Write short notes on uterus bigger than date. 1.2000 (B.

8) (5%)
Causes of uterine size larger than date. 4.1997 (B.14) (5%)
Management of uterus bigger than date at 32 weeks of gestation. (5%)

Uterus bigger than date always find after performing abdominal examination, the
symphysio- fundal height is not corresponded to its gestational age.

It may cause by maternal factors such as unsure last menstrual period (LMP), irregular
or short cycle, wrong date; poor controlled gestational diabetes mellitus (GDM);
abnormal pregnancy includes molar pregnancy, multiple pregnancy, polydramnios;
abnormal growth of fibroids, ovarian cyst, pelvic tumour.
Fetal factors are macrosomia or big baby and fetal abnormalities such as hydrops.

Assessment is needed to identify the underlying cause.

History taking includes the menstrual history of LMP, regularity of cycle to rule out
wrong date; family history of body build, diabetes mellitus (DM); medical history of
established DM; obstetric history of previous big baby, poor controlled GDM.

Abdominal examination should be done to rule out any abnormalities such as

polyhydraminos, abnormal growth; and multiple pregnancy.

Investigation includes oral glucose tolerance test (OGTT) to rule out GDM;
ultrasonography (USG) to detect the fetal size, abnormal growth of fetus, liquor volume
by measuring the amniotic fluid index (AFI) to rule out polyhydramnios. Dating scan
should be performed and measure the fetal parameters (Early dating scan should be
performed before 32 weeks of gestation).

Specific management should be performed according to the identified cause.

If GDM is confirmed, the client should refer dietitian for diet control, regular check ups
should be done to monitor maternal condition and fetal well-being, and exercises
should be advised. The client of poor controlled GDM may consult medical doctor for
insulin therapy, the optimal time and mode of delivery should be discussed with the
client. If polyhydramnios is confirmed, which is also induced by GDM, the
management is same as above stated.
If multiple pregnancy is confirmed, dietary advice should be given to the client, the
weight gain should be considered about 16-20kg throughout the pregnancy, regular
check ups should be done to monitor maternal condition and fetal well-being, the
optimal time and mode of delivery should be discussed with the client.

1
Write short notes on uterus smaller than date. (5%)

Uterus smaller than date always find after performing abdominal examination, the
symphysio- fundal height is not corresponded to its gestational age.

It may cause by unsure last menstrual period (LMP), irregular cycle, wrong date,
genetically small baby, oligohydramnios, intrauterine growth retardation (IUGR) and
intrauterine death (IUD).

Assessment is needed to identify the underlying cause.

History taking includes menstrual history of LMP, regularity of cycle, cycle length, date
of first positive pregnancy test to rule out wrong date; social history of life style, dietary
habit, malnutrition, smoking or drinking alcohol, substance abuse; medical history of
anaemia, renal or cyanotic heart disease; family history of small build of members and
congenital abnormality; obstetric history of previous small babies and abnormal infants.

Physical examination should be done to detect any abnormalities such as thyroid or

heart disease. Abdominal examination should be done to rule out oligohydramnios,
abnormal growth and to note for the uterine size in order to determine is it
corresponded to the gestational age.

Investigation includes ultrasonography (USG) to detect the fetal size; liquor volume by
measuring the amniotic fluid index (AFI) to rule out oligohydramnios; doppler studies
to detect the fetal heart rate and the velocity of placental blood flow to rule out
uteroplacental insufficiency. Dating or morphology scan should be done. Blood/ urine/
viral studies should be performed.

Specific management should be performed according to the identified cause.

Causes of uterine size smaller than date. 10.1996 (B.1) (5%)

It may cause by unsure last menstrual period (LMP), irregular cycle, wrong date,
genetically small baby, oligohydramnios, intrauterine growth retardation (IUGR) and
intrauterine death (IUD).

IUGR is defined as subnormal body weight or mass. Neonates below the 10th percentile
for gestation are generally considered growth restricted.

2
There are few risk factors of IUGR. The maternal factors include genetic predisposition;
social factors of malnutrition, smoking or drinking alcohol, substance abuse; medical
diseases such as anaemia, poor controlled gestational diabetes mellitus (GDM), cardiac
or renal disease; obstetric complications such as antepartum haemorrhage (APH),
pregnancy induced hypertension (PIH) caused poor placental perfusion and lead to
growth restriction.

The fetal factors include chromosomal abnormalities, congenital abnormalities, chronic

infections, e.g. TORCH, multiple pregnancy.

Causes of intrauterine growth retardation. 10.1998 (B.13) (5%)

Factors contributing to intrauterine growth restriction. 10.2002 (B.2) (5%)

Intrauterine growth restriction (IUGR) is defined as subnormal body weight or mass.

Neonates below the 10th percentile for gestation are generally considered growth
restricted.

There are few risk factors of IUGR. The maternal factors are genetic predisposition;
social factors of substance abuse, smoking, drinking heroin, malnutrition, decreased
body mass index (BMI); medical diseases such as pre-eclampsia (PET), poor controlled
gestational diabetes mellitus (GDM), anaemia, renal or cyanotic heart disease; obstetric
complications such as antepartum haemorrhage (APH), pregnancy induced
hypertension (PIH) caused poor placental perfusion and lead to growth restriction.

The fetal factors are chromosomal abnormalities, congenital abnormalities, chronic

infections, e.g. TORCH, multiple pregnancy.

Uteroplacental risk factors are uteroplacental insufficiency, placental abruption,

placenta praevia, uterine abnormality, cord abnormality, multiple pregnancy.

There are 2 types of IUGR. They are symmetrical IUGR and asymmetrical IUGR.
Symmetrical IUGR usually begins before 32 weeks and associated with factors directly
impair the intrauterine growth potential of the fetus, e.g. chromosomal abnormalities,
congenital infection, maternal infection, severe placental abnormality. The whole fetus
is small with the same growth rate of head circumference (HC) and abdominal
circumference (AC).

3
Asymmetrical IUGR usually begins after 32 weeks and associated with uteroplacental
insufficiency leading to a reduced support for fetal growth. It may cause by maternal
illness such as PET, poor controlled GDM, smoking and placental abnormality. The
growth rate of HC is normal and AC is below normal (brain- sparing effect).

Diagnosis of intrauterine growth retardation. 1.1998 (B.3) 10.2000 (B.8) (5%)

Intrauterine growth restriction (IUGR) is defined as subnormal body weight or mass.

Neonates below the 10th percentile for gestation are generally considered growth
restricted.

Assessment is needed to identify the underlying cause.

History taking includes last menstrual period (LMP), regularity of cycle, cycle length to
rule out wrong date; family history of small build of members, congenital abnormality;
social history of substance abuse, smoking, drinking alcohol, malnutrition; maternal
medical disease such as anaemia, renal or cyanotic heart disease, pre- eclampsia (PET),
poor controlled gestational diabetes mellitus (GDM); obstetric history of previous
IUGR or abnormal infants; obstetric complications such as antepartum haemorrhage
(APH) and pregnancy induced hypertension (PIH) may cause poor placental perfusion
and lead to growth restriction.

Physical examination should be done to rule out the static maternal weight gain.
Abdominal examination should be done to note for any abnormalities such as
oligohydramnios, abnormal growth. It is done to note the uterine size and determine is
it corresponded to the gestational age.

Investigations include ultrasonography (USG) and laboratory tests. They are the
confirmatory test if there are signs of IUGR in the physical examination.

USG can detect the fetal size by measuring the abdominal circumference (AC) and
head circumference (HC). USG can detect the liquor volume by measuring the amniotic
fluid index (AFI) to rule out oligohydramnios. USG can detect the fetal abnormalities,
biophysical profiles, placental condition and location to rule out placenta praevia,
placental abruption, uterine or cord abnormality. Doppler studies can detect the fetal
heart rate and the velocity of placental blood flow to rule out uteroplacental
insufficiency.
The laboratory tests are blood/ urine/ viral studies depending on the history.

4
Describe the cause and management of cord prolapse at term. 4.1996(A.1) (15%)
Causes and management of cord prolapse. 1.1998 (B.1) (5%)
Management of cord prolapse. 1.2000 (B.2) (5%)
Management of sudden cord prolapse during a vaginal examination. (5%)

Causes of cord prolapse

The causes of cord prolapse are contracture pelvis such as anthropoid/ android pelvis;
uterine malformation, uterine fibroids and laxity; long cord; malpresentations of fetus,
unstable lies such as oblique or transverse lie, prematurity and multiple prequancy;
polyhydramnios; rupture of membranes at the same time of established labour; artificial
rupture of membranes (ARM) or intrauterine manipulation.

Management during a vaginal examination/ at term

1. We need to call for assistant and medical aid and inform obstetrician, anesthetist
and pediatrician immediately.
2. Explanation and reassurance should be given.
3. In order to relieve pressure of the presenting part onto the cord until the baby is
delivered, the woman should be arranged in knee chest position by keeping the
thighs straight, therefore the fetus gravitates towards the fundus and pressure on
the cord is relieved; or exaggerated position to elevate the buttocks with pillows
or large foam- rubber wedges for transportation for delivery.
4. The foot of the bed should be elevated to relieve cord compression until the baby
is delivered.
5. The gloved fingers are kept in the vagina and hold the presenting part off the cord,
especially during a uterine contraction in order to relieve cord compression. The
cord should replace in vagina gently if cord is prolapse to exterior.
6. If the cord cannot be replaced in vagina, warm moisten saline pad should be used
to cover the cord to prevent blood vessels from going into “spasm” due to
coldness.
7. Rough handling or increase manipulation of the cord may induce spasm of blood
vessels.
8. The woman should given oxygen by face mask and Syntocinon infusion should be
stopped.
9. The assistant needs to auscultate the fetal heart rate closely or observe the
continuous fetal heart monitoring (CFHM) to assess the fetal well-being.
10. Assessment of the stage of labour is needed during this vaginal examination/ by
vaginal examination.

5
If in first stage of labour (cervix is not fully dilated) unless the fetus is dead or very
immature.
1. We should prepare and assist emergency crash caesarean section immediately.
2. The significant others of the client should be informed and consent should be
obtained.
3. The woman should keep nil per oral (NPO).
4. The blood should be taken and sent for cross matching, complete blood picture
(CBP) and clotting profile.
5. Large bore intravenous catheters should be inserted and intravenous fluid should
be given.
6. In the community for transfer purpose, 500-1000 ml Normal Saline is infused
into the bladder via the 16 Fr foley catheter while presenting part is held up. While
waiting for caesarean section, we still need to relieve pressure of the presenting
part off the cord.
7. Proper documentation of the condition is needed.

If in second stage of labour (cervix is fully dilated), delivery is expedited in the most
appropriate manner.
1. Episiotomy is performed in multiparous woman and the client is encouraged to
push.
2. The delivery is speed up by using low forceps (to shorten the second stage).
3. Breech extraction should be performed if not delivered spontaneously.
4. The equipments for infant’s resuscitation should be well prepared.
5. Active resuscitation of the infant should be performed by the pediatrician after
delivery immediately.
6. Proper documentation of the condition is needed.

Write short notes on external cephalic version of breech at term. 10.2000 (B.10)
(5%)

External cephalic version (ECV) is an operation by which the fetus is turned in- utero
for the purpose of changing the breech/ transverse lie/ oblique lie to a cephalic
presentation. The optimal time to perform ECV is after 36 or 37 weeks.

The associated factors of successful ECV are multiparity (abdominal laxity facilitates
ECV), normal amount of amniotic fluid, unengaged presenting part, fetal back is not
posterior, use of tocolytic agents to suppress labour.

6
The risks of ECV are abnormal cardiotocography (CTG) patterns, e.g. fetal bradycardia;
premature rupture of membranes; preterm labour; cord entanglement; placental
abruption; uterine rupture; fetomaternal transfusion; Rhesus isoimmunization.

The absolute contraindications of ECV are fetal abnormality; fetal compromise such as
intrauterine growth retardation (IUGR), abnormal CTG, e.g. bradycardia; placenta
praevia; premature rupture of membranes; previous uterine surgery (rupture of previous
uterine scar); in established labour. The relative contraindications are oligohydramnios,
polyhydramnios and previous lower uterine segment caesarean section.

ECV should be performed only by the physicians who were experienced in the
procedure. The client should keep nil per oral (NPO) and blood taken for cross
matching for the preparation of emergency caesarean section if ECV fails and lead to
labour. The maternal vital signs of blood pressure and pulse and fetal heart rate are
closely monitored before, during and after the procedure. Ultrasonography (USG) is
performed after the procedure to confirm successful version and to exclude fetal
bradycardia. Repeat CTG is required to assess fetal well- being. The client is counseled
on the mode of delivery if ECV fails. Midwives should watch out for complications
after the procedure.

Causes of fetal mortality in external cephalic version for breech presentation.

1.1998 (B.12) (5%)

The causes for fetal mortality in external cephalic version (ECV) for breech
presentation are increased risk of infection due to prolonged leaking which caused by
premature rupture of membranes (PROM); cord prolapse due to PROM; hypoxia due to
cord entanglement; fetal distress and hypoxia due to placental abruption; fetomaternal
transfusion.

ECV can also cause Rhesus isoimmunization, since it occurs in a Rhesus negative
woman if Rhesus positive cells from her fetus pass into her circulation via the placenta,
causing sensitization and then antibody production (anti- D), to these red cells. When
the antibody enters the fetal circulation, haemolysis occurs can lead to fetal mortality.

If ECV is done in the maturity of less than 37 weeks, preterm premature rupture of
membranes (PPROM) may occur, risk of preterm labour of low birth weight (LBW)
will increase, therefore risk of infection will increase and lead to fetal mortality.

7
Modes of delivery for breech presentation. 10.1998 (B.8) (5%)

There are 2 modes of delivery for breech presentation. They are vaginal breech
delivery and elective caesarean section. There are some criteria for vaginal breech
delivery. It must be an uncomplicated pregnancy; the woman with adequate pelvis has a
good obstetric history; the estimated fetal weight (EFW) must less than 3.5 kg; the
presentation is a complete/ frank breech with a flexed head.

Therefore the woman need to have an elective caesarean section must have the
following features. There is presence of maternal complications. The woman with an
unfavourable pelvis has a poor obstetric history or history of previous uterine scar. The
EFW is over 3.5 kg or it is a preterm breech with EFW of 1-1.5kg. The presentation is
an incomplete breech such as footling breech or knee presentation with a
hyperextended head.

There are 3 ways of vaginal breech delivery. They are spontaneous breech delivery,
assisted breech delivery and breech extraction. The baby is expelled spontaneously
without any traction or manipulation is known as spontaneous breech delivery. Some
assistance is necessary in delivery is known as assisted breech delivery. A manipulative
delivery carried out by an obstetrician and is performed to hasten delivery in emergency
is known as breech extraction.

There are some techniques of assisted breech delivery. Burns Marshall Technique is
used for the delivery of flexed head. Mauriceau- Smellie- Veit Maneuver (Jaw flexion
& shoulders traction) is used for the delivery of extended/ deflexed head. Forceps are
used for the delivery of the aftercoming head. Lovset’s Maneuver is used for the
delivery of extended arms. Pinard’s Maneuver is used for the delivery of extended
legs (abduction of the thigh will flex the knee and aid extraction of the foot).

Diagnosis of abruptio placentae. 4.1996 (B.2) (5%)

Placental abruption is the premature separation of a normal situated placenta after 24th
week of pregnancy. There is present history of pre-eclampsia (PET) or pregnancy
induced hypertension (PIH) which can cause uteroplacental insufficiency. The signs and
general condition will depend on the degree of placental separation and amount of
blood loss.

8
The woman complains of vaginal bleeding with abdominal discomfort. The changes of
vital signs and degree of deterioration will depend on the amount of bleeding ranging
from tachycardia to shock. But the changes of vital signs are not proportional to the
amount of vaginal blood loss.

The changes of vital signs in the revealed type of placental abruption are proportional
to the amount of vaginal bleeding. Since the blood escapes from the placental site,
separates the membranes and drains through the vagina. The changes of vital signs in
the concealed type are disproportional to the amount of vaginal bleeding. Blood is
retained behind the placenta and forced into the myometrium and infiltrates between
the muscle fibres of the uterus and caused couvelaire uterus or uterine apoplexy.

Abdominal examination can find abdominal tenderness, painfulness and spasm;

increase in fundal height and uterine size; difficult in palpating the fetal parts.
Concealed haemorrhage leads to excessively abdominal pain and couvelaire uterus
which causes uterine enlargement with tenderness and hard consistency. It is difficult in
auscultation of fetal heart rate or abnormal fetal heart rate may be detected.

Ultrasonography (USG) can detect retroplacental haematoma or clots may be seen.

USG can also detect the placental condition and location to exclude placenta praevia.

Abnormal cardiotocography (CTG) tracing shows decelerations of fetal heart rate, from
fetal tachycardia to bradycardia.
Blood clots will be seen in examining the placenta and membranes after the delivery of
baby.

Management of accidental haemorrhage (abruptio placentae). 1.1998 (B.8) (5%)

Management of mild separation of placenta

1. Reassurance and explanation of the condition are given.
2. Maternal condition is assessed by vital signs; save pads for inspection of amount
and colour of vaginal bleeding; abdominal examination to note for the uterine size,
tenderness and consistency; measuring the fundal height.
3. Fetal condition is assessed by cardiotocography (CTG) and fetal movement felt by
mother. Ultrasonography (USG) is done to assess degree of placental abruption,
fetal growth and fetal well- being.
4. Conservative management of hospitalization and bed rest is needed if mild

9
 bleeding and satisfactory condition.
5. Blood is taken to monitor complete blood picture (CBP), clotting profile, liver/
renal function test (L/RFT).
6. Steriod such as Dexamethasone should be given intramuscularly to enhance the
fetal lung maturity if less than 34 weeks of gestation.
7. If the maturity is more than 37 weeks of gestation, induction of labour (IOL) can
be performed.
8. If the maturity is less than 37 weeks of gestation and vaginal bleeding is stopped,
the woman can discharge and advise her to remain bed rest and hospitalization if
bleeding occurs again.
9. If further heavy bleeding occurs, caesarean section may be necessary. Woman
should keep nil per oral (NPO), blood taken for cross matching, large bore
intravenous catheter should be inserted and intravenous fluid are given.

(Management of moderate/ severe separation of placenta and shock refer to APH

notes Pg. 12 to 13)

Write short note on symphysio- fundal height measurement. 10.1999 (B.1) (5%)

The symphysio- fundal height is the distance between the upper border of symphysis
pubis and the top of the fundus.

Before measurement, woman’s bladder should be emptied. The woman has to lie down
with both legs slightly flexed and she was asked to be relaxed. Privacy is maintained by
screen or room. Measuring tape is prepared.

The top of the fundus is palpated first. A tape is stretched from the upper border of the
symphysis pubis, over the abdominal curve, to the top of the fundus. During
measurement, the tape with the cms face down, then turn over the tape measure and
read the actual measurement.

Fundal height in cms correlates well with weeks of gestation between 22 to 24 weeks &
34 weeks. If measurement is more or less than 2-3 cm from the expected height,
inappropriate fetal growth is suspected.

The sensitivity of symphysio- fundal height measurement for the detection of

intrauterine growth retardation (IUGR) is 60-85%. The specificity of symphysio- fundal

10
height measurement for the detection of IUGR is 80-90%.

Methods of antenatal screening for Down’s syndrome. 4.2001 (B.14) (5%)

There are few screening methods: using background information includes maternal age
and family history; maternal serum screening; ultrasonography (USG); combined/
integrated screening.

Maternal serum screening is the biochemical screening for Down’s syndrome. It can
determine the risk for Down’s syndrome. The serum markers for Down’s syndrome
are the followings:
1. Alphafeto- protein (AFP ↓)
2. Unconjugated estriol (uE3 ↓)
3. Free β human chorionic gonadotrophin (β hCG ↑)
4. Pregnancy- associated plasma protein- A (PAPP- A ↓)
5. Inhibin- A ↑

The sensitivity of the screening test increases if more serum markers are used. In
the first trimester (11-14 weeks), β hCG & PAPP- A are used as the markers. In the
second trimester (16-20 weeks), AFP, β hCG, uE3 & inhibin- A are used as the
markers.

The screening is called positive when the calculated risk exceeds the cutoff
determined by the screening program. E.g. 1 in 250, 1 in 300. Further confirmatory
test is needed if screened positive.

USG can be used as a screening and diagnostic tool for congenital abnormalities.
Routine fetal anomaly scan is commonly performed at 18-22 weeks. Increased nuchal
translucency (NT) between 10-14 weeks is associated with Down’s syndrome.
Sonographic measurement of NT is done at 10 3/7 – 13 6/7 weeks of gestation.

Combined screening is known as One- Stop Clinic for Assessment of Risk (OSCAR)
for Down’s syndrome. It can perform in first trimester (11-14 weeks) and result is
available in 1-2 hours after blood taking. The 2 serum markers are increase in β hCG
& decrease in PAPP- A.

It used the background risk which includes maternal age and previous history of

11
chromosomal abnormalities to determine the risk of Down’s syndrome. Sonographic
measurement of NT is done at 10 3/7 – 13 6/7 weeks of gestation.

The combined screening method offers a higher detection rate (90%) among all other
screening methods for fetal Down’s syndrome. High risk case (1 in 300 or above) will
be counseled for the invasive diagnostic tests.

Integrated screening is performed in first and second trimester by using the

background risk; sonographic measurement of NT is done at 10 3/7 – 13 6/7 weeks
of gestation; biochemical blood test is done at 16-20 weeks of gestation with 2 serum
markers: decrease in AFP & increase in β hCG.

A screen positive result (1 in 320 or above) means that the risk of fetal Down’s
syndrome is high and a diagnostic test is needed to confirm the diagnosis.

What is the risk of 2nd twin? (5%)

The delayed delivery of 2nd twin due to malpresentation (breech/ footling/ knee
presentation) may result in cord prolapse and cause fetal hypoxia. The failed version
of 2nd twin can also cause delayed delivery. The delayed delivery due to failed version
will increase the risk of intrauterine manipulation and operative procedure, e.g.
use of forceps for the delivery of the aftercoming head in assisted breech delivery;
breech extraction if not delivered spontaneously (a manipulative delivery carried out
by an obstetrician and is performed to hasten delivery in emergency); or caesarean
section, therefore the risk of infection and birth injury will increase. The premature
separation of placenta after delivery of the 1st twin in the monochorionic pregnancy
will cause fetal hypoxia.

Describe twin- twin transfusion syndrome. (5%)

It is a severe condition affecting about 15% of all monochorionic diamniotic

(MCDA) pregnancies. The placental vascular anastamoses allows communication
between 2 placental circulation. It results in the imbalance in the blood flow and
leading to a net flow of blood from one twin to the other.

The donor becomes anaemic, hypovolemic (an abnormally low circulating blood

12
volume) and hypoxia. The growth of the donor becomes restricted. It becomes
oliguric with oligohydramnios and intrauterine death (IUD) of the donor may occur.

The recipient becomes hypervolemic, polycythemic (an excess of RBCs, the newborn
child is normally polycythemic due to high levels of fetal Hb), polyuric with
polyhydramnios. Congestive heart failure and hydrops may develop and severe
neonatal jaundice may develop in newborn child.

Management of twin- twin transfusion syndrome (TTTS) depends on the severity

and gestation. TTTS can be relieved by fetoscopic laser coagulation of the
communicating placental blood vessels and serial amniodrainage.

The definition of compound presentation. 1.1997 (B.1.iv) (1%)

A condition in which there are 2 presenting parts, i.e. when there is prolapse of one
or more of the limbs along with the head or the breech, both entering at the same
time, but footling breech is not included.

The definition of face presentation. (1%)

When the attitude of the head is one of complete extension, the occiput of fetus will
be in contact with its spine and face will present (majority develop during labour).
The presenting diameter is submento-bregmatic diameter (SMB 9.5cm).

The definition of brow presentation. (1%)

The head is partially extended with frontal bone (bounded by anterior fontanelle
and orbital ridges) lying at the pelvic brim. The presenting diameter is mentovertical
diameter (MV 13.5cm).

The definition of breech presentation. (1%)

The fetus is in longitudinal lie with buttocks occupying the lower pole of uterus.
There are 3 types of breech presentations. Frank breech presentation is extended leg

13
breech presentation with hips flexed and knees extended. Complete breech
presentation is flexed leg breech presentation with hips and knees flexed, buttocks and
feet are at the same level. Incomplete breech presentation is footling breech
presentation or knee presentation, one or both hips and knees are extended with one or
both feet are presenting. The presenting diameter of complete breech presentation (the
fetus is in left-sacral anterior position) is bitrochanteric diameter (10cm).

The definition of vertex presentation. (1%)

The head is well-flexed. The part of the fetus which lies in the lower pole of the
uterus is the part which between the anterior fontanelle (bregma) and posterior
fontanelle (lambda), and the 2 parietal eminences. The presenting diameter is
suboccipito-bregmatic diameter (SOB 9.5cm).

The definitions of oblique lie and transverse lie. (2%)

Oblique lie is the fetus lies diagonally across the long axis of the uterus.
Transverse lie is the fetus lies at right angles across the long axis of the uterus.
This is a condition when the fetal cephalocaudal axis lies perpendicular to the maternal
spine, the fetus is in dorso-anterior or dorso-posterior position.

The definition of longitudinal lie. (1%)

Longitudinal lie is the fetus lies parallel to the long axis of the uterus. This is a
condition when the fetal cephalocaudal axis lies parallel to the maternal spine.

The definition of unstable lie. (1%)

After 36 weeks of gestation, instead of remaining longitudinal, the lie varies from one
examination to another between longitudinal, oblique or transverse.

14
Diagnosis of brow presentation during labour at term. 4.1998 (B.6) (5%)

Brow presentation is not usually detected before the onset of labour.

By abdominal examination, high head will found. Fetal back is difficult to feel and
fetal heart can be auscultated on the same side as the limbs.
By vaginal examination, the presenting part is difficult to reach, anterior fontanelle is
felt on one side of pelvis, orbital ridges, and possibly the root of nose at the other side,
but nose, mouth and chin cannot be felt. If woman has been in labour for some time,
large caput may mask landmarks.

Diagnosis of face presentation during labour at term. (5%)

Most of the face presentation is develop during labour. Majority anencephaly can
made diagnosis in the antenatal period.
During intrapartum, abdominal and vaginal examination can help to diagnose face
presentation. By abdominal examination, occiput feels prominent, a groove is felt
between head and neck (mistaken for sinciput). Limbs are palpated anteriorly on the
same side opposite to occiput. Fetal heart is best heard through chest on the same side
of the limbs. Fetal heart is difficult to hear if the fetus is in mento-posterior position
(with the chin directed posteriorly in the pelvis).

By vaginal examination, the presenting part is high, soft and irregular. The orbital
ridges, eyes, nose and mouth can be felt (the examination finger may feel sucking). The
eyes should not be injured with the examination finger and antiseptics. Cord
presentation and cord prolapse should be alerted.

Management of shoulder dystocia. 4.1996 (B.6)/ 10.2002 (B.1) (5%)

Emergency management of shoulder dystocia. 10.1997 (B.4) (5%)
Immediate management of shoulder dystocia. 10.1999 (B.2) (5%)
Midwife’s management of shoulder dystocia. 4.2001 (B.7) (5%)

Shoulder dystocia is the impaction of anterior shoulder against maternal symphysis

pubis after delivery of baby’s head (head to body delivery time intervals ≥ 2 minutes).

Midwives should keep calm and call for help. Obstetrician and pediatrician should
be informed to standby for maternal and fetal resuscitation. Anesthetist should be

15
informed for the possible operation and operation theatre should be arranged for
emergency caesarean section. More midwives should be called for help.
Explanation and reassurance should be given to the mother.

The oxytocin infusion should be withheld if any. Any tight cord round neck or
localized abnormality of fetal neck or chest should be excluded. The baby’s airway is
cleared with suction. The mother should be arranged in lithotomy position and moved
to the edge of delivery bed and the bed end must drop in order to increase the room
for intravaginal manipulation. Episiotomy must be made or enlarged before applying
different maneuvers.

Before the obstetrician’s arrival, some non-invasive maneuvers can be performed by

midwife, such as McRobert’s Maneuver and suprapubic pressure, with or without
gentle traction again to deliver the anterior shoulder.

McRobert’s Maneuver is to keep hyperflexion of the maternal thigh against the

abdomen in addition with maternal pushing, straighten the sacrum relative to lumbar
spine and upward movement of maternal pelvis and symphysis, therefore decreases the
angle of inclination and increases the size of posterior outlet, so the impacted
anterior shoulder can be released.

Suprapubic pressure is applying the downward force with finger, palm or fist on the
anterior shoulder to displace it from behind the symphysis pubis. But the lateral
diameter of the trunk and shoulder cannot be compressed and no fundal pressure is
used in order to prevent uterine rupture. Rather pressure is applied to induce rotation of
the trunk. If delivery is not accomplished, a rocking motion is recommended to
dislodge the shoulder from behind the pubic symphysis.

After the obstetrician’s arrival, some invasive maneuvers may attempted if previous
maneuver fails. Rubin Maneuver is to approach the anterior shoulder from behind
vaginally, exerting pressure on the scapula then pushing the shoulder forward
towards the fetal chest, therefore rotating the shoulders into oblique position. So the
bisacromial diameter is decreased by shoulder adduction and the anterior shoulder is
dislodged from behind the pubic symphysis.

Woods’ (Cork) Screw Maneuver is to gently rotate the shoulder backward towards
the symphysis about 180º (anti-clockwise). The posterior shoulder is abducted or
extended. The posterior shoulder becomes the anterior shoulder and delivered by

16
downward traction. This maneuver will be more effective if combined with Rubin’s
Maneuver. Reverse Woods’ Screw Maneuver is to rotate the posterior shoulder
forward towards the symphysis pubis about 180º with adduction (clockwise).

The last approach is to roll the woman to all four position, therefore increases the
pelvic diameters. The shoulder impaction can be released by pelvic movement and
gravity, the posterior shoulder is delivered with downward traction.

After the delivery of the baby, active management of the 3rd stage should be
performed to prevent postpartum haemorrhage (PPH). Active management includes
give oxytocin drug to promote good uterine contraction, early clamping and cutting
of the cord and controlled cord traction (CCT) to deliver the placenta. Examination
of genital tract should be done immediately to find any laceration or tear. Early
repair of episiotomy or tear should be done. We should watch out for PPH and
infection.

Active resuscitation of the baby by the pediatrician should be performed

immediately. The baby is examinated for any birth injury or trauma and evaluated
for any birth asphyxia. Special Care Baby Unit (SCBU) or Neonatal Intensive Care
Unit (NICU) care may be arranged if necessary. Documentation of the maternal and
fetal conditions should be done clearly.

Clinical features of neonatal sepsis. 4.2000 (B.6) (5%)

Symptoms and signs of neonatal sepsis. 10.2002 (B.3) (5%)

Clinical features/ symptoms and signs are:

1. tachypnoea/ apnoea
2. hyperventilation to hypoventilation/ retraction of chest
3. tachycardia/ bradycardia
4. hypothermia/ hyperthermia (fever)
5. lethargic/ irritable/ high pitch cry
6. cyanosis/ pallor (poor circulation)
7. hypotension
8. metabolic acidosis or alkalosis, hypoxia and hypercapnia
9. feeding intolerance/ repeated vomiting/ abdominal distension
10. starvation leads to hypoglycemia
11. dehydration

17
12. early onset of neonatal jaundice
(+/- infection/sepsis → hemolysis → hyperbilirubinaemia)
13. skin lesion/ rash
14. hepatosplenomegaly
15. damage of central nervous system (CNS), e.g. neonatal seizures

Causes of neonatal infection. 10.1996 (B.9) (5%)

The maternal risk factors are premature rupture of membranes (PROM), preterm
labour, peripartum factors such as infection or fever, obstetric manipulations, Group B
Streptococcus (GBS) carrier, exist of microorganisms in the genital tract, medical
condition such as poor controlled gestational diabetes mellitus (GDM) or poor
nutrition.

The neonatal risk factors are prematurity which induces immaturity of the immune
system; low birth weight; 1st born twin may have early-onset infection; foreign bodies
include intravenous catheters (IV lines), umbilical catheters, endotracheal tube (ETT),
urinary catheter.

Exposure to viruses from mother without antibodies and exposure to organisms

postnatally also increases the susceptibility of neonatal infections.

Prevention of neonatal infection. 10.2001 (B.6) (5%)

Antenatal period
Maternal immunization before pregnancy such as anti-Rubella and Hepatitis B
vaccination should be done. Antenatal screening such as serology, high vaginal swab
(HVS) and mid-stream urine (MSU) for culture, can early detect the maternal infection
and start the treatment. Mother is advised to keep personal hygiene and to improve
heath status by well balanced diet, adequate fluid intake and rest and doing more
exercises. Optimal time of delivery and caesarean section should be discussed with the
mother to avoid the fetus being infected during vaginal delivery, e.g. HIV or Herpes.

Intrapartum period
Intrapartum prophylactic antibiotics should be given to prevent the fetus being affected
by the maternal infection, such as Penicillin G or Ampicillin for Group B Streptococcus

18
(GBS). If premature rupture of membranes occurs ≥ 18 hours, prophylactic antibiotics
must be prescribed. Invasive procedures should be minimized, e.g. vaginal examination,
and aseptic technique must be maintained during procedure.

Postnatal period
Early breastfeeding and early enteral feeding are suggested in the postnatal period.
Skin/ umbilical/ eye care should be given to the neonate to keep good hygiene. Rational
use of antibiotics in the neonate is suggested. Hepatitis B immunoglobulin should be
given to the Hepatitis B carrier’s baby. The neonate should be protected from
hypothermia and hypoglycemia. Invasive procedures should be minimized, e.g.
insertion of intravenous catheters, and aseptic technique must be maintained during
procedure. Screening of neonatal blood products and/or sepsis workup must be done.
Strict hand wash and universal precaution for the infected neonate must be done.
Rooming in must be encouraged as soon as possible to prevent outbreak of the infection.
The number of visitors must be restricted for the rooming in case. Cohort and isolation
of the infected neonate during outbreak should be done. The hospital environment
should keep room temperature and clean by dump dusting and vacuum cleaning,
visitors must be limited in the visiting time.

G6PD deficiency in newborns. 10.1998 (B.11) (5%)

Counseling to mother whose baby has G6PD deficiency. 4.2000 (B.14) (5%)

Explanation and reassurance should be given to the mother. We should show

empathy about the baby having this disease and reassure the mother that her baby can
grow normally. The information should be given to the mother includes the
introduction and impact of the disease, the prevention of acute hemolysis, careful
clinical observation of the baby for early diagnosis of neonatal jaundice, and
education on caring of the baby. We should allow time for question finally.

Glucose 6-Phosphate Dehydrogenase (G6PD) deficiency is a X-linked hereditary

disease and more males are affected. The enzyme G6PD maintains the integrity of the
cell membrane of Red Blood Cell (RBC). Deficiency of G6PD leads to fragility and
easy breakdown of RBC, so hemolysis occurs and raised bilirubin, then
hyperbilirubinaemia induces jaundice which is a yellow discoloration of the skin, sclera
and mucous membranes. The most adverse effects of jaundice are Kernicterus, heart
failure and acute renal failure. G6PD deficiency is identified by the cord blood for
neonatal screening. The mother should carry the warning card of G6PD deficiency

19
for the baby.

The characteristics of G6PD deficiency are early onset at first 24-48 hours, rapid
rising of serum bilirubin (SB) > 85umol/L per day. The precipitating factors for acute
hemolysis are infection, drugs such as Aspirin and Chloramphenicol, Chinese herbs,
moth balls and fava bean. Therefore the baby should be protected from the exposure
to these known toxic drugs or chemicals.

Early diagnosis of neonatal jaundice is important since prevention is better than

cure. The clinical features of G6PD deficiency are lethargy and decreased eagerness
to feed; irritability or a high pitched cry; feeding intolerance and/or vomiting; dark
urine or light stools; presence of dehydration, starvation, hypothermia, hypoxia,
acidosis; increased extent and progression of jaundice. The baby needs to seek for
medical aid immediately if the above occurs. The neonatal jaundice can be
diagnosed by transcutaneous bilirubinometer (TCB) and serial SB checking.

If the baby is term with body weight > 2500gm and SB > 250umol/L, phototherapy
is required to correct hyperbilirubinaemia, preterm baby need to start
phototherapy at lower SB.

The care of the baby with phototherapy includes close observation of vital signs,
general conditions, neuro-behavioural status, intake and output; skin care to prevent
rash and dryness; cover eyes securely with eye shields; give extra fluid if dehydration;
maintained the baby in a warm thermo-neutral environment; watch out for
complications such as hyperthermia, hypocalcaemia and dehydration; adequate
information, support and reassurance must be given to the parents. The exchange
transfusion will be used as the management of bilirubin cephalopathy.

Efficient care of the newborn is maintained to prevent hypothermia, hypoglycemia,

dehydration and infection or injury. The parents should increase the baby’s feeding
and hydration; and closely observe its general conditions, intake and output. The baby
needs to seek for medical aid if any abnormalities arise must be reinforced.

20
Causes of neonatal jaundice. 4.1996 (B.9)
Write short notes on neonatal jaundice. 10.1997 (B.14)/ 4.2001 (B.8) (5%)

Neonatal jaundice (NNJ) is a yellow discoloration of the skin, sclera and mucous
membranes due to an increase in the serum bilirubin (SB) level in newborns, raised
bilirubin induces hyperbilirubinaemia. There are 2 types of NNJ: physiological
jaundice and pathological jaundice.

The course of physiological jaundice is a progressive rise of bilirubin with jaundice

appears after 48 hours of life but never appears before 24 hours of life, peak at 3-5 days,
subsides by the end of the first week and disappears by 10-14 days.

There are some criterias for physiological jaundice. Jaundice appears when SB reach
85-120umol/L, SB never increase > 85umol/L per day, maximum SB level up to
200-250umol/L, pathological cause has been excluded, baby is well and healthy.

The causes of physiological jaundice are an increased red cell breakdown increases
the bilirubin production; a decreased albumin binding capacity reduced the
transport of bilirubin to liver for conjugation; liver immaturity with insufficient
supply of glucuronyl transferase (UDP-GT) for conjugation; increased
enterohepatic reabsorption of unconjugated bilirubin caused by lack of normal
bacteria in gut, increased β- glucuronidase enzyme activity and decreased gut motility
due to delayed feeding.

Pathological jaundice is any interference with bilirubin production, transport and

conjugation which induces hyperbilirubinaemia, rapid rising of SB > 85umol/L
per day. There are 2 types of pathological jaundice: early jaundice and prolonged
jaundice. Early jaundice is early onset at first 24-48 hours, e.g. G6PD deficiency or
ABO blood group incompatibility. Prolonged jaundice onset later after Day 4 and
persists more than 10 days, and recurrent after initial treatment, e.g. biliary
obstructive jaundice or congenital hypothyroidism which induces jaundice.

The causes of pathological jaundice are maternal history of congenital infections,

diabetes mellitus (DM), excessive ingestion of aspirin (may induce G6PD deficiency);
ABO blood group incompatibility and Rhesus isoimmunization cause acute hemolysis;
family history of anemia or liver disease; race of mother and neonate, e.g. Chinese or
Korean are predisposed to higher bilirubin levels; labour history for delayed cord
clamping, vacuum extraction causes cephalhaematoma and oxytocin induced labour;

21
evidence of asphyxia, infection, extensive bruising, feeding difficulties.

Investigations are needed to identify the underlying causes, which includes

complete blood picture, blood culture, urine culture, viral study to rule out infection;
serum bilirubin to determine levels and whether the bilirubin is conjugated or
unconjugated; ABO blood group and Rhesus type for possible incompatibility;
hemoglobin and haemotocrit to exclude anaemia and polycythemia; peripheral blood
smear for red cell structure to rule out any abnormal cells; reticulocytes count to rule
out hemolytic disease. Then the underlying causes should be treated, such as
antibiotics for bacterial infection; galactose free milk for galactosaemia; treat
congential hypothyroidism with thyroid hormone; operation for severe biliary
obstruction.

Early diagnosis of NNJ is important since prevention is better than cure. The cord
blood is sent for neonatal screening of G6PD, thyroid stimulating hormone (TSH)
and thyroxine-4 (T4). The clinical features of NNJ are lethargy and decreased
eagerness to feed; irritability or a high pitched cry; feeding intolerance and/or vomiting;
dark urine or light stools; presence of dehydration, starvation, hypothermia, hypoxia,
acidosis; increased extent and progression of jaundice. The baby needs to seek for
medical aid immediately if the above abnormalities arise must be reinforced. The
NNJ can be diagnosed by transcutaneous bilirubinometer (TCB) and serial SB
checking.

If the baby is term with body weight > 2500gm and SB > 250umol/L, phototherapy
is required to correct hyperbilirubinaemia, preterm baby need to start
phototherapy at lower SB.

The care of the baby with phototherapy includes close observation of vital signs,
general conditions, neuro-behavioural status, intake and output; skin care to prevent
rash and dryness; cover eyes securely with eye shields; give extra fluid if dehydration;
maintained the baby in a warm thermo-neutral environment; watch out for
complications such as hyperthermia, hypocalcaemia and dehydration; adequate
information, support and reassurance must be given to the parents. The exchange
transfusion will be used as the management of bilirubin cephalopathy.

Efficient care of the newborn is maintained to prevent hypothermia, hypoglycemia,

dehydration and infection or injury. The parents should increase the baby’s feeding
and hydration; and closely observe its general conditions, intake and output.

22
Write short notes on physiology of neonatal jaundice. (5%)

Neonatal jaundice (NNJ) is a yellow discoloration of the skin, sclera and mucous
membranes due to an increase in the serum bilirubin (SB) level in newborns, raised
bilirubin induces hyperbilirubinaemia.

The breakdown of Red Blood Cell (RBC) in spleen and liver will form globin to
reuse, haem to bilirubin (a fat-soluble waste) and iron to reuse. The fat soluble
bilirubin binds with albumin in circulation and transport to liver for conjugation.

In the liver, bilirubin detach from albumin, glucuronyl transferase (UDP-GT) joins
bilirubin with glucuronic acid to form bilirubin diglucuronide (water-soluble), and
transport to the biliary system, then to the intestine for excretion. Oxygen and
glucose is essential in conjugation.

In the gut, normal flora changes bilirubin into urobilin. Most of the urobilin
become stercobilinogen to stain stool brown. The rest of the urobilin is adsorbed
from the gut and transport to blood and excreted in urine as urobilinogen.

Some water soluble bilirubin pass through the gut too slowly, β- glucuronidase
hydrolyses them from conjugated bilirubin back to unconjugated bilirubin, then
the unconjugated bilirubin transport to the portal system for further reconjugation.

SB level depends on bilirubin production, conjugation and efficient excretion.

The causes of NNJ are increased red cell breakdown, decreased albumin binding
capacity, glucuronyl transferase (UDP-GT) enzyme deficiency, increased
enterohepatic reabsorption of unconjugated bilirubin.

Increased red cell breakdown will increase the bilirubin production. Large
hemoglobin (Hb) mass of +/- 20gm/dl at birth and shorter life span of RBC ~ 60-70
days (may due to prematurity) can increase the breakdown of RBC.

Decreased albumin binding capacity will reduce the transport of bilirubin to liver
for conjugation, so the presence of unconjugated bilirubin will increase. Decreased
albumin binding capacity can cause by lower albumin concentrations in preterm
babies; possible competition for albumin-binding sites from some drugs; the
unconjugated bilirubin find tissues with fat affinity such as skin and brain. Albumin
binding capacity is affected by increase tendency of hypoxia, acidosis, hypothermia,

23
hypoglycemia and hypoproteinaemia.

Glucuronyl transferase (UDP-GT) enzyme deficiency will result in failure of

conjugation in liver. Enzyme deficiency can cause by liver immaturity with
insufficient supply of Glucuronyl transferase, since normal enzyme level usually
achieved in 6-14 weeks. Enzyme deficiency is caused by delay in the expression of the
enzyme UPD-GT in premarurity.

Increased enterohepatic reabsorption of unconjugated bilirubin is due to lack of

normal bacteria that breaks down bilirubin into urobilinogen; increased β-glucuronidase
enzyme activity which hydrolyses conjugated bilirubin back to unconjugated bilirubin;
delayed feeding than decreased gut motility further compromising excretion of bilirubin
(delay of feeding if the baby is sick and immature gut function with slow
peristalsis if the baby is prematurity).

The other pathological causes of NNJ are maternal history of congenital infections,
diabetes mellitus (DM), excessive ingestion of aspirin (may induce G6PD deficiency);
ABO blood group incompatibility and Rhesus isoimmunization cause acute hemolysis;
family history of anemia or liver disease; race of mother and neonate, e.g. Chinese or
Korean are predisposed to higher bilirubin levels; labour history for delayed cord
clamping, vacuum extraction causes cephalhaematoma and oxytocin induced labour;
evidence of asphyxia, infection, extensive bruising, feeding difficulties.

Early diagnosis of NNJ is important since prevention is better than cure. The cord
blood is sent for neonatal screening of G6PD, thyroid stimulating hormone (TSH)
and thyroxine-4 (T4). The clinical features of NNJ are lethargy and decreased
eagerness to feed; irritability or a high pitched cry; feeding intolerance and/or vomiting;
dark urine or light stools; presence of dehydration, starvation, hypothermia, hypoxia,
acidosis; increased extent and progression of jaundice. The baby needs to seek for
medical aid immediately if the above abnormalities arise must be reinforced. The
NNJ can be diagnosed by transcutaneous bilirubinometer (TCB) and serial SB
checking.

The adverse effects of NNJ are kernicterus, heart failure and acute renal failure. If
the baby is term with body weight > 2500gm and SB > 250umol/L, phototherapy is
required to correct hyperbilirubinaemia, preterm baby need to start phototherapy
at lower SB. The exchange transfusion will be used as the management of bilirubin
cephalopathy.

24
A baby is born flaccid and cyanotic looking, with heart rate of 100 bpm,
respiratory rate of 30 per minute. Meconium stained liquor is seen during delivery.
Discuss the possible causes and management.

Resuscitation of a flaccid newborn with thick meconium-stained liquor and poor

respiratory effort at birth. 4.2003 (B.2) (5%)

Resuscitation of asphyxia baby. 1.1998 (B.7) (5%)

Resuscitation of newborn. 4.1996 (B.5)/ 4.1997 (B.6)/ 1.2000 (B.12) (5%)

The possible causes are maternal risk factors and neonatal risk factors.
The maternal risk factors are premature rupture of membranes (PROM) and/or
prolonged leaking, preterm/ prolonged labour, obstetric manipulations, Group B
Streptococcus (GBS), all of the above can induce neonatal infection/ sepsis. The other
risk factors are Pre-eclampsia (PET), maternal hypertension, oligohydramnios,
maternal heavy smoking and chronic respiratory disease.

The fetal risk factors are birth asphyxia (may be caused by tight cord round neck,
prolonged labour due to poor maternal effort), neonatal infection/ sepsis, prematuirty
induces fetal lung immaturity, low birth weight infants, intrauterine growth retardation
(IUGR), meconium aspiration, respiratory distress syndrome.

The signs and symptoms of a compromised newborn are cyanosis, bradycardia,

hypotension, depressed respiratory effort, poor muscle tone (flaccid). This indicated
that the newborn need resuscitation.

Preparation for neonatal resuscitation

Prepare the equipments such as resuscitaire; overhead radiant warmer/ warm towels;
freeflow oxygen, ventilation bag and mask; wall suction/ suction cylinder and suction
catheters; airway and endotracheal tubes; laryngoscope with blade; drugs.

Assessment includes clear airway (any meconium); respiratory effort (any breathing
or crying); muscle tone (good/strong or poor/flaccid); colour of the skin (pink or
pale/cyanosis); gestational age (term or preterm).

** Pediatrician must be informed for the resuscitation of the newborn of asphyxia/

cyanosis/ flaccid or with meconium-stained liquor (MSL).

25
Initial steps need to complete in 30 seconds
1. We need to provide warmth for the infant under the radiant warmer by drying
the body thoroughly, and remove the wet linen to prevent heat loss.
2. Position the head in a sniffing position (neck slightly extended) to ensure an
open airway for suction.
3. Suction the mouth first then nose with the suction pressure is about 100mmHg.
Aggressive pharyngeal suction is avoided to prevent laryngeal spasm and
vagal bradycardia.
4. Slapping or flicking the sole of the feet; and gently rubbing the back, trunk or
extremities to provide tactile stimulation.
5. 90-100% oxygen (O2) (with reservoir) is delivered in an O2 flowmeter rate of
5L/min by a mask covering the baby’s nose, mouth and chin to enhance the
peripheral circulation.

Management of newborn with MSL

Assessment of the vigorous level of the newborn after delivery is needed, which
includes respiratory effort, muscle tone and heart rate.

 For the vigorous newborn with MSL, whose respiratory effort is strong, muscle
tone is good, heart rate > 100bpm, resuscitation as the initial steps, suction the
mouth first then nose to clear the airway from meconium.
 For the non-vigorous newborn with MSL, whose respiratory effort is poor (<
40 breaths/min), muscle tone is poor (flaccid), heart rate < 100bpm (or even <
60bpm), tracheal suctioning and/or further intervention are needed.

Management of non-vigorous newborn with MSL

Tracheal suctioning
 Endotracheal tube (ETT) is inserted and connected to meconium aspirator
and suction catheter, suction for 3-5secs. The thumb is placed over suction
control port to regulate suction.
 Suction can stop if no MSL recovered.
 The procedure is repeated if MSL recovered and heart rate is normal.
 Resuscitation is proceeded if bradycardia occurs.

Evaluation of the respiratory effort, heart rate and colour of skin is needed.
The heart rate is determined by palpating the base of cord and listening with a
stethoscope. The heart rate is counted for 6 seconds then times 10.
 If heart rate > 100bpm, only free flow O2 is needed.

26
1. If heart rate < 100bpm or apnoea occurs, positive pressure ventilation (PPV)
by bag and mask is needed.
2. Mask of appropriate size is used to cover the nose, mouth and chin (size 0 for
small baby; size 1 for average weight baby). A self inflating bag with
pressure-release valve (set point at 30-40cmH2O) is used.
3. An assisted ventilation rate is at 40-60 breaths/min. We should watch out for
adequate chest expansion, reposition of the head is required to ensure an open
airway if inadequate chest expansion.
4. Evaluation of the respiratory effort, heart rate and colour of skin is done again.
5. If heart rate > 100bpm, only free flow O2 is needed.
6. If heart rate < 100bpm, bagging must continue.

 If heart rate < 60bpm, PPV with endotracheal intubation may be provided,
together with chest compressions are administered for 30 seconds, then
evaluation again.

1. Pre-oxygenation with bag and mask is given before endotracheal intubation.

2. Free flow O2 is delivered during intubation.
3. Appropriate size of ETT (3-3.5mm for term baby of average weight) and
laryngeal blade (size 0 for preterm baby; size 1 for term baby), attempt of
intubation is limited to 20 seconds.
4. Placement of ETT is confirmed by chest x-ray.
5. There are some techniques of chest compression. We can use the thumb or 2
fingers to apply pressure at the lower 1/3 of sternum, the depth of each
compression is 1/3 of the antero-posterior (AP) diameter of the chest.
6. The compressions are coordinated with ventilation. The ratio is 3
compressions to 1 breath and each cycle takes 2 seconds. 120 events occur in
one minute (120 events/min) (90 compressions and 30 breaths).
7. Evaluation of the respiratory effort, heart rate and colour of skin is done again.
8. If heart rate > 100bpm, only free flow O2 is needed.
9. If heart rate < 100bpm, only PPV is continued.
10. If heart rate < 60bpm, PPV coordinated with chest compression for 30
seconds are continued, then evaluation again.

 If heart rate still < 60bpm, administration of drug, e.g. Adrenaline 0.1-0.3
ml/kg of 10000 solution, must be given endotracheally or intravenously. PPV
coordinated with chest compression for 30 seconds are continued, then
evaluation again.

27
Post resuscitation care
1. Close observation and monitoring of vital signs, blood taken for arterial blood
gases (ABG) to determine metabolic acidosis; blood glucose to determine
hypoglycemia; electrolyte level to determine electrolyte imbalance.
2. Appropriate diagnostic evaluation must done, e.g. X-ray for respiratory
disease; sepsis workup for bacterial infection.
3. Orogastric tube is inserted to relieve gastric distension.
4. Special Care Baby Unit (SCBU) or Neonatal Intensive Care Unit (NICU) care
are arranged.
5. Adequate information, support and counseling must be provided to the
parents.
6. Documentation of the resuscitation and fetal condition is needed.

**After 10 minutes of continuous and adequate resuscitative efforts,

discontinuation of resuscitation may be justified if there are no signs of life.

Complications of amniocentesis. 1.1997 (B.2) (5%)

Write short notes on amniocentesis. 10.1997 (B.2) (5%)

Amniocentesis is the collection of the amniotic fluid and its cellular components.
The use of amniocentesis is to detect chromosomal or genetic disorders, e.g.
Down’s syndrome, muscle atrophy. The method of amniocentesis is to aspirate 15-20
ml amniotic fluid transabdominally through a spinal needle under ultrasound guidance
and send for analysis. The optimal time to perform the procedure is 16-18 weeks;
test result is available in 2-3 weeks.

The indications for amniocentesis are advanced maternal age; the parents are at risk
of carrying a baby with genetic or chromosomal abnormalities; there are family history
of genetic disease, previous history of two or more spontaneous abortions or their
previous child with congenital abnormalities; the woman has an abnormal prenatal
screening test result.

Counseling is needed prior to procedure, which includes the optimal time to perform
the procedure; the indications for this invasive procedure; the method of amniocentesis
and the implications of the result.

The complications of amniocentesis are miscarriage (0.5-1%); leakage of amniotic

28
fluid; infection and haematoma. Rhesus isoimmunization may occur in a Rhesus –ve
woman if Rhesus +ve cells from her fetus pass into her circulation via the placenta,
causing sensitization and then antibody production (anti-D), to these red cells. When
the antibody enters the fetal circulation, haemolysis occurs.

Write short notes on chorionic villus sampling. (5%)

Chorionic Villus Sampling (CVS) is the collection of chorionic villi which consist of
rapidly dividing cells of fetal origin. The use of CVS is to detect genetic and
chromosomal abnormalities. The method of CVS is to obtain a small sample of the
chorionic villi from the developing placenta transvaginally or transabdominally under
ultrasound guidance and send for analysis. The optimal time to perform the
procedure is 10-12 weeks and result is available in 2 weeks.

The indications for CVS are advanced maternal age; the parents are at risk of carrying
a baby with genetic or chromosomal abnormalities; there are family history of genetic
disease, previous history of two or more spontaneous abortions or their previous child
with congenital abnormalities; the woman has an abnormal prenatal screening test
result.

Counseling is needed prior to procedure, which includes the optimal time to perform
the procedure; the indications for this invasive procedure; the method of CVS and the
implications of the result.

The complications of CVS are a higher miscarriage rate (1-2%) than that of
amniocentesis (0.5-1%); causes limb reduction of early CVS; leakage of amniotic fluid;
infection; haematoma and Rhesus isoimmunization.

Write short notes on cordocentesis. (5%)

Cordocentesis is aspiration of fetal blood from the umbilical cord. The use of
cordocentesis is to evaluate a variety of inherited blood disorders, genetic problem,
as well as fetal karotyping. The method of cordocentesis is to obtain a sample of fetal
blood from the umbilical vein transabdominally through a needle under ultrasound
guidance. It can be performed at 20-22 weeks and result is available within one
week.

29
The indications for cordocentesis are advanced maternal age; the parents are at risk of
carrying a baby with genetic or chromosomal abnormalities; there are family history of
genetic disease, previous history of two or more spontaneous abortions or their previous
child with congenital abnormalities; the woman has an abnormal prenatal screening test
result.

Counseling is needed prior to procedure, which includes the optimal time to perform
the procedure; the indications for this invasive procedure; the method of cordocentesis
and the implications of the result.

The complications of cordocentesis are cord laceration or haematoma; thrombosis;

infection; fetal bradycardia; preterm labour and premature rupture of membrane;
miscarriage (＜1%).

Describe the indications and methods of prenatal diagnosis of fetal abnormalities.

10.1996 (A.2) (15%)
Methods to diagnose Down’s syndrome in pregnancy. 4.1998 (B.5) (5%)
Indications and methods of prenatal diagnosis. 10.1998 (B.4) (5%)

The indications for prenatal diagnosis are advanced maternal age; the parents are at
risk of carrying a baby with genetic or chromosomal abnormalities; there are family
history of genetic disease, previous history of two or more spontaneous abortions or
their previous child with congenital abnormalities; the woman has an abnormal prenatal
screening test result.

The methods of prenatal diagnosis/ to diagnose Down’s syndrome are as follow.

Amniocentesis
15-20 ml of amniotic fluid is aspirated transabdominally through a spinal needle under
ultrasound guidance and send for analysis. The optimal time to perform the procedure is
16-18 weeks. The method is simple, relatively safe and painless.
The result is available in 2-3 weeks, but it is more difficult to make decision if result
is abnormal, since the second trimester abortion can increase danger and stresses
of women.
Its complications are miscarriage (0.5-1%); leakage of amniotic fluid; infection;
haematoma and Rhesus isoimmunization.

30
Chorionic Villus Sampling (CVS)
A small sample of the chorionic villi from the developing placenta is obtained
transvaginally or transabdominally under ultrasound guidance and send for analysis.
The optimal time to perform the procedure is 10-12 weeks and result is available in 2
weeks, so it saved women from stresses of second trimester abortion.
Its complications are a higher rate of miscarriage (1-2%); limb reduction of early
CVS; leakage of amniotic fluid; infection; haematoma and Rhesus
isoimmunization.

Cordocentesis
A sample of fetal blood from the umbilical vein is obtained transabdominally through a
needle under ultrasound guidance. It can be performed at 20-22 weeks and result is
available within one week. Its advantage is that it can be performed after 20 weeks,
but its complications are cord laceration or haematoma; thrombosis; infection;
fetal bradycardia; preterm labour and premature rupture of membrane;
miscarriage (＜1%).

Fetoscope
It is a procedure for direct visualization of the fetus via an endoscope. But it is
rarely performed nowadays as it has been superseded by other tests, and it has a
higher fetal loss rate of 5%.

Risks of grand multiparity. 10.1997 (B.12) (5%)

Maternal risks
In antenatal period:
1. Minor disorder are exaggerated, e.g. varicosities, haemorrhoid.
2. Pendulous abdomen caused by abdominal wall becomes lax due to repeated
childbearing, therefore increased discomfort & pain experienced. A well fitted
maternal corset is recommended to wear.
3. Iron deficiency anaemia due to insufficient time to replenish iron stores before
next pregnancy.
4. Medical diseases due to advanced age, e.g. diabetes mellitus, hypertension.
5. Antepartum haemorrhage due to high risk of abruptio placentae in case of
pre-eclampsia for advanced age.
6. Multiple pregnancy due to increased fertility.

31
In intrapartum & postnatal period:
1. Pendulous abdomen induced
 Malpresentation & unstable lie
 Prolonged labour due to force of uterine contraction is misdirected
 Early rupture of membrane & associated cord prolapse

2. Cephalo-pelvic disproportion due to bigger baby in successive pregnancies

which reduces pelvic capability, it may result in caesarean section.
3. Precipitate labour
4. Rupture of uterus may due to precipitate labour
5. Postpartum haemorrhage due to atonic uterus or decreased uterine
contractility caused by precipitate or prolonged labour

Fetal risks
1. Low birth weight due to
 Preterm labour by early rupture of membrane
 Mother has medical disease, e.g. hypertension

2. Macrosomia induces shoulder dystocia if mother of advanced age has

gestational diabetes mellitus (GDM).

3. Higher risk of congenital abnormalities or malformation due to advanced

maternal age, e.g. Down’s syndrome or others.

Incidence of having a baby with Down’s syndrome of maternal age

 35: 1 in 350
 38: 1 in 250
 40: 1 in 100
 43: 1 in 50
 45: 1 in 30

Problems with teenage pregnancy. 10.2000 (B.13) (5%)

Obstetric problems
1. Nutritional deficiency
2. Iron deficiency anaemia due to malnutrition
3. Preterm labour

32
4. Pregnancy induced hypertension (PIH) may be due to pre-eclampsia /
inflammatory response of pregnancy
5. Cephalopelvic disproportion (CPD) may occur due to possible contracted pelvis in
teenage
6. Low birth weight babies due to intrauterine growth retardation (IUGR) &
prematurity

Psycho-social problems
1. Prolonged dependence on parents
2. drop out of school
3. associated with smoking, alcohol & drug abuse; which is harmful to mother &
fetus
4. associated with sexually transmitted disease (STD); which is also harmful to
mother & fetus
5. more stress in teenage pregnancy; the stress may come from legal aspect, social
isolation, childbearing problem & financial problems
6. marriage in teenage may easy lead to marital breakdown
7. increased society burden since lack of financial support on childbearing, which
may result in taking CSSA provided by the government
8. Since the teenagers are psychologically immaturity and not well prepared to be
parents. The risks of children are increased incidence of
 Impaired intellectual functioning
 Poor school adjustment
 Behavioural problem
 Child abuse

Dietary advice for a woman with gestational diabetes mellitus (GDM). (5%)

1. Explain the aim of dietary control to the woman is to reduce the risks of serious
congenital abnormalities.
2. Establish a partnership by planning the diet with the woman.
3. If the woman weighs 60kg, we need to emphasize the importance of 1800kcal
diet, daily caloric intake is 30kcal / kg / day.
4. A well balanced diet & high fiber diet is recommended, which is low in simple
sugars, high in complex carbohydrate, moderate in fat, high in protein.
Proportion of carbohydrate to fat to protein is 45 to 35 to 20.
5. Fatty & sweeten food, drinking alcohol and smoking must be avoided.

33
6. The consistent timing of the meals is 3 main meals & 3 snacks to maintain
constant blood sugar level.
7. In the absence of medical or obstetric complications, regular & moderate exercise
for about 30 minutes a day in the antenatal period is recommended for all pregnant
women.
8. The woman is taught to observe the signs & symptoms of hypoglycemia, e.g.
dizziness & fatigue.
9. Refer the woman to dietitian & diabetic nurse for nutritional counseling of
diet regimen and suggest possible recipe for her.
10. Hospitalization for sugar profile is needed to evaluate the effectiveness of diet
control of GDM.
11. Explain the need of performing hemo-glucostix at home.

Management of pregnancy that reaches 41 weeks of gestation. 10.1997 (B.7) (5%)

Firstly, confirmation of dates is needed, but clinical parameters are not always accurate,
so ultrasound examination & dating scan must be done in 1st & 2nd trimesters. Secondly,
assessment of risk factors, such as gestation diabetes mellitus (GDM), pre-eclampsia,
antepartum haemorrhage (APH) or intrauterine growth retardation (IUGR), must be
done. Thirdly, counseling the client for induction of labour (IOL) or expectant
management must be done.

IOL is the safest alternative for mother & baby at confirmed dates ( 41 weeks)
with favourable cervix. Cephalopelvic disproportion (CPD) & macrosomia should
avoided, therefore the rate of meconium stained liquor (MSL) (sign of fetal distress),
caesarean section & perinatal mortality can decrease. Moreover, unexpected stillbirth in
non-anomalous fetus must be avoided.

IOL takes place if decrease in amniotic fluid on scan (oligohydramnios); decrease in

fetal growth & fetal movement; suboptimal antepartum cardiotocography; maternal
complication, e.g. hypertension or significant medical condition.

The methods of induction of labour are:

 Medical methods include pessary of Prostaglandin E2 (PGE2) to ripen the cervix &
Syntocinon infusion to bring about uterine contractions.
 Surgical methods include amniotomy & sweeping / stripping of the cervix.
 Combined method is both medical & surgical methods.

34
 Complementary methods are sexual intercourse, stimulation of nipples, use of
herbs.

Expectant management is needed at confirmed dates ( 41 weeks) but with

unfavourable cervix. It is safe if appropriate fetal surveillance is performed, such as
fetal movement chart, fetal growth ultrasound, non stress test (NST), assessment of
amniotic fluid volume. The other methods are biophysical profile such as fetal
breathing; fetal movement; fetal tone; reactivity of fetal heart rate (FHR); amniotic
fluid volume by measuring the amniotic fluid index (AFI); doppler ultrasound to detect
the velocity of placental blood flow to rule out uteroplacental insufficiency.

The client must admit to hospital at 41 weeks of gestation. The surveillance of fetal
well-being can be detected by NST twice weekly & ultrasound for liquor volume. The
low risk case is suitable for IOL. Caesarean section should be arranged for the client
with complications, e.g. polyhydramnios. In labour, we should watch out for CPD,
macrosomia & MSL; amnioinfusion must be done for significant variables & to dilute
meconium if MSL occurs; fetal monitoring, NST must be done to detect fetal distress;
beware of shoulder dystocia. We should check for any maternal complication such
as infection & postpartum haemorrhage (PPH) after delivery. Documentation of
the maternal condition; antenatal, labour & postnatal period is needed.

The management of newborn is examination for any birth trauma; early feeding;
closely observation of the vital signs and monitoring for hypoglycaemia & hypothermia;
checking for polycythaemia if small for gestational age (SGA), since it will lead to
neonatal jaundice; psychological support must be given to the parents. Active
resuscitation of the baby must be done if MSL occurs, which includes clearing the
oropharynx & nasopharynx by suction; clearing & visualizing the vocal cords; gastric
aspiration if necessary. Documentation of the resuscitation & fetal condition is
needed.

Labour presenting with occipito-posterior position. 4.2003 (B.3) (5%)

It is a vertex presentation with fetal back directed posteriorly, which is a

malposition. Right occipito-posterior (ROP) position is more common than left
occipito-posterior (LOP) position because the presence of sigmoid colon on the left side
of the maternal pelvis.

35
Causes of OP position
1. anthropoid & android pelvis due to narrow fore-pelvis
2. A flat sacrum with a poorly flexed head leads to further deflexion & OP
∵ The head of OP position is deflexed, so the largest diameter, occipito-fronto (OF)
diameter (11.5cm) is presented
3. anterior insertion of the placenta
∵ the fetus usually faces the placenta
4. other causes: placenta praevia / pelvic tumours / pendulous abdomen /
polyhydramnios / multiple pregnancy

Clinical presentations during labour

1. early rupture of membranes
2. slow descent of head due to increased diameters (OF is 11.5cm) / high head at
term due to deflexion (the deflexed head is felt with occiput & sinciput are on the
same level by abdominal palpation)
3. Slow progress of labour due to insufficient stimulation of the cervix by the fetal
head
4. severe backache due to a pressure of the bony portion of fetal head against the
sacrum of maternal pelvis
5. a strong urge to push at the end of 1st stage due to occiput compresses the
rectum
6. vaginal examination reveals
 large caput
 anterior fontanelle is felt in the anterior part of the pelvis due to poorly flexed head
 the pinna of the ear is found pointing to the occiput

Maternal complications
1. early rupture of membranes has a higher risk of cord prolapse & infection
2. prolonged 1st stage of labour / prolonged rupture of membranes
3. uterine inertia
4. obstructed labour
5. maternal distress or fetal distress
6. higher risk of operative delivery, e.g. vacuum extraction / forceps delivery /
caesarean section
7. perineal trauma or laceration
8. higher risk of postpartum haemorrhage (PPH)

36
Fetal risks
Cerebral haemorrhage due to upward moulding
 tentorial tear
 intracranial haemorrhage

Possible course & outcome of labour

1. long anterior rotation, delivery is completed as in normal labour
2. short posterior rotation
 occurs in persistent occipito-posterior (POP) position
 mostly occurs with an anthropoid pelvis
 the head can be delivered spontaneously with a face to pubes delivery

3. deep transverse arrest

 occurs in persistent occipito-transverse (POT) position
 mostly occurs with an android pelvis
 the occiput rotates 1/8 circle anteriorly & the head is arrested with the sagittal
suture in the transverse diameter
 the labour is obstructed and vacuum extraction / forceps delivery / caesarean
section should be done

4. conversion to face or brow presentation

 If face presentation occurs, vaginal delivery occurs if adequate pelvis &
mento-anterior (MA) position
 If brow presentation occurs, caesarean section is required

Management plan depends on the clinical presentations such as lie on the same side as
the fetal limbs, e.g. ROP: lie on left lateral, or knee chest position; avoid premature
rupture of membranes; advise mother to avoid early pushing; adequate pain relief, e.g.
epidural analgesia; augmentation for slow progress if no contraindication.

Way of measuring blood pressure for pregnant woman. (10%)

The pregnant woman is sitting or lying with lateral tilt (prefer on right side) after
resting for at least 2-3 minutes.

 An appropriate size of cuff is used, according to the arm circumference

 Clothings are removed from the arm

37
 Lower border is applied not less 1” from the cubital fossa, neither too loose nor
too tight
 Cuff & manometer (mercury) are placed at the heart level

The correct phase of Korokoff sounds are as follow:

 Phase I ― first sound appear (systolic blood pressure)
 Phase II & III ― turbulent flow through a partially occluded vessel
 Phase IV ― sounds become muffled
 Phase V ― sounds disappear (diastolic blood pressure)

Phase I & Phase V should be taken as the systolic blood pressure & the diastolic blood
pressure in pregnancy (ISSHP, 2001).

Counseling on postpartum sterilization. 1.2000 (B.13) (5%)

Considerations before sterilization

1. Age of the couple
2. Possibility of other methods
3. Stability of marriage, which includes sexual relationship, social & financial
situations
4. The number & ages of children the couple have
5. The couple, either the husband or wife is liable to transmit inherited disease
6. The wife who has medical grounds for avoiding pregnancy as further pregnancy
might endanger her life
7. The couple’s view about the possible death of existing child

Methods of female sterilization

1. Laparoscopy is an usual method of choice
 Ligation & excision
 Application of plastic clips & ring
2. Mini-laparotomy to carry out tubal ligation followed by excision

Timing of doing female sterilization

1. Can be performed at any time providing the woman is not pregnant
2. After a vaginal delivery or abortion
3. When caesarean section is being performed

38
Advantages
1. Immediately effective
2. Long term contraception. Most women feel extremely relieved

Complications
1. Wound bleeding & infection
2. Recanalization (very rare)
3. Ectopic pregnancy ― increased risk after sterilization but rare

Counseling of the couples requesting sterilization

 The couple should be seen together in a relaxed but professional atmosphere
 They should provide details of themselves, their circumstances and their reason for
their request

 While the counselor gives the facts about the operation

1. Irreversibility of the operation
2. A simple description of the method, technique, possible complications and failure
rate of the operation
3. Alternative methods available
4. The couple’s informed consent is obtained. Although the consent of the other
partner is not legally required, it is good practice to obtain it to ensure agreement
between the couple

Contraceptive advice to a lactating mother. (10%)

Progesterone only contraceptives

Progesterone only pill (POP), e.g. 0.03mg Levonorgestrel LNG

Action:
1. Changes in the endometrium preventing implanation
2. Altering cervical mucus thick and impenetrable to sperms
3. 40% women still ovulates normally

Duration of action: 24 hours

Method of use:
1. It is necessary to await the return of menstruation if the woman is breastfeeding in

39
 the postpartum period.
2. The first pill is taken on the 1st day of the menstruation & no extra contraceptives
are required.
3. One pill is taken at the same time each day without a break.
4. The optimal time to take pills is about 4 hours for maximum effect on the cervical
mucus to be achieved.
5. The pills should be taken regularly several hours before intercourse usually takes
place.

Advantages:
1. acceptable efficacy
2. controlled by women
3. reversible fertility
4. lactation is not suppressed
5. premenstrual tension, dysmenorrhoea are often relieved

Disadvantages:
1. higher failure rate
2. heavier irregular bleeding
3. acne due to androgenic activity of LNG

Contraindications:
1. all the absolute contraindications for the combined pills.
2. irregular menstruation
3. current breast cancer
4. < 6 weeks postpartum and breastfeeding

Progesterone only injectable, e.g. Depo-provera ― in conjunction with Rubella

immunization

Action:
1. Changes in the endometrium preventing implanation
2. Altering cervical mucus thick and impenetrable to sperms
3. Inhibition of ovulation

Duration of action: 3 months +/- 2 weeks

40
Advantages:
1. high effectiveness
2. convenient & simple
3. long lasting as only one injection is needed every 3 months, it is suitable for
unreliable pill-takers
4. no estrogenic side-effects
5. lactation is not suppressed
6. premenstrual & menstrual symptoms may be relieved

Disadvantages:
1. drug’s action cannot be reversed once given
2. menstrual disturbances ― irregular & heavy bleeding, or oligo-menorrhoea
3. delayed return of fertility
4. prolonged use may result in significant loss of bone density
5. minor side effects: headache, mood changes, breast tenderness, fluid retention

Contraindications: similar to the POPs

Follow-up of clients:
Women on oral contraceptives or injectables should have an annual follow-up for
1. complete physical examination
2. vaginal examination & Pap smear
3. urine testing for sugar

Intrauterine contraceptive device (IUCD)

The insertion into the uterus of a plastic or metal device with different sizes and shapes
to prevent conception and can be removed when the woman wishes to become
pregnant.

All IUCDs cause a foreign body reaction in the endometrium → ↑numbers of

leucocytes → endometrium less suitable for implantation.

Method of use:
1. Time of insertion
 During or shortly after a menstrual period has been recommended.
 Postpartum: 6-8 weeks after delivery; Post-abortion: 2 weeks after abortion
2. Teach the woman how to feel for the thread coming through the cervical os
3. Teach her to check the IUCD thread each month after the end of menstruation

41
4. The first period after insertion of IUCD will be slightly heavier and may be
associated with dysmenorrhoea.
5. IUCD should be removed if planned pregnancy, menorrhagia, abdominal pain,
displacement of IUCD, pelvic infection, one year after her last period at the
menopause.

Advantages:
1. cheap
2. immediately effective & long acting
3. fully reversible
4. independent of intercourse
5. no systemic side effects

Side effects & complications:

1. abnormal bleeding ― ↑amount & duration; spotting
2. cramping pains
3. pelvic infection → risk of future infertility
4. perforation of uterus
5. pregnancy while an IUCD is in place, the pregnancy
→ may result in a spontaneous abortion (~5%)
→ may be ectopic (~5%)

Contraindications:
1. known or suspected pregnancy
2. current or past history of pelvic infection
3. previous ectopic pregnancy
4. undiagnosed abnormal uterine bleeding, heavy periods
5. large uterine fibroid, structural abnormalities of the uterus
6. valvular heart disease ― risk of subacute bacterial endocarditis (SBE)
7. suspected malignancy of the genital tract

Follow-up of clients:
1. client should be seen 6-8 weeks after insertion & yearly thereafter
2. client should seek medical aid if she
 cannot feel the string of IUCD
 has symptoms of pelvic infection
 has missed a period

42
Barrier methods: mechanical barrier
Condoms are made of fine latex rubber, available in various colors & textures,
lubricated and spermicide incorporated.

Action: Condoms prevent spermatozoa from reaching the female upper genital tract.

Advantages:
1. simple to use & easy obtained
2. inexpensive
3. effective when used correctly & consistently
4. free from medical risks
5. protection against most sexually transmitted diseases (STDs)
6. improvement of performance in some patients with premature ejaculation

Disadvantages:
1. sexual activity is interrupted
2. some couples complain discomfort or local irritation
3. loss of pleasurable sensation
4. allergy to latex type of condom but rare

Femshield is a female condom. It is a soft, pliable polyurethane sheath which lines the
vagina. It has an inner ring which is used for insertion and which holds the sheath in
place beyond the pubic bone and an outer ring which lies flat against the labia. It is
pre-lubricated and likely to offer a high degree of protection against pregnancy and all
the STDs.

Action: Femshield like condom

Advantages:
1. women would feel more in control
2. effective when used correctly & consistently
3. free from medical risks
4. protection against all the STDs

Disadvantages:
1. expensive
2. slippery to hold & difficult to insert
3. looks awkward as there is something hanging out of the vagina

43
4. sexual activity is interrupted
5. some couples complain discomfort or local irritation
6. loss of pleasurable sensation

Diaphragm is a soft rubber cup with a stiff but flexible rim around the edge. It comes
in different sizes from 50-105mm in diameter.
After care ― wash the diaphragm with warm, soapy water, rinsed & dried carefully. It
should be stored in its container in a cool place.

Advantages:
1. no systemic side-effects
2. can be inserted well in advance of sexual activity

Disadvantages:
1. It requires anticipation, and thereby there is loss of spontaneity with intercourse
2. Some women find it difficult to insert, spermicides make the method rather messy
3. Local irritations if sensitive to rubber or spermicides
4. Does not protect against human immunodeficiency virus (HIV)

Contraindications:
1. women with poor vaginal tone, uterine prolapse, cystocele
2. inability to learn the insertion technique
3. a notch behind the pubic bone is too shallow to support the diaphragm rim
4. allergy to rubber
5. lack of hygiene or privacy for insertion

Follow-up of clients:
1. The woman should be seen once a year to check the correct usage, the fitness and
physical state of the diaphragm
2. A diaphragm should be replaced annually, or immediately if any defects develop

Cervical cap is a soft, thimble-shaped rubber device that fits tightly over the cervix and
blocks the passage of sperms. It can be used in women who want a diaphragm type but
cannot because of anatomic reasons.

Barrier methods: chemical barriers or spermicide

Action: physically blocking the sperm, immobilizing & destroying them

44
Method of use: all types need to be inserted high into vagina before coitus

Foam
 Aerosol foam (pressurized containers)
 Immediately effective, remains effective for 12 hours

Foam tablets
 At least 5 minutes should be allowed to foam before coitus
 Repeated if there is a delay of 1 hour

Jellies (in tubes) / creams

Vaginal contraceptive film / spermicidal sponge

 Insert into the vagina 15 minutes before sexual intercourse
 Sponge can stay in vagina for 12 hours and should be taken off 6 hours after last
intercourse
 If sex takes place 1 hour after insertion of film, another one should be inserted

Advantages:
1. easy to use
2. freedom from major health risks
3. provide some genital lubrication
4. provide some protection against STDs

Disadvantages:
1. unreliable method
2. require anticipation or interruption of sexual activity
3. varying degree of messiness according to the preparation
4. occasional complaints of local irritation or allergy

For lactating mother, if she is exclusive breastfeeding her baby with no supplement,
the hormones secreted, prolactin & oxytocin, can suppress ovulation. Therefore
lactation can be used as natural contraceptive method, but the rate of failure is
also high.

45
Complications of twin pregnancy. 4.1996 (B.4) (5%)

Maternal complications
1. exaggerated minor disorders
 increased nausea & vomiting (~50%) caused hyperemesis gravidarium
∵ higher level of βhuman chorionic gonadotrophin (βhCG)

 increased pressure symptoms caused

→ ankle edema, varicose veins, haemorrhoids
∵ higher level of progesterone
→ backache, dyspnoea, tiredness
∵ increased uterine size & weight

2. anaemia
 greater demand for iron & folic acid
 more “dilutional” anaemia due to exaggerated increase in plasma volume

3. pre-eclampsia (PET) (3 times higher)

∵ greater placental mass
 earlier onset (~21-24 weeks) and with greater the severity and complications

4. gestational diabetes mellitus (GDM)

 increased in multiple pregnancy
∵ increased human placental lactogen (hPL) & other hormones
 higher incidence in triplets as compared with twins

5. urinary tract infection (UTI)

∵ exaggerated ureteral changes
∵ decreased ureteral peristalsis → increased stasis of urine & more UTI

6. polyhydramnios
 more likely to occur in monochorionic twins
→ exaggerated pressure symptoms

7. higher risk of hepatic disorders

 cholestasis of pregnancy
 acute fatty liver of pregnancy (16.7% occurs in twin pregnancy)

46
8. antepartum haemorrhage (APH)
 placenta praevia
∵ larger placenta is liable to encroach onto lower uterine segment
 abruptio placentae
∵ larger placental site, associated with PET

9.psychologic
 more stress to care 2 babies who may be preterm, often with handicaps or special
needs
 bereave for the loss fetus/baby
∵ intrauterine death (IUD) or multifetal pregnancy reduction

10. preterm labour / delivery

 major complication, greater in monochorionic (MC) twins
?∵ over-distention of uterus

11. malpresentation ∵ inadequate space

12. increased operative delivery

 vacuum extraction / forceps delivery / caesarean section

13. postpartum haemorrhage (PPH)

∵ uterine atony / larger placental site

14. higher risk of puerperal sepsis

∵ anaemia / larger placental site / increased obstetric manipulation

Fetal complications
1. higher perinatal mortality (4-5 times higher)
 mainly related to preterm birth

2. prematurity ∵ preterm birth

 58% are born < 37 weeks in twins
 9 times higher to have low birth weight babies

3. fetal growth problem

 intrauterine growth retardation (IUGR) (60%)
∵ early in pregnancy: placental insufficiency because of limited vascular supply

47
∵ late in pregnancy: fetal crowding → limited decidual area for placental growth

 discordant fetal growth (~15%)

→ ≧ 20% difference in estimated fetal weight (EFW) between the twins babies
∵ placental insufficiency / twin-twin transfusion syndrome

4. congenital anomalies
 higher incidence in structural defect as in monozygotic twins
 increased in chromosomal abnormalities ∵ older maternal age
 intrauterine crowning → foot deformities, skull asymmetry
 specific malformation: acardia (end up in death of fetus), conjoint twins

5. twin-twin transfusion syndrome (TTTS)

 a severe condition affecting ~ 15% of all monochorionic diamniotic (MCDA)
pregnancies
 placental vascular anastamoses allows communication between 2 placental
circulation (anastomosis ― a communication between 2 vessels or other structures,
either natural or established operatively)
→ imbalance in the blood flow → a net flow of blood from one twin to the other
 “Donor”: anaemic, hypovolemic &hypoxia → growth restricted & oliguric with
oligohydramnios → +/- IUD
 “Recipient”: hypervolemic → congestive heart failure; polycythemic → severe
neonatal jaundice in newborn or hydrops; polyuric with polyhydramnios
 management depends on severity / gestation
― fetoscopic laser coagulation of the communicating placental blood vessels
― serial amniodrainage

6. umbilical cord entanglement

 occurs in > 70% of monochorionic monoamniotic (MCMA) twins
 major cause of sudden IUD

7. fetal wastage
 miscarriage in early pregnancy
 vanishing twin ― fetus payraceous
 single intrauterine fetal demise (death) → higher risk of preterm delivery &
IUGR
 higher risk in monochorionic (MC) pregnancy
― surviving twin will have acute hypotension episode & serious neurological

48
impairment
 in dichorionic (DC) pregnancy
― surviving twin will have better neonatal outcome

8. risks increase in 2nd twin (hypoxia)

∵ delayed delivery
∵ malpresentation (breech / oblique lie / transverse lie) → cord prolapse
∵ failed version → malpresentation (breech presentation) → cord prolapse
∵ increased intrauterine manipulation & operative procedure (vacuum extraction /
forceps delivery / caesarean section)
∵ premature separation of placenta after delivery of the 1st twin

9. interlocking twins (very rare)

 1st twin in breech presentation & 2nd twin in cephalic presentation
 the chin of aftercoming head of the 1st twin is caught by the forecoming chin
of the 2nd twin

Causes of hyperemesis gravidarum. 4.1999 (B.5) (5%)

Hyperemesis gravidarum is excessive & persistent vomiting occurring during the 1st
20 weeks of pregnancy that results in dehydration, ketonuria, electrolyte imbalance
& weight loss which needs interventions or hospitalization.
It onset at early stage, usually persist throughout the pregnancy.

Causes of hyperemesis gravidarum

1. psychological factor
 anxiety & stress
 negative feeling to the pregnancy
 attention seeking
 an association with a previous history of hyperemesis or unsuccessful pregnancy

2. endocrine factor
 multiple pregnancy / molar pregnancy → high level of estrodial & βhuman
chorionic gonadotrophin (βhCG)
 thyroid dysfunction: ↓thyroid-stimulating hormone (TSH); ↑T3 & T4

49
3. metabolic factor
 vitamin B deficiency or disturbance of carbohydrate metabolism

4. other medical causes of vomiting

 gastroenteritis
 urinary tract infection (UTI) or pyelonephritis
 appendicitis, cholecystitis & pancreatitis

5. other obstetrical causes of vomiting

 morning sickness
 acute polyhydramnios
 recurrent jaundice of pregnancy
 impending eclampsia

Diagnostic criteria
1. history of intractable vomiting in the 1st half of pregnancy
2. dehydration
3. ketonuria
4. weight loss of ≧ 5% of pre-pregnancy weight

Maternal effects
 weight loss; dehydration; starvation
 if untreated → pathologic changes in essential organs:
1. liver → jaundice
2. renal → oliguria, polyneuritis
3. brain (central nervous system(CNS)) → encephalopathy
4. heart → ↓activity of heart musculature
5. stomach → ↓availability of instrinsic factor for absorption of Vitamin B 12,
Vitamin C & folic acid → anaemia

Fetal effect
1. intrauterine growth retardation (IUGR) may cause stillbirth
2. if condition is severe & is uncontrolled, possible fetal anomalies or CNS
malformations

50
What is fetal distress? Discuss its diagnosis and management during labour?
10.1998 (A.2) (15%)

Fetal distress is a term used to describe a condition where the fetus is suffered from
oxygen deprivation, & is associated with a high false positive result, this term has a
low positive predictive value & often is associated with an infant who is born with
good condition.

The diagnosis of fetal distress are non-reassuring / abnormal fetal heart rate (FHR)
pattern; meconium-stained amniotic fluid (when fetus is in cephalic presentation);
result of fetal blood sampling (FBS) is low scalp blood pH <7.25.

Non-reassuring / abnormal FHR pattern in the 1st stage of labour

1. Obstetrician must be informed
2. Explain & reassure the mother
3. Look for possible causes & manage according to it
 Any malposition of transducer
 Change maternal position to left lateral
 Stop / ↓rate of syntocinon infusion if hyperstimulation of uterus occurs
 Give oxygen if maternal hypoxia occurs

4. Woman will keep nil by mouth / nil per oral (NPO)

5. Intravenous fluid infusion (IVF) & blood taking for cross-matching must be
prepared
6. Vaginal examination; fetal scalp electrode (FSE); fetal blood sampling (FBS) must
be prepared
7. Closely monitoring the maternal condition by vital signs, blood pressure (BP) &
pulse (P); & general condition
8. The fetal condition is closely monitored with electronic fetal monitoring (EFM)

9. When obstetrician arrives, he will assess fetal & maternal condition, set up
intravenous line for infusion, blood taken for cross-matching
10. Vaginal examination will perform to exclude cord prolapse & assess progress of
labour; or insert FSE for better monitoring; or perform FBS if needed to check for
scalp blood pH
 If pH is 7.2-7.25 (pre-acidotic state) → repeat FBS 30 minutes later
 If pH is <7.2 (acidotic state) → arrange emergency caesarean section (C/S)

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Non-reassuring / abnormal FHR pattern in the 2nd stage of labour
1. Obstetrician must be informed
2. Paediatrician must be informed to stand-by at delivery for resuscitation of baby
3. If labour proceeds normally, delivery is expedited by adequate episiotomy;
encouraging maternal pushing; instrumental delivery if necessary, e.g. vacuum
extraction or forceps delivery
4. Active resuscitation for infants who are not vigorous should be performed
immediately

Management of meconium-stained liquor (MSL)

If fetal hypoxia occurs & persists, parasympathetic activity increases, FHR decreases &
triggers vagus nerve, which will increase gut peristalsis & relax the anal sphincter, then
passage of meconium occurs & result in MSL.

1. Obstetrician must be informed

2. Woman will keep nil by mouth / nil per oral (NPO)
3. Intravenous line will set up for infusion, blood will taken for cross-matching &
complete blood picture (CBP)
4. Explain & prepare for amnioinfusion if moderate to thick MSL is detected during
labour
 It is a common procedure done during labour to dilute meconium in the amniotic
fluid by normal saline (NS) to decrease the risk of fetal meconium aspiration
syndrome (MAS)
 Prevention of MAS is vital to improve perinatal mortality & morbidity
 1L NS solution at room temperature is intilled into the uterine cavity via an
intrauterine pressure catheter over a period of about 30 minutes
 The procedure is needed to repeat if undelivered within 4 hours & delivery is not
imminent

5. The fetal condition is closely monitored with EFM

6. If labour proceeds normally, paediatrician should be informed to stand-by at
delivery for resuscitation of baby
7. Endotracheal suctioning for infants who are not vigorous should be
performed immediately

8. If MSL occurs with non-reassuring FHR pattern, there is an increased chance of

acidotic baby, birthing with poor condition & need resuscitation

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9. In case of MSL with non-reassuring FHR pattern, decision for C/S will be more
readily made in view of 2 signs of fetal distress (FBS can also be performed to
check for scalp blood pH for diagnosis of fetal distress)

Write short notes on fetal blood sampling. 4.2001 (B.5) (5%)

Fetal blood sampling (FBS) is a sample of fetal blood taken from fetal scalp correlate
reasonably well with the acid-base condition of the central circulation. The
measurement of acid / base (pH) of fetal blood, usually undertaken as an adjunct to
electronic fetal monitoring (EFM) particularly when the cardiotocogram (CTG) is
non-reassuring for diagnosis of fetal distress.

Although FBS reduces the false positive & negative responses to abnormal fetal heart
rate (FHR) patterns, but this invasive procedure causes certain injury on fetal scalp,
which increases the risk of infection & haemorrhage.

Results interpretations
 Normal scalp pH: >7.35 – 7.45
 Pre-acidotic state pH: 7.20 – 7.25
 Acidotic state pH: <7.20

Procedure of FBS
1. insert an amnioscope via vagina & reach the fetal scalp
2. dried the scalp skin with swabs
3. spray ethyl alcohol to produce reactive hyperemia
4. apply a water-repellent gel (Vaseline or silicone)
5. make a small incision of ~2mm
6. collect blood in a heparinized capillary
7. assess for pH
8. haemostasis of wound

Methods of intrapartum fetal monitoring. (10%)

Continuous Fetal Heart Monitoring (CFHM)

It is a continuous recording of the fetal heart rate (FHR) changes & uterine
contractions (UC) by using fetal heart (FH) monitor.

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There are 2 methods of CFHM: external monitors & internal monitors.
For the external monitors, FH is monitored by an external transducer, which is a
Doppler ultrasound device to interpret & count the signals. UC is monitored by a
tocodynamometer placed on the fundus of the abdomen.

The internal monitoring is an invasive procedure.

For the internal monitors, FH is monitored by an internal sensor (fetal electrode),
which is a spiral wire placed directly on the presenting part, usually the fetal scalp. UC
is monitored by an intrauterine catheter.

CFHM can reveal the baseline FHR; rhythm, regularity & variability of FHR; any
acceleration or deceleration of FHR; frequency, basal tone, strength & duration of
UC.

Observation on colour of liquor

Colour & characteristics of liquor are one of the indicators to reflect fetal
condition. There are different states of liquor: clear liquor / meconium-stained
liquor (MSL) / blood stained liquor (BSL). MSL is a traditional sign associated
with fetal distress.

Presence of meconium in liquor may reflect fetal gastrointestinal maturity. But

moderate to thick MSL is associated with a 3-fold increase risk of adverse
intrapartum outcomes.

If with non-reassuring FHR pattern, there is an increased chance of acidotic baby,

birthing with poor condition & needing resuscitation. Aspiration of meconium into
the fetal or neonatal lung is associated with clinical disease ranging from mild
transitory respiratory distress to severe respiratory compromise (Meconium
Aspiration Syndrome ― MAS).

Fetal Blood Sampling (FBS)

FBS is a sample of fetal blood taken from fetal scalp correlate reasonably well with
the acid-base condition of the central circulation. The measurement of acid / base
(pH) of fetal blood, usually undertaken as an adjunct to electronic fetal monitoring
(EFM) particularly when the cardiotocogram (CTG) is non-reassuring for diagnosis of
fetal distress.

Although FBS reduces the false positive & negative responses to abnormal FHR

54
patterns, but this invasive procedure causes certain injury on fetal scalp, which
increases the risk of infection & haemorrhage.

Results interpretations
 Normal scalp pH: >7.35 – 7.45
 Pre-acidotic state pH: 7.20 – 7.25
 Acidotic state pH: <7.20

New ancillary test includes fetal electrocardiography (ECG waveform) & fetal
pulse oximetry.

Fetal ECG
It assesses fetal well-being by assessing changes in its ECG waveform.
It requires an internal monitoring of the FHR & a special equipment to process
the fetal ECG.

Studies evidenced that in addition with this method to conventional fetal monitoring
significantly decrease the rate of caesarean section for fetal distress as well as metabolic
academia in umbilical artery blood.

Fetal pulse oximetry

It is a continuous fetal oxygen saturation monitoring using an oxygen sensor which
placed on the fetal cheek, rate of fetal oxygen saturation ≧30% indicates adequate
fetal oxygenation. The procedure is non-invasive & safe.

But it has technical problem for accurate & continuous monitoring which affects its
effectiveness, so it needs more study support.

Infection control measures for pregnant women with HIV infection during labour.
4.2000 (B.2) (5%)
How to reduce the risk of HIV transmission from an HIV-infected mother to her
baby. 10.2000 (B.5) (5%)

Natural history
1. Human Immunodeficiency Virus (HIV) exposure
2. incubation: 2 -6 weeks

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3. acute primary infection
 up to 50% patients symptomatic
 usually lasts 1 – 2 weeks
 window period ~ 3 weeks to 3 months from exposure

4. chronic asymptomatic infection

 clinically latent
 may have persistent generalized lymphadenopathy (PGL)
 CD4 usually >500

5. symptomatic disease
 early ― acquired immunodeficiency syndrome (AIDS) related complex (ARC)
― CD4 200 - 500
 late ― AIDS usually developed (~ half over 10 years without treatment)
― CD4 <200

Serological diagnosis
1. screening
 Enzyme Immunoassay (EIA)
 Enzyme-linked immunosorbent assay (ELISA)

2. confirmatory
 Western blot assay (WB)
 Immunofluorescence assay (IFA)

*** 2 +ve ELISA / EIA & 1 +ve WB: false positive < 1:100000

3. supplementary tests (for serological tests with indeterminate result)

 viral isolation by culture
― gold standard (specific)
― insensitive
― time consuming

 Polymerase Chain Reaction (PCR)

― highly sensitive
― shorter turnaround time than culture
― amplifies HIV DNA or RNA with enzymes to detectable level

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 p24 antigen assay
― sensitive
― ELISA based assay

Antepartum management
1. universal antenatal & rapid HIV screening
2. discuss pregnancy options: termination / continuation
3. clinical / laboratory screening for at risk conditions
 sexually transmitted diseases (STDs): syphilis, warts, herpes, Chlamydia
 CIN / cervical cancer
 CMV; hepatitis B, C
4. treat chorioamnionitis, STDs ∵ may lead to placental damage
5. look for other high risk social factors, e.g. drug abuse, smoking, low maternal
vitamin A level
6. avoid invasive diagnostic / therapeutic procedures
 chorionic villi sampling (CVS) / amniocentesis / cordocentesis
 external cephalic version (ECV)

7. regular follow up every 2 weeks till 36 weeks, then weekly

8. baseline ultrasonography (USG) for dating & fetal growth
9. serial USG for fetal growth
10. regular cardiotocogram (CTG) if indicated
11. check baseline CD4 count; CD4 / CD8 each trimester & if indicated

12. discuss & offer maternal / neonatal antiretroviral treatment

 regime individualized & discuss with HIV physician (HAART preferred)
 depends on whether for maternal or fetal indications
13. admit for obstetric / medical indications
14. prevent preterm delivery

15. HAART therapy

 Avoid in 1st trimester as safety on fetus unknown unless already taking before
pregnancy for maternal health; individualized by HIV physician
 Clinical / laboratory monitoring of side effects:
1. baseline complete blood picture (CBP); liver function test (LFT); CPK (if on
zidovudine ZDV)
2. CBP taken every 2 weeks for 1 month, then taken every 4 weeks
3. LFT, CPK taken every 4 weeks

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 4. more frequent testing if indicated, discontinue if
 haemoglobin (Hb) <8 gm%
 platelet <100
 granulocyte < 0.75
 ALT / AST > 5 times of upper limit of normal

Intrapartum management
Strict observation of universal infection control precautions:
Notification of Infection Control Unit & other relevant medical & midwifery
personnel

 general measures
1. universal precautions especially with blood, cervical & vaginal secretions,
amniotic fluid
2. use of disposable equipment / instruments, consumables
3. proper patient isolation; proper disinfection / sterilization of environment,
equipments / instruments; proper handling, labeling & disposal of medical
wastes should be executed per protocol
4. use of protective wears when appropriate, e.g. caps, goggles, face masks,
water-proof gown, boots, shoe covers, double gloves
5. re-sheathing needles with caps is strictly prohibited
6. proper labeling / handling of laboratory specimens

 specific measures
1. no artificial rupture of membranes (ARM) / care should be taken in
amniotomy to avoid splashing of liquor
2. deliveries should not be conducted by inexperienced staff, e.g. medical
students, pupil midwives, interns
3. episiotomy repair should not be performed by interns & should be done with
assistants with vaginal wall retractors
4. Uterine exploration / manual removal of placenta (MROP) should be done
with wearing long gloves

5. For caesarean section (C/S), specific measures include

 Careful transfer of needles & avoid passing by hand
 Using blunt point needles / staplers
 Using dissecting forceps to pick up needles
 Avoid blood splashing during cord cutting

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1. avoid invasive diagnostic / monitoring / therapeutic procedures
 intrauterine catheter monitoring / fetal scalp electrode (FSE) / fetal blood sampling
(FBS)
 amnioinfusion
 instrumental delivery / episiotomy

2. blood taken to check CBP, LFT, CPK & cross-matching

3. if in intravenous (IV) ZDV therapy & booked case, continue HAART therapy
4. if in intravenous (IV) ZDV therapy & unanticipated (unbooked) case, lamivudine
& nevirapine therapy must be given
5. continuous fetal heart monitoring (CFHM)
6. delay ARM
7. perform episiotomy only if indicated & timely
8. delivery should be conducted by experienced personnel
9. avoid anticipated difficult instrumental delivery
10. forceps delivery is preferred to ventouse extraction

11. elective C/S has a 50% reduction in vertical transmission of HIV

 it is beneficial even with low viral load <1000 copies/ml
 but it is uncertain if viral load <50 copies/ml or on HAART therapy with
undetectable viral load
 emergency C/S after spontaneous rupture of membranes (SRM) or onset of
labour is not beneficial

12. For elective C/S, we should

 performed in a reserve operation theatre
 cover uterine wound edges with pads before rupturing membranes
 give pre-operative prophylactic antibiotics to the client

13. early cord clamping at delivery of baby

14. early cleansing of baby off maternal blood / liquor
15. paediatrician should be informed to stand-by at delivery for resuscitation of baby
16. cord blood sampling for neonatal HIV diagnosis is not reliable

Postpartum management
1. advise against breastfeeding & on personal hygiene
2. stop maternal IV ZDA therapy
 booked case: continue HAART therapy till stopped by HIV physician if needed

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 unanticipated case: oral ZDV & lamivudine for 1 week will be prescribed

3. advise on contraception / family planning / future pregnancy / safe sex

4. advise on gynaecological surveillance on CIN
 semi-annually for 2 times; if 2 normal smears occurs, thereafter check up
annually

5. liaise with paediatrician for neonatal therapy

 oral ZDA therapy for 6 weeks will be given
 unanticipated case: nevirapine for 1 dose will be given also
 vaccination program: Hyperhep, Hepatitis B Vaccine (HBV), Bacille
Calmette-Guerin (BCG) Vaccine, polio vaccines as usual
 laboratory testing for perinatal HIV infection & long term baby follow up

6. no need to isolate baby from mother

7. maintain confidentiality of patient’s status

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