OBSTETRICS

SMAHRT NOTES
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Anatomy & Physiology ...............................................................................................................................5
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Physiological changes during Pregnancy ...................................................................................................9
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Diagnosis in Pregnancy .............................................................................................................................10
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Fetal skull and Maternal Pelvis ................................................................................................................12
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Antenatal Care, Pre-Conceptional Counselling & Care ...........................................................................14
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Normal labour ...........................................................................................................................................18
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Complications of 3rd stage of labour ........................................................................................................22
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Induction of Labour ..................................................................................................................................25
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Complicated labour ..................................................................................................................................27
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Normal Puerperium ..................................................................................................................................36
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Abnormalities of Puerperium...................................................................................................................38
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Complicated Pregnancy ............................................................................................................................40
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Multiple pregnancy, Amniotic disorders, Abnormalities of Placenta and Cord ....................................49
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Antepartum haemorrhage .......................................................................................................................53
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Hypertensive disorder in pregnancy ........................................................................................................57
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Medical and Surgical illness complicating pregnancy .............................................................................62
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Gynaecological disorders in pregnancy ...................................................................................................68
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Operative Obstetrics.................................................................................................................................69
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 Safe Motherhood, Epidemiology of obstetrics........................................................................................74
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Special topics in obstetrics .......................................................................................................................76
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Imaging in obstetrics ................................................................................................................................77
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Preterm labour, PROM, post maturity IUFD ...........................................................................................79
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Abnormal Uterine action ..........................................................................................................................82
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Contracted pelvis ......................................................................................................................................84
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Pharmacotherapeutics in Obstetrics .......................................................................................................86
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New born Infant ........................................................................................................................................88
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Diseases of Fetus and New Born ..............................................................................................................89
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Anencephaly [17]

Complete Perineal Tear [17]

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 Anatomy & Physiology

1) Describe the development of placenta and its functions. [63]

a. Functions of Placenta. [15, 11, 10]
b. Mention four important hormones produced in the placenta. [90]
Ans.
The placenta has 2 components:
 Fetal component – develops from the chorion frondosum
 Maternal component – develops from decidua basalis.
 These two, i.e., chorion frondosum and the decidua basalis form the discrete placenta. It begins at
6th week and is completed by 12th week.
 Subsequently, it circumferentially till term.
 The human haemochorial placenta derived
its name from hemo- (blood) that is in
contact with the syncytiotrophoblasts of
chorionic tissue
 Full Term Placenta –

1) Transfer of Substances between the mother and fetus via Simple Diffusion, Facilitated Diffusion,
Active Transport, Endocytosis, Exocytosis & Leakage in the Placental membranes. This helps in:
 Respiratory Functions – Ex: Intake of O2 and output of CO2 via Simple Diffusion
 Excretory Functions – Ex: Waste products from the fetus such as urea, uric acid & creatinine are
excreted in the maternal blood by simple diffusion.
 Nutritive Functions – Ex: Transfer of Glucose (via GLUT-1), Lipids, Amino acids, water & electrolytes to
Fetus
2) Endocrine function: Placenta is an endocrine gland. It produces both steroid and peptide hormones
to maintain pregnancy. Examples are:
 Progesterone (by the end of the 4th month)
 Estrogens, which promotes uterine growth and development of mammary gland
 HCG, which has an effect similar to luteinizing hormone (LH)
 Somatomammotropin (HCS), which has an anti-insulin effect on maternal blood
3) Barrier function – protect the fetus against noxious agents (of high molecular weight) circulating in the
maternal blood
4) Immunological function – Placenta offers immunological protection against rejection of fetus
(containing paternal antigens) by the mother. Some of the possible mechanisms are:
▪ Placental hormones have got some immunosuppressive effect
▪ Villous trophoblasts do not express HLA Class I or Class II molecules
▪ There is a shift of maternal response from cell-mediated (TH1) to humoral (TH2) immunity,
which may be beneficial to pregnancy
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1. Functions and clinical significance of amniotic fluid [21]
Ans.
Functions of amniotic fluid: Its main function is to protect the fetus –
During pregnancy During labor
1. It acts as a shock absorber, protecting the 1) The amnion & chorion  form a hydrostatic
fetus from external injury; wedge  help in dilatation of cervix;
2. Maintains an even temperature; 2) During uterine contraction, it prevents marked
3. The fluid distends the amniotic sac and interference with the placental circulation
thereby allows for growth and free 3) It guards against umbilical cord compression;
movement of the fetus and prevents 4) It flushes the birth canal at the end of first stage
adhesion between the fetal parts and of labor and by its aseptic and bactericidal action
amniotic sac; protects the fetus and prevents ascending
4. Water supply to the fetus infection to the uterine cavity.
Clinical significance of amniotic fluid
a) Study of the amniotic fluid provides information about the wellbeing and also maturity of the fetus;
b) Intra-amniotic instillation of chemicals helps in induction of abortion;
c) Excess or less volume of liquor amnii is assessed by amniotic fluid index (AFI) – to diagnose the
clinical condition of polyhydramnios or oligohydramnios respectively;
d) Rupture of the membranes with drainage of liquor is a helpful method in induction of labor
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2. Lower uterine segment and its clinical importance. [19, 10]
Ans.

 It is developed from the isthmus of the (nonpregnant) uterus, which is bounded above anatomical
and below by histological internal os.
 In labor, it is bounded above by the physiological retraction ring and below by the fibromuscular
junction of cervix and uterus
 It measures 7.5–10 cm when fully formed
 This segment has got poor retractile property
compared to the upper segment
 Clinical Importance:
 Cesarean section is performed through this
segment
 Implantation of placenta in lower segment is
known as placenta previa
 Poor decidual reaction in this segment facilitates morbid adherent placenta
 It is entirely the passive segment of the uterus. Because of poor retractile property, there is
chance of postpartum hemorrhage if placenta is implanted over the area
 In obstructed labor, the lower segment is very much stretched and thinned out and ultimately
ruptures especially in multiparae.
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3. Fetal circulation. [05]
Ans.
 The fetal circulation is different from that of adult circulation in the following 3 ways:
1. Blood in the fetus is oxygenated by placenta & not by lungs.

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 2. During fetal life, the lungs are collapsed; hence,
the resistance to blood flow through the lung is
much higher. As a result, only minimal amount of
blood passes through the lungs to supply oxygen
and nutrients to the lungs.
3. Portal circulation is of little significance.
 The fetal blood flow through the placenta is about
400 mL/min
 The highly oxygenated, nutrient-rich blood from the
placenta returns to the fetus by umbilical vein →
through the umbilical cord, enters the abdomen →
passes to the liver through falciform ligament.
 In the liver, the umbilical vein joins the left branch of
portal vein → bypasses the sinusoids of the liver
through ductus venosus into the IVC → mixes with
the deoxygenated blood returning from the lower
limbs → blood enters in the right atrium
 Most of the Blood enter via into the left atrium via foramen ovale.
 Some of the Blood remain in Right Atrium & mixes with the deoxygenated blood from the SVC and
passes to the right ventricle → pulmonary trunk, and right and left pulmonary arteries → most of it
passes into the aorta through the DA
 Blood from the left atrium passes to the left ventricle → into the ascending aorta → →→ common
iliac arteries → internal iliac arteries → 2 umbilical arteries pass through umbilicus and enter the
placenta through the umbilical cord, where it is oxygenated.
Changes in Fetal Circulation Just after Birth:
 Umbilical vein obliterates and forms a fibrous ligament called ligamentum teres hepatis.
 Ductus venosus obliterates to form a fibrous ligament called ligamentum venosum.
 At first the closure of foramen ovale is physiological, but later on septum primum fuses with the
septum secundum and there is an anatomical closure of foramen ovale. The closed foramen ovale
forms fossa ovalis.
 DA obliterates to form a fibrous ligament called the ligamentum arteriosum.
 Umbilical arteries (right and left) obliterate. However, their proximal parts remain open. The
proximal parts of umbilical arteries form superior vesicle arteries, whereas their distal parts form
fibrous ligaments called medial umbilical ligaments
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1. Anterior Fontanelle [21]

Ans.
The fontanelles are soft membranous areas in the vault of newborn skull
At sites where more than two bones meet the sutures are wide and are called fontanelles.
There are 6 fontanelles at birth – one at each angle of the parietal bone.
The most prominent of these is Anterior Fontanelle. It is diamond shaped and located where two
halves of the frontal bone and two parietal bones meet
The anterior fontanelle is usually closed between 2nd and 3rd year of age
All the fontanelles except anterior fontanelle are closed within 3 or 4 months after birth.
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2. Adherent placenta [05]
Ans.
A placenta may be adherent partially or completely.
 Partial adherence is often a/w partial separation and hence with bleeding; this is seen in the
third stage.
 A completely adherent placenta does NOT give rise to bleeding
Treatment: Manual Removal - The placenta must be removed en-masse and not piecemeal
• The tendency for hemorrhage should be controlled by iv oxytocics
• Abx should be given to control infection

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 Physiological changes during Pregnancy

1. Hemodynamic changes during normal pregnancy. [15, 98]

a. Cardiovascular changes in pregnancy {at least 4 changes} [09, 90]
b. Pregnancy changes in the first trimester. [04]
Ans.
Volume of Blood: pregnancy induce hypervolemia. Hence:
Increase in Blood volume by about 30% - The blood volume starts increasing during the 1st
trimester, expands most rapidly during the 2nd trimester & plateaus during the last weeks of
pregnancy
Packed Cell Volume
Increase in the total cell volume by about 20% - begins around 10-20 weeks of gestation – occurs
due to erythroid hyperplasia in the bone marrow
Increase in Plasma by about 50% – This accounts for the haemodilution in pregnancy (aka
physiological anemia of pregnancy).
The presence of a fetus is not essential for hypervolemia – since it is also seen in hydatidiform mole
Significance of Hypervolemia:
 It meets the demands of the enlarged uterus
 It protects the mother against blood loss during delivery
 It protects the fetus against deleterious effects of impaired venous return in supine & erect
positions
Composition of Blood
  Erythrocyte count from 4.5 to 3.7 million/mm3 at about 30 weeks
  Hb conc. from 13-14 g/l to 11-12 g/l
  hematocrit from 40 – 33%
  leucocyte count upto 12,000/mm3 in the postpartum period.
Coagulation
▪  Fibrinogen by about 50%
▪ All clotting factors except XI and XIII increase during pregnancy.
▪ Clotting time and bleeding time are unchanged
▪  in plasminogen activity & fibrinogen degradation products
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1. Causes of oedema in pregnancy. [18]

Ans.
Physiological edema – disappears on rest, confined to one leg (R>L) – occurs due to  venous
pressure on the lower limbs by the gravid uterus pressing on the common iliac veins.
Preeclampsia
Anemia
Hypoproteinaemia
Cardiac failure
Nephrotic syndrome

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 Diagnosis in Pregnancy

1. Signs and symptoms of pregnancy. [18]

a. Symptoms and signs of early pregnancy [11]
b. Hegar’s sign. [15, 98]
c. Quickening. [09]
Ans.
Trimester Subjective symptoms Objective signs
 Breast Changes: General Enlargement,
Montgomery's follicles, clear fluid in breast etc.
 Bluish discolouration of the vagina – Jacquemier’s
or Chadwick’s sign – visible at 8th week
 Amenorrhea   vaginal pulsations – Osiander’s sign aet 8th week
 Morning sickness  Uterine changes:
 Salivation, longings &  Pear-shaped uterus becomes rounded or
1st pica globular & more anteflexed.
trimester  Easy fatiguability  Uterus reman a pelvic organ until 12th week
 Breast discomfort  Hegar’s Sign: Softening and compressibility of the
 Irritability of the bladder isthmus or lower uterine segment – seen from 6th-
( micturition due to pressure on the
bladder by the growing uterus) 12th week of pregnancy
 Cervical Changes
▪ Transverse slit
▪ Cervix softens (lie the lips of the mouth)
▪ Cervical mucus – beaded pattern on microscopy
Breast Changes: 2° areolae develop on Breast
Skin Changes:
 Pigmentation on forehead, cheeks, breast etc.
 Striae on abdomen
Active fetal movements & Palpation of fetal parts
Uterine changes: gradual increase in size &
becomes ovoid in shape.
Per abdomen: Uterus can be palpated at different
levels in abdomen at successive periods of pregnancy
Intermittent uterine contractions (Braxton Hick
Quickening –
Sign): elicited by keeping the hand in contact with abdominal
2nd perception of fetal wall over the uterus.
trimester movements by mother Auscultatory signs
start around 16th week Fetal heart – can be heard from 17th week with
a pinard fetoscope
Funic souffle – sharp, whizzing sound
synchronous with fetal pulse – occurs due to
rush of blood through umbilical arteries
Uterine souffle – soft, blowing sound
synchronous with maternal pulse – occurs due
to passage of blood via dilated uterine arteries.
Internal ballottement
External ballottement

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  Uterus fills almost the entire abdomen
3rd  Fetal movements are more easily felt & seen
trimester  Fetal parts are easily palpable
 Fetal heart is heard clearly & Ballottement is not obtainable
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2. Pap smear. [05]
Ans. Pap smear is the gold standard for screening cervical cancers
➢ Cells are scraped from the transformation zone using a brush and analyzed under a microscope
to identify cytologic abnormalities.
➢ Dysplastic cells are classified as low grade (CIN I) or high grade (CIN II and III).
 Limitations of the Pap smear include inadequate sampling of the transformation zone (false -ve
screening) and limited efficacy in screening for adenocarcinoma.
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3. Pregnancy tests. [01, 98, 96]
Ans.
 Detect hCG in urine & blood – immunoassays, ELISA & Home PT kits
 Ultrasound detects:
 Gestational sac by 4-6 weeks
 Yolk sac at 5-6 weeks
 Fetal heartbeat by the end of 6th week
 Gestational age

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 Fetal skull and Maternal Pelvis

1. Posterior sagittal diameter. [02]

Ans.
Posterior sagittal diameter of the pelvic outlet – It is the distance from the midpoint of line
between the ischial tuberosities & the external surface of the tip of sacrum. It is usually > 7.5 cm
Posterior sagittal diameter of the Midpelvis – This is an area behind the line joining the ischial
spines and in front of the sacrum. It measures 4.5 cm
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2. Moulding. [02]
Ans.
As the fetal skull bones are united only by fibrous tissue, they can slide and override each other to
accommodate to the shape and size of the maternal pelvis. This process occurs during labour and is
known as moulding.
Because of moulding, the diameters of the fetal skull become slightly shortened and the
circumference reduces.
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3. Types of pelvises [05]
Ans.
GAAP Caldwell and Moloy’s Classification of Pelvic Shapes
Type of Pelvis Unique Features Clinical Significance
1. Gynecoid Here the diameters are  There is a delay at every stage of labour due to lack
pelvis proportionately reduced, of space.
but the shape is normal  Powerful uterine contractions are required to push
the presenting part downward.
AP diameter of inlet > With this type of pelvis, Persistent Occipito-
2. Anthropoid
Transverse diameter posterior position is common.
pelvis
(ape type)
Due to Funnel shape of With this type of pelvis, the Occipito-
3. Android
pelvis, rotation fails to posterior position is common
Pelvis
occur & transverse arrest
(male type)
is common
4. Platypelloid Transverse oval inlet With this type of pelvis, there is difficulty
pelvis in engagement of the fetal head.
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1. What is Caput succedaneum? Mention its importance [14]

Ans.
Caput succedaneum is an area of edema over the presenting part, which is seen at birth & resolves
spontaneously within the next few days.
It is an extracranial injury which occurs while the head descends to press over the dilating cervix

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 Importance:
It signifies static position of the head for a long period of time
In left position, the caput is placed on right parietal bone and vice
versa
With increasing flexion, the caput is placed more posteriorly
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2. Diagonal conjugate [13, 01]
Ans.
Diagonal conjugate is the distance from the promontory of the sacrum to the apex of the pubic arch
 It is about 1.5-2 cm greater than the obstetric conjugate (Obstetric conjugate is the shortest
diameter through which the presenting part of the fetus must pass at the time of delivery)
 Hence obstetric conjugate is indirectly calculated using diagonal conjugate.
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3. Diameters of foetal skull [11]
Ans.
Certain diameters of the fetal skull are important as they give an idea of the shape and size of the
fetal skull and an approximate measurement of the
circumference
The diameters of the fetal skull commonly taken into
consideration are:
Bitemporal diameter: 8 cm BOSS BV
Biparietal diameter:
Sub-Occipito-bregmatic diameter:
Sub-mento-bregmatic diameter:
Occipito-frontal diameter: 11 cm
Vertico-mental diameter: 13 cm

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 Antenatal Care, Pre-Conceptional Counselling & Care

1. Mrs. Y aged 23 years with 2 months of Amenorrhoea, UPT +ve comes to hospital for check-up.
Write in brief the examination, antenatal investigations, antenatal advice and follow up for the
patient. [19]
a. Antenatal investigations. [20]
b. Tetanus immunization in pregnancy. [14]
c. Nutrition in pregnancy. [05]
d. Describe the schedule of Antenatal visits in each trimester & the importance of such visits. [02]
Ans. Systematic supervision (examination & advice) of a woman during pregnancy is called Antenatal
(prenatal) care.
:
– as soon as the pregnancy is suspected (≥ 2 missed period)
:
 To confirm the pregnancy
 To identify risk factors for the pregnancy
 To estimate the gestational age of the fetus
 To formulate a plan for prenatal care & advice
:
General History Obstetric History
Identification Data – name, age, SES. Obstetric Formula: G P L A D
Menstrual history; LMP; EDD LCB
OCPs used? Past Obstetric History: Eventful? If yes, then describe
Mode of conceiving? in detail.
Immunisation history ▪ Nature of Delivery?
Nausea, vomiting, constipation, ▪ Any abortions, eclampsia, APH, stillbirth?
sleeplessness? High-risk Pregnancies
Marital History – Any consanguinity? Pre-existing maternal diseases: DM, HTN, Epilepsy, Auto-
Any infertility treatment taken? immune disorders, Renal & cardiac anomalies etc.
BOH; teenage & elderly pregnancy; Chromosomal
Diet History anomaly; h/o LSCS, Rh incompatibility etc.
Drug history – H/o allergy to drugs?

 Uterus may not be palpable per abdomen till 12-14 weeks

 Height, weight & BMI
 PV – to confirm pregnancy, look for any lesions in
 BP, pallor & pedal edema
cervix & obtain Pap smear
 Check Breast & Nipples for infection
 Auscultate for FHS
Naegle’s Rule: EDD = LMP + 7 days & 9 months
high-risk pregnancy – if yes, then
multi-disciplinary approach is required – Label them with RED stickers in their AN cards.
– in uncomplicated pregnancy – once a month till 28 weeks
 once a fortnight till week 36  once a week till term.
:
ABO & Rh typing – to arrange for Blood & to check for Rh-incompatibility with the husband
Hb & CBP – to check for iron deficiency anemia – 4 times (once in each trimester & at term).

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 Coagulation profile – to check for bleeding disorders
Serology – VDRL, HBsAg, HIV etc.
Screening for Diabetes (with OGTTHbA1c) & thyroid disorders
CUE & urine C/S tests – to detect & treat asymptomatic bacteriuria – in each trimester
USG – at least 4 scans:
a. Dating/viability scan @ 6-8 weeks – to know POG & viability of fetus
b. NT scan @ 11-13 weeks – to look for anencephaly, omphalocele, nasal bridge (down syndrome)
c. TIFFA /Anomaly / target / booking scan @ 18-20 weeks – is a MUST!!!
d. Growth scan @ 30-32 weeks
:
Avoid hard & tiring work
Restrict sexual intercourse especially in the 1st & last few weeks
Read books on motherhood & avoid stress.
Assure that she can anticipate an uneventful pregnancy with uncomplicated delivery.
Educate her about the Warning signs in pregnancy: Bleeding PV, escape of fluid from vagina,
dysuria, pelvic pain, fever, blurring of vision, fetal movements etc.
Optimal Weight gain in Pregnancy – 12.5 kg
Nutrition in pregnancy:
During pregnancy, there is calorie requirement due to growth of the maternal tissues,
fetus, placenta and increased basal metabolic rate
Generally, the diet in pregnancy should be of woman’s choice as regard the quantity & type
- Woman with normal BMI should eat adequately so as to gain the optimum weight (12.5 kg).
- Overweight women with BMI between 26 and 29 should limit weight gain to 7 kg and obese
women (BMI > 29) should gain less weight.
- Excess weight gain  antepartum and intrapartum complications including fetal macrosomia
- Avoid excess caffeine intake – may lead to miscarriage
Dietary supplements:
⇨ 100 mg of elemental iron & 500 mcg of FA should be taken daily for 100 days during
pregnancy (avoid iron in 1st trimester)
⇨ IFA (iron-folic acid) tablets are also given during the lactation period.
Vaccination: Td vaccine – 2 doses with 4 weeks apart – to prevent neonatal tetanus
 Covid-19 vaccine can be given in any trimester

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1. Methods of calculation of expected date of delivery. [21]
Ans.
EDD can be calculated by the following methods:

Date of fruitful coitus: Add 266 days to the date of the single fruitful coitus = EDD. This is not
much practicable except when the pregnancy occurs in instances of sudden death or absence of
the husband or rape.
Naegele’s formula: EDD = LMP + 7 days & 9 months
Date of quickening: Add 22 weeks in primigravidae and 24 weeks in multiparae to the date of
quickening.
– The required weeks are to be added to make it 40 weeks.
Clinical Records – Ex: Palpation of fetal parts at the earliest by 20th week.
Investigation records:
 +ve UPT at 1st missed period by earliest.
 USG findings at the earliest are:
a. Gestation sac — at 5 weeks.
b. Measurement of crown rump length (CRL): CRL in cm + 6.5 = weeks of pregnancy.

Height of the uterus above the symphysis pubis in relation to the landmarks on the abdomen
Lightening: the labor is likely to commence within 3 weeks of lightening.
Size of the fetus, hardening of the skull and girth of the abdomen etc.
Vaginal examination: If the cervix becomes dilated, the labor is fairly not far off.
: Sonography & X-ray {ossification centers in the Lower end of femur (36–37 weeks) & upper end of the tibia
(38–40 weeks)}
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2. Amniocentesis and its significance. [09, 02, 90]
a. Define amniocentesis and mention its two diagnostic indications. [14]
Ans.
: Amniocentesis is the deliberate puncture of the amniotic fluid sac per abdomen.
It is the MC used invasive technique for prenatal diagnosis
:
Diagnostic indications Therapeutic indications
(15-20 weeks): To 1st half:
diagnose chromosomal & genetic
Induction of abortion by instillation of chemicals
disorders like: Sex-linked
such as hypertonic saline, urea or prostaglandins.
disorders, Karyotyping, Inborn Repeated decompression of the uterus in acute hydramnios
errors of metabolism & Neural nd
tube defects 2 half:
: Decompression of uterus in unresponsive cases of
- To assess fetal maturity chronic hydramnios
- To assess the degree of fetal To give intrauterine fetal transfusion in severe
hemolysis in Rh-sensitized hemolysis (after Rh isoimmunization)
mother & Amnioinfusion in oligohydramnios

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 - To detect Meconium staining
of liquor
: Infection, Hemorrhage (placental or uterine injury), PROM, premature
labour & Maternal isoimmunization in Rh-negative cases
: Trauma, Oligohydramnios due to leakage of amniotic fluid, Feto-maternal
hemorrhage & Fetal loss etc.
Early amniocentesis (11–14 weeks) not to be done for genetic indications as the cell culture failure
rate & complications are high
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1. Chorion villous biopsy. [10]

Ans.
Aka Chorionic villous sampling – it is an invasive diagnostic procedure done in the 1st trimester
between 10-12 weeks of gestation for prenatal diagnosis of genetic disorders.
It is an alternative to genetic amniocentesis.
It is carried out transcervically between 10 weeks and 13 weeks and transabdominally from 10
weeks to term
Results can be obtained within 24 hours.
It  the psychological stress of awaiting the results till mid-pregnancy & allows a safer method of
pregnancy termination in the 1st trimester itself, should an abnormality be detected
Complications: fetal loss, oromandibular limb deformities or vaginal bleeding.

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 Normal labour

1. Normal labour – Define; Causes of onset; Events; Mx of each stage [09]

a. Physiology & Mx of 3rd stage {placental stage} of normal labour. [19, 18, 15, 08, 03, 02]
b. Active Mx of 3rd stage of labour. [19]
c. Immediate care of newborn [07]
Ans.
: Series of events that take place in the genital organs in an effort to expel the viable
products of conception (fetus, placenta and the membranes) out of the womb through the vagina
into the outer world is called Labor
if it fulfils the following criteria:
(1) Spontaneous in onset and at term.
(2) With vertex presentation.
(3) Without undue prolongation.
(4) Natural termination with minimal aids.
(5) Without having any complications to the mother or baby
:
Uterine distension (stretch) by the growing fetus and liquor amnii.
Fetal hypothalamic-pituitary-adrenal axis activation  cortisol  production of estrogen &
Prostaglandins from the placenta
Estrogen  oxytocin release from maternal pituitary & potentiates its effect on myometrium
Prostaglandins  initiate and maintain labor. Their synthesis is triggered by  estrogen &
cortisol & by mechanical stretching in late pregnancy
 myometrial oxytocin receptors & their sensitivity during labour
Neurological factor: α adrenergic receptors under effect of estrogen  contractile response
around the cervix, and the lower part of the uterus
Events Duration in primi Duration in multi
st
1 1) Dilatation & effacement of the cervix 12 hours 6 hours
Stage 2) Full formation of lower uterine segment {8.6h avg.} {5.3h avg.}

2nd It begins with the full dilatation of the cervix & ends with
2 hours 30 minutes
Stage expulsion of the fetus via propulsive & expulsive forces
3rd Placental separation & it’s descent to the lower 15 minutes 15 minutes
Stage segment and finally its expulsion with the membranes. (5 min with Active Mx) (5 min with Active Mx)
th
4 Stage of observation to monitor maternal vitals, uterine
at least 1 hour at least 1 hour
Stage retraction and any vaginal bleeding; Baby is examined

Mechanism of Placental Separation:

 Retraction of uterus reduces the surface area at the placental site. But as the placenta is inelastic, it
cannot keep pace with such an extent of diminution.
 A shearing force is instituted between the placenta and the placental site  Placental separation.
 There are 2 ways of separation of placenta:
a) Central separation (Schultze) – starts at the center  retroplacental hematoma  facilitate the
placental detachment along with uterine contraction.

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 b) Marginal separation (Mathews-Duncan) – starts at the margin; it is more common.
Separation of the Membranes – is facilitated partly by uterine contraction and mostly by weight of
the placenta as it descends down from the active part.
Expulsion of Placenta: either by voluntary contraction of abdominal muscles (bearing down
efforts) or by manual procedure
Mechanism of Control of Bleeding: After placental separation, innumerable torn sinuses have free circulation of blood from
uterine and ovarian vessels. To minimize blood loss, the following mechanisms play a key role:
 Complete retraction of uterus (arterioles are literally clamped);
 Thrombosis occurs to occlude the torn sinuses (due to hypercoagulable state of pregnancy).
 Apposition of the walls of the uterus following expulsion of the placenta (myotamponade)
Clinical course of 3rd stage:
Pain: For a short time, the patient experiences no pain. There might be intermittent discomfort
in the lower abdomen
Examination
findings
Before separation After separation
Uterus becomes discoid in shape, Uterus becomes globular, firm,
Per firm in feel and non-ballottable. and ballottable
abdomen Fundal height reaches below the Fundal height is slightly raised
umbilicus Slight bulging in suprapubic region
Slight trickling of blood Slight gush of vaginal bleeding
Per vaginum Length of umbilical cord remains Lengthening of the cord is seen
static
Stage of
Management
Labour
 General—Encouragement, emotional support and assurance
 Rest and ambulation – to encourage descent of head (walk only if membranes are intact)
 Diet—food is withheld during active labor; Fluids can be given.
 Bladder care – encourage to pass urine (as full bladder inhibits uterine contraction)
 Relief of pain: Pethidine 50–100 mg + Metoclopramide 10 mg IM – ONLY in early stage.
Pethidine crosses the placenta and is a respiratory depressant to the fetus – hence AVOID in the late stage.
 Record partograph.
1st Stage  Partograph is charted every half an hour.
 Record Urine output
 Abdominal palpation – note the gradual disappearance of poles of head on
pelvic grip
 For fetal well-being – Note FHR along with its rhythm & intensity
 PV exam – to check Dilatation of the cervix (in cm), position of the head &
degree of molding of the head.
Expectant should be in bed in Dorsal position with 15° left lateral tilt + flexion
at hip & knee + Abduction of thigh
Clean the external genitalia and inner side of the thighs with cotton swabs
soaked in Savlon or Dettol solution
2nd Stage Delivery of the head, shoulder & trunks
3 Cs - (a) Clean hands, (b) Clean surface & (c) Clean cutting & ligaturing of the cord
To prevent perineal tear – warm compress, perineal massage & modified Ritgen maneuvers
In cases of 2nd stage arrest, go for –
 C-section – if there is severe moulding {CPD} or fetal station is ABOVE +2
 Instrumental delivery – if fetal station is ≥ +2.

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 Immediate care of newborn – clear the oropharynx, APGAR rating; Delayed
cord Clamping {to prevent anemia of newborn}. Early clamping should be done in Rh-incompatibility,
Diabetic mother, preterm babies etc. General check-up of the Baby

3rd Stage Active management of 3rd stage labour is preferred to prevent PPH

Inject uterotonic to the

mother within 1 min of
delivery of the baby
Delayed cord clamping
Deliver placenta by
controlled cord traction
– modified Brandt
Andrews technique
Intermittent
assessment of uterine
tone

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1. Mechanism of labour in Occipito-anterior position [21, 19, 18]

a. Mechanism of labour. [10, 09]
Ans.
 Definition: 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.
 Mechanism: in Occipito-lateral position
1) ngagement nternal rotation 7) estitution,
2) escent rowning, 8) xternal rotation, and
3) lexion xtension, 9) xpulsion of the trunk
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2. Define first stage of labour. [05, 90]
Ans.

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 First Stage of Labor
 Begins with regular uterine contractions and ends with complete cervical dilatation at 10cm
 Divided into a Latent phase (< 3 cm) and an Active phase (3-10 cm)
 Latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix
 Contractions become progressively more rhythmic and stronger
 Active phase begins at about 3-4 cm of cervical dilation and is characterized by rapid cervical
dilation and descent of the presenting fetal part.
 (Refer 1st LQ for Mx)
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1. True labour pains. [19]

Ans.
True labor pain is characterized by:
1) Painful uterine contractions at regular intervals,
2) Frequency, Intensity & duration of contractions increases gradually,
3) associated with “show” {cervical mucus plug mixed with blood}
4) Progressive effacement and dilatation of the cervix,
5) Descent of the presenting part,
6) Formation of the “bag of forewaters” and
7) Not relieved by enema or sedatives
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2. Crowning. [04]
Ans.
 It is one of the mechanisms of labor
 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

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 Complications of 3rd stage of labour

1. PPH – Define; Causes; Mx & Prevention of Atonic PPH. [21, 20, 16, 15, 14, 11, 08, 05]
a. Predisposing causes for atonic PPH [21]
b. Traumatic PPH & it’s causes [03, 94]
Ans.
The clinical definition of PPH states, “any amount of bleeding from or into the genital tract following
birth of the baby up to the end of the puerperium, which adversely affects the general condition of the
patient evidenced by rise in pulse rate and falling blood pressure is called postpartum hemorrhage”.
: 4 T’s
– atonicity – MCC of PPH – Predisposing
factors for atonic uterus are: Mismanaged 3rd
stage of labor, Grand multipara, Overdistension
of the uterus {big baby, hydramnios, multiple
pregnancy}, uterine malformations, uterine
fibroid, Prolonged labor, Malnutrition, anemia,
APH, Anesthesia, obesity etc.
– genital tract injury – Ex: after operative delivery, episiotomy wound etc.
Combination of atonic and
traumatic causes
(retained bits of placenta,
blood clots)
– coagulopathy.

 Bleeding PV
 Per abdomen:
▪ Contracted uterus 
traumatic PPH
▪ Flabby uterus  atonic PPH
:
–
- Identify High-risk patients,
correct anemia, malnutrition,
- Blood grouping
- Placental localization by USG or
MRI to detect placental
abnormalities
–
Active management of the 3rd
stage;
Infusion of oxytocin should be
continued for at least 1 hour
after the delivery;

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 Exploration of the uterovaginal canal for evidence of trauma following difficult labor, examine
placenta to detect any missing part & keep under observation for about 2 hours after delivery
----------------------------------------------------------------------------------------------------------------------------------------

1. Inversion of uterus. [13, 01]

Ans. It is an extremely rare but a life-
threatening complication in third stage in
which the uterus is turned inside out
partially or completely
Degrees of inversion:
▪ 1st Degree - There is dimpling of the fundus
▪ 2nd Degree – The fundus passes through the cervix but lies inside the vagina
▪ 3rd Degree (complete inversion) – The endometrium with or without the attached placenta is
visible outside the vulva.
Etiology:
 Spontaneous inversion – occur due to localized atony on the placental site over the fundus a/w
intra-abdominal pressure as in coughing, sneezing or bearing down effort
 Iatrogenic – due to mismanagement of 3rd stage – Ex: Pulling
the cord when the uterus is atonic
 Other risk factors: prolonged labor, fetal macrosomia, uterine
malformations, morbid adherent placenta, short umbilical cord,
tocolysis and manual removal of placenta.
Diagnosis of Inversion of uterus:
- Acute lower abdominal pain with bearing down
sensation
– dimpling of fundus on PA; Bi-manual examination
confirm the Dx; shock
▪ In complete inversion, a pear-shaped mass protrudes
outside the vulva.
Sonography can confirm the diagnosis when clinical examination is not clear
Complications of Inversion of uterus: neurogenic shock; Hemorrhage, Pulmonary embolism; infection,
uterine sloughing etc.
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2. Retained placenta. [12, 03, 2000]
a. Manual removal of placenta. [03]
Ans. : The placenta is said to be retained when it is not expelled out even 30 minutes after
the birth of the baby {WHO, 15 minutes).
:
Poor voluntary expulsive efforts
Simple adherent placenta, atonic uterus, Morbid adherent placenta
Premature attempts to deliver the placenta before it is separated.
Placenta incarcerated following partial or complete separation due to constriction ring
: the diagnosis of retained placenta is made by an arbitrary time (15 minutes) spent following
delivery of the baby; features of placental separation are assessed

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 – Hemorrhage, shock, Puerperal sepsis & risk of recurrence in
next pregnancy
:
Period of watchful expectancy – watch the patient carefully for half-an-hour & note the signs of
separation of placenta.
Any bleeding during the period should be managed as outlined in third-stage bleeding
If Placenta is separated and retained express the placenta out by controlled cord traction
If Unseparated retained placenta  is to be done under general
anesthesia
:
 Hour-glass contraction  difficulty in introducing the hand
 Morbid adherent placenta  difficulty in placental separation.
: Hemorrhage, Shock; Injury to the uterus; Infection;
Inversion (rare); Subinvolution; Thrombophlebitis; Embolism
----------------------------------------------------------------------------------------------------------------------------------------
3. Secondary Post-partum haemorrhage. [04, 95]
Ans.
: Secondary PPH refers to the bleeding which occurs beyond 24 hours and within puerperium
– aka delayed or late puerperal hemorrhage.

Retained bits of cotyledon or membranes (most common);

Infection and separation of slough over a deep cervicovaginal laceration;
Endometritis and subinvolution of the placental site – due to delayed healing process;
Secondary hemorrhage from cesarean section wound (usually occurs between 10 and 14 days).
Withdrawal bleeding following estrogen therapy for suppression of lactation;
Other rare causes are: chorionepithelioma; carcinoma cervix; placental polyp; infected fibroid,
uterine AV fistula formation and puerperal inversion of uterus.
: bleeding is bright red
Examination reveals evidence of anemia, sepsis & subinvolution of the uterus
Ultrasonography is useful in detecting the bits of placenta inside the uterus
:
Supportive therapy – Blood transfusion + methergine 0.2 mg IM + Abx (clindamycin & metronidazole)
Identify the cause & treat accordingly – Ex: if the cause is retained bits of cotyledon or membranes
 explore the uterus urgently under general anesthesia  remove the products by ovum forceps
send for Histopath examination curettage  Methergine 0.2 mg IM.
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1. Mention complications of 3rd stage of labour [21]

Ans.
Primary Postpartum Hemorrhage & Secondary Postpartum Hemorrhage
Retained Placenta
Shock – hemorrhagic or non-hemorrhagic
Pulmonary embolism either by amniotic fluid or by air
Inversion of the Uterus

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 Induction of Labour

1. Partograph / Partogram [16, 14, 12, 06, 04]

Ans.
A Partograph / Partogram is a composite graphical record of cervical dilatation and descent of head
against duration of labor in hours.
It also gives information about fetal and maternal condition, which are all recorded on a single
sheet of paper.
Modified WHO Partogram – MC used; it consists of 3 parts:
Top most part – indicates fetal condition {FHR, status of amniotic fluid & moulding}
Middle part – indicates progression of Labour {dilatation of cervix w.r.t time}
Bottom part – indicates maternal conditions {contractions, Drugs given, Pulse, BP, urine output & Temp.}
Cervical dilatation is usually measured with fingers but
recorded in centimeters.
1 finger = 1.6 cm
Cervical dilatation is a sigmoid curve and the 1st stage
of labor has 2 phases—
1. Latent phase – it is a period from the onset of true
labor pain till the cervical dilatation becomes 3-4 cm.
It is 20h in primi {8.6h avg.} & 14h in multipara {5.3h avg.}
with cervical dilatation averaging only 0.35 cm/h
2. Active phase – (the pink bar) .
Here cervical dilatation is @ 1 cm/h in primi & 1.5 cm/h in multipara.
----------------------------------------------------------------------------------------------------------------------------------------
2. Induction of labour. [04, 02, 93, 67]
Ans.
Induction of labor (IOL) means initiation of uterine contractions (after the period of viability) by any
method (medical, surgical or combined) for the purpose of vaginal delivery
Methods of IOL Common Indication Methods
Intrauterine fetal death Drugs used are:
Fetus with a major congenital - Misoprostol (PGE1)
anomaly - Oxytocin
Premature rupture of - Mifepristone
Medical
membranes - Relaxin
methods
Maternal medical Non-pharmacologic methods:
complications – Ex: DM Mechanical dilators; Transcervical
In combination with surgical balloon catheter & Extra-amniotic saline
induction (ARM) infusion
 Abruptio placentae
 Chronic hydramnios
 Amniotomy or Artificial rupture of the
 Postmaturity
Surgical membranes (ARM)
 Severe pre-eclampsia/
methods  Stripping the membranes
eclampsia
 Low rupture of membranes
 In combination with medical
induction

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 Combined Commonly done – to shorten the delivery interval.
methods Medical methods followed by surgical or surgical methods followed by medical

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1. Bishop's score. [13]

Ans.
 Bishop's score is used to assess the cervical condition and the station of fetal head, in order to
choose the best method for induction.
 Bishop’s preinduction cervical score can predict the success of induction

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 Complicated labour

1. What are the causes of Shoulder Presentation? Discuss the management of a case seen - (a) Early
in Labour & (b) Late in Labour with hand prolapse [16]
a. Neglected shoulder presentation. [04]
Ans.
Shoulder Presentation is seen in transverse lie {When the long axis of fetus lies perpendicular to
the maternal spine or centralized uterine axis, it is called transverse lie}
:
Multiparity: Lax abdomen and imperfect uterine tone
Multiple pregnancy: Mote common for the second baby
Polyhydramnios Placenta previa
Prematurity Pelvic tumors (fibroids/ ovarian cysts)
Uterine anomalies CPD/contracted pelvis
:
:
External cephalic version – if there is
good amount of liquor amnii and there is
no contraindication. External cephalic
version should be tried in all cases.
Cesarean section is the preferred
method of delivery if version fails or is
contraindicated.
:
Baby alive— go for LSCS. Internal version is not
recommended except in the case of second twin.
Baby dead—Cesarean section even in
such cases. Internal version should not
be done.

 By neglected shoulder, it means the series of complications that may arise

out of shoulder presentation when the labor is left uncared
 Such complications are impacted shoulder obstructed labor rupture of
uterus dehydration, ketoacidosis, shock and sepsis.
 These complications put the mother and the fetus at risk.
 With proper Intranatal supervision, the condition is avoidable but
unfortunately, the condition is still rampant in rural areas of the developing
countries.
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2. Breech presentation – types, mechanism of labour in breach & Mx in a multipara [06]

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 a. List the diameters of engagement in Breech presentation [21]
b. Etiology of Breech presentation [21]
c. Delivery of after coming head in breech. [13, 04, 2000, 96]
d. Management of after coming head in breech presentation. [10]
e. Indications for caesarean in Breach presentation. [02]
Ans. Breech is the most common malpresentation seen during pregnancy & labour
: In breech presentation, fetus is in longitudinal lie with the podalic pole occupying
the lower pole of uterus with the fetal buttocks and/or feet presenting at the maternal pelvic inlet
 Hydrocephalus (big head can fit well in the fundus)
Prematurity is the most common Fetal  Polyhydramnios/ oligohydramnios
cause factors  Multiple pregnancy
 Trisomies, anencephaly & myotonic dystrophy
{sacroanterior position}: ▪ Congenital malformation of the uterus
▪ Multiparity
Engagement of buttocks  Maternal
▪ CPD
Internal rotation of the anterior factors
▪ Uterine fibroid/pelvic tumors
buttock by 1/8th of a circle
▪ Past history
placing it behind the symphysis
 Placenta previa
pubis. Placental
 Cornufundal attachment of placenta
The buttocks and trunk, which factors
 Short cord
are compressible
structures, are Buttocks – one of the oblique diameters of the inlet
{engaging diameter is bitrochanteric – 10cm}
delivered first followed
by the head, which is Shoulder - same oblique diameter as that occupied
Diameters of
by the buttocks at the brim
the least compressible engagement of:
structure. Head - either the opposite oblique diameter as that
This can result in the occupied by the buttocks or the transverse diameter
{engaging diameter is suboccipitofrontal – 10cm}
entrapment of fetal
head which is common in footling presentation when the fetal legs
deliver through partially dilated cervix followed by entrapment of
fetal head
Breech is an Irregular-fitting fetal part and a slow dilator of cervix
 risk of PROM & cord prolapse
:
Engagement occurs either through the opposite oblique diameter or through the transverse diameter
The engaging diameter of the head is sub-occipitofrontal (10 cm).
Descent with increasing flexion  Internal rotation of the occiput anteriorly, through 1/8 th or 2/8th of a circle 
occiput behind the symphysis pubis Further descent  subocciput hinges under the symphysis pubis.
Head is born by flexion—chin, mouth, nose, forehead, vertex and occiput appearing successively. Th e expulsion of the
head from the pelvic cavity depends entirely upon the bearing-down eff orts and not at all on uterine contractions.

Burns-Marshall method: 👉🏻👉🏻👉🏻👉🏻👉🏻👉🏻👉🏻👉🏻👉🏻👉🏻

Forceps delivery When the occiput lies against the
back of the symphysis pubis, an assistant raises the legs of the child
to facilitate introduction of the blades from below
Malar flexion and shoulder traction (modified Mauriceau-Smellie-
Veit technique):
Baby placed on supinated left hand of the obstetrician
Obstetrician’s left hand – middle & index fingers – are placed on
malar bones to maintain head flexion

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 Obstetrician’s right hand over the baby’s shoulder
Assistant give suprapubic pressure
Give downward & backward traction till nape of neck is
visible
Give upward & forward traction to release face & brow
Depress to release occiput & vertex
If the head delivers suddenly without undergoing molding 
sudden compression & decompression  risk of tentorial
tears and intracranial hemorrhages
In sacroposterior position, the head has to rotate through 3/8th of a circle to bring the occiput
behind the symphysis pubis

 Primi with breech

 Big baby (fetal weight > 3.5 kgs) or
contracted pelvis
 Footling breech (high risk of cord prolapse)
 Twins with 1st baby in breech (risk of
interlocking of twins and risk of cord
prolapse)
 Previous LSCS with breech (risk of
scar rupture)
 Preterm breech (risk of intracranial
hemorrhage vaginal delivery)
 Star-gazing/flying fetus {fetal head
with extreme hyperextension}
 Precious pregnancy (like BOH,
previous stillbirths, previous
complications during vaginal breech
delivery, IVF conception, etc.)
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3. Dx and Mx of Rupture uterus. [10, 05]
a. Mention the causes of ruptured uterus. [12]
Ans.
Definition: Disruption in the continuity of all uterine
layers (endometrium, myometrium and serosa) any
time beyond 28 weeks of pregnancy is called rupture of
the uterus
Diagnostic features of Rupture uterus:
During Pregnancy:
h/o hysterotomy
Dull abdominal pain over scar area
Tenderness on palpation
Following uterine rupture, there will be sudden
FHR

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During labour:
Cessation of contractions
Shock and exhaustion
Absence of FHS & Loss of station
Bleeding PV
Shortening of cord immediately following a difficult vaginal delivery is pathognomic
Management:
– secure IV lines; Start blood transfusion, IV fluids & IV antibiotics

 Repair of uterus – if margins are clear & desirous of child

 Hysterectomy - Unless there is sufficient reason to preserve the uterus
Prevention:
Antenatal detection of factors likely to cause obstructed labor (Macrosomy, CPD, short stature,
malpresentations, etc.) and rupture uterus (previous cesarean section, hysterotomy,
myomectomy) and mandatory hospital delivery
Avoid undue force in ECV; Judicious selection of cases for VBAC
IPV and destructive operations not to be done in modern day obstetrics
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4. Right Occipito-posterior presentation – etiology, Dx & Mx. [04, 02, 93]
a. Describe the causes of persistent Occipito-posterior presentation [04]
Ans. When the occiput is placed over the right sacroiliac joint, the position is called right
occipitoposterior (ROP)
Right OP is 5 times more common than left OP since dextrorotation of the uterus & presence of the
sigmoid colon on the left disfavour LOP
Etiology:
 Pelvic Inlet – a/w anthropoid or android pelvis
 Fetal head deflexion due to: Anterior
placentation, Primary brachycephaly, High
pelvic inclination etc.
 Abnormal uterine contraction
Diagnosis of Occipito-posterior presentation
 Fetal limbs are felt more easily on either
side of the midline
Umbilical Grip
 Fetal back is felt in the flank away from
the midline
Head is not engaged;
Pelvic Grip The cephalic prominence (sinciput) is not as
prominent as it is in OA
Maximum intensity of FHS is on the flank {in
Auscultation direct OP – FHS is on midline}
▪ Elongated bag of membranes
▪ Posterior fontanelle is felt near the
sacroiliac joint
PV ▪ Anterior fontanelle is felt more easily & at
a lower level than the posterior one
▪ In late labour, the unfolded pinna points
towards the occiput.
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1. Cord prolapse & it’s causes [21, 16, 06]
Ans.
Cord prolapse refers to the abnormal descent of umbilical cord by the side of the presenting part.
: Anything which interferes with adaptation of the presenting part to the
lower uterine segment, may favor cord prolapse. These can be:
a) Malpresentations—the most common being transverse (5–10%) and breech (3%) especially
with flexed legs or footling and compound (10%) presentation
b) Contracted pelvis
c) Prematurity; Twins; Hydramnios
d) Placental factor— minor
degree placenta previa with
marginal insertion of the cord
or long cord
e) Iatrogenic—low rupture of the
membranes, manual rotation
of the head, ECV, IPV
:
 Cord pulsations can be palpated
directly
 USG for cardiac movements or
auscultation for FHS
 Continuous electronic fetal
monitoring – variability in FHR
may suggest occult prolapse
: 👉🏻

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2. Vaginal Delivery in previous Caesarean section [21]
a. Trial labour. [02, 91]
Ans. Pregnancy with a previous cesarean delivery belongs to a high-risk category
For this Pregnancy to opt for vaginal delivery, ACOG recommends the following guidelines:
 Only 1-2 previous LSCS
 Clinically adequate pelvis (no CPD)
 No other uterine scars or previous rupture
 Obstetrician available throughout active labor to
monitor & perform emergency LSCS if required
 Availability of resources (anesthesia, OT, blood) for
emergency cesarean delivery
 Informed consent of the woman.
VBAC {Vaginal Birth After previous Cesarean} and Trial Of Labor After Cesarean (TOLAC) is
successful in 70–76% of cases
Spontaneous onset of labor is desired. Induction of labor with prostaglandins increases the risk of
uterine scar rupture
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3. Deep Transverse Arrest [17, 13, 09]
Ans.
 Deep transverse arrest can be defined as a failure of both rotation and descent of the head from a
transverse position at or just above the level of the spines despite full dilatation of the cervix
 Toe head is deep into the cavity, sagittal suture is in the transverse bispinous diameter and there is
no progress in descent of the head even after 1 hour of full cervical dilatation
Causes of DTA Dx of DTA
 Faulty pelvic architecture such as prominent
 The head is engaged,
ischial spines, flat sacrum and convergent
 The sagittal suture lies in the transverse
side walls; Android pelvis
bispinous diameter,
 Deflexion of the head,
 Anterior fontanel is palpable,
 Weak uterine contraction,
 Faulty pelvic architecture may be detected.
 Laxity of the pelvic floor muscles.
Management: It depends on the fetal condition and pelvic assessment
 If vaginal delivery is not safe (big baby or inadequate pelvis) – go for Cesarean section.
 If Vaginal delivery is found safe, then any of the following Operative vaginal delivery methods can
be employed:
Ventouse—Excessive traction force should not be used
Manual rotation and application of forceps
Forceps rotation and delivery with Kielland in the hands of an expert.
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4. External Cephalic version. [16, 14, 11, 06, 05, 03]
Ans.
: ECV is a procedure to convert the fetus from
breech to cephalic presentation by external manipulation on
the maternal abdomen.
:
Decreases vaginal breech delivery and its associated
perinatal morbidity and mortality
Decreases rate of CS for breech
ECV is done at around 36 weeks (35-37 weeks) as an OPD
procedure
:
Premature onset of labor
Entanglement of the cord round the fetal part or formation of
a true knot leading to impairment of fetal circulation and fetal
death
Premature rupture of the membranes
Placental abruption and bleeding
 chance of feto-maternal bleed.
Amniotic fluid embolism
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5. Obstructed labour – causes, Dx and Mx. [05, 04, 03]
Ans.
: Obstructed labor is one where in spite of good uterine contractions, the progressive
descent of the presenting part is arrested due to mechanical obstruction.

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 Causes of Obstructed labour
 CPD; Contracted pelvis {undernutrition in childhood of the women}
 Cervical dystocia (prolapse or scarring)
Fault in Passage  Cervical or broad ligament fibroid
 Impacted ovarian tumor/nongravid horn of bicornuate uterus below
presenting part
▪ Transverse lie
▪ Brow/mento posterior face presentation/compound presentation
Fault in Passenger ▪ Occipito-posterior position
▪ Hydrocephalus/fetal ascites & Macrosomy
▪ Locked twins.
:
Patient is in agony, discomfort, restless
Exhaustion, ketoacidosis & sepsis
Retraction (Bandl's) ring will be formed at the junction of upper & lower segment
Per Abd – uterus is tense & tender; No FHS; Retraction ring is felt as a groove placed obliquely.
:
Principles of treatment: 'Never wait and Watch and Never use oxytocin' {to avoid rupture uterus}
Control dehydration, ketoacidosis & sepsis
Send blood for cross matching and. keep one pint ready
LSCS is the definitive treatment
If the head is low down (station +2 or +3), then forceps extraction can be done.
:
Antenatal detection of factors which likely to cause obstructed labor
Intranatal: Use of partograph, strict vigilance and timely intervention and referral if needed.
----------------------------------------------------------------------------------------------------------------------------------------

1. Lovset’s manoeuvre. [15]

Ans.
Lovset's manoeuvre is done for delivery of extended arms in vaginal breech
delivery
: Sacral promontory is at a higher level than pubic symphysis because of
the obliquity of the pelvis – Hence, when the anterior shoulder is above the
pubic symphysis, the posterior shoulder lies below sacral promontory
: The fetus is rotated through 180° in one direction and then in the
other direction to bring the arms down.
----------------------------------------------------------------------------------------------------------------------------------------
2. Causes for face presentation. [15]
Ans.
It is a rare variety of cephalic presentation
Here, the attitude of the fetus shows complete flexion of the limbs with extension of the spine.
There is complete extension of the head so that the occiput is in contact with the back. The
denominator is mentum
:
- Multiparity with pendulous abdomen; Contracted pelvis; Flat pelvis; Pelvic
tumors

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 – Congenital malformations {anencephaly}; Congenital goiter; Dolichocephalic
head; Congenital bronchocele; Twist of the cord several turns round the neck &  tone of the
extensor group of neck muscles
----------------------------------------------------------------------------------------------------------------------------------------
3. Diagonal conjugate. [12]
Ans.
It is the distance between the lower border
of symphysis pubis to the midpoint on the
sacral promontory
It measures 12 cm (4 ¾")
It is measured clinically during pelvic
assessment in late pregnancy or in labor
Obstetric conjugate is computed by
subtracting 1.5–2 cm from the diagonal conjugate
----------------------------------------------------------------------------------------------------------------------------------------
4. Face to pubis delivery. [11]
Ans.
It is one of the outcome of vaginal delivery in an
occipitoposterior position
:
If there is Marked deflexion  sinciput reaches the pelvic floor
first  occiput rotates 1/8th of a circle backwards so that it lies
more towards the sacrum  head is delivered by flexion
If there is moderate deflexion  both the sinciput & occiput
reach the pelvic floor simultaneously  head cannot rotate
further  labour comes to a standstill
If there is mild deflexion  occiput rotates 1/8th anteriorly  arrest of the head transversely
Face to pubis delivery can result in extensive perineal lacerations because the bulky occiput
distends the perineum.
Hence in all cases of face-to-pubis delivery, episiotomy is mandatory and perineal lacerations
should be anticipated and managed
----------------------------------------------------------------------------------------------------------------------------------------
5. Causes of unstable lie. [09]
Ans.
Unstable lie is a condition where the presentation of the fetus is constantly changed even beyond
36th week of pregnancy when it should have been stabilized
Causes of unstable lie:
a) Grand multipara with lack of uterine tone and pendulous abdomen— the most common cause,
b) Hydramnios
c) Contracted pelvis
d) Placenta previa
e) Pelvic tumor
----------------------------------------------------------------------------------------------------------------------------------------
6. Prolonged labour. [07]
Ans.

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 : The labor is said to be prolonged when the combined duration of the first and second
stage is more than the arbitrary time limit of 18 hours or cervical dilatation rate & descent of the
presenting part is < 1 cm/h for a period of minimum 4 hours observation.
:
– uterine inertia; inability to bear down; Regional (epidural) analgesia & constriction
ring
– CPD, android pelvis, contracted pelvis, cervical dystocia, pelvic tumor
- Malposition (occipitoposterior), Malpresentation (face, brow), Big baby &
Congenital anomalies of the baby (hydrocephalous).

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 Normal Puerperium

1. Define Puerperium. What are its abnormalities? Write in brief about physiology of lactation and
enumerate causes of failed lactation. [19, 10, 07]
Ans.
Puerperium is the period following childbirth during which the body tissues, especially the pelvic
organs revert back approximately to the prepregnant state both anatomically and physiologically
: Puerperium begins as soon as the placenta is expelled and lasts for approx. 6 weeks
:
Puerperal Pyrexia
Puerperal Sepsis
Subinvolution SUB - 5P
Urinary Complications – UTI, retention of urine, incontinence of urine & suppression of urine
Breast Complications
Puerperal Venous Thrombosis and Pulmonary Embolism
Psychiatric Disorders
: it consists of 4
phases:
Preparation of breasts (mammogenesis)
Synthesis and secretion from the breast
alveoli (lactogenesis)
Ejection of milk (galactokinesis)
Maintenance of lactation (galactopoiesis).
The milk, which is secreted initially before
parturition is called colostrum.
When the baby suckles, the impulses from touch receptors around the nipple stimulate
hypothalamus
Prolactin is responsible for lactogenesis but the activity of prolactin is suppressed by estrogen and
progesterone secreted by placenta
When the baby suckles, the impulses from touch receptors around the nipple stimulate
hypothalamus  secrete prolactin-releasing factors 
release of prolactin from anterior pituitary  Prolactin
acts on glandular tissues and maintains the functional
activity of breast
Prolactin also inhibits GnRH secretion  lactational
amenorrhea
Milk ejection is a reflex phenomenon

Infrequent suckling
Endogenous suppression of prolactin (ergot preparation, pyridoxine, diuretics or retained placental
bits)
Pain, anxiety and insecurity may be the hidden reasons
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1. Define Lochia and mention its clinical importance. [18]
Ans.
Lochia is the vaginal discharge for the first fortnight during puerperium. It originates from the
uterine body, cervix and vagina.
Clinical importance: The character of the lochial discharge gives information about the abnormal
puerperal state
: Duration of the lochia alba beyond 3 weeks suggests local genital lesion
: Persistence of red color beyond the normal limit signifies subinvolution or retained bits
of conceptus.
: Scanty or absent — signifies infection or lochiometra. If excessive indicates infection
: If malodorous—indicates infection

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 Abnormalities of Puerperium

1. Puerperal infection – etiology, clinical features, and management [01]

a. Puerperal sepsis – Causes, Symptoms, signs, Inv. Treatment & prevention [17, 14, 08, 05, 04, 02]
b. Causes of puerperal pyrexia. [15]
c. How will you manage a case of puerperal fever? [10]
Ans.
Puerperal Sepsis (Syn: Puerperal infection)
Definition: An infection of the genital tract which
occurs as a complication of delivery is termed puerperal
sepsis
Causes of Puerperal sepsis:
Endometritis, endomyometritis, endoparametritis or
a combination of all these called as pelvic cellulitis
Derangement in Vaginal flora
Causative organisms – most infections are polymicrobial with a mixture of aerobic and anaerobic
organisms:
– Group A beta-hemolytic Streptococcus (GAS), Group B beta-hemolytic Streptococcus (GBS),
MRSA, Staphylococcus pyogenes, S. aureus, E. coli, Klebsiella, Pseudomonas, Proteus, Chlamydia etc.
– Streptococcus, Peptococcus, Bacteroides, Fusobacteria, Mobiluncus and Clostridia.
Sources of infection may be endogenous or exogenous (from hospital or attendants)
Clinical Feature:
Local infection of wound – the wound becomes red and swollen with pus + fever, generalized
malaise or headache;
Uterine infection – fever, tachycardia, Offensive & copious Lochial discharge initially & in severe
cases it will be scanty & odourless; uterus is sub-involuted and tender
Extra-uterine spread of infection – pelvic tenderness (pelvic peritonitis), tenderness on the fornix
(parametritis), bulging fluctuant mass in the pouch of Douglas (pelvic abscess) & septicemia.
A case of puerperal pyrexia is considered to be due to genital sepsis unless proved otherwise
Investigations: thorough history & clinical examination – to localise the site of infection
High vaginal and endocervical swabs for C/S
"Clean catch" midstream specimen of urine for analysis & C/S
CBP; Thick blood film for malarial parasites; Blood culture
Blood urea and electrolytes
Imaging: Pelvic ultrasound; X-ray chest; CT and MRI
Treatment:
General measures:
Isolation of the patient – avoid frequent visitors
IV fluids & electrolytes, respiratory support, circulatory support – esp. in shock
Correct anemia by oral iron or if needed by blood transfusion
Catheterise the bladder

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Specific treatment – Abx
Empirical therapy is started first and is changed when culture sensitivity report is available.
Pending the report, gentamicin (2 mg/kg IV loading dose, followed by 1.5 mg/kg IV every 8 hours) and clindamycin (900 mg IV
every 8 hours) should be started. Metronidazole 0.5 g IV is given at 8 hours interval to cover the anaerobes

Cases with septic pelvic thrombophlebitis are treated with IV heparin for 7-10 days
Hemodialysis for renal failure
Open the stitches of perineal wound to facilitate drainage of pus and relieve pain  clean the
wound with sitz bath & antiseptic ointment or powder.
Colpotomy to drain pelvic abscess under ultrasound guidance.
Laparotomy in unresponsive peritonitis
Prevention:
▪ Antenatal prophylaxis: good nutrition (to raise hemoglobin level) of the pregnant woman and
eradication of any septic focus (skin, throat, tonsils) in the body.
▪ Intranatal prophylaxis: Full surgical asepsis during delivery; Prophylactic use of antibiotic at the
time of cesarean section
▪ Postpartum prophylaxis: aseptic precautions for at least 1 week, following delivery until the open
wounds in the uterus, perineum and vagina are healed up

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 Complicated Pregnancy

1. Tubal pregnancy – Causes, Dx, C/F & Mx. How will you diagnose & manage ruptured tubal
pregnancy? [14, 08, 04]
a. Ectopic pregnancy – Etiology, Types, Dx & Mx [16, 13, 04]
b. Secondary abdominal pregnancy. [10]
c. Acute Ectopic pregnancy. [07]
d. Treatment of unruptured tubal pregnancy. [03]
Ans.

: An ectopic pregnancy is one in which the fertilized ovum is

implanted and develops outside the normal endometrial cavity
: 👉🏻👉🏻👉🏻👉🏻👉🏻👉🏻👉🏻👉🏻👉🏻👉🏻
:
Clinically 3 distinct types of Ectopic pregnancy are described
Symptoms Signs
Triad of
Acute (tubal abdominal pain, Severe pallor;
rupture or
amenorrhea & Features of shock;
abortion)
ectopic vaginal bleeding Tense, tender abdomen;
{avoid pelvic examination as it may
pregnancy + Vomiting, precipitate more intraperitoneal
hemorrhages}
fainting attack
Spotting;
Un-ruptured Bimanual examination
delayed
Tubal reveals pulsatile small,
period; U/L
Ectopic well-circumscribed
Pregnancy flank
tender mass in one fornix
tenderness
▪ Severe pallor;
▪ Features of shock;
▪ Tense, tender abdomen;
abdominal
▪ Cullen's sign- dark
pain, bluish discoloration around
amenorrhea & the umbilicus – suggests
Chronic or
vaginal intraperitoneal
old Ectopic hemorrhage.
bleeding;
Pregnancy ▪ Bimanual examination
features of
bladder is painful and reveals
an ill-defined, boggy and
irritation extremely tender mass in the
posterolateral fornix
extending to the pouch of
Douglas
:
Estimation of beta-hCG – UPT kits
Transvaginal sonography (TVS) – reveals absence of intrauterine pregnancy with a +ve pregnancy
test; Fluid (echogenic) in the pouch of Douglas
Color Doppler Sonography: (TV-CDS)- can identify the placental shape (ring-of-fire pattern) and
enhanced blood flow pattern outside the uterine cavity.
Laparoscopy offers benefit in diagnosis & simultaneous removal of mass

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 Culdocentesis – if TVS or laparoscopy is not readily available
No time should be wasted for investigations in acute ectopic case as it requires urgent laparotomy
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1. Hyperemesis gravidarum – Def, C/F, inv. & Mx [19, 15, 03]

Ans.
Definition: It is a severe type of vomiting of pregnancy which has got deleterious effect on the health
of mother and/or incapacitates her in day-to-day activities
Risk factors: young age; 1st pregnancy; 1st trimester; low body mass; familial history; hydatidiform
mole and multiple pregnancy
Clinical features:
– the patient is usually a nullipara; Vomiting occurs throughout the day disturbing her
day-to-day activities. There is no evidence of dehydration or starvation
– Evidences of dehydration and starvation are present.
Symptoms: Vomiting; Urine output; Epigastric pain & constipation
Signs – Features of dehydration and ketoacidosis – Dry coated tongue, sunken eyes, acetone smell
in breath, tachycardia, hypotension, fever, jaundice etc.
Investigations:
Ultrasonography – to confirm pregnancy & to r/o other causes like hydatidiform mole
Urinalysis - quantity; dark color; Presence of acetone; chloride
Abnormal LFTs & serum electrolytes;
Thyroid function tests – Women with hyperemesis gravidarum suffer from transient form of
hyperthyroidism
ECG when there is abnormal serum potassium level
Ophthalmoscopy – to detect Retinal hemorrhage and detachment in severe cases
Complications:
–
CNS: Wernicke's encephalopathy, beriberi due to thiamine deficiency; Korsakoff's psychosis,
convulsions, coma etc.
Stress ulcer in stomach
Esophageal tear (Mallory-Weiss syndrome)
Jaundice, hepatic failure prothrombin due to vitamin K deficiency
Renal failure
– low birth weight and preterm birth.
Management:
Hospitalise & start IV fluids – The total amount of fluid approximates 3 litres, of which half is 5%
dextrose and half is Ringer's solution
Potassium chloride may be given additionally
Antiemetic drugs –
 Promethazine (Phenergan) 25 mg or Prochlorperazine (Stemetil) 5 mg - twice or thrice daily IM
 Metoclopramide & Ondansetron as a 2nd line drug
Hydrocortisone 100 mg IV in the drip – given in cases with hypotension or intractable vomiting
Nutritional supplementation – Vitamins B1 {thiamine}, B6, C & B12

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 Neurologic complications can be treated with Inj. Thiamine 100 mg IV daily
For stress ulcers – give PPI {i.v.}
Maintain Hyperemesis progress chart
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2. Septic abortion - (incl. Mx & Complications) [17, 14, 06, 01, 97, 93]
Ans.
: Any abortion associated with clinical
evidences of infection of the uterus and its
contents is called septic abortion SIM - CIT
Causative organisms – most infections are
polymicrobial with a mixture of aerobic and
anaerobic organisms:
– Group A beta-hemolytic
Streptococcus (GAS), Group B beta-hemolytic
Streptococcus (GBS), MRSA, Staphylococcus pyogenes, S. aureus, E. coli, Klebsiella, Pseudomonas, Proteus,
Chlamydia etc.
– Streptococcus, Peptococcus, Bacteroides,
Fusobacteria, Mobiluncus and Clostridia.
Sources of infection is usually endogenous (from vaginal flora)
:
Immediate Complications: Injury to the uterus; Hemorrhage;
Spread of infection  Generalized peritonitis, Endotoxic shock,
Thrombophlebitis, Acute renal failure, atelectasis, ARDS etc.
Late Complications – chronic pelvic pain and backache;
emotional depression; dyspareunia, ectopic pregnancy &
secondary infertility due to tubal blockage

Investigations: Cervical or high vaginal swab; Blood & Urine analysis; USG pelvis; Coagulation
profile; Plain X-ray Abdomen & Chest
General measures: {same as puerperal sepsis}
Antibiotics – Empirical therapy is started first and is changed
when culture sensitivity report is available 👉🏻
Prophylactic antigas gangrene serum of 8,000 units and
3,000 units of anti-tetanus serum IM are given if there is a
history of interference
Analgesics and sedatives
Surgery:
Evacuation of the uterus – as abortion is often incomplete with a septic foci.
Laparotomy – if there is suspected injury to uterus or bowel

To boost up family planning acceptance to curb the unwanted pregnancies

Rigid enforcement of legalized abortion in practice &  prevalence of unsafe abortions
Take antiseptic and aseptic precaution s either during internal examination or during operation in
spontaneous abortion
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3. Vesicular mole {Molar Pregnancy/Hydatidiform mole} – C/F, Dx,
Prophylaxis, Mx, Follow-up & Complications [16, 15, 13, 11, 10, 04,
03, 02]
Ans.
Gestational trophoblastic disease (GTD) encompasses a spectrum of
proliferative abnormalities of trophoblasts associated with pregnancy.

: It is an abnormal condition of the placenta where there are

partly degenerative and partly proliferative changes in the young
chorionic villi.
Types: Complete mole & partial mole
Complete mole Partial mole
 Fertilization of an empty egg by a sperm with
Fertilization of an egg with
Pathogenesis duplication of its genetic material (androgenesis). 2 sperms
 Genetic material is completely of paternal origin
Karyotype Diploid (46XX) Triploid (e.g., 69XXY)
Fetal tissue Absent PRESENT
Risk of development of invasive
Complications Risk of development of invasive mole & choriocarcinoma mole but NOT choriocarcinoma

{complete mole}
Age: Teenagers & 40-50yrs
: Often the symptoms mimic an incomplete or threatened abortion
Vaginal bleeding & lower abdominal pain
Expulsion of grape-like vesicles per vaginum is
diagnostic of vesicular mole
Hyperemesis gravidarum – Vomiting of pregnancy
becomes excessive; No h/o quickening
Thyrotoxic features due to  chorionic thyrotropin
Breathlessness due to pulmonary embolization of
the trophoblastic cells
:
Patient looks more ill; Pallor is present
Features of pre-eclampsia (hypertension, edema
& proteinuria)
Per abdomen: Uterus > dates; Uterus is firm
elastic (doughy-due to absence of the amniotic
fluid sac); Absence of fetal parts and FHS
Vaginal examination – enlargement (theca lutein
cyst) of the ovary; Finding of vesicles in the
vaginal discharge
{complete mole}
 Immediate Complications: Hemorrhage, perforation
of uterus, sepsis, shock & rarely Pre-eclampsia,
pulmonary embolization & Coagulation failure
 Late Complications: Risk of development of
invasive mole & choriocarcinoma

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 USG: snowstorm appearance
High hCG titer in urine (positive pregnancy test)
Full blood count, ABO and Rh grouping
Hepatic, renal and thyroid function tests
Plain X-ray abdomen – negative fetal shadow
X-ray of the chest to r/o pulmonary embolism {cannon ball shadow}
Definitive diagnosis is made by histological examination of the products of conception
- Routine follow-up is mandatory for all cases for at least 1 year
▪ Initially, the checkup should be once in every week till the serum hCG level becomes negative.
▪ Enquire about relevant symptoms; detect hCG in urine or serum;
▪ Abdominovaginal examination to note involution of the uterus, ovarian size & malignant deposit
▪ Look for choriocarcinoma
▪ Chest X-ray
▪ Contraceptive Advice: The patient is traditionally advised not to be pregnant for at least one year
▪ Prophylactic chemotherapy with MTX in cases where follow-up facilities are not adequate
----------------------------------------------------------------------------------------------------------------------------------------
4. Missed abortion. [15, 10, 08, 05, 03, 02]
Ans.
: When the fetus is dead and
retained inside the uterus for a variable period,
it is called missed abortion or early fetal demise
The cause of prolonged retention of the dead
fetus in the uterus are not clear.
Beyond 12 weeks, the retained fetus becomes
macerated or mummified.
----------------------------------------------------------------------------------------------------------------------------------------
5. Threatened abortion – Define; clinical features & Mx. [14, 11, 05, 04, 02]
Ans.
: It is a clinical entity where the process of miscarriage has started but has not progressed to
a state from which recovery is impossible
: mild pain, mild bleeding; closed external os
: cervical ectopy, polyps or carcinoma, ectopic pregnancy and molar
pregnancy
:
Retroplacental hemorrhage may be seen on USG
Advice on discharge – Bed Rest; avoid coitus; avoid heavy work
Unfavourable indicators: falling serum beta-hCG, decreasing size of the fetus, irregular shape of
the gestational sac or presence of fetal bradycardia.
If the pregnancy continues, there is chance of preterm labor, placenta previa, IUGR of the fetus
and fetal anomalies
----------------------------------------------------------------------------------------------------------------------------------------
6. Recurrent abortions – causes & inv. [13, 10, 07, 03]
a. Causes of 2nd trimester abortion. [02, 01]
Ans. : Recurrent miscarriage is defined as the sequence of 2 or more spontaneous
abortions as documented by either sonography or on histopathology, before 20 weeks.

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 Causes of recurrent abortion
 Parental chromosomal abnormalities {Ex: translocations}
 Endocrine & metabolic causes – Ex: Uncontrolled DM, Luteal phase defect, PCOS etc.
In 1 st
 Infection in the genital tract – Ex: bacterial vaginosis
trimester  Inherited thrombophilia – MCC is Protein C resistance (factor V Leiden mutation)
 Autoimmunity – Ex: Antiphospholipid antibody, ANA, anti-DNA antibodies etc.
 Idiopathic – in majority
▪ Congenital anomalies – Ex: Females with developmental anomalies of uterus {e.g.,
unicornuate, bicornuate, septate or double uterus}
▪ Acquired anomalies: intrauterine adhesions, uterine fibroids and endometriosis and
In 2nd
cervical incompetence
trimester
▪ Chronic maternal illness - such as uncontrolled DM with arteriosclerotic changes,
hemoglobinopathies, chronic renal disease, IBD, SLE etc.
▪ Idiopathic – in majority
:
A thorough medical, surgical and obstetric history with meticulous clinical examination should be
done to find out the cause
Diagnostic tests include:
Karyotyping (husband and wife)
Blood-glucose (fasting and postprandial), VDRL, thyroid function test, ABO & Rh grouping
(husband and wife), toxoplasma antibodies etc.
Autoimmune screening – lupus anticoagulant and anticardiolipin antibodies.
Serum LH on D2/D3 of the cycle.
USG – to detect congenital malformation of uterus, polycystic ovaries and uterine fibroid.
Hysterosalpingography in the secretory phase to detect – cervical incompetence, uterine synechiae
and uterine malformation. This is supported by hysteroscopy and/or laparoscopy.
Endocervical swab to detect chlamydia, mycoplasma and bacterial vaginosis.
:
–
Counselling – to alleviate anxiety & improve the psychology
Hysteroscopic resection of uterine septa, synechiae and submucous myomas
Uterine unification operation (metroplasty)
Preimplantation or prenatal genetic diagnosis or pregnancy with donor gametes for couples
with Chromosomal anomalies
Treat PCOS – esp. start metformin for insulin resistance
Manage Endocrine dysfunction – Ex: control of DM & thyroid disorders
Treat genital tract infections
–
Reassurance, rest & periodic ultrasound;
Progesterone therapy in cases with luteal phase defect
Low-dose aspirin & heparin – for women with Antiphospholipid antibody syndrome & Inherited
thrombophilias etc.
Cerclage operation for cervical incompetence
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7. Diagnosis of cervical incompetence. [14, 04]
a. Incompetent OS. [07]

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Ans. (Cervical Insufficiency)
: Cervical Incompetence is the inability for the cervix to retain an intra-uterine pregnancy till
term as a result of structural & functional defects of the cervix.
:
Congenital uterine anomalies
Acquired {iatrogenic) causes – Ex: after D&C, operation, vaginal operative delivery through an
undilated cervix, amputation of the cervix or cone biopsy of trachelectomy etc.
Other causes - multiple gestations, prior preterm birth etc.

 – h/o repeated mid-trimester painless cervical dilatation

(without apparent cause) and escape of liquor amnii followed by
painless expulsion of the products of conception.

Passage of number 6-8 Hegar dilator beyond the internal os without any resistance and pain
Hysterosalpingography in the secretory phase shows funnel-shaped shadow

• Speculum examination – Painless cervical shortening and dilatation of internal os

• USG – Short cervix <25 mm; funnelling of the internal os; Y-shaped incompetent cervix
: Cerclage operation {McDonald's technique & Shirodkar's technique}
Principle: The procedure reinforces the weak cervix by a non-absorbable tape, placed around the
cervix at the level of internal os.
Removal of stitch: at 37th week
----------------------------------------------------------------------------------------------------------------------------------------
8. Intrapartum management of Rheumatic heart disease complicating pregnancy. [12, 2000]
a. Antenatal management of a patient with cardiac disease. [03]
b. Management of labour in a rheumatic mitral stenosis patient [03]
Ans.
Antepartum management of cardiac disease
The patients with heart disease should be supervised in a tertiary care hospital
The initial assessment should be made in consultation with a cardiologist.
Injection penidure LA-12 (benzathine penicillin) is given at intervals of 4 weeks throughout
pregnancy and puerperium to prevent recurrence of rheumatic fever.
Counselling is to be done regarding prognosis and risks.
Special care in each antenatal visit is to detect and to treat the risk factors that precipitate cardiac
failure in pregnancy.
:
Infections – Urinary tract, dental and respiratory tract
Anemia
Obesity; Hypertension
Arrhythmias; Hyperthyroidism
Drugs – Betamimetics.
Dietary indiscretion: Excess intake of caffeine, alcohol, high calorie diet, excess salt.
In rheumatic mitral stenosis patient – epidural analgesia in labour; avoid fluid overload
Consider valvotomy in failure of medical treatment; Best time of surgery is between 14 and 18
weeks

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 Intrapartum Management of Rheumatic heart disease
– continuous epidural analgesia; Prophylactic Abx {iv ampicillin 2g +
gentamycin 1.5 mg/kg} against bacterial endocarditis; avoid fluid overload; Cardiac monitoring and
pulse oximetry to detect arrhythmias and hypoxemia
– No maternal pushing; Under pudendal + perineal block anesthesia 
Ventouse > forceps delivery {Ventouse is preferable as it can be applied without putting the patient in lithotomy position
which cardiac load}. Avoid i.v. ergometrine
– follow AMTSL
– keep under observation for 24 hours – Administer O2; Record hourly pulse, BP and
respiration; Give Diuretic (i.v. furosemide) if there is volume overload
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9. Causes of vaginal bleeding in first trimester [99]
a. A primigravida with 2 months amenorrhoea presents with abdominal pain and bleeding PV.
Discuss the DDx [03] – refer APH
Ans.
The causes of bleeding in early pregnancy are broadly divided into 2 groups:
– abortion (95%), ectopic pregnancy, hydatidiform mole and
implantation bleeding.
– these are either pre-existing or aggravated during pregnancy – Ex:
Cervical lesions such as vascular ectopy (erosion), polyp, ruptured varicose veins and malignancy
----------------------------------------------------------------------------------------------------------------------------------------
10. M.T.P. [07]
a. Methods of 2nd trimester MTP (16)
b. Medical Methods of Abortions {MMA} [11, 08]
Ans. {Refer Gynae notes}
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1. Couvelaire’s uterus [21, 11, 08, 07, 05]

Ans.
Couvelaire Uterus (Uteroplacental Apoplexy):
It is a pathological entity seen in association with severe form of concealed abruptio placentae.
Due to placental hemorrhage  massive intravasation of blood occurs into the uterine
musculature upto the serous coat.
The condition can only be diagnosed on laparotomy
Naked eye features: The uterus is of dark port wine color
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2. Features of Hydrops fetalis. [19, 09]
Ans.
Mother is Rh-negative;
Serological examination reveals presence of Rh-antibody;
There may be presence of polyhydramnios;
Previous history of affection of a baby due to hemolytic disease;
Sonography— (real time combined with pulse Doppler) to detect edema in the skin, scalp and
pleural or pericardial effusion and echogenic bowel;

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 Straight X-ray abdomen showing— “Buddha” position of the fetus with a halo around the head due
to edematous scalp;
The baby at birth looks pale and edematous with an enlarged abdomen due to ascites. There is
enlargement of liver and spleen
Placenta is large, pale and edematous with fluid oozing from it. The placental weight may be
increased to about half or even almost equal to the fetal weight. There is undue persistence of
Langhans layer with marked swelling of the villi.
----------------------------------------------------------------------------------------------------------------------------------------
3. Anti-D {Rh} Immunoprophylaxis [18, 17]
c. Prevention of Rhesus isoimmunization. [12]
Ans.
Prevention of Rhesus isoimmunization:
Anti-D {Rh} Immunoprophylaxis: In Rh-negative women not
yet sensitized to Rh antigen, anti-D gammaglobulin – 50 μg (if
gestation <12 weeks) or 300 μg (if >12 weeks) IM is given
after childbirth
▪ It is done to prevent isoimmunization & hydrops fetalis.
▪ Other indications of Anti-D {Rh} Immunoprophylaxis are: 👉🏻
To prevent or minimize fetomaternal bleed –
 Precautions during cesarean section – prevent blood
spilling into the peritoneal cavity
 Amniocentesis should be done after USG localization of
the placenta to prevent its injury.
 Forcible attempt to perform external version under anesthesia should be avoided.
 Manual removal of placenta should be done gently.
 Refrain from abdominal palpation as far as possible in abruptio placentae.
Avoid giving Rh-positive blood to the Rh-negative female from her birth to the menopause
----------------------------------------------------------------------------------------------------------------------------------------
4. Signs of scar rupture. [16]
Ans.
Abnormal CTG — (abnormal FHR, variable and late decelerations)—MC;
Suprapubic pain if severe and especially 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 and
Loss of station of the presenting part.

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 Multiple pregnancy, Amniotic disorders, Abnormalities of Placenta and Cord

1) Multiple pregnancy – Diagnosis & Complications [15, 12, 05]

a. Twin peak sign [21]
b. Twin transfusion syndrome. [09]
c. Complications of twin pregnancy [08, 05, 04, 03]
Ans. : When more than one fetus simultaneously develops in the uterus, it is called multiple
pregnancy.

–
h/o ovulation inducing drugs, for infertility or use of ART;
Family history of twinning (more often present in the maternal side).
:
 Minor symptoms of normal pregnancy are exaggerated –  N&V; palpitation or SOB, swelling of
the legs, varicose veins and haemorrhoids;
 Unusual rate of abdominal enlargement and excessive fetal movements
: anemia; weight gain;

Inspection: 'barrel shape' of uterus and the abdomen is unduly enlarged.

Palpation:
• The height of the uterus is more than the period of amenorrhea.
• girth of the abdomen at the level of umbilicus more than the normal average at term
• Palpation of too many fetal parts
• Finding of 2 fetal heads or 3 fetal poles makes the clinical diagnosis almost certain.
Auscultation –2 distinct fetal heart sounds (FHS) located at separate spots with a silent area in
between by 2 observers, provided the difference in heart rates is at least 10 beats per minute.

Sonography:
Twin peak/lambda sign – characteristic of dichorionic twins – it
indicates chorionic tissue of 2 gestational sacs between 2 layers of
intertwin membrane at the placental origin 👉🏻
'T' sign’ – Presence of one gestational sac with a thin (<2 mm) dividing membrane, and two
foetuses suggests monochorionic diamniotic pregnancy.
Biochemical tests: Maternal serum hCG, α -fetoprotein and unconjugated estriol are almost double
than those of singleton pregnancies

It is a clinicopathological state, exclusively seen in monozygotic twins

Here, one twin bleed into the other through some kind of placental
arteriovenous anastomosisanemia-polycythemia syndrome 👉🏻
Management: diagnosis is by doppler ultrasound
Laser photocoagulation for the anastomotic vessels
Repeated amniocentesis to control polyhydramnios
Septostomy (making a hole in the dividing amniotic membrane).
Selective reduction (feticide) of one twin is done when survival of both the foetuses is at risk

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▪ Complications are higher in monozygotic twins compared to dizygotic twins.
▪ Complications are further higher in monochorionic diamniotic twins & highest in monochorionic
monoamniotic twins.
N&V; anemia; risk of pre-eclampsia
Hydramnios – more common in monozygotic twins
During APH; risk of placenta previa
Pregnancy Mechanical distress – like palpitation, dyspnea, varicosities &
haemorrhoids
Malpresentation – more common in 2nd baby
Preterm labor
Maternal
 Early rupture of the membranes and cord prolapse
Complications
 Prolonged labor
During
 chance of operative interference
Labor
 Bleeding (intrapartum) following the birth of the first baby
 risk of PPH
▪ risk of subinvolution {because of bigger size of uterus}
During
▪  risk of infection
Puerperium
▪ Lactation failure
 Premature LBW babies
 chance of miscarriage – especially with monozygotic twins
Fetal  Discordant twin growth; Locked twins
complications  Intrauterine death of one fetus – more in monozygotic twins
 chance of fetal anomalies – more in monozygotic twins
 Asphyxia and stillbirth – the second baby is more at risk
Complications of Monochorionic twins: TTTS, Dead fetus syndrome, Twin reversed arterial
perfusion (TRAP); Monoamniocity & Conjoined twin
----------------------------------------------------------------------------------------------------------------------------------------
2) Hydramnios- causes, investigations, treatment. [08, 04, 03, 99]
a. Causes of polyhydramnios. [21, 19, 13]
b. Maternal complications of Hydramnios [13]
c. Polyhydramnios. [07]
Ans.

Definition:
▪ Anatomically, polyhydramnios is defined as a state where liquor amnii exceeds 2,000 mL.
▪ 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 fetus.
Causes of Hydramnios:
– MCC
– Diabetes, Cardiac or renal disease- may lead to edema of the placenta leading
to increase in transudation.
– esp. in monozygotic twins – Ex: in TTTS the recipient twin develops polyhydramnios
– Chorioangioma of the placenta  transudation.

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 – Congenital fetal malformations – Ex: Hydrops fetalis, Anencephaly, Open spina
bifida, Esophageal or duodenal atresia, Aneuploidy etc. VACTREL =
Complications of Hydramnios:

During pregnancy - risk of Pre-eclampsia, Malpresentation, PROM, Preterm labor & Accidental
hemorrhage
During labor – Early rupture of the membranes, Cord prolapse, Uterine inertia,  operative delivery
due to malpresentation, Retained
placenta, PPH and shock.
During puerperium: Subinvolution &
puerperal infection
-  perinatal
mortality due to prematurity &
Congenital malformations
Investigations of Hydramnios:
▪ Sonography – AFI> 25cm
▪ Blood – ABO and Rh grouping
{Rhesus isoimmunization may cause
hydrops fetalis and fetal ascites}
▪ Postprandial sugar
▪ Amniotic fluid - levels of alpha-
fetoprotein suggest neural tube
defect
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3) Intrapartum management of twins. [02]
Ans.

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1. Oligohydramnios. [11, 08]
Ans. : It is an extremely rare condition where the liquor amnii is deficient in amount to the
extent of less than 200 ml at term.

– Renal agenesis, Obstructed uropathy, IUGR, Amnion nodosum, Postmaturity,

chromosomal anomalies etc.
– Dehydration, Hypertensive disorders, Uteroplacental insufficiency
Idiopathic
:
Uterine size is much smaller than the period of amenorrhea
Less fetal movements
Malpresentation (breech) is common
USG – largest liquor pool is less than 2 cm.

– Prolonged labor due to inertia;  operative interference due to

malpresentation;  maternal morbidity
– Abortion, deformity, Fetal pulmonary hypoplasia, cord compression; fetal
mortality etc.
:
Refer to paediatrician if there are congenital fetal malformation
Hydrate the mother – to amniotic fluid volume
Amnioinfusion (prophylactic or therapeutic) – to improve neonatal outcome
Delivery - should be done irrespective of the period of gestation
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2. Placenta succenturiata. [10]
Ans. It is a placental abnormality where one or more small lobes of placenta are placed at varying
distances from the main placental margin
A leash of vessels connects the main lobe to the small lobe
Clinical significance: If the succenturiate lobe is retained, following birth of the placenta, it may
lead to PPH, Subinvolution, Uterine sepsis and polyp formation
Treatment: if there is missing lobe  exploration of the uterus and removal of the lobe under
general anesthesia is to be done
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3. Conjoined twins. [07]
Ans.

Termination of pregnancy is an option when early diagnosis

has been made

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 Antepartum haemorrhage

1. Antepartum haemorrhage (APH) – Definition & Causes. Outline the Mx of multigravida presenting
at 32 weeks of pregnancy with painless bleeding PV [20, 13, 11, 09, 05, 04, 03]
a. Vaginal bleeding in 3rd trimester – causes & diagnosis [17, 10]
b. Placenta previa – Etiology, C/F & Mx [12]
c. Vasa previa. [12]
d. Expectant management in a case of Placenta praevia. [14, 10, 03]
e. Macafae’s Regime in placenta praevia. [08]
f. Major degree placenta praevia [07]
Ans.
: It is defined as bleeding from
or into the genital tract after the 28th week of
pregnancy but before the birth of the baby
:

: When the placenta is implanted partially or completely over the lower uterine segment (
over and adjacent to the internal os) is called placenta previa
:
Theories to explain Placenta praevia – Dropping down
theory; Big surface area of the placenta; Defective decidua &
Persistence of chorionic activity in the decidua capsularis
Vasa previa is defined as fetal vessels running in close
proximity to the inner os; these vessels are at risk of rupture
when the supporting membranes rupture
:
 The only symptom of placenta previa is vaginal bleeding – painless, recurrent & sudden onset;
often occurs during sleep & patient becomes frightened on awakening
 Signs – pallor is proportionate to the blood loss
 Abdominal examination – size of uterus is proportionate to the period of gestation.; No local
tendernes; Persistence of malpresentation & displacement of the fetal head {head can’t be
pushed doen into the pelvis}
 Stallworthy's sign – Slowing of the fetal heart rate on pressing the head down into the pelvis
 Vulval inspection – to note bright red blood of placenta previa
 Avoid Vaginal examination as there is risk of hemorrhage

 Sonography – TAS, TVS, TPS

 MRI – can better diagnose posterior placenta previa and placenta previa accreta or percreta with
bladder invasion
 Placental implantation on the lower segment can be confirmed during cesarean section

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 {McAfee’s Regime}
:
The aim is to continue pregnancy for
fetal maturity without compromising the
maternal health.
Pre-requisites:
Availability of blood for transfusion
whenever required.
Hospital setting is ideal
Facilities for LSCS should be available
throughout 24 hours
Duration of pregnancy is < 37 weeks
Fetal well-being is assured (CTG & USG)
👉🏻
The expectant treatment is carried up to
37 weeks of pregnancy
Steroid therapy – Ex: Betamethasone –
indicated when the duration of
pregnancy is < 34 weeks – to 
respiratory distress of the newborn in preterm delivery
----------------------------------------------------------------------------------------------------------------------------------------
2. Multigravida with 8 months amenorrhoea presents with bleeding PV. Discuss the DDx. Write about
Abruptio placenta – Grades, inv. & treatment of Abruptio Placenta Grade III. [21]
a. Abruptio-placenta – Classification (varieties), C/F, Dx, Mx & Complications [18, 16, 02]
b. Management of concealed accidental haemorrhage. [08]
c. Indications for caesarean section in abruptio placenta. [01]
Ans.
Abruptio Placentae
(Syn: Accidental Hemorrhage, Premature Separation of Placenta)
: It is one form of antepartum hemorrhage where the bleeding occurs due to premature
separation of normally situated placenta.

a) Revealed {MC type}: the blood comes out of the cervical canal to be visible externally
b) Concealed: The blood collects behind the separated placenta & is not visible outside.
c) Mixed: In this type, some part of the blood collects inside (concealed) and a part is expelled out
(revealed). Usually, one variety predominates over the other.
– Depending upon the degree of placental abruption, the cases are graded as:
 Grade 0: Clinical features may be absent – Diagnosis is made by inspection of placenta following delivery.
 Grade 1 (40%) – Vaginal bleeding is slight; FHS is good.
 Grade 2 {45%) – Vaginal bleeding mild to In revealed type In concealed variety
moderate; fetal distress or even fetal death maternal risk is
Hemorrhage, Shock,
Blood coagulation
occurs. Maternal proportionate
disorders, Oliguria and
 Grade 3 {15%) – Vaginal bleeding is moderate to complications to the visible anuria; PPH; Puerperal
blood loss
severe or may be concealed; fetal death is the sepsis
Fetal Fetal death due to premature placental
rule.
complications separation and anoxia

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 :
:
 Diagnosis is mainly clinical
 USG or MRI maybe helpful – but,
even negative findings on USG do
not exclude placental abruption
:
Indications for caesarean section in
abruptio placenta:
Severe abruption with live fetus,
Amniotomy could not be done
(unfavourable cervix)
Amniotomy failed to control
bleeding
Amniotomy failed to arrest the
process of abruption (rising fundal
height)
Prospect of immediate vaginal
delivery despite amniotomy is remote
Appearance of adverse features (fetal distress, falling fibrinogen level, oliguria).
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3. How will you evaluate an infertile couple? [05]
Ans. {refer Gynae notes}
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1. Placentography. [16]

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Ans.
Placentography is a radiological examination of the placenta after injection of a radiopaque dye.

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2. Placental abnormalities. [10]
Ans.

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 Hypertensive disorder in pregnancy

1. Eclampsia – Define, inv. & Mx [21, 20, 16, 15]

a. Magnesium Sulphate [21]
b. Obstetric management of antepartum eclampsia [14, 04]
c. Pritchard regimen in eclampsia. [10, 08]
d. Antihypertensive drugs in pregnancy. [09]
e. Control of convulsions in eclampsia. [04, 03, 2000]
f. Use of Anti-hypertensives in Obstetrics. [01]
Ans.
Eclampsia is defined as BP ≥140/90 mm Hg in pregnancy after 20 weeks, with proteinuria &
complicated with grand mal seizures and/or coma.
Investigations:
Urine examination – for proteinuria (esp. albuminuria)
Complete blood picture – for Hb, PCV, RBC count, Platelet count, WBC-TC & DC.
Blood Biochemistry – for blood urea, uric acid & creatinine
Liver Function Tests – for bilirubin, AST, ALT & ALP – to rule out HELLP syndrome
Coagulation Profile – for Serum fibrinogen, PT, aPTT & INR
Fundoscopic / Ophthalmoscopic Exam – to check for Papilledema
Management of Eclampsia

Eclamptic patients Anticonvulsant – Magnesium sulphate is the DOC

should never be left
alone 4 g (20% MgSO4) IV over 15 min. 5 g (50%) IM 4
IM
followed by 10 g (50%), deep IM hourly in alternate
The bladder is (Pritchard)
(5 gm in each buttock) buttock
catheterised to monitor IV (Zuspan or
hourly urine output and 4–6 g IV slow over 15–20 minute 1–2 g/h IV infusion
Sibai)
proteinuria
A/E of MgSO4 – Respiratory arrest – Assist ventilation & give the
Antidote Calcium gluconate 1 g (10 ml of 10% solution) is given IV
Monitor vital signs slowly, until respiration begins
Antihypertensives - if no response till 10 min, then dose
 Labetalol – 10 mg IV
Maintain fluid balance
 Nifedipine – 10 mg oral
 Hydralazine – 5 mg slow IV
Obstetric Management:
Deliver the child ASAP after stabilising the mother
If vaginal delivery is not possible (due to transverse lie, CPD etc.) – go for LSCS
Monitor BP for the first 24 hours of postpartum
Continue MgSO4 for the first 24 hours of postpartum
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2. Pre-eclampsia – Define, pathophysiology & Mx [11, 07]
a. Define preeclampsia and mention two risk factors for it. [16]
b. Classify hypertensive disorders of pregnancy [12, 08]

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 c. Management of severe pre-eclampsia [10]
d. Investigations in a case of severe pre-eclampsia. [03, 05]
Ans.
Classification of hypertensive disorders of pregnancy:
Gestational hypertension – aka Pregnancy-induced hypertension (PIH)
Pre-eclampsia
Eclampsia
Chronic hypertension
Chronic hypertension with superimposed Pre-eclampsia
Pre-eclampsia is defined as BP ≥140/90 mm Hg in pregnancy after 20 weeks, with proteinuria
Risk Factors for Pre-eclampsia:
 Nulliparous & older women
 Familial tendency
 Complications of pregnancy – multiple pregnancy, hydramnios, vesicular mole etc.
 Maternal co-morbidities – DM, HTN, renal disorders, antiphospholipid antibody syndrome etc.
 Other Factors: Emotional stress, obesity, periodontal disease etc.
Pathophysiology of Pre-eclampsia:
Cytotrophoblast cells fail to penetrate the tunica media of spiral arteries  Spiral arteries fail to
develop into large vascular channels  the vessels remain narrow  placental hypoperfusion 
maternal endothelial dysfunction  vascular permeability & coagulopathy
Proteinuria and edema (due to vascular permeability)
Vasospasm  resistance to blood flow  HTN
Damage to target organs like Brain, liver, kidney etc.
 production of anti-angiogenic factors by the placenta – Ex: soluble fms-like tyrosine kinase
(sFlt-1) and soluble endoglins (sEng)
Investigations: refer 1st LQ – Investigations +
 Screening Tests for Pre-eclampsia:
Roll over test
Maternal serum level of sFlt-1 & uric acid
Fetal DNA in maternal plasma
Average mean arterial pressure (MAP) in 2nd trimester ≥ 90 mm Hg
Management of Pre-eclampsia:
:
Supportive Measures – Advice rest in Afternoon & night;
Monitor the mother – Check BP (4 times/day); Examine urine for proteinuria daily
Monitor the fetal growth (via ultrasound) & count fetal movements
For Gestation < 37 weeks – Discharge if BP is in control & proteinuria subsides
For Gestation more than 37 weeks – if BP is in control & proteinuria subsides  assess fetal
maturity & induce Labour (PGE2 Gel / ARM / Oxytocin)
:
Admit in Labour room
Administer anti-hypertensives: Labetalol (IV 10-20 mg) or Nifedipine (10 mg orally)
Administer prophylactic MgSO4
If Gestation < 24 weeks – MgSO4 & pregnancy termination

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 If Gestation 24-34 weeks – aim to reach at least 34 weeks with Corticosteroid therapy {IM
betamethasone 12 mg}
Delivery within 48 hours if there is eclampsia, pulmonary edema, abruptio placentae,
oliguria, uncontrolled severe HTN etc.
----------------------------------------------------------------------------------------------------------------------------------------
3. What are the causes of swelling of feet during pregnancy? How will you investigate and manage a
case of Pregnancy Induced Hypertension presenting with 34 weeks? [04]
a. Complications of PIH [05, 2000]
b. Investigations, Dx & Mx in pregnancy induced hypertension. [03]
Ans.
Causes of swelling of feet during pregnancy:
Pre-eclampsia
Eclampsia
Anemia
Cardiac Failure
Nephrotic Syndrome
is defined as sustained BP
≥140/90 mm Hg on at least two occasions ≥ 4 hours apart, in pregnancy after 20 weeks or within the
first 48 hours of delivery, without proteinuria, in a previously normotensive woman
Investigations of PIH: (refer 1st LQ - Investigations)
Diagnosis of PIH: It should fulfil the following criteria:
1) Absence of any evidences for the underlying cause of hypertension
2) Generally, not a/w other evidences of preeclampsia (edema or proteinuria).
3) Majority of cases are ≥ 37 weeks pregnancy.
4) Generally, not a/w haemoconcentration or thrombocytopenia, serum uric acid level or hepatic
dysfunction.
5) The BP should come down to normal within 12 weeks following delivery
Management of PIH: (same as Pre-eclampsia)
 Urine Examination – to rule out proteinuria
 Supportive Measures – Advice rest in Afternoon & night
 Monitor the mother – Check BP (4 times/day); admit if there is rise in BP or IUGR
 Start Antihypertensives if BP isn’t controlled by the above measures
Complications of PIH:
It is a/w higher incidence of essential hypertension in later life than preeclampsia
Gestational HTN may go to proteinuric phase  Preeclampsia  a/w seizures  Eclampsia
End organ damage – Cerebral hemorrhage, Puerperal psychosis, Renal failure, Pulmonary edema etc.
----------------------------------------------------------------------------------------------------------------------------------------

1. Roll-over test. [02, 94]

Ans.
This is a screening test done for Pre-eclampsia
Timing: It is done between 28 and 32 weeks.
Procedure: BP is measured with the patient on her side first and then the patient is asked to roll on
her back to check the BP once again.

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 Inference: An increase of 20 mm Hg in diastolic pressure from side to back position indicates a
positive “roll over test”.
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1. Proteinuria in pregnancy. [14, 09]

Ans.
 Proteinuria is defined as “Urinary excretion of ≥0.3 g protein/24 hours specimen or 0.1 g/L”
 Pathogenesis: Spasm of the afferent glomerular arterioles → anoxic change to the endothelium of
the glomerular tuft → glomerular endotheliosis → increased capillary permeability → increased
leakage of proteins.
 Causes:
 Transient Proteinuria – UTI, heavy exercise
 Primary Renal Disease – Ex: Glomerulonephritis
 Nephrotic Syndrome
 Pre-eclampsia
 Eclampsia
 Anemia
 Cardiac Failure
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2. What is HELLP syndrome [21, 13, 09, 07]
Ans.
 syndrome stands for emolysis, levated iver enzymes & ow latelets
 This is a rare complication of preeclampsia (10–15% cases)
 Management: (same as Pre-eclampsia & Eclampsia) + platelet transfusion
Start corticosteroid therapy if gestation is < 34 weeks
If the condition worsens, irrespective of the gestational age, deliver
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3. Fundoscopy in Pre-eclampsia [05]
Ans.
 Fundoscopy is done in Pre-eclampsia as Fundal changes are related to the duration of the disease
 The American
Grade 0 Normal Fundus
Ophthalmological
Grade 1 & 2 Slight or moderate degrees of A-V narrowing & spasm
Society has graded
+ edema, hemorrhage & exudates
the retinal changes as Grade 3 (pre-eclamptic retinopathy)
follows: Grade 4 + Papilledema

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4. Differential diagnosis of convulsions in pregnancy. [03]
Ans.
Eclampsia
Pre-existing Epileptic disorders
Stroke
Trauma & Tetany
Infections – Cerebral malaria & meningitis

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 Cerebral tumours
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5. Eclamptic fit. [06]
Ans.
Eclamptic fit or Convulsion occur in 4 stages:
1) Premonitory stage – Here facial twitching is seen which last from a few seconds to half a minute
2) The tonic stage – Here entire body becomes rigid in a generalised muscular contraction. This may
persist for 15-20 seconds.
3) The clonic stage: In this stage, there is alternate contraction and relaxation of the muscles. The
tongue may be bitten by the violent action of the jaws. This phase may last about a minute.
 Throughout the seizure, the diaphragm is fixed  No respiration  cyanosis (blue face).
 There is froth in the mouth. If not properly protected, the patient may fall from the bed and
injure herself.
4) Coma: Here, the convulsive movements cease, the patient breathes stertorously; coma supervenes
and the respiration gradually becomes quieter.
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6. Imminent Eclampsia [01]
Ans.
▪ Imminent Eclampsia refers to rapid deterioration in an established case of pre-eclampsia
▪ Besides the usual features, symptoms such as restlessness, severe headache, vomiting, epigastric
pain and visual disturbances are very marked in these cases
▪ Management: (same as Eclampsia)

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 Medical and Surgical illness complicating pregnancy

1. Anaemia in pregnancy – Define; Etiopath; Mx, complications & prophylaxis [21, 16, 07, 04, 03]
a. Causes, Inv. & Treatment of Fe Deficiency anemia in pregnancy [20, 05]
b. Maternal & Fetal Complications in Anemia complicating Pregnancy [19]
a. Parenteral iron therapy. [15, 13, 12]
b. Peripheral blood smear in anaemia of pregnancy [13]
c. Prevention of anaemia in pregnancy [12]
d. Management of severe IDA during pregnancy. [11]
Ans.
: WHO defined anaemia in pregnancy as the haemoglobin (Hb)
concentration of less than 11 g/dl
: Depletion of iron stores results in inadequate
synthesis of Hb anemia
 intake of iron due to poor dietary habits, vomiting, loss of appetite, socioeconomic factors, etc.
  absorption - Intake of antacids, H2 blockers & PPI {Acid environment in the duodenum helps iron absorption}
 erythropoiesis – especially due to presence of infection (asymptomatic bacteriuria)
 demands of iron - Ex: Multiple pregnancy; Repeated pregnancies at short intervals etc.
 Iron loss – Hookworm infestation, Chronic malaria, bleeding piles and dysentery B2 H3 ID

Physiological anemia of Mostly marked during 2nd half of pregnancy due to haemodilution and
pregnancy negative iron balance
▪ Iron deficiency
Deficiency
▪ Folic acid & B12 deficiency
anemia
▪ Protein deficiency
 Acute – Following bleeding in early months or APH
Hemorrhagic
 Chronic – Hookworm infestation, bleeding piles, etc.
Hereditary Thalassemias, Sickle cell & other hemoglobinopathies, spherocytosis etc.
Pathological Bone
Hypoplasia or Aplasia due to radiation, drugs (aspirin, indomethacin)
anemia marrow
Chronic renal disease
insufficiency
Blood
leukemias, lymphomas
cancers
Infection Malaria, tuberculosis, kala-azar
SLE, HELLP syndrome, autoimmune hemolysis, Drug induced G-6-PD
Hemolytic:
deficiency etc.
:
 RBCs: microcytic, hypochromic,
ring/pessary cells, anisocytosis &
poikilocytosis (pencil/cigar shaped
cells).
 ↓ in MCV, MCH & MCHC

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 :
 During pregnancy – Pre-eclampsia, Intercurrent infection, Preterm
labor & Heart failure near term
 During labor – Uterine inertia, cardiac overload & failure, PPH &
Shock
 Puerperium - risk of Puerperal sepsis, Subinvolution, Poor
lactation, Puerperal venous thrombosis,
Pulmonary embolism & Poor wound healing
 Effects on baby - risk of LBW & Intrauterine
death
:
:
 Indications of Parenteral iron:
Intolerance to oral iron
Malabsorption of iron
Non-compliance to oral iron
Severe iron deficiency
Along with erythropoietin in patients with
renal disease
 Preparations of parenteral iron:
1) Iron-dextran {IM or IV}
2) Iron-sorbitol-citric acid {IM}
3) Ferrous-sucrose {IV}
4) Ferric-carboxymaltose.
 Adverse effects of Parenteral iron therapy:
 The injections are painful, may cause abscess
and discolouration of the skin at the site of
injection.
 The systemic side effects are headache,
pyrexia, nausea, vomiting, arthralgia, lymphadenopathy, urticaria and anaphylactic reaction.
:
Avoidance of frequent childbirths – min. interval should be at least 2 years
Supplementary iron therapy - Daily administration of 200 mg of ferrous sulfate (containing 60 mg
of elemental iron) along with 1 mg folic acid
Avoid tea within 1 hour of taking iron tablet
A realistic balanced diet, rich in iron and protein, should be prescribed which should be within the
reach of the patient
Treat any associated pathologies
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2. GDM – Define & Screening Tests. Discuss the Mx of primi with GDM at 34 weeks of Gestation [18, 08]
a. Screening for gestational diabetes. [21, 06, 05]
b. Maternal & Fetal Complications in Diabetes complicating Pregnancy [20]
c. Causes of glycosuria in pregnancy & Mx of a case of Diabetes complicating pregnancy. [01]
Ans.

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 : Gestational Diabetes Mellitus is defined as carbohydrate intolerance of variable
severity with onset or first recognition during the present pregnancy.

– Diet, exercise + insulin

Diet with 2,000- 2,500 kcal/day for normal weight woman and restriction to 1,200- 1,800 kcal/ day
for overweight woman is recommended;
Prefer complex carbohydrates over simple ones
Self-blood glucose monitoring – FBS should be <90 mg/dL
Human insulin should be started if fasting plasma glucose level exceeds 90 mg/dL
Exercise (aerobic, brisk walking) programs are safe in pregnancy and may obviate the need of
insulin therapy
Elective delivery (induction or cesarean section) is preferred in patients on insulin therapy or with
complications (macrosomia)
Follow-up: Nearly 50% of women with GDM would develop overt diabetes & cardiovascular
complications which should be detected & managed appropriately
----------------------------------------------------------------------------------------------------------------------------------------

1) Measures to prevent vertical transmission of HIV. [17]

Ans.
Transplacental transmission – aka Vertical transmission of HIV
Mainly occur the time of labor and delivery – take
precautions accordingly.
Mainly seen in preterm birth & with prolonged membrane
rupture.
Risks of vertical transmission is directly related to maternal
viral load (measured by HIV RNA) and inversely to maternal immune status (CD 4+ count).
Maternal anti-retroviral therapy reduces the risk of vertical transmission by 70%
Avoid Breastfeeding
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2) What are the causes of jaundice during pregnancy? [09]
Ans.

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3) Congenital heart disease with pregnancy. [08]
a. Peripartum Cardiomyopathy. [07]
Ans. become pregnant they have  risk of complications
like Cyanosis, Left ventricular dysfunction, Pulmonary hypertension, CCF, HTN & Arrhythmias
:
Acyanotic CHD (L to R shunt): ASD, VSD, PDA & MVP
ASD (ostium secundum type) is the most common congenital heart lesion during pregnancy.
Even uncorrected cases tolerate pregnancy and labor well – avoid hypovolemia & epidural
anesthesia as they precipitate shunt reversal
Endocarditis prophylaxis should be given
Cyanotic CHD (R to L shunt) - Fallot's tetralogy; Eisenmenger’s syndrome
After surgical correction, patients tolerate pregnancy well
Consider termination of pregnancy in Eisenmenger’s syndrome
Complications like bacterial endocarditis, brain abscess, cerebral embolism, IUGR are common.
Other congenital heart lesions:
Coarctation of aorta – Surgical correction should be clone prior to pregnancy; else terminate.
Primary pulmonary hypertension – termination is better; else bed rest from 20 weeks, heparin,
sildenafil; majority die (75%) postpartum
Marfan's syndrome – autosomal dominant – may transmit to offspring; avoid HTN by using β-
blockers, correct dilated aorta; Deliver vaginally with shortening of 2nd stage
Prosthetic valves – risk of thromboembolism – hence, start on LMW heparin
Peripartum cardiomyopathy:
Peripartum cardiomyopathy is a weakness of the heart muscle that begins during the final month
of pregnancy or about five months after delivery, without any other known cause
It is a diagnosis of exclusion
Clinical presentation – multiparous women with complain of weakness, shortness of breath,
cough, nocturnal dyspnea and palpitation. Examination reveals – tachycardia, arrhythmia,
peripheral edema and pulmonary rales
Treatment: Bed rest, digoxin, diuretics (preload), hydralazine or ACE inhibitors (postpartum)
(afterload), β blocker and anticoagulant therapy. Vaginal delivery is preferred under epidural
anesthesia.
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4) Complications of laparoscopy. [05]
Ans.

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5) Oedema in Pregnancy. [04]
Ans.

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6) Treatment of pyelonephritis in pregnancy. [03]
a. Urinary tract infection in pregnancy-diagnosis & treatment. [02]
b. Significance of Asymptomatic bacteriuria. [01]
Ans.

IV antibiotics—Cephalosporins, aminoglycosides (gentamicin), Cefazolin or Ceftriaxone, for 48

hours till culture report is available and then changed to oral therapy for another 10-14 days.
IV fluids (crystalloid) for adequate hydration. Monitor urine output (> 60 ml/hr), temperature & BP
Evaluate hemogram, serum electrolytes, creatinine.
Acetaminophen is given for the fever.
Repeat urine culture after 2 weeks of antimicrobial therapy and is repeated at each trimester of
pregnancy.
If the symptoms recur, repeat urine culture  treat based on sensitivity
Antimicrobial suppression therapy is continued till the end of pregnancy to prevent recurrence –
Nitrofurantoin 100 mg daily at bed time is effective
Patient not responding with this therapy  evaluate (sonography, CT scan, radiography) for urinary
tract obstruction & manage accordingly.
:
It refers to the presence of >105 CFU/mL of bacteria in a voided urine from asymptomatic patients

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 Significance – This indicates actively multiplying bacteria within the urinary tract & if left untreated
it will lead to acute pyelonephritis, IUGR, premature labor etc.
Treatment: Any one of these drugs could be prescribed – amoxicillin (500 mg t.i.d), nitrofurantoin
(100 mg bid), cephalexin (500 mg t.i.d) or amoxicillin-clavulanic acid (875 mg bid) for 10-14 days
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1. Cardiotocography [18]
Ans.
 Continuous electronic monitoring of the FHR is termed as
cardiotocography (CTG)
 Indications – High risk cases – IUGR, Severe preeclampsia /GDM,
VBAC, Prematurity, Multiple pregnancy, Meconium-stained liquor etc.
 Ex: Severe anemia and impending death produces a sinusoidal FHR
pattern on cardiotocography

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 Gynaecological disorders in pregnancy

1. Red Degeneration. [04, 02]

Ans.
It is a Degenerative effect of pregnancy on fibroid
It predominantly occurs in a large fibroid during the 2nd half of pregnancy or puerperium.
The cause is not known but is actually a hemorrhagic infarction
:
Acute onset of focal pain over the tumor; Tenderness and rigidity over the tumor
Malaise or even rise of temperature;
Dry or furred tongue; Rapid pulse; Constipation;
– Blood count shows leukocytosis.
The diagnosis is confused with acute appendicitis or twisted ovarian tumor. The diagnosis is often
made only on laparotomy
:
 Patient is put to bed. Ampicillin 500 mg capsule thrice daily for 7 days is given.
 Analgesic and sedative are frequently given.
 The symptoms usually clear off within 10 days.
 When Laparotomy is done with mistaken diagnosis, abdomen is to be closed without any
intervention. Pedunculated subserous fibroid, if found, can be removed

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 Operative Obstetrics

1. Caesarean section –indications (Absolute), complications & post operative care [20, 16, 13, 12, 11]
Ans. Cesarean section is the removal of fetus through an incision in the abdominal wall and the
uterine wall after the period of viability.
In LSCS – Modified Pfannenstiel incision is made 3 cm above the symphysis pubis

Absolute Indications
Vaginal delivery may be possible but risks to the mother and/or baby a dead fetus are high

Factors impeding vaginal delivery – Ex: Abnormal

Central placenta previa
presentation (Breech, brow, transverse lie, oblique lie), Fetal-distress,
Placenta accreta
Macrosomy, Triplets and higher order pregnancy etc.
Contracted pelvis (severe CPD)
Failed labor induction
Pelvic mass (Ex: fibroid)
Complications of Labour – Ex: Prolonged labor, obstructed
Previous classical cesarean
labor
section
Failed instrumental delivery by forceps or ventouse
Previous ≥ 2 LSCS
Cord prolapse & severe IUGR
Advanced carcinoma cervix
In Complicated Pregnancy – Ex: Preeclampsia, Marfan’s
Vasa previa
Syndrome (weak heart), STDs in mother (HIV, genital
Cord presentation.
herpes), pr. h/o uterine rupture etc.
Cesarean is needed even with a
In precious pregnancy – Ex: long standing infertility, elderly
dead fetus
primigravida, BOH etc.
Complications:
Bleeding – due to uterine atony – Treat with oxytocin & transfuse blood
Wound infections – esp. in women who had a cesarean in labour – Treat with Abx
UTIs – due to urinary catheterisation – Treat with Abx
Paralytic ileus – Treat with gastric suction & IV fluids until bowel sounds are heard
Thromboembolism – due to post-op immobilisation
Scar rupture – in a subsequent pregnancy
Observation – look for bleeding
Maintain fluids & electrolyte balance
Blood transfusion
In first 24 Oxytocics: Inj. oxytocin 5 units IM or IV (slow) or methergine 0.2 mg IM is given and
hours may be repeated
{Day 0} Prophylactic antibiotics (cephalosporins, metronidazole)
Analgesics – Pethidine hydrochloride 75-100 mg
Post-
Ambulation – encourage to walk to avoid DVT
Op
care: Baby is put to the breast for feeding when mother is stable & relieved of pain
Day 1 Start Oral feeding in the form of plain or electrolyte water or black tea
Day 2-4 Light solid diet of the patient's choice + 3-4 teaspoons of lactulose
Day 5 or The abdominal skin stitches are to be removed on the D-5 (in transverse) or
day 6 D-6 (in longitudinal)
The patient is discharged on the day following removal of the stitches.
Discharge
Depending on post-op recovery – discharge can be done at 3-7 days
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1) Internal podalic version – indications, Procedure & hazards [18, 11, 04]
Ans.
: Internal podalic version comprises a series of manoeuvres performed prior to breech
extraction to deliver a fetus with a persistent transverse or oblique lie in the second stage of labour.

 Currently, it’s only indication is the transverse lie of the 2nd baby of twins.
 Can be used in situations where cesarean section facilities are lacking & there is –
 Transverse lie with cervix fully dilated
 Cord prolapse with cervix fully dilated with transverse lie
- Internal version should be done under general or epidural anesthesia
Step I: Patient is placed in dorsal lithotomy position.
Antiseptic cleaning, draping and catheterization
Introduce the hand in a cone-shaped manner into the uterine cavity keeping the back of the hand
against the uterine wall until the hand reaches the podalic pole.
Step II: Grasp a foot {foot is identified by palpating the heel}
Step III: Bring the leg down by a steady traction with the external hand pushing the cephalic pole.
Step IV: complete the delivery with breech extraction
Step V: Routine exploration of the uterovaginal canal to exclude rupture of the uterus
High perinatal mortality of about 50%.
– placental abruption, rupture of the uterus and increased morbidity.
– asphyxia, cord prolapse and intracranial hemorrhage + all hazards of breech delivery
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2) Episiotomy- indications (at least 4), types and complications [17, 14, 10, 08, 07]
a. List out the types of episiotomies with labelled diagrams [21]
Ans. Definition: An episiotomy (perineotomy) is a planned, surgical incision on the perineum and the
posterior vaginal wall during 2nd stage of labor.
Objectives:
▪ To prevent over-stretching and tearing of perineal muscles (tears can involve the perineal skin or
extend to the muscles and the anal sphincter and anus).
▪ To enlarge the introitus so as to the strain on fetal head and facilitate easy delivery of the fetus.
Indications:
 When perineal muscles are excessively rigid/inelastic perineum
 Instrumental delivery: Forceps, ventouse
 If there is a risk of 2nd or 3rd degree tearing in cases like - Macrosomia, Face delivery, After coming
head of breech etc.
 When a woman has undergone FGM (female genital mutilation) or perineal reconstructive surgery
 Prolonged late decelerations or fetal bradycardia during active pushing
 Shoulder dystocia
Procedure:
Bulging thin perineum just prior to or at the time of crowning (when 3-4 cm of the head is visible).

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 1 % lignocaine, local anesthesia.
There are 4 main types of episiotomies:
1) Mediolateral – MC type
2) Median
3) Lateral
4) J-shaped – very rarely done

Posterior vaginal wall

Superficial and deep transverse perineal muscles bulbospongiosus, and part of levator ani and
fascia covering those muscles
Transverse perineal branches of pudendal vessels and nerves
Subcutaneous tissue and skin.
It is done in 3 layers in the following order with number 0 chromic catgut or polyglactin
(vicryl rapide) sutures
Vaginal mucosa: Sutured by continuous/continuous interlocking sutures.
Perineal muscles: Interrupted sutures.
Skin and subcutaneous tissue: Interrupted or vertical mattress
The wound is to be kept open, dry and clean.
Antiseptic ointment/cream to be applied 2-3 times a day and each time following urination and
defecation.
Analgesics and anti-inflammatory tablets and oral antibiotics for 3-5 days.
The stitches need not be removed as they are absorbable.
Complications:
Immediate Complications: extension to rectum (esp. in median episiotomy), Forniceal tear, Vulval
Hematoma, infection, wound dehiscence, Rectovaginal fistula etc.
Late Complications: Dyspareunia (occurs due to faulty repair) & Scar endometriosis (rare).
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3) Outlet Forceps delivery [14, 12, 08, 05, 03, 01]
a. Prerequisites of outlet forceps [19, 10, 09]
b. Indications & complications of forceps delivery. [17, 2000]
c. Prophylactic Forceps [05]
d. Complications of Instrumental delivery. [04]
Ans.

:
Informed consent (verbal or written)
Experienced operator, a valid indication and neonatologist
The head must be engaged
The fetus must present as a vertex or by the face with the chin anterior

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 The position of the fetal head must be precisely known
As per the ACOG guidelines station should be > + 2
The cervix must be completely dilated (10 cm)
The membranes must be ruptured
There should be no suspected cephalopelvic
disproportion (pelvis deemed adequate)
Bladder must be empty
Backup plan in case of failure {LSCS facilities)
Adequate maternal analgesia.
Outlet forceps:
It is a variety of low forceps used when the Fetal head is
on the perineum
Wrigley's forceps are used exclusively in outlet forceps
operation
– Perineal and vulval infiltration with 1 %
lignocaine
:
a) Identification of the blades and their application with
utmost gentleness – the left or lower blade is to be
introduced first.
b) Locking of the blades - blades should be articulated with
ease when correctly applied (bimalar, biparietal placement); The handles should NEVER be forced to lock them
c) Traction – Give steady traction (in the axis of birth canal)
In outlet forceps delivery the direction of the pull is straight horizontal then upwards forwards.
d) Removal of blades – The blades are removed one after the other, the right one first.
Prophylactic forceps:
It refers to forceps delivery only to shorten the second stage of
labor when maternal or fetal complications are anticipated
It prevents possible fetal cerebral injury due to pressure on the
perineum and spares the mother from the strain of bearing
down efforts
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4) Vacuum delivery (incl. Advantages & Disadvantages) [08, 04, 02, 99]
a. Fetal & Maternal complications of Ventouse Delivery [18, 05]
b. Vacuum extractor. [16]
Ans.
Ventouse is an instrumental device designed to assist delivery
by creating a vacuum between the cup and the fetal scalp.
Ventouse cup should be placed on the flexion or pivot point
– {refer 3rd SQ}

– scalp abrasion, Cephalhematoma,

Subaponeurotic (subgleal) hemorrhage, intracranial
hemorrhage, Retinal hemorrhage & Jaundice

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 – injuries can occur due to inclusion
of the soft tissues, such as the cervix or vaginal wall inside the
cup
are:
a) Suction cups with 4 sizes (30 mm, 40 mm, 50 mm & 60 mm);
b) A vacuum generator &
c) Traction tubing

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5) Classical Caesarean Section. [06, 96]
Ans. This is relatively easy to
perform than LSCS
❖ Abdominal incision is always
longitudinal (paramedian) and
about 15 cm (6") in length,
1/3rd of which extends above
the umbilicus  A longitudinal
incision of about 12.5 cm (5") is
made on the midline of the
anterior wall of the uterus
starting from below the fundus
❖ The baby is delivered
commonly as breech extraction
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1) Craniotomy [12]
Ans.
: It is an operation to make a perforation on the fetal head, to evacuate the contents
followed by extraction of the fetus.

Cephalic presentation producing obstructed labor with dead fetus

Hydrocephalus even in a living fetus
Interlocking head of twins.
:
Craniotomy should not be done when the pelvis is severely contracted – in such condition, the
baby cannot be delivered, as the bimastoid diameter (base of the skull) of 7.5 cm cannot be
compressed.
Rupture of the uterus – go for laparotomy instead

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 Safe Motherhood, Epidemiology of obstetrics

1) Define social obstetrics. What are the aims and objectives of MCH (Maternal and Child Health)
Care? What are the measures that can Improve the MCH care? [09]
Ans. Social obstetrics is defined as the obstetric care of a community that can be provided in the
perspective of its social, economic, environmental and cultural background
Aims & Objectives of antenatal care:
To promote, protect and maintain the health of the mother during pregnancy;
To detect "high-risk" cases and give them special attention;
To foresee complications and prevent them;
To remove anxiety and dread associated with delivery;
To reduce maternal and infant mortality and morbidity;
To teach the mother elements of child care, nutrition, personal hygiene, and environmental sanitation;
To sensitize the mother to the need for family planning, including advice to cases seeking medical
termination of pregnancy; and
To attend to the under-fives accompanying the mother.
:
– It promotes institutional deliveries by giving cash incentives
JSSK (Janani Shishu Suraksha Karyakram) – It provides free health services (OPD/IPD/
Investigations/Rx/Diet/Transport) to pregnant females & infants
HBNC (Home based neonatal care) - provided by ASHA workers.
FBNC (Facility Based Neonatal Care) – categorised into 3 levels
i. Special newborn care unit (SNCU) – situated in district hospitals & above level
ii. Newborn Stabilisation Unit {NBSU} – situated at PHC & above level
iii. Newborn care corner {NCC} (in the Labor room) – situated at the lowest level
INAP (India Newborn Action Program) – to↓ neonatal mortality rate & to↓still birth rate
ARSH {Adolescent Reproductive & Sexual Health} – aka AFHC {Adolescent Friendly Health Clinic}
 For health education of Adolescent girls aged between 10-19 years
 Also provides WIFS (Weekly Iron-Folic acid Supplementation) tablets
RKSK (Rashtriya Kishore Swasthya Karyakram) – for Adolescent Boys & Girls
 Here, Peer to Peer Approach (SAATHIYA approach) is used.
 Strategy – “7 Cs”: open Clinics, for Counselling, using very good Content, for Communication &
Convergence of health Care, in the Community
RBSK (Rashtriya Bal Swasthya Karyakram) - For all children aged between 0 – 18 years. Strategy
used is 4 Ds i.e., Defects at birth, Diseases, Deficiencies, Development delays.
Nutritional Rehabilitation Centre [NRC] – 24x7 working facility - Only for the Severe acute
malnourished (SAM) child
LQSHYA Program {Labor Room Quality Improvement Initiative} – to ensure safe delivery
SUMAN Scheme {Surakshit Matritva Aashwasan} – the facilities provided under this are:
Ambulance services, min. 4 ANC, Free Delivery, Health Care of Mother & infant till 6 months of
Lactation & Grievance cell.
ICDS - Integrated Child Development Services
IMNCI – Integrated Management of Neonatal & Childhood illnesses

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 Here integration of human resources is done for early treatment & referral
Strategy: LACT {Look, Assess, Classify, Treat}
Classification:
Under 5 Clinic & Lactation management Centres
Pradhan Mantri Surakshit Matritva Abhiyan – Free ANC on 9th of every month & 26
weeks of leave for delivery
Anemia Mukht Bharat – 6x6x6 strategy
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1. Perinatal mortality – Causes & Predisposing factors [16, 14, 13, 11, 07]
a. Maternal Mortality. [16, 12, 01, 2000, 97]
b. Mention 4 causes of maternal mortality in India. [14, 07, 06]
Ans.
Causes of perinatal mortality
Antenatal causes Intranatal causes Postnatal causes
1. Maternal Chronic Diseases: DM, (1) Birth injuries
HTN, cardiovascular diseases, (2) Asphyxia
tuberculosis, anaemia (3) Prolonged labour 1. Pre maturity &
2. Pelvic diseases: uterine myomas, (4) Obstetric complications LBW
endometriosis, ovarian tumours 2. Respiratory
3. Anatomical defects: incompetent distress syndrome
cervix, uterine anomalies 3. Respiratory and
4. Endocrine imbalance alimentary
5. Blood incompatibilities infections
6. Malnutrition 4. Congenital
7. Toxaemias of pregnancy anomalies
8. Antepartum haemorrhages
9. Congenital defects
10. Advanced maternal age
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1) Baby friendly hospital initiative. [20, 18, 16]

Ans. BFHI was launched to ensure that all maternal–child health services in healthcare facilities are made
breastfeeding friendly and support for breastfeeding becomes a vital point of their program as a standard
for care.
This program was started by UNICEF and WHO in Ankara, Turkey in the year 1991
Healthcare facility should implement “The Ten Steps to Successful Breastfeeding” to be qualified as
“baby friendly” hospital {refer Paeds notes}
Health care staff working in MCH services should be trained to offer skilled support for initiation and
continuation of exclusive breastfeeding.
Low-cost breastmilk substitutes, feeding bottles or teats should not be allowed inside the facility.
Establishment of community outreach support systems for breastfeeding mothers.

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 Special topics in obstetrics

1. Cord Blood Banking [21]

Ans.

Cord blood is a rich source of blood stem cells

Stem cells are the building blocks of the blood &
immune cells
Cord blood banking involves collecting blood left in
newborn’ s umbilical cord and placenta & storing it for
future medical use
Cord blood can be used to treat a variety of blood &
bone marrow diseases, blood cancers, metabolic
disorders & immune deficiencies

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2. Amniotic fluid embolism [19, 16]
Ans. AMNIOTIC FLUID EMBOLIM: Amniotic fluid along with fetal cells and debris enter the maternal
circulation via ruptured uterine veins or a tear in the placental membranes
Cause: Occurs as a complication of labor
Pathogenesis:
1) Tear in the placental membranes or rupture of uterine veins allow infusion of amniotic fluid or fetal
tissue into maternal circulation → enter the right-side of the heart → rest in pulmonary circulation
 reactive pulmonary vasoconstriction  RH Failure  cardiac output  Cardiogenic Shock
2) Amniotic fluid has a high thromboplastin activity → activate coagulation factors → Disseminated
intravascular coagulation (DIC)  consumption of clotting Factors  Bleeding
Presenting Features & Diagnosis:
 Abrupt onset of dyspnea, cyanosis, hypotension & bleeding (PV, venepuncture site) due to
DIC—at the end of labor or immediate postpartum period.
 a/w premature separation of placenta, rupture of the uterus etc.
 Other Findings: Pulmonary edema and features of DIC
Differential Dx: Pulmonary embolism, Air embolism, septic shock, hemorrhagic shock etc.
Management: It is mainly supportive
Anticipate possible cardiopulmonary arrest & emergent C-section
▪ Place the patient in Left Uterine Displacement {LUD}
▪ Prepare for emergent intubation
▪ Support circulation with IV fluid, vasopressors & inotropes
▪ Consider circulatory support with ECMO
Anticipate massive hemorrhage & DIC
The maternal prognosis after amniotic fluid embolism is very poor though infant survival rate is
around 70%.
Comp.: Maternal death or permanent neurological deficit

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 Imaging in obstetrics

1. Antepartum Fetal Surveillance in Late Pregnancy [21]

a. Biophysical profile {BPP} [21, 19]
b. Modified biophysical profile. [14]
Ans.

Prevention of fetal death &

Avoidance of unnecessary
interventions

Clinical methods – {refer Antenatal care}

Biochemical methods – done for assessment of pulmonary maturity by Amniocentesis – check for
surfactant; Presence of phosphatidylglycerol, phosphatidylcholine, Amniotic fluid turbidity etc.
Biophysical method - Biophysical profile {BPP} – is a screening test for utero–placental insufficiency
combines NST with other parameters determined by ultrasound examination
A score of 0 or 2 is assigned for the absence or presence of each of the following:
A reactive NST
Amniotic fluid volume (vertical fluid pocket >2 cm)
Fetal breathing movements
Fetal activity
Fetal tone.
:
Reassuring results (8 to 10) – repeat at weekly intervals
Less reassuring results (4 to 6) – suspect chronic asphyxia
 repeat BPP later the same day
Very low scores (< 4)  Strongly suspect asphyxia 
delivery regardless of gestational age
A modified BPP includes assessment of NST (acute stress) and ultrasonographically determined
amniotic fluid index (chronic stress).
Modified BPP is considered abnormal (non-reassuring) when the NST is non-reactive and/ or the
AFI is < 5.
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2. Non-stress test (NST) and its importance [14, 12, 04, 99]
Ans.
NST is one of the biophysical tests used for antepartum fetal surveillance (in late pregnancy)
NST indicates fetal condition and is most widely used for the assessment of fetal well-being.
ln this test, the response of FHR to the fetal movements is studied.
 FHR accelerates temporarily in response to fetal movements – – it indicates a

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  : it indicates no FHR acceleration which means (over 40 min)
Non-reactive NST indicates utero–placental insufficiency {Hypoxia → metabolic acidosis → CNS
depression → changes in fetal biophysical activity}
In high-risk cases NST should be done after 30 weeks and frequency should be twice weekly.
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3. Indication for ultrasound in 1st trimester. [05, 03, 2000, 98, 88]
a. Uses of Ultrasonogram in Obstetrics. [01, 97, 88]
b. Indications for ultrasound in late pregnancy. [2000]
Ans.

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 Preterm labour, PROM, post maturity IUFD

1. Preterm labour – causes, complications & Mx. [17, 12, 05, 02]
a. Tocolytic agents to arrest pre term labour. [09]
Ans.
A preterm labor is one when labor starts after the period of viability (20-28 weeks) but before 259 days
(<37 completed weeks) of pregnancy

Idiopathic – MC – early engagement of head occurs

Iatrogenic – Indicated preterm delivery clue to medical or obstetric complications
Complications in present pregnancy
Maternal - Uterine anomalies: Cervical incompetence, Medical and surgical illness etc.
Fetal – Multiple pregnancy, congenital malformations and intrauterine death
Placental – Infarction, thrombosis, placenta previa or abruption.
History – h/o preterm delivery, ART, asymptomatic bacteriuria, maternal stress, smoking habits etc.
: Preterm infants are at risk of many complications due to immaturity
of various organs and also for the cause of preterm birth.
 length of hospital stay. RBL - I
Hypothermia – due to
less fat & surface area
Asphyxia – due to
anatomical and
functional immaturity.
Hypoglycemia {due to
lack of glycogen stores in
liver} & Jaundice
{hepatic immaturity}
Patent DA
Long term
Complications: Poor
Growth, Cerebral palsy,
hearing loss, chronic
lung disease & ADHD.

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 :
Tocolytics are drugs that inhibit uterine contractions =
Uterine relaxants
Examples: Oxytocin receptor antagonists, Nitric oxide
donors, Betamimetics, Prostaglandin synthetase
inhibitors, Magnesium sulfate, Calcium channel
blockers etc.
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2. Intra Uterine Fetal Demise/Death – causes, signs & complications. [16, 10, 05, 04]
Ans.
Definition: IUFD refers to all fetal deaths weighing >500 g occurring both during pregnancy
(antepartum death) or during labor (intrapartum).
Causes of IUFD:
Idiopathic
Iatrogenic – External cephalic version; Drugs (quinine beyond therapeutic doses}
Maternal factors – Hypertensive disorders, Diabetes, infections (malaria, hepatitis, influenza,
toxoplasma, syphilis}, Thrombophilias, SLE, Antiphospholipid syndromes, Post-term pregnancy.
Abnormal labour etc.
Placental factors – APH; Cord accident; TTTS etc.
Fetal factors – Chromosomal anomalies, Structural anomalies, Infections, Rh-incompatibility etc.
Symptoms – Absence of fetal movements which were
previously noted by the patient.
Signs – Retrogression of the positive breast changes that
occur during pregnancy is evident.
Per Abdomen
Gradual retrogression of the fundal height.
Uterine tone is diminished and the uterus feels flaccid.
Fetal movements are not felt during palpation.
Fetal heart sound is absent.
Cardiotocography (CTG): Flat trace.
Egg-shell crackling feel of the fetal head is a late
feature.
Complications
Psychological upset.
During labor- Uterine inertia, retained placenta and
postpartum hemorrhage
Infection- especially by gas forming organisms like
Clostridium welchii may occur. The dead tissue favors
their growth with disastrous consequences.
Blood coagulation disorders if the fetus is retained for
> 4 weeks defibrination from 'silent' DIC. It is due to gradual absorption of thromboplastin,
liberated from the dead placenta and decidua, into the maternal circulation.
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3. Management of post-term pregnancy. [16]
Ans.

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Definition: a pregnancy continuing beyond 2 weeks of the expected date of delivery (>294 days) is
called post-maturity or post-term pregnancy.

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4. Causes of intrauterine growth retardation. [02]
a. Etiological factors of asymmetrical growth restriction. [10]
Ans.

Constitutional – Small women, slim, low BMI etc.

Maternal nutrition before and during pregnancy & Toxins – Alcohol, smoking, cocaine, heroin etc.
Maternal diseases: Anemia, HTN, thrombotic diseases, heart disease, chronic renal disease etc.
: Placenta previa, Abruption, Circumvallate, Infarction and Mosaicism  poor
uterine blood flow
– Structural anomaly, Chromosomal anomalies, TORCH infections, Multiple pregnancy
 hinders utilisation by the fetus
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1. Diagnosis of pre labor rupture of membranes. [13]

Ans. Symptom: escape of watery discharge per vaginum either in the form of a gush or slow leak.
To Confirm diagnosis –
1) Speculum examination – to inspect the liquor escaping out through the cervix;
2) To examine the collected fluid from the posterior fornix {vaginal pool} for:
Detection of pH by litmus or Nitrazine paper – Nitrazine paper turns from yellow to blue at pH >6;
Examination under microscope – note the characteristic ferning pattern on a smeared slide
On staining with 0.1 % Nile blue sulfate orange blue coloration of the cells (exfoliated fat containing cells
from sebaceous glands of the fetus);
3) AmniSure – A rapid immunoassay is accurate;
4) Ultrasonography & Cardiotocography

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 Abnormal Uterine action

1. Bandl’s ring and its management. [14, 10, 04, 02, 74]
Ans.
Tonic Uterine Contraction & Retraction (Syn: Bandl's ring,
Pathological retraction ring)
: Bandl's ring is a constriction between a
woman's thickened upper contractile uterine segment
and thinned distended lower uterine segment (LUS)
during parturition
It is an end result of tonic uterine contraction and
retraction
: occurs following obstructed labor
:
 Patient is in agony from continuous pain and discomfort and becomes restless;
 Features of exhaustion and ketoacidosis are evident;
 Per Abdomen – reveals Upper segment is hard and tender; Lower segment is distended & tender;
 Per Vaginum – Features of obstructed labor; Lower segment is very much pressed by the forcibly
driven presenting part
:
 Exclude Rupture of uterus
 Internal version is contraindicated
 Correction of dehydration and ketoacidosis by infusion of Ringer's solution
 Analgesics & Parenteral antibiotic is given (Ceftriaxone 1 g IV}
 Cesarean delivery is done in majority of the cases
Prevention – Partographic management of labor, early diagnosis of malpresentation, disproportion
and delivery by cesarean section can prevent this condition completely
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2. Uterine inertia [04]
Ans.
{Hypotonic Uterine Dysfunction):
It refers to intensity; duration & good relaxation in between uterine contractions
– Patient feels less pain; palpation reveals less hardening of the uterus; fetal parts are
well palpable and FHR remains normal.
:
 Exclude CPD, Malpresentations & Fetal distress
 Vaginal delivery
 General measures: AVOID supine position; relieve maternal stress; catheterize the bladder;
maintain hydration by infusion of Ringer's solution
 Active measures – to uterine contraction by low rupture of the membranes + oxytocin drip.
The drip is to be continued till 1 hour after delivery
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1. Constriction ring. [11]

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Ans.
Constriction Ring (Syn: Contraction ring, Schroeder's ring): It is one form of incoordinate uterine action
Causes: Injudicious administration of oxytocics; PROM; & Premature attempt at instrumental delivery.

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 Contracted pelvis

1) What are the causes of unengaged head in a primigravida in labour? How will you manage a case of
borderline cephalopelvic disproportion? [03]
a. Assessment of CPD (Cephalopelvic Disproportion). [16, 13]
b. Clinical pelvimetry. [15]
Ans.
Causes of unengaged head in a primigravida in labour: CPD, Deflexed head, Loop of cord around neck,
Hydrocephalous, Placenta previa, etc.
It is a state where the normal proportion between the size of fetal head to the size
of the pelvis is disturbed.
:
Clinical pelvimetry:
 Abdominal method – fetal head can be pushed down a little or cannot a pushed down into the
pelvis
 Abdominovaginal method (Muller-Munro Kerr) – Muller suggested to place the vaginal finger
tips at the level of ischial spines to note the descent of the head
X-ray pelvimetry: Lateral X-ray view with the patient in standing position
Cephalometry – USG or MRI can be used to measure the bi-parietal diameter of the fetal head.
– based on clinical and supplemented by imaging pelvimetry
Borderline disproportion: Where obstetric conjugate is between 9.5 cm and 10 cm
Severe disproportion: Where obstetric conjugate is <7.5 cm (3")
:
 Minor degrees of inlet contraction can be left to have a spontaneous vaginal delivery at term
 For moderate & severe CPDs:
Induction of labor 2-3 weeks prior to EDD
Elective cesarean section at term
Trial labour
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1. Trial labour. [11]

Ans.
: It is the conduction of spontaneous labor in a minor to moderate degree of CPD, in an
institution under supervision with watchful expectancy, hoping for vaginal delivery
:
 Associated mid-pelvic and outlet contraction;
 Presence of complicating factors like elderly primigravida, malpresentation, post-maturity, post-
cesarean pregnancy, pre-eclampsia, medical disorders such as heart disease, diabetes,
tuberculosis, etc.;
 Where facilities for cesarean section is not available round the clock.
: (1) It eliminates unnecessary cesarean section electively decided upon;
(2) It reduces the need of preterm induction of labor with its antecedent hazards;
(3) A successful trial ensures the woman a good future obstetrics
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2. Complications of dilatation & curettage and their prevention. [05]
Ans.
D&E: It consists of dilatation of the cervix & evacuation of the products of conception from the uterine
cavity
:
Injury – Cervical lacerations, Uterine perforation;
Excessive hemorrhage – it can be due to incomplete evacuation, or atonic uterus;
Shock – it can be due to anesthesia, excessive blood loss etc.
Perforation – injury to major blood vessels, bowel or bladder.
Sepsis – endometritis, myometritis and pelvic peritonitis;
Hematometra may cause pain;
Continuation of pregnancy (failure)- 1 %.
: Pelvic inflammation; Uterine synechiae; Infertility; Cervical incompetence and in
subsequent pregnancy risk of preterm labor & ectopic pregnancy.
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1. Contracted pelvis. [07]

Ans.
Definition: it refers to 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
Causes:
Nutritional – rickets, osteomalacia & bone TB
Diseases or injuries of the bones
Pelvic injuries – fracture, tumors, tubercular arthritis;
Spine abnormality – kyphosis, scoliosis, spondylolisthesis, coccygeal deformity;
Lower limbs – poliomyelitis, hip joint disease
Development defects: Naegele's pelvis, Robert's pelvis; high or low assimilation pelvis.

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 Pharmacotherapeutics in Obstetrics

1. Labour Analgesia. [15]

a. Drugs used for labour analgesia. [04]
b. Pain relief during labour. [03]
Ans.

 Epidural (regional/neuraxial) anaesthesia – safest and simplest – provides complete relief of pain
throughout the pain
 Spinal anesthesia is obtained
by injection of local
anaesthetic agent into the
subarachnoid space
 TENS – works by inhibiting transmitter release through interneuron level.

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2. Uses of magnesium sulphate in obstetrics. [13, 11]
Ans.
To prevent seizures in pre-eclampsia
To stop premature labour
To protect the brains of premature babies
{refer hypertensive disorders for regimens}
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3. Prostaglandins in obstetrics. [09, 05]
a. Uses of misoprostol. [13]
Ans. Increased biosynthesis of PGs of E and F series in the uterus is a prerequisite for labor.
Uses of PGs in obstetrics:
 Cervical ripening prior to induction of abortion or labor Contraindications:
 Induction of abortion (MTP and missed abortion) • Hypersensitivity;
 Induction of labor • Uterine scar
 Augmentation (acceleration) of labor • Active cardiac, pulmonary,
 Termination of molar pregnancy renal or hepatic disease
 Management of atonic PPH • Bronchial asthma
 Medical management of tubal ectopic pregnancy
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1. Mention maternal and fetal dangers of oxytocin. [15, 07]
a. Uses of oxytocin in Obstetrics. [02]
Ans.
Maternal Complications of oxytocin Fetal Complications of oxytocin
 Uterine hyperstimulation
 Uterine rupture
Fetal distress, fetal hypoxia or
 Antidiuretic effect  water intoxication
even fetal death may occur due
 nausea, vomiting
to uterine hyperstimulation
 Arrhythmias, Anginal pain
 rarely hypotension
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2. Drugs used for suppression of lactation. [12]
a. Bromocriptine. [09, 07]
Ans.
: If baby is born dead or dies in the neonatal period or if breastfeeding is
contraindicated due to medical reasons;
: estrogen, androgen or bromocriptine
Side effects of bromocriptine are: hypotension, rebound secretion, seizures, myocardial infarction
and puerperal stroke.
: ice packs to prevent engorgement; analgesics (aspirin) to relieve pain
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3. Contraindications for use of prophylactic ergometrine. [12, 03]
Ans.

TOPER

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 New born Infant

1. Merits of breast feeding. [17, 15, 05, 2000, ,99, 98]

Ans. Breast milk contains necessary nutrients to sustain appropriate growth and development during
the first 6 months of life in term infants
Breastfeeding should be initiated within half an hour after vaginal delivery and within 4 h after
caesarean delivery
Exclusive breastfeeding: Giving a breastfeeding baby no other food or drink, including water (with
the exception of prescribed drugs) during first 6 months of age
It Protect against common childhood infections and reduction in infant and under 5 mortality rates.
Breast milk is with no risk of infection
Improves bonding between mother and baby
Breastfed babies are protected against diabetes, heart disease, allergic disorders etc.
Reduces postpartum bleeding, prevents anemia in mother in addition to contraceptive effect
Protective factors {Anti-infective Factors} in Breast milk:
—Protects against amoeba and giardia infection
—Protects against malaria
—Surface protection to respiratory tract and GIT
—Ensures absorption of iron and makes it unavailable for microorganisms.
Bacteriostatic, inhibits Escherichia coli.
—Colonization of lactobacillus
—Precursor of tryptophan which is a neurotransmitter
: Phosphorus ratio >2; Ensures good calcium absorption
: Promotes brain growth, reduces dyslexia/hyperactivity.
—Binds to thyroxine, Vitamin D, and B12
—Promotes growth, neurotransmitters
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1. Mention two indications and two objectives of exchange transfusion in newborn. [15]
Ans.
Exchange transfusion is a life-saving procedure in hemolytic disease of the newborn
Indications of exchange transfusion Objectives of exchange transfusion
 To stop hemolysis, and bilirubin production
 Cord blood bilirubin level > 4
 To correct anemia and to improve congestive cardiac
mg/dL and hemoglobin level less
failure of the neonate
than 11 g/dL
 To remove the circulatory antibodies
 Rising rate of bilirubin is over 1
 To remove sensitized RBCs
mg/dL/hour despite phototherapy
 To eliminate the circulatory bilirubin
 Total bilirubin level > 20 mg/dL
 To stop hemolysis and bilirubin production.

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 Diseases of Fetus and New Born

1. Jaundice of the new born baby. [15, 04, 03, 01] ➔ refer Paeds notes – Pg. 24
2. Management of asphyxia neonatorum. [15, 03, 01] ➔ refer Paeds notes – Pg. 26
3. Cephalhematoma. [14, 11] ➔ refer Paeds notes – Pg. 26
4. Birth Injuries in the newborn. [03] ➔ refer Paeds notes – Pg. 26
5. Respiratory Distress Syndrome. [04] ➔ refer Paeds notes – Pg. 25
a. Foetal distress. [06, 03]
6. Apgar score. [10, 05, 04, 2000] ➔ refer Paeds notes – Pg. 25
7. Assessment of foetal growth. [05] ➔ refer Paeds notes – Pg. 08
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8. Caput succedaneum. [11, 2000] ➔ refer pg. no. 12 in OBS
Ans.
Definition: Serosanguineous fluid collection over the presenting part between the pericranium and
scalp
Cause: This is the swelling of the soft tissue of scalp over presenting part during vaginal delivery
Clinical Features:
Swelling seen at birth – Diffuse, soft, edematous, pitting, non-fluctuant
Swelling crosses (not limited by) suture lines
Disappears spontaneously within 2–4 days of life.
Treatment: No treatment is required
 Phototherapy – if Hyperbilirubinemia develops {rarely}
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9. Meconium aspiration syndrome. [04]
Ans.
Meconium aspiration either happens in utero, during delivery or immediately after birth
Meconium may cause partial-ball valve effect & air trapping or complete peripheral airway
obstructionatelectasis
Clinical presentation:
 These babies develop hypoxemia and respiratory distress – Gasping efforts by fetus
 Meconium staining of nails, skin and umbilical cord
 Neurological symptoms—Depressed, hypotonic with occasional hypoxic seizures
Complications: Sepsis, Persistent pulmonary hypertension (PPHN), Air leak syndromes etc.
Treatment – Conservative therapy
 Supplemental oxygen for Hypoxemia {Avoid CPAP as it can worsen air trapping}
 Ventilation for severe cases
 Other options: Surfactant therapy & ECMO
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1. Down’s Syndrome. [17, 05] ➔ refer Paeds notes – Pg. 79

2. Erb’s palsy. [12] ➔ refer Paeds notes – Pg. 77
3. Problems of low-birth-weight babies. [05] ➔ refer Paeds notes – Pg. 23

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