Relevant physiology

Chadwick sign/ Jacquimers sign: bluish discoloration of vagina cervix

8 weeks of POG

Hegars sign: softening of the isthmus , 6 weeks of POG

Goodles sign: softening of the cervix, 6 weeks of POG

Piskaceks sign: one half of uterus is softer than the other due to lateral
implantation, 8 weeks

Osianders sign:

Palmars sign: uterine contractions on bimanual palpation

Hartmans sign: implantation bleeding

Chloasma/ melasma: mask of pregnancy

Additional calories: 300

Wt : 12.5 kg

Water: 6.5 liters

In pregnancy

Fasting hypoglycemia

Post prandial hyperglycemia

Iron requirement in pregnancy is1000 gm

1st half : 3-4 mg / day

2nd half: 6-7 mg/ day

Anemia: < 11

WBC count: physiological rise

Max rise in puerpeuriam( 20000)

Average platelet count: falls

All clotting factors increase except 11 and 13

Cardiovascular system

Plasma vol increases by 40%

Red cell mass increases by 20%

This is physiological hemodilution

Oxygen carrying capacity of blood decreases coz it depends on Hb

Cardiac output increases by 40%

Oxygen demand increases by 20%

Arterio venous oxygen gradient decreases as the venous blood has more
oxygen

All heart sounds are loud

Heart rate increases by 10-16 BPM ( early to late)

Heart shifts upwards and rotates laterally

Apex beat is in the 4th ICS

Systolic murmur upto grade 2 are physiological, ejection systolic murmur

Physiological splitting S1

S3 can be heard

ECG: LAD

Physiological ST elevation

X ray: cardiac silhouette is larger

Straightening of left heart border

Systemic vascular resistance falls

Therefore both DBP and SBP fall, more in DBP

Supine hypotension syndrome

In late second and third trimester

IVC compressed

Therefore lie in left lateral position in second and third trimester

Venous pressure in lower limbs is increased

Cardiac output is max in immediate post partum

Then during the second stage of labour

Then 28-32 weeks of POG

Uterine blood flow at term

750 ml per minute

This represents 10% of the CO

Utero placental blood flow at term

450-650 ml/ min

This is 90% of the blood flow to the uterus

What time is utero placental circulation is established: day 12

Fetal circulation is established by day 21

Fetal CVS

It is the first system to develop

Heart develops from mesoderm

Spleen

Adrenal cortex

Are all mesodermal

While rest abdominal organ devlop from endoderm

Heart beats at day 21

TVS: heart beat at 5-6 weeks

TAS: 6 weeks

TVS , first sign of pregnancy, gestational sac seen at 4.5-5 weeks

TAS: 5 weeks

Function of lungs done by placenta

Umbilical vein carries the oxygenated blood

Oxygen saturation is 70-80% of umbilical vein

This meets IVC via the ductus venosus, saturation falls

This blood is brought to the right atria

Through foramen ovale, goes to left atrium

Then to left ventricle, then to aorta then to brain

Only 10% of the CO enters the pulmonary vasculature

This passes through the ductus arteriosus to aorta

Saturation in left atria: 60%

???

After birth

First to close

Umbilical vessels

Foramen ovale

Ductus arteriosus

Ductus venosus

Baseline fetal heart rate: 120-160 beats / min

at 5 weeks: 90

9 weeks: 160

More than 9 weeks: 120

Fetal blood volume at term: 125 ml/ kg

Renal system

GFR increases by 50% in pregnancy

Each kidney increases in length by 1 cm

Serum creatinine and BUN: decreases

serum uric acid: no change, coz reabsorbed

Hydroureter and hydronephrosis is physiological

Progesterone is the ms relaxant, causes dilation

Uterus compresses rt ureter more at the pelvic brim therefore more on the
rt side

Fetus begins to pass urine at 12 weeks

Fetal urine production at term: 650 ml/ day

Respiratory system

Tidal volume and alveolar ventilation increases in pregnancy

40%

Respiratory rate does not increase

Only the depth increases

Progesterone increases the sensitivity of respiratory centre to CO2

Therefore PCO2 decreases

Thus pregnancy is a state of Mild Respiratory alkalosis

pH of blood does not change

Serum bicarbonate level will fall, excreted by kidney

Increased sodium excretion, thus plasma osmolarity falls

Diaphragm rises in pregnancy by 4 cm

Transverse thoracic diameter by 2 cm

Therefore total lung capacity falls

But vital lung capacity shows no change

No change in inspiratory reserve volume

Decrease in exploratory reserve volume

PCWP no change

Fetal respiratory system

Fetal lungs derived from

Outpouching from foregut, therefore endodermal

Canalicular network developed by 20 weeks

Alveoli by 24 weeks

These are lined by pneumocytes

Therefore surfactant production begins at 24 weeks

But appears in amniotic fluid at 28 weeks

Fetal breathing movements: 11 weeks

Swallowing: 10-12 weeks

Gross body movements: 8 weeks

Urine production: 12 weeks

Meconium at 16 weeks

Fetus can hear in utero at 24 weeks

Light perception at 28 weeks

Amniotic fluid

Major source

1-12 weeks: ultrafilterate of maternal plasma

12-20 weeks: transudate from fetal skin

>20 weeks: fetal urine

pH of amniotic fluid: 7( 7-7.5)

Water in amniotic fluid is replaced every three hours

Osmolarity: 250 mosm/ liter

Rate of turnover at term is 500 ml / day

It is clear

Green : meconium staining

Golden: RH incompatibility

Greenish yellow/ saron: maturity

Dark color: abruption

Dark brown/ tobacco juice: intrauterine death

Amount

12 weeks: 50 ml

20 weeks: 250 ml

28 weeks: 1000 ml

36: 900 ml

40: 800 ml

42: 200 ml

Functions of amniotic fluid

It has no nutritive function

Amniotic fluid index

Normal: 8-24

>24: polyhydroamnios or more than 2 liters

Deep vertical pocket: 2-8

Therefore any clay more than 8 is polyhydroamnios

Oligohydroamnios

AFI < 5

5-8 is borderline normal

Less than 200 ml

Less than 2 in DVP

Most common cause of mild polyhydroamnios : idiopathic

Most common cause of moderate to sever polyhydroamnios is gross

congenital anamoly

Most common anamoly

GIT followed by neural tube defect

Most common cause of oligohydroamnios is idiopathic

Most common severe oligohydroamnios is bilateral renal agenesis

Cardiac anamoly in fetus can be asso with all possible scenarios

Labour

First stage

From the onset of contractions to full dilation( 10 cm)

Latent stage

Active stage: beyond 3 cms of dilation

Second stage

Full dilation to delivery

Third stage

Delivery of placenta

Fourth stage

Observation

engagement

When biparietal diameter of fetal skull crosses the pelvic inlet

It rules out CPD at pelvic brim

Station when the head is engaged: zero

How many fifths are palpable per abdo: 2/5

Lie: relationship of longitudinal axis of the baby to spine

Longitudinal

Transverse

Oblique/ unstable lie: most common cause is placenta previa

Presentation

Cephalic

Breech

Shoulder( transverse)

Cephalic further divided based on flexion and extension

Fully flexed(Chin touching chest): vertex

Transverse diameter( biparietal) always remains constant

Antero posterior keeps changing

Sub occipito Bregmatic: 9.5 cm

Face presentation( full extension)

Sub mento bregmatic , 9.5 cm

Brow

Partial extension

Mento vertical, 14 cm

Sinciput

Partial flexion

Fetal diameters

Bi mastoid: 7.5 cm

Bi temporal: 8 cm

Bi parietal: 9.5 cm

Mento vertical : 14 cm

True pelvis: below pelvic brim

False pelvis

True further divided into

Inlet

Smallest diameter is AP diameter

Diagonal conjugate( can be assessed clinically)

Measures 12 cm

Obstetric: subtract 1.5 from diagonal

True conjugate: 11 cm

Cavity

Inter ischial diameter

10.5 cms

Outlet

Inter tuberous diameter

11 cms

Steps of normal labour

1. Engagement

2. Descent and flexion

3. Internal rotation( at level of ischial spines)

Then crowning: BPD stretches vulval outlet and does not go back

4. Delivery of the head( extension)

5. External rotation / restitution of shoulders

6. Delivery of rest of body by lateral flexion

Abnormal labour
These three things need to be coordinated for normal labour
Path

Passenger

Push

Path

Pelvis types: Cadwell Malloy classification based on Shape of inlet

Gynecoid 50%, circular, side walls parallel, ischial spines blunt, sub pubic
angle is obtuse

Anthropoid 25%, heart shaped, convergent, prominent, acute

Android 20%

Platypelloid 5%

Contracted pelvis

Could be anything

Inlet, cavity, outlet

Shortest AP diameter is less than 10 cm

Or diagonal conjugate should be less than 11.5 cm

Cavity

IID less than 8 cm

Outlet

Inter tuberous diameter less than 8 cm

Rachitic pelvis

Triradiate in vit D deficiency

Naegele's pelvis: one ala of sacrum missing

Roberts: both ala missing

Above two pelvis, only C section

Trial of labour

Nulliparous

When there is CPD at the level of inlet

This is not done for suspected CPD at the level of cavity or the outlet

If it is done at the level of inlet, head won't go in therefore safe

Best assessment of CPD: process of labour itself

Pelvic assessment( best by MRI)

In nulliparous women done at 37 weeks

In multi, at onset of labour

Push

Contractions

Cornu is the pacemaker of uterus, rt side predominates

From the Cornu, at 2 cm/ sec

Depolarize entire organ in 15 sec

At what intra uterine pressure, contraction palpable: 10 mm of hg

Painful: 15 mm of hg

To dilate the cervix: 15 mm of hg

Fundus cannot be indented: 40 mm of hg

Adequate uterine contraction

3 contractions in 10 min, each lasting 45 seconds

Uterine contractions that generate 200-220 Monte video units

No. of contractions in 10 min X pressure generated by 1 contraction

80-120

200-220

???

Scenario

2 pm

1 cm dilated

30% eaced

10 pm at night, everything same

Next step

Identify the stage of labour

This is false labour pains

Managed by sedation

Next scenario

2 pm

2 cm dilated

30% eaced

6 pm

3 cm dilation

50% eaced

latent stage

Sedate

Scenario 3

2 pm

3 cm dilated

50% eaced

Accidental rupture of membranes during PV

6 pm

4 cm dilated

70% eaced

Active stage of labour

Therefore slow labour

Do ARM

Oxytocin augmentation till uterine contractions are adequate

Scenario 4

2 pm

5 cm dilated

50% eaced

Accidental ARM

Adequate contractions

6 pm

5 cm dilation

Stage is active

ARM is already done

Contractions are already adequate

Arrest of labour is the diagnosis

No change in cervical dilation even after 2 hours of adequate contractions

This is a diagnosis only in the active phase of labour

Membranes should always be ruptured

Managed by C section

At 2 pm

5 cm dilated

Eaced

Adequate contractions

Membranes ruptured

Progress is slow, not arrest

It could be CPD or occipito posterior

Therefore do a repeat PV to rule out both these conditions

Caput and moulding will tell CPD

Grade 1 moulding: just touching

Grade 2:

Grade 3:

Manage by C section

If it is occipito posterior

Wait and watch

Arrest of labour is present

But we failed to diagnose

Leads to obstructed labour

Which in turn leads to rupture

Pt will show

Tachycardia

Tachypnea

Acidotic breath

Exhaustion

On P/A examination

Bandl's ring

Groove between upper and lower segment

Contracted upper and stretched lower segment

Dilated bowel loops

Fetal distress or IUD

P/V

Hot and dry vagina

Caput and moulding

Repeated bladder filling

Treatment is C section

Passenger

Most common position in which the baby is present at the onset of labour

LOT(40%)

As labour progresses

Converted into LOA

Occipito posterior presentation

It's a vertex presentation

It's not a mal presentation, it's a mal positioned

Most common cause of OP is android pelvis

Common in primi although mal presentations in multi

At the onset of labour, 15-20 % babies are in OP

Only 5% remain as such

Maternal pelvis decided into 8 positions

Anterior and posterior

When occiput is anterior, LOA is most common

When posterior, ROP is most common

If all the conditions are met, converts to anterior position and delivery
takes place normally

If it tries to rotate anteriorly, but rotates only 1/8 of pelvis

DTA: deep transverse arrest

More in android than anthropoid

Do manual rotation or forceps delivery

Sometimes rotates posteriorly

Ka

Direct occipito posterior

Seen in anthropoid

Delivery is by face to pubes

Head could be deflected as well, the dimensions are more

Engaging diameter is Suboccipitofrontal or occipito frontal, both are more

than mento Bregmatic

Higher grades of perineal tear in face to pubes delivery

Delivery is by extension in face to pubes

Doesn't rotate at all

Persistent OP

More common in anthropoid pelvis

Do C section

face presentation

Engaging diameter: sub mento Bregmatic

Most common cause is anencephaly

Platypeloid pelvis

Multigravidas

Premature babies

Presentation can be mento anterior or mento posterior

Vaginal delivery can occur only in mento anterior and delivery of the head
is by flexion

MP converts to MA

But if persistent MP

C section

Brow presentation

All causes of face are also the causes of brow

Engaging diameter is mento vertical

It can not be delivered vaginally

Do C section

Brow is a transient presentation

It can convert into face by complete extension

And vertex , OP due to deflexed

Transverse lie

Shoulder presentation

Grid iron feel

???

Most common cause is prematurity

In term baby, placenta previa

Platypeloid pelvis

Managed by

Primi at 37 weeks presents with transverse lie

Next step

Do external Cephalic version

Do ECV only when

POG more than 36 weeks

Liquor should be adequate

Membranes should be intact

Pt in latent phase/ early labour

No CI for vaginal delivery

If membranes are ruptured: do C section

Corpora conduplicata

Delivery in double up fashion

Seen in old macerated preterm IUD

Baby gets folded on itself

Vaginal delivery possible

Usually the baby is less than 800 gms

Hand prolapse also seen in transverse lie

Transverse lie with IUD

Do a C section( also in obstructed labour with IUD)

Destructive procedures no longer done

Decapitation

Evisceration

Breech presentation

Longitudinal lie

Incidence of breech at term is 3%

Most common cause is prematurity

3 types

Complete

Frank

???

Most common in primi: frank

Multi: complete or flexed

Max incidence of cord prolapse: footling

Min incidence with frank

Overall Max risk of cord prolapse is with transverse lie

Star gazer baby

Breech baby in which the neck is hyperextended

Absolute contraindications of vaginal delivery in breech

Footling

Star gazer baby

Relative CI

Primi with breech

Macrosomia( >4kg)

Preterm baby

Hydrocephalus ( ventriculoperitoneal shunt after delivery)

Prev LSIS with breech

Q. 37 weeks with breech

ECV

Pinards maneuver

For extended legs in breech

Lovsets: extended arms( method of choice)

Classical : also for extended arms

Maneuvers after coming head

Burns Marshall method

Baby legs are grasped and taken 180 degrees towards maternal
abdomen and delivery is by flexion ???

Mauriceau smellie veit method

Malar flexion and shoulder traction

Head delivered by flexion

Fipers forceps

Prague's Maneuver is used for dorso posterior breech

Forceps can also be used

Duhrsson's incision

Cervix cut at 2 and 10 o'clock

Preterm breech baby with a stuck head

Instrumental delivery

Forceps

Vacuum

To cut short the second stage of labour

F: fully dilated cervix

O:

R: ruptured membranes

C:

Outlet forceps: station is more than equal to 3

Low forceps: more than equal to 2

Mid cavity: 0-2

High: more than 0

Outlet forceps

Head on perineum

Fetal skull on pelvic floor

Scalp at introitus

Sagittarius suture in AP diameter( only 45 degree rotation allowed)

Contraindications for instruments

HIV positive

CPD

Bone deformity like osteogenesis imperfecta

Coagulation defects