BONY PELVIS AND SIDE WALLS

¢ Bony ring of pelvis is made up of 2 symmetrical bones.

¢ Each innominate bone is made up of: -ilium -ischium -pubis which joined anteriorly to
symphysis pubis and posteriorly to the sacrum and sacroiliac joints.
¢ The female pelvis has evolved for giving birth, and differs from the male pelvis in the
following ways:
• The female pelvis is broader than those of the male.
• The male pelvic brim is heart-shaped and the female pelvic brim is oval-shaped
• The female pelvic cavity has a wider outlet than the male pelvis.
• The subpubic angle is rounded in a female pelvis and more acute in the male pelvis.
¢ PELVIC BOUNDARIES:
V

Zarg
4 Basic
of

pelvis
PERINEUM
¢ Perineum is the thin layer of skin between vaginal opening or scrotum and anus.
¢ It consists of tissue that makes up the bottom of the pelvic cavity (common site for
tears during childbirth).
¢ The area inferior to the pelvic diaphragm can be divided into:
• anterior urogenital triangle (pierced by the vagina and the urethra)
• posterior anal triangle.
¢ The superficial and deep perineal fascias are continuous with the labia majora and
are attached:
• anteriorly to the pubic symphysis
• laterally to the body of the pubis.
• The superficial perineal muscles are:
• superficial transverse perineus
s
• ischiocavernosus
• bulbocavernosus
petae
! The positions of the sutures and fontanelles play a
FETAL HEAD very important role in identifying the position of the

¢ Anatomy of the fetal skull: -S fetal head in labour

-Made up of 5 main bones: two parietal bones, two frontal bones, and the occipital
bone.
-These are held together by sutures, which permit movement during birth:
• The coronal suture
• The lambdoid suture
• The frontal suture
-When two or more sutures meet, there is an irregular membranous area between them
called a fontanelle.
• The anterior fontanelle or bregma.
• The posterior fontanelle or the lambda.
¢ Regions of the fetal head:
• The occiput The degree of moulding can be assessed vaginally:
• No moulding: when the suture lines are separate.
• The vertex • 1+ moulding: when the suture lines meet.
• 2+ moulding: when the bones overlap but can be reduced with gentle digital
• The bregma pressure.
• 3+ moulding: when the bones overlap and are irreducible with gentle digital
• The sinciput pressure.

¢ Capital and moulding of the fetal head: V

-During labour, the dilating cervix may press firmly on the fetal scalp preventing
venous blood and lymphatic fluid from flowing normally. Resulting in a tissue swelling
beneath the skin called caput succedaneum.
-It is soft and boggy to touch and usually disappears within 24h of birth.
-There is usually some alteration in the shape of the fetal head and a reduction in
the head circumference in labour by a process of overlapping of the cranial bones (a
reduction of up to 4cm is possible).
-This moulding is physiological and disappears a few hours after birth.
-The presence of caput and moulding can play an important part in diagnosing
obstructed labour.
CLINICAL DIAGNOSIS OF PREGNANCY:
• The vagina and cervix have a bluish tinge due to blood congestion.
• The size of the uterus may be estimated by bimanual examination (reasonably accurate
in early pregnancy).
• After 12wks the uterus is palpable abdominally and the fetal heart may
be heard using a hand-held Doppler.
• The most obvious symptom of pregnancy is cessation of periods, i.e. a period of
amenorrhoea in a woman having regular menstruation.
• Other common symptoms of early pregnancy:
¢Nausea and vomiting (morning sickness)
¢Frequency of micturition (Make sure the frequency is not associated with
dysuria, which may denote possible infection.)
¢Excessive fatigue
¢Breast tenderness or ‘heaviness’ (often seen early in pregnancy, particularly
in the month after the first period is missed).
¢Fetal movements or quickening (Many women may experience fetal
movements earlier than this and some may not perceive movements until term.)
¢Occasionally a pregnant woman may experience an abnormal desire to eat
something not normally regarded as nutritive (such as dirt). This is known as pica.
LAB DIAGNOSIS OF PREGNANCY
¢The hormone hCG is secreted by trophoblastic tissue:
• i exponentially from 78 days after ovulation (doubles every second day in
an ongoing pregnancy)
• peaks at 8–12wks gestation.
¢ hCG levels can be measured in blood or urine.
¢ Test kits are available commercially (home pregnancy tests):
• can show a positive result with urinary hCG levels >50IU/L.
• some ‘early’ pregnancy test kits will detect levels of >25IU/L.
¢These tests can confirm pregnancy within 1 week of a missed period.

PRECONCEPTION COUNSELLING
¢ It is a visit with a healthcare provider where the patient discuss many aspects of pregnancy
and plan for a healthy pregnancy.
¢ Preconception counselling should be offered to:
• optimize maternal cardiovascular status (may involve surgery)
• modify medication
• discuss maternal and fetal risks of pregnancy.
¢During preconception counselling the following topics are discussed:
• Family history
•General medical history
•OB/GYN history
•Lifestyle
•Vaccination
¢Physical examination and lab tests
TERATOGENESIS:
¢ Teratogenesis is a prenatal toxicity characterized by structural or functional defects in
the developing embryo or fetus.
¢ Teratogens are substances that cause congenital disorders in a developing embryo or
fetus.
¢ A teratogen is anything a person is exposed to or ingests during pregnancy that’s
known to cause fetal abnormalities.
¢ Drugs, medicine, chemicals, certain infections and toxic substances are examples of
teratogens. Teratogens can also increase the risk for miscarriage, preterm, labor or
stillbirth.
¢ The following factors determine how dangerous teratogen exposure is during
pregnancy:
• The drug, substance or type of toxin.
• How long the pregnant person was exposed.
• The amount of exposure (dosage or quantity).
• The gestational age of the fetus (weeks of pregnancy) at exposure.
• Hereditary factors that could increase the fetus’s risk

ULTRASOUND EXAMINATION IN OBSTETRICS

¢ Any clinical suspicion that the fetus may be small or large for gestational age should be
followed by a formal ultrasound assessment of fetal growth and amount of amniotic fluid
(liquor volume).
¢ Biparietal diameter and head circumference: The anatomical landmarks used to ensure
the accuracy and reproducibility of the measurement are a midline falx, the thalami
symmetrically positioned on either side of the falx, the visualization of the cavum septum
pellucidum at one-third the fronto-occipital distance, and the lateral ventricles with their
anterior and posterior horns identifiable.
¢ Abdominal circumference: The abdominal circumference (AC) is the single most
important measurement in assessing fetal size and growth. It is measured where the
image of the stomach and the portal vein is visualized in a tangential section.
¢ Femur length: By convention, measurement of the FL is considered accurate only when
the image shows two blunted ends.
¢ Uterus measurement anomalies:The uterus may measure small for dates because of:
• Wrong dates. • Oligohydramnios. • Intrauterine growth restriction.
• Presenting part deep in the pelvis. • Abnormal lie of the fetus.
The uterus may measure large for dates because of: • Wrong dates. • Macrosomia.
Polyhydramnios. • Multiple pregnancy. • Presence of fibroids.
LIE, PRESENTATIONS,POSITIONS
 9-Labour and Delivery
 Cardinal Movements of Labor. The first 3 steps occur simultaneously.
 Engagement: movement of the presenting part below the plane of the pelvic inlet.
 Descent: movement of the presenting part down through the curve of the birth canal.
 Flexion: placement of the fetal chin on the thorax.
 The next 4 steps occur in order.
 Internal rotation: rotation of the position of the fetal head in the mid pelvis from transverse to anterior-
posterior.
 Extension: movement of the fetal chin away from the thorax.
 External rotation: rotation of the fetal head outside the mother as the head passes through the pelvic
outlet.
 Expulsion: delivery of the fetal shoulders and body.
 Stage 1
 This begins with onset of regular uterine contractions and ends with complete cervical dilation at 10 cm.
It is divided into:
 Latent phase begins with onset of regular contractions and ends with the acceleration of cervical
dilation. Its purpose is to prepare the cervix for rapid dilation through effacement. Essentially no
descent of the fetus occurs. Average duration of the latent phase is 6,4 hours in a primipara and 4.8
hours in a multipara. The upper limit of duration may be up to 20 h in a primipara and up to 14 h in a
multipara. Abnormalities include prolonged latent phase.
 Active phase begins with cervical dilation acceleration, usually by 6 cm of dilation, ending with
complete cervical dilation. Its purpose is rapid cervical dilation. The cardinal movements of labor
occur, with beginning descent of the fetus in the latter part of the active phase. The rate of dilation is
at least 1.2 cm/h in a primipara and 1.5 cm/h in a multipara. Abnormalities include prolonged active
phase or arrest of active phase.
 Stage 2
 This begins with complete cervical dilation and ends with delivery of the fetus. Its purpose is descent of
the fetus through the birth canal as maternal pushing efforts augment the uterine contractions. Duration
may be up to 3 h in a primipara and 2 h in a multipara. Abnormalities include prolonged second stage or
arrest of descent.
 Stage 3
 This begins with delivery of the fetus and ends with expulsion of the placenta. Placental sepa-AStion
from the uterine wall occurs as myometrial contractions shear off the anchoring villi.
 This is often augmented with IV oxytocin infusion. Signs of the third stage include gush of blood
vaginally, change of the uterus from long to globular, "lengthening" of the umbilical cord.
 Duration may be up to 30 min in all women. Abnormalities include prolonged third stage.
 Stage 4
 This is a 2-h period of close observation of the parturient immediately after delivery. Vital signs and
vaginal bleeding are monitored for onset of preeclampsia and postpartum hemorrhage.
 10-Mechanism of Labour in Occipital Presentation
 In a vertex presentation where the occiput is placed posteriorly over the sacroiliac joint or directly over the
sacrum, it is called an occiput-posterior position. When the occiput is placed over the right sacroiliac joint,
the position is called right occipitoposterior (ROP), traditionally called third position of the vertex and
when placed over the left sacroiliac joint, is called left occipitoposterior (LOP), traditionally called
fourth position of the vertex and when it points toward the sacrum, is called direct occipitoposterior.
All the three positions may be primary (present before the onset of labor) or secondary (developing after labor
starts).
Mechanism of Labour in Occipital Presentation
 The head engages through the right oblique diameter in ROP and left oblique diameter in LOP. The engaging
transverse diameter of the head is biparietal (9.5 cm) and that of anteroposterior diameter is either
suboccipitofrontal (10 cm) or occipitofrontal (11.5 cm). Because of deflexion, engagement is delayed.
 In favorable circumstances
 Flexion: Good uterine contractions result in good flexion of the head. Descent occurs until the head
reaches the pelvic floor.
 Internal rotation of the head: As the occiput is the leading part, it rotates 3/8th of a circle (135°)
anteriorly to lie behind the symphysis pubis. As the neck cannot sustain such amount of torsion, the
shoulders rotate about 2/8th of a circle to occupy the right oblique diameter in ROP and the left oblique
in LOP with 1/8th of a circle torsion of the neck still left behind. Thus, the rest of the mechanism is like
that of right occipitoanterior in ROP and that of left occipitoanterior in LOP.
 Further descent and delivery of the head occurs like that of occipitoanterior position.
 Restitution: There is movement of restitution to the extent of 1/8th of a circle in the opposite direction
of internal rotation of the head.
 External rotation: The external rotation of the head occurs through 1/8th of a circle in the same
direction of restitution as the shoulders rotate from the oblique to anteroposterior diameter of the pelvis.
 Birth of the shoulders and trunk: The process of expulsion is the same as that of occipitoanterior.
 In unfavorable circumstances:
 Incomplete forward rotation: In this condition, the occiput rotates through 1/8th of a circle anteriorly
and the sagittal suture comes to lie in the bispinous diameter. Thereafter, further anterior rotation is
unlikely and arrest in this position is called deep transverse arrest (DTA)
 The head is deep into the cavity; the sagittal suture is placed in the transverse bispinous
diameter and there is no progress in descent of the head even after ½–1 hour following full
dilatation of the cervix. The arrest in occipitotransverse position may be the end result of incomplete
anterior rotation (1/8th of circle) of oblique occipitoposterior position, or it may be due to nonrotation
of the commonly primary occipitotransverse position of normal mechanism of labor.
 Nonrotation: Both the sinciput and the occiput touch the pelvic floor simultaneously due to moderate
defl exion of the head resulting in nonrotation of the occiput. The sagittal suture lies in the oblique
diameter. Further mechanism is unlikely and the condition is called oblique posterior arrest.
 Malrotation: In extreme deflexion, the sinciput touches the pelvic floor first resulting in anterior rotation
of the sinciput to 1/8th of a circle and putting the occiput to the sacral hollow. This position is termed as
occipitosacral position. This is, in the true sense, “Persistent Occipitoposterior Position” (POP) of
the vertex. In favorable circumstances, i.e. with an average size baby, good uterine contractions and an
adequate pelvis such as an anthropoid or spacious gynecoid— spontaneous delivery may occur as ―face
to pubis‖. In unfavorable circumstances, when arrest occurs, it is called occipitosacral arrest.
 Persistent occipitoposterior:
 It is an abnormal mechanism of the occipitoposterior position where there is malrotation of the
occiput posteriorly toward the sacral hollow (occipitosacral position). As previously mentioned,
delivery may occur spontaneously as face-to-pubis but arrest may occur in this position and is
called occipitosacral arrest. It also includes two other arrested positions of the
occipitoposterior, namely deep transverse arrest and oblique posterior arrest.
 Mechanism of “face to pubis” delivery
 Further descent occurs until the root of the nose hinges under the symphysis pubis.
 Flexion occurs—It releasing successively the brow, vertex and occiput out of the stretched
perineum and then the face is born by extension.
 Restitution: The head moves 1/8th of a circle in the opposite direction of internal rotation thus
turning the face to look toward the mother‗s left thigh in ROP and right thigh in LOP.
  External rotation: The occiput further rotates to the same direction of restitution to 1/8th of a
circle placing finally the face looking directly toward the left thigh in ROP and the right thigh in
LOP.
 Occipitosacral arrest
 If the head is engaged and the occiput descends below the ischial spines, forceps application
in unrotated head followed by extraction as face-to-pubis is an effective procedure. Liberal
mediolateral episiotomy should be done. If the occiput remains at or above the level of
ischial spines, caesarean section should be considered.
 11-Mechanism of Labour in Face Presentation
 Face is a rare variety of cephalic presentation where the presenting part is the face. The attitude of the fetus
shows:
 Complete flexion of the limbs
 Extension of the spine.
 Complete extension of the head so that the occiput is in contact with the back.
 The denominator is mentum
 Position: There are four positions of the face according to the relation of the chin to the left and right
sacroiliac joints or to the right and left iliopubic eminences. Face presentation results most likely from
complete extension of deflexed head of a vertex presentation. The numbering of the face positions is
obtained as follows:

 The most common position is left mentoanterior (LMA)—As the ROP position is 5 times more common
than LOP and as the conversion of face occurs from deflexed OP, LMA is the commonest. Overall anterior
positions are more frequent than the posterior one.
Mechanism of Labour in Face Position
Mentoanterior 60–80% (LMA or RMA)
 The principal movements are like those of corresponding occipitoanterior position. The exceptions are
increasing extension instead of flexion and delivery by flexion instead of extension of the head.
 Engagement: The diameter of engagement is the oblique diameter—right in LMA, left in RMA, with
the mentum related to one iliopubic eminence and the glabella to the opposite sacroiliac joint. The
engaging diameter of the head is submentobregmatic 9.5 cm (3 3/4") in fully extended head or
submentovertical 11.5 cm (4 1/2") in partially extended head. Engagement is delayed because of long
distance between the mentum and biparietal plane (7 cm). Descent with increasing extension occurs till
the chin touches the pelvic floor.
 Internal rotation—Internal rotation of the chin occurs through 1/8th of a circle anteriorly, placing the
mentum behind the symphysis pubis. Further descent occurs till the submentum hinges under the pubic
arch.
 Delivery of the head—The head is born by flexion delivering the chin, face, brow, vertex and lastly the
occiput. The diameter distending the vulval outlet is submentovertical—11.5 cm (4 1/2"). Restitution
occurs through 1/8th of a circle opposite to the direction of internal rotation. External rotation occurs
further 1/8th of circle to the same side of restitution so that ultimately the face looks directly to the left
thigh in LMA and right thigh in RMA. This follows delivery of the anterior shoulder followed by the
posterior shoulder and the rest of the trunk by lateral flexion.
 12-Mechanism of Labour in Brow Presentation
 Brow is the rarest variety of cephalic presentation where the presenting part is the brow and the attitude of the
head is short that of degree of extension necessary to produce face presentation, i.e. the head lies in between
full flexion and full extension. The denominator is the fore head
Mechanism of Labor in Brow Position
 Typically converts to either a vertex or face presentation, but, if persistent, may cause dystocia requiring
caesarean delivery.
 Diameter of engagement is through the oblique diameter with the brow anterior or posterior. As the engaging
diameter of the head is mentovertical (14 cm), there is no mechanism of labor in an average size baby with
normal pelvis. However, if the baby is small and the pelvis is roomy with good uterine contractions, delivery
can occur in mentoanterior brow position. The brow descends until it touches the pelvic floor. Internal
rotation and descent occur till the root of the nose hinges under the symphysis pubis. The brow and the vertex
are delivered by flexion followed by extension to deliver the face. The mechanism is more or less the same as
face-to-pubis delivery. Usual restitution and external rotation occur. There is no mechanism in posterior brow
position
 13-Mechanism of Labour in Breech Presentation
 In breech presentation, the lie is longitudinal and the podalic pole presents at the pelvic brim
 There are two varieties of breech presentation:
 Complete (flexed breech): Thighs are flexed at hips and legs at knees. The presenting part consists of
two buttocks, external genitalia and two feet. It is commonly present in multi-parae
 Incomplete: This is due to varying degrees of extension of thighs or legs at the podalic pole.
 Breech with extended legs (Frank breech): In this condition, thighs are flexed on the trunk and legs
are extended at the knee joints. The presenting part consists of the two buttocks and external genitalia
only. It is commonly present in primigravidae due to a tight abdominal wall, good uterine tone and
early engagement of breech.
 Footling presentation: Both thighs and legs are partially extended bringing the legs to present at
brim.
 Knee presentation: Thighs are extended but the knees are flexed, bringing the knees down to present
at the brim.
 Positions
 Sacrum is the denominator of breech and there are four positions. In anterior positions, sacrum is
directed toward iliopubic eminences and in posterior positions, sacrum is directed to sacroiliac joints.
 The positions are:
 Left Sacroanterior (LSA): the most common
 Right Sacroanterior (RSA
 Right Sacroposterior (RSP)
 Left Sacroposterior (LSP).
Mechanism of Labor in Breech Presentation
 The principal movements occur at three places:
 Buttocks:
 The diameter of engagement of the buttock is one of the oblique diameters of the inlet. The
engaging diameter is bitrochanteric (10 cm or 4") with the sacrum directed toward the iliopubic
eminence. When the diameter passes through the pelvic brim, the breech is engaged.
 Descent of the buttocks occurs until the anterior buttock touches the pelvic floor.
 Internal rotation of the anterior buttock occurs through 1/8th of a circle placing it behind the
symphysis pubis.
 Further descent with lateral flexion of the trunk occurs until the anterior hip hinges under the
symphysis pubis which is released first followed by the posterior hip.
 Delivery of the trunk and the lower limbs follow.
 Restitution occurs so that the buttocks occupy the original position as during engagement in oblique
diameter.
 Shoulders
 Bisacromial diameter (12 cm or 4 3/4") engages in the same oblique diameter as that occupied by
the buttocks at the brim soon after the delivery of the breech.
 Descent occurs with internal rotation of the shoulders bringing the shoulders to lie in the
anteroposterior diameter of the pelvic outlet. The trunk simultaneously rotates externally through
1/8th of a circle.
 Delivery of the posterior shoulder followed by the anterior one is completed by anterior flexion of
the delivered trunk.
 Restitution and external rotation: Untwisting of the trunk occurs putting the anterior shoulder
toward the right thigh in LSA and left thigh in RSA. External rotation of the shoulders occurs to the
same direction because of internal rotation of the occiput through 1/8th of a circle anteriorly. The fetal
trunk is now positioned as dorsoanterior.
 Head
 Engagement occurs either through the opposite oblique diameter as that occupied by the buttocks or
through the transverse diameter. The engaging diameter of the head is suboccipitofrontal (10 cm).
 Descent with increasing flexion occurs.
 Internal rotation of the occiput occurs anteriorly, through 1/8th or 2/8th of a circle placing the
occiput behind the symphysis pubis.
 Further descent occurs until the subocciput hinges under the symphysis pubis.
 Head is born by flexion—chin, mouth, nose, forehead, vertex and occiput appearing successively.
The expulsion of the head from the pelvic cavity depends entirely upon the bearing-down efforts and
not at all on uterine contractions.
14. Amnioscopy
 To examine the amniotic fluid
and the fetus through the cervical
canal after dilation of the cervix.
 Conditions:
1. fetus should be at term
2. the cervix must be open,
3. the membrane should be non-
rupture
4. the baby should be alive
 Procedure:
1. Patient in lithotomy position
2. Speculum is applied
3. Amnioscope inserted through the
vagina and the cervix (when it’s
dilated)
4. Obturator is removed. That light
will be on, so we can see the
amniotic fluid through the
amniotic sac which is intact and
part of the fetus is presenting.
 Results:
1- Yellow - indicates bilirubin
2- Green - indicates meconium,
which leads to fetal distress.
3- Reddish - indicates death
 Indications:
1- If the mother is Rh -
2- Suspected fetal death
3- Used when the pregnancy
extends approximately 2
weeks after term.
 Contraindications:
1- Active labor
2- Ruptured membranes
3- Cervical infections
4- Unexplained vaginal bleeding
5- Closed cervix
15. Amniocentesis
 test to check if the baby has a
genetic or chromosomal
anomaly.
 Procedure:
1. Done by using a needle,
placed into a pocket of
amniotic fluid, under
direct ultrasound
guidance
2. Aspirating amniotic fluid
containing desquamated
living cells (amniocytes)
3. Performed after 15 weeks
without anesthesia.
 Indications:
1. Risk of a malformation,
check the karyotype
(chromosomes) and the DNA
of the fetus, because amniotic
fluid contains fetal cells.
2. Age older than 35 years
3. If there is prematurity risk,
check the fetal lung maturity
by measuring the Lecithin-
sphingomyelin ratio which is
supposed to be > 2. (if the
lungs are immature and we
want to deliver the fetus as
soon as possible then we
have to give glucocorticoids.
Examples: Betamethasone
12mg/12h for 24hours (it’s
better because it acts faster)
or Dexamethasone 6mg/12h
for 2 days.
4. Treatment in case of
polyhydramnios.
5. Check for Rh
isoimmunization. We can see
if there is a reaction between
the mother and fetus by
bilirubin which can be seen
in the amniotic fluid after
week 24.
 Complications:
 16-Clinical and Laboratory Diagnosis of the Membrane Ruptures
 PROM (Premature rupture of the membranes) is defined as amniorrhexis prior to the onset of labor at any
stage of gestation. Amniorrhexis means spontaneous rupture of membranes as opposed to amniotomy
 PPROM is used to defined that the patient who are preterm with ruptured membranes, whether or not they
have contractions
 Diagnosis
 It is based on the history of vaginal loss of fluid and confirmation of amniotic fluid in the vaginal
 A sterile vaginal speculum examination should be performed
 Before labor, vaginal examination should not be performed
 Carry out a complete ultrasonic examination
 Confirmation of the diagnosis can be made by:
 Testing the fluid with nitrazine paper, which will turn blue in the presence of the alkaline amniotic
fluid
 Placing a sample on a microscopic slide, air drying, and examining for ferning
 17-Clinical and Laboratory Diagnosis of the Fetal Distress
 Fetal distress is an ill-defined term, used to express intrauterine fetal jeopardy, a result of intrauterine
fetal hypoxia. Nonreassuring fetal status (NRFS) is characterized by tachycardia or bradycardia, reduced
FHR variability, decelerations and absence of accelerations (spontaneous or elicited). It must be
emphasized that hypoxia and acidosis is the ultimate result of the many causes of intrauterine fetal
compromise.
 FHR patterns in labor are dynamic and can change rapidly from normal to abnormal and vice versa.
Because of this uncertainty about the diagnosis of fetal distress, terminologies used are ―Reassuring‖ and
―Nonreassuring‖.
 Nonreassuring fetal heart rate pattern is associated with fetal hypoxia, acidosis and therefore called fetal
distress.
 Features to rule out metabolic acidosis are:
 Presence of accelerations
 Moderate variability
 Scalp blood pH > 7.25.
Etiology

Acute Signs & Symptoms

 Cardiotocography signs:
 Increased / decreased fetal heart (tachycardia and bradycardia), especially during and after a contraction
decreased varibility in the fetal heart rate
 Abnormal fetal heart rate (< 110 or > 160 bpm)
 A normal fetal heart rate may slow during a contraction but usually recovers to normal as soon as the
uterus relaxes
 A very slow fetal heart rate in the absence of contractions or persisting after contractions is suggestive
of fetal distress
 In the absence of a rapid maternal heart rate, a rapid fetal heart rate = a sign of fetal distress
 For a diagnosis of fetal distress to be made, one or more of the following must be present:
 Persistent severe variable deceleration
 Persistent and non-remediable late declarations
 Persistent severe bradycardia
 Amniotic fluid is contaminated by meconium. If the amniotic fluid is severely contaminated, it suggests the,
fetal distress. There are 3 degrees about contamination
 I: Slight contamination. Slight green
 II: Mild contamination. Dark green
 III: Severe contamination. Dark yellow.
 Decreased fetal movement felt by the mother
 Biochemical signs: Assessed by collecting a small sample of baby‗s blood from a scalp prick through the open
cervix in labor:
 Fetal acidosis elevated fetal blood lactate levels
 A fetal scalp pH < 7.2 , Po2 >60mmHg suggests fetal distress
Chronic Signs & Symptoms
 Decreased or disappearance fetal movement:
 < 10 times per 12 hours is regarded as decreased
 With the first effect of hypoxia, the fetal movement is increased
 If the hypoxia persists, the fetal movement is decreased, and may disappear. If the fetal movement lost,
the fetal heartbeat will be disappearing within 24 hours
 Abnormal cardiotocography signs:
 Slow fetal heart rate(180bpm) last more than 10 min in the absence of contractions is suggestive of fetal
distress
 The fetal heart rate > 160 bpm , especially > 180 bpm, suggests early hypoxia, unless the maternal heart
rate is faster
 FHR < 120bpm, typically less than 100bpm
 The fetal heart rate normally show continuous minor variations, with a range of about 5 bpm, loss of
base line variability implies that the cardiac reflexes are impaired, either from the effect of hypoxia or of
drugs such as valium
 Early deceleration: The rate often slows with each contraction, but it returns to normal soon after
removal of the stress The early deceleration in the heart rate start within 30 seconds of the onset of
the contraction and return rapidly to the baseline rate. It is not of serious significance as a rule and
indicate that while the fetus is undergoing some stress the cardiac control mechanisms are
responding normally
 Variable deceleration: no consistent relationship with uterine contraction. • It is sometimes caused
by compression of the umbilical cord between the uterus and the fetal body, or because it is looped
round some part of the fetus • Provided that it does not persist for more than a few minutes it may
have little significance, but persistence for more than 15 minutes would call for treatment
 The most serious pattern of heart rate changes is fetal bradycardia with loss of baseline variability and
late decelerations.
 Decrease (defined as onset of deceleration to nadir =30 seconds) and return to baseline FHR associated
with a uterine contraction.
 The deceleration is delayed in timing, with the nadir of the deceleration occurring after the peak on the
contraction
 Biophysical profile (If < 4 suggest fetal distress)
 Amniotic Fluid Volume Normal = 2 Points
 Non-Stress Test Result Positive = 2 Points
 Fetal Breathing Movements Active = 2 Points
 Fetal Extremity/Trunk Movements Active = 2 Points
 Fetal Movements Active= 2 Points
Ticket 18-19
Induction of labor

➢ Labor induction is when a pregnancy care provider starts labor instead of letting
labor starts on its own. Normally, they wait until 39 weeks to start a labor but
when fetus in risk , they can do it before 39 weeks.

Reasons for inducing labor;

1)Pregnancy longer than 41-42 weeks(fetus will not get enough nutrition or oxygen)
2)Placental abruption(placenta separating from uterus)
3)Early water break but there is no contractions
4)When there is not enough amniotic fluid
5)Fetus stops growing
6)Other health conditions: high BP , preeclampsia or infection in uterus or Rh system

Ways of to do labor;
1) Administration of medication to soften,thin and open(dilate) your cervix to prepare
it for birth.(Oxytocin)
2) Rupture the amniotic sac or break your water with a device
3) Medications to cause contractions (Prostaglandins ripen the cervix and induce
uterine contractions)
4) Cervical ripening balloon.( The balloon puts pressure on the inside of your cervix to
allow it to slowly open. The balloon will fall out once your cervix has opened enough
(about 4 cm), or it will be removed after about 12 hours.)

Management of labor and delivery

Management of stages;
1)First stage;
o Analgesia upon request
o Fetal heart monitoring and determine fetal position with examination
o Regular assessment of cervical dilation and fetal head
2) Second stage
o Warm compression, helping mother for safe and comfortable position
o Guide delivery of fetus through vaginal canals
o Cord clamping
3)Third stage
o Oxytocin administration after cutting umbilical cord to reduce blood loss with
strong contractions
 o Examine placenta, umbilical cord , amniotic membranes, blood vessels to confirm
completeness
o Repair any obstetric lacerations
4)Stage Four
o Monitoring to rule out postpartum hemorrhage or preeclampsia

Ticket 21
Episiotomy and Perineum repair

❖ Episiotomy is a procedure in which a small cut is made to widen

theopening of the vagina when a woman is giving birth.This area is called
perineum.
An incision might be recommended if a baby needs to be quickly delivered because:

• The baby's shoulder is stuck behind the pelvic bone

• The baby has an unusual heart rate pattern during delivery
• Forceps or vacuum extraction is needed during a vaginal delivery.

There are two types of episiotomy incisions:

• Midline incision. A midline incision is done vertically. A midline incision is

easier to repair. But it has a higher risk of extending into the anal area.
• Mediolateral incision. A mediolateral incision is done at an angle.It is less
likely to result in an extended tear into the anal area. However, It is often
more painful and more difficult to repair.

Risks ;

1)Bleeding 2) Swelling 3)Infection 4)Collection of blood in perineal tissue

5)Tearing in to reactal tissues and anal sphicnter muscle which controls passage of
stool

Perineum Repair
There are four degrees of tears that can occur during delivery:
• First degree tears involve the vaginal mucosa and connective tissue; most of them close
spontaneously
• Second degree tears involve the vaginal mucosa, connective tissue and underlying muscles.
requires one or two sutures
• Third degree tears involve complete transection of the anal sphincter.
• Fourth degree tears involve the rectal mucosa.
Third and fourth they need anesthesia. Close the rectum with inverted stiches, and then we suture the
sphincter and the muscle layer, followed by the skin and mucosa, Rectum > anus >muscle>mucosa
Ticket 22 – 23

Complications of the IIIrd stages of labor and Complications of the IVth

stages of labor

3rd Stage

1. Postpartum hemorrhage=is severe vaginal bleeding after childbirth.

The average amount of blood loss after the birth of a single baby in vaginal delivery is about
500 ml.
2. Retained placenta= placenta will remain inside of the uterus more than 30 mins after
delivery. Can be cause by urinary bladder full causing obstruction or premature closure
of cervix.
3. Shock (hemorrhagic or non h.)
4. Uterine inversion =is when the uterus turns inside out

4th Stage
1) Post-partum hemorrhage, which can be because of:
- Abnormal placental insertion
- Partially separated placenta (some of the placenta is inserted in the uterine
wall
- Hypotonic uterus (less contration)
- Retained placenta (placenta is separated fron the uterine wall, but remains
inside of the uterine cavity
2) Perineum rupture

Ticket 24. Manual extraction of the placenta

Indications;

– Placenta not yet expelled 30 to 45 minutes after delivery.

– Haemorrhage prior to spontaneous expulsion of the placenta.

Procedure: a hand is introduced inside the uterine cavity and with the fingers/cubital side of
hand, we remove the placenta.
1) Brandt-Andrew maneuver:We press in front or just over the symphysis and with
pulling of the umbilical cord. It is done only if placenta is separated from the uterine
wall.

2) Crede maneuver= placing a hand on the abdominal wall near the uterine fundus and
squeezing the uterine fundus between the thumb and finger

3) Controlled cord traction (CCT) is applied to the umbilical cord once the woman's
uterus has contracted after the birth of her baby, and her placenta is felt to have
separated from the uterine wall, whilst pressure is applied to her uterus beneath her
pubic bone until her placenta delivers.
25. Manual and instrumental curettage of the uterine cavity
▪ Health care providers perform dilation and curettage to diagnose and treat certain
uterine conditions — such as heavy bleeding — or to clear the uterine lining after a
miscarriage or abortion.
• Curettage = refers to the scraping or removal of tissue lining the uterine cavity
(endometrium) with a surgical instrument called a curette.

Reasons for curettage ; 1)Prevent infection or heavy bleeding by clearing tissues

that remain in the uterus after a miscarriage or abortion

2) Remove a tumor that forms instead of a typical pregnancy (molar pregnancy)

3)Treat excessive bleeding after delivery by clearing out any placenta that remains in
the uterus

4)Remove cervical or uterine polyps, which are usually noncancerous (benign)

Steps for curettage; 1) Patient will be positioned on an operating or examination table,

with feet and legs supported as for a pelvic examination

2)An intravenous (IV) line may be started in your arm or hand and A urinary catheter
may be inserted.

3)Your doctor will insert an instrument called a speculum into your vagina to spread the
walls of the vagina apart to expose the cervix and cervix may be cleansed with an
antiseptic solution

4)Focal /local or generalized anesthesia will be done , determine the length of uterus
with instrument. A type of forceps, called a tenaculum, may be used to hold the cervix
steady for the procedure.

5) The cervix will be dilated by inserting a series of thin rods. Each rod will be larger in
diameter than the previous one. This process will gradually enlarge the opening of the
cervix so that the curette (spoon-shaped instrument) can be inserted.

6) The curette will be inserted through the cervical opening into the uterus , to scrape
away the tissues. In some cases, suction may be used to remove tissues. If you have
local anesthesia, this may cause cramping.

• Instrumental curettage = The curette will be inserted through the cervical opening into
the uterus and the sharp spoon-shaped edges will be passed across the lining of the
uterus to scrape away the tissues.
Risk factors ; Perforation of uterus, Infection, damage to cervix

20. Obstetric anesthesia and analgesia

 X
1. Rupture of the membrane
leads to premature labor
2. Fetal trauma
3. Pregnancy loss
26. Lie, presentations and positions
 Fetal Lie
The relation of the long axis of the
fetus to that of the mother
 Longitudinal lie - found in
99% of labours at term
 Transverse lie - multiparity,
placenta praevia,
hydramnios, uterine
anomalies
 Oblique lie: unstable
(become longitudinal
transversal)
By abdominal palpation, vaginal
examination, and auscultation, or by
technical means (USG, X-ray)
 Fetal presentation: The portion of the
fetus that is in the birth canal. The
presenting part can be felt through
the cervix on vaginal examination.
 Longitudinal lie: cephalic and
breech presentations
 Transverse lie: shoulder
presentations. Down, with the
back facing the birth
canal. With one shoulder
pointing toward the birth
canal. Up, with the hands and
feet facing the birth canal.
27. Caesarian section
 Fetus is delivered through incisions
in the anterior abdominal and uterine
walls.
 Indications:
1) Placenta previa= An abnormally
implanted placenta, placed totally or
partially in the lower segmented of
the uterus.
2) Vasa previa= Umbilical cords
cross the internal os during delivery,
it is like an umbilical cord prolapse.
3) Umbilical cord prolapse
4) Previous C-sections= The lady has
to wait at least 1.5 years to get
pregnant again and avoid the rupture
risk. If vaginal delivery, there is a
risk of uterine rupture due to a weak
uterus.
5) Abnormal presentation of the
fetus (brow presentation, or footling)
6) Placental abruption
7) Uterine rupture
8) Large fetus
9) Small pelvis
10) Active genital infection
11) Uterine dysfunction
12) Fetus malformation
13) Multiple pregnancy (triplets)
14) Uterine abnormalities (tumors)
 Indication for primary caesarian:
- Cephalopelvic disproportion: most
common indicator. This means that
the pelvis is too small for the fetal
head.
- Fetal malpresentation: refers most
commonly to breech presentation.
Also means any fetal orientation
other than cephalic.
- Non-reassuring strip: fetal heart
rate monitor suggests fetus may not
be prepared for the labor (strong
enough)
 Procedure:
1. Epidural anesthesia, general only
in emergency c sections
2. 3 possible incisions:
 Midline: in case of
extreme emergency
because it gives faster
access.
 Paramedian: in case
of a scar or obstacle
on the midline
  Low uterine segment
section (transverse
cut): most commonly
used, the non-
contractile portion of
the uterus, low chance
of uterine rupture.
3. Uterine incision: done above the
urinary bladder (thin area with less
bleeding). Don’t cut the mid of the
uterus because it is a thick wall with
a lot of blood.
 Complications: Maternal morbidity
and mortality is higher than with
vaginal delivery.
1) Hemorrhage: blood loss is twice
that of a vaginal delivery, with
average of 1000ml
2) Infection: sites of infections
include endometrium, abdominal
wall wound, pelvis, urinary tract or
lung.
3) Visceral injury: surrounding
structures can be injured (bowel,
bladder, uterus).
4) Thrombosis: deep venous
thrombosis is increased in the pelvic
and lower extremity veins.
28. Post-partum period in Caesarian
section
 After c section the patient has to be
hospitalized for 3 days because of
possible complications
 During hospitalization we have to
evaluate the general state of the
mother by the following:
1) Measuring of temperature
2) Pulse
3) BP
4) Check the incision, if there is any
bleeding or infections
5) Lochia, the color (vaginal
discharge after giving birth,
containing blood, mucous and
uterine tissue):
- Lochia rubra,
- Lochia serosa
- Lochia alba
In the beginning, first 3 days it is red
in color, after that it becomes
brownish for several days, then after
that yellow. All together it lasts 5
weeks.
6) Intestinal transit (if there is
constipation or diarrhea)
7) Urination
8) Level of the fundus: after
delivery, the fundus should be at the
level of the umbilicus. By
approximately 2 weeks we should
feel the uterus above the symphysis.
9) Breast examination: sensitivity,
engorgement, if there is milk present.
10) Examine lower limbs for DVT
(deep venous thrombosis)
29. Normal puerperium.
 the time from the delivery of the
placenta through the first few weeks
after the delivery.
 the period of 4 to 6 weeks (40 days)
 It will end when the reproductive
organs return to the non-pregnant
condition.
 Changes of the organs in this period:
1) Uterus:
- Immediately after delivery the
fundus uteri should be at the level of
the umbilicus
- By the 2nd week we should not feel
the uterus anymore, above the
symphysis
- The uterus during this time will
return to its normal weight of 50-
100g (during pregnancy it reaches
1kg)
- Breast feeding accelerates uterine
involution (when the baby is
suckling it releases oxytocin that
causes uterine contraction)
- By the 1st week after delivery the
endometrium starts to recover and by
almost the 2nd week, the
endometrium is covering the whole
uterine cavity
2) Cervix: it is very rapidly closing
to the non-pregnant state, and
approximately by the 1st week it is
only 1 finger wide.
3) Vagina: will regress but never to
the non-pregnant size. In women
who don’t breast feed, it will recover
faster, because estrogen will increase
faster. (when women are
breastfeeding prolactin stays high
which will block the hypophysis –
FSH, LH, no estrogen, and that’s
why there is no menses)
4) Perineum: fast recovery, we have
to look at the sutures to check if
there are scars
5) Abdominal wall: it is recovering
but not as fast as the uterus, and this
is because of the distention, and it
depends very much on maternal
exercises.
6) Ovaries: women who breast feed
will have longer periods of
amenorrhea and no ovulation (no
menses). Women who do not breast
feed may ovulate 27 days after
delivery.
7) Breast:
- It will not regress after delivery,
actually it will continue producing
milk, under the influence of prolactin
- In vaginal delivery the colostrum
will be present until 48h after
delivery. Lactation of normal milk
production starts after that.
- In C section, colostrum will be
present after 72h
o Lactation of normal milk
production starts after that
o Because it is done earlier than the
labor time.
30. Pathological puerperium.
 pathologies during puerperium, and
the most common are infections and
hemorrhage
 affected organs are vulva, cervix,
vagina, uterus, fallopian tubes,
breast, urinary tract
1.Infection
2.Sepsis
3.Breast problems: mastitis
4.Urinary tract infection:irritation of
urethra during delivery
5.Venous thrombosis:hypercoagulability
state of pregnancy
6.Psychitic problems: depression
7.obstetric palsy:severe neuralgia due to
pressure on thee lumbosacral nerve
plexus
 Diagnosis: pelvic pain,fever at least
twice in the first 10 days, discharge
with bad smell, Painful during the
examination, leukocytosis, increased
ESR and fibrinogen
 For treatment: broad spectrum
antibiotics, if pus we should drain it.
To prevent thrombophlebitis, we
give heparin LMWH.
31. Cardinal Symptoms in Gynaecology: Pain 32. Cardinal Symptoms in Gynaecology: Bleeding
Related to Menses Vaginal bleeding can be a clinical feature of a number
Primary Dysmenorrhea of genitourinary conditions that affect not only the
- Crampy or dull pain vagina but also the uterus, ovarian tubes, ovaries, and
- Headache urethra.
- Nausea
Determined by the patient's age and pregnancy status.
- Constipation / Diarrhoea
Endometriosis Pain is an important differentiating factor.
- Dysmenorrhea, dyspareunia & infertility Age group
- Sharp
Premenachal Children
- Dull pelvic pain
Mittelschmerz - Estrogen withdrawal
- Severe, sharp pain lasting 1-2 days during - Abnormally young puberty
ovulation - Trauma
- Light spotty vaginal bleeding Non pregnant women
Unrelated to Menses - Endometriosis
Ovarian cyst (benign or malignant) - Pelvic Inflammatory Disease
- Dull, Persistent unilateral pain - Polycystic Ovary Syndrome
- Palpable pelvic mass - Trauma
Pregnant Women
Ruptured Ovarian Cyst - Ectopic Pregnancy
- Sudden onset of pain - Spontaneous Abortion
- Slight vaginal bleeding
- Uterine Rupture
- Nausea
- Vomiting - Trauma
Postmenopausal Women
Adnexal torsion - Gynaecologic Malignancies (cervical or
- Nausea
endometrial cancer)
- Vomiting
- Peritoneal signs - Endometriosis
- Cervical motion tenderness - Hormone replacement therapy
- Endocrine disorder (hypothyreosis)
Pelvic inflammatory disease
- Sometimes fever or dyspareunia
- Cervical motion tenderness or uterine Painful Vaginal Bleeding
tenderness - Ectopic pregnancy
- mucopurulent cervical discharge - Spontaneous abortion
- Benign neoplasms: Adenomyosis & Uterine
Acute degeneration of uterine fibroid Leoiomyoma
- Sudden onset of pain
- Ovarian Cyst Rupture
- Most common during the first 12 weeks of
- Infection / Inflammation: Pelvic Inflammtory disease
pregnancy
& Cervicitis
Pelvic Adhesions - Endometriosis
- Trauma
Pregnancy related
- Miscarriage Painless Vaginal Bleeding
- Ectopic pregnancy:
- Round Ligament Pain - Polycystic ovary syndrome
- Urinary Tract Infection - Endometrial Hyperplasia
- Fibroids - Endometrial Polyp
- Braxton Hicks contractions - Malignant neoplasms: Cervical Cancer & Endometrial
cancer
- Adverse Effects: Anticoagulants, Oral contraceptives,
intrauterine devices
- Anembryonic Pregnancy
33. Cardinal Symptoms in Gynecology: Amenorrhea 34. Cardinal Symptoms in Gynaecology: Vaginal
The absence of menarche at 15 years of age despite Discharge
normal development of secondary sexual The amount of vaginal discharge varies by individual
characteristics, or absence of menses at 13 years of age and by the stage of the menstrual cycle
in female individuals with no secondary sexual
characteristics.
Insertion of a speculum device facilitates the inspection
Causes of Primary Amenorrhea of the vaginal wall and ectocervix.
Constitutional growth delay Evaluate the quality of vaginal discharge to determine
Normal pubertal development, but adrenarche and whether a smear should be acquired
gonadarche occur at a later age
Causes of increased vaginal discharge
- Hypogonadotropic hypogonadism
Caused by deficient release of GnRH Physiological
- Oestrogen related—puberty, pregnancy, COCP.
- Hypergonadotropic hypogonadism - Cycle related—maximal mid-cycle and premenstrual.
GnRH is released but the ovaries fail to produce
- Sexual excitement and intercourse.
estrogen and progesterone.
- Anatomic anomalies Pathological:
Outflow tract obstruction with otherwise normal Infection
puberty - Non-sexually transmitted (BV, candida).
- Receptor & enzyme abnormalities - Sexually transmitted (TV, chlamydia, gonorrhoea).
Complete androgen insensitivity syndrome Non-infective
- Foreign body (retained tampon, condom, or post-
Diagnostics partum swab).
- Pregnancy Test - Malignancy (any part of the genital tract).
- If Galactorrhoea is present: check prolactin & TSH - Atrophic vaginitis (often blood-stained).
levels. - Cervical ectropion or endocervical polyp.
- If blood pressure is high: Suspect congenital adrenal - Fistulae (urinary or faecal).
hyperplasia - Allergic reactions.
Treatment
- Anatomical abnormalities: Surgery Characteristics of discharge
- Hypogonadism: Hormone replacement therapy with (Onset, duration, odour, colour)
estrogens & progesterone - Associated symptoms (itching, burning, dysuria,
The goal of treatment is the progression of normal superficial dyspareunia).
pubertal development. - Relationship of discharge to menstrual cycle.
- Precipitating factors (pregnancy, contraceptive pill,
Causes of Secondary Amenorrhea sexual excitement).
- Pregnancy - Sexual history (risk factors for sexually transmitted
- Ovarian disorders infections).
- Medications (antipsychotics, chemotherapy, oral - Medical history (diabetes, immune-compromised).
contraceptives) - Non-infectious causes (foreign body, ectopy,
- Hypothyroidism malignancy, dermatological conditions).
- Hyperthyroidism - Hygiene practices (douches, bath products, talcum
- Cushing syndrome powder).
- Obesity - Allergies.
Diagnostics
- Pregnancy Test
- ↑ FSH: ovarian insufficiency
- ↑ TSH: hypothyroidism
- ↑ Prolactin

Treatment
Tumors: Surgical resection
Premature ovarian failure: combined oral contraceptives
35. Cervical & Endometrial Neoplasm – Screening,
HPV- CIN, Pap smear
Screening
For average-risk patients (asymptomatic,
immunocompetent, and normal cervical cancer
screening history), they include three screening
strategies depending on age:
- 21–29 years of age: Pap smear every 3 years
- 30–65 years of age any of the following:
Pap smear every 3 years
HPV DNA testing every 5 years
Pap smear with HPV DNA testing every 5 years
HPV – CIN
Cervical intraepithelial neoplasia (CIN)
Precursor lesion characterized by epithelial dysplasia
that begins at the basal layer of the squamocolumnar
junction and extends outward
May progress to invasive carcinoma if left untreated
Classification: classified as ClN I–III
CIN I:
- mild dysplasia, involves ∼ ⅓ of the basal epithelium
- Koilocytes may be present
- Epithelial cells with perinuclear halos
- Pathognomonic for HPV infection
CIN II:
- moderate dysplasia, involves ⅓–⅔ of basal epithelium
- Loss of epithelial architecture into as far as the middle
third of the epithelium
- Koilocytes may be present.
CIN III:
- severe, irreversible dysplasia or carcinoma in situ,
involves > ⅔ of basal epithelium
- Loss of organized epithelial architecture
- Koilocytes may be present.
HPV – DNA testing
A screening test for cervical cancer in which cells
collected from the cervix are tested for infection with
high-risk HPV types
Primary HPV test
- Preferred cervical cancer screening test
Co-test (with concurrent Pap smear)
- Used when primary HPV tests are not available
- The sample obtained for the Pap smear can also
be used for DNA testing.
Reflex HPV test (triage HPV test)
- A test used to detect the DNA of high-risk HPV
types
- Performed after an abnormal Pap smear,
typically using the same Pap smear sample
showing abnormal cells
Screening interval: perform every 5 years with HPV
primary test and co-test
PAP smear
Description: a cytological screening test for cervical
cancer in which a cell sample taken from the cervix is
examined for cellular abnormalities that may be
indicative of cervical cancer
Technique:
- To obtain the specimen, use a sterile speculum to
visualize the cervix
- Cleanse the cervix using a cotton pledget.
- Visualize the transformation zone and, if possible, the
squamocolumnar junction.
- The specimen must be collected using a spatula or
brush that is rotated by 360 degrees.
- Scraping of ectocervix
- Scraping of endocervix
- A thin layer of the specimen is uniformly applied to
the labelled glass slide.
- Immediate fixation
- Using 95% ethyl alcohol (or spray fixative) to avoid
drying
- Hold the fixative spray 15–20 cm away from the slide
and spray evenly.
- Stain using Papanicolaou dye.
36. Vaginal Smear
Smear taken from the vaginal mucosa for cytological
analysis it is used to find the cause of vaginitis or
vulvitis
Indications:
- May be considered in case of vaginitis symptoms such
as: vaginal itching, burning, rash, odour, or discharge
- It may assist in suspicion of vaginal yeast infection,
trichomoniosis, and bacterial vaginosis
Method
- Is not done during menstrual period, because
menstrual blood can affect the results
- Vaginal irrigation, tampon use or sex (disrupting the
pH) should be avoided for 24 hours before the test
- Antibiotics treatment is not administered at least 8
days before.
- The sampling is done with the patient in lithotomy
position.
- A speculum is used to facilitate use of a swab or
spatula to sample fluid inside the vagina.
- The sampling procedure may cause some discomfort
and minor bleeding, but otherwise there are no
associated risks.
- The sample is then smeared upon a microscope slide
and is observed by wet mount microscopy by placing
the specimen on a glass slide and mixing with a salt
solution.
37. Colposcopy
Colposcope: a type of microscope used to acquire a
magnified view of the ectocervix or vaginal wall
-Allows for assessment of the ectocervix under
magnification.
-Application of acetic acid or iodine facilitates the
colposcopic detection of precancerous and cancerous
lesions
Benign lesions:
- Cervical ectopy
- Nabothian cysts
- Cervical polyps
Abnormal findings:
- Condylomata acuminate
- Cervical leukoplakia
- Cervical intraepithelial neoplasia
- Cervical cancer
38. Lahm-Schiller test
Medical test in which iodine solution is applied to the
cervix in order to diagnose cervical cancer.
-Procedure: Schiller's iodine solution is applied to the
cervix under direct vision. Normal cervical mucosa
contains glycogen and stains brown, whereas abnormal
areas, such as early cervical cancer, do not take up the
stain.
-The abnormal areas can then be biopsied and examined
histologically.
-Schiller's test is not specific for cervical cancer, as
areas of inflammation, ulceration and keratosis may also
not take up the stain.
39. Biopsy
A cervical biopsy is usually done when abnormalities
are found during a pelvic exam, Pap smear, and/or HPV
test. It is often performed as part of a colposcopy.
Types
Punch biopsy
- A small piece of cervical tissue (diameter < 5 mm) is
removed by a circular blade.
*Indication: Acetowhite area seen during colposcopy
Cone biopsy:
A procedure in which a cone of cervical tissue
comprising both the ectocervix and endocervix is
excised with either a scalpel (cold-knife conization) or a
laser loop (LEEP)
Endocervical curettage (ECC)
- The mucous membrane of the endocervical canal is
scraped by a curette.
*Indications: Nonpregnant patients in whom
colposcopy is inconclusive
*Positive screening test (primary HPV test, Pap smear,
co-testing) without visible lesion on the ectocervix
*Suspicion of glandular abnormalities on cytology (e.g.,
adenocarcinoma)
40. Biopsic Curettage
The scraping or removal of tissue lining the uterine
cavity (endometrium) with a surgical instrument called
a curette and examined under a microscope
Indications:
- Abnormal uterine bleeding
- Endometrial cancer
- Endometrial hyperplasia
- Uterine polyps
41. Hysterometry 43. Tubal Patency Test
Is the use of the hysterometer to measure the length of Hysterosalpingography:
the uterine cavity and the cervical canal in centimeters. - Easily done
- Good sensitivity and specificity
Normal uterine cavity length: - Can be uncomfortable
- 7 cm in nulliparas - May have false positive results (suggesting
- 8 cm in multiparas Procedure: tubal blockage due to spasm)
Laparoscopy and dye test:
1. Lithotomy position - Day-case procedure that can be combined with
2. Bimanual examination to orientate the position of hysteroscopy to assess the uterine cavity if
the uterus necessary.
3. Insert speculum - “Gold standard”
4. Desinfection of the area - Pelvic pathology (endometriosis, peritubular
adhesions) can be diagnosed and treated.
5. Grasp (catch) the superior/ anterior part of the cervix - Requires general anesthetics.
6. Introduce the hysterometer through the vagina and - Carries surgical risks.
then into the cervical and then to uterine cavity.
Hysterosalpingo-sonograph (HyCoSy):
Indication: - Ultrasound with galactose-containing contrast
- Use it before doing D&C to know how deep to medium.
introduce the curette to avoid the uterine perforation. - Similar sensitivity to HSG.
- In case of uterine tumour like leiomyoma and if the - No radiation exposure.
-
uterus is very big and we need to take biopsy by
44. Ultrasound in Gynaecology
curette we will use it to orientate obviously to know Transabdominal ultrasound:
how deep we need to inside. -An abdominal ultrasound is the easiest method of
Complications assessing the uterus, ovaries, and adnexal structures.
- Perfomation of uterus. Assessment of:
- Urogenital tract
Conditions:
- Assessment of fetal development
- Have to be done in follicular phase of the cycle (not in
- Pelvic organs
the luteal phase)
- No genital phase Transvaginal Ultrasound:
- No pregnancy Ovaries:
- Performed to diagnose ovarian cysts, tumors,
and follicular maturation
Uterus:
- Myometrium (e.g., to diagnose leiomyomas)
42. Hysterosalpingography:
- Endometrium (Endometrial thickness varies
Imaging technique involving the injection of contrast
with the menstrual cycle)
dye into the cervical canal and serial radiographs to
evaluate the uterine cavity and morphology/patency of *Postmenopausal women with an endometrial thickness
the fallopian tubes. >10 mm should undergo hysteroscopy and endometrial
- Also known as uterosalpingography. curettage to rule out endometrial carcinoma.
- HSG may also have therapeutic benefits for infertility
-Assessment of fetal development during the first
treatment. trimester
-Measurement of cervical length in cases of cervical
incompetence
Breast Ultrasound:
-Can be used to assess breast lesions which were
detected by palpation, mammography, and/or breast
MRI scans.
- Ultrasound can also be used to assess the axilla for
lymph node involvement if there is suspicion for breast
cancer.
45. Hormonal Investigations 47. Infertility- Investigations & Basic Therapeutic
- Progesterone Approaches
- Estrogens - Infertility is generally defined as the inability to
- Human placental lactogen achieve pregnancy despite regular unprotected sex after
-FSH at least one year in women <35 years of age and after 6
- LH months in women >35 years of age.
- Prolactin - Female infertility may manifest with symptoms of
- TSH T3, T4 anovulation (e.g., amenorrhea, irregular menses).
- Human chorionic gonadotropin (hCG) Diagnostics:
- ACTH - Medical history of both partners, especially
- Cortisol gynecological history (e.g., children, family history)
- Oxytocin - Assess ovulatory function
- Testosterone - Menstrual history
- Body temperature analysis to monitor menstrual
- Aldosterone
cycle
- Hormone tests (Progesterone, LH, FSH,
46. STD- Diagnosis and Prevention Estradiol, Anti-Mullerian H., TSH, Prolactin)
The most common symptoms of STIs are pain in the - Ovarian sonography: antral follicle count
suprapubic and genital area, urethral or vaginal - Endometrial Biopsy: to determine thickness
discharge, and genital lesions, which may or may not be - Imaging: assess the patency of fallopian tubes and
painful. uterus.
- Examine cervix
Diagnosis:
- Physical examination
- Chlamydia: Vulvovaginal or endocervical swab for - Pap smear
nucleic acid amplification test (NAAT) - Testing for antisperm antibodies in cervical
- Herpes Simplex: Appearance of typical rash & PCR & mucus
Culture
- Gonorrhoea: Endocervical or vulvovaginal swab with Treatment:
NAAT & Culture for sensitivity - Lifestyle modifications: cessation of alcohol, nicotine,
- Syphilis: Specific EIA for screening (IgG +IgG) and recreational drug use as they contribute to
- Trichomonas: Direct observation by wet smear & subfertility.
culture media & NAAT
- HPV: Clinical appearance & Smear tests & - Treatment of underlying causes (e.g., levothyroxine
Colposcopy for hypothyroidism, bromocriptine for
- Bacterial Vaginosis: Homogenous grey white hyperprolactinemia, metformin for PCOS)
discharge & ph>5.5 & fishy smell & “clue cells” on
microscopy Ovulation induction:
- Clomiphene citrate
Prevention: - GnRH (pulsatile): stimulation of FSH and LH
Preexposure prophylaxis: release leads to follicle maturation
1. Safe sex practice - Gonadotropins (e.g., recombinant hCG,
- Abstinence recombinant LH)
- Condom use during vaginal sex or anal sex - Tamoxifen (selective estrogen receptor
- Dental dam use during oral sex modulator)
- Mutual monogamy - GnRH-antagonists
- Reducing number of sex partners
Assisted reproductive technology:
2. Vaccination
- In vitro fertilization
- HPV, HBV, and HAV vaccine
Intrauterine insemination (IUI): a procedure in which
3. Disease-specific prophylaxis
washed and concentrated sperm are introduced directly
- Adherence to screening guidelines for STIs
into the uterine cavity
- Postexposure prophylaxis
- Oocyte donation
- HIV postexposure prophylaxis
- Surgery: removal of tubal, cervical, or uterine
- Hepatitis B postexposure prophylaxis
adhesions, myomas, and/or scar tissue
- Antibiotic postexposure prophylaxis (e.g.,
doxycycline for chlamydia or syphilis)
- Self-sampling/-testing and pooled sampling
- Expedited partner therapy
48. Family planning- practical medical strategies
Family planning is the ability of individuals and couples
to control their number of children and the spacing
between births.
Goals:
Improve pregnancy planning and spacing
Prevent unintended pregnancies
STI prevention
Family planning services include:
- Fertility counselling
- Reproductive life plan and preconception
counselling
- Pregnancy testing and counselling
- STI counselling
- Preventive health counselling (e.g., breast
cancer screening, cervical cancer screening)
Family planning counseling:
Counseling on the use of contraceptives and infertility
treatment to prevent pregnancy or attain the desired
number of children and determine the spacing of
pregnancies.
Preconception Counceling:
A form of medical counselling provided to couples of
reproductive age who are planning to conceive.
Goals:
- Identify and address any modifiable factors that may
negatively affect pregnancy and childbirth
- Educate couples about risks and how to mitigate
them.
Key components:
- Risk assessment (e.g., immunizations, medication
use, genetic carrier screening, environmental risks)
- Healthy lifestyle promotion (e.g., counseling on
proper nutrition, regular exercise, smoking cessation,
alcohol use)
- Medical and psychosocial intervention and
counseling (e.g., chronic disease management, folic
acid supplementation, psychosocial risks)
- Physical assessment
Emergency Contraception:
Refers to measures taken to prevent pregnancy within 5
days of unprotected intercourse or contraception failure
(e.g., condom breakage, missed oral contraceptives).

Goals of family planning counseling:

- Encourage individuals to make informed decisions
about their reproductive goals.
- Discuss contraceptive methods and potential barriers
to contraception based on the individual's preferences.
Provide pregnancy testing and counselling, including
current vaccination status
- Discuss pregnancy spacing to reduce adverse
outcomes
Reproductive life plan (RLP) counselling:
Reproductive life plan: a set of goals regarding the wish
and timing to have children based on personal values,
priorities, and resources
Infertility Counseling:
Evaluation for couples who have not conceived after
one year of unprotected vaginal intercourse and
counseling for individuals and couples who are sterile
or are not physically able to conceive.
Goals:
- Offer counseling on optimizing fertility (i.e., sexual
and lifestyle practices relating to conceiving)
- Provide counseling and offer an appropriate
treatment plan to support individuals and couples
with fertility problems (i.e., infertility, sterility)
- Offer counseling on preventing tubal infertility due
to STIs
- Provide counseling on assisted reproductive
technology
 49-Uterine Curettage
 Dilation and curettage (D&C) is a brief surgical procedure in which the cervix is dilated and a special
instrument is used to scrape the uterine lining.
 Indications:
 Remove tissue in the uterus during or after a miscarriage or abortion or to remove small pieces of
placenta after childbirth. This helps prevent infection or heavy bleeding.
 Diagnose or treat abnormal uterine bleeding. A D&C may help diagnose or treat growths such as
fibroids, polyps or endometriosis, hormonal imbalances, uterine cancer. A sample of uterine tissue is
viewed under a microscope to check for abnormal cells.
 Complication
 Perforation
 Ashermans‘s syndrome – infertility
 Infection
 Cramping
 Spotting or light bleeding
50-Termination of Pregnancy-Voluntary or Therapeutic
 A: continuance of the pregnancy would involve risk to life of pregnant woman greater than if pregnancy were
terminated.
 B: termination is necessary to prevent grave permanent injury to physical or mental health of pregnant
woman.
 C: pregnancy has not exceeded 24th week and continuance of the pregnancy would involve risk, greater than
if pregnancy were terminated, of injury to physical or mental health of pregnant woman.
 D: pregnancy has not exceeded 24th week and continuance of pregnancy would involve risk, greater than if
pregnancy were terminated, of injury to physical or mental health of any existing child(ren) of family of
pregnant woman.
 E: there is a substantial risk that if the child were born it would suffer from such physical or mental
abnormalities as to be seriously handicapped.

 Method of TOP depends on gestation of pregnancy and the woman‘s choice. Procedures offered also vary
from one centre to another (usually determined by local resources).
 Surgical
 <7wks: conventional suction termination should be avoided.
 7–13wks: conventional suction termination is appropriate, although, in some settings, the skill and
experience of the practitioner may make medical TOP more appropriate at gestations >12wks.
 >13wks: dilatation and evacuation following cervical preparation; requires skilled practitioners (with
necessary instruments and sufficiently large case load to maintain skills). The greater gestation, the
higher the risk of bleeding, incomplete evacuation, and perforation.
 Cervical preparation is highly beneficial:
 it reduces difficulties with cervical dilation
 particularly if patient is <18yrs or gestation is >10wks.
 Possible regimes include:
 misoprostol 400 micrograms PV 3h prior to surgery, or
 gemeprost 1mg PV 3h prior to surgery, or
 mifepristone 600mg PO 36–48h prior to surgery.
 Medical
 <9 wks: using mifepristone priming plus a prostaglandin regime (misoprostol) is the most effective
method of TOP in gestations <9wks. Antiprogesterone (given 24–48h prior), which results in uterine
contractions, bleeding from the placental bed, and sensitization of uterus to prostaglandins. Its use has
been shown to reduce the treatment to delivery interval in medical TOP.
 9–13wks: medical TOP is an appropriate, safe, and effective alternative to surgery (incomplete
procedure rates increase after 9wks).
 13–24 wks: medical TOP as above is also appropriate, safe, and effective in this group. Feticide
should be considered in advanced gestations (>20wks).