LMCHK Part 1

Paper 2

Induction of labor
Breech Delivery
2019.03.30
 Postdate pregnancy
Postdate pregnancy
1. Definition of postdate pregnancy: -pregnancy of 41
completed weeks or more
2. Post-maturity syndrome成熟后综合症 – clinical
syndrome with the neonate manifesting signs of:
a. Long and thin in body girth and underweight from
loss of subcutaneous tissues
b. Patchy areas of desquamation and skin is stained
with meconium, although rarely the latter feature may
be absent.
c. The ventral surfaces of the hands and feet are
wrinkled and the nails are long and stained with
meconium
新生儿临床综合征表现为:
a.体长而薄，由于皮下组织的减少而导致体重不足
b.脱落的斑片状区域和皮肤被胎粪污染，尽管很少有胎粪
的特征
c.手、脚腹侧表面起皱，指甲长，甲胎粪染色

I am 41 years old
but i dont go out of home you got to force me out
 Causes(Insight) Negele failure this guy dont
even know how to count.
Incidence
1.4% -Varies from 3 to 10%, depending the accuracy of the dating of pregnancy

Causes
1. Most common is reason is not dating properly, maternal obesity, nulliparity.
2. Rarely it is associated with foetal abnormalities (0.1-1%): -anencephaly, foetal adrenal hypoplasia, absence of
foetal pituitary, placental sulfatase deficiency. The deficiencies of hormones in the above conditions are thought to
cause the failure of initiation of labour.很少与胎儿异常相关(0.1-1%):-无脑畸形、胎儿肾上腺发育不良、胎儿垂体缺
失、胎盘硫酸酯酶缺乏。在上述情况下激素的缺乏被认为是导致分娩失败的原因。
3. 30% chance with one previous prolonged pregnancy, 40% with two.

The most common reason for postdate pregnancy is: 过期怀孕最常见的原因是:

A. Inaccurate gestational age. A.妊娠年龄不准确。
B. Fetal anencephaly. B胎儿畸形。
C. Oligohydramnios. C羊水过少。
D. IUGR. D 宫内生长迟缓
E. Advanced maternal age. E.高龄产妇。
 Complication(Insight)
I am running out of suppy

1. Maternal risk1. 产妇风险 In postterm pregnancy all the followings are

a. Maternal anxiety母亲焦虑 true EXCEPT:
b. Higher caesarean section rate (17.6-25.8%) resulting from A. Associated with meconium stained liquor.
macrosomia, failure of induction of labour, and foetal distress b.巨 B. The fetus has long nails and macrosomia.
大儿、引产失败、胎儿窘迫导致剖宫产率较高(17.6-25.8%) C. May results in oligohydramnios.
c. Birth canal injury resulting from difficult delivery of macrosomic D. Associated with respiratory distress
baby c.巨大儿难产造成产道损伤 syndrome.
E. It is a gestational age beyond 43 weeks.
2. Foetal risk 2. 胎儿的风险
a. Post-maturity syndrome a.成熟后综合症 在怀孕后期，下列各项均为真实情况，但:
b. Macrosomia (10%) and associated birth injury (0.5%) such as A与甲胎粪污染液有关。
shoulder dystocia , b.巨大儿(10%)和相关的分娩损伤(0.5%)，如肩 B胎儿的指甲很长。
难产 C可能导致羊水过少。
c. Intrauterine growth retardation宫内发育迟缓 D.与呼吸窘迫综合征相关。
d. Foetal compromise胎儿妥协 E 孕周超过43周。
e. High chance of meconium stained liquor (MSL) and therefore Toward the end of pregnancy, calcium is deposited
meconium aspiration syndrome on the walls of blood vessels, and proteins are
胎粪污染液(MSL)及胎粪吸入综合征发生率高 deposited on the surface of the placenta, which
f. Overall 2-fold increase in perinatal mortality rate when compared changes the placenta. This limits the blood flow
through the placenta and ultimately leads to placental
to term gestation (Intrapartum and neonatal death)与足月妊娠(产时
insufficiency, and the baby is no longer properly
和新生儿死亡)相比，围产期死亡率总体增加2倍。 nourished. Induced labor is strongly encouraged if
this happens.
 Insight Oh i am thirsty

A healthy, 28-year-old nulliparous woman comes to the physician at 41 weeks gestation for a follow-up prenatal
visit. The patient has had an uncomplicated pregnancy so far with an ultrasound at 18 weeks gestation that
showed normal fetal anatomy and a fundal placenta. Blood pressure is 110/80 mm Hg and pulse is 80/min.
Examination shows that fundal height is consistent with dates, fetus is in cephalic presentation, and the cervix is
closed. Nonstress test is reactive. She is scheduled for an induction of labor at 42 weeks. This patient is at
greatest risk for which of the following complications?
A Abruptio placenta 一名健康的28岁待产妇女在怀孕41周时来到医生那里进行产
B. Low fetal birth weight 前随访。到目前为止，这名妇女在怀孕18周时进行了超声检查，
结果显示胎儿解剖结构正常，并有一个底部胎盘。血压110/80
C. Oligohydramnios 毫米汞柱，脉搏80/分钟。检查显示，宫高与日期相符，胎儿
D. Polyhydramnios 呈头位，宫颈闭合。非应力测试是反应性的。她计划在42周时
E. Preeclampsia 引产。这个病人患以下哪一种并发症的风险最大?
A脱离胎盘
F. Uterine rupture B.胎儿出生体重低
c .羊水过少
d .羊水过多
E子痫前期
F.子宫破裂
Oligohydramnios (single deepest vertical pocket of amniotic fluid </=2 Cm or an amniotic fluid index of </=5 cm on
transabdominal ultrasound) is a common complication of prolonged pregnancies. An aging placenta may have
decreased fetal perfusion, resulting in decreased renal perfusion and decreased urinary output from the fetus. The
diagnosis of oligohydramnios is an indication for delivery even if antepartum fetal testing is normal.羊水过少(经腹超
声检查羊水指数</= 5cm)是妊娠期延长的常见并发症。老化的胎盘可能会降低胎儿的灌注，导致肾脏灌注减少和胎儿
尿量减少。即使产前胎儿检查正常，羊水过少的诊断也是分娩的一个指标。
 Meconium stained liquor (MSL)
Whatt????/No

Meconium stained liquor (MSL)-胎粪染色液(MSL)

Meconium is a dark green fecal material that accumulates in the foetal intestines
and is discharged at or near the time of birth. When the foetus passes meconium
before or during labour, the meconium mixes with the amniotic fluid, and
depending on the relative amount of meconium and amniotic fluid, it is classified
into light, moderated and thick MSL 胎粪是一种深绿色的粪便物质，聚集在胎儿的
肠道内，在出生时或临近出生时排出。当胎儿在分娩前或分娩过程中排出胎粪时，
胎粪与羊水混合，根据胎粪与羊水的相对量，胎粪可分为轻胎粪、轻胎粪、重胎粪。
Significance of MSL-It was thought in the past that MSL is a sign of foetal distress.
Nowadays it is clear that foetuses pass meconium very often when they undergo
stress, as a normal parasympathetic response. MSL does not necessarily imply
distress, and is commonly seen in postterm pregnancies. However, thick MSL
may imply that the actual amniotic fluid is reduced (oligohydramnios) which itself
is a sign of foetal compromise. When foetuses aspirate thick meconium to the
airway or lung during labour, the meconium will induce a chemical pneumonitis
which is called meconium aspiration syndrome. It is a severe disease and
potentially fatal. MSL is uncommon in preterm pregnancy. When it occurs, it is
associated with listeriosis and is associated with high foetal morbidity and
mortality. 胎粪染色液的意义-过去人们认为胎粪染色液是胎儿窘迫的一种迹象。现在很清楚的是，胎儿在承受压力时经常排出胎粪，这是一种正
常的副交感神经反应。MSL并不一定意味着痛苦，通常出现在怀孕后期。然而，厚厚的MSL可能意味着实际的羊水减少(羊水过少)，
这本身就是胎儿妥协的迹象。分娩过程中，胎儿将厚胎粪吸入气道或肺部，胎粪会诱发化学性肺炎，称为胎粪吸入综合征。这是一种
严重的疾病，有可能致命。MSL在早产中并不常见。当它发生时，它与李斯特菌病有关，并与高胎儿发病率和死亡率有关。
 Meconium stained liquor (MSL) It stink plz clean up

Plan of delivery: 交货计划:

a. Allow vaginal delivery if no sign of foetal distress 如果没有胎儿窘迫的迹象，允许阴道分娩
i For induction of labour if no onset yet i .如尚未发病，应立即引产
ii Start amnioinfusion in case of moderate and thick MSL. ii.中厚MSL开始羊水输注。
iii IV access, Cross-match iii IV接入，交叉匹配
iv. Continuous foetal monitoring with CTG iv.持续胎儿CTG监测
b. For Caesarean section if foetal distress or malpresentation. b.如果胎儿窘迫或畸形，用于剖宫产。
2. On delivery: 2. 交付:
a. Inform paediatrician upon delivery. 分娩时通知儿科医生。
b. Suck baby’s oral cavity and nasal cavity upon delivery of foetal b.胎头分娩后，吮吸宝宝的口腔和鼻腔。(如果宝宝
head. (not recommended if the baby is active and crying) 活泼好动，哭闹，不推荐)
c. No need for tracheal aspiration unless intubation is required c.不需要气管抽吸，除非需要插管
In a Case of labor with meconium stained amniotic fluid, your next step is:
A. Amnio-infusion
B. Close observation Immediate therapy for infants with suspected meconium should routinely
C. Fetal scalp blood sample include : 疑似胎粪的婴儿应常规立即治疗包括:
D. Immediate C/S A. Corticosteroid A:皮质类固醇
在胎粪污染羊水分娩的情况下，你的下 B. Antibiotics b .抗生素
一步是: C. Sodium bicarbonate c .碳酸氢钠
A:羊膜穿刺输液 D. Clearing of the airway D.清理气道
B .密切观察
C胎儿头皮血样
E. Giving Oxygen under positive pressure 在正压力下给氧
 Management of postdate pregnancy
Need to force him out
Diagnosis
Accurate dating of pregnancy from menstrual history, early ultrasound assessment, landmarks of foetal
development: -quickening, foetal heart sound, uterine size准确的怀孕日期从月经历史，早期超声评估，胎儿发育的
里程碑:-加速，胎儿心音，子宫大小
怀孕推迟日期
2. Management of postdate pregnancy(from local protocol) 1. 过期妊娠的定义:妊娠41周或以上
a. Ensure the EDC is well defined.
2. 过期妊娠的处理
b. Arrange morning admission for induction of labour at 41 weeks for
uncomplicated pregnancy
a.确保EDC预计分娩日期定义良好。
c. If it is a holiday or day before holiday at 41 week, delay the date of b.安排上午入院引产，第41周为简单妊娠
admission to the first working day after the holidays c.如果是节假日或假期前第41周，则将入学
d. Arrange follow-up in MCH meanwhile. 日期推迟至节假日后第一个工作日
e. On the day of admission at 41 weeks, perform routine examination and 同时安排MCH母婴健康院的跟进。
CTG by midwives. e.在入院第41周的当天，助产士进行常规检
f. Assess by team doctors in the evening round. Start IOL on the next day, 查和CTG心分娩力描记法检查。
unless declined by the patient
f.晚上轮询时由队医进行评估。除非病人拒
g. Refer to induction of labour form method of induction
h. If patient declines IOL at 41 weeks, rearrange IOL no later than 42 weeks.
绝，否则从第二天开始服用人工晶体
i. If gestational age is uncertain, decide time of IOL and methods of fetal g.参照引产形式的引产方法
monitoring with MRCOG h.如果患者在41周时IOL引产术下降，则不
迟于42周重新安排IOL。
To the first day of LMP add 7 days, then subtract 3 months, and 如胎龄不确定，可采用MRCOG确定人工授
then add 1 year. e.g.: -LMP: -10/10/2009 EDC:17/07/2010 精时间及胎儿监护方法
 Bishop score I want the cervix to be soft come on
PG
The score used to assess the ripening of the cervix for induction of labour. Scores are assigned to each of the five
cervical features and the total score is obtained by summation. With a low score (0-3), there is a higher risk of
failed induction, resulting in caesarean section (over 20%) compared with a score of eight or more, where the
failed induction rate is less than 3%. With a high score the cervix is said to be ripe.分值用于评估用于引产的宫颈成
熟程度。将评分分配到五个颈椎特征中的每一个，并通过求和得到总分。评分较低(0-3分)，引产失败的风险较高，
导致剖宫产失败(超过20%)，而评分8分或以上，引产失败率小于3%。得分高的子宫颈被认为是成熟的。

Considering the Bishop’s score: 考虑到主教的评分:

a) It includes station of the presenting part. a)包括呈递部分的工位。
b) It includes the length of the cervical canal. b)包括颈椎管的长度。
c) It includes the gestation of the fetus. c)包括胎儿的妊娠。
d) It includes parity of the mother. d)包括母亲的奇偶性。
e) A score of 4 indicates the cervix is unfavourable e) 4分表示宫颈状况不佳
True: a, b, e.

宫口扩张
稠度
颈椎管长度
 Bishop Score Please do the maths

You examine a lady who has attended a labour ward for induction of labour at term + 12 days. She has a cephalic
presentation which is three-fifths palpable. The cervix is not dilated 子宫颈没有扩张at all, is 2 cm long, of average
consistency稠度 and is in a mid-position. The station is –2. What is her Bishop score?
A. 0
B. 2
C. 4
D. 6
E. 8

This woman scores 0 for dilation, 1 for length of

cervix, 1 for station, 1 for consistency and 1 for
position, giving a score of 4.
 Induction of labour引产术 I cant wait anymore

Definition Indications
It is an obstetric procedure designed to pre-empt the 1. Foetal indications
natural process of labour by initiating its onset a. Postterm pregnancy: -the most common indication (23.9-30.0%)
artificially before this occurs spontaneously. 这是一 b. Prolonged rupture of membranes: -the second most common indication
种产科程序，其目的是在自然分娩过程发生之前，通 (29.0-31.0%)
过人工启动分娩过程，从而预先预防分娩过程。 c. Foetal compromise that may risk intrauterine death if pregnancy is
continued: -IUGR (2.7%), oligohydramnios, before 34 weeks these can be the
indication.
The following are indications for induction of d. Lethal foetal abnormalities requiring termination of pregnancy (0.2%): -such
labor EXCEPT : as Edward syndrome, Patau syndrome, anencephaly, thanatophoric dwarfism
A. Sever pre-eclampsia e. Stillbirth (0.6%)
B. Trisomy 13 and 18 迹象
C. Prolonged rupture of membrane without 1. 胎儿的迹象
uterine contraction无子宫收缩的长时间膜破裂 a.后期妊娠:-最常见的适应症(23.9-30.0%)
D. IUFD ( intrauterine fetal death) b.膜破裂时间延长:-第二常见的适应症(29.0-31.0%)
c.如果继续妊娠，可能有宫内死亡风险的胎儿妥协:-IUGR(2.7%)，羊水过少
E. Previous 3 LSCS剖腹产术 ( lower segment
d.需要终止妊娠的致命胎儿畸形(0.2%):-如爱德华综合征、帕托综合征、无脑儿、
c/s) 致畸性侏儒症
•Twin pregnancy continuing beyond 38 weeks
• Intrahepatic cholestasis of pregnancy e。死胎(0.6%)
• Maternal iso-immunization against red cell antigens 2. Maternal indications
Presence of medical diseases that may deteriorate or is poorly controlled as
• ‘Social’ reasons - only if cervix is favourable•双胎妊娠持
•续超过38周 pregnancy continues: -such as pre-eclampsia (3.6%), poorly controlled
•妊娠肝内胆汁淤积 diabetes mellitus (4.7%)2. 母亲的迹象
•母体对红细胞抗原的等免疫 妊娠期间可能恶化或控制不良的医疗疾病的存在:-例如先兆子痫(3.6%)、控制不
•“社交”原因——只有在宫颈状况良好的情况下
良的糖尿病(4.7%)
 IUFD宫内胎儿死亡
A 24-year-old woman, gravida 2 para 1, at 28 weeks gestation comes to the office with her husband because she
has felt no fetal movement for 3 days. She has no pain, leakage of fluid, or bleeding. All testing during this
pregnancy has been normal, including an anatomy ultrasound at 20 weeks gestation Her first child was delivered
vaginally at term. Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, and pulse is 94/min. Fetal heart
tones are not heard by Doppler. Ultrasound demonstrated an absence of fetal cardiac activity and a small for
gestational age fetus in breech presentation .A digital cervical examination shows the cervix to be long and
closed. Laboratory results are as follows一名24岁的孕妇在怀孕28周的时候和她的丈夫来到办公室，因为她已经3天
没有感觉到胎儿的移动了。她没有疼痛、漏液或出血。怀孕期间的所有检查都很正常，包括怀孕20周时的解剖超声
检查，她的第一个孩子是足月顺产的。体温36.7 C(98华氏度)，血压120/80毫米汞柱，脉搏94/min。多普勒无法听
到胎儿心脏的声音。超声显示胎儿心脏活动缺乏，臀位显示胎龄胎儿较小，数字宫颈检查显示子宫颈长而窄
关闭。实验结果如下
Which of the following is the most appropriate management advice for this patient?
A. Cesarean delivery is the safest mode of delivery
B. Dilation and evacuation under general anesthesia is recommended
C. External cephalic version should be performed because the baby is breech
D. Labor can be induced in the hospital when you feel ready
E. Spontaneous labor provides the best outcome以下哪一条是对这个病人最合适的治疗建议?
A剖宫产是最安全的分娩方式 Normal
B全身麻醉下建议扩张和撤离 Fibrinogen正常的
C.因为宝宝是臀位，所以要做外置头位 纤维蛋白原
D当你准备好的时候，可以在医院引产 150-400 mg/dL

E自然分娩的效果最好
 Insight
Intrauterine fetal demise (IUFD) refers to fetal death at 20 weeks gestation and before the onset of labor. Although
IUFD most commonly occurs in uncomplicated pregnancies, risk factors include fetal growth restriction, abnormal
fetal karyotype, and tobacco use. Patients typically present with decreased or absent fetal movement. Fetal heart
tones are not heard by Doppler sonography, and ultrasound confirms the absence of fetal cardiac activity. Once
the diagnosis is confirmed, it is critical to inform the parents as empathically as possible.
宫内胎儿死亡(IUFD)指妊娠20周及分娩前胎儿死亡。虽然IUFD最常见于非复杂妊娠，但危险因素包括胎儿生长受限、
胎儿核型异常和烟草使用。多普勒超声不能听到胎儿心脏音的降低或缺失，一旦确诊，超声证实胎儿心脏活动的缺
失，以同理心告知父母是至关重要的。
The timing and route of an IUFD delivery are dependent on gestational age
and patient preference The diagnosis can be overwhelming for prospective
parents, and some patients are unable to make decisions at the time of
diagnosis. Patients should be informed that vaginal delivery is the preferred
delivery route at >24 weeks gestation, regardless of fetal presentation (eg,
vertex, breech). Although most patients prefer to begin an induction
immediately, it can generally be delayed until the patient is ready. However,
retention of the fetus for several weeks can lead to coagulopathy. Therefore,
waiting for spontaneous labor (Choice E), which usually occurs 2-3 weeks
after the diagnosis, is not recommended.
IUFD分娩的时间和路线取决于胎龄和患者的偏好。对于未来的父母来说，诊
断可能是压倒性的，一些患者在诊断时无法作出决定。患者应被告知，阴道
分娩是首选的分娩路线在>妊娠24周，无论胎儿的表现(如顶点，臀位)。虽然
大多数病人喜欢立即开始诱导，但一般可以推迟到病人准备好。然而，胎儿
滞留数周可导致凝血障碍。因此，不建议等待自然分娩(选项E)，这通常发生
在诊断后2-3周。
 Contraindications(Insight) Operate me rather
Contraindications禁忌(Mainly the indication of CS)
- Malpresentation: -foetuses may better be delivered by caesarean section or external cephalic version (ECV) before
induction. -产状不良:-引产前胎儿最好采用剖宫产或体外头位分娩(ECV)。
- Date problems: -日期问题-we should know normal delivery is better because there is risk of hyperstimulation of
uterus子宫过度刺激, - Presence of indications of caesarean section: -such as placenta praevia, classical caesarean
section(greater risk of uterine rupture子宫破裂 is relative contraindication)
- Severe foetal compromise that is likely to fail to sustain the stress of labour: -better to deliver by caesarean section
- Poor maternal condition such as severe pre-eclampsia or mitral stenosis: -better to deliver by caesarean section-:-
-有无剖宫产指征:-如前置胎盘、经典剖宫产
-胎儿严重受损，可能无法承受分娩压力:-最好剖宫产
-孕妇状况差，如严重先兆子痫:-最好剖宫产
Which is a contraindication of induction of labor
A. History of upper segment caesarian section
A pregnant woman presents with a placenta praevia of a major defect
B. Severe Pre eclampsia at 36 weeks and fetus is malformed. Which of the following will be the best
C. Gestational diabetes on insulin at 39 weeks management?孕妇表现为前置胎盘的主要缺陷和胎儿畸形。以下哪一项是
D. Post term pregnancy 最好的管理
E. Chorioamnionitis A. Caesarian section剖腹产手术
引产的禁忌症是什么 B. Oxytocin drip催产素滴
A.上段剖腹产史 C. Rupture of membranes胎膜破裂
B.重度子痫前期在36周 D. Induce with PG E2
C.妊娠39周时应用胰岛素治疗妊娠糖尿病 E. Forceps delivery in the second stage to accelerate delivery第二阶段为
D.足月后妊娠 产钳分娩加速阶段
E.绒毛膜羊膜炎
 Prostaglandin前列腺素 I told you it breaks the sulfide bond

What are Prostaglandins?

The most important groups of prostaglandins in obstetrics and gynaecology are
prostaglandin E (PGE) and prostaglandin F (PGF). They are involved in the
process of ovulation, initiation of labour, and pathogenesis of dysmenorrhea
and menorrhagia.前列腺素E (PGE)和F (PGF)是妇产科中最重要的两组前列腺
素。它们参与排卵的过程，启动分娩，痛经和月经过多的发病机制。

Indications迹象
- For induction of abortion or labour-用于引产或分娩
- For prophylaxis and treatment of primary postpartum haemorrhage
-用于预防和治疗原发性产后出血

The increase in local PGE2 leads to a series of important

changes associated with cervical ripening, including the
following: Dilation of small vessels in the cervix , Increase in
collagen degradation, Increase in hyaluronic acid, Increase in
chemotaxis for leukocytes, which causes increased collagen
degradation, Increase in stimulation of interleukin (IL)–8
release 子宫颈小血管扩张，胶原蛋白降解增加，透明质酸增加，
白细胞趋化增加，导致胶原蛋白降解增加，白细胞介素(IL) -8释
放增加.
 Cervical ripening-宫颈成熟
Methods Which of the following has NOT been shown to stimulate
1. Cervical ripening-宫颈成熟 (induce) labor:
A.Amniotomy.
a. With vaginal insertion of prostaglandin E2 B. Prostaglandins.
b. Required if the cervix is unfavourable, with bishop score less C. Enemas.
than 6 D.Breast stimulation.
E. Overeating.

下列哪项没有显示出能刺激(诱导)分娩:
A:人工破膜。
Prostaglandin E2 (Dinoprostone)- Local protocol. B.前列腺素。
1. Nature – A PGE-2 analogue of the prostaglandin group C .灌肠。
D.乳房的刺激。
2. Indications2. 迹象 E .暴饮暴食。
a. Induction of labour a.引产
b. Softening and dilatation of cervix before induction of labour分娩前宫颈软化和扩张
3. Caution – Patients with high risk for uterine rupture, hypersensitivity患者易发生子宫破裂、过敏
4. Adverse reactions – Uterine hyperstimulation, foetal distress, uterine rupture子宫过度刺激，胎儿窘迫，子宫破裂
5. Side effects – GI upset, vomiting, pyrexia呕吐、发热
6. Route of administration – Vaginal pessary inserted high into the posterior vaginal fornix阴道子宫托高插入阴道后
穹窿
7. Regimen -
a. 1 tablet every 4-6 hours
b. Maximum dosage 3 tablets
 Initiation of uterine contractions子宫收缩的开始
2. Initiation of uterine contractions
a. With amniotomy (artificial rupture of membranes) and syntocinon intravenous infusion
b. Syntocinon infusion rate should be titrated with frequency and strength of uterine contractions (aim at 4
uterine contactions in 10 minutes) to avoid hyperstimulation.
2. 子宫收缩的开始
a.采用羊膜切开术(人工破膜)和催产素静脉滴注
b。催产素输注速度应根据子宫收缩的频率和强度进行滴定(目标为10分钟内4次子宫收缩)，以避免过度刺激。

It is a simple instrument with a small hook at the tip for amniotomy. Under
aseptic technique, amnihook slides between index and middle fingers, which are
already in contact with membrane. Amnihook is then turned upward to rupture
the membranes. Fingers should withdraw after cord prolapse excluded. If liquor
not seen, treat as Meconium Stained Liqour.这是一种简单的工具，顶端有一个小
钩用于羊膜切开术。在无菌技术下，羊膜钩在食指和中指之间滑动，而食指和中
指已经与膜接触。然后将羊膜向上翻转，使羊膜破裂。手指应退出后，脊髓脱垂
排除。如未见有酒，视为胎粪染利库尔。
One of the following contraindications for the use of amnio-hook : 羊膜钩(人工破膜)除:
A. Placental previa a前置胎盘 Amnio-hook (artificial ROM) may cause all except: A羊水栓塞
B. Abruptio placenta b分开胎盘 A. Amniotic fluid embolus b .胎儿宫内发育迟缓
C. Breech presentation c .臀先露 B. IUGR
C. Abruptio placenta c .剥落胎盘
D. IUGR D. Fetal distress d .胎儿窘迫
E. Face presentation面先露 E. Cord prolapse e .绳下垂
 Insight
A 21-year-old lady at 40 weeks+ 12 days is being induced. She has received two doses of prostaglandins after examination
revealed a low Bishop score. She is experiencing mild contractions with good fetal movements. Her CTG trace is reactive. She
is fed up, tired and is becoming angry with the midwives as she thought she would have delivered sooner. On abdominal
palpation there is cephalic presentation with two-fifths palpable. On vaginal examination after the second dose of progesterone
she is 3 cm dilated with a partially effaced cervix. What would be the next course of action?
一个21岁的女士在40周þ12天被诱导。她接受了两剂前列腺素检查，检查显示她的主教评分很低。她正在经历轻微的
宫缩，胎儿活动良好。她的CTG跟踪是反应性的。她受够了，累了，并且对助产士们感到愤怒，因为她认为自己本可
以更快地分娩。腹部触诊以头侧表现，可触及五分之二。第二次注射黄体酮后，阴道检查显示她的宫颈扩张了3厘米，
宫颈部分被切除。下一步的行动是什么This lady has received two doses of vaginal prostaglandins (PGE2) to initiate
A. Artificial rupture of membranes contractions and encourage cervical ripening. The tablets are 3 mg and are
B. Caesarean section given 6–8 hourly with a maximum dose of 6 mg/day. They have clearly
C. Further prostaglandin worked as she has progressed from a low Bishop score to a cervical dilation
D. Observation alone of 3 cm. If women are progressing well with strong contractions no other
E. Oxytocin action is needed, however if there is slow progress with minimal contractions
(in this case) an ARM can be performed and an oxytocin infusion is used to
A.人工破膜 maintain the contractions after membrane rupture. Further prostaglandins
B .剖腹产 are contraindicated due to the risk of hyperstimulation as she already feels
C .进一步前列腺素 some uterine activity.
D .观察单独 这位女士接受了两剂阴道前列腺素(PGE2)来启动宫缩和促进宫颈成熟。片剂为3毫克，每小时6 - 8粒，最大剂量为6毫克/
E 催产素 天。当她从一个较低的主教评分发展到宫颈扩张3厘米时，它们显然起了作用。如果妇女进展良好，收缩较强，不需要采
取其他行动，但是，如果进展缓慢，收缩最小(在本例中)，则可以进行手臂注射催产素，以维持膜破裂后的收缩。进一步
的前列腺素是禁忌的，因为有过度刺激的风险，因为她已经感觉到一些子宫活动。
 Amniotomy羊膜穿破术 Please dont poke

Amniotomy or artificial rupture of membranes is a common intrapartum procedure, performed with an amnihook
(or with a DrewSmythe cannula in hindwater amniotomy).
Indication
1. Augmentation of labour in spontaneous rupture of membrane, and Induction of labour. The procedure would
stimulate production of endogenous prostaglandins which brings about uterine contractions as well as cervical
softening.自发破膜时产程的增加和引产。该手术将刺激内源性前列腺素的产生，从而导致子宫收缩和宫颈软化。
2. Application of foetal scalp electrode or blood sampling;应用胎儿头皮电极或采血;
3. Instrumental delivery.仪器交付。
Complications of artificial rupture of membranes
Risk include all the following, EXCEPT :
1. Compression of foetal head during labour, thus it should A. Abruptio placenta.
be avoided in vaginal delivery of preterm foetuses as the B. Amniotic fluid embolism. Failure to induced
forewater protects the vulnerable foetal head C. Fetal distress. effective contraction.
2. Cord prolapse, particularly if there is polyhydramnios. D. Meconium aspiration. 未能诱导有效收缩
3. In the management of intrauterine death, amniotomy E. Cord prolapse.
should be avoided until the late stage of labour, in order to 人工破膜的并发症包括:
prevent intrauterine infection1. 分娩过程中胎儿头部受压， A:分开胎盘。 Placental abruption- this may be caused by the
因此在早产时阴道分娩时应避免这种情况，因为前水保护脆 B羊水栓塞。 sudden reduction in the volume of liquor where
弱的胎儿头部 C胎儿窘迫。 there has been polyhydramnios.
2. 脐带脱垂，尤其是羊水过多时。 D胎粪吸入。 胎盘早剥-这可能是由胎盘的突然减少引起的
3.在处理宫内死亡时，应避免羊膜切开术，直至分娩后期， E .绳下垂。 有羊水过多的地方的酒量。Bleeding from forced
dilatation by examing finger.
以防止宫内感染
 Amniotic fluid embolism羊水栓塞 Allegic reaction

It is a very rare but serious and unpredictable condition in which amniotic fluid enters the maternal circulation,
resulting in acute cardiorespiratory compromise and coagulation derangement.这是一种非常罕见但严重且不可预
测的情况，羊水进入母体循环，导致急性心肺功能损害和凝血紊乱。
Incidence
About 1 in 30000 pregnancies. 发病率
Risk factors 约有三万分之一的孕妇怀孕。
- Rupture of membranes 风险因素
- Rapid labou -膜破裂
- Caesarean section -快速分娩
- Use of oxytocin -剖腹产
-催产素的使用
Mechanism(Anaphylactic or septic shock)机制
Amniotic fluid accesses directly into the maternal circulation through a
defect somewhere near the placental site at a higher than usual
intrauterine pressure. The biochemical constituents of the amniotic
fluid activate the coagulation cascade, and the foetal squames may
also plug into the pulmonary circulation resulting in failure of gaseous
exchange. 羊水直接通过胎盘附近的缺陷进入母体循环，其压力高于通
常的宫内压力。羊水的生化成分激活凝血级联，胎儿的鳞片也可能进
入肺循环导致气体交换失败
血管痉挛，心源性休克，低氧性呼吸衰竭，凝血病合并弥漫性血管内凝血病(DIC)
 Insight Its an emergency

Diagnosis诊断
- The diagnosis is mainly on clinical basis.AFES is diagnosed clinically after excluding other causes of sudden
postpartum cardiorespiratory failure (eg, eclampsia, peripartum cardiomyopathy, pulmonary embolism) Treatment
is mainly supportive to correct the hypoxemia (eg, oxygen, intubation, mechanical ventilation) and
hypotension (eg, vasopressors). 诊断以临床为主。AFES的临床诊断排除了产后突发心肺功能衰竭(如子痫、围生期
心肌病、肺栓塞)的其他原因后，治疗主要支持纠正低氧血症(如吸氧、插管、机械通气)和低血压(如升压药)。

The diagnosis may be confirmed by demonstration of amniotic debris and trophoblasts in pulmonary vasculature,
by aspirating blood from the pulmonary artery (via a Swan-Ganz catheter), or during postmortem examination.诊断
可以通过在肺血管系统中发现羊膜碎片和滋养细胞，通过从肺动脉抽出血液(通过Swan-Ganz导管)，或在尸检期间
得到证实。
Management管理
1. Cardiopulmonary resuscitation with circulatory support and artificial ventilation1. 心肺复苏与循环支持和人工通风
2. Correction of coagulopathy2. 纠正凝血障碍
3. Correction of acidosis3.纠正酸中毒
4. Delivery of baby:
The foetus is unlikely to survive such a major insult, but immediate delivery by caesarean section carries a high
maternal risk. Therefore delivery should be undertaken after stabilization of the mother, and vaginal delivery is
preferable.
4. 分娩:胎儿不太可能在如此严重的伤害下存活下来，但立即剖腹生产有很高的产妇风险。因此，分娩应在母亲稳定
后进行，阴道分娩更为可取。
drugs like- dolbutamine, nor adrenaline can be utilised.
 Insight
A 43-year-old patient, gravida 6, para 5, at 39 weeks gestation has a brief generalized tonic-clonic seizure in the delivery room.
She became disoriented, lightheaded, breathless, and cyanotic 20 minutes after an uncomplicated spontaneous vaginal delivery
of a healthy neonate and placenta .Her pregnancy was uncomplicated, and she has no past medical history. Her blood pressure
is 80/40 mm Hg, pulse is 110/min, and respirations are 30/min. Oxygen saturation is 75% on facemask. Examination shows an
unconscious woman who is no longer seizing. A generalized purpuric rash and bleeding from the intravenous line site are seen.
Which of the following is the most appropriate next step in management of this patient?一名43岁的孕妇，妊娠6周，第5段，怀孕
39周，在产房有短暂的全身性强直阵挛发作。20分钟后，她神志不清，头昏眼花，气喘吁吁，发绀，在一个健康的新生儿和胎盘
的自然阴道分娩后，她的怀孕是不复杂的，她没有过去的病史。她的血压是80/40毫米汞柱，脉搏是110/分钟，呼吸是30/分钟。面
罩上的氧饱和度为75%。检查显示一名失去知觉的妇女不再抽搐。广泛的紫癜皮疹和静脉导管出血。以下哪一项是治疗这个病人最
合适的下一步
A Abdominal ultrasound This patient's presentation is concerning for respiratory failure from amniotic fluid
B. Intramuscular magnesium sulfate embolism syndrome (AFES), a rare but catastrophic complication during pregnancy
or shortly after delivery. This patient's risk factors include advanced maternal age
C. Intravenous furosemide
and high gravida (>/=5 live births or stillbirths). Amniotic fluid can enter the maternal
D. Intravenous heparin circulation through endocervical veins, placental insertion site, or areas of uterine
E. Intubation and mechanical ventilation trauma (eg, cesarean incision site). This leads to an inflammatory response causing
a.腹部超声检查 vasospasm, cardiogenic shock, hypoxemic respiratory failure, and coagulopathy
b.肌内硫酸镁 with disseminated intravascular coagulopathy (DIC). Hypoxia can lead to seizures
c .静脉注射速尿灵 and loss of consciousness, as in this patient这位病人的报告是关于由羊水栓塞综合征
d .静脉注射肝素 (AFES)引起的呼吸衰竭，这是一种罕见但灾难性的并发症，在怀孕期间或怀孕后不久
e.插管和机械通气 交付。该患者的危险因素包括高龄产妇和高妊娠(>/=5个活产或死产)。羊水可通过宫
颈内静脉、胎盘植入部位或子宫损伤部位(如剖宫产切口部位)进入母体循环。这导致
炎症反应，引起血管痉挛、心源性休克、低氧性呼吸衰竭和凝血病合并弥漫性血管内
凝血病(DIC)。就像这个病人一样，缺氧会导致癫痫发作和意识丧失
 Insight
I fell down suddenly

A 26-year-old primigravid woman has been induced at 40 weeks due to moderate pre-eclampsia with 6 mg vaginal
prostaglandin and artificial rupture of membranes. She is not on an oxytocin infusion. There are no
other antenatal complications. On vaginal examination her cervix is 5 cm dilated and fully effaced, with the
presenting part at station –1. She has an epidural in situ so she does not feel the contractions. Suddenly she
develops abdominal pain and there are deep decelerations on the CTG. On examination, her uterus feels hard.
She feels faint and her blood pressure is low with a maternal tachycardia. What event has just occurred?
A. Amniotic fluid embolism
一名26岁的原发性偏头痛妇女在40周时因中度子痫前期使用6毫克阴道前列
B. Epidural failure
腺素和人工破膜而被诱导。她没有注射催产素。没有其他产前并发症。经阴
C. Placental abruption
道检查，她的宫颈扩张5厘米，完全消失，在1号站出现。她有硬膜外麻醉，
D. Uterine hyperstimulation
所以她感觉不到宫缩。她突然出现腹痛，CTG上有深度减速。检查时，她的
E. Uterine rupture
子宫感觉很硬。她感到头晕，血压很低，母亲的心跳过速。刚才发生了什么
早剥的危险因素有高血压、先 事?
兆子痫、羊水过多或多胎破膜 A.羊水栓塞 Risk factors for abruption are
hypertension, pre-eclampsia,
后突然减压、早剥(10%复发)、 b .硬膜外失败 sudden decompression after
腹部外伤和滥用烟草或可卡因， c .胎盘早剥 membrane rupture in
但在许多病例中病因不明。发 d .子宫过度刺激 polyhydramnios or multiple
pregnancies, previous abruption
病率为0.5-2%。 e .子宫破裂 (10% recurrence), trauma to the
abdomen and tobacco or
cocaine abuse although the
cause is unknown in many cases.
The incidence is 0.5–2%.
 胎盘早剥
Placental abruption describes separation of the placenta
from the uterus prior to third stage of labour. Mild
abruption, where there is minimal separation, may
present with little pain or bleeding and with minimal
consequence to fetus or mother. Major abruptions
present with sudden-onset constant, sharp, severe low
abdominal or back pain, maternal shock and variable
amounts of vaginal bleeding. The uterus is irritable and
tender and may become hard due to tonic contraction.
The tense uterus means it is difficult to palpate fetal parts 胎盘早剥是指在第三产程之前胎盘与子宫分离。轻度早剥，
and there is often loss of fetal movements. Intrauterine 即分离程度最低，可伴有轻微的疼痛或出血，对胎儿或母
death from hypoxia is common unless action is taken. 亲的影响最小。主要的突发性表现为持续性、剧烈、严重
The clinical condition of the mother and degree of shock 的下腹部或背部疼痛、母体休克和不同程度的阴道出血。
may not correlate well with the amount of blood loss seen 由于强直性收缩，子宫易激变软并可能变硬。子宫紧张意
vaginally as bleeding can be contained behind the 味着难以触诊胎儿的各个部位，常常会出现胎儿运动障碍。
placenta (concealed abruption). In this case the epidural 除非采取行动，否则宫内缺氧死亡是常见的。母亲的临床
was effective for the level of pain from contractions but 情况和休克程度可能与阴道失血量没有很好的相关性，因
the increased level of pain from the abruption was such 为出血可以被控制在胎盘后面(隐匿性早剥)。在这种情况下，
that it was registered by the mother despite the epidural. 硬膜外麻醉对宫缩引起的疼痛程度是有效的，但由于早剥
Delivery must be expedited and in this case a Caesarean 引起的疼痛程度增加，母亲在硬膜外麻醉下仍能感觉到疼
section is required. If the cervix had been fully dilated an 痛。分娩必须加快，在这种情况下需要剖腹产。如果子宫
instrumental delivery could have been considered. 颈完全扩张，可以考虑使用仪器分娩。
 催产素
What is oxytocin
It is a peptide hormone secreted from the hypothalamus and transported to the posterior
lobe of the pituitary where it is eventually released.它是一种从下丘脑分泌的肽激素，被输送
Actions of Oxytocin include:
到垂体后叶，最终在那里被释放。 A. Anti-diuretic activity.
What are the effects of oxytocin B. Production of transient
It has two major actions in human: -它对人类有两大作用:- hypotension.
1. Firstly, it stimulates smooth muscle contraction in uterus (oxytocic) C. Increase in uterine muscle
a. It is essential for the initiation and progression of labour contractility.
b. It binds to oxytocin receptors of myometrial cells and activate the contractile protein D. Activation of myoepithelial cells
c. The number of oxytocin receptors increases gradually as pregnancy go on, and of the breast.
exponentially before onset of labour. The production of receptors is stimulated by
prostaglandins催产素有什么作用
E. All of the above
1. 首先，它刺激子宫平滑肌收缩(催产素)
它对劳动的开始和发展是必不可少的 催产素的作用包括:
b.与肌层细胞的催产素受体结合，激活收缩蛋白 A.抗利尿作用。
c.催产素受体的数量在怀孕期间逐渐增加，在分娩前呈指数增长。前列腺素刺激受体的产生 B瞬态低血压的产生。。
d. A positive feedback loop acts on the pituitary secretion of oxytocin. More oxytocin is C增加子宫肌肉收缩力。
secreted as uterine contractions are stimulated and continued正反馈回路作用于垂体催产素 D.乳腺肌上皮细胞的活化。
的分泌。当子宫收缩受到刺激并持续时，会分泌更多的催产素
E.以上所有
2. Secondly, it stimulates contractions of myoepithelial cells of mammary glands. It
facilitates lactation
3. Besides, as its biochemical structure is similar to that of vasopressin (antidiuretic
hormone also secreted from the posterior pituitary gland),其次，刺激乳腺肌上皮细胞的收缩。
它促进泌乳
3.此外，由于其生化结构与垂体后叶加压素(抗利尿激素也由垂体后叶分泌)相似，
 Clinical use of syntocinon催产素 He knows how to
contract so we use him
How is oxytocin metabolised
The peptide is rapidly broken down into amnio acid by oxytocinase in blood. The half-life of
What is the 1/2 life of
oxytocin is therefore 3-4 minutes.催产素是如何代谢的——肽在血液中被氧化酶迅速分解成 Oxytocin:
羊膜酸。因此催产素的半衰期为3-4分钟。 A.< 1 min.
1. Intrapartum use: - B. 3 min.
a. For induction of labour and augmentation of labour. Syntocinon is given as C. 10 - 15 min.
intravenous infusion. The rate of infusion is titrated against the frequency of D.20 - 30 min.
uterine contractions. The optimal frequency is 3 to 4 contractions in 10 minutes.
Care must be taken to avoid uterine hyperstimulation.(一)引产、引产。催产素是 3. Other uses: -
a. As an adjuvant agent for evacuation
静脉注射的。输注速度与子宫收缩的频率成正比。最佳频率是10分钟内收缩3到4
of uterus in treatment of abortions在流产
次。必须小心避免子宫过度刺激。 治疗中作为子宫排出的辅助剂
b. To overcome uterine inertia in the second stage delivery of twin pregnancy. b. As an oxytocic in a stress test: -
Uterine contractions may diminish after the first twin is delivered, and the second Syntocinon was used to stimulate
twin may not descend. Augmentation is required to hasten the delivery of the uterine contractions in a stress test for
second twin克服双胎妊娠第二产程子宫惯性。在第一个双胞胎出生后，子宫收缩 foetal wellbeing. This test is rarely
可能会减弱，第二个双胞胎可能不会下降。为了加快第二个双胞胎的分娩，需要增 required nowadays as less invasive
2. Postpartum use: - tests for foetal well-being are now
a. As an alternative of routine syntometrine（ 5 mg of syntocinon clonic contraction and 0.5mg of available.在压力测试中催产素是一种催
ergometrine sustained tonic contraction） in the third stage of labour against uterine atony. It is given as 产素:-催产素被用于刺激子宫收缩，在压
a bolus injection作为替代常规syntometrine(5毫克的syntocinon阵挛的收缩和0.5毫克的麦角新碱持续紧张 力测试中用于胎儿健康。现在很少需要这
性收缩)在第三阶段的劳动对子宫弛缓。这是作为一剂注射。 b. As a prevention or maintenance 种测试，因为现在已经有了对胎儿健康的
treatment against uterine atony in high risk cases such as placenta praevia, abruptio placentae, twin
pregnancy. It is given by continuous infusion作为预防或维持治疗子宫弛缓症的高危病例，如前置胎盘，
低侵入性测试。
胎盘早剥，双胎妊娠。它是通过持续的注射而产生的
 Contraindication禁忌症
Most important contraindication to the use of Oxytocin for stimulating labor at term is:
A. Dead fetus.
使用催产素刺激产程最重要的禁忌是:
B. Hypertonic uterine dysfunction.
A:胎儿死亡。
C. Hypotonic uterine dysfunction.
B. 高渗性子宫功能障碍。
D. Twin gestation.
C.低渗性子宫功能障碍。
E. Prior history of LSCS下段剖宫产术.
D .的双胞胎妊娠。
Contraindication:
Hypertonic uterine patterns-The major risk is uterine hyperstimulation, which would result in foetal distress and
uterine rupture.高张力子宫模式-主要风险是子宫过度刺激，这将导致胎儿窘迫和子宫破裂。
Hypersensitivity to drug-
In cases where vaginal delivery is contraindicated禁止阴道分娩的病例-contracted pelvis, obstructed labour,
malpresentation, history of Classical CS,对药物感染的骨盆过敏，难产，畸形，经典CS病史，In cases of fetal
distress在胎儿窘迫的情况下
Oxytocin should not be used in cases of hypovolemic states and cardiac disease.催产素不应用于低血容量状态和
心脏病.
Indication of CS,-Fetal distress when delivery is not imminent,Substantial cephalopelvic disproportion头盆不称
Risks of syntocinon
The other risks are less common and mild, and include hypotension (related to direct peripheral vasodilatation),
water intoxication (related to anti-diuretic effect).
其他风险较不常见且较轻，包括低血压(与直接外周血管舒张有关)、水中毒(与抗利尿作用有关)。
 Insight
Risks and complications of induction of labor include all the following, EXCEPT :
A. Failed induction.
B. Syndrome of Inappropriate Antidiuretic Hormone
C. Uterine hyperstimulation leading to fetal hypoxia.
D. Prostaglandin may cause hypothermia due to its direct effect on thermo regularity centers in the brain.
E. Ruptured uterus in grand multipara of patients with previous C-section.

引产的风险和并发症包括以下所有情况，但不包
括:
A:失败的感应。
B.抗利尿激素分泌异常综合征
C.子宫过度刺激导致胎儿缺氧。
D前列腺素可能会导致体温过低，因为它直接影
响大脑的热规律性中心。
E.既往剖宫产患者大腹段子宫破裂。

Uterine hyperstimulation can occur when using prostaglandin or oxytocin for induction of labour. It can lead to
significant fetal distress as there is inadequate time to allow adequate blood flow to the fetus between
contractions. Oxytocin should be stopped and tocolytics can be used if needed.
当使用前列腺素或催产素诱导分娩时，可能会发生子宫过度刺激。它可以导致严重的胎儿窘迫，因为没有足够的
时间让足够的血液流动到胎儿之间的收缩。催产素应该停止，如果需要可以使用解宫缩药。
 Induction of Labour(Local Protocol)
Unfavourable cervix (Bishop’s score <6)
a. Rule out any contraindications of prostaglandins, like asthma, allergy, cardiac disease and raised intraocular
pressure.排除前列腺素的任何禁忌症，如哮喘、过敏、心脏病和眼压升高。
b. Perform 20-minute CTG. If reactive, insert one 3 mg prostaglandin E2 (PGE2) pessary into the posterior fornix.
执行CTG 20分钟。如果反应性，将一个3mg前列腺素E2 (PGE2)子宫托插入后穹窿。
c. Repeat another 20-minute CTG 1 hour after insertion or when uterine
contractions occur.
d. Reassess 4 to 6 hours later, and give second PGE2 pessary if Bishop
Score still < 6.
2. Favourable cervix (Bishop’s score ≥6 )

a. Transfer patient to labour ward.把病人转到产房。

b. Cross -match and insert IV line.交叉匹配并插入IV线。
c. Perform artificial rupture of the membranes (ARM).人工破膜
d. Start syntocinon infusion and titrate the infusion rate until regular uterine
contractions of 1 in 3-4 minutes is achieved开始后叶催产素输注，滴定输
注速度，直到3-4分钟内达到正常子宫收缩1次
e. Avoid uterine hyperstimulation避免子宫过度刺激
Uterin子宫过度刺激 You loaded with
me too many oxy
Uterine hyperstimulationIt is an iatrogenic
complication due to the excessive use of oxytocics,
resulting in too frequent or too strong uterine
contractions. The uteroplacental blood flow is
jeopardised, resulting in foetal hypoxia and foetal
distress. The cardiotocogram typically shows frequent
uterine contractions (>4 in 10 minutes) and recurrent
foetal decelerations or bradycardia. The other risk is
uterine rupture. 这是一种医源性并发症，由于过度
使用催产素，导致过于频繁或过于
强烈的子宫收缩。子宫胎盘血流受
到损害，导致胎儿缺氧和胎儿窘迫。
心脏心动图通常显示频繁的子宫收
缩(10分钟内> - 4)和反复发作的胎儿
减速或心动过缓。另一个风险是子
宫破裂。
Prevention- Titrate the rate of infusion of
syntocinon and avoid using
prostaglandins in multiparous women or
when women already in labour. 预防-滴
定催产素的输注率，避免在多胎妇女或已
经分娩的妇女中使用前列腺素
 Uterine Hyper stimulation
1. Definition – More than 4 painful uterine contractions in 10 minutes induced by prostaglandins or syntocinon
2. Inform Medical Officer.
3.子宫过度刺激，胎儿心率正常
3. Uterine hyperstimulation with normal foetal heart rate a. PGE2诱导的过度刺激
a. Hyperstimulation induced by PGE2 i.进一步放弃PGE2，清除阴道内任何残留的PGE2。
i. Abandon further PGE2 and remove any residual PGE2 from vagina. ii。NPO，血型匹配。
ii. Nil per oral, Cross-match. iii。分娩病房连续监测胎儿心脏。
iii. To labour ward for continuous foetal heart monitoring. iv 、过度刺激消退后联合诱导。
iv. For combined induction after hyperstimulation subsides. b.催产素引起的过度刺激-滴定催产素，使收缩在10分钟内少于4次。
b. Hyperstimulation induced by syntocinon – Titrate oxytocin to keep contractions less than 4 in 10 minutes.
4. Uterine hyperstimulation with abnormal foetal heart rate 4. 子宫过度刺激，胎儿心率异常
a. Hyperstimulation induced by PGE2
a. PGE2诱导的过度刺激
i. NPO, Cross-match.
ii. Immediate delivery.
i.禁食,Cross-match。
b. Hyperstmulation induced by syntocinon ii。立即胎儿分娩。
i. Stop syntocinon. b.b.催产素引起的过度兴奋
ii. Immediate delivery if no improvement in foetal heart rate. i.停止syntocinon。
5. Tocolytic treatment for hyperstimulation ii.如果胎儿心率没有改善，立即分娩。
a. Not recommended unless there is persistent bradycardia when arranging emergency Caesarean section.
b. Beware of hypotension particularly if epidural anaesthesia, and beware of uterine atony after delivery.
c. Hexoprenaline is the only choice. Give IV bolus 5 mg. Can only repeat once if no improvement after 2 mins除非a.在安排紧急剖
腹产时出现持续性心动过缓，否则不建议使用。
b.注意低血压，特别是硬膜外麻醉，分娩后注意子宫弛缓。
c丙六肾上腺素是唯一的选择。静脉注射5毫克。如果2分钟后没有改善，只能重复一次.
 Insight
Regarding induction of labour: Which on of the following is FALSE
A. Uterine hyperstimulation secondary to prostaglandin administration is best treated with tocolysis.
B. Prolonged rupture of membrane is second most common indication of induction of labour.
C. Uterine rupture occurs more frequently among women undergoing a trial of vaginal delivery following caesarean
section in their previous pregnancy than among those undergoing elective repeat caesarean delivery.
D. The ideal contaction rate of uterus is 8 contraction 10 mins.
E. Women who do not labour after an induction should be offered caesarean section.
关于引产:下列哪一项是错误的
A前列腺素引起的子宫过度刺激最好通过解宫来治疗。
B长时间的膜破裂是引产的第二个最常见的迹象。
C.子宫破裂在前一妊娠期剖宫产后进行阴道分娩试验的妇女中发生的频率比选择性重复剖宫产的妇女高。
D理想的子宫接触率为8次宫缩10分钟。
E引产后不分娩的妇女应进行剖腹产。
Hyperstimulation with prostaglandin used for induction of labour is not uncommon. Strategies involve washing out or removing the
prostaglandin, use of tocolysis and urgent delivery. Tocolysis is often effective. Intravenous or subcutaneous routes are best. Inhaled
dministration is ineffective. The rates of uterine rupture are approximately doubled when women undergo induction of labour with a single
prior caesarean section scar, compared to women delivered by elective caesarean section. A small increase in the rate of neonatal jaundice
has been reported in women who receive Syntocinon in labour. This is not the case for prostaglandin administration. The management of
failed induction of labour must be individualized. Caesarean section must be considered as an option and discussed with women.
Contraction should not exceed more then 4 per 10 mins. 前列腺素过度刺激用于引产并不罕见。策略包括冲洗或移除前列腺素，使用解酵解
和紧急分娩。解酵解通常是有效的。静脉或皮下途径是最好的。吸入式管理无效。与择期剖宫产的妇女相比，子宫破裂的发生率大约是前者
的两倍。据报道，在分娩时服用合成cinon的妇女中，新生儿黄疸的发生率略有增加。这不是前列腺素管理的情况。引产失败的管理必须因材
施教。必须考虑剖宫产作为一种选择，并与妇女讨论。收缩不应超过每10分钟4。
 Amniotic fluid-羊膜水 It mee peeing

Definition-Also called 'liquor', is the fluid normally inside the amniotic cavity. It is foetal urine.也叫“酒”，通常是羊膜
腔内的液体。这是胎儿的尿液
Abnormality related to amniotic fluid
Volume体积
1. Oligohydramnios and anhydramnios
- Normal range depends on gestation, with the peak at 34 to 36 week
2. Polyhydramnios
-正常范围视妊娠情况而定，高峰期为34至36周
3. Meconium stained liquor
Composition 4. Amniotic fluid embolism
1. Electrolytes-电解质 5. Blood stained liquor: -may be a result of
2. pH: -slightly alkaline, changes amniostrix from abruptio placentae
orange to blue, a test for rupture of membranes轻度 6. Leaking of amniotic fluid because of rupture
碱性，使羊膜由橙色变为蓝色，用于检测羊膜破裂 of membranes
3. Foetal cells: -amniocytes can be collected with
amniocentesis and cultured for foetal karyotyping羊
膜穿刺术可以收集羊膜细胞，培养胎儿核型

与羊水有关的异常
1. 羊水过少和无羊水
2. 羊水过多
3.胎粪染色液
4. 羊水栓塞
5. 血染液:-可能是胎盘破裂的结果
6. 羊水由于羊膜破裂而漏出
 Amnioinfusion
What is amnioinfusion?
Amnioinfusion is a procedure by which normal saline is
infused into the amniotic cavity. It can be done
transcervically using an intrauterine catheter during
intrapartum period, or abdominally during antepartum
period.羊膜腔关注是什么?
羊水灌注是将生理盐水注入羊膜腔的过程。可以在分娩期
间使用宫内导管进行经腹穿刺，也可以在产前进行。
1. Intrapartum:
a. Meconium stained liquor (MSL)
Heavily meconium stained liquor increases the risk of meconium
aspiration syndrome. The aim of amnioinfusion is to dilute the MSL
and hence reduce the risk.甲胎粪染色液(MSL)
重度胎粪污染液增加胎粪吸入综合征的风险。羊水注射的目的是稀释 2. Antepartum - Severe oligohydramnios
MSL，从而降低风险。 a. For diagnostic purpose, Ultrasound images are suboptimal as transmission of
b. Umbilical cord compression ultrasound wave is poor in case of oligohydramnios. Replenishment of liquor helps to
Cord compression may occur during labour. It may result in variable improve ultrasound imaging and allow better assessment of foetal morphology that may
be abnormal in case of severe oligohydramnios.
decelerations of foetal heart rate, particularly when the liquor volume
b. For therapeutic purpose, Replenishment of liquor may help to reduce the complications
is reduced. It has been suggested that amnioinfusion may help to of oligohydramnios such as postural deformities or pulmonary hypoplasia. In order to
prevent the event. However, no control trials have yet proven its role prevent pulmonary hypoplasia, the procedure must be performed before mid-gestation
in preventing intrapartum foetal distress.b.脐带压缩 because it is the critical period of bronchial and alveolar differentiation.2. 严重羊水过少
脐带受压可能发生在分娩过程中。它可能导致胎儿心率的可变减速， a.诊断上，羊水过少时超声图像的透射率较低，超声图像的透射率较低。补充液体有助于改
特别是当酒量减少时。有人认为羊水注射可能有助于预防这一事件。 善超声成像，并允许更好地评估胎儿形态，可能是异常的情况下严重羊水过少
b.为了治疗目的，补充液体可能有助于减少羊水过少的并发症，如体位畸形或肺发育不良。
然而，还没有对照试验证明它在预防分娩时胎儿窘迫方面的作用。
为了防止肺发育不良，必须在妊娠中期之前进行，因为这是支气管和肺泡分化的关键时期。
 Amnioreduction羊水减量
What is amnioreduction?
It is a procedure by which excessive amniotic fluid is drained, usually via a needle inserted abdominally.
这是一种排出过多羊水的过程，通常通过一根针插入腹部。
有什么迹象?
What are the indications?
1. Severe polyhydramnios1. 严重的羊水过多
When the uterus is over distended, there may be maternal discomfort and an increased risk of preterm labour and
cord prolapse. Amnioreduction would be required to relieve pressure symptoms. To avoid cord prolapsed during
rupture of membranes in a case with severe polyhydramnios going into labour; reduction of the liquor volume
abdominally beforehand is also suggested. The role of amnioreduction in prevention of preterm labour is not well-
defined. 当子宫过度膨胀时，母体可能会感到不适，早产和脐带脱垂的风险也会增加。为了缓解压力症状，需要进
行羊水回吸。避免严重羊水过多分娩时胎膜破裂导致脐带脱垂;此外，还建议在此之前先降低酒的体积。羊水回吸在
预防早产方面的作用尚未明确界定。
2. Twin-twin transfusion syndrome双胞胎输血综合征
As the recipient twin is polyhydramnic, repeated amnioreduction on the recipient may help to improve the
prognosis of the disease and prolong the pregnancy.
为注入- 1。无菌技术下插入宫内导管。
由于受者双胎羊水过多，重复羊水回吸有助于改善预后，延长妊娠期。
2. 室温下注入1L生理盐水(每分钟-10-
For Infusion-1. Insert intrauterine catheter under aseptic technique. 15毫升)。
2. Infuse 1L of normal saline at room temperature (rate: -10-15 ml per minute). 3.每4小时重复一次，直到分娩的第二
3. Repeat every 4 hours until the second stage of labour. 阶段。
 Production and removal
1. Production1. 生产
a. Foetal urine胎儿的尿液。
i The major source of liquor主要来源是羊水
ii Urine production starts from 12 week尿量从12周开始
iii Anhydramnios无羊水 in case of absent foetal kidneys
or infantile type of polycystic kidneys缺胎肾或婴儿型多囊
肾
b. Foetal lung fluid – Constitutes small portion of liquor
production as most of the fluid is swallowed by the foetus
胎儿肺液-占羊水生产的一小部分，因为大部分羊水被胎
儿吞食
2. Removal What all day around i was just drinking me own pee.
a. Foetal swallowing and absorption via GI tract Awwwwwww.
Which one the following is incorrect？Choose 2
Polyhydramnios when there is pathology affecting the
A. Total absence Fetal kidney can lead to anhydraaminos.
mechanism such as anencephaly, esophageal atresia B. Amnioreduction is used for Meconium aspiration is syndrome
and duodenal atresia.羊水过多时，有病理影响的机制如 C. Amnioinfusion can be used in umbilical cord compression.
无脑儿、食管闭锁和十二指肠闭锁。 D. For twin to twin transfusion amnioreduction is given to the donor twins.
E. Esophageal atresia can lead to more high amniotic fluid index. 下列哪一个是
b. Transmembranous and intramembranous: -account 不正确的?选择2呢
for small percentage of amniotic fluid circulation.跨膜和 A. 胎儿肾脏完全缺失可导致氨酰亚胺。
膜内的:-占羊水循环的一小部分。 B. 羊水回吸法用于胎粪吸入综合征
C. 羊水输注可用于脐带压缩。
D. 对于双胞胎之间的输血，羊膜导入术是给供体双胞胎。
E. 食管闭锁可导致羊水指数升高。
 Amniotic fluid index羊水指数 (AFI)
What is amniotic fluid index (AFI)?
It is a semi-quantitative way in assessing liquor volume. The value
of AFI is the summation of the vertical depths of the largest pocket
in each of four equal uterine quadrants. It is said to be more
accurate than using just a single pocket.
The normal range varies according to the gestational age: -In
general, it is polyhydramnios when AFI is greater than 24cm, and
oligohydramnios when it is less than 8cm. AFI is not applicable to
assess the amniotic fluid volume in multiple pregnancy. 什么是羊
水指数?
这是一种半定量的方法来评估酒的体积。AFI的值是四个相等的子宫
象限中，每个象限中最大口袋的垂直深度之和。据说它比只用一个
口袋更精确。正常范围因胎龄而异:AFI大于24cm为羊水过多，小于
8cm为羊水过少。AFI不适用于多胎妊娠羊水体积的评估。

How to measure amniotic fluid index

1. Divide the uterine surface into 4 equal quadrants. 如何测量羊水指数
2. Set transducer parallel to maternal sagittal plane and 1. 将子宫表面分成四个相等的象限。
perpendicular to maternal coronal plane. 2. 平行于母体矢状面垂直于母体冠状面设置换
3. Apply constant gentle pressure during measurement. 能器。
4. Measure the depth of liquor at the deepest 3.测量时施加恒定的压力。
unobstructed, clear pocket of each quadrant. 4. 测量酒的深度在最深处，畅通无阻，每个象
5. AFI = sum of the depths of the 4 pockets 限的明确口袋。
5. AFI = 4个口袋的深度之和
 Oligohydramnios
Oligohydramnios is associated with:
a) Gestational diabetes
b) Tracheo-oesophageal fistula
Definition c) Intrauterine growth restriction
- Oligohydramnios is an inadequate volume of amniotic fluid d) Anencephaly
- Anhydramnios无羊水 is the complete absence of amniotic fluid. e) Myotonic dystrophy羊水过少与:
Causes a)妊娠期糖尿病
1. Leaking of amniotic fluid after rupture of membranes b)气管食管瘘
a. The most common cause of oligohydramnios c)宫内生长受限
1. 羊水膜破裂后羊水漏出 d)无脑畸形
羊水过少最常见的原因 e)肌强直性营养不良
b. however, the amniotic fluid volume may still appear normal after
rupture of membranes if the leaked volume is not much但是，如果漏出 2. Foetal malformations resulting in decreased
的羊水量不大，破膜后羊水量仍可能正常 production of urine:
3. Foetal compromise resulting in decrease production: a. Bilateral renal agenesis (Potter's syndrome) – no
functional foetal kidneys and therefore completely no
Intrauterine hypoxia or growth retardation (IUGR) – Renal blood flow foetal urine production and anhydramnios
decreases and hence the urine production b. Infantile type of polycystic kidneys
2. 胎儿畸形导致尿量减少: i. Dysgenesis of kidneys which become non-functional
a.双侧肾脏发育不全(波特氏综合征)-胎儿肾脏没有功能，因此完全没有胎 ii. Autosomal recessive inheritance
c. Posterior urethral valve
儿尿的产生和羊水过多
i. Urine production is present but excretion is impaired
b.婴儿型多囊肾
because of urethral obstruction
i.肾脏发育异常，变得无功能 ii. Bladder is therefore distended and there is
ii.常染色体隐性遗传 secondary dilated renal pelvis. Renal function may be
c.后尿道瓣膜- i.有尿生成，但因尿道阻塞而排泄受损 eventually impaired
ii.因此膀胱扩张，继发性肾盂扩张。肾功能最终可能受损
 Causes(Insight)
A woman who is 34 weeks
pregnant is found to have an
amniotic fluid volume of 440 ml. 肾不发生
Which one of the following
conditions is not part of the
differential diagnosis?
A. Premature rupture of
membranes
B. Pre-eclampsia
C. Tracheo-oesophageal fistula 胎盘功能不全
D. NSAIDs
E. Intrauterine growth restriction
Note it work againts prostaglandin
怀孕34周的妇女的羊水量为440毫升。
下列哪一种情况不属于鉴别诊断?
A. 膜早破
早期破水
B. 子痫前症
C. 气管食管瘘 Diagnosis
1. Clinically, the uterus small for date and foetal parts can be easily felt
D. 肾发育不全 临床上，子宫小的日期和胎儿部分可以很容易感觉到
E. 宫内生长受限 2. Ultrasonical: -Decreased amniotic fluid volume demonstrated e.g. by amniotic fluid index measurement羊水
体积减少，例如通过测量羊水指数
a AFI < 8cm or Greatest pocket <2cm pubic symphysis and uterine fundal height
b Anhydramnios if complete absence of liquor 耻骨联合与子宫底高度
 Fundal height
Full name is symphysial-fundal height. It is the distance between the top of the uterus and the upper border of the
pubic symphysis at the midline. It is an objective method of monitoring uterine size which in term reflects foetal
growth. The fundal height in centimetre is correlated with gestation age in week, starting from 20 week of maturity.
For example, at 30 week, the fundal height is around 30±2cm. After 37 week, the fundal height may decrease,
due to the engagement of the foetus, as well as the reduction of amniotic fluid.IUGR less then 4 cm then Gesation
age
全称为辛体-漏斗高度。它是子宫顶部和耻骨
联合上边界之间的距离。它是一种客观的监
测子宫大小的方法，在一定程度上反映胎儿
的生长。宫高以厘米为单位与孕周年龄相关，
从成熟20周开始。例如，在30周时，眼底高
度约为30±2cm。37周后，由于胎儿的参与
以及羊水的减少，子宫底高度可能会下降。
 Complications How can i sleep in such a small
space, i cannot even stretch my feet.

Foetal Risks
Depends on underlying causes and time of occurrence:
1. Rupture of membranes: -intrauterine infection, preterm labour,
cord prolapse
2. Foetal malformations: -may not be viable such as Potter's
syndrome and infantile type of polycystic kidneys
3. Foetal compromise: -intrauterine death
4. Pulmonary hypoplasia, when severe oligohydramnios occurs
before 20 weeks of gestation during when development of lung is
critical
5. Postural deformities: -various degree of limbs and facial
deformities
胎儿的风险
视乎潜在原因及发生时间而定:
1. 胎膜破裂:宫内感染、早产、脐带脱垂
2. 胎儿畸形:-可能不可行，如波特综合征和婴儿型多囊肾
3.胎儿妥协:-宫内死亡
4. 肺发育不良，当严重羊水过少发生在妊娠20周之前，此时肺的发
育是至关重要的
5. 体位畸形:-不同程度的肢体和面部畸形
 Insight
Oligohydramnios: Choose one false option. All of the following causes
A. Is commonly associated with amniorrhexis. oligohydrominas except:
B. Is associated at 16 weeks with a >90 per cent risk of pulmonary hypoplasia. A. Renal agenesis
C. May cause postural anomalies in the fetus. B. Poor placental perfusion
D. Is commonly found in diabetic pregnancies. C. Post term pregnancy
E. Fundal height is less then the gestational Age. D. Anencephaly
羊水过少:选择一个错误的选项。 E. Urinary obstruction
A. 通常与羊膜破裂有关。 除:
B. 在16周时，有90%的肺发育不良的风险。 A:肾发育不全
C. 可能导致胎儿姿势异常。 B胎盘灌注不良
D. 常见于糖尿病孕妇。 C.足月后妊娠
E. 宫高小于胎龄。 D .无脑畸形
E.尿道梗阻
Pre-labour, ruptured membranes or amniorrhexis are a common cause of oligohydramnios. The association with
pulmonary hypoplasia is stronger the earlier it is noted in gestation. Between 16 and 20 weeks, there is at least a
90 per cent association with pulmonary hypoplasia. However, ultrasound is unable to predict which cases will be
affected. Prolonged oligohydramnios will lead to postural anomalies (i.e. talipes). Diabetic pregnancies are often
associated with polyhydramnios.临产前，羊膜破裂或羊膜破裂是羊水过少的常见原因。妊娠早期发现肺发育不良与
肺发育不良的关系越密切。在16到20周之间，至少有90%与肺发育不良有关。然而，超声波无法预测哪些病例会受
到影响。羊水过少时间过长会导致体位异常(如足内翻)。糖尿病孕妇通常与羊水过多有关。
 Local guideline(Oligohydraminos)
1. Antenatal Management
a. Investigate for the underlying cause: 1. 产前管理
i. Rule out rupture of membranes a.调查潜在原因:
ii. Rule out foetal growth restriction i.排除膜破裂的可能性
iii. Check for abnormalities of fetal kidneys and bladder in case of ii.排除胎儿生长受限
anhydramnios iii.检查胎儿肾脏和膀胱有无异常，以防羊水过多
b. Refer to the corresponding protocol when any of the above b.以上诊断均参照相应的诊断方案
diagnoses is made c.隔离原发性低羊水症:-每两周监测胎儿生长、液
c. For isolated primary oligohyramnios: -Monitor foetal growth, 量和脐动脉血流
liquor volume and umbilical arterial flow bi-weekly 2. 分离羊水过少的产时管理
2. Intrapartum Management of isolated oligohydramnios 目标是在38周内分娩
a. Aim at delivery at 38 weeks 如无其他禁忌证，以阴道分娩为目的
b. Aim at vaginal delivery if there is no other contra-indications c.如果没有其他胎儿损害的迹象，可以考虑在产
c. Induction of labour with PGE2 can be considered in antenatal 前病房用PGE2引产
ward if there is no other signs of foetal compromise 如果胎儿发育不良，考虑提前分娩
d. Consider early delivery if case of foetal compromise 3.治疗取决于潜在的原因:
3. Treatment depends on the underlying causes: a.致命畸形的终止妊娠
a. Termination of pregnancy for lethal malformations b.羊水灌注补充羊水，避免肺发育不良和体位畸
b. Amnioinfusion to replenish amniotic fluid to avoid pulmonary 形
hypoplasia and postural deformities
 Renal agenesis No bud for so no kidney part
then how can i have urine
Etiology
Usually sporadic occurrence but 20-36% of bilateral renal agenesis
(BRA) present a familial recurrence (possibly autosomal dominant with
incomplete penetrance and variable expression).双侧肾发育不全(BRA)
常为零星发生，但有20-36%为家族性复发(可能为常染色体显性遗传，
外显不完全，表达多样)。

Diagnosis
The absence of kidney results in the absence of amniotic fluid after 12-
13 weeks (before fluid is an exudate or an extension of the intercellular
fluid of the foetus). The diagnosis is first suggested by the absence of
amniotic fluid then by the absence of the bladder and the lack of
kidneys. Colour Doppler has been found useful in those difficult exams
to identify the lack of renal arteries. Before a final diagnosis is made
one should think and if possible exclude the possibility of pelvic or
ectopic kidneys that could compress the bladder and exclude the Definition-Bilateral absence of the kidneys,
possibility of ectopic ureter that could explain the absence of bladder. usually associated with the oligohydramnios
诊断首先是由于没有羊水，然后是由于没有膀胱和肾脏。彩色多普勒已 sequence.双侧肾的缺失，通常与羊水过少有关。
被发现有用的那些困难的检查，以确定缺乏肾动脉。在做出最终诊断之 Synonyms-Potter syndrome (no longer used).
前，人们应该考虑，如果可能的话，排除盆腔或异位肾压迫膀胱的可能 Incidence
性，排除异位输尿管解释膀胱缺失的可能性。 1-2:10,000 Genetic anomalies
Unknown.遗传异常
未知的。
 Pathogenesis(Oligohydraminos Sequence)
The presentation described here is consistent with Potter's syndrome,
one cause of which is bilateral renal agenesis肾缺如. The renal
parenchyma (except for the nephrons) is derived from the ureteric bud
输尿管芽(recall that the nephrons arise from mesoderm surrounding
the ureteric bud). A failure of ureteric bud maturation would result in a
fetus without kidneys.输尿管芽成熟失败会导致胎儿没有肾脏. An
absence of kidneys would lead to oligohydramnios羊水过少, as the
fetus would be unable to excrete urine into the amniotic sac羊膜囊.
This, in turn, would lead to compression of the fetus by the uterine
wall, causing limb deformities肢体畸形, abnormal facies不正常的脸,
and wrinkly skin. Death would occur shortly after birth unless an
appropriate kidney donor could be found.

Potter syndrome
Several entities use the eponym Potter:
1. Potter syndrome, now renamed either oligohydramnios sequence or bilateral renal agenesis (BRA) depending on whether the
cause of the syndrome (BRA) or the mechanism is referred to.
2. Potter syndrome Type I is now referred to as Autosomal recessive polycystic kidney disease
I need some more
3. Potter syndrome Type II is now referred to as Renal dysplasia
4. Potter syndrome Type III is now referred to as Autosomal dominant polycystic kidney disease space alright?
 Insight
A baby boy dies several hours after his birth despite several
attempts to save his life. He was born with wrinkled skin衰老性皮
肤, deformed limbs肢体畸形, and abnormal facies不正常的脸.
Prenatal ultrasonography at 15 weeks indicated that the mother's
pregnancy was complicated by oligohydramnios羊水过少. Which
of the following embryologic processes most likely failed in this
child?

A. Closure of the rostral neural tube喙的神经管

B. Development of the ureteric buds输尿管芽

C. Formation of the tracheoesophageal septum气管食管隔

D. Migration of neural crest cells 神经嵴细胞to t he distal colon

E. Recanalization重通 of the duodenum

Ureteric bud输尿管芽—derived from caudal end of mesonephric
duct中肾管; gives rise to ureter, pelvises, calyces, collecting ducts收
集导管; fully canalized by 10th week.
 Differential diagnosis鉴别诊断
Differential diagnosis-Bilateral renal medullary cystic dysplasia and bilateral renal hypoplasia may appear as BRA.
Further normal but non-functioning kidneys abnormal placental implantation (on a uterine septum for instance) can
lead to the same presentation of severe oligohydramnios. This information is important to convey during patient's
counseling: -The concern is not only the renal agenesis (which may be absent) but the oligohydramnios that will
lead to pulmonary hypoplasia. 鉴别诊断-双侧肾髓质囊性发育不良和双侧肾发育不良可作为乳罩出现。进一步正常
但无功能的肾脏异常胎盘植入(例如在子宫间隔)可导致严重羊水过少。这一信息在患者咨询过程中很重要:-关注的不
仅是肾脏发育不全(可能不存在)，还包括羊水过少，这会导致肺发育不良。
Associated anomalies-Since this is a common anomaly, many different associations have been described (Vacterl,
Meckel, chromosome 22 malformations#). In practice most of these are difficult to identify by ultrasound because
of the oligohydramnios.相关异常——由于这是一种常见的异常，已经描述了许多不同的关联(Vacterl, Meckel, 22号
染色体畸形#)。在实际操作中，由于羊水过少，超声很难鉴别。
Prognosis-Lethal.
Management-Many authors have suggested the use of amnioinfusion or even intraabdominal infusion of saline in
order to better visualize the anatomy. Although there might be indications for such aggressive approach in a non-
viable foetuses, these are quite uncommon, and not justified in the majority of cases. Termination of pregnancy can
be offered before viability. Standard prenatal care is not altered when continuation the pregnancy is opted for.
Confirmation of diagnosis after birth is important for genetic counseling.管理-许多作者建议使用羊水注射，甚至腹
腔内注射盐水，以便更好地可视化解剖。虽然在不能存活的胎儿中可能有这种激进做法的迹象，但这种情况相当少
见，在大多数情况下并不合理。可以在存活之前终止妊娠。如果选择继续妊娠，则不改变标准产前护理。出生后确
诊是遗传咨询的重要内容。
 Insight

C缺损
H先天性心脏病
A闭锁
R精神发育迟滞
G .泌尿系统异常
E 耳朵异常

Regarding congenital anal atresia, which of the

following is NOT an associated anomaly?关于先
天性肛门闭锁，以下哪一项与之无关
异常
A. esophageal atresia A:食管闭锁
B. renal agenesis b .肾发育不全
C. malrotation c .旋转不良
D. hemi-vertebra d .半椎
 Case Study
A 40-year-old woman, gravida 5 para 0 aborta 4, at 35 weeks gestation comes to labor and delivery triage because
she has not felt her baby move for the past 24 hours. The patient has not eaten much all day and skipped dinner
due to nausea. She has a 25-pack-year history of cigarette use but has cut down on her smoking during her
pregnancy. Her last ultrasound at 32 weeks gestation showed a fetus in breech position measuring at the 15th
percentile and placenta previa. A nonstress test shows a baseline fetal heart rate in the 130s with moderate
variability and no decelerations. There are no accelerations after an hour of monitoring despite vibroacoustic
stimulation. Tocometry shows no contractions. 一位40岁的妇女，在怀孕35周的时候流产了，因为她已经24小时没
有感觉到婴儿的移动，所以要进行分娩和分诊。病人整天吃得不多，由于恶心而没吃晚饭。她有25包香烟的使用历
史，但她在怀孕期间减少了吸烟。她怀孕32周时的最后一次超声波检查显示，胎儿的臀位位于第15百分位和前置胎
盘。一项非压力测试显示，胎儿心率基线在130左右，具有中等变异性，没有减速。在一个小时的监测后没有加速度，
尽管振动声学刺激。张力测定法显示没有收缩。 Which of the following is the most appropriate next step in
management of this patient?
This patient presents with decreased fetal movement, a subjective and nonspecific symptom
A. Biophysical profile that may be benign (eg, normal fetal sleep cycle) or ominous (eg, central nervous system
B. Cesarean delivery hypoxia) .A nonstress test (NST) is performed to assess fetal status and identify fetuses at
C. Continuation of nonstress test risk of adverse outcomes. During an NST, the heart rate of a well-oxygenated fetus rises with
fetal movement (accelerations). A reactive NST (>/=2 accelerations) has a high negative
D. Contraction stress test predictive value to rule out fetal acidemia. A nonreactive NST has a high false-positive rate
E. Umbilical artery flow velocimetry and low positive predictive value and cannot rule in fetal acidemia本例胎儿运动减少，是一种
主观的、非特异性的症状，可能是良性的(如正常胎儿睡眠周期)，也可能是不祥的(如中枢神经
以下哪一项是治疗这个病人最合适的下一步?
系统缺氧)。在NST期间，氧合良好的胎儿心率随着胎儿运动(加速)而升高。反应性NST(>/=2加
A:生物物理配置文件
B.剖腹产 速)对排除胎儿酸血症具有很高的阴性预测值。非反应性NST具有较高的假阳性率和较低的阳性
C.非应力试验的延续 预测值，在胎儿酸血病中不具有决定性
D.收缩应力试验 Umbilical artery flow velocimetry is beneficial in monitoring growth-restricted fetuses (estimated fetal weight <1oth
E脐动脉血流测速仪 percentile) This fetus has normal growth
 Insight
Components of biophysical
profile include all of the 生物物理剖面的组成部分
following, EXCEPT: 包括以下所有部分，但不
A. Fetal movement 包括:
A:胎儿运动
B. Placental thickness
B .胎盘的厚度
C. Fetal tone C.胎儿的语气
D. Fetal breathing movement D.胎儿呼吸运动
E. Amniotic fluid volume E羊水体积评估
assessment
A nonreactive NST requires further evaluation with a biophysical profile
(BPP) or contraction stress test (CST). These tests are equivalent in
assessing fetal status and are selected based on available resources
and relevant contraindications. A BPP includes an NST plus an
ultrasound evaluation of the amniotic fluid index as well as fetal
movement, tone, and breathing. A CST {Choice D) is performed by
administering oxytocin or using nipple stimulation until 3 contractions
occur every 10 minutes. Contraindications to CST include
contraindications to labor (eg,placenta previa, prior myomectomy).
Therefore, a BPP is more appropriate for this patient非反应性NST需要
进一步的生物物理剖面(BPP)或收缩应力测试(CST)评估。这些测试在评
估胎儿状态时是等价的，并且是基于可用资源及有关禁忌症。BPP包括
NST和超声对羊水指数以及胎儿运动、音调和呼吸的评估。一个中科
{选择D)通过使用催产素或乳头刺激来完成，直到每10分钟发生3次宫缩。
CST的禁忌症包括分娩禁忌症(如前置胎盘、子宫肌瘤切除术前)。因此，
BPP更适合这个病人
 Case Continued
An ultrasound confirms an anterior placenta covering the cervical os and an amniotic fluid index of 1.5 with a single
fluid pocket measuring 1.5 x 1 cm. Over a period of 45 minutes, there are 4 episodes of fetal movement, 3
flexion/extension events(2+2), and no fetal breathing movements. The fetus is breech. Which of the following is the
most likely cause of the patient's biophysical ultrasound findings?
A Fetal malpresentation This patient has oligohydramnios (a single deepest pocket <2 em or an amniotic fluid index </=5)
B. Maternal hypoglycemia and an abnormal BPP score of 4/10. A score of 0/10 to 4/10 indicates fetal hypoxia due to
C . Placental dysfunction placental dysfunction (placental insufficiency). 该患者羊水过少(单袋最深<2 cm或羊水指数</=5)，
D. Placental location BPP评分异常4/10。0/10到4/10的评分表明胎盘功能不全(胎盘功能不全)导致胎儿缺氧。
E. Prematurity
超声证实前胎盘覆盖宫颈os，羊水指数为1.5，单个液袋大小为1.5 x 1 cm。在45分钟的时间里，有4次胎儿运动，3
次屈伸，没有胎儿呼吸运动。胎儿是臀位。下列哪一项是最有可能导致病人的生物物理超声发现的原因?
A胎儿先露异常
b 孕产妇低血糖
C胎盘功能障碍 Patients with an anterior placenta more frequently report a decrease in fetal movement
d 胎盘位置 as this placental position may make perception of movement more difficult. However,
e 早产 there is no association between placental location and an abnormal BPP.有前胎盘的病
人更常报告胎儿运动的减少，因为这个胎盘位置可能使运动的感觉更加困难。然而，胎盘
位置与异常的BPP之间没有关联。
 Insight
The biophysical profile (BPP) is performed to assess fetal
oxygenation through ultrasound observation and the nonstress
test .The components of the ultrasound assessment include
measurement of amniotic fluid volume and observation of fetal
tone, breathing movement, and gross body movement.生物物理
剖面图(BPP)是通过超声观察来评估胎儿氧合的，非应激试验超声
评估的组成部分包括测量羊水体积和观察胎儿的音调、呼吸运动
和全身运动 .Each component of the BPP is scored 0 or 2 and
summed to give a score of 0 to 10. A normal BPP (8/10 or 10/10)
suggests that the fetus is well-oxygenated. This patient has
oligohydramnios (a single deepest pocket <2 em or an amniotic
fluid index </=5) and an abnormal BPP score of 4/10. A score of
0/10 to 4/10 indicates fetal hypoxia due to placental dysfunction
(placental insufficiency). Risk factors for placental insufficiency
include advanced maternal age, tobacco use, hypertension, and
diabetes. The patient requires prompt delivery due to the high
likelihood of fetal demise. BPP的每个组件的得分都是0或2，并求
和得到0到10的分数。正常的BPP(8/10或10/10)表明胎儿氧合良好。 Abnormal biophysical profile score (eg, 4/10) is
该患者羊水过少(单个深袋<2 em或羊水指数</=5)，BPP评分异常 consistent with fetal hypoxia. Prompt delivery
4/10。0/10到4/10的评分表明胎盘功能不全(胎盘功能不全)导致胎 is indicated due to the high probability of fetal demise
儿缺氧。胎盘功能不全的危险因素包括高龄产妇、吸烟、高血压 异常的生物物理特征评分(如，4/10)与胎儿缺氧一致。
由于胎儿死亡的可能性很高，因此应立即分娩
和糖尿病。由于胎儿死亡的可能性很高，病人需要立即分娩。
 Polyhydramnios羊水过多
Definition-It is an excess of amniotic fluid, in contrast to oligohydramnios where there
is a decrease in amniotic fluid (Norm: 500-1500 ml). Ultrasound would reveal a
Single pocket > 8cm or AFI >95th centile for gestation on ultrasound estimation.定义-
羊水过多，羊水过少(正常:500-1500毫升)。超声估计妊娠时可显示单袋> 8cm或AFI
>95公分 诊断-1. 临床
Diagnosis a.子宫大，适合约会
1. Clinical b.胎儿部位很难摸到
c.不稳定的谎言或不良表现
a. Uterus large for date d.液体刺激可能被证明
b. Foetal parts are difficult to feel 2. 超声-单袋> 8cm或AFI表上的AFI> 2SD
c. Unstable lie or malpresentation
d. Fluid thrill may be demonstrated
2. Ultrasonical – Single pocket of liquor > 8cm or AFI> 2SD on AFI chart

Which amniotic fluid index would indicate

polyhydramnios?
A ≥5 cm
B ≥10 cm
C ≥15 cm
D ≥18 cm
E ≥22 cm
 羊水过多
All the following conditions result in
A patient presents for her routine prenatal visit at 32 weeks’ EGA.
polyhydroamnios EXCEPT :
Her pregnancy up to now has been uncomplicated. Her BMI is 25.
A. Renal agenesis.
Her laboratory testing is normal including a 1-hour glucose
B. duodenal atresia.
screen. Ananatomic ultrasound done at 22 weeks was normal
C. Spina bifida.
and confirmed her dating. Her fundal height is 37 cm today. A
D. Anencephaly.
brief bedside ultrasound reveals an amniotic fluid index (AFI) of
E. Fetal hydrops除:
30 cm. Which of the following situations is most likely to be the
A肾发育不全。
etiology of polyhydramnios? 一位病人在怀孕32周时进行常规产前检查。
B十二指肠闭锁。
(A) duodenal atresia 到目前为止她怀孕了简单的。她的体重指
C脊柱裂。 数是25。她的实验室测试很正常，包括一
(B) renal atresia
D先天无脑畸形。 个1小时的葡萄糖筛查。22周时做的解剖超
(C) pulmonary hypoplasia 声检查是正常的，证实了她的约会。她的
e .易漏诊
(D) gestational diabetes 眼底高度是37厘米 今天。床边超声显示羊
水指数(AFI)为30厘米。中的哪一个
(E) anencephale
Causes 以下情况最有可能是羊水过多的病因?
It is related to the increase in production or decrease in removal of the amniotic fluid. In A十二指肠闭锁 , (B)肾闭锁, (C)肺发育不
one-third of cases the cause is idiopathic, but some are due to foetal, maternal or 全 , (D)妊娠(期)糖尿病
placental disorders: 1. 胎儿的原因 (E) 无脑的
1. Foetal causes- Twin to twin (recipient)
a. Anencephaly
a.无脑畸形
b. Oesophgeal atresia, duodenal atresia b.耳间闭锁，十二指肠闭锁
c. Gastroschisis and omphalocele c.腹裂和脐膨出
d. Foetal hydrops(congestive heart filure, hypoprotenemia-fluid exudation液分泌. d。胎儿积水
2. Maternal causes – poorly controlled diabetes(polyuria)
3. Placental causes – rarely due to placental tumour such as choriangioma 2. 母性原因——糖尿病控制不力
3.胎盘原因-很少由于胎盘肿瘤，如绒毛膜血管瘤
 Insight
Maternal complications associated with polyhydramnios include :
A. High blood pressure.
与羊水过多相关的产妇并发症包括:
B. Urinary tract anomalies.
a高血压。
C. Diabetes.
b尿路异常。
D. Postmature pregnancy.
c .糖尿病。
E. All of the above.
Risks d .过度成熟的怀孕。
1. Foetal1. 胎儿 e .以上所有。
a. Preterm labour a.早产。
b. Unstable lie b 不稳定的谎言
c. Premature rupture of membranes and cord prolapse c.膜早破，脐带脱垂

2. Maternal-2. 孕产妇 3. Prevention of cord prolapse

a. Discomforts secondary to pressure effects- a. Precaution in performing amniotomy
a.压力效应引起的不适 when patient goes into labour.
b. Dyspnea, indigestion, abdominal pain, edema and varicose veins b. Avoid amniotomy when there is cord
呼吸困难、消化不良、腹痛、水肿和静脉曲张 presentation
c. High risk of operative delivery 3.预防脐带脱垂 c. High water amniotomy
c.手术分娩风险高 a.分娩时施行羊膜切开术时的预防措施。 d. Sit up patient to encourage descend of
b.出现脐带时避免羊膜切开术 foetal head before amniotomy
c.高位羊膜切开术 e. Control the rate of flow of liquor
d.在羊膜切开术前，坐直病人以鼓励胎儿头部下降
e.控制酒的流量
 Local Protocol羊水过多
1. Investigation of underlying causes
a. Ultrasound for foetal morphology 超声波检查胎儿形态
b. OGTT test for diabetes mellitus b.糖尿病OGTT检查
2. Treatment
a. Treat underlying cause: -e.g. control DM
b. Conservative treatment: -
i. For patients have mild symptoms, especially idiopathic polyhydramnios which usually resolve spontaneously
ii. Regular follow up in clinic with USG to monitor liquor volume
i.对于症状较轻的患者，尤其特发性羊水过多，通常自行消退
ii.定期与USG在临床进行跟踪，监测酒量
c. For symptomatic patients: -
i. Admission.
ii. Give dexamethasone if high risk for preterm labour (<34 wks)早产高危人群给予地塞米松(<34周)
iii. Amnioreduction if patients have severe symptoms, to reduce the liquor volume, to be decided by specialist如果
患者有严重的羊水回吸症状，要减少酒量，由专家决定
iv. Delivery.胎儿分娩
v. NSAID has no clinical use非甾体抗炎药没有临床应用
Twin-to-twin transfusion syndrome is a rare cause of acute polyhydramnios in the recipientThe condition may be
rapidly fatal for both twins; amniodrainage and removal by laser of the placental vascular connections are two
therapeutic modalities employed in dealing with this condition
双对双输血综合征是一种罕见的原因，急性羊水过多的受体，这种情况可能是迅速致命的双胞胎;羊水引流和激光切
除胎盘血管连接是治疗这种情况的两种方法
 Insight All the following are possible causes
of polyhydramios,
EXCEPT:
With regard to polyhydramnios: 2 FALSE Option A. Diabetes
A. Increased amniotic fluid index has a detrimental effect on uterine blood flow. B. Multiple pregnancy
B. It may be associated with fetal oesophageal atresia. C. Fetus with hydrops fetalis
C. It is commonly associated with the ‘donor’ twin in TTTS. D. Fetus with duodenal atresia or
D. It may be safely managed with indomethacin in the third trimester. neural tube defect
E. It is diagnosed in 3 per cent of all pregnancies. E. IUGR
关于羊水过多:
A:羊水指数升高对子宫血流有不利影响。
B可能与胎儿食管闭锁有关。
C它通常与TTTS中的“供体”双胞胎有关。
D在妊娠晚期使用吲哚美辛可以安全处理。
在所有孕妇中，有3%的人被诊断出患有此病。

Polyhydramnios is defined as an amniotic fluid index of >95% confidence interval (CI) for gestation and occurs in 3
per cent of all pregnancies. It can occur in any syndrome of fetal bowel obstruction or impairment of swallowing,
including oesophageal atresia. It may be noted in the ‘recipient’ twin of TTTS. Indomethacin is best avoided in the
third trimester of pregnancy, because of the risk of premature ductal closure in utero.
羊水过多定义为妊娠期羊水指数为>95%置信区间(CI)，占所有妊娠期的3%。它可以发生在任何胎儿肠梗阻或吞咽障
碍的综合征，包括食管闭锁。它可能会在TTTS的“收件人”中被注意到。吲哚美辛在妊娠晚期最好避免使用，因为有
在子宫内过早关闭导管的风险。
 Obstetric abdominal exam
Introduction-Wash hands-Introduce yourself-Confirm patient details – name/DOB-Ask if the patient currently has any
pain
Explain the examination (as shown below)
Positioning of patient
1. Patient should lie as flat as possible
2. Discrete exposure from just below the breasts to the symphysis pubis
解释考试内容(如下图所示)
定位的病人
1. 病人应尽量平躺
2. 从乳房下方到耻骨联合的分散暴露
Inspection
1. Inspect for signs of pregnancy:
a. Abdominal distension d. Striae gravidarum
b. Pigmented and flattened umbilicus i. Recent striae are purplish red while old striae from previous
c. Linear nigra pregnancy are silvery white
i. Pigmented linea alba ii. Striae follow the lines of stress in the skin of the abdominal wall
ii. May persist after the first pregnancy and may also occur on the lateral aspect of the thighs
d。妊娠纹-i 最近的纹是紫红色的，而以前怀孕的旧纹是银白色 and the breasts
的
ii。纹状体沿着腹壁皮肤的应力线分布，也可能发生在大腿和乳
2. Inspect for foetal movements: - observable after 24 weeks
房的外侧. 3. Inspect for any surgical scar: - caesarean section is usually
2. 检查胎儿运动:- 24周后观察 performed with pfannenstiel incision
3.检查手术疤痕:-剖宫产手术通常采用腹部横弧形切线
 Palpation of uterus
1. Palpate the outline and contour of the uterus
2. Irregular if there are fibroids or uterine anomalies
3. Palpate for any uterine tenderness – tender if abruptio placentae or intrauterine infection
4. Assess the size of the uterus
a. 12 week: -just palpable over the abdomen
b. 14 week: -a quarter-way from symphysis to umbilicus
c. 16 week: -midway between the symphysis and umbilicus
d. 18 week: -three-quarter-way from symphysis to umbilicus
e. 20 week: -uterus fundus at the umbilical level
1. 触诊子宫的轮廓
2. 如有肌瘤或子宫异常，则为不规则
3.触诊有无子宫压痛——如果胎盘破裂或宫内感染，则为触痛
4. 评估子宫的大小
a第12周:-在腹部可以摸到
b第14周:从联合到脐部的四分之一路程
c.第16周:-在联合和脐的中间
d第18周:-四分之三从联合到脐部
e. 20周:-脐水平子宫底

5.Measurement of symphysial-fundal height-Measure the distance between the fundus and the symphysis pubis
f. After 20 week, the fundal height in centimetre correlates to gestation in week: -e.g. The fundal height at 30 week
should be around 30 ± 2cm
 Fetal Lie
a. Number of foetus: - suspect multiple pregnancy if more than two foetal poles are identified如果发现两个以上的
胎极，怀疑是多次妊娠
b. Foetal lie: -
i Search for the foetal poles at the fundus and over the suprapubic region. If present, then it is longitudinal lie;
ii Otherwise, search carefully at the frank region (transverse lie) or iliac fossa (oblique lie)i.在基底部和耻骨上区域
寻找胎儿的两极。如果存在，则是纵向的谎言; , 否则，仔细搜索弗兰克区(横卧位)或髂窝(斜卧位)

Foetal back: - if it is longitudinal lie, push the foetus to the other size of
the uterus and feel the foetus with the other hand, and vice versa. The
back is round and soft while the limbs are irregular, and moving胎儿背部
:-如果是纵向躺着，将胎儿推到子宫的另一边，用另一只手摸胎儿，反之
亦然。背部圆润柔软，四肢不规则，活动自如
 Presentation
Foetal presentation: - i Cephalic: -hard round well-defined border, ii Breech: -soft, bulky(deep papation)
 Engagement
d. Engagement: - some degree of engagement is common when gestation is near term. High floating
presenting part should lead to the suspicion of pelvic inlet obstruction or placenta praeviad.参与:-妊娠期临近
时，一定程度的参与是常见的。高浮力部分应引起盆腔入口梗阻或前置胎盘的怀疑
f. Liquor volume:羊水体积:
i. Foetal parts are difficult to define when there is significant polyhydramnios. The fundal height is large for date.
Fluid thrill may also be demonstrated.当出现明显羊水过多时，胎儿各部分很难界定。就日期而言，漏斗高度很大。
液体刺激也可以被证明。
ii. In oligohydramnios, the foetal parts are easily felt and prominent. The fundal height is also small for date.
g. Foetal parts are usually not palpable before 24 week羊水过少时，胎儿的部分很容易被感觉到并突出。对于日期
来说，漏斗的高度也很小。 胎儿部位通常在24周之前无法触及
 Auscultation of foetal heart sound 缺点是:-
1. Site: -. 网站: 1. 它需要电池才能工作
a. Best heard over the shoulder (back) of the foetus 2. 当多胎妊娠同时使用多
b. In cephalic presentation, it is at the level midway between the maternal umbilicus and 个多巴胺时，可能会发生
the anterior superior spine of the ilium 干扰
c. In breech presentation, it is at or slightly above the level of the umbilicus 3.母体脉搏易被检出，易
2. Instruments: - use a pinard stethoscope or a doptone 被误认为胎儿脉搏
3. Foetal heart sounds are usually not audiable with a pinard stethoscope before 24 week
最好从胎儿的肩膀(背部)开始听
It is a hand-held electrical apparatus used for detection of foetal
b.在头侧表现中，位于母亲脐和髂骨前上棘之间的水平 heart pulsation by Doppler effect.
在臀位上，它位于或略高于脐的水平 It has several advantages over the Pinard stethoscope: -
2. 仪器:-使用皮纳德听诊器或doptone 1. The foetal heart sounds are audible as early as 12 weeks of
3.胎儿的心音通常在24周之前用皮纳德听诊器是听不到的 gestation
2. It is more sensitive in picking up heart sounds, even though it
is not placed exactly over the foetal back.
3. The mother can also hear the heart sounds at the same time
The disadvantages are: -
1. It requires battery to work
2. Interference may occur when more than one doptone are
used at the same time for multiple pregnancies
3. Maternal pulse can be picked up easily and may be mistaken
as the foetal pulse是一种利用多普勒效应检测胎儿心脏搏动的手
持电子仪器。
它有几个优点比皮纳尔听诊器:
1. 胎儿的心音早在怀孕12周就能听到
2. 它对听到心音更敏感，尽管它并没有完全盖过胎儿的背部。
3.母亲也能同时听到心音
 Insight
You examine a woman’s abdomen who has attended for induction of labour at 40 weeks +12 days. The abdomen
is soft and non-tender. It is difficult to feel any definite presenting part in the pelvis. The baby is longitudinal lie,
you can feel a smooth part on the patient’s left side and the right side feels more irregular. The fundus has a
ballottable object. You find the fetal heart above the umbilicus.
How is the position best described? 你检查一个女人的腹部曾参加劳动在40周þ12天。腹部软而不软。很难感
A. Breech 觉到骨盆中有任何明确的部位。宝宝是纵向躺着的，你可以在患者的左侧
B. Occipitoposterior 感觉到一个光滑的部分，而右侧则感觉更加不规则。fundus有一个可选对
C. Occipitotransverse 象。你可以看到胎儿的心脏在脐上。
D. Occipitoposterior fully engaged 这个职位怎样描述最好?
E. Transverse lie A:臀位
b .枕后
c .枕横
D.枕后部完全投入
e .横向躺
This is a breech presentation for a number of reasons. Firstly, no definite presenting is felt in the pelvis, as the
bottom is softer than the head. The head is felt by balloting in the fundus of the uterus. The heartbeat is heard
above the umbilicus. The back is on the left where the smoothness was felt and the feet are on
the right where it was more irregular.这是一个臀位演讲，原因有很多。首先，骨盆没有明显的表现，因为底部比头
部柔软。头部是通过子宫底部的气球来感觉的。心跳在肚脐上方可以听到。背部在感觉平滑的左边，脚在感觉不规
则的右边。
 Breech presentation I dont want to be straight.

Incidence
- The most common type of malpresentation
- Incidence deceases with maturity.
„ 25-30% at 28 weeks.
„ 3.3-4.2% of all term deliveries.
„ Due to spontaneous version.由于自发的版本, so i two fetus
or legs are extended the dont become cephalic
- Up to one third are undiagnosed before labour
Types
1. Complete or flexed (15%): -both legs flexed at hip and knee
2. Frank or extended (70%): -both legs extended at the knee
and flexed at the hip
3. Footling or incomplete (20-25%): -one or both feet tucked
underneath the buttock
Complete breech means:完全臀位的意思是:
A. Flexion at hip joint and extension in knee joint髋关节屈曲，膝关
节伸展
B. Flexion at hip joint and flexion at knee joint
B.髋关节屈曲，膝关节屈曲
C. Extension at the hip jointC.髋关节伸展
D. Flexion at knee joint and extension at the hip jointD.膝关节屈曲，
髋关节伸展
E. Flexion of one leg at hip joint and extension of the other leg at the
 Causes of breech Come on give me some more space
for sommersault筋斗
孕产妇 All are causes of breech EXCEPT:
•肌瘤 A. Prematurity.
先天性子 B. Congenital anomalies. All of the following associated
宫异常， C. Hydrocephalus. with increase incidence of
如双圆状 D. Pelvic tumor. breech presentation, EXCEPT:
子宫 E. Increased maternal age. A. Placenta previa
B. Müllerian anomaly
•子宫手术 除: C. Uterine leiomyoma
胎儿和胎 1. The majority occurs by A:早产。 D. Nulliparity
盘 chance B .先天性异常。 E. Prematurity
•多种妊娠 C脑积水。
所有下列情况均与臀位呈现的发
•早产 D .盆腔肿瘤。
生率增加有关，但以下情况除外:
•前置胎盘 E.产妇年龄增加。
A:前置胎盘
•异常，如
its seems b·缪勒异常
无脑畸形
或脑积水 Multiple pregnancy will interfere i am are not able to c .子宫平滑肌瘤
with spontaneous version. move.-fetal entities d .未产妇
•胎儿神经
多胎妊娠会干扰自发性。 e .早产
肌肉状况
•羊水过少
•羊水过多
 Insight
While evaluating a 30-year-old woman for infertility,
you diagnosed a bicornuate uterus. You explain that
additional testing is necessary because of the
woman's increased risk of congenital anomalies in
which system?
A. Skeletal.
B. Hematopoietic.
C. Urinary.
D. Central nervous.
E. Tracheoesophageal.

在评估一名30岁女性的不孕症时，您诊断为双圆状子
宫。你解释说额外的检查是必要的，因为女性先天畸
形的风险增加在哪个系统?
A:骨骼。 The following are possible causes of
B造血。 breech presentation EXCEPT :
C尿。 A. Prematurity
d .中枢神经。 B. Sub-serous fundal fibroid
E气管的。 C. Multiple pregnancy
D. Placenta previa
E. Bicornuate uterus
 Vaginal breech delivery
Introduction介绍-Vaginal breech delivery is a high risk procedure. A recent randomized controlled study has showed
that it is associated with higher perinatal mortality and morbidity than elective caesarean section in delivering
singleton pregnancy with breech presentation. Women should be counselled for external cephalic version (ECV) or
elective section. Vaginal breech delivery should only be considered in highly-selected group of pregnancies:
阴道臀位分娩是一个高风险的过程。最近的一项随机对照研究表明，与选择性剖宫产相比，臀位呈单胎妊娠的围产儿
死亡率和发病率更高。妇女应被建议为外部头位版本(ECV)或选修部分。阴道臀位分娩只应考虑在高度选择的怀孕组:
1. Multiparous with previous successful vaginal deliveries
2. Term foetuses of average size (estimated weight between 1.5 to 3.5kg)
3. Foetal neck is not hyperextended For term breech presentations: Which one is FALSE 2
A. Hyper extended neck gives better outcome.
4. Frank or complete breech presentation B. Planned caesarean delivery is most preffered
5. There is no evidence of foetal compromise C. Post date pregnancy is contrindication for vaginal delivery.
6. Induction and augmentation are not required D. All women should be offered external cephalic version (ECV).
1. 多胞胎，有过成功的阴道分娩经历 E. Its better that fetal have normal CTG and its footling delivery.
An absolute contraindication for vaginal breech delivery is:
2. 平均身高(估计体重在1.5至3.5公斤之间)的足月胎儿 A. Footling breech presentation.
3.胎儿颈部没有过度伸展 B. Hyperextension of the head.
对于学期臀位陈述:哪一个是错误的2 C. Prolonged latent phase of labor.
4. 坦率或完整的臀位展示
A.颈部过度伸展效果更好。 D. A large fetus with estimated fetal weight > 3000 gm.
5. 没有证据表明胎儿会妥协 E. Previous pregnancy loss.
B计划剖腹产是最常见的
6. 不需要诱导和增强 阴道臀位分娩绝对禁忌:
C.产后妊娠是阴道分娩的禁忌证。 A.细跟臀位展示。
D.所有女性均应给予体外头位注射(ECV)。 B.头部过度伸展。
E胎儿CTG正常及足底分娩效果较好。 C.分娩潜伏期延长。
D一个估计胎儿体重为> 3000克的大胎儿。
E.既往妊娠失败。
 Vaginal breech delivery How are you going to
deal with my butt. Haha
1. Delivery of the lower part of the body
a. Vaginal breech delivery begins with its
bitrochanteric diameter fitting into the lateral
diameter of the maternal pelvis, and
the rotation is therefore sacral anterior or
posterior.1. 下半身的分娩
阴道臀位分娩开始于其粗隆直径与产妇骨盆外侧直
径相适应，因此旋转为骶前或骶后。
b. As the breech descends towards the outlet, it
rotates into a sacral lateral position, and the baby
presents by the anterior buttock. During delivery,
the baby bends its back laterally, so first the
anterior buttock, then the anus, then the posterior
buttock delivers. Episiotomy is made at this stage.
b.当臀位向出口下降时，它旋转成骶侧位，婴儿出
现在前臀位。在分娩过程中，婴儿的背部向外侧弯
曲，所以首先是前臀部，然后是肛门，然后是后臀
部。会阴切开术是在这个阶段进行的。
 Vaginal breech delivery How are you going to
deal with my shoulder
c. The lower limbs and the trunk usually deliver
spontaneously. The baby will then be lying with the
shoulders in the transverse diameter.c.下肢和躯干
通常自发分娩。然后婴儿将躺在与肩膀的横向直径。
2. Delivery of the shoulder
a. The arms may extend and abduct over the back of
the foetal neck (see nuchal arm below). Rotation of
the body by Loveset maneuver is then necessary to
deliver the shoulders:肩关节脱位
a.手臂可伸展并外展至胎儿颈后(见下面的nuchal颈背
的手臂)。然后，需要通过“Loveset”动作使身体旋转，
以传递肩部:
b. The shoulders are rotated into anterio-posterior
diameter, so that the anterior shoulder is adducted.
The anterior shoulder and elbow are then flexed and
delivered. 肩关节旋转成前后径，使前肩关节内收。然
后前肩关节和肘关节弯曲并分娩。The posterior
shoulder is then rotated to the anterior position and
delivered in a similar way. The shoulders finally lie in
the transverse diameter again. 然后将后肩关节旋转到
前位，并以类似的方式传递。肩膀终于又回到了横径上。
 Loveset maneuver I need a screw driver我需要一个螺丝刀

A maneuver originally described to deliver the shoulder in a breech

presentation. The principle is that the pelvic canal is curved, so that
its anterior wall (pubic symphysis) is much shorter than the posterior
wall (the sacrum). It is most likely therefore when the foetal part is
obstructed anteriorly by the pubic symphysis, the posterior part is
already below the sacral promontory. Given that the baby is held
firmly by pelvic tissue, a rotation of the baby will cause the posterior
part of the baby to come to the front, and as this is already below the
inlet, the baby descends. In other words, the pelvis acts like a screw,
and any rotation of the baby will bring it lower. The maneuver is very
useful to deliver the shoulders of the baby after the breech is
delivered. The principle is also used when there is shoulder dystocia
after cephalic delivery. Sometimes, if the baby can be rotated, the
shoulder will slip under the pelvic inlet and can be delivered一种最初
描述在臀位演讲中传递肩膀的动作。其原理是骨盆管是弯曲的，因此
它的前壁(耻骨联合)比后壁(骶骨)短得多。因此，最可能的情况是，当
胎儿部分被耻骨联合向前阻塞时，后部分已经位于骶岬下方。假设婴
儿被盆腔组织牢牢地抱着，婴儿的旋转会导致婴儿的后半部来到前面，
而这部分已经在入口下方，婴儿就会下降。换句话说，骨盆就像一颗
螺丝钉，婴儿的任何旋转都会把它拉低。这种手法对于臀位分娩后分
娩婴儿的肩部非常有用。该原则也适用于头位分娩后出现肩难产。有
时，如果婴儿可以旋转，肩膀会滑到骨盆入口下方，可以分娩
 Delivery of the head How about my head

The head usually requires assisted delivery. Head

entrapment is an dangerous condition (see below).
The aim is to encourage flexion of the neck. This
can be done with a pair of Piper forceps, the Burns
Marshall maneuver(360 sommetsault), or the
Mauriceau Smellie Viet maneuver.
头部通常需要辅助分娩。头部被夹住是一种危险的
情况(见下文)。目的是鼓励颈部弯曲。
 Potential difficulties in vaginal breech delivery
Potential difficulties in vaginal breech delivery-阴道臀位分娩的潜在困难 Umbilical cord prolapse is most likely
1. Cord prolapse1. 绳下垂 to occur with:
In case of footling breech presentation, the foetal buttock is not well fit to A. Frank breech.
the cervix, and is more prone to cord prolapse.胎儿臀位不适合子宫颈， B. Complete breech.
更容易出现脐带脱垂。 C. Single footling breech.
2. Nuchal arm2. 颈背的手臂 D. Double footling breech.
One or both foetal arms are extended, abducted over the back of the 脐带脱垂最可能发生以下情况:
foetal neck. This results in obstruction.一个或两个胎儿的手臂被伸展，在 A:弗兰克臀位。
胎儿脖子的后面外展。这会导致阻塞。 B .完全臀位。
C.单脚臀位。
3. Head entrapment3.夹头 D双足臀位。
During vaginal delivery, the foetal head is presented to the birth canal The most frequent severe complication of vaginal
with the base of the skull, and there is not adequate time for moulding. breech delivery:
A. Cord prolapse.
The head may be trapped by the cervix. In both cases of nuchal arm and B. Spinal cord injury.
head entrapment, the umbilical cord is being compressed and occluded C. Head entrapment.
between the cervix and the head. Prolonged delivery results cause D. Cord avulsion.
E. Placental Separation
hypoxic damage. Excessive traction to overcome dystocia also causes 阴道臀位分娩最常见的严重并发症:
severe trauma. A:绳下垂。
阴道分娩时，胎儿头部与颅底一起出现在产道中，没有足够的时间成型。 B脊髓损伤。
头部可能被子宫颈卡住。在这两种情况下的颈背的手臂和头部夹闭，脐带 C夹头。
D.绳扯开。
被压缩和闭塞之间的子宫颈和头部。长时间的分娩会导致缺氧损伤。过度 E .胎盘分离
牵引以克服难产也会造成严重的创伤。
 Complication of breech
Cord prolapse: -risk is lowest in frank breech presentation
but highest in footling. 脐带脱垂:-弗兰克臀位的风险最低，但
足部风险最高。
Birth asphyxia: -as a result of delayed delivery分娩窒息:-由
于分娩延迟
Birth injury: -e.g.: -Intracranial haemorrhage, rupture of
viscus, dislocation of joints, fractures of long bones,
peripheral nerve injury出生损伤:如。-颅内出血，内脏,破裂，
关节脱位，长骨骨折，周围神经损伤
Maternal risk产妇风险
1. Maternal risk related to the underlying causes.
e.g. Placenta praevia
2. Maternal risk related to breech delivery: -
In breech presentation:臀先露:
Higher caesarean section rate and Birth canal A. Frank breech is the commonest type. Frank breech是最常见
injury 的类型。
1. 与孕产妇风险相关的潜在原因。如前置胎盘 B. Brachial plexus injury is a recognized complication.臂丛损伤
2. 与臀位分娩相关的产妇风险:-较高的剖宫产率 是一种公认的并发症。
和产道损伤
The major cause of serious neonatal morbidity & mortality for infants with
C. Prolapse of the umbilical cord can occur.脐带可能会脱垂。
breech presentation is: 臀位呈现新生儿严重并发症及死亡率的 D. Fetal mortality is increased.胎儿死亡率增加。
A. Birth trauma.
B. IUGR.
主要原因是:
A:出生创伤。
E. Intracranial hemorrhage颅内出血
C. Cord prolapse. BIUGR。 F. All of the above
D. Associated congenital anomalies. C.绳下垂。
E. Cerebral palsy. D.相关先天性异常。
 Investigations
1. Ultrasound
Regarding Breech presentation, the following are true EXCEPT:关
a. Define the type of breech, assess foetal
于臀位的陈述，以下内容是真实的，除了:
growth and estimate of foetal weight, and
A. Accounts for up to 3 % term pregnancies占足月妊娠的3%
liquor volume确定臀位类型，评估胎儿生长，
B. May be diagnosed on clinical examination of the abdomen可通
估计胎儿体重和酒量
过腹部临床检查确诊
b. Look for any underlying causes like foetal
C. May be associated with fetal abnormality可能与胎儿畸形有关
anomalies, placenta praevia and uterine
D. Is a contraindication for vaginal delivery阴道分娩的禁忌症
abnormalities寻找任何潜在的原因，如胎儿
E. Makes intrapartum hypoxia more likely than is true of cephalic
畸形，前置胎盘和子宫异常
presentation是使产时缺氧的可能性大于头侧表现
2. CT pelvimetry
a. Ensure adequate pelvis before allowing Breech presentation: Which is true?臀位陈述:哪个是正
vaginal breech delivery阴道臀位分娩前确保 确的?
骨盆足够 A. Constitutes 10% of all term deliveries构成所有定期交
b. Rarely indicated now as vaginal breech 货的10%
delivery is not recommended现在很少显示， B. Common in post term laborB.常见于足月后分娩
因为阴道臀位分娩是不推荐的 C. Vacum extraction can be used when cervix is fully
dilated当宫颈完全扩张时，可以使用真空抽提法
Decision of mode of delivery 胎儿分娩方式的决定 D. Forceps can be used for after coming head来头后可
1. External cephalic version (ECV) 1. 头外型(ECV) 使用镊子
2. Elective caesarean section 2. 选择性剖腹产 E. External cephalic version is best performed between
3. Vaginal breech delivery 3.阴道臀位分娩 32-34 weeks gestation.E.妊娠32-34周时采用头外翻法效
果最佳。
 Insight
A 28-year-old woman attends labour ward for induction of labour at term + 12. She has some contraction pains but
these are mild and she is not troubled by them. She has had an uncomplicated pregnancy and had
two previous normal deliveries both of which needed inducing due to postmaturity. The CTG is normal. A scan is
done which shows a transverse lie of the fetus. The cervix is 3 cm dilated. What would be the next course of action?
A. Artificial rupture of membranes 一名28岁女子在产房接受+ 12期的引产。她有一些宫缩的疼痛，但这些是轻微的，
B. Emergency Caesarean section 她不受它们的困扰。她有过一次简单的怀孕前两次正常分娩均因早产需要引产。
C. Oxytocin CTG正常。扫描显示胎儿横卧的位置。宫颈扩张3厘米。下一步的行动会是什么?
D. Prostaglandin A.人工破膜
E. Semi-elective Caesarean section B.紧急剖腹产
c .催产素
d .前列腺素
E.半选择性剖腹产
This lady would not be suitable for a normal delivery as the baby is in a transverse position. She would therefore
need a semi-elective section which would be classified as grade 3 on the RCOG guidelines. Urgency of Caesarean
section is indicated as follows: Grade 1 – immediate threat to the life of the woman or the fetus; Grade 2 – maternal
or fetal compromise which is not immediately life-threatening; Grade 3 – no maternal or fetal compromise but needs
early delivery; and Grade 4 – delivery timed to suit woman or staff. This would not be a true elective section of grade
4 as she has started to contract and the cervix is starting to dilate. It would not be grade 1 or 2 as there is no fetal or
maternal compromise.这位女士不适合正常分娩，因为婴儿是横向的。因此，她需要一个半选修课，在RCOG的指导
方针中将其列为3级。剖宫产急迫性表现为:1级-对妇女或胎儿生命的直接威胁;二级-母亲或胎儿的妥协不会立即危及生
命;三级-没有母亲或胎儿的妥协，但需要提前分娩;4级-分娩时间适合女性或工作人员。这不是四年级的选修课因为她
已经开始收缩子宫颈开始扩张。它不会是1级或2级，因为没有胎儿或母亲的妥协。
 External Cephalic Version (ECV) Now i am going to push
you back to normal
Definition- External cephalic version is an operative procedure to turn the mal-presented foetus to cephalic
presentation, by applying forces over the maternal abdomen 头外翻是一种手术程序，通过施加力量在孕妇腹部，
将畸形胎儿转变为头侧翻
A woman who is 36 weeks pregnant is reviewed. This is her
Indication first pregnancy. Her baby is known to currently lie in a
1. Breech presentation at term(atleast 36 weeks) breech presentation. What is the most appropriate
2. Transverse lie and unstable lie: -ECV followed by induction of labour management?
3. Occasionally to rotate a non-cephalic presenting second twin into cephalic A. Reassure mother baby will most likely turn to a cephalic
presentation during second stage of labour presentation prior to delivery
指示 B. Refer for external cephalic version
1. 学期臀位报告 C. Admit for induction of labour and trial of vaginal delivery
2. 横卧和不稳定卧:-ECV，继之以引产 D. Refer for radiological pelvimetry
3.在分娩的第二阶段，偶尔将一个没有头侧表现的双胎旋转成头侧表现 E. Admit for caesarean section
Advantages of ECV 回顾一位怀孕36周的妇女。这是她第一次怀孕。她的宝
1. High success rate成功率较高 (depends on hospital). 宝目前躺在臀位上。什么是最合适的管理?
2. Low complication rate低并发症率 A. 放心，宝宝很可能会在分娩前转向头侧分娩，
B. 参考外部头侧分娩版本
3. Mother still has choice of caesarean section after failure母亲
C. 接受引产和阴道分娩试验
失败后仍可选择剖腹产 D. 请参阅放射球量学
Disadvantages of ECV E. 接受剖腹产
Chance of caesarean section after success is still higher than
normal population缺点ECV .剖宫产成功率仍高于正常人群
 Insight
A 38 year old primigravida is pregnant with dichorionic diamniotic twins. The antenatal course was uneventful. There
was spontaneous onset of labour at 37 weeks gestation. Twin 1 was cephalic and delivered vaginally after 6 hours
of labour. The abdominal examination showed twin 2 to be in transverse lie. What is the most appropriate
management?
A. Lower segment caesarean section
B. Classical caesarean section
C. External version
D. Internal version
E. Amniotomy
一名38岁的原偏头痛患者怀了一对双胎二胎。分娩过程很顺利。37周时出现自发性分娩 妊娠。双胞胎1是头型的，分
娩6小时后顺产。腹部检查显示2号胎儿横卧。最重要的是什么?
适当的管理?
A下段剖宫产术 Indication-指示
B经典的剖腹产 1. Breech presentation at term 1. 学期臀位报告
2. Transverse lie and unstable lie: -ECV followed by induction of labour 2. 横卧和不稳定卧:-ECV，继之以引产
C .外部版本
3. Occasionally to rotate a non-cephalic presenting second twin into cephalic presentation during second stage of
D .内部版本 labour. 3.在分娩的第二阶段，偶尔将一个没有头侧表现的双胎旋转成头侧表现
E.人工破膜
 Contraindications I cannot turn you because

1. Maternal-a. Obesity
b. Pelvic abnormalities, e.g. placenta or fibroid at the lower pole, ovarian cysts, uterine anomalies or uterine
scar盆腔异常，如下极胎盘或肌瘤、卵巢囊肿、子宫异常或子宫瘢痕
c. Pre-eclampsia子痫前症 External cephalic version is contraindicated
2. Feoetal-a. Multiple pregnancy妊娠多胎 in all of these conditions EXCEPT
b. IUGR胎儿宫内发育迟缓 A. Scarred uterus
c. Cord round neck线圆领 B. Multiple pregnancy
d. Polyhydramnios or oligohydramnios多水合物或少水合物 C. Placenta previa
e. Foetal compromise胎儿妥协 D. Severe maternal hypertension
E. Gestational diabetes
3. Obstetrical factors产科因素 除上述情况外，所有病例均禁止外头型
a. Antepartum haemorrhagea.产前出血。 A:疤痕子宫
b. Rupture of membranes b.膜破裂 b .多个怀孕
c. Established labour c.建立劳动 C .前置胎盘
D.严重孕妇高血压
The following are contraindication to external cephalic version, E .妊娠期糖尿病
EXCEPT: 以下是头外翻的禁忌症 EXCEPT
A. Contracted pelvis a:骨盆狭窄
B. Placenta previa b .前置胎盘
C. Multiple pregnancy c .多个怀孕
D. Presence of cervical suture in site d.现场是否有颈部缝合
E. Scared uterus e .有疤痕的子宫
 Insight You need to make sure i am fine first but you turn me around

A 29-year-old woman, gravida 2, para 1, comes to the physician for a prenatal

visit at 37 weeks gestation The patient had a previous uncomplicated
Prerequisites
pregnancy where she delivered a 3.5 kg (7 7 lb) baby vaginally If possible, she 1. No contraindications
prefers to have a vaginal delivery again. Examination shows a closed cervix. 2. Gestation at least 36 week
Fetal heart tracing shows a reactive fetal heart rate pattern . An ultrasound 3. Normal foetal morphology and well-being
confirms a frank breech presentation with an estimated fetal weight of 3.6 kg (8 4. Facilities for rapid progression to
lb) There are no fetal or uterine abnormalities and she has an adequate amount caesarean section, if necessary
of amniotic fluid. Which of the following is the most appropriate next step in 5. Rh-D negative women must be given anti-
management?
D immunoglobulin
A Cesarean section
B. Expectant management with vaginal delivery
先决条件
C. External cephalic version 1. 没有禁忌症
D. Internal podalic version 2. 妊娠至少36周
E. MRI pelvimetry 3.正常的胎儿形态和健康
一名29岁的妇女，2号孕妇，第1段，在怀孕37周时到医生那里进行产前检查。 4. 如有必要，为快速进展到剖腹产的设施
这名妇女以前有过一次简单的怀孕，她顺产了一个3.5公斤(7 7磅)的婴儿。如果 5. Rh-D阴性的妇女必须服用抗d免疫球蛋白
可能的话，她更愿意再次顺产。检查显示宫颈闭合。胎心示踪显示反应性胎心率
模式。超声检查证实胎儿臀位正常，胎儿体重约3.6公斤(8磅)，没有胎儿或子宫
异常，羊水充足。下列哪一项是管理中最合适的下一步?
A剖腹产 Fetal well-being must be documented by a nonstress test and there should be no contraindications to a vaginal delivery.
B阴道分娩的期待管理 As ECV has the potential to cause fetal distress, it should be performed only when arrangements have been made for a
C.头外翻 back-up emergency cesarean delivery. Contraindications to ECV include ruptured membranes, hyperextended fetal head,
D.内回转术 fetal/uterine abnormalities, and non-reassuring fetal monitoring (Table).胎儿的健康状况必须通过非压力测试记录下来，阴
道分娩不应该有禁忌。由于ECV有可能引起胎儿窘迫，因此只有在安排了备用紧急剖宫产时才应实施ECV。ECV的禁忌症
E. MRI骨盆测量
包括胎膜破裂、胎儿头部过度扩张、胎儿/子宫异常和不可靠的胎儿监护(表)。
 Insight
The recommended delivery for a 25-year-old nulliparous woman at 39 weeks’ gestation in early labour with
confirmed breech presentation and spontaneous rupture of membranes is:
a) Vaginal breech extraction
b) External cephalic version (ECV)
c) Elective caesarean section
d) Ventouse delivery
e) Immediate caesarean section

一名25岁的孕妇，在怀孕39周时，经证实有臀位表现及自发性胎膜破裂，建议在早产时分娩:
a)阴道臀位拔除术
b)头外型(ECV)
c)选择性剖腹产
d) 拔罐
e)立即剖腹产

ECV is contraindicated after spontaneous rupture of membranes due to high failure rates and risk of cord prolapse
and fetal distress. As the woman is in labour, delivery should be expedited by caesarean section.
ECV是由于高失败率和脐带脱垂和胎儿窘迫的风险，在自发性膜破裂后禁用。由于产妇正在分娩，应通过剖宫产加
快分娩速度
 Insight
With regard to ECV for term breech presentation: 3 correct options With regard to breech presentation :
A. Fetal heart activity should be documented. A. In vaginal delivery the fetus is prone to
B. Tocolysis is always required. Cephalohematoma
C. It is less likely to be successful in a multiparous woman. B. Hyperextension of the fetal head is a
D. It reduces the need for caesarean section. favorable
E. Anti-D should be administered to Rhesus-negative women. C. External cephalic version (ECV), reduces the
关于学期臀位报告的ECV: 3个正确选项 breech presentation at term.
A.胎儿心脏活动应该被记录下来。 D. Mid trimester amniocentesis is likely to result
B.解酵解总是必需的。 in breech presentation at term
C.对于多胎生育的女性来说，这种方法不太可能成功。 E. The perinatal morbidity is ten time higher than
D.它减少了剖腹产的需要。 in cephalic presentation
E.抗d药物应给予阴性的恒河猴妇女。
关于臀位介绍:
External cephalic version has been demonstrated to reduce the likelihood A阴道分娩时胎儿容易出现头孢血肿
of a caesarean section significantly in pregnancies where there is a term B胎儿头部过度伸展是有利的
breech presentation , and should be offered between 37 and 42 weeks. C.头外翻(ECV)，使臀位减少
Tocolysis is effective but does not have to be used if the uterus is relaxed. D妊娠中期羊膜穿刺术很可能导致足月后臀位
The likelihood of success increases in association with:multiparity, 的出现
adequate liquor volume , non-engagement of the presenting part E围生儿的发病率是头位的十倍
外部头型已被证明可以显著降低剖宫产的可能性，在怀孕期间有一个术语臀
位出现，并应提供37至42周。解宫术是有效的，但如果子宫是放松的，则不
必使用。成功的可能性增加与下列因素有关:
多胎产, 足够的酒卷, 呈现部分的非约定
 External Cephalic Version (ECV) Now i am going to push
you back to normal
Procedure过程
1. USG to exclude any contraindications such as placenta praevia
and foetal anomalies1. 排除任何禁忌症，如前置胎盘和胎儿畸形
2. CTG, USG for growth and liquor to exclude foetal compromise2.
CTG、USG为生长发育和排除酒精对胎儿的危害
3. Ask patient to empty the urinary bladder3.请病人排空膀胱
4. Give tocolytic to relax the uterus4. 用解宫药使子宫放松
5. Disengage the breech5. 脱离的臀位
6. Forward roll technique: the breech is pushed to the side where
the back is; the head is pushed forward.6. 前滚技术:将臀部推到背部
的侧面;头向前推
7. Follow up for complications of ECV 7. 追踪ECV的并发症

。
 Insight Now i am going to push
you back to normal
A 24-year-old G1 P0, Rh-negative , 36 weeks a breech presentation and is
considering external cephalic version. She should be told :
A. She should be offered general anesthesia
B. The procedure can be done with oligohydraminos
C. Prophylaxis with anti-globulin D can wait until after delivery
D. Engagement of the presenting part is not considered a contraindication
to version
E. Tocolysis with intravenous Retodrine has been shown to improve the
results of external version

24岁G1 P0, rh阴性，臀位36周，考虑头外位。应该告诉她:

A.应该给她做全身麻醉
B.这个过程可以用羊水过少来完成
C..抗球蛋白D预防可等到分娩后
D.提交部分的参与不被认为是对版本的禁忌症
E.经静脉注射的利托君解大肠杆菌已被证明可以改善外源性版本的结
果
 Complication Placental abruption
• Premature rupture of the membranes
• Cord accident
• Transplacental haemorrhage (remember anti-D
Complications
administration to Rhesus-negative women)
1. Transient foetal bradycardia:
• Fetal bradycardia
a. Most common 3-10%
胎盘早剥
b. Last for seconds to few minutes
•膜早破
c. No long term sequelae, only 0.4% needs further investigation for
•绳事故
persistent episodes.
•经胎盘出血(记住对阴性恒河猴妇女使用抗d药物)
2. Acute foetal distress that requires immediate delivery 0.5%
•胎儿心动过缓
3. Reversion 3%
并发症 The most common complication of External Cephalic
1. 瞬态胎儿心动过缓: Versions:
a.最常见的3-10% A. Placental separation.
b.持续几秒钟到几分钟 B. Fetomaternal hemorrhage.
c.无长期后遗症，持续性发作仅0.4%需要进一步调查。 C. Persistent fetal bradycardia.
2. 急性胎儿窘迫，需要立即分娩0.5% D. Inability to convert the fetus to the vertex presentation.
3.降级3% E. Reversion of the fetus to breech presentation.头外翻最常
4. Rare: 4. 罕见: 见的并发症:
a. Antepartum haemorrhage or abruptio placentae. A:胎盘分离。
产前出血或胎盘早剥 B胎母出血。
b. Uterine rupture子宫破裂 C.持续性胎儿心动过缓。 压迫脐带或迷走神经介导
c. Rupture of membranesabc.膜破裂 D无法将胎儿转化为胎儿的顶点。的心动过缓
E胎儿退到臀位。
 Local Protocol
1. Let the ECV team know either by booking patient via computer CMS system or inform directly before labour
2. Adequate counselling and obtain consent
3. Ascertain gestation 1. 通过计算机CMS系统预约患者或分娩前直
4. Assess foetal well-being by CTG 接通知ECV团队
5. Ascertain adequate fasting 2. 获得足够的咨询和同意
6. Perform ultrasound examination to look for any contraindications 3.确定怀孕
7. Secure intravenous access; keep NPO, Cross-match. 4. 用CTG评估胎儿健康
8. After the procedure 5. 确定适当的禁食
a. Perform CTG 6. 进行超声检查，以发现任何禁忌
b. Counsel on the mode of delivery if ECV fails 7. 安全静脉访问;保持禁食,试验。
c. Arrange follow up to ascertain presentation if success 8. 术后
9. PWH Data a,Do CTG
a. 150-200 breech per year b.如果ECV失败，对交付方式进行咨询
b. 1/3 ECV, 1/3 Contraindicated and 1/3 Refused c.安排跟进，确定演示是否成功
10. Territory wide 9. PWH数据
a. 1400-1700 breech per year; 180 (10%) ECV; Sucessful rate 55%. a.每年150-200臀位
b. Vaginal breech delivery 200 (1999) ¬ 60 (2004) b. 1/3 ECV, 1/3禁忌症，1/3拒绝
10. 领域广泛
a.每年1400-1700臀位;180 (10%)ECV;成功率
55%。
b.阴道臀位分娩200例(1999)60例(2004)
 Insight（Extra IQ)
A 32-year-old woman, gravida 2 para 1, at 29 weeks gestation comes to the office for follow-up of
a recent ultrasound performed to reevaluate a low-lying placenta. The ultrasound reveals a posterior placenta 3 cm
(1.18 in) from the cervix, a fetus in transverse lie, and fetal weight consistent with gestational age. The patient's
first pregnancy required a low-transverse cesarean delivery at 39 weeks gestation for an abnormal fetal heart
tracing. The patient prefers a trial of labor and vaginal delivery for this pregnancy. Which of the following is the
most appropriate response to this patient?
A External cephalic version is recommended at this visit
B. Internal podalic version will likely be necessary during vaginal delivery
C. The fetus will likely convert to cephalic presentation spontaneously
D. Vaginal delivery is contraindicated due to prior cesarean delivery (note its low transeverse so trial of labor can
be done)
E. Vaginal delivery is contraindicated due to the location of the placenta(not all type only when it cover the os
grade IV
一名32岁妇女，妊娠29周，第1段，来到办公室进行最近一次超声检查的随访，以重新评估一个低洼的胎盘。超声
波显示后胎盘3厘米(1.18英寸)从子宫颈,横向躺胎儿,胎儿体重符合孕龄病人的第一次怀孕需要低横向剖腹产在妊娠
39周胎儿心脏异常跟踪病人倾向于审判和阴道分娩的妊娠。以下哪项是对这个病人最合适的反应?
A本次就诊建议采用头侧外固定位
B.阴道分娩时可能需要使用内足病版 Internal podalic version is performed to facilitate the breech
C胎儿可能会自发地转变为头侧 extraction of a malpresenting second twin but is not used in the
D剖宫产前禁止阴道分娩 management of a singleton fetus in transverse lie.内足弓式胎位是
E由于胎盘的位置，阴道分娩是禁忌的 为了方便对第二胎畸形的臀位取出，但不用于横卧单胎的管理。
 Insight
A transverse lie occurs when the longitudinal axis of the fetus is
perpendicular to the longitudinal axis of the uterus. A fetus in transverse
lie can be positioned either back up (with the spine toward the maternal
head) or back down (with the spine toward the cervix). Risk factors for
transverse lie include prematurity, uterine anomalies, placenta previa,
and multiple gestation. Palpation of the fetal head near the mother's
side and/or absence of a fetal presenting part during digital cervical
examination suggest transverse lie, but the diagnosis must be confirmed
via ultrasound. Transverse lie is typically transient prior to term. Most
fetuses in transverse lie spontaneously convert to breech or vertex
presentation. Consequently, an ultrasound will be required to assess
fetal position at or around 37 weeks to determine delivery management
If the fetus converts to vertex presentation (the most likely scenario), the
patient can be offered a trial of labor (TOL).
横卧是指胎儿的纵轴垂直于子宫的纵轴。横卧位的胎儿可以仰卧(脊柱朝
向母体头部)，也可以仰卧(脊柱朝向子宫颈)。横卧位的危险因素包括早产、
子宫异常、前置胎盘和多次妊娠。触诊胎儿头部靠近母亲一侧和/或在宫
颈指位检查中没有胎儿出现，提示横卧位，但诊断必须通过 超声波。横
向谎言通常在学期前是短暂的。大多数横卧胎儿会自发地向臀位或顶位转
变。因此，将需要超声来评估 胎儿位置在37周或37周左右，以确定分娩
管理，如果胎儿转换到顶点表示(最有可能的情况)，病人可以提供分娩试
验(TOL)。
 Antenatal Care产前保健
Definition- A planned programme of observation, education, and medical
management of pregnant women directed towards making pregnancy and
delivery safe and satisfying experiences 一项有计划的孕妇观察、教育和医
疗管理方案，旨在使怀孕和分娩安全而令人满意
Elements-1. Screening of Risk factors-1. 风险因素筛选
a. To regularly look for any risk factors which adversely affect the health of
mother and babya.定期寻找对母婴健康有不利影响的任何危险因素.
maternal medical illness eg-heard diease, or diabetes, hypertension
b. This is achieved through regular history taking, examination, and
screening tests.这是通过定期的病史检查、检查和筛选试验来实现的。Eg
Down syndrome screen.
a. Advice on wearing seat-belt
2. Counselling – To advise on the nature and extent of any perceived risks,
b. Instructions to admit to hospital
and how to minimize or eradicate them就任何可察觉的风险的性质和程度，
when significant symptoms occur
以及如何尽量减少或消除这些风险，提供意见. Eg. Mother with HIV,
such as fever, vaginal bleeding or
infection etc
discharge, abdominal pain, etc
3. Monitoring – To monitor the maternal and foetal well-being in high risk
Antepartum care consists of booking
cases- CTG, biophysical profiles
assessment; and continuing antenatal
4. Treatment – To treat any medical condition which might affect or be
care.出现发烧、阴道出血或分泌物、
affected by the pregnancy eg Diabetes control
腹痛等明显症状时应立即入院
5. Management of minor disorders – See minor disorders of pregnancy-
产前护理包括预约评估;以及持续的产
Nausea vomiting, back pain etc, 6. Education – To provide advice,
前护理。
reassurance and support for the woman and her family, such as: -
 Booking assesment
Dating is one of the most important tasks in antenatal care. 20% of pregnant women will have date problems
because: -约会是产前保健中最重要的任务之一。20%的孕妇会有约会问题，因为:
1. Last menstrual period is forgotten or uncertain1. 上一个月经周期被遗忘或不确定
2. Menstrual cycles are irregular 2. 月经周期不规则

The Expected date of delivery of a human pregnancy can be calculated:

A. From a change in the patient's weight. 可计算人类怀孕的预期分
B. As 10 lunar months after the time of ovulation. 娩日期:
A从病人体重的变化。
C. As 40 weeks after last menstrual period. B如排卵后的10个月。
D. As 280 days from the last full moon. C.如上次月经后40周。
E. As 36 weeks after the last menstrual period. D从上次满月算起280天。
E如上次月经后36周。
Some definitions
1. Last menstrual period (LMP) – date of the first day of last menstrual
flow
2. Estimated date of confinement (EDC): Booking assessment
a. The mean duration of pregnancy 1. Timing
b. About 40% of women will deliver within 5 days of EDC and 66% a. Optimally takes place at 8 to 10 weeks and
should not later than 16 weeks
within 10 days
b. Important for dating of pregnancy: -to look for any
c. It is 280 days from the LMP provided that ovulation occurs at day 14 date problem and confirm the estimated date of
of the menstrual cycle confinement (EDC) c. Check for any pre-existing
d. It is 266 days from the date of ovulation risk factors by history taking (Obs), examination
(Obs) and screening tests
 How to calculate EDC (Nagele's rule)
1. By LMP: It is calculated by using LMP by adding 280 days (40 weeks) to it. It is assumed that ovulation occurs
at or day 14
of LMP, in a normal regular 28 days cycles. To the first day of LMP add 7 days, then subtract 3 months, and then
add 1 year.
最后一次月经是6月30日。预计
e.g.: -LMP: -10/10/2009 EDC:17/07/2010
交货日期(EDD)约为:
1. By First positive pregnancy test (5-6 weeks of amenorrhoea)
A:3月23日。
2. By Ultrasound dating.
4月7日。
3月28日。
The last menstrual period was June 30. the expected date of delivery (EDD) is
4月23日。
approximately:
3月7日。
A. March 23.
B. April 7.
C. March 28.
D. April 23.
E. March 7.

1.通常，当早期的USG预测与LMP分配的EDC不一致超过一周时，USG的日期为 分配。
2. 如果扫描和LMP在一周内达成一致，则使用基于LMP的EDC。这可能并不总是直接的，因为股骨长度可能与基于
BPD的估计胎龄相一致，也可能不一致
 History taking
In an antenatal clinic, you are seeing a patient who has an emergency caesarean section 4 years ago in China.
What question concerning that delivery would you want to ask your patient?在一个产前诊所，你看到一个病人谁有
一个紧急剖腹产4年前在中国。关于分娩你想问你的病人什么问题?
Past medical history- 过去病史,
To identify any pre-existing diseases that may affect the pregnancy, or may
get worse during pregnancy. Common diseases are hypertension, diabetes
mellitus, thyroid disorders, epilepsy and psychiatric disorders, blood
disorders(thalasemia), ask age etc.
确定任何可能影响怀孕或在怀孕期间可能恶化的预先存在的疾病。常见的疾
病有高血压、糖尿病、甲状腺疾病、癫痫和精神疾病
Past obstetric history
- To look for any foetal or maternal complications in past pregnancies that
may recur in current pregnancy, e.g. preterm labour, pre-eclampsia,
gestational diabetes - To review mode of deliveries of past pregnancies
that may affect the management of current pregnancy. The number,
indications and mode (Classical or Lower Segment) of C/S affect the
management of subsequent modes of delivery.过去的产科史
-寻找过去怀孕期间可能在现时怀孕期间复发的胎儿或产妇并发症，例如早
产、先兆子痫、妊娠糖尿病-检讨过去怀孕期间可能影响现时怀孕管理的分
娩方式。C/S的数量、适应症和模式(经典的或较低的部分)影响后续交付模
式的管理。 https://geekymedics.com/obstetric-history-taking/
 History taking
Present obstetric history
1. To confirm the gestation 目前产科史
a. Date of last menstrual period: - 1. 来确认妊娠
b. Cycle length and regularity of menstrual period a.最后月经期日期:-
c. Date of pregnancy test, with both positive and negative results b.月经周期长度及规律
d. Result of any dating scan c.妊娠检查日期，有阳性和阴性结果
2. To look for any teratogenic agents: - d.任何日期扫描的结果
a. Any rash and fever during pregnancy 2. 寻找致畸剂:-
b. Any drug taken during pregnancy 怀孕期间出现皮疹和发烧
3. To look for any symptoms related to the pregnancy: - such as nausea, b.怀孕期间服用的任何药物
vomiting
Family history 家族病史
- To look for any risk of having hereditary diseases, such as thalassemia, -研究患上遗传性疾病的风险，例如地中海
haemophilia 贫血、血友病等
- To check consanguinity -检查血缘关系
- To look for any risk of having gestational maternal diseases, such as -研究孕妇患妊娠期疾病的风险，例如妊娠
gestational diabetes, pre-eclampsia or hypertension 期糖尿病、先兆子痫或高血压
Social history 社会历史
Drug abuses, smoking and alcohol intake 滥用药物、吸烟和酗酒
Family planning and childcare 计划生育与托儿
Plan of breast-feeding, childcare, and contraception 母乳喂养、育儿和避孕计划
 Antenatal imaging and fetal assessment
Sure sign of pregnancy is:
A. Amenorrhea The softening of the cervical isthmus 颈部峡部软
B. Hegar's sign 化that occurs early in gestation is called:
C. Nausea and vomiting A. Hegar's sign.
D. Auscultation of fetal heart B. Chadwick's sign.
E. Abdominal distension C. Braxton Hick's contraction.
怀孕的确切迹象是: D. Von fernwald's sign.
A:闭经 E. Cullen's sign.
b .黑格尔说道的迹象
C.恶心呕吐
D胎儿心脏听诊
e .腹胀

Which of the following is NOT a presumptive symptom/sign

of pregnancy:
A. Cessation of menstruation.
B. Quickening.胎动
C. Nausea & vomiting.
D. Breast changes.
E. Darkening of the skin on the palms of the hands.
 Antenatal obstetric complications
The followings are considered normal
symptoms of pregnancy EXCEPT:
A. Backache due to an increased
lumbar lordosis.
B. Lower abdominal pain and groin
pain due to stretch of round ligaments.
C. Visual disturbance.
D. Calf pain due to muscle spasm.
E. Increased vaginal discharge.
以下为正常妊娠症状，但不包括:
由于腰椎前凸增加而引起的背痛。
A. 下腹部疼痛和腹股沟疼痛，由于伸
展的圆形韧带。
B. 视觉障碍。
C. 肌肉痉挛引起的小腿疼痛。
D. 阴道分泌物增多。
Frequency of micturition
1. Symptoms of early pregnancy when it may be
due to increased renal filtration
2. Also in late pregnancy when it is due to pressure
from the enlarged uterus
3. Urinary tract infection has to be excluded when
there is also dysuria or urgency
 Antenatal care A 23-year-old woman attends
her antenatal booking
Antenatal Booking investigations include the following EXCEPT: appointment. She thinks that she
A. Glucose is 10 weeks pregnant. This is
B. CBC Antenatal care can prevent all the
following complications, EXCEPT : her first pregnancy. Which one
C. Hepatitis A. Anemia due to iron deficiency or folic of the following is not routinely
D. Toxoplasma acid deficiency. performed?
E. Beta HCG B. UTI of pyelonephritis. A. Assess body mass index
C. Macrosomia.
D. Preterm labor.
B. Pelvic examination
Initial screening tests should include: E. Rh immunization. C. Urine culture if dipstick urine
a. Haematological normal
i. Haemoglobin to screen for anaemia Additional screening tests such as the
followings may be required if additional
D. Check for red cell
ii. MCV to screen for thalassemia alloantibodies
risk markers are present:
iii. Blood group and Rhesus type a. Urine culture E. Hepatitis B testing一名23岁
b. Microbiological b. Screening for sexually transmitted 妇女参加产前预约。她认为她
i. Rubella antibodies diseases 十岁 周的身孕。这是她第一
ii. Hepatitis B surface antigen c. Oral glucose tolerance test 次怀孕。下列哪一项不是常规
iii. VDRL/ EIA for syphilis d. Biochemical screening for neural tube 的 执行?
c. Biochemical – Urinalysis for protein defects and Down syndrome如有其他风
F. 评估身体质量指数
and glucose 险标记物，可能需要额外的筛选测试，例
如:
G. 盆腔检查
d. Radiological H. 尿培养如沾尿正常
aUrine culture
i. Dating scan before 16 weeks b.筛查性传播疾病 I. 检查红细胞同种抗体
ii. Morphology scan around 20 weeks c.口服葡萄糖耐量试验 J. 乙肝检测
 Subsequent assessment
1. When and where to be seen Routine maternal assessment常规孕产妇评估
a. Uncomplicated (low risk) pregnancy - Weight and notation of any change(Average weight
i. Women should be seen every 4 weeks for the first gain is approximately -10 to 15 kg)
28 weeks of pregnancy, then every 2 weeks until 36 - Blood pressure with notation of any change
weeks, and weekly until delivery - Urine glucose and protein
ii. Can be seen in maternal child health centre, by - Periphera oedema
midwives or general practitioners - Presence of any symptoms-任何更改的重量和符号
b. High risk pregnancy -血压与任何变化的符号
c. Women with medical or obstetric problems require -尿液中的葡萄糖和蛋白质
close surveillance at an interval determined by the -周边水肿
nature and severity of the problem. -出现任何症状
d. Under care of a specialist Routine foetal assessment
1. 何时何地可以被看到 - Foetal activity (from history)
简单(低风险)妊娠 - Foetal size: -both the actual size and the growth rate;
i.妊娠头28周每4周见一次孕妇，然后每2周见一次， assessed with fundal height measurement
直到36周，每周见一次，直到分娩 - Foetal presentation and engagement (in late pregnancy)
二世。是否可在母婴健康院、助产士或全科医生那里 - Amount of amniotic fluid
看到 - Foetal heart rate, by auscultation with Pinard
b.高危妊娠 stethoscope or a hand-held Doppler apparatus (Doptone)
c.有医疗或产科问题的妇女需要根据问题的性质和严 - Please refer to history taking (Obs) and examination
重程度每隔一段时间进行密切监测。 (Obs) for detail
d.由专家照料
 ANTE-NATAL CARE（EMQ)
8 ANTE-NATAL CARE
1 A 27-year-old woman attends the ante-natal clinic at 16 weeks for results of her booking tests. She 1 C If the partner is haemoglobin A/A there
is found to have sickle cell trait. She is concerned about the risk to the fetus. will be no risk of sickle cell disease in the
2 A 35-year-old woman who attends the ante-natal clinic at 15 weeks who wishes to have a fetus and amniocentesis is not indicated.
screening test for Down’s syndrome. 2 G The combined test is performed in the
3 A nulliparous woman who is 24 weeks has attended her GP surgery for a routine check, her urine first trimester. The triple test can be
dipstick is normal.
performed up to 20 weeks’ gestation.
4 A 36-year-old woman has a high-risk result on Down’s syndrome screen of 1 in 220. She has
declined diagnostic testing because of the risk of miscarriage.
3 E Blood pressure should be checked at
5 A 28-year-old vegetarian who is 28 weeks’ pregnant and feeling increasingly tired. every ante-natal visit to screen for
A一名27岁妇女于16周时到产前诊所检查预约检查结果。她被发现有镰状细胞特征。她担心对胎儿的 pregnancyinduced hypertension and pre-
危险。 eclampsia.
2一名35岁妇女，15周前来产前诊所，希望进行唐氏综合症筛查。 4 H An anomaly ultrasound should still be
3一名24周未产的妇女接受了全科医生的常规检查，她的尿量尺正常。 performed to exclude other congenital
4一名36岁的妇女在唐氏综合症筛查中有1 / 220的高风险结果。由于有流产的风险，她拒绝接受诊断 anomalies and confirm placental site.
测试。 5 A Iron deficiency anaemia is common in
5一个28岁的素食者，怀孕28周，感觉越来越累。 为下面描述的每个患者选择最合适的 pregnancy and should be treated with iron
单一测试
Choose the single most appropriate test for each of the patients supplements.8产前保健
described below 全血计数 如果伴侣是血红蛋白A/A，胎儿不会有镰状
A Full blood count B血红蛋白电泳 细胞病的风险，也不需要进行羊膜穿刺术。
B Haemoglobin electrophoresis C伴侣血红蛋白电泳 联合试验在妊娠的前三个月进行。三次试验
C Partner haemoglobin electrophoresis D尿液试纸 可进行长达20周的妊娠期。
D Urine dipstick E血压 每次产前检查都应检查血压，以筛查妊高征
E Blood pressure F组合测试 和先兆子痫。。
F Combined test G三测试
4h仍需行异常超声排除其他先天性异常，确
G Triple test H异常超声
认胎盘位置。
H Anomaly ultrasound i羊膜穿刺术
缺铁性贫血在怀孕期间很常见，应该用铁补
I Amniocentesis
 HIV
Virology
1. Single-stranded(+ve) RNA virus: -retroviridae
2. Several types; type 1 is the most common and type 2 is similar to type 1, which is confined to West Africa and
Less virulent
Epidemiology
1. Worldwide distribution; Africa is the most prevalent area.
2. In the USA and Europe, AIDS is mainly caused by HIV-1; HIV-2 is responsible for a proportion of infections in
Africa.
3. Hong Kong (in July 1999): -1255 HIV positive cases have been reported, the male-to-female ratio of new cases
is around 6:1 with an increasing trend for females, 9 cases of vertical transmission were found.
4. Parenteral transmission through blood and body fluids, sexual intercourse or from mother to the child.
5. Risk factors of infection:
a. Multiple sexual partners 4. 通过血液和体液、性交或母亲传给孩子的非
b. Bisexual activity 肠道传播。
c. Sexually transmitted diseases (previous or current) 5. 感染的危险因素:
d. IV drug addicts a.多个性伴侣
e. Transfusion of blood or blood products b。双性恋活动
f. Originating from an endemic area. c.性传播疾病(以前或现在)
d.吸毒者
e.输血或血液制品
起源于流行地区的。
 Maternal infection I had a pateint from france who has
oral candida i prescribed fluconazole
then was not responding properly
1. Asymptomatic in early stage
2. Some women may have early diseases like vulvovaginal
candidiasis, pelvic inflammatory disease (PID) and cervical
dysplasia
3. Anaemia, thrombocytopenia or neutropenia may occur
4. Women with thrombocytopenia may have epistaxis,
petechiae and menorrhagia
5. Some may have non-specific symptoms like fever,
arthralgias, myalgias and fatigue
6. Advanced cases: -at increased risk of opportunistic
infections, such as Pneumocystis carinii pneumonia,
toxoplasmosis, lymphoma, cryptococcal meningitis
1. 早期无症状
2. 有些妇女可能有早期疾病，如外阴阴道念珠菌病、盆腔炎
(PID)和宫颈发育不良
3.可能发生贫血、血小板减少或中性粒细胞减少
4. 血小板减少的妇女可能有鼻出血、瘀点和月经过多
5. 有些可能有非特异性症状，如发烧、关节痛、肌痛和疲劳
6. 晚期病例:-机会性感染风险增加，如卡氏肺囊虫肺炎、弓形
虫病、淋巴瘤、隐球菌脑膜炎
 Perinatal infection
1. The transmission rate of HIV-1 to foetus was estimated to be 15-35%. Infections occur either in utero (13-33%)
or at delivery.
2. The rate of transmission to infants by infected mothers increases with the clinical severity of maternal disease
and is inversely proportional to the maternal CD4+ T-lymphocyte count.
3. The progress of the disease in these infants varies directly with the disease severity in the mother at the time
of delivery.
4. Antenatal and intrapartum antiviral therapy decreases the transmission by 60-70%.
5. Breast-feeding is associated with an additional 14% risk of transmission.

1. 估计HIV-1对胎儿的传播率为15-35%。感染发生在子宫内(13-33%)或分娩时。
2. 受感染的母亲传染婴儿的比率随产妇疾病的临床严重程度而增加，并且呈反比关系 与母体CD4+ t淋巴细胞计数
成正比。
3.这些婴儿疾病的进展与母亲分娩时疾病的严重程度直接相关。
4. 产前和产时抗病毒治疗可使病毒的传播降低60-70%。
5. 母乳喂养与另外14%的传播风险有关。
 Management of for HIV-positive carriers
Which of the following is the contraindication to breast feeding? 下列哪项是母乳喂养的禁忌症?
A) Mastitis A)乳腺炎
B) Maternal anaemia B)产妇贫血
C) Maternal thalassaemia carrier C)孕妇地中海贫血带菌者
D) Maternal HIV carrier D)母体HIV携带者
E) Maternal hepatitis B carrier E)乙型肝炎母体携带者

1. Pre-conception counselling:1. 前概念咨询:

3. Intrapartum: - Elective caesarean
section may reduce the risk of perinatal
a. Counselling of risks and prognosis of the child.a.儿童危险和预后咨询。
transmission.
b. Consider avoiding pregnancy.考虑避免怀孕。
4. Postnatal: -
2. Antenatal:2. 产前:
a. The newborn's skin should be
a. Monitoring of CD4+ counts.a.监测CD4+计数。
cleansed of all maternal secretions
b. Extensive and ongoing counselling.b.广泛和持续的咨询。
before being punctured by a needle.
c. Zidovudine (azidothymidine, AZT) treatment is offered to the mother
b. Breast-feeding is avoided if possible.
during pregnancy, labour and delivery, and to the newborn. This
c. Prevent the baby from contacting
reduces the risk of perinatal transmission.
with maternal secretions
c.齐多夫定(azidothymidine, AZT)在妊娠、分娩和新生儿期间提供治疗。
a.新生儿的皮肤在被针头刺穿之前，应 这降低了围产期传播的风险。
清除所有母体分泌物。
d. Looking for any development of opportunistic infections机会性感染
b.尽可能避免母乳喂养。
or AIDS.
c.防止婴儿接触母体分泌物