FBS: 95 mg/dl
1hr PPBS: 180 mg/dl
2hr PPBS: 155 mg/dl
3hr PPBS: 140 mg/dl
: according to National Diabetes Data Group criteria
FBS: 105 mg/dl
1hr PPBS: 190 mg/dl
2hr PPBS: 165 mg/dl
3hr PPBS: 145 mg/dl
: according to O’ Sullivan/ Mahan criteria (venous whole blood)- not used anymore
FBS: 90 mg/dl
1hr PPBS: 165 mg/dl
2hr PPBS: 145 mg/dl
3hr PPBS: 125 mg/dl

ADA criteria (American Diabetes Association)

Same as IADPSG criteria, if 75g GTT is done.
Carpenter and Couston or NDDG criteria to be followed for 100g GTT.

Govt of India- DIPSI at 1st trimester and if negative, screening at 24- 28 weeks and then 32- 34 weeks.
JIPMER- IADPSG screening at 24- 28 weeks.
Universal screening for all pregnant women is done.

Since India is termed as the Diabetic capital, screening for Diabetes in pregnancy is done at the first visit,
from 24- 28 weeks in the 2nd trimester and in the 3rd trimester.
Screening in the 1st trimester helps to identify cases of overt diabetes that are diagnosed for the first time in
pregnancy. Screening in the 3rd trimester helps to prevent diabetes related pregnancy complications and to
diagnose any late onset diabetes.
Features Pregestational diabetes Gestational diabetes mellitus
Definition Known case of diabetes prior Normoglycemic before pregnancy, becomes
to pregnancy diabetic due to increased insulin resistance
Blood glucose levels High from day 1 High from 24- 28 weeks
Free radicals Day 1 From 24-28 weeks
Congenital malformations Yes No

Advantages and disadvantages of screening methods

DIPSI advantages- no need of fasting. It serves as both screening and diagnostic test. It is more economical
and the patient does not come back for another test/ visit.
DIPSI disadvantages- the fasting glucose levels of the patient is not known. Also since no blood tests are
done before the test, the long term hyperglycaemic condition of the patient is also not known.
Disadvantages of IADPSG/ ADA/ ACOG GTTs- fasting is required, patient needs to have an additional
hospital visit in fasting state to get the test done.

Pre-gestational diabetes/ overt diabetes

A patient with symptoms of diabetes mellitus (polyuria, polydipsia, weight loss) and random plasma glucose
concentration of 200 mg/dL or more is considered overt diabetic.
According to American Diabetic Association diagnosis is positive if:
(a) the fasting plasma glucose exceeds 126 mg/dL,
(b) the 2 hours post glucose (75 gm) value exceeds 200 mg/dL
(c) HbA1C ≥ 6.5%

NICE guidelines for GDM- for UK

Anaemia in pregnancy
Anaemia in pregnancy (according to WHO): Hb concentration <11g% or a haematocrit <33%

ICMR classification of Anaemia in pregnancy

Grading Haemoglobin (g/dL)
Mild 10- 10.9
Moderate 7- 9.9
Severe <7
Very severe <4

CDC classification of Anaemia in pregnancy

Hb< 11g/dL in the 1st and 3rd trimesters
Hb< 10.5g/dL in the 2nd trimester

Causes of anaemia in pregnancy

- Physiological: due to haemodilution

What is physiological anaemia of pregnancy?

Maternal plasma volume increases by about 40–50%. RBC volume increases by 20%. There is relative fall in
the level of haemoglobin and hematocrits during pregnancy. In addition, there is marked demand of extra
iron during pregnancy especially in the second half. Thus, there always remains a physiological iron
deficiency state during pregnancy.

- Pathological
Nutritional: iron deficiency, folate deficiency, B 12 deficiency
Blood loss: Antepartum haemorrhage, worm infestation, haemorrhoids
Haemolytic Anaemia: Thalassemia, Hereditary Spherocytosis, Sickle cell anaemia, malaria
Others: Aplastic anaemia, neoplasms, CKD, TB

Iron requirements during pregnancy

1st trimester: 2mg/kg
2nd trimester: 4-6mg/kg
3rd trimester: 6-8mg/kg

Maternal complications of anaemia during pregnancy

Antenatal
- increased risk of infections, preeclampsia
- Preterm labour
- CCF
Intrapartum
- CCF
- PPH and shock
Puerperium
- CCF
- Puerperal sepsis
- Subinvolution
- Failed lactation
- Venous Thrombosis

Dating scan
Foetal viability and gestational age is determined by detecting the following structures by trans vaginal
ultrasonography.
Gestational sac and yolk sac by 5 menstrual weeks.
Foetal pole and cardiac activity — 6 weeks.
Embryonic movements by 7 weeks.

Foetal gestational age is best determined by measuring the CRL between 7 and 10 weeks (variation ± 5
days). Doppler effect of ultrasound can pick up the foetal heart rate reliably by 10th week.

NT scan
NT scan or Nuchal Translucency test is an ultrasound (optional) performed in the 1st trimester.
It identifies the risk of congenital anomalies. It’s a part of first trimester screening.
It is used to screen aneuploidies: trisomy 21 (Down’s), 13 (Patau’s) and 18 (Edward’s).
It is done between 11- 13+6 weeks.
A nuchal fold thickness of <3mm is normal and does not indicate anomalies.
Other structures seen in an NT scan- nasal bone, Tricuspid Regurgitation, ductus Venosus flow, PDA.

What is 1st trimester screening?

It is not a mandatory investigation in 1st trimester but it can be carried out in high risk conditions like
pregnancy post infertility, elderly primigravida, family history of congenital anomalies, etc.
It includes 3 components:
- beta HCG
- PAPP- A
- Nuchal Translucency (USG): appearance of fluid filled space below skin, under neck

If Nuchal Translucency >3mm: Trisomy 21>18>13, Turner’s syndrome, cardiac defects in the foetus
The invasive test done in 1st trimester is Chorionic Villi Sampling (CVS).
beta HCG PAPP- A
Down’s syndrome increased decreased
Edward syndrome decreased decreased

Aspirin in pregnancy
Given in cases where there is high risk of developing preeclampsia like:
- Previous preeclampsia
- Multiple pregnancy
- Maternal age >40 years
- Chronic hypertension
- Obesity
- Diabetes in mother
- Coagulopathy in mother
- Autoimmune diseases like SLE, Rheumatoid Arthritis, Sjögren’s syndrome

Screening for preeclampsia (not done on a regular basis)

Screening for early onset preeclampsia in high risk patients is an optional test that is performed alongside 1st
trimester screening (11 to 13+6 weeks).
Screening includes:
- Serum PAPP- A
- PIGF (Placental Growth Factor)
- Maternal BP, weight, family history and Routine USG

If the woman is high risk for developing preeclampsia, she is prophylactically started on low dose Aspirin
(75- 150 mg daily) beginning early in the pregnancy (< 12 weeks or utmost < 16 weeks).

Diagnosis of Cardiac disease in pregnancy

All pregnant women should undergo cardiac examination at the very first antenatal visit. In case of any
suspected symptoms and signs of cardiac disease, they should undergo investigations-
- ECG
- ECHO cardiogram
Why cardiac diseases have to be ruled out in pregnancy?
Refer: physiological changes in the cardiovascular system during pregnancy
Increase in cardiac output during pregnancy and precipitate pulmonary oedema and congestive heart failure.
There is high risk of CCF from 28- 30 weeks, labour and immediate postpartum period.
Also, there’s increased requirement of anticoagulants in women with prosthetic valves.

Risk assessment in pregnancy complicated by heart disease

- CARPREG II Risk score
- WHO modified classification of maternal cardiovascular risk

Risk category Conditions

I - Mild Pulmonary stenosis, PDA, MVP
- Repaired ASD, VSD
II - Unoperated ASD, VSD
- Repaired TOF
- Arrhythmias
II/ III - Mild LV dysfunction
- HCM
- Marfan without dilatation of aorta
- Repaired coarctation of aorta
III - Mechanical valve
- Fontan circulation
- Unrepaired cyanotic heart disease
- Marfan with 40- 45mm aortic dilatation
- Bicuspid aortic valve with 45- 50mm aortic
dilatation
IV - PAH
- Severe LV dysfunction
- Previous peripartum cardiomyopathy
- Severe MS, AS
- Marfan with >45mm aortic dilatation
- Bicuspid aortic valve with >50mm aortic dilatation
- Severe coarctation of aorta

• Quickening
Perception of foetal movements for the 1st time in pregnancy.
Primigravida: 18-20 weeks
Multigravida: 16-18 weeks
It assures a living foetus at that point of time.

In case of irregular cycles or unknown LMP-

In primigravida, EDD= Quickening + 20 weeks
In multigravida, EDD= Quickening + 22 weeks

• Iron
Iron supplements are taken as a prophylaxis to combat the increased need during pregnancy as well as to
compensate the haemodilution.
Iron supplements are started from 14 weeks (2nd trimester) when the nausea and vomiting in pregnancy
subsides.
According to Iron Plus Initiative, recommended prophylaxis is 100mg of elemental iron daily during
pregnancy.
Anaemia Mukt Bharat- current guidelines- one tablet each of iron and folic acid containing 60mg of
elemental iron- starting from 2nd trimester and continued upto 6 months post delivery.
180 days before delivery and 180 days after delivery.
Low dose iron- containing 30mg elemental iron- can also be given starting from 1st trimester onwards to
minimise side effects of iron.

• Calcium
Calcium supplements are also given from the 2nd trimester and is continued 6 months after pregnancy.
The dosage of calcium is daily 1g.
In cases of patients with previous history of gestational hypertension or preeclampsia, and if the patient has
calcium deficiency, she is started on 2g (higher dose of calcium) of calcium daily.

• Antepartum haemorrhage
Refers to bleeding from or into the genital tract after 28 weeks of gestation but before the delivery of the
baby.
Antepartum haemorrhage is a cause of bleeding p/v in 3rd trimester.
It includes-
- Placenta previa: placenta is attached completely or partially in the lower uterine segment. The patient
presents with bleeding when the lower uterine segment is formed.
- Abruption placentae: premature separation of a normally located placenta
- Vasa previa
- Cervical pathology

Placenta previa vs Abruptio placentae

Placenta previa Abruptio placentae
Bleeding >= 28 weeks >= 28 weeks
Pain in abdomen Painless (except during preterm labour) Painful (due to thromboplastin)
Blood colour Bright red Dark red
Causes Absent Trauma, high BP
Recurrent bleeding Present Absent
Warning haemorrhage Present followed by excessive bleeding Absent
Blood pressure (before bleeding) Normal High/ normal
Uterus Relaxed, soft, non tender Tense, rigid, tender
Placental detachment Does not occur Occurs
FHS Easily heard Not heard
Foetal parts Easily palpable Non palpable
Fundal height Same as period of gestation (unless More than/ same as the period of
associated with any other conditions) gestation
Malpresentations Common (transverse lie, breech) Uncommon

Abruptio placentae vs Physiological show

 Abruptio placentae Physiological show
Contractions Sustained, without relaxation periods in Intermittent contractions, with periods of relaxation
between in between
Pain Constant, does not progress Pain increases consistently
Bleeding Frank dark red blood, excessive in amount Bright red blood mixed with mucus, small amounts
Uterus Consistently tense, rigid and tender Tense and rigid during contractions only

Hypertensive disorders in pregnancy

Hypertension is one of the common medical complications of pregnancy and contributes significantly to
maternal and perinatal morbidity and mortality.
Hypertension is defined as systolic BP>140 mm of Hg or diastolic BP> 90mm of Hg or both, measured at 2
occasions, 4 hours apart. PIH or pregnancy induced hypertension is an old term and is replaced by
Hypertensive disorders in pregnancy.

Hypertensive disorders in pregnancy include:

- Gestational hypertension is defined as BP recordings of more than 140/90 mm Hg (systolic, diastolic or
both) on 2 occasions, separated 4 hours apart, without proteinuria and end organ failure, diagnosed only
after 20 weeks of gestation and which comes back to normal within 12 weeks of postpartum period, in a
previously normotensive woman.

Other criteria for diagnosis:

- Mean arterial pressure (MAP)>= 105mm of Hg
- Rise in SBP>= 30mm of Hg or DBP>= 15mm of Hg from baseline (used when the patient’s baseline BP is
low)
- Rise in MAP by 20mm of Hg from baseline

- Preeclampsia is defined as BP recordings of more than 140/90 mm Hg on 2 occasions, separated 4 hours

apart, with proteinuria (defined as urine protein creatinine ratio>0.3 (or) dipstick>=1+in at least 2 samples
tested 4 hours apart (or) 24 hour urine protein>=300mg/day, in the absence of urinary tract infection),
diagnosed after 20 weeks of gestation in a previously normotensive and nonproteinuric woman.
or
- Preeclampsia is defined as BP recordings of more than 140/90 mm Hg on 2 occasions, separated 4 hours
apart, without proteinuria, with signs of cerebral oedema, convulsions, pulmonary oedema, sub-capsular
haematoma of liver, renal failure, hypertensive retinopathy or with components of HELLP syndrome
(signs of end organ failure).
Preeclampsia can be with severe features or without severe features.

Severe features: any one or more of the following abnormalities is considered severe
- Pulmonary oedema
- Elevated liver enzymes: AST, ALT (twice the baseline)
- Low platelets <1 lakh/mm3
- Systolic BP > 160mm of Hg (or) diastolic BP> 110mm of Hg on 2 occasions, 4 hours apart
- Creatinine values double the baseline value or >1.1
- CNS symptoms: blurred vision, photopsia, severe headache, altered mental status, stroke symptoms

- Eclampsia is defined as new onset generalised tonic- clonic seizures (GTCS) in a pregnant woman, not
attributed to any other cause.
- Chronic hypertension in pregnancy is defined as the presence of hypertension (BP >140/ 90 mm of Hg
(or) cardiac hypertrophy in ECG or chest X-ray) of any cause (Essential Hypertension, CKD, Coarctation
of Aorta, DM, etc) diagnosed before 20 weeks of gestation and which persists beyond 12 weeks after
delivery.
Exception to this: molar pregnancy and multiple pregnancy- where high BP recordings or features of
preeclampsia may set in before 20 weeks. So it is considered as Gestational Hypertension and not Chronic
Hypertension.

- Superimposed preeclampsia or eclampsia is defined as occurrence of new onset of proteinuria or end

organ dysfunction in women with chronic hypertension.
Criteria for diagnosis:
- New onset of proteinuria> 500mg/ day in 24 hour urine protein or end organ dysfunction after 20 weeks of
gestation in a woman with chronic hypertension
- Aggravation of hypertension (raise in BP values after 20 weeks)
- Development of HELLP syndrome
- Development of symptoms of preeclampsia

HELLP Syndrome
- Haemolytic Anaemia (Schistocytes in peripheral blood smear, elevated LDH levels >300 U/L)
- Elevated liver enzymes (twice the baseline)
- Low platelets (< 1 lakh/mm3)

Complications of hypertensive disorders

Immediate complications
- Eclampsia
- Accidental haemorrhage
- Blindness
- Preterm labour
- HELLP Syndrome
- Cerebral haemorrhage
- Acute Respiratory Distress Syndrome
- Postpartum haemorrhage
- Shock
- Sepsis
- Intrauterine death
- Perinatal asphyxia
Remote complications
- Residual hypertension
- Recurrent preeclampsia
- Chronic renal disease

Foetal Echocardiography
Indications to do foetal echocardiography:
- Foetal cardiac anomalies suspected in routine antenatal ultrasound
- Family history (first degree) of congenital heart disease (eg: maternal)
- Abnormal foetal heart rate or rhythm
- Any abnormalities in other organ systems
- Twin- Twin Transfusion Syndrome
- Overt Diabetes in mother
- Sjögren’s syndrome
- Systemic lupus erythematosus
- Exposure to teratogenic drugs like anti- epileptics in early pregnancy
- Hydrops in foetus
- Nuchal Translucency > 3mm in first trimester
- Any chromosomal abnormalities associated with congenital heart disease (eg: trisomy 21)

Foetal echocardiography is usually done from 20- 24 weeks.

What is anomaly scan?

Anomaly scan is a 2nd trimester scan done between 16- 20 weeks of gestation to rule out any gross or
chromosomal anomalies in the foetus.
Only anomaly detected in the 1st trimester USG- Anencephaly (absolute indication for abortion)
- absence of foetal skull and protruding eyeballs (frog’s eye appearance)

Anomaly scan is a trans abdominal scan and looks in detail at the baby's bones, heart, brain, spinal cord,
face, kidneys and abdomen. Conditions diagnosed can be neural tube defects, cleft lip, diaphragmatic hernia,
exomphalos, gastroschisis, gross cardiac anomalies, renal agenesis, skeletal dysplasia, etc.

2nd trimester screening

It is an optional screening done in case of elderly primigravida or whenever there is risk of chromosomal
anomalies (familial) or the 1st trimester screening is abnormal.
It includes-
- Triple screening/ Kettering test/ Bart’s test: beta HCG, MSAFP (Maternal Serum Alpha FetoProtein),
Estriol
- Quadruple screening: beta HCG, MSAFP, Estriol, Inhibin A

MSAFP: used to rule out open neural tube defects.

Trisomy with maximum viability: 21 (Down’s syndrome)
Most lethal trisomy: 16
Soft tissue markers - used for trisomies 21, 16, 18.

Soft Tissue markers: positive if any 2 are present

- Nuchal skin fold thickness: >=6mm
- Absent nasal bone
- Short humerus
- Short femur
- Simean crease
- Sandal gap
- Echogenic cardiac focus (calcifications in heart)
- Echogenic bowel
- Pelvicalyceal dilatation
- Choroid plexus cyst
Anomaly scan if abnormal (screening is positive for any anomaly) the patient has to go for invasive tests like
Amniocentesis and then do foetal karyotyping to rule out chromosomal anomalies.

• Indications of steroids in pregnancy

Maternal administration of corticosteroids is advocated where the pregnancy< 34 weeks.
This helps in foetal lung maturation and reduces the incidence of Respiratory Distress Syndrome,
Intraventricular Haemorrhage, Necrotising Enterocolitis, Patent Ductus Arteriosus.
Indications in various maternal conditions
- Severe preeclampsia and eclampsia
- Cholestasis
- DM
- Antepartum haemorrhage
- FGR, multiple pregnancy
Complications of antenatal steroids: flaring of any infection, insulin dose adjustment in Diabetic, transient
increase in WBC counts for 48 hours, transient reduction in foetal movements and breathing.
Dosage: Betamethasone 12mg IM 2 doses in 24 hrs (or)
Dexamethasone 6mg IM every 12 hours- 4 doses
Rescue therapy of corticosteroid should be given before 34 weeks, if the last dose of steroids given was more
than 2 weeks earlier.
In JIPMER, Dexamethasone is given as the prescribed formulation of Betamethasone (Betamethasone Acetyl
Phosphate) is not available.

• Inter-pregnancy interval
Ideally, inter- pregnancy interval should be 2 years.
For TOLAC, the interval should be at least 18 months (outside- 24 months)

• Weight gain in pregnancy

Weight gain during the course of pregnancy for a single foetus: 10- 12 kg

Pregnancy weight gain recommendations in a singleton pregnancy according to BMI (pre pregnancy)
Category Pre pregnancy BMI Total weight gain
Underweight <18.5 14- 16 kg
Normal weight 18.5- 22.9 10- 12 kg
Overweight 23- 29.9 7- 10 kg
Obese >=30 5- 9 kg
Rapid gain in weight: >0.5 kg in a week or >2 kg in a month- can be early manifestation of preeclampsia
Stationary or falling weight: IUGR, IUDs

Weight gain recommendations in a twin pregnancy according to American Institute of Medicine with respect
to pre pregnancy BMI (refer)
Category Pre pregnancy BMI Total weight gain
Normal weight 18.5- 22.9 16- 24 kg
Overweight 23- 29.9 14- 22 kg
Obese >=30 11- 19 kg

• Absolute signs of pregnancy

- Palpation of foetal parts
- Palpation of foetal movements
- Auscultation of foetal heart sounds
- USG confirmation
• Differential diagnosis of pregnancy
- Distended bladder
- Ovarian mass
- Fibroid
- Pyometra/ Haematometra
- Pseudocyesis

• Warning signs of pregnancy

- Pain abdomen
- Bleeding p/v
- Leaking p/v
- Symptoms of preeclampsia

Foetal surveillance in early pregnancy

It is mainly aimed to detect congenital abnormalities in the foetus.
It includes- biochemical, biophysical and cytogenetic/prenatal screening methods.

Biophysical methods
Ultrasound and NT scan in the first trimester and Anomaly scan in the second trimester.
Noninvasive screening for chromosomal anomaly (trisomy 21, 18, 13) should be a routine to all pregnant
women, irrespective of their age.

Cytogenetic study/ Prenatal screening methods

These tests are aimed at detection and identification of couples who are at high risk for having a child with
an inherited (chromosomal or genetic) disorder. Women who screen positive should be offered foetal
karyotyping for confirmation.

Risk factors for prenatal genetic screening

Maternal risk factors
- Maternal age >35 years
- Family history of neural tube defects
- Previous baby with neural tube defect or chromosomal anomaly
- Parents carriers of sex linked or autosomal traits
- History of recurrent pregnancy loss
Prenatal risk factors
- Oligohydramnios/ Polyhydramnios
- Severe symmetrical IUGR
- Abnormal USG- structural anomalies/ soft tissue markers
- Uncontrolled DM in periconceptional period
- Teratogenic exposure (TORCH, drugs, radiation)

Procedures for early detection of foetal abnormalities

- 1st trimester screening/ Integrated test
- 2nd trimester screening- triple or quadruple tests
- Chorionic villi sampling
- Amniocentesis
- Cordocentesis or Percutaneous Umbilical Blood Sampling
- High resolution USG
- Foetoscopy
These should be followed by Karyotyping studies.

Noninvasive methods of prenatal testing from maternal plasma/blood

Foetal DNA comes in the maternal circulation from the placenta and can be detected in maternal plasma and
whole blood from the first trimester onward. Cell-free foetal DNA (cff-DNA) is a reliable source for prenatal
diagnosis.The test is generally done from 10 weeks of pregnancy.
Detection rates for foetal trisomy 13, trisomy 18 and trisomy 21 are greater than 98%. However, a woman
with a positive test result should be referred for genetic counselling and should be offered invasive prenatal
diagnosis for confirmation of test results.
Conditions that can be diagnosed with cff- DNA
- Foetal Rh typing
- Single gene disorders: Marfan syndrome, Cystic Fibrosis
- Trisomy 21

Antepartum Foetal Surveillance

Antenatal assessment of foetal well being done in the later phase of pregnancy to prevent foetal death and to
avoid unnecessary interventions.
Methods- can be clinical, biochemical, biophysical

Clinical methods
1. Maternal weight gain
2. Maternal BP recordings
3. Assessment of size of uterus and fundal height
- symphysis fundal height is measured
- It is plotted on a chart for gestational age and the measured height is compared with the expected one
(provided that the correct LMP of the woman is known)
- If the measurement falls below the 10th centile, FGR is suspected
4. Clinical assessment of liquor
5. Documentation of the girth of abdomen

Biochemical methods
Foetal lung maturity (lecithin:sphingomyelin ratio >2)

Biophysical methods
1. Foetal movement count
2. USG
3. Cardiotocography
4. NST
5. BPP
6. Doppler ultrasound
7. Vibroacoustic stimulation test
8. Contraction stress test
9. Amniotic fluid volume

Foetal movement count

Cardiff “count 10” formula: The patient counts foetal movements starting at 9 am. The counting comes to an
end as soon as 10 movements are perceived. She is instructed to report the physician if—(i) less than 10
movements occur during 12 hours on 2 successive days
 (ii) no movement is perceived even after 12 hours in a single day.

Daily foetal movement count (DFMC): Three counts each in 1 hour duration (morning, noon and evening-
usually post meal) are recommended. The total counts multiplied by four gives daily (12 hour) foetal
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 foetal compromise.
The count should be performed daily starting at 28 weeks of pregnancy.
Maternal perception of foetal movements may be reduced with foetal sleep (quiet), foetal anomalies (CNS),
anterior placenta, hydramnios, obesity, drugs (narcotics), chronic smoking and hypoxia.
Maternal hypoglycaemia is associated with increased foetal movements.

Ultrasonography (USG)
In early pregnancy, dating scan (>6 weeks), NT scan (11-14 weeks) and Anomaly scan (16- 20 weeks).
From 3rd trimester, biometry can be done for growth scans.
Parameters assessed- head circumference, abdominal circumference, biparietal diameter, femoral length.

Foetal Cardiotocography (CTG)

After 32 weeks
- normal baseline heart rate 110- 160 bpm
- Variability: 5-25 bpm
- 2 or more acceleration per 20 minutes
- With no deceleration (or early deceleration of very short period)

Non- Stress Test (NST)

A continuous electronic monitoring of the foetal heart rate along with recording of foetal movements
(cardiotocography) is undertaken. There is an observed association of FHR acceleration with foetal
movements, which when present, indicates a healthy foetus.
Testing should be started after 30 weeks and frequency should be twice weekly.
Interpretation of NST
Reactive (Reassuring)—When two or more accelerations of more than 15 beats per minute above the
baseline and longer than 15 seconds in duration are present in a 20 minute observation
Non-reactive (Non-reassuring)—Absence of any foetal reactivity

Biophysical Profile (BPP)

Indications—Non-reactive NST, high-risk pregnancy.

Test frequency weekly after a normal NST, and twice weekly after an abnormal test.
Parameters Minimal normal criteria Score
NST Reactive 2
Foetal breathing movements 1 or more episode lasting for more than 30 seconds 2
Gross body movements 3 or more discrete body/ limb movements 2
Foetal muscle tone 1 or more episode of active extension with flexion, opening and 2
closing of hand
Amniotic fluid 1 or more pockets measuring 2cm in 2 perpendicular planes 2

BPP scoring, interpretation and management

 BPP score Interpretation Management
8- 10 Normal less risk of foetal asphyxia Repeat testing at weekly intervals
6 Suspect chronic asphyxia Deliver if 36 weeks or more
If L/S ratio<2, repeat in 4-6 hours
4 Suspect chronic asphyxia Deliver if 36 weeks or more, if <32 weeks, repeat in 4-6
hours
0-2 Strongly suspect asphyxia Test for 120 minutes, If score persistently 4 or less, deliver
regardless of gestational age

Modified BPP- includes NST and AFI alone.

NST is indicative of any acute events affecting foetal well being while AFI indicates chronic causes.

Doppler ultrasound
It can be arterial or venous doppler studies.
Arterial Doppler waveforms are helpful to assess the vascular resistance.
The arterial Doppler waveform is used to measure the peak systolic (S), peak diastolic (D) and mean (M)
volumes. From these values S/D ratio,
pulsatility index (PI) [PI = (S–D)/M]
resistance index (RI) [RI = (S–D)/S] are calculated.
In a normal pregnancy the S/D ratio, PI and RI decreases as the gestational age advances.
Increased Doppler indices means that there is increased vascular flow resistance.
Higher values greater than 2 standard deviations above the gestational age mean indicate reduced diastolic
velocities and increased placental vascular resistance. These features are at increased risk for adverse
pregnancy outcomes.
Arterial Dopplers include- Umbilical artery and Middle Cerebral artery
Abnormal umbilical artery waveforms- Reduced, Absent or Reversed end- diastolic flow

Venous Doppler parameters provide information about cardiac function (cardiac compliance, contractility
and after-load). Abnormal cardiac function is indicated by pulsatile flow in the venous doppler whereas the
normal flow is monophasic.
Venous Dopplers include- Umbilical vein and Ductus Venosus.

Vessel Change in Doppler Inference

Umbilical artery Reduced/ absent/ reversed end diastolic flow IUGR (placental insufficiency)
Preeclampsia
Middle cerebral artery Decreased S/D, pulsatality index (increased Brain sparing in response to hypoxia
D) (dilation of cerebral vessels)
Ductus Venosus Increased indices Foetal acidemia
Umbilical vein Increased indices, pulsatile flow Decreased cardiac function, foetal
acidemia

Vibroacoustic stimulation test is used to change the foetal sleep state from quiet (non-REM) to active (REM)
sleep. A reactive NST after VAS indicates a reactive foetus. The procedure is harmless.
Contraction stress test (CST) is based to observe the response of the foetus at risk for uteroplacental
insufficiency in relation to uterine contractions.

Amniotic fluid volume

Amniotic fluid volume is primarily dependent upon the foetal urine output, pulmonary fluid production and
foetal swallowing.
Normal amniotic fluid volume: 200ml- 1.5 L at term gestation (refer)
Volume <200ml at term- Oligohydramnios
Volume >2L (refer) at term- Polyhydramnios

Amniotic fluid index (AFI) is the sum of vertical pockets from four quadrants (divided by linea nigra and
horizontal line through umbilicus) of uterine cavity.
Normal AFI: 5-25 cm
AFI <5 indicates Oligohydramnios
AFI>25 indicates Polyhydramnios

Single deep vertical pocket- cord free deepest vertical pocket is measured
It is usually done in twin pregnancy.
Normal SDVP: 2-8 cm

• Degrees of consanguinity
First degree (incest) Brother- sister/ parent- child
Second degree Uncle- niece/ aunt- nephew
Third degree First cousins (half uncle- neice/ half aunt- nephew)
It is important in case of multiple pregnancies, congenital anomalies that run in the families

• Preterm vs Term vs Post term

Preterm: pregnancy after viability but before the completion of 37 weeks
(Extreme preterm: <28 weeks
Very preterm: 28 completed weeks to 31+6 weeks
Moderate preterm: 32 completed weeks to 33+6 weeks
Late preterm: 34 completed weeks to 36+6 weeks)

Term: period of gestation from 37 completed weeks to 41+6 weeks

Post term: any period of gestation continuing beyond 42 completed weeks

• Post term vs Post date

Date or EDD: usually corresponds to 40 weeks of gestation
Post date: any pregnancy continuing beyond EDD to 41+6 weeks
Post term: any period of gestation continuing beyond 42 completed weeks

• Contraceptives post pregnancy

IUCDs can be inserted- CuT
Tubectomy can be done
OCPs are never given.

Abortion
Abortion is the expulsion or extraction from mother of an embryo or foetus when it is not capable of
independent survival.
In India, it’s 28 weeks and less than 1 kg (JIPMER- 26 weeks/ ESHRE guidelines: 24 weeks)
Types
Abortion in general can be of 2 types:
A. Spontaneous- isolated spontaneous abortions and recurrent pregnancy loss
B. Induced
Causes of abortion include-
- genetic
- Immunologic
- Endocrine and metabolic
- Thromboplilias
- Anatomic causes: uterine anomalies
- Infections
- Environmental causes
- Unexplained

Isolated abortions can happen in 1st or 2nd trimesters and the most common cause is chromosomal
anomalies (aneuploidies) followed by uterine anomalies (fibroids, adhesions, septae, cervical incompetence),
traumas and infections.

Recurrent pregnancy loss is >=3 pregnancy losses at <20 weeks of gestation. Investigations to analyse the
cause has to be started at >=2 pregnancy losses.
Causes for recurrent pregnancy loss include-
- Endocrinopathies: hypothyroidism, uncontrolled DM, PCOS
- Uterine causes: cervical incompetence, uterine malformations, fibroids, Asherman’s syndrome
- Immunological causes: APLA
- Chromosomal anomalies

Types of spontaneous abortion

Threatened: It is a clinical entity where the process of miscarriage has started but has not progressed to a
state from which recovery is impossible.
Inevitable: It is the clinical type of abortion where the changes have progressed to a state from where
continuation of pregnancy is impossible.
Incomplete: When the entire products of conception are not expelled, instead a part of it is left inside the
uterine cavity.
Complete: When the products of conception are expelled en masse
Missed: When the foetus is dead and retained inside the uterus for a variable period (early foetal demise).

Any abortion associated with clinical evidences of infection of the uterus and its contents is called septic
abortion.
Abortion is usually considered septic when there are:
(1) rise of temperature of at least 100.4°F (38°C) for 24 hours or more
(2) offensive or purulent vaginal discharge
(3) other evidences of pelvic infection such as lower abdominal pain and tenderness.

Abortion type Clinical features Abdomen Speculum USG

Threatened Pain abdomen, bleeding FH= POG Spotting+, cervical os closed Cardiac activity good
p/v
Inevitable Pain abdomen, bleeding FH~ POG Bleeding +, os open CA +
p/v
 Abortion type Clinical features Abdomen Speculum USG
Incomplete Pain abdomen, bleeding FH< POG Bleeding +, os open Retained products of
p/v conception
Complete Pain subsided, no or Normal Bleeding-, os closed Uterine cavity empty
minimal bleeding uterus
Missed No symptoms FH< POG Blood stained discharge, os CA -
closed

Induced abortion
According to the MTP act 1971 (amendment 2021)
- Only female’s consent needed if >=18 years
- If female <18 years/ or mentally ill: Guardian’s consent
- Has to be done in a hospital setup or a training institute approved by the Government for providing safe
MTPs
- Qualification for doing MTP:
Upto 12 weeks: any RMP who has assisted 25 MTPs of which at least 5 MTPs have been done
independently in a hospital or training institute approved by Government for this purpose.
12 -20 weeks: any RMP who has a PG degree or diploma in Obs & Gynae, has completed 6 months of house
job in the dept of OBG or has at least 1 year of practice of OBG in a hospital with all facilities.

Indications for doing MTP

Upto 20 weeks
- To save the life of mother
- Foetus has some lethal congenital anomalies
- Pregnancy is a result of rape or incest
- Mentally unstable female
- Contraceptive failure in married couple
- Minor female
20- 24 weeks
- Mentally unstable female, differently abled women
- Minor female
- Pregnancy as a result of rape or incest
>24 weeks
- Continuation of pregnancy is potential risk to maternal health
- Lethal foetal anomalies and malformations

Changes in the 2022 amendment

- MTP can be done upto 24 weeks (indications mentioned above)
- MTP can be done upto 20 weeks for contraceptive failure
- Till 20 weeks only 1 doctor’s opinion needed
- From 20- 24 weeks : 2 doctors’ opinion needed
- In case of foetal anomalies any time MTP can be done (>24 weeks)
- For MTP >24 weeks, severity of the condition is decided by a Medical Board consisting of a
Gynaecologist, Paediatrician, Radiologist and a person assigned by the state.

Methods of MTP in 1st trimester

Medical methods
- Can be done upto 7 weeks or 49 days
- Done as an outpatient procedure
- Day 1: tablet Mifepristone 200mg orally
- Day 3: tablet Mifepristone 400microg oral/ buccal/ per vaginal/ sublingual/ per rectal
- Day 15: to ensure the procedure is complete
- USG is not needed in any step

Surgical methods
1. Suction and evacuation
2. Manual vacuum aspiration (using MVA syringe, in rural areas as an alternative to suction and
evacuation)

Steps of suction and evacuation

• Anaesthesia
• Oxytocin 20 units in 500ml saline
• Patient in lithotomic position
• Per speculum examination using Sim’s speculum
• Cervical dilatation using Hegar’s dilator’s corresponding to size of uterus
• Suction cannula is chosen (same as the size of uterus) and inserted just above internal os with continuous
rotatory motion
• One hand is placed over the fundus and the reduction in size of uterus can be appreciated
• At the end point of suction there would be gripping sensation of cannula, air bubbles in the cannula
• After suction is completed, gentle curettage is done with blunt curette

In case of molar pregnancy, sharp curettage is done along with Histopathological examination (gold standard
investigation)

In case of dilatation and evacuation (2nd trimester surgical abortion), after the dilatation of cervix, abortion is
carried out by sponge holding forceps/ ovum forceps and is followed by blunt curettage.

MTP in 2nd trimester

Medical methods
- Prostaglandins
PG E1: Misoprostol 200- 800microg
Most commonly used protocol: 400 micrograms tablets per vaginum x 4 hourly

Other PGs- Carboprost (PGF2 alpha)

- Dinoprostone (PGE2)
- Oxytocin
- Extramniotic ethacridine
- Intramniotic saline

Surgical methods
- Dilatation and evacuation

Still birth
All foetal deaths weighing more than 500g during the antepartum period (more than 28 weeks) or
Intrapartum period.

Causes of stillbirth
Maternal
• Hypertensive disorders in pregnancy
• Diabetes in pregnancy
• Maternal infections (malaria, hepatitis, influenza, toxoplasma, syphilis)
• Hyperpyrexia (temp > 39.4°C)
• Antiphospholipid syndromes (APS)
• Thrombophilias: Factor V Leiden, protein C, protein S-deficiency, hyperhomocysteinemia
• Abnormal labor (prolonged or obstructed labor, ruptured uterus)
• Post-term pregnancy
• Systemic lupus erythematosus
Foetal
• Chromosomal abnormalities
• Major structural anomalies
• Infections
• Rh-incompatibility
• Growth restriction
Placental
• Antepartum haemorrhage
• Cord accident (prolapse, true knot, cord round the neck)
• Twin transfusion syndrome (TTTS)
• Placental insufficiency
Iatrogenic
• External cephalic version
• Drugs (eg: quinine)

Clinical features
Symptoms—Absence of foetal movements which were previously noted by the patient.
Signs: Retrogression of the positive breast changes that occur during pregnancy is evident after variable
period following death of the foetus.

Per abdomen
• Gradual retrogression of the fundal height and it becomes smaller than the period of gestation.
• Uterine tone is diminished and the uterus feels flaccid.
• Foetal movements are not felt during palpation.
• Foetal heart sound is absent. Use of Doppler ultrasound is better than the stethoscope.
• Cardiotocography (CTG): Flat trace
• Egg-shell crackling feel of the foetal head is a late feature.

• Diet modifications in pregnancy

In any normal pregnancy, additional 350 kcal/ day is needed.

Protein requirements
Additional 9.5g/ day in 2nd trimester
22g/ day in 3rd trimester

Dietary requirements of women with GDM

BMI status Calorie requirements (kcal/day)
Underweight 35- 40
Normal weight 30- 35
Overweight 25- 30
• Short stature
Maternal height <=145 cm
Increased incidence of contracted pelvis and CPD

• Physiological changes in pregnancy

Skin changes
- Striae gravidarum
- Linea nigra (due to MSH)
- Cholasma
Genitals
- Vulva: hypertrophy, striae
- Labia: hypertrophy, hyperpigmentation
- Vagina: bluish, acidic pH
- Uterus: hypertrophy and hyperplasia
(Normal: 60g/ 7cm/ 10-15 ml—— — pregnant uterus: 1kg/ 35cm/ 1l)

Blood
- Volume: increases by 30-40%
- Plasma volume: increases by 30-40%
- Red cells: increases by 20-30%
- Hb: increases by 18-20% (disproportionate to volume increase — physiological anaemia)
- Leukocytosis
- Proteins increase, globulins decrease
- Fibrinogen: 300- 600microg
- Clotting factors: increase except 11 and 13

CVS
- Apex: upwards and outward (due to diaphragm)
- Systolic murmur in hyper dynamic circulation
- S3
- Mammary soufflé
- Cardiac output: increase by 50%
- Diastolic BP: decrease by 10-15mm Hg

Respiratory system
- Diaphragm moves up
- Widening of subcostal angle upto 107 degrees
- Transverse diameter increases
These lead to physiological hyperventilation causing increased tidal volume and minute volume by 40%

Carbohydrate metabolism
- anabolic state
- Insulin increases due to hypertrophy and hyperplasia of beta cells of pancreas
- Insulin resistance increases
- Insulin is opposed by HPL
These lead to diabetogenic state

Lipids: HDL increases by 15%

Protein metabolism
- positive nitrogenous state
- Amino acids to urea conversion is suppressed causing decreased urea, creatinine, uric acid levels

Renal system
- size of kidney increase upto 1cm due to pelvicalyceal dilatation
- Ureteric atonicity
- Physiological hydroureter more on right side
- Bladder oedematous
- Asymptomatic bacteriuria
- Physiological glycosuria

GIT
- gum hyperplasia
- Sphincteric relaxation causing regurgitation
- Constipation due to reduced peristalsis
Liver: ALP increases

Breast
- engorgement
- Enlargement upto 1kg

• Hypothyroidism in pregnancy
Associated with increased risk of foetal loss.
Complications of hypothyroidism in pregnancy
- Preeclampsia
- Placental abruption
- Low birth weight
- Foetal loss
- Intellectually underdeveloped child

Treatment: levothyroxine: 2-2.4 micrograms/kg/day

: serum TSH tested every 4-6 weeks
There’s increased demand for thyroid hormones from second trimester. Most of the patients undergo an
increase in dosage in the beginning of 2nd trimester, if the TSH levels are further increased.

• Hyperthyroidism in pregnancy
Autoimmune hyperthyroidism (Graves’ disease) due to thyroid stimulating antibodies is the commonest
cause. Other causes are : Nodular thyroid disease, sub-acute thyroiditis, hyperemesis gravidarum and
trophoblastic disease.
Complications of hyperthyroidism in pregnancy
- Miscarriage
- Preterm delivery
- Preeclampsia
- Congestive Heart Failure
- Abruptio placentae
- Thyroid storm
- FGR
- Stillbirth
- Prematurity

Treatment: anti- thyroid drugs

Carbimazole is given orally with a daily dose of 10–40 mg and maintained at this dose until the
patient becomes euthyroid. Then it is progressively reduced to a maintenance of between 5
mg and 15 mg daily.
Propylthiouracil is given at a daily dose of 300–450 mg and continued till the patient becomes
euthyroid—the maintenance dose being 50 and 150 mg daily.

• Abnormal spine and gait

Can be associated with pelvis abnormalities
Contracted pelvis, CPD

• BP monitoring
Ideal position of patient- semi recumbent position with 15 degrees of left lateral inclination (to prevent
compression of IVC by the gravid uterus) with BP measured on left arm.

Supine hypotension syndrome

It is also known as aorto- caval compression and occurs in some pregnant women when they lie down. It is
caused by the gravid uterus compressing the IVC and aorta, which reduces blood flow from the lower
extremities to the heart and placenta. This can cause:
- Hypotension: drop in systolic BP by 15- 30 mm of Hg
- Increased heart rate by almost 20 beats per minute
- Reduction in cardiac output by about 30%
- Increase in uterine venous pressure
- Reduction in uteroplacental blood flow

• Fundal height

Abdominal organ

The symphysio- fundal height in cm is equal to the gestational age in weeks from 16- 32 weeks.
After 32 weeks, the SFH increases by 1cm every 2 weeks.

Normally longitudinally ovoid abdomen.

Transverse lie: horizontally distended
Polyhydramnios: over distended

Gravidogram
It is a system for monitoring pregnancy that compares changes in a pregnant woman’s weight, BP, abdominal
girth and symphysio- fundal height to known normal values. It is used to detect FGR and is comparable in
effectiveness to an USG.

McDonald’s rule
It us a clinical rule used to measure the size of the uterus during pregnancy to assess foetal growth and
development.
According to this rule,
Symphysio- fundal height divided by 3.5 gives the period of gestation in lunar months. (or)
Symphysio- fundal height multiplied by 8 and divided by 7 gives the period of gestation in weeks.

Bartholomew’s rule of fourths

This rule is traditionally used for clinical assessment of gestational age.
Three fixed landmarks are given- symphysis pubis, umbilicus and xiphysternum- corresponding to 12, 24
and 36 weeks of gestation respectively.

• SFH w/r/t POG

Conditions where SFH<POG
- Wrong date
- Oligohydramnios
- FGR
- IUD
- Transverse lie

Conditions where SFH>POG

- Wrong date
- Full bladder
- Polyhydramnios
- Large fibroid
- Molar pregnancy
- Big baby
- Multiple gestation
- GDM

FGR
Foetal Growth Restriction (FGR) is said to be present in those babies whose birth weight is below the 10th
percentile of the average for the gestational age.

Types of FGR
Symmetrical Asymmetrical
Uniformly small Head larger than abdomen
Ponderal index- normal Low
HC:AC, FL:AC- normal Elevated
Intrinsic genetic or infection of foetus Extrinsic- chronic placental insufficiency
Total cell number- less Normal
Cell size- normal Smaller
 Complicated with poor prognosis Usually uncomplicated with good prognosis

Causes of FGR
Maternal Foetal Placental
- Constitutional (low BMI/ racial) - Structural abnormality - Placenta previa
- Maternal nutrition status during and before - Aneuploidies, Turner’s - Abruptio placentae
pregnancy - TORCH - Circumvallate
- Maternal heart and renal diseases - Multiple pregnancy - Infarction
- Toxins- alcohol, smoking, cocaine, heroine - Mosaicism

Grading of FGR
1. Estimated foetal weight <3rd centile
2. Absent end diastolic flow
3. Reverse end diastolic flow
4. Absent flow in ductus venosus

Complications of FGR
Foetal- chronic foetal distress, foetal death, hypoxia and acidosis
After birth
- Asphyxia, bronchopulmonary dysplasia, RDS
- Hypoglycaemia
- Meconium Aspiration Syndrome
- DIC
- Anaemia, Thrombocytopenia
- Necrotising Enterocolitis
- Intraventricular haemorrhage
- Multi organ failure

Oligohydramnios
It’s a condition where the liquor amnii is deficient in amount to the extent of less than 200 mL at term.
Sonographically, it is defined when the maximum vertical pocket of liquor is less than <2 cm or when
amniotic fluid index (AFI) is less than 5 cm.

Clinical features: (examination findings)

- SFH< POG
- Uterus full of foetus
- Flanks not full at term
- FHS heard clearly
- Malpresentations

Causes of Oligohydramnios
Maternal Foetal Placental Idiopathic
- Preeclampsia - Chromosomal anomalies - Amnion nodosum - most common
- Post term pregnancy - Renal agenesis
- Placental insufficiency (IUGR) - Urinary tract obstruction
- PROM
Complications of Oligohydramnios
Maternal Foetal

Increased operative interference Deformities due to intraamniotic adhesions- club foot

Complications due to preeclampsia Pulmonary hypoplasia
IUGR
Foetal distress
Cord compression
Meconium aspiration syndrome

Polyhydramnios
It is defined as a state where liquor amnii exceeds 2,000 mL at term.
Clinical definition states—the excessive accumulation of liquor amnii causing discomfort to the patient and/
or when an imaging help is needed to substantiate the clinical diagnosis of the lie and presentation of the
foetus.

Sonographic diagnosis is made when amniotic fluid index (AFI) is more than 24 cm (more than 95th centile
for gestational age) and a deepest vertical pocket (DVP) is more than 8 cm.

Clinical features: (examination findings)

- Overdistended abdomen
- Skin stretched and shiny
- Umbilicus is everted with flanks full
- SFH> POG
- Foetal parts not easily palpable
- Muffled FHS
- Malpresentations

Causes of Polyhydramnios
Maternal Foetal Placental Idiopathic
- Diabetes - Congenital malformations like - Chorioangioma of - most common
- Rh incompatibility anencephaly, spina bifida, circumvallate placenta
- Cardiac or renal - Foetal hydrops
diseases - Foetal aneuploidies
- Parvovirus B19 infection
- Multiple pregnancy

Grades of polyhydramnios
Grading AFI SDVP
Mild 25- 30 8-11
Moderate 30-35 12-15
Severe >35 >=16

Differential Diagnosis of polyhydramnios: twin pregnancy, huge ovarian cyst, maternal ascites

Complications of polyhydramnios
Maternal complications
- Respiratory compromise
- Preeclampsia
- Malpresentations
- PROM
- Preterm labour
- Placental abruption
- Uterine dysfunction and inertia
- Cord prolapse
- Postpartum haemorrhage
- Subinvolution of uterus

Foetal complications
- Congenital malformations
- Prematurity
- Increased morbidity and mortality

• Presentation vs Position vs Lie of foetus

Presentation: lower most foetal part in relation to cervix and lower uterine segment
Normal: vertex

Position: foetal part in relation to maternal pelvis

Normal: left Occipito anterior/ left Occipito transverse

Lie: relationship of long axis of foetus to the long axis of mother (spine)
Normal: longitudinal

• Malpresentation
Presenting part other than vertex
- Cephalic: brow/ face
- Breech
- Shoulder
- Compound: cephalic + any other part
- Cord: occult/ funic/ prolapse

Breech presentation
• Types of breech
Complete: normal attitude of full flexion is maintained (Thighs are flexed at hips and legs at knees)
Incomplete: it can be Frank/ footling/ knee presentation

Causes of breech presentation

- Prematurity: most common cause of breech presentation.
- Factors preventing spontaneous version: Breech with extended legs, Twins, Oligohydramnios, Congenital
malformation of the uterus such as septate or bicornuate uterus, Short cord, Intrauterine death of the fetus.
- Favorable adaptation: Hydrocephalus, Placenta previa, Contracted pelvis
- Undue mobility of the fetus: Polyhydramnios, Multiparae with lax abdominal wall
- Fetal abnormality: Trisomies 13, 18, 21, anencephaly and myotonic dystrophy

Complications of breech presentation

Maternal- increased LSCS
Foetal- prematurity, congenital anomalies
Vaginal breech delivery
- Birth asphyxia: cord prolapse, cord compression, aspiration of amniotic fluid
- Intracranial haemorrhage: birth asphyxia, sudden compression- decompression
- Birth injuries
Dislocation/ fracture of knee, hip, shoulder joints, femur, humerus, clavicle
Visceral injuries- liver, spleen
Erb’s palsy, Klumpke’s palsy
Spinal cord injury
Jaw dislocation, fracture of mandible

• ECV (External Cephalic Version)

A procedure done in cases of breech to change the presentation of baby to cephalic at term.
Time of version >36 weeks in primigravida, >37 weeks in multigravida (if done earlier chances of reversion
are higher, after 38 weeks liquor decreases)
Foetal well being is monitored via USG, FHS monitored for 1hr before and after the procedure.
Procedure is abandoned if foetal distress occurs or in case of failed multiple attempts (>4)
Anti D injection given to Rh -ve mother before procedure.
It can be done with or without tocolytics.

Contraindications of ECV
• Antepartum hemorrhage
• Fetal causes—hyperextension of the head, large fetus (> 3.5 kg), congenital abnormalities (major), dead
fetus, IUGR
• Multiple pregnancy
• Ruptured membranes
• Known congenital malformation of the uterus
• Contracted pelvis
• Previous cesarean delivery—risk of scar rupture
• Obstetric complications: Severe pre-eclampsia, obesity, elderly primigravida, bad obstetric history (BOH),
oligohydramnios

Causes of failure of version

- Breech with extended legs
- Oligohydramnios
- Big baby
- Obesity
- Irritable uterus
- Short cord
- Sepate or bicornuate uterus

Dangers of version
- Premature onset of labour
- Premature prelabour rupture of membranes
- Placental abruption
- Entanglement of cord
- Amniotic fluid embolism
- Rupture of uterus

• Malpositions
Presenting part of the foetus is head, but not in the left occipito- anterior or direct Occipito anterior positions.
Malpositions include: occipito posterior, mento anterior/ mento posterior, dorsoanterior/ posterior

• Abnormal lies
Transverse/ oblique/ unstable lies

• Clinical analysis of liquor (How to find out liquor abnormalities clinically?)

- Fundal height
- SFH
- Distension of abdomen, appearance of skin, umbilicus and flanks
- Palpation of foetal parts
- FHS: normal/ muffled

Foetal Heart Rate

Foetal heart sound (FHS) is the most conclusive clinical sign of pregnancy.
With an ordinary stethoscope, it can be detected between 18–20 weeks. The sounds resemble the tick of a
watch under a pillow.
Its location varies with the position of the foetus. In a term foetus in cephalic presentation, it is heard on the
side of foetal back in the respective spino- umbilical line.
The rate varies from 110–160 beats per minute.

If the FHS is heard towards the midline in spino- umbilical line, the foetus is usually in Occipito anterior
position.
Similarly when the FHS is heard towards the flanks along the spino umbilical line, it usually indicates
Occipito posterior position.

Methods of foetal weight estimation

Foetal growth velocity is maximum (26.9 g/day) over the 32–36 weeks of pregnancy. It declines gradually to
24 g/day over the 36–40 weeks of gestation.

Johnson’s formula: Height of the uterus above the symphysis pubis in centimetres minus 12, if the vertex is
at or above the level of ischial spines or minus 11, if the vertex is below the level of ischial spines —
multiplied by 155 in either case gives the weight of the foetus in grams
EFW= (SFH- 11 or 12) X 155 g

Foetal weight has been estimated by combining a number of biometric data, e.g. BPD, HC, AC and FL.
Estimated foetal weight likely to be within 10 percent of actual weight.

Shepard’s formula: Log 10 EFW (g) = 1.2508 + (0.166 × BPD) + 0.046 × AC) – (0.002646 × AC × BPD)

Hadlock’s formula: Log 10 EFW (g) = 1.3596 – 0.00386 (AC × FL) + 0.0064 (HC) + 0.00061 (BPD × AC) +
0.0425 (AC) + 0.174 (FL).

Maternal pelvis and Pelvimetry

An articulated pelvis is composed of four bones—two innominate bones, sacrum and coccyx. These are
united together by four joints—two sacroiliac joints, sacrococcygeal joint and the symphysis pubis.
The pelvis is anatomically divided into a false pelvis and a true pelvis, the boundary line being the brim of
the pelvis.
The bony landmarks on the brim of the pelvis from anterior to posterior on each side are—upper border
of symphysis pubis, pubic crest, pubic tubercle, pectineal line, iliopubic eminence, iliopectineal line,
sacroiliac articulation, anterior border of the ala of sacrum and sacral promontory.

Pelvis is divided into inlet, cavity and outlet.

Inlet is formed by the pelvic brim.
Cavity is the segment of the pelvis bounded above by the inlet and below by plane of least pelvic
dimensions.
Obstetrical outlet is the segment of the pelvis bounded above by the plane of least pelvic dimensions and
below by the anatomical outlet.

On the basis of the shape of the inlet, the female pelvis is divided into four parent types-
- Gynecoid (50%)
- Anthropoid (25%)
- Android (20%)
- Platypelloid (5%)

Gynaecoid Anthropoid Android Platypelloid

Shape Round Longitudinally Triangle Horizontally oval
oval
Anterior and Almost equal, spacious Both increased Posterior segment Both reduced-flat
posterior segment with slight short and anterior
anterior segment narrow
Inlet
narrowing
Sacrum Inclined backwards. Inclined Inclined forwards Inclined
Well curved from above posteriorly. Long and straight posteriorly. Short
down and side to side and narrow. and straight

Sacrosciatic notch Wide and shallow More wide and Narrow and deep Slightly narrow
shallow and small
Cavity
Sidewalls Straight or slightly Straight or Convergent Divergent
divergent divergent
Ischialnspines Non prominent Non prominent Prominent Non prominent
Pubic arch Curved Long, curved Long, straight Short, curved
Outlet Sub- pubic angle Wide Slightly narrow Narrow Very wide
Bituberous Normal Normal/ short Short Wide
diameter

Pelvic inlet measurements

In the erect posture, the pelvis is tilted forward. As such, the plane of the inlet makes an angle of about 55°
with the horizontal and is called angle of inclination. When the angle of inclination is increased due to
sacralisation of fifth lumbar vertebra, it is called high inclination.

High inclination has got obstetric significances:

1. There is delay in engagement because the uterine axis fails to coincide with that of inlet
2. It favours occipito posterior position
3. There is difficulty in descent of the head due to long birth canal and flat sacrum interfering with internal
rotation.
Anteroposterior diameters
True conjugate: It is the distance between the midpoint of the sacral promontory to the inner margin of the
upper border of symphysis pubis (11 cm)
Obstetric conjugate: It is the distance between the midpoint of the sacral promontory to prominent bony
projection in the midline on the inner surface of the symphysis pubis (10 cm)
Diagonal conjugate: It is the distance between the lower border of symphysis pubis to the midpoint on the
sacral promontory (12 cm)

Transverse diameter: It is the distance between the two farthest points on the pelvic brim over the
iliopectineal lines. It measures 13 cm.

Oblique diameters: There are two oblique diameters— right and left. Each one extends from one sacroiliac
joint to the opposite iliopubic eminence and measures 12 cm.

Measurements of pelvic cavity

Plane of pelvic cavity is called plane of greatest pelvic diameters.
All the diameters measure 12 cm.

Pelvic outlet measurements

Outlet plane is called the plane of least pelvic dimensions or narrow pelvic plane.
Obstetric Significance of Plane of Least Pelvic Dimension
• It is the narrowest plane in the pelvis
• This plane corresponds roughly to the origin of levator ani muscles.
• It is at this plane that the internal rotation of the foetal head occurs.
• It marks the beginning of the forward curve of the pelvic axis.
• It is a landmark used for pudendal nerve block analgesia.
• This level of ischial spines indicate Station ‘O’.
• It is irregularly oval and notched on each side by ischial spine.

Transverse diameter/ Bispinous diameter- It is the distance between the tip of two ischial spines (10.5 cm)
Anteroposterior: It extends from the inferior border of the symphysis pubis to the tip of the sacrum (11 cm)
Posterior sagittal: It is the distance between the tip of the sacrum and the midpoint of bispinous diameter
(5cm).

Assessment of the pelvis (pelvimetry)

Assessment of the pelvis can be done by bimanual examination: clinical pelvimetry or by imaging studies—
radio-pelvimetry, computed tomography (CT) and magnetic resonance imaging (MRI).
Clinical pelvimetry: This is commonly done.

Time:
In primigravida: at 38 weeks of gestation (usually done along with sweeping/stripping of membranes)
In multigravida: at the onset of labour

Procedures: The patient has to empty the bladder. The pelvic examination is done with the patient in dorsal
position taking aseptic preparations.
The following features are to be noted simultaneously:
(1) State of the cervix
(2) To note the station of the presenting part in relation to ischial spines
(3) To test for Cephalopelvic disproportion in non-engaged head
(4) To note the resilience and elasticity of the perineal muscles.

Parameters assessed in Pelvimetry

The internal examination should be gentle, thorough, methodical and purposeful. It should be emphasised
that the sterilised gloved fingers once taken out should not be reintroduced.
Pelvis is assessed from the innermost parts to the outlet.

Parts assessed in order from inside to outside:

1. Sacrum— The sacrum may be smooth, short and well curved, and the sacral promontory usually cannot
be reached.
If the sacral promontory is reached, it indicates inadequacy of pelvic brim.
2. Sacral curvature- it is assessed by sacrosciatic notch
Sacrosciatic notch — The notch is sufficiently wide so that two fingers can be easily placed over the
sacrospinous ligament covering the notch. The configuration of the notch denotes the capacity of the
posterior segment of the pelvis and the sidewalls of the lower pelvis.
3. Ischial spines— Spines are usually smooth (everted) and difficult to palpate. They may be prominent and
encroach to the cavity thereby diminishing the available space in the mid-pelvis.
4. Inter spinous distance- the bilateral spines are not palpable simultaneously. If they are palpable, it
indicates contraction of the mid pelvis.
5. Iliopectineal lines— To note for any beaking suggestive of narrow fore pelvis (android feature).
6. Sidewalls — Normally they are parallel or divergent. They may be convergent.
7. Posterior surface of the symphysis pubis — It normally forms a smooth rounded curve. Presence of
angulation or beaking suggests abnormality.
8. Sacrococcygeal joint — Its mobility and presence of hooked coccyx, if any, are noted.
9. Subpubic angle: The inferior pubic rami are defined and in female, the angle roughly corresponds to the
fully abducted thumb and index fingers (obtuse angle- gynaecoid pelvis). In narrow angle, it roughly
corresponds to the fully abducted middle and index fingers (acute angle- android pelvis).
10. Transverse diameter of the outlet (TDO) — It is measured by placing the knuckles of the clinched fist
between the two ischial tuberosities. Normally, it accommodates four knuckles.

Contracted pelvis (inlet contraction)

Anatomically, contracted pelvis is defined as one where the essential diameters of one or more planes are
shortened by 0.5 cm. But of more importance is the obstetric definition which states alteration in the size
and/ or shape of the pelvis of sufficient degree as to alter the normal mechanism of labor in an average size
baby.
Common causes of contracted pelvis are:
(1) Nutritional and environmental defects —
Minor variation: Common
Major: Rachitic and osteomalacic — rare
(2) Diseases or injuries affecting the bones of the
pelvis — fracture, tumours, tubercular arthritis
spine — kyphosis, scoliosis, spondylolisthesis, coccygeal deformity
lower limbs — poliomyelitis, hip joint disease.
(3) Development defects — Naegele’s pelvis, Robert’s pelvis, high or low assimilation pelvis.

Cephalopelvic disproportion
The disparity in the relation between the head and the pelvis is called cephalopelvic disproportion.
Disproportion may be either due to an average size baby with a small pelvis or due to a big baby
(hydrocephalus) with normal size pelvis or due to a combination of both the factors.

Pelvic inlet contraction is considered when the obstetric conjugate is < 10 cm or the greatest transverse
diameter is < 12 cm or diagonal conjugate is < 11 cm.
Contracted Midpelvis: Midpelvis is considered contracted when the sum of the interischial spinous and
posterior sagittal diameters of the midpelvis (normal: 10.0 + 5 = 15.0 cm) is 13.0 cm or below.
Contracted outlet is suspected when the interischial tuberous diameter is 8 cm or less. A contracted outlet is
often associated with midpelvic contraction.

Foetal Skull
Areas of skull include:
Vertex : It is a quadrangular area bounded anteriorly by the bregma and coronal sutures behind by the lambda
and lambdoid sutures and laterally by lines passing through the parietal eminences.
Brow : It is an area bounded on one side by the anterior fontanel and coronal sutures and on the other side by
the root of the nose and supraorbital ridges of either side.
Face : It is an area bounded on one side by root of the nose and supraorbital ridges and on the other, by the
junction of the floor of the mouth with neck.

Sinciput is the area lying in front of the anterior fontanel and corresponds to the area of brow and the occiput
is limited to the occipital bone.

Sutures in the skull

• The sagittal or longitudinal suture lies between two parietal bones.
• The coronal sutures run between parietal and frontal bones on either side.
• The frontal suture lies between two frontal bones.
• The lambdoid sutures separate the occipital bone and the two parietal bones.

Wide gap in the suture line is called fontanel. Of the many fontanels (6 in number), two are of obstetric
significance:
(1) Anterior fontanel or bregma
(2) Posterior fontanel or lambda.

Anterior fontanel is formed by joining of the four sutures in the midplane. The sutures are anteriorly frontal,
posteriorly sagittal and on either side, coronal. The shape is like a diamond. Its anteroposterior and transverse
diameters measure approximately 3 cm each. The floor is formed by a membrane and it becomes ossified 18
months after birth. It becomes pathological, if it fails to ossify even after 24 months.
Importance of anterior fontanel:
• Its palpation through internal examination denotes the degree of flexion of the head.
• It facilitates moulding of the head.
• As it remains membranous long after birth, it helps in accommodating the marked brain growth; the brain
• becoming almost double its size during the first year of life.
• Palpation of the floor reflects intracranial status—depressed in dehydration, elevated in raised intracranial
• tension.
• Collection of blood and exchange transfusion, on rare occasion, can be performed through it via the
superior longitudinal sinus.
• Cerebrospinal fluid can be drawn, although rarely, through the angle of the anterior fontanel from the
lateral ventricle.
Posterior fontanel is formed by junction of three suture lines — sagittal suture anteriorly and lambdoid
suture on either side. It is triangular in shape and measures about 1.2 × 1.2 cm. Its floor is membranous but
becomes bony at term.

Anteroposterior diameters of foetal skull include:

Diameters Measurement Attitude of head Presentation
Suboccipitobregmatic — extends from the nape of the
9.5cm Complete flexion Vertex
neck to the center of the bregma
Suboccipito-frontal — extends from the nape of the
neck to the anterior end of the anterior fontanel or center 10cm Incomplete flexion Vertex
of the sinciput
Occupitofrontal — extends from the occipital eminence
11.5 cm Marked deflexion Vertex
to the root of the nose (Glabella)
Mento-vertical — extends from the midpoint of the chin
14 cm Partial extension Brow
to the highest point on the sagittal suture
Submentovertical — extends from junction of floor of
Incomplete
the mouth and neck to the highest point on the sagittal 11.5 cm Face
suture extension

Submentobregmatic — extends from junction of floor

9.5 cm Complete extension Face
of the mouth and neck to the center of the bregma

Transverse diameters of skull:

Biparietal diameter—9.5 cm: It extends between two parietal eminences. Whatever may be the position of
the head, this diameter nearly always engages.
Super-subparietal—8.5 cm: It extends from a point placed below one parietal eminence to a point placed
above the other parietal eminence of the opposite side.
Bitemporal diameter—8 cm: It is the distance between the antero- inferior ends of the coronal suture.
Bimastoid diameter — 7.5 cm: It is the distance between the tips of the mastoid processes.

Moulding is the alteration of the shape of the fore-coming head while passing through the resistant birth
passage during labor. During normal delivery, an alteration of 4 mm in skull diameter commonly occurs.
Moulding disappears within few hours after birth.
Grades of moulding-
Grade-1—the bones touching but not overlapping
Grade-2— overlapping but easily separated
Grade-3—fixed overlapping

Respectful maternity care

- Freedom from harm and ill treatment
- Right to information, right to informed consent and refusal
- Confidentiality and privacy
- Equality, freedom from discrimination and equitable care
- Liberty and autonomy
- Self- determination and freedom from coercion
- Right to timely healthcare and to the highest attainable level of health
- Communication with dignity and respect
• Induction and augmentation of labour
Induction: initiation of uterine contractions >28 weeks by any method (medical, surgical or combined) for
the purpose of vaginal delivery, when there is a risk continuing pregnancy.
Augmentation: stimulation of uterine contractions that are already present but are found to be inadequate.

Indications of induction of labour

- Hypertensive disorders in pregnancy
- DM
- CKD
- Cholestasis in pregnancy
- Abruptio placentae
- Rh isoimmunisation
- PROM
- Oligohydramnios, Polyhydramnios
- Bad obstetric history
- IUGR/ IUD
- Congenital malformations
- Post maturity

Contraindications of induction of labour

- Contracted pelvis
- Cephalopelvic disproportion
- Cord presentation
- Previous >=2 LSCS section
- Placenta previa
- Vasa previa
- Previous classical C section
- Heart disease in pregnancy
- Ca cervix
- Any active infection

Complications of induction
- increased rate of operative interference and instrumental delivery due to induction failure
- Hyper stimulation
- Abruptio placentae due to sudden decompression of uterus in ARM
- Increased rate of postpartum haemorrhage
- Increased chorioamnionitis and sepsis
- Amniotic fluid embolism
- Iatrogenic prematurity
- Hypoxia
- Cord prolapse

Prerequisites for induction

• There should be a genuine indication for induction
• Contraindications should be ruled out
• Confirm dates/foetal maturity
• Assess foetal well-being
• Assess cervix (Bishop's score)
• Provide counselling and obtain informed consent of the patient

Bishop’s score (modified: effacement replaced by cervical length)

It is a prerequisite for cervical ripening (augmentation of labour)
Score
Parameters
0 1 2 3
Cervix
Dilatation Closed 1-2 3-4 >=5
Effacement % (older) 0-30 40-50 60-70 >=80
Consistency Firm Medium Soft -
Position Posterior Midline Anterior -
Cervical length in cm (new) >4 2-4 1-2 <1
Head station -3 -2 -1, 0 +1, +2

• Cervical ripening is a complex biochemical process that occurs in the cervix due to hormones making it
soft and pliable.
If Bishop’s score >=6 cervix favourable
<6 unfavourable

Methods of induction of labour

-Mechanical methods (discussed under cervical ripening)
-Medical methods

Methods of cervical ripening

Mechanical methods
• Foley's catheter: No. 22 F size Foleys catheter is inserted into the cervix and the balloon is inflated with 50
mL normal saline at the level of internal os.
- Foley's catheter causes separation of membranes from the lower uterine segment and release of endogenous
prostaglandins that help in dilatation of cervix and initiation of uterine contraction.
• Sweeping of membranes (stripping of membranes): Membranes are stripped off from the lower uterine
segment with the fingers introduced through the cervical canal.
- Principle: Separation of membranes causes release of endogenous prostaglandins.
- It is done at 38- 39 weeks along with pelvic assessment

Medical methods
• Dinoprostone gel: PGE2 gel 0.5 g is given as intracervical application. Reassessment is done after 6 hours
and not to exceed 3 doses in total.
• Misoprostol tablet: Misoprostol 25 µg placed vaginally in the posterior fornix or 50 µg is given orally.
Dose can be repeated at 4- to 6-hour interval for up to four doses.
• Oxytocin (discussed later)

Methods of Augmentation of labour

Amniotomy/ Artificial Rupture of Membranes (ARM)- surgical method
ARM: It is the procedure by which the membranes are ruptured with a Kocher's forceps/ Amnicots to allow
escape of liquor.
Things to be checked after ARM
• Colour of liquor
• Cord prolapse to be ruled out
• Vaginal bleeding (abruption can occur following sudden uterine decompression)
• Station of the presenting part
• Foetal heart rate (foetal distress can occur in cord compression and occult cord prolapse)

Advantages of ARM
• Colour of the liquor can be made out.
• Intrauterine scalp pH monitoring can be done in case of foetal distress.
• Descent of foetal head can occur to some extent.
Disadvantages of ARM
• Once ARM is done, delivery is mandatory as the patient is committed to deliver
• Risk of cord prolapse
• Risk of abruption
• Risk of infection
Contraindications of ARM
• IUD
• Cord presentation
• Any infections in the mother
• Free floating head

Medical methods of Augmentation of labour

• Oxytocin
Primigravida
: started at 2.5m IU/min delivered to patient
: High dose regimen: 6m IU/min
(Contraindicated in previous C section. IUGR, multigravida)
Multigravida
: Dose: 1m IU/min
Escalation of oxytocin has to be done in 30 minutes (due to half life) and >30 minutes tachyphylaxis occurs.

Maximum dose of oxytocin

Primigravida: 32m IU/min
Previous C section: 22- 24m IU/min
Multigravida: <=20m IU/min

Target contractions with induction: good intensity (unable to intend uterus during peak of contraction),
frequency of 3-5 in 10 minutes, each lasting for 40- 45 seconds.

• Induction in different medical conditions of pregnancy (in number of completed weeks)- refer
Gestational hypertension (controlled BP): 37 weeks
Preeclampsia without severe features : 37 weeks
Preeclampsia with severe features : 34 weeks
Eclampsia : 32 weeks (latest)
Twin pregnancy (MCDA): 36 weeks
Twin pregnancy (DCDA): 38 weeks
Gestational Diabetes Mellitus (GDMA1): 40 weeks
Gestational Diabetes Mellitus- GDMA2- (delayed lung maturity): 38 weeks
Chronic type 2 DM: 37- 37+6 weeks
Abruptio placentae : 34- 37 weeks
Rh isoimmunisation : 40 weeks
PPROM: 36-37 weeks
Post dated pregnancy : 41 weeks
FGR: 37 weeks
FGR with doppler abnormalities (grade 2): 34 weeks , (grade 3): 32 weeks
Oligohydramnios: 37 weeks

Labour analgesia
Methods of Pain Relief
• Psycho prophylaxis
• Sedatives and analgesics
• Inhalation agents
• Patient controlled analgesia (PCA)
• Transcutaneous electric nerve stimulation (TENS)
• Regional (neuraxial) analgesia
• General anaesthesia

Commonly Used Sedatives and Analgesics in Labor

Regional Anaesthesia
Advantages of regional anaesthesia
- Patient is awake and can enjoy birth time.
- CSE allows women to move
- Good newborn APGAR score
- Low risk of maternal aspiration
- Better post operative pain control

Epidural analgesia
When complete relief of pain is needed throughout labor, epidural analgesia is the safest and simplest method
for procuring it.
Epidural analgesia is especially beneficial in cases like pregnancy-induced hypertension, breech presentation,
twin pregnancy and preterm labor. Previous cesarean section is not a contraindication. Epidural analgesia
when used there is no change in duration of first stage of labor. But second stage of labor appears to be
prolonged by 15–30 minutes. This might lead to frequent need of instrumental delivery like forceps or
ventouse.
Contraindications of epidural
- Supine hypotension
- Maternal coagulopathy or anticoagulant therapy
- Hypovolaemia
- Neurological disorders
- Spinal deformity
- Skin infection at site of injection
Complications of epidural
- Hypotension
- Back pain, pain at injection site
- Post-spinal headache
- Injury to nerves, convulsions , pyrexia
- Ineffective analgesia

Other regional analgesia

- Paracervical nerve block
- Pudendal nerve block
- Spinal anaesthesia
- Combined spinal- epidural analgesia

Stages of labour
Labour is divided into 3 stages-

Stage 1 of labour
The first stage is chiefly concerned with the preparation of the birth canal so as to facilitate expulsion of the
foetus in the second stage. The main events that occur in the first stage are—
(a) dilatation and effacement of the cervix
(b) full formation of lower uterine segment

Factors causing dilatation of cervix include-

- Uterine contraction and relaxation
- Foetal axis pressure
- Bag of membranes
- Vis-a-tergo (downward thrust of the presenting part of foetus and upward pull of cervix)

Effacement is the process by which the muscular fibres of the cervix are pulled upward and merges with the
fibres of the lower uterine segment. The cervix becomes thin during first stage of labor or even before that in
primigravidae. In primigravidae, effacement precedes dilatation of the cervix, whereas in multiparae, both
occur simultaneously.

Formation of lower uterine segment

The wall of the upper segment becomes progressively thickened with progressive thinning of the lower
segment. This segment is formed maximally during labor and the peritoneum is loosely attached anteriorly. It
measures 7.5–10 cm when fully formed and becomes cylindrical during the second stage of labor. The wall
becomes gradually thin due to: (i) Relaxation of the muscle fibres to allow elongation, (ii) the muscle fibres
are drawn up by the muscle fibres of the upper uterine segment by contraction and retraction during labor
and (iii) descent of the presenting part causes further stretching and thinning out of wall. This segment has
got poor retractile property compared to the upper segment.

Clinically, stage 1 of labour is divided into latent phase and active phase.
Latent phase of labor is defined as the period between the onset of true labor pain and the point when the
cervical dilatation becomes 3–4 cm. Normal duration of latent phase of labor in a primigravida is about
20 hours (maximum) and 14 hours (maximum) in a multipara.

The active phase has got three components.

(i) Acceleration phase with cervical dilatation of 3–4 cm.
(ii) Phase of maximum slope of 4–9 cm dilatation.
(iii) Phase of deceleration of 9–10 cm dilatation.
Dilatation of the cervix at the rate of 1 cm/h in primigravidae and 1.5 cm in multigravidae beyond 4 cm
dilatation (active phase of labor) is considered satisfactory.

Management of stage 1
- General management- antiseptic dressing, emotional support and assurance, constant supervision
- An enema with soap and water or glycerin suppository is traditionally given in early stage. This may be
given if the rectum feels loaded on vaginal examination. If the membranes are intact, the patient is allowed to
walk about. Fluids in the form of plain water, ice chips or fruit juice may be given in early labor. Intravenous
fluid with ringer solution is started where any intervention is anticipated. Patient is encouraged to pass urine
by herself as full bladder often inhibits uterine contraction and may lead to infection.

- Assessment of progress of labor and partograph recording.

Uterine contractions as regard the frequency, intensity and duration are assessed.
Foetal heart rate (FHR) along with its rhythm and intensity should be noted every half hour in the first stage
and every 15 minutes in second stage or following rupture of the membranes.

- P/V examination- Dilatation of the cervix in centimetres in relation to hours of labor is a reliable index to
note the progress of labor, To note the position of the head and degree of flexion, To note the station of the
head, etc
- Look out for evidence of foetal distress using NST or by auscultation.
Routine checkup of maternal BP, pulse, temperature, hydration status, urine output, etc.

Stage 2 of labour
The second stage begins with the complete dilatation of the cervix and ends with the expulsion of the foetus.
This stage is concerned with the descent and delivery of the foetus through the birth canal.
Second stage has two phases:
(1) Propulsive—from full dilatation until head touches the pelvic floor.
(2) Expulsive—since the time mother has irresistible desire to “bear down” and push until the baby is
delivered.

Clinical course of 2nd stage- Second stage begins with full dilatation of the cervix and ends with expulsion
of the foetus.
The intensity of the pain increases. The pain comes at intervals of 2–3 minutes and lasts for about 1–1.5
minutes. Bearing down efforts start spontaneously with full dilatation of the cervix.
Along with uterine contraction, the woman is instructed to exert downward pressure as done during straining
at stool. Sustained pushing beyond the uterine contraction is discouraged. Membranes may rupture with a
gush of liquor per vaginum.
As the head descends down, it distends the perineum, the vulval opening looks like a slit through which the
scalp hair is visible. During each contraction, the perineum is markedly distended with the overlying skin
tense and glistening and the vulval opening becomes circular (crowning). Head is born by extension,
followed by shoulders and trunk.

Management of 2nd stage

- Patient should be in bed under constant supervision. FHR is recorded every 5 minutes. P/V examination is
done to assess the position and station of head and to detect any cord prolapse.

- Position the patient in dorsal with 15 degree left lateral tilt or lithotomic position.
Scrub up and put on sterile gown, mask and gloves.
Toileting of external genitalia with cotton swabs soaked in savlon or dettol.
Catheterise the bladder if full.

- The patient is encouraged for the bearing-down efforts during uterine contractions to facilitate the descent
of head. When the scalp is visible for about 5 cm in diameter, flexion of the head is maintained during
contractions. This is achieved by pushing the occiput downward and backward by using thumb and index
 fingers of the left hand while pressing the perineum by the right palm with a sterile vulval pad. The
process is repeated during subsequent contractions until the subocciput is placed under the symphysis
pubis.
- At this stage, crowning of head occurs. When the perineum is fully stretched and threatens to tear
especially in primigravidae, episiotomy is done at this stage. Slow delivery of the head in between the
contractions is to be regulated. The forehead, nose, mouth and the chin are thus born successively over the
stretched perineum by extension.
- Wait for the uterine contractions to come and for the movements of restitution and external rotation of the
head to occur. During the next contraction, the anterior shoulder is born behind the symphysis. If there is
delay, the head is grasped by both hands and is gently drawn posteriorly until the anterior shoulder is
released from under the pubis. By drawing the head in upward direction, the posterior shoulder is
delivered out of the perineum. After the delivery of the shoulders, the fore finger of each hand are inserted
under the axillae and the trunk is delivered gently by lateral flexion.

Stage 3 of labour
The third stage of labor comprises the phase of placental separation; its descent to the lower segment and
finally its expulsion with the membranes.
3rd stage bleeding- vaginal bleeding after the delivery of baby till the placenta is delivered

There are two ways of separation of placenta:

- Central separation
- Marginal separation
After complete separation of the placenta, it is forced down into the flabby lower uterine segment or upper
part of the vagina by effective contraction and retraction of the uterus. Thereafter, it is expelled out either by
voluntary contraction of abdominal muscles (bearing down efforts) or by manual procedure.

Clinical course of 3rd stage

Before separation of placenta, Uterus becomes discoid in shape, firm in feel and non- ballotable. Fundal
height reaches slightly below the umbilicus.
After separation of placenta,
1. Uterus becomes globular, firm, and ballotable.
2. The fundal height is slightly raised as the separated placenta comes down in the lower segment
and the contracted uterus rests on top of it.
3. Slight bulging in the suprapubic region due to distension of the lower segment by the separated placenta.
4. Slight gush of vaginal bleeding.
5. Permanent lengthening of the cord is established.

Management of 3rd stage- discussed later

Mechanism of labour
The series of movements that occur on the head in the process of adaptation during its journey through the
pelvis is called mechanism of labor.
In normal labor, the head enters the brim more commonly through the available transverse diameter (70%)
and to a lesser extent through one of the oblique diameters. Accordingly, the position is either occipitolateral
or oblique occipitoanterior. Left occipitoanterior is little more common than right occipitoanterior as the left
oblique diameter is encroached by the rectum.
The engaging anteroposterior diameter of the head is either suboccipitobregmatic 9.5 cm (if full flexed head)
or in slight deflexion—the suboccipitofrontal 10 cm. The engaging transverse diameter is biparietal 9.5 cm.
Cardinal movements in normal labour (Occipito transverse/ occipitolateral)
Engagement of head
It is the process by which the largest diameter of the presenting part crosses the largest diameter of maternal
pelvis - which is pelvic brim in normal occipito- transverse position.
Studies have shown that because the head is inclined laterally, the sagittal suture of the foetal skull does not
correspond very accurately to the transverse diameter of the pelvic inlet. Therefore there is slight deflection
of the foetal head in relation to the pelvis. This deflection of head is called lateral flexion or asynclitism.
If the sagittal suture of the skull lies anterior to the transverse diameter of pelvic inlet (closer to
pubic symphysis), the presenting part of the head is the posterior parietal bones. This is called posterior
asynclitism or posterior parietal presentation and is frequently found in primigravida.
If the sagittal suture of the foetal skull lies posterior with respect to the transverse diameter of pelvic
inlet (closer to the sacral promontory), the presenting part of the head becomes the anterior part of the
parietal bone. This is called anterior asynclitism or anterior parietal presentation and is frequently seen in
multiparae.
Mild degrees of asynclitism are common but severe degrees indicate Cephalopelvic disproportion.

Descent
It is the process of downward movement of the presenting part (head) from the pelvic inlet to the floor of
pelvis by the time cervix is fully dilated. It is a continuous process provided there is no undue bony or soft
tissue obstruction. It is slow in first stage but pronounced in second stage of labour.
Descent occurs due to - uterine contractions, bearing down efforts and pressure exerted by bag of membranes
and amniotic fluid.

Flexion
Flexion is achieved when the head meets the resistance of the birth canal (either pelvic floor or by the walls
of pelvis) during descent. Though there may be some degree of flexion at the beginning of labour, full
flexion (foetal chin touches foetal chest) occurs occurs when the descent of head is resisted by the maternal
pelvis. Flexion either precedes internal rotation or coincides with it.

Internal rotation
It is the rotation of the head with respect to the body, towards the pubic symphysis (medial or internal
rotation). As the head navigates through the pelvis, the floor of the pelvis is inclined medially downwards.
Also levator ani muscle is inserted such that it lies medially downwards towards the midline. As a result of
this, the AP diameter of the outlet is larger than the transverse bispinous diameter. So the head undergoes
internal rotation to accommodate in the maximum available diameter (AP diameter of outlet).
In Occipito- transverse position, the head rotates by 2/8th of circle medially while in LOA position, it has to
rotate only 1/8th of the circle medially.
Torsion of the neck is an inevitable phenomenon during internal rotation of the head. If the shoulders
remain in the antero- posterior diameter, the neck has to sustain a torsion of two-eighths of a circle
corresponding with the same degree of anterior rotation of the occiput. But the neck fails to withstand such
major degree of torsion and as such there will be some amount of simultaneous rotation of the shoulders in
the same direction to the extent of one-eighth of a circle placing the shoulders to lie in the oblique diameter
with one-eighth of torsion still left behind. Thus, the shoulders move to occupy the left oblique diameter in
left Occipito lateral position and right oblique diameter in right Occipito lateral position. In oblique Occipito
anterior position, there is no movement of the shoulders from the oblique diameter as the neck sustains a
torsion of only one-eighth of a circle.

Crowning
After internal rotation of the head, further descent occurs until the sub occiput lies underneath the pubic arch.
At this stage, the maximum diameter of the head (biparietal diameter) stretches the vulval outlet without any
recession of the head even after the contraction is over— called “crowning of the head”.

Extension
The occiput of the head slips beneath the suprapubic arch. The bearing down efforts of mother pushes head
downward while the pelvic floor offers a resistance upwards. As a result, the head undergoes extension and is
delivered stretching the perineum. The successive parts of occiput, including the vertex, brow and face are
delivered and the nape of the neck pivots at the suprapubic arch.

Restitution
It is the visible passive movement of the head due to untwisting of the neck sustained during internal rotation.
Movement of restitution occurs rotating the head through one-eighth of a circle in the direction opposite to
that of internal rotation. The occiput thus points to the maternal thigh of the corresponding side to which it
originally lay.

External rotation
It is the movement of rotation of the head visible externally due to internal rotation of the shoulders. As the
anterior shoulder rotates toward the symphysis pubis from the oblique diameter, it carries the head in a
movement of external rotation through one-eighth of a circle in the same direction as restitution. The
shoulders now lie in the anteroposterior diameter. The occiput points directly toward the maternal thigh
corresponding to the side to which it originally directed at the time of engagement.

Birth of Shoulders and Trunk: After the shoulders are positioned in anteroposterior diameter of the outlet,
further descent takes place until the anterior shoulder escapes below the symphysis pubis first (downward
traction). By a movement of lateral flexion of the spine, the posterior shoulder sweeps over the perineum
(upward traction). Rest of the trunk is then expelled out by lateral flexion.

Episiotomy
A surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labor
is called episiotomy (perineotomy).
It is in fact an inflicted second-degree perineal injury. It is the most common obstetric operation performed.
Objectives
- To enlarge the vaginal introitus so as to facilitate easy and safe delivery of the foetus
- To minimise overstretching and rupture of the perineal muscles and fascia; to reduce the stress and strain on
the foetal head.

Indications of episiotomy
• In elastic (rigid) perineum: Causing arrest or delay in descent of the presenting part as in elderly
primigravidae.
• Anticipating perineal tear: (a) Big baby (b) face to pubis delivery (c) breech delivery and (d) shoulder
dystocia.
• Operative delivery: Forceps delivery, ventouse delivery.
• Previous perineal surgery: Pelvic floor repair, perineal reconstructive surgery.
Common indications are:
(1) Threatened perineal injury in primigravidae
(2) rigid perineum
(3) forceps, breech, Occipito posterior or face delivery.
Timing of episiotomy: Bulging thinned perineum during contraction just prior to crowning (when 3–4 cm of
head is visible) is the ideal time. During forceps delivery, it is made after the application of blades.
If done early, the blood loss will be more. If done late, it fails to prevent the invisible lacerations of the
perineal body and thereby fails to protect the pelvic floor.

Types of episiotomy
The following are the various types of episiotomy:
Mediolateral: The incision is made downwards and outwards from the midpoint of the fourchette either to
the right or to the left. It is directed diagonally in a straight line which runs about 2.5 cm away from the anus
(midpoint between anus and ischial tuberosity).
Median:The incision commences from the centre of the fourchette and extends posteriorly along the midline
for about 2.5 cm.
Lateral: The incision starts from about 1 cm away from the centre of the fourchette and extends laterally. It
has got many drawbacks including chance of injury to the Bartholin’s duct. It is totally condemned.
‘J’ shaped: The incision begins in the centre of the fourchette and is directed posteriorly along the midline for
about 1.5 cm and then directed downwards and outwards along 5 or 7 O’clock position to avoid the anal
sphincter.
Apposition is not perfect and the repaired wound tends to be puckered. This is also not done widely.

Median vs Mediolateral episiotomy

Median Mediolateral
- Muscles are not cut - Safe from rectal involvement
- Less blood loss - Incision can be extended
- Easy repair
Merits - More post op comfort
- Faster healing
- Less wound disruption
- Less dyspareunia
- Extension can cause class 3 perineal tears - Apposition of tissues not good
- Not suitable for manipulative delivery - More blood loss
Demerits - Post op discomfort
- Increased wound disruption
- More dyspareunia

Steps of mediolateral episiotomy

The perineum is thoroughly swabbed with antiseptic (povidone-iodine) lotion and draped properly.
Local anaesthesia: The perineum, in the line of proposed incision is infiltrated with 10 mL of 1% solution of
lignocaine.
Incision—Two fingers are placed in the vagina between the presenting part and the posterior vaginal wall.
The incision is made by a curved or straight blunt pointed sharp scissors, one blade of which is placed inside,
in between the fingers and the posterior vaginal wall and the other on the skin.
The incision should be made at the height of an uterine contraction. It is directed diagonally in a straight line
which runs about 2.5 cm away from the anus. The incision ought to be adequate to serve the purpose for
which it is needed.
Structures cut in episiotomy:
(1) Posterior vaginal wall
(2) superficial and deep transverse perineal muscles, bulbospongiosus and part of levator ani
(3) fascia covering those muscles
(4) transverse perineal branches of pudendal vessels and nerves
(5) subcutaneous tissue and skin.
Repair of episiotomy
Timing of repair: the repair is done soon after expulsion of placenta.
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.
The principles to be followed are:
(1) perfect haemostasis
(2) to obliterate the dead space
(3) suture without tension.

The repair is done in three layers. The repair is to be done in the following order:
(1) Vaginal mucosa and submucosal tissues
(2) perineal muscles
(3) skin and subcutaneous tissues.
The vaginal mucosa is sutured first with continuous sutures using “0” chromic catgut sutures. Perineal skin is
sutured with interrupted sutures.

Active management of third stage of labour

The underlying principle in active management is to excite powerful uterine contractions within 1 minute of
delivery of the baby (WHO) by giving parenteral oxytocin. This facilitates not only early separation of the
placenta but also produces effective uterine contractions following its separation. It is done in all women
after delivery of baby and is the best method to prevent PPH.

Advantages- minimise blood loss in 3rd stage approx to 1/5th, shorten the duration of 3rd stage to half
Disadvantages- slight increased incidence of retained placenta

Steps of AMTSL
- Injection oxytocin 10 units IM (preferred) or methergine 0.2 mg IM is given within 1 minute of delivery
of the anterior shoulder of the baby
- Clamp, divide and ligate the cord: Delayed cord clamping unless foetal distress or non- Rh
isoimmunisation
- To deliver the placenta by controlled cord traction soon after the delivery of the baby availing first uterine
contraction : modified Brandt Andrews technique
- If it fails, repeat after 2-3 minutes and again after 10 minutes. If still not possible, do manual removal of
placenta.
- Slow infusion of iv oxytocin 5- 10 units or methergine 0.2 mg IM
- Examine placenta and membranes
- Inspection of vulva, vagina and perineum
- Intermittent assessment of uterine tone for 2 hours every 15 minutes

FOURTH STAGE OF LABOR:

It is the stage of observation for at least 1 hour after the delivery of the baby, placenta and the membranes to
ensure that both the mother and the baby are well.

Caesarean section
It is an operative procedure whereby the foetuses after the end of 28th weeks are delivered through an
incision on the abdominal and uterine walls.
Types of C Section
Depending on incision- Classical C section
- Lower segment C section
Depending on time of operation- Elective C section
- Emergency C section

• Elective vs Emergency C section

Elective C section: When the operation is done at a prearranged time during pregnancy to ensure the best
quality of obstetrics, anaesthesia, neonatal resuscitation and nursing services.
When maturity is certain, operation is done about 1 week prior to the expected date of confinement.
When maturity is uncertain, ultrasound assessment in first or second trimesters if available is corroborated. If
not, spontaneous onset of labor is awaited and then CS is done.

Emergency C section: When the operation is to be done due to an acute obstetric emergency.

NICE category for Emergency C section

Category 1: When there is immediate threat to the life of the woman or the fetus. Decision delivery interval
should be 30 minutes.
Category 2: When there is maternal or fetal compromise which is not immediately life threatening. CS
should be done within 75 minutes of making decision.
Category 3: There is no maternal or fetal compromise but needs early delivery.
Category 4: Delivery is planned to suit the woman, family members and the hospital staff.

• Classical vs Lower segment C section

Features Classical C section Lower Segment C section
Incision Upper uterine segment: Sanger’s incision Lower uterine segment: Kerr incision
(transverse) or Kronig’s incision/ De- Lee
vertical incision
Techniques - Technically easy - Technically difficult
- More blood loss - Less blood loss
- Imperfect apposition due to thick walls - Perfect apposition due to thin wall
- Perfect peritonisation not possible - Perfect peritonisation
- Safer in placenta previa and transverse lie - Difficult in placenta previa and transverse
lie
Adv/ Disadv - More bleeding - Less bleeding
- Difficult repair - Easy repair
- Healing not good - Better healing
Post operative - More haemorrhage and shock - Less haemorrhage and shock
- Higher chances of peritonitis in uterine - Very less chances of peritonitis even in
infection uterine infection
- More peritoneal adhesions - Peritoneal adhesions are less
- More intestinal obstruction - Less intestinal obstruction
- Convalescence delayed - Convalescence is better
- Higher morbidity and mortality - Low morbidity and mortality
Wound healing Scar is weak because Scar is better healed due to
- Imperfect apposition - Perfect apposition
- Thick margins - Thin margins
- More wound hematoma - Minimal wound hematoma
- Wound in tension due to contraction and - Wound is quiescent during healing
relaxation of upper segment - No or less gutter formation
- Increased gutter formation on inner aspect
Features Classical C section Lower Segment C section
Subsequent Always C section Transverse incision: VBAC can be tried
pregnancies Vertical incision: Always C section (except
for constriction ring)
Risk of rupture High (4-9%) Low (0.5-1.5%)

• Indications and contraindications of C section

Absolute indications of C section
- Central placenta previa
- Contracted pelvis
- Pelvic mass
- Advanced Ca cervix
- Vaginal stenosis (atresia, stenosis)
- Cord prolapse
- Macrosomia >4.5 kg
Relative indications of C section
- Cephalopelvic disproportion
- Previous C section (recurrent indications/ previous 2 sections/ scar dehiscence/ previous classical C
section)
- Non reassuring FHR
- Dystocia
- Antepartum haemorrhage: Placenta previa, Abruption placenta
- Malpresentations: breech, transverse lie
- Failed surgical induction
- Bad obstetric history
- Coarctation of aorta, Marfan syndrome

Common indications of C section in primigravida

- Failed induction
- Foetal distress
- CPD
- Malpositions, Malpresentations
Common indications of C section in multigravida
- Previous C section
- Antepartum haemorrhage
- Malpresentations

Indications of classical C section

- Ca cervix
- Placenta acreta spectrum
- Mass obstructing lower segment

• Complications of C section
Intraoperative complications
- Injury to uterine vessels
- Uterine lacerations
- Bladder injury
- Ureteric injury
- Haemorrhage

Postoperative complications in mother

Immediate complications
- Postpartum haemorrhage
- Shock
- Anaesthetic complications: Aspiration pneumonitis (Mendelson’s syndrome), hypotension, spinal
headache
- Infections: endomyometritis, peritonitis, septic pelvic thrombophlebitis
- Paralytic ileus
- Deep vein thrombosis
- Wound complications: discharge/ hematoma/ dehiscence/ burst abdomen
- Secondary postpartum haemorrhage

Remote complications
Gynaecological: menstrual abnormalities
: chronic pelvic pain
General surgical: incisional hernia
: intestinal obstruction
Future pregnancy: scar dehiscence

Foetal complications: iatrogenic prematurity, RDS

• Steps of C section
Steps of LSCS
- Anaesthesia: spinal/ general (emergency)
- Patient in supine position with wedge on left side
- Painting and draping abdomen (betadine/ iodine) and cautery plate
- Palpation of abdomen for foetal position
- Pfannenstiel (skin) incision: 2cm above the pubic symphysis 12- 15cm transverse
- Vertical incision is given in emergency C section/ placenta acreta spectrum/ if hysterectomy indicated
- Subcutaneous tissue: 2-3 cm midline incision
- Rectus sheath is stretched and not cut
- Peritoneum is cut with artery forceps
- Bladder is retracted
- Palpate uterus for rotation of uterus- correct rotation
- Identification of lower segment : look for uterovesical fold (with forceps hold the peritoneum and identify
the free loose fold)
- Uterine incision: LS transverse curvilinear incision 1.5 cm below the UV fold- small incision is given and
is stretched
- Other incisions: J/ W/ T shaped incisions (done in conditions like Macrosomia)
- Delivery of foetus
In case of prolonged labour: push/ pull methods for impacted head
- Delayed clamping and cutting of cord
- Watch for signs of placental separation
- Placenta and membranes removed
- Uterus sutured with absorbable sutures in 2 layers: continuous sutures with vicryl/ cadgut
- Close the layers of abdomen in the order of incision
- Clean the suture site, ensure haemostasis, remove instruments and mop
• Catheterisation post CS
Normally kept for 24 hours
Kept for longer period of 5-7 days in bladder injury, 2nd stage LSCS in CPD
• TOLAC/ VBAC
Selection Criteria of Cases for VBAC–TOL
- One or two previous lower segment transverse scar
- Nonrecurring indication for prior cesarean section
- Pelvis adequate for the fetus
- Continued labor monitoring possible
- Availability of resources (anesthesia, blood trans- fusion and theater) for emergency cesarean section
within 30 minutes of decision
- Informed consent of the woman

Benefits of TOLAC
- decreased maternal morbidity
- Reduced length of hospital stay
- Decreased need for blood transfusion
- Decreased risk of abnormal placentation
Risks of Elective Repeat CS
- increased maternal morbidity
- Increased length of hospital stay
- Increased risk of haemorrhage and need for blood transfusions
- Increased risk of abnormal placentation
Complications of unsuccessful TOLAC
- wound dehiscence
- Uterine rupture
- Increased blood transfusion
- Increased risks of hysterectomy
- Increased maternal morbidity
- NICU admission
- Hypoxic Ischaemic Encephalopathy
- Neonatal death
Contraindications for VBAC-TOL (Indications for Cesarean Delivery)
- Previous classical or inverted T-shaped uterine incision
- Previous two or more lower segment cesarean section
- Pelvis contracted or suspected CPD
- Presence of other complications in pregnancy: Obstetric (preeclampsia, malpresenation, placenta previa)
or medical
- Resoruces limited for emergency cesarean delivery or patient refusal for VBAC-TOL
- History of prior uterine rupture

• Scar rupture
lower segment scar: during labor (0.2–1.5%)
classical or hysterotomy scar: during late pregnancy and labor (4–9%)

Features of scar rupture during labour

Abnormal CTG—(abnormal FHR, bradycardia, variable and late decelerations)
suprapubic pain persisting in between contractions
shoulder tip pain or chest pain or sudden onset of shortness of breath
acute onset of scar tenderness
abnormal vaginal bleeding or hematuria
cessation of uterine contractions which were previously adequate
 maternal tachycardia, hypotension or shock
loss of station of the presenting part

Risk Factors for Scar Rupture

- More the number (>2) of prior cesarean delivery
- Interpregnancy interval <24 months
- Induced labor
- Augmentation of labor [with high dose oxytocin (>20 mU/min)]
- Women having single layer uterine closure in prior cesarean delivery

• Normal Puerperium
Puerperium 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.
Duration: 6 weeks/ 42 days
Immediate Puerperium: first 24 hours
Early Puerperium: upto 7 days
Remote Puerperium: upto 6 weeks

• Involution of uterus
Immediately following delivery, the uterus becomes firm and retract with alternate hardening and softening.
Immediately following delivery, the lower segment becomes a thin, flabby and collapsed structure.
Following delivery, the fundus lies about 13.5 cm (5 1/2") above the symphysis pubis. During the first 24
hours, the level remains constant; thereafter, there is a steady decrease in height by 1.25 cm (0.5") in 24
hours, so that by the end of 2nd week the uterus becomes a pelvic organ.

• Lochia
It is the vaginal discharge for the first fortnight during puerperium. The discharge originates from the uterine
body, cervix and vagina. It has got a peculiar offensive fishy smell. Its reaction is alkaline, tending to become
acid toward the end. Depending upon the variation of the colour of the discharge, it is named as:
(1) lochia rubra (red) 1–4 days. Lochia rubra consists of blood, shreds of foetal membranes and decidua,
vernix caseosa, lanugo and meconium.
(2) lochia serosa (5–9 days) — the colour is yellowish or pink or pale brownish. Lochia serosa consists of
less RBC but more leukocytes, wound exudate, mucus from the cervix and microorganisms.
(3) lochia alba — (pale white) — 10–15 days. Lochia alba contains plenty of decidual cells, leukocytes,
mucus, cholesterin crystals, fatty and granular epithelial cells and microorganisms.
The average amount of discharge for the first 5–6 days is estimated to be 250 mL.

• General physiological changes

For a few hours after normal delivery, the pulse rate is likely to be raised, which settles down to normal
during the second day.
The temperature should not be above 37.2°C (99°F) within the first 24 hours.
slight reactionary rise following delivery by 0.5°F but comes down to normal within 12 hours
3rd day, there may be slight rise of temperature due to breast engorgement which should not last for more
than 24 hours.
In addition to the weight loss (5–6 kg) as a consequence of the expulsion of the foetus, placentae, liquor and
blood loss, a further loss of about 2 kg occurs during puerperium chiefly caused by diuresis.

• Puerperal pyrexia
A rise of temperature reaching 100.4°F (38°C) or more (measured orally) on two separate occasions at 24
hours apart (excluding first 24 hours) within first 10 days following delivery is called puerperal pyrexia.
Causes of puerperal pyrexia
- Puerperal sepsis
- Urinary tract infections: Cystitis, Pyelonephritis Mastitis, Breast abscess
- Wound infections: CS or Episiotomy
- Pulmonary infections : Atelectasis, Pneumonia
- Septic pelvic thrombophlebitis
- A recrudescence of malaria or pulmonary tuberculosis
- Others: Pharyngitis, Gastroenteritis

• Puerperal sepsis
An infection of the genital tract which occurs as a complication of delivery is termed puerperal sepsis.
Puerperal sepsis is commonly due to—
(i) endometritis,
(ii) endomyometritis
(iii) endoparametritis
(iv) or a combination of all these when it is called pelvic cellulitis.

Antepartum risk factors: Malnutrition and anaemia, Preterm labor, Premature rupture of the membranes,
Immunocompromised (HIV), Prolonged rupture of membrane more than 18 hours, Diabetes.
Intrapartum risk factors: Repeated vaginal examinations, Dehydration and keto acidosis during labor,
Traumatic vaginal delivery, Haemorrhage—antepartum or postpartum, Retained bits of placental tissue or
membranes, Prolonged labor, Obstructed labor, Cesarean delivery.

Causative organisms
Aerobic—Group A beta haemolytic Streptococcus, Staphylococcus pyogenes, S. aureus, E. coli, Klebsiella,
Pseudomonas, Proteus, Chlamydia
Anaerobic—Streptococcus, Peptococcus, Bacteroides, Fusobacteria, Mobiluncus and Clostridia

Clinical features
• Local infection: local wound becomes red and swollen, pus discharge from wound, high rise of
temperature with chills and rigour.
• Uterine infection: rise in temperature (>100.4°F) and pulse rate (>90), lochial discharge becomes offensive
and copious, uterus is sub-involuted and tender
• Spreading infection

Investigations
- High vaginal and endocervical swabs for culture and sensitivity test to antibiotics
- Urinalysis and culture
- Complete blood count
- Thick blood film should be examined for malarial parasites
- Blood culture, if fever is associated with chills and rigour
- Blood urea and electrolytes
- Blood culture, if fever is associated with chills and rigour
- Xray chest (CXR) should be taken in cases with suspected pulmonary Koch’s lesion

General care:
(i) Isolation of the patient is preferred
(ii) Adequate fluid and calorie are maintained by intravenous infusion (IV),
(iii) Anaemia is corrected by oral iron or if needed by blood transfusion,
(iv) An indwelling catheter is used to relieve any urine retention due to pelvic abscess
(v) monitoring by recording pulse, respiration, temperature, lochial discharge, and fluid intake and output
(vi) Antibiotics: Ideal antibiotic regimen should depend on the culture and sensitivity report. gentamicin (2
mg/kg IV loading dose, followed by 1.5 mg/kg IV every 8 hours) + clindamycin (900 mg IV every 8 hours)
+ Metronidazole (0.5 g IV is given at 8 hours) x 7–10 days
Surgical treatment: wound debridement/ secondary suturing, etc

Maternal Mortality
Triad of maternal mortality - haemorrhage, infections, hypotension
Maternal Mortality Rate indicates the number of maternal deaths divided by the number of women of
reproductive age (15–49). It is expressed per 100,000 women of reproductive age per year.
Maternal Mortality Ratio (MMR): The MMR is expressed in terms of such maternal deaths per 100,000 live
births.
MMR of India (2020): 97 per 1,00,000 live births
Target MMR by 2030: <70 per 1,00,000 live births

Causes of maternal mortality

- Direct obstetric deaths are those resulting from complications of pregnancy, delivery or their management.
Such conditions are abortion, ectopic gestation, preeclampsia-eclampsia, antepartum and postpartum
haemorrhage and puerperal sepsis.
- Indirect deaths include conditions present before or developed during pregnancy but aggravated by the
physiological effects of pregnancy and strain of labor.
These are anaemia, cardiac disease, diabetes, thyroid disease, etc. of which anaemia is the most important
single cause in the developing countries. Viral hepatitis when endemic, contributes significantly to maternal
deaths.
- Non-obstetric or fortuitous deaths: Accidents, typhoid and other infectious diseases.

Maternal Near Miss (MNM): Women who experienced and survived a severe health condition during
pregnancy, childbirth or postpartum are considered as maternal near miss or severe acute maternal morbidity
(SAMM) cases. Maternal near miss is defined as:“a woman who nearly died but survived a complication that
occurred during pregnancy, childbirth or within 42 days of termination of pregnancy” (WHO).