1.

Bony pelvis, side walls

A. largepelvis
 Bitrocanteriandiameter: 32 cm
 Bicrestdiameter: 28 cm
 Bispinosdiameter: 24 cm
 Antero-posterior diameter: 20cm
B. smallpelvis
I. Superior Inlet
 Transverse diameter - 13.5 cm
 Oblique diameter - 12 – 12.5 cm
 promonto-suprapubic diameter - 11 cm Or Ant.-
post.(CONJUGATA VERA)
II. Middle Inlet
 Sagittal diameter - 11.5 cm
III. Inferior Inlet
 Lower margin of coccyx - 9.5 cm apex.scro-inf.symph13.5 cm
 bi-ischialdiametre 11cm
 Pelvimetry
 diagonal conjugate 12.5 – 13cm
 bi-ischialdiametre 11 cm
 incisura ischiadica 5 cm
 angle of sub-pubic arch 90 degrees
Linea terminalis = pubis crest + pectinal line of pubis + Arcuat line of ilium
You need to know: sacro iliac joint, ala of sacrum, promontory of the sacrum,
lig.sacrotuberale, lig.sacrospinale, spinaischiadica, tuber ischiadicum,
eminentiailiopubica, tuberculum pubicum, trochanter major. Apex of sacral bone,
coccyges bone.
 2. Fetal head

- We need to know sagittal and transverse and transverse diameter because they are
important for the delivery
- Each presentation we have different diameters

 Fetal head is composed of:

 face, 2 frontal bones, 2 parietal bones, 2 temporal bones, occipital
bone, the wings of the sphenoid
 Sutures:
 Frontal, sagittal, coronal, lambdoid
 The diameters of the newborn skull:
- The occipitofrontal diameter = 11.5 - 12cm
- The biparietal diameter = 9.5 cm
- The bitemporal diameter = 8 – 8.5 cm
transverse diameters
- The mobility of fetal head in relation with the
vertebral column

 Sagital diameters

1. Occipital presentation – the largest diameter is suboccipito-bregmatic

– 9.5 cm
2. Inbregmatic presentation – the largest diameter is occipito-frontal -
11.5 cm
3. In brow presentation – the largest diameter is mento-vertical - 13 cm
4. In face presentation - the largest diameter is submento-bregmatic
which is 9.5 cm
 Head circumference:
1. Great circumference – occipito-frontal diamenter = 34,5cm
2. Small circumference – suboccipito-bregmatic diamenter = 32-33 cm
 Fontanele :
1. Greater-bregmatic / anterior : - Similar to quadrant shape
Close by 1 year
2. Lesser – lambdoid / posterior : - triangular in shape
Close by 3 months
 Sutures
1. Frontal - between two frontal bones
2. Sagital – between two parietal bones
3.Clinical diagnosis of the pregnancy

There are three degrees of certainty in diagnosis approach:

1- Presumptive signs: - Amenohrea
- Breast tenderness
- Nausea
- Vomiting
- High skin pigmentation

2- Probable signs : - enlargement of the uterus

- Maternal sensation of the uterus contractions
- Fetal movement
- Hegar sign
- Positive urine of serum B-HCG

3- Positive signs : - hearing fetal heart tones

- Sonographic visualization of a fetus
- Perception of fetal movements by an external
examiner
- X-ray showing a fetal skeleton

1 - presumptive
1- Skin changes: - abdominal stretch marks and lineanegra
2- Fatigue
3- Breast changes: high in volume, hyperpigmentation of alveolar, enlargement
of Montgomery gland, dilation of superficial veins.
4- Vaginal changes: Chadwick´s sign – violet discoloration of the vagina due
to high blood supply. Discharge – Leucorrhea.
5- Quickening : mother feel the fetal movement by week 16-18

2 - probable

1- Uterine changes: by the week 12 it arises above symphysis and after that it
grows every week 1cm. it will reach the xiphoid process by week 36-38 which
is the peak.
Hegar´s sign: softening of the lower part of the uterus just above the cervix,
by Drexamination found in 6-8 weeks.
2- Cervical changes:
Goodell´s sign: softening of the cervix, become like lips soft by
Drexamination found in 6 week.
Formation of mucus plug: released just before delivery
3- Braxton-hacks contraction: start from week 12, painless contraction not
strong enough to causes delivery
4- Basal temperature

3 - positive

1- By Doppler US – fetal heart sounds by 10 weeks

2- By US – gestational sac seen by 4 week
3- By physical examination – palpation of the entire fetus by 24 week
4- By x-ray – we visualize theskeletonofthe baby

 1st trimester
A. Examination of the genital area:
 -Coloration – violet coloration of the vaginal walls,
thus is called Chadwick Sign ( due to venus
dilation)
- Goodell´s sign – softening of the cervix, but when
lady is not pregnant cervix is cartilage like
- Leucorrhea – abundant
- Mc Donalt´s sign – hypermobility of the uterine
corpus
- Low consistency of the istmus? but with the
cervix an corpus of uterus
B. Examination of the breast:
- Increase in the volume
- Increase in sensibility
- Hyperpigmentation of the alveolar
- Enlargement of Montgomery glands
C. Sometimes the linea alba can be with pigmentation and become
lineanegra

 2nd and 3rd trimester

- Increase abdominal volume

- At the breast can see dilated superficial
- Veins Haller vascularization
- Increase volume of mammary glands
- Appears lactation/ colostrum ( specially in the 3rd
trimester )
4.Laboratory diagnosis of the pregnancy

 Afterovulation if it is fertilized, the zygote will take about 6 days to implant and
from that time it will start to produce HCG.
 Β-HCG from blood – is the most accurate.

Definitions:
- 1st the laboratory test, to see if there is pregnancy, by measuring level of human
chorionic godanotropin( HCG) in the urine or blood
- In HCG, we have 2 subunits:
α : is common with other hormones ( CH, FSH, TSH )
β : is only for HCG, that’s why is more specific
- HCG produced by syncytiotrophoblast

Urine test:

1- test can be done around 42 days after last menstruation because from that time it
will be enough for the test to be detected
2- 1st morning test urine
3- after 1 or 2 weeks repeat the test again

Blood test:

Test can be done around 22 days after last menses from venous blood. Ovulation is
in day 14+ 6 days for zygote to be implanted and in 2 days HCG will be in mother
blood.

False Positive(negative):

- If α subunit test used – because it cross reach with the hormone

- Tumors which producing HCG ( lung tumor)
- Ovarian tumor - because it secrete too much estrogen it causes + feedback –
result in high LH cause eraction with other hormone

False negative ( positive):

- Technical error 8 problem in the lab )
- If test is done early ( HCG can´t be detected very well
- sensitive screen assay
5.Ultrasound examination in obstetrics

Ultrasound diagnostic of pregnancy.,you should look for the Yolk sac(not the gestational sac),the embryo,if the it s a
ongoing pregnancy,the number of embryo,if the pregnancy is intrauterine,,and to identify some abnormalities
1st trimester:

1- Us can be done transvaginally or transabdominally

2- We can do it to confirm the diagnosis of pregnancy and by 4 weeks (
transvaginally) of gestation can see youlk sac which is a signal of pregnancy
3- Can see how many fetus there is
4- Can see if fetus is alive or not by looking to the fetus cardiac activity
5- Evaluate gestational age by measurement of fetal crown-rump length 6 to 13
weeks gestation can estimate fetal age within 5 days
6- Look at the placental insertion
7- Can measure amniotic fluid index (AFD)
8- Cranio-caudal length (CCL)

2nd Trimester:

1- done transabdominally
2- week 18 – 20 will start doing US till the end of pregnancy routinely because
we need to look for : Fetal anatomy, Placental location, AFI; head
circumference, biparietal diameter, femoral length, abdominal…

3rd trimester:

1- Us done by transabdominally
2- Estimate fetal weight:
a) If estimated 10% less than it supposed to be then it´s called Small
gestation age (SGA) then suspect (IUGR) (intrauterine growth restriction)
b) If estimated fetal is 90% more that is supposed to be is called Large
gestational age (LGA) then suspect macrosomia
3- AFI (amniotic fluid index)
4- Follow up: fetal anomaly, presentation will being

 Generally in US examination need to measure:

a- Length of the fetus
b- The circumference of the abdomen and the head
c- Diameter of the other long bones ( humerus)
d- Biparietaldiamenter of the head
6.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 logitudinal or transversal)
 By abdominal palpation, vaginal examination, and auscultation, or by
technical means (USG, X-ray)

Fetal Presentation
 The presenting part is the portion of the body of the fetus that is foremost in
the birth canal
 The presenting part can be felt through the cervix on vaginal
examination
 Longitudinal lie - cephalic presentation
- breech presentation
 Transverse lie - shoulder presentation
Cephalic Presentation
 Head is flexed sharply - vertex / occiput presentation
 Head is extended sharply - face presentation
 Partially flexed - bregma presenting (sinciput presentation) 11
cm
 Partially extended - brow presentation sincipito-mentorion 13,5 cm
Breech Presentation
 Frank breech
 Complete breech
 Footling breech

Position
 The relation of an arbitrary chosen point of the fetal presenting part to the Rt
or Lt side of the maternal birth canal
 The chosen point
 Vertex presentation - occiput
 Face presentation - mentum
 Breech presentation - sacrum
 Each presentation has two positions Rt or Lt
 Each position has 3 varieties: anterior, transverse, posterior

The shoulder (transverse) presentation:

1- Shoulder right in dorso anterior
2- Shoulder right in dorso posterior
3- Shoulder left in dorso anterior
4- Shoulder left in dorso posterior
7.Mechanism of labor in occipital presentation

Definition:
a. Occipital presentation means that the fetal head is fully flexed
b. Biggest diameter of fetal head is thus presentation is suboccipito-bregmatic
which is 9.5cm
c. Orientation point fot this presentation is occiput
Varitation:

R AO LOA AO
R OP LOP OP
R OT LOT ------- MOST COMMON

Mechanism:
1. Engagement – in primapara occurs earlier thus in multipara)
2. Descent
3. Flexion
4. Descent
5. Internal rotation
6. Descent
7. Extension / because if makes extension, the head is oval
8. External rotation / in the same side where the engagement started
9. Anterior AVM
10. Posterior AVM
11. Rest of the body will follow
8.Mechanism of labor in facial presentation

Definition:
a. Face presentation mean that the fetal head is fully extended
b. Biggest diameter of fetal head is this presentation is submento-bregmatic
which is 9.5 cm
c. Orientation point for this presentation is mentum

Variation:
1. RmALmA mA
2. RmPLmPmP
3. RmTLmT

Mechanism: same as Q q
9.Mechanism of labor in brow presentation

Definition:
It is a cephalic presentation in which the head is midway between flexion and
extension.

Incidence:
About 1:1000 labour.

Mechanism:
a. Persistent brow: The engagement diameter is the mento-vertical
13.5 cm which is longer than any diameter of the inlet so there is no
Mechanism of labour and labour is obstructed.
b. Tsansient brow: May occur during conversion of vertex into face
presentation.
So if brow is flexed to become vertex or extended to become face it may be
delivered.
10.Mechanism of labor in breech presentation

Definition:
a. Breech presentation means that the fetal sacrum is the presenting point at
delivery
b. The orientation point for breech presentation is SACRUM

Variation:
1. RSA LSA SA
2. RSP LSP SP
3. RST LST

 We have 3 types of breech presentation

1. Complete (knees and the hip are in flexion)
2. Frank / incomplete ( knees in extension, hip in flexion)
3. Footling – indication for C-section

Frank Mechanism:
1- Biggest diameter of fetal pelvis is bi trochanteric 9.5 cm
2- Biggest diameter of fetal shoulder is bi acromion 9.5 cm

1- Engagement
2- Descent
3- Internal rotation (to get ant post diameter)
4- Descent till the legs are out
5- External rotation / Ao the same position as engagement
6- Descent of the shoulders
7- Internal rotation of the shoulder
8- Further decent of the shoulder
9- When we will see the scapula we will pull the anterior arm out
10- Dr rotate by 180º the fetus and pull the 2nd arm out
11- Rotate the fetal head than the fetus will be towards the position of mother
pelvis
12- Dr put left hand in fetal shoulders and right hand fingers put on babies mouth
13- Make full extension of the head and take the head out

Complete breech mechanisms:

a. The biggest diameter of fetal pelvis is sacro-pre? Diameter which is 12cm
b. The biggest diameter of fetal shoulder is biacromial which is 9.5 cm
11.Amnioscopy
Conditions for Amioscopy are,fetus should be at tem,the cervix must be open,the menbrane should be non
rupture,and the baby should be alive

Definition: We use anamnioscope to examine the amniotic fluid and the fetus
through the cervical canal after dilation of the cervix.

Procedure and conditions:

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- Seen through the amniotic sac because it’s transparent

2- Fetal position
3- State of amniotic fluid :
A) Yellow (indicates bilirubin)
B) Green (indicates meconium which would result in hypoxia, there is a
deprivation of O2 and therefore the possibility of fetal distress is occurring
c) Reddish (indicates death)

Indications:

1- If mother is Rh-
2- Suspected fetal death
3- Used when the pregnancy extends approximately 2 weeks after term.
Contra indications:

1- Active labor
2- Ruptured membranes
3- Cervical infections
4- Unexplained vaginal bleeding
5- Closed cervix
12. Amniocentesis

Definition:

- Done by using a needle, placed into pocket of amniotic fluid, under direct
ultrasound guidance
- Aspirating amniotic fluid containing desquamated living cells (amniocytes)
- Performed after 15 weeks without anesthesia.
Indications:

1) If there is a risk of malformation, in this case we check the karyotype

(chromossomes) and the DNA of the fetus, because amniotic fluid contains
fetal cells. Ex:
- Down syndrome – trisomy 21
- Edward syndrome – trisomy 18
2) If the woman is older than 35 years
3) If there is prematurity risk, in this case we check the fetal lung maturity by
measuring the Lecithin-sphyngomyelin 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) We use it as a treatment in case of polyhydramnios.

5) We use it to check for Rh isoimmunization. We can see if there is a reaction
between mother and fetus by bilirubin which can be seen in the amniotic fluid
after week 24.
Complications:

1) Rupture of the membrane leads to premature labor

2) Fetal trauma
3) Pregnancy loss
13, 14. Clinical and laboratory diagnosis of the membranes rupture.

Definition:

- Rupture of the membranes at any timeof the pregnancy

- In-term pregnancy when the membranes will rupture, usually after 24 hours of
the labor starting.
Clinical:

1) We see clean fluid from the vagina by speculum, on examination the fluid is
accumulated like a pool
2) The mother tells us she lost fluid
3) Ultrasound examination we see oligohydramnios
Laboratory (procedure):

1) Nitrazine tests/pH test of the vaginal fluid:

- If the pH is alkaline? If alkaline it is a sign that there is amniotic fluid (normally
vagina is acidic, amniotic fluid is basic)
- Nitrazine paper, if it turns blue it is a sign that it is an alkaline pH
2) Microscopic examination of a sample taken from vagina and if we will see a
turning leaf shape it is a sign that amniotic fluid is present.
Management in case of the “premature rupture of membrane” (PROM):

1) If less than 34 weeks:

- Give broad spectrum antibiotics to prevent infections
- Give corticosteroids in order for the babies’ lungs become mature
- If labor will not start until 24hours after the rupture, then we induce labor by
oxytocin or prostaglandin
2) At 34 weeks or more, if labor does not start after 24 hours, we induce labor.
15,16 . Clinical and laboratory diagnosis of the fetal distress.

Definition:

1) Term used to describe fetal hypoxia (due to less blood supply)

2) Distress can be acute or chronic
Etiology:

Acute

1- Placenta abruption (hematoma between placenta and uterus)

2- Umbilical cord prolapse, in breech presentation (umbilicus came over first)
3- Hypertonic uterus, uterus is contracting too much and not fully relaxing
between contractions, and compressing the blood vessels
4- Use of oxytocin, uterus contracts too much
Chronic (maternal causes)

1- Hypotension
2- Hypovolemia
3- Other diseases
Clinical diagnosis: (signs and symptoms of fetal distress)

1- Decreased fetal movements felt by the mother (normally the mothers start to
feel fetal movements around 16-18 weeks)
2- Abnormal fetal heart rate (normal= 120-160bpm)
3- Amniotic fluid contamination by the meconium
4- Abnormal cardiotopograph (CTG)/ non-stress test
5- Ultrasound to check if fetus is alive and the heart is pumping, etc
Laboratory diagnosis:

NOO!! Blood sample from the fetal scalp and after that we check for:

1) pH, if pH is acidic then it is a sign of fetal distress

2) PO2 (pressure of O2 inside the blood vessels), if it’s > 60mmHg then it is a
sign of fetal distress
17. Induction of labor.

Definition:

To induce labor in a lady in which by herself the labor didn’t start.

Procedure:

1) We use prostaglandin (it is better to use a gel than a pill, and we use the
prostaglandin in case of the cervix being not ready/closed, with BISHOP
score < 7. BISHOP score is from 0-13, less than 7 is a not ready cervix)
2) Stripping of the membrane (amniotic sac), we induce our finger in between
the cervix and the membrane and we will make a 360 degree rotation
(sweep).
3) We use a balloon catheter, we introduce a Foley catheter in the cervix and we
fill it with water which causes the balloon to open inside the cervix
4) Oxytocin, if we have a favorable/ready cervix for labor
5) Artificial breaking of the membranes (amniotic sac)
Indication:

1) Post term pregnancy (>42 weeks)

2) If we have fetal distress or oligohydramnios
3) Preeclampsia (hypertension alone – only magnesium sulfate is used as a
diuretic. Hypertension + proteinuria – we induce labor)
4) Premature rupture of the membranes (PROM)
5) Intrauterine growth restriction (poor growth of a baby). There can be many
causes, as poor maternal nutrition, lack of enough O2 supplied to the fetus.
18. Obstetric anesthesia and analgesia

Analgesia in normal Delivery:

For many women, normal labor may be easy and trouble free provided arational
approach is made with the beginning of pregnancy. Labour pain is experienced by
most women with satisfaction at the end of a successeful labor. Antenatal classes,
sympathetic care and encouraging environment during labor can reduce the need of
analgesia.

The ideal procedure should produce efficient relief of pain but should neither depress
the respiration of the fetus nor depress the uterine activity causing prolonged labour.
The drugs must be non-toxic and safe for both mother and the fetus. But it is
regretted that no such agent is available at present that fulfils all these conditions.

Methods of pain relief:

A- sedatives and analgesics

B- Inhalation agents
C- regional analgesia

A - Sedatives and analgesics

Factors to control the dose of sedatives and analgesics

1- The threshold of pain

2- Primigravidae or multiparea (multiparous women need less analgesia)
3- Maturity of the fetus ( minimal doses in premature fetus to avoid asphyxia)

For selecting general anesthesiawe divide labour in 2 phases:

1st phase 8cm dilation of the cervix for primigravida; 6cm in case of multipara

2nd phase correspond to the dilation of the cervix beyond the above limits upto
delivery

For the 1st phase is controlled by sedatives and analgesics and the second phase is
controlled by inhalatory agents.

Opioid Analgesics:

Pethidine used in the first phase of labour, initial dose 100mg (1.5 mg/kg body wt)
I.M. and repeated as the effect of the first dose begins to wane, without wainting for
the re-establishing of labour pain.

Side effects to mother are nausea, vomiting, delayed gastric emptying. Pethidine
crosses the fetal membrane and causes depression of respiration.
Meptazinol– has similar analgesic and sedative property as Pethidine. It causes less
respiratory depression of the new born.

Tranquilisers:

Diazepam it is well tolerated by the patient. It does not causes vomiting and helps in
the dilation of the cervix. It is metabolized in the liver. The usual dose is 5-10mg.
larger doses can be used in pre-eclampsia. However diazepam is avoided in labour
as it causes neonatal hypotonia and hypothermia. It should not be given in preterm
labour.

Midazolam is more potent and neonatal side effects are less compared with
diazepam. It has good anxiolytic property. It is cleared from the tissues more rapidly.
Dose of 0.05mg/kg given I.V.

B - Inhalation methods:

- Nitrous oxide and air

- Premixed nitrous oxide and oxygen

C - Regional anestesia

Epidural anesthesia is regional anesthesia that blocks pain in a particular region of

the body. The goal of an epidural is to provide analgesia, or pain relief, rather than
anesthesia which leads to total lack of feeling. Epidurals block the nerve impulses
from the lower spinal segments. This results in decreased sensation in the lower half
of the body.

Epidural medications fall into a class of drugs called local anesthetics, such as
bupivacaine, chloroprocaine, or lidocaine. They are often delivered in combination
with opioid and narcotics such as fentanyl and sufentanil in order to decrease the
required dose of local anesthetic. This produces pain relief with minimal effects.
These medications may be used in combination with epinephrine, fentanyl, morphine,
or clonidine to prolong the epidural’s effect or to stabilize the mother’s blood
pressure.

How is an epidural given?

Intravenous (IV) fluids will be started before active labor begins and prior to the
procedure of placing the epidural. You can expect to receive 1-2 liters of IV fluids
throughout labor and delivery. An anesthesiologist (specialist in administering
anesthesia), an obstetrician, or nurse-anesthetist will administer your epidural. You
will be asked to arch your back and remain still while lying on your left side or sitting
up. This position is vital for preventing problems and increasing the epidural
effectiveness.

What are the types of epidurals?

There are 2 basic epidurals in use today. Hospitals and anesthesiologists will differ
on the dosages and combinations of medication. You should ask your care providers
at the hospital about their practices in this regard.
Regular Epidural

After the catheter is in place, a combination of narcotic and anesthesia is

administered either by a pump or by periodic injections into the epidural space. A
narcotic such as fentanyl or morphine is given to replace some of the higher doses of
anesthetic such as bupivacaine, chloroprocaine, or lidocaine. This helps reduce
some of the adverse effects of the anesthesia.

Combined Spinal-Epidural (CSE) or “Walking Epidural”

An initial dose of narcotic, anesthetic or a combination of the two, is injected beneath

the outermost membrane covering the spinal cord, and inward of the epidural space.
This is the intrathecal area. The anesthesiologist will pull the needle back into the
epidural space, threading a catheter through the needle, then withdrawing the needle
and leaving the catheter in place.

This allows more freedom to move while in the bed and greater ability to change
positions with assistance. With the catheter in place you can request an epidural at
any time if the initial intrathecal injection is inadequate. You should ask about your
hospital’s policy on moving around and eating/drinking after the epidural has been
placed. With the use of these drugs, muscle strength, balance and reaction are
reduced. CSE should provide pain relief for 4-8 hours.

Contraindications:

- Sepsis at the site of injection

- Haemorrhagic disease or anticoagulant therapy
- Hypovolemia
- Neurological disease
- Spinal deformity or chronic low back pain

Complicatons:

- Hypotension
- Post spinal headache
- Injury of the nerves

Side effects:

- hypotension

- Respiratory depression may occur

- Postspinal headache

- Meningitis

- Transient or permanent paralysis

19,20 . Episiotomy. Perineum repair.

Definition:

It is an incision made by the doctor on the perineum, which is made in order to make
a larger vaginal outlet, which makes the delivery easier. Also with that, we will avoid
perineum rupture.

It is made at the end of the second stage of labor, just before the delivery.

It is made in case of assisted delivery with forceps, or vacuum extraction.

Types of episiotomy:

1) Median, or medial (is better because of less bleeding and faster repair
2) Medio-lateral
!!!!!!!!!!!!!!!!!!!!!!!!!In the lecture the doctor said otherwise!!!!!!!!!!!!!!!!!!!!!

Indications of episiotomy

1) Large sized baby

2) Pre term baby, because it is very rigid
3) Breech delivery
4) Assisted delivery (vacuum or forceps)
Perineum repair (now we repair perineum after rupture)

There are 4 degrees of perineum tearing/rupture

1) 1st degree, only mucosa is involved

2) 2nd degree, muscles are involved
3) 3rd degree, external sphincter of the anus is involved
4) 4th degree, anus is totally open and can reach to the lumen of the rectum

Procedure/technique of the perineum repair:

1st degree, some of them don’t require suturing

2nd degree, requires one or two sutures

3rd and 4th degree, 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

21. Complications of 3rd stage of labor

3rd stage is placental expulsion, the complication can result from abnormal placental
insertion.

When nevilli invade too deeply into the wall of the uterus:

1) Placenta acreta – placenta extends too far into the endometrium

2) Placenta increta – placenta invades into the myometrium
3) Placenta pancreta – placenta goes through the myometrium and even behind
the myometrium till serosa.
If we have one of these conditions, then, the delivery of the placenta will be very
difficult, and sometimes impossible.

Can lead to a tearing of the placenta, and some of the coledons will stay behind in
the uterus, which will inhibit the uterine contraction, that leads to a hemorrhage, that
can kill the woman in 5 minutes

Those complications of placental insertion, can lead to uterine inversion by the

delivery.

Retained placenta (placenta will remain inside of the uterus) more than 30 minutes
after delivery of the baby, can be because of:

- !!!!!!!!!!!!!!!!!!!!! In a degree uterine contraction in order to expel the placenta

- The cervix will retract too fast
- Urinary bladder is full, which is causing an obstruction.
22. Complications of 4th stage of labor

Complications of the 4th stage of labor, which means immediate puerperium, are:

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 (as in previous question)
23. Manual extraction of the placenta.

Definition/indications:

Extraction of the placenta with the hands, which is done in case of retained placenta
that is not delivered spontaneously for more than 30 minutes after delivery of the
baby.

Procedure/maneuvers:

1) Eredes maneuver:
In this maneuver we push the uterus towards the vulva (from outside top of the
uterus). Forbidden during delivery.

2) 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.

3) Controlled cord traction:

We have to be careful not to pull with a lot of strength which might lead to inversion
of the uterus.

Complications of manual extraction: hemorrhage and infection.

Procedure: a hand is introduced inside the uterine cavity and with the fingers/cubital
side of hand, we remove the placenta.
24. Caesarian section.

Describes a procedure in which the fetus is delivered through incisions in the

maternal anterior abdominal and uterine walls.

Indications:

1) Placenta previa
It is an abnormally implanted placenta, placed totally or partially in the lower
segmented of the uterus. Normally, the placenta is inserted on the fundus 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
It is better to be done at the same place. 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 weak uterus.

5) Abnormal presentation of fetus brow presentation, or footling.

6) Abruptio placenta
7) Uterine rupture
8) Large fetus
9) Small pelvis
10) Active genital infection
11) Uterine disfunction
12) Fetus malformation
13) Multiple pregnancy (triplets)
14) Uterine abnormalities (tumours)
Indication for primary caesarian:

- Cephalopelvic disproportion: most common indicator. Means that the pelvis is

to 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) Anesthesia: epidural is most commonly used, general anesthesia only in

emergency C sections.
2) Abdominal incision: 3 possibilities
– Mid line: in case of extreme emergency because it gives us a faster acess.
- paramedian line: can be used if we have a scar or obstacle on the mid-line.
 - Low uterine segment section (tranverse cut) (the guy had written
“ptannested”): most commonly used because of osmotic reasons. Made in the
non-contractile portion of the uterus. It has a low chance of uterine rupture in
subsequent labor.

3) Uterine incision: is done just above the urinary bladder because it is a thin area
with much less bleeding. We don’t cut in 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.
25. Post-partum period in Caesarian section.

Generally, after c section the patient has to be hospitalizaed for 3 days. During this
period there are risks for the mother and the fetus, and that’s why it is better to stay
at the hospital.

Risks: (complications)

- Infections
- Post-partum hemorrhages
During this time we have to evaluate the general state of the mother by the following:

1) Measuring of temperarure
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, small (duration?)
- 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)
26. Normal puerperium.

Definition: it is the period of 4 to 6 weeks (40 days). It starts immediately after

delivery. 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
27. Pathological puerperium.

Definition: pathologies during puerperium, and the most common are infections and
hemorrhage.

1) Infection (puerperial infection)

- Fever: ≥ 38◦C, at least twice in the first 10 days after delivery (don’t measure
it in the first 24h because it is not possible for germ to cause infection that
fast)
- Risk factors: anemia, hemorrhage, episiotomy, C section, retained placenta,
Diabetes mellitus, malnutrition.
- Organs that can be infection: vulva, vagina, cervix, uterus, annexes (fallopian
tubes), breast, urinary tract
- Diagnosis: fever, discharge with bad smell, swelling of the vagina and vulva.
Painful during examination, leukocytosis and increased ESR and fibrinogen.
- Treatment: broad spectrum antibiotics, if pus we should drain it. To prevent
thrombophlebitis we give heparin LMWH.
2) Sepsis:
- Pelvic pain
- Fever of 38,5◦C
- Vaginal discharge with smell
- Sub-involution (not well contracted uterus)
- Treatment: antibiotics, anti-inflammatory and drainage if there is pus
- Diagnosis:
o Endometriosis
o Sub-involution
o Pelvic cellulitis
o Salpingitis and peritonitis
o Pelvic thrombophlebitis
3) Breast problems:
- Mastitis: fever, local edema, tenderness of the breast
- Treatment: antibiotics, analgesics, pumping of the milk out, if there is an
abcess aspiration.
4) Urinary problems: retention, incontinence, infection, “re!!!!!!!!” because of
irritation of urethra by delivery.
5) Venous thrombosis: due to hypercoagulability state of pregnancy. Risk factors
are increased maternal age, obesity, anemia, infection, reduced mobility and
smoking.
6) Psychic problems: post-natal blues, post-natal depression, puerperial
psychosis.
7) Obstetric palsy: it’s a severe neuralgia due to pressure on the lumbosacral
nerve plexus. It will recover spontaneously.
28. Cardinal symptoms in gynecology: pain.

Can have many causes:

1) Pelvic Inflammatory disease:

- It is an inflammation which can involve the cervix, uterus, fallopian tubes and
sometimes the ovary
- Symptoms: pain in the lower abdomen, fever, discharge, tenderness and
painfulness on that area.
- Most common causes: chlamydia, thracomatis, Neisseria, Gonorrhea
- Diagnosis: CBC, increased fibrinogen, increased ESR, increased CRP,
leukocytes, culture from vagina and cervix, laparoscopy and ultrasound
- Treatment: Ofloxacin 500mg 2x/day for 2 weeks with or without metronidazole
2) Dyspareunia:
- Painful sexual intercourse, due to medical physiological causes
- Causes: infections in the vagina, malformations, endometriosis
3) Dysmenorrhea
- Painful menses, which is 24 to 48h from the onset of menses.
4) Endometriosis
- Endometrium growth outside of the uterine cavity.
- Unknown cause
- Symptoms: dysmenorrhea, dyspareunia, chronic pelvic pain, infertility
(because endometrium surrounds the ovaries and don’t allow the ovulation to
occur
- Diagnosis: ultrasound, laparoscopy, MRI, biopsy
- Treatment: for pain NSAIDS, for endometriosis we use GNRH agonists given
less than 6 months to stop FSH to not have estrogen, surgery.
5) Leyomyomioma, benign tumor of myometrium. Pain is because the patient
has vascular occlusion
6) Choriocarcinoma
- Malignant tumor of very early cells which are originating from “hydecticform”
- Vaginal bleeding
- Pain
- Uterine enlargement
- Diagnosis: ultrasound, alpha and beta HCG, CT, biopsy
- Treatment: chemo, surgery, metrotrexate
29. Cardinal symptoms in gynecology: bleeding.

Definition: an abnormal condition in which blood is passed from the vagina which is
related to menstruation.

Causes: abnormalities of uterus, cervix, ovaries, fallopian tubes or vagina.

Cervix:

- Polyps, squamous cell carcinoma/adenoma

- Vaginal bleeding, increased menses, bleeding during intercourse or after.
Abnormal uterine bleeding:

- Heavy or prolonged bleeding of the menses (monorragia)

- Causes: dysfunctional uterine bleedings (normal cycles with increased
duration 7-18days – normal is from 3-7 days) because of bleeding may result
into anemia. Leyomioma (heavy prolonged menses), choryocarcinoma,
polyps, tumors, coagulopathies.
Dysfunctional uterine bleeding:

- Abnormal genital tract bleeding based in the uterus and found in the absence
of organic or structural pathology. It is usually due to hormonal disturbances
(progesterone decrease, PG
Post-menopausal bleeding:

Always abnormal and caused by cancer until proven otherwise.

30. Cardinal symptoms in gynecology: amenorrhea.

Definition: absence of menstruation for 3 to 6 months after menarche or failure of

menarche by age of 16.

Types:

- Primary amenorrhea:
o Failure of menarche by age 14 to 16
o Or primary means that menstrual bleeding has never occurred.
o Diagnosed with absence of menses at age 14 without secondary
sexual development or at age 16 with secondary sexual development.
o Etiology: cerebral tumors (that affect hormones), chromosomal
abnormalities (Turner syndrome), ovarian diseases, mullerian
agenesis (Rukitansky syndrome) which is absence of uterus or
vagina, pituitary insufficiency, imperforated hymen, pituitary tumors
(prolactinoma).
- Secondary amenorrhea:
o Amenorrhea means absence of menstrual bleeding
o Secondary means that previously menstrual bleeding has occurred
o Absence of menstruation for 3 to 6 months after menarche
o Etiology: we should rule out normal or ectopic pregnancies; cerebral
tumors, pituitary tumors, ovarian failure (leads to early menopause,
which normally is from 42-52 years), anorexia, psychic diseases
(stress), ovarian diseases, pituitary insufficiency, oral contraceptives
(because it inhibits FSH and LH)
o Diagnosis: MRI (to see the tumors), karyotype test, ultrasound (to see
abnormal uterus), measure hormone levels.
 31 .Cardinal Symptoms in Gynecology: Vaginal Discharge

Definition:

- It’s a combination of fluid and cells continuously shed through the vagina.
- It function to clean and protect the vagina.
- The color and consistency of the vaginal discharge vary from whitish and
sticky to clear and watery between menstrual periods, roughly corresponding
to the stage of the reproductive cycle.
- Some amount of vaginal discharge is completely normal
- If vaginal discharge has an unusual odor and appearance or occur along with
itching or pain it may be a sign that something wrong

Diagnostic tests:

- Visual inspection - vulva and vagina should be examined for evidence of an

inflammatory response as well as the gross characteristics of the vaginal
discharge seen on a speculum examination
- Vaginal pH – normal pH in vagina acidic <4.5;
- Normal vaginal discharge leaves the paper yellow;
- Abnormal vaginal discharge leaves the paper dark;
- Microscopic examination

Etiology: (STDs)

- Bacterial vaginosis- (normal present is lactobacilli) anaerobic species and

facultative aerobes
- Trichomonasvaginalis
- Candida (yeast) vaginitis not (STD) normal pH

Physiologic Discharge:

- Thin, watery cervical mucus discharge seen estrogen dominant

- Appears particularly in patients with wide eversion of columnar epithelium

Risck factors: Chronic anovulatory conditions such as Polycystic discharge

syndrome

Normal pH

Treatment:

Steroid contraceptive with progestins

That will convert the thin watery estrogen- dominant cervical discharge to a thick
sticky progestin dominant mucus.
32. Pap smear

Definition: It’s a test used for detection of pre-cancerous and cancerous processes
in the endocervix and execervix; Any changes called cervical intraepithelial neoplasm
(CIN)(cervical dysplasia). The aim is to prevent progression to cervical cancer.

Procedure:

- Put speculum to open vaginal canal

- With small brush that collect cells from the endocervix and ectocervix (and
vagina)
- Cells areexaminel under the microscope to look for abnormalities

Condition:

- Don’t wash (vagina) at least 24h before the test

- Avoid intercourse 24h
- No taking sample during menstruation
- Speculum is inserted without lubricant but if necessary then we use only a
small amount and by tacking a sample, we have to be far away from lubricant.

Indications:

- Sexually active women age (20-25 until age 50-60) every 3-5 years.
- For indication of precancerous lesions in order to treat them which are caused
by sexually transmitter HPV

Results according to the Belhesda system

1) Squamous cell abnormalities

- Atypical squamous cell of undeferensiate significance
- Low grade squamous intraepithelial lesion (LSIC)
- Atypical squamous cells ASC)
- High-grade squamous intruppit (HSIC)
- Squamous cell carcinoma (carcinoma in situ)
2) Glandular epithelium cell abnormalities
- Atypical condition cells not otherwise specified (AGC orAGC-NOS)

Cervical cancer Diagnosis

Pap- Test:

- Cells are removed from the cervix and examined under the microscope
- It can detect epithelial cells abnormalities
Eg: atypical squamous cell (ASC); squamous intraepithelial lesions
(SIC) and squamous cell carcinoma ( carcinoma in situ).

Treatment: Surgical ; Radiation; chemotherapy.

33.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, odor, 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.
34. Colposcopy

Definition:

- Medical diagnostic procedure to examine with a light and magnified view of

the cervix (and the tissues of the vagina and vulva)
- Allow the doctor to have a better view ant to differentiate between norman
and abnormal tissues and take to differentiate further pathological
examination
- The main goal is to prevent cervical cancer by detecting precancerous lesions
and treating them .

Indication: Is done for women after seeing modified pap smear results.

Eg: CIL; ASC; carcinoma in situ

Procedure:

1) Lithotomy position
2) Pre speculum in the vagina
3) Examnine the cervix to look for abnormal blood vessels ( associates with
malignant and premalignant lesion)
4) Wash the cervix with saline and look through green filter and blood vessels
will appear as black lines.
5) Apply acetic acid then look with colposcope then abnormal lesion appear as
white color
6) Lahn-schiller test: Abnormal tissue will not absorb iodine
-apply iodine solution then look with a colposcope and the abnormal
tissue will appear as white compare to normal tissue which will be
brown.
7) We can take biopse from the abnormal areas and send it to pathology.
8) Usually after colposcopy if we find abnormal lesions we will make conisation –
which is a large biopsy in which we remove all the abnormal tissue that can
be used a diagnostic and treatment procedure.

Complications: When taken biopsy may have infection or bleeding in that site.
35. Lahm-schiller test.

Definition: Is the second part of colposcopy

Procedure:

1) We apply iodine solution to cervix

2) Look though the colposcope and the abnormal lesion will not change color (
so they stay as white areas) compare to the normal tissue which will appear
as a brown color because normal tissue can absorb the iodine.
3) Is not a method of diagnosis for cervical cancer but just for precancerous
lesion because the definitive diagnosis of the cancer is possible only with
pathology.
36,37. Biopsy and Bioptic-curettage

Definition: Is the procedure to collect a sampling to tissue for histopathological

examination and diagnosis.

Cervical biopsy (endocervix)

 Sample from the cervix is collected and analyzed by histopathology.

 We take the biopsy either by forceps or electroresection.
 If the suspicious lesions are not visible for the naked eye then we use
colposcope.
 We can use the cervical conization in which a cone shaped sample is taken
from the mucous membrane.
o This conization can be either used for diagnostic or therapeutic
purposes.
o It is a sided effect can be stenosis of the cervix because or to a mud
removed the tissue.

Endometrial biopsy

Definition:

Sample from the endometrial lining of the uterus is collected and analysed
histopathology.

Procedure:

We make dilatation and curettage of the endometrium and then collect a sample with
a syringe or suction.

Indication:

 Suspition of tumor
 Abnormal Ultrasound with a suspicion of a tumor in the uterus
 Thick endometrium seen by ultrasound
 Abnormal PAP-Smear
 Bleeding after menopause
 Abnormal menstrual bleeding
Contraindication (Not absolute):

 Pregnancy
 Bleeding disorder
Results (Abnormal):

 Endometrial cancer or precancerous lesions

 Uterine polyp
 Uterine fibroid
 Uterine infections
Complication of biopsy:

 Bleeding
 Infections
Bioptic curettage

Definition:

 The removal of the endometrial tissue by using D&C for diagnostic

procedures and screening.
 Can be performed in cervix and uterus

Indication:

 Abnormal or heavy bleeding (menorrhagia)

 Severe menstrual pain (dysmenorrhea)
 Infertility
 Abnormal PAP smear results/ we make PAP smear and we find abnormalities
in the cervix eg. CIL, ASC, CIS
 After PAP smear we perform endocervical curettage which mean bioptic
curettage from the cervix and then sample is sent to histopathology.
Procedure:

 Lithotomy position
 Anesthesia (local or general)
 Insert speculum
 Insert Smooth Rods (metal sticks) in order to dilate the cervix starting from
small to big.
 We perform the curettage by inserting the curate and then remove tissue from
the endometrium.
 Then send the sample to histopathology.
Contraindication:

Pregnancy

Inflammation of the cervix and the uterus

Bleeding

Results (From histopath what we can be found):

Cervix:

 Invasive carcinoma
 Endocervical polyps
 Glandular hyperplasia
 Precancerous lesions: ASC and CIL
 Carcinoma in situ
Uterus

 Endometrial hyperplasia
 Leiomyoma
38. Hysterometry

Definition:

 Is the use of the hysterometer to measure the length of the uterine cavity and
the cervical canal in centimeters.
 Normal uterine cavity length
o 7 cm in nulliparas
o 8 cm in multiparas
Procedure:

 Lithotomy position
 Bimanual examination to orientate the position of the uterus
 Insert speculum
 Desinfection of the area
 Grasp (catch) the superior/ anterior part of the cervix
 Introduce the hysterometer through the vagina and then into the cervical and
then to uterine cavity.
Indication:

 Use it before doing D&C to know how deep to introduce the curette to avoid
the uterine perforation.
 In case of uterine tumor like leiomyoma and if the uterus is very big and we
need to take biopsy by curette we will use it to orientate obviously to know
how deep we need to inside.
Complications

 Perfomation of uterus.
Conditions:

 Have to be done in follicular phase of the cycle (not in the luteal phase)
 No genital phase
 No pregnancy
39. Hysterosalpingography

Definition:

 Is an X-ray examination of the uterus and fallopian tube by the used of

contrast substance, which will be injected through the cervix
Indication:

 To see the structure of the uterus and fallopian tubes and to see if there is
any obstruction or any other problems (eg. Tubal rupture)
 It is generally used in case of infertility.
Results:

 What can be seen: is happening after a curettage when the doctor went to
deep with curettage and removed too much from endometrium which lead to
adhesion b/n the walls of uterus and causing hemorrhage and infertility.
 Malformation of the uterus of fallopian tubes
 Intrauterine adhesion
 Obstruction of the fallopian tube
 Presence of foreign bodies
 Uterine tumors of polyps
 Procedure:
 Lithotomy position
 Insert a speculum till the cervix is visible
 Inject the contrast substance through the cervix under X-ray monitoring.
Conditions:

 Is done in the follicular phase of the cycle because we want to avoid when the
ovulation is happening because there is still a chance for fertilization.
Contraindication:

 Pregnancy
 Vaginal bleeding
 Infections

Complications

 Allergic reaction because of the contrast

 Perforation of the uterus
 Infections
40. Ultrasound in gynecology.

 Ultrasound of the uterus

 In longitudinal section the uterus is a pear-shaped mass with greater
upper extremity, echogenic, homogeneous, with regular contours.
 In cross section appears as a more oval uterus, myometrium is
homogeneous, poorly echogenic, and measures typically 2-3 cm.
 The endometrium is poorly visible in the first week after menstruation,
then appearing as a low echogenic band that thickens progressively up
to menstruation.
 Uterine cavity, usually virtual, are viewed as a fine linear echoes the
union of the two girls endometrial.
 Pathological changes of the uterus can be confirmed by
echocardiography.
 malformation, endometrial polyp, endometrial cancer
 Uterine fibroids less echogenic than the myometrium, are easily
detected and measured, especially subserosal and earlier. Endometrial
hyperplasia translates into an area of endometrial thickening.
 Intrauterine collections are viewed as a hypoecogenic areas in the
uterine cavity.
 Intrauterine pregnancy is confirmed by the presence of ovular sac
surrounded by an echo trophoblastic, and an embryo, after 6 weeks of
amenorrhea abdominal and after 5 weeks of amenorrhea intravaginal probe.

 Ultrasound of the ovaries

 Ovaries, most commonly latero-uterine, measuring 25-35 mm in
length and 12-20 mm thick.
 Ovarian pathology that can be appreciated at ultrasound is represented
by serous cysts, mucous, dermoid tumor or cancer.
 Fallopian tubes, which normally can’t be clear in ultrasound, they may
be pathological cases such as: tubal pregnancy, hydrosalpinx,
hematosalpinx, pyosalpinx.
 Indication of Ultrasound
 suspected intrauterine pregnancy;
 suspicion of ectopic pregnancy;
 differential diagnosis between uterine fibroids and an ovarian
pathology;
 indication of organic or functional origin of adnexal masses;
 specifying the structure of a liquid or solid tumor
 examination of obese patients, which is inconclusive vaginal cough;
 monitoring of ovulation induction treatment
41. Family planning – Practical medical strategies

Family planning is the planning of when to have children and the use of birth
control and other techniques to implement such plans. Other techniques commonly
used include sexuality education, prevention and management of sexually
transmitted infections, pre-conception counseling and management,
and infertility management.
Modern methods of family planning include birth control, assisted reproductive
technology and family finance planning programs

Birth control
1-Abstinence: As a means of contraception, abstinence is the voluntary refraining
from sexual activity. (100% effective).

2-Fertility Awareness Method: is a contraceptive method that uses the natural

functions of the body and your menstrual cycle to calculate ovulation. The most
common features of NFP involve recording of your body temperature and changes in
your cervical mucus each day. It requires periodic abstinence (approximately 7 to 10
days) during the ovulation period

3-Barrier Methods: Barrier or device methods of contraceptives are physical or

chemical barriers designed to stop sperm from entering a woman’s uterus.
 Male Condom:
 Female Condom: It is a seven-inch long pouch of polyurethane with two
flexible rings and is inserted into the vagina prior to intercourse. The female
condom covers the cervix, vaginal canal, and the immediate area around the
vagina.
 Spermicides: are chemicals that are designed to kill sperm.
 Spermicide chemicals are available as foam, jelly, foaming tablets and
vaginal suppositories.
 Diaphragm: It is a soft rubber dome stretched over a flexible ring; the dome
is filled with a spermicidal cream or jelly. The diaphragm is inserted into the
vagina and placed over the cervix no more than 3 hours prior to intercourse.
 Cervical Cap: The cervical cap is a small cup made of latex rubber filled with
a spermicidal cream or jelly and inserted into the vagina and placed over
the cervix.
 ContraceptiveSponge: The contraceptive sponge is a soft saucer-shaped
device made from polyurethane foam.

4-Hormonal Methods: Whether administered as a pill, patch, shot, ring or implant,

hormone medications contain manufactured forms of the hormones estrogen
and/or progesterone. Hormonal contraceptives do NOT protect against the
transmission of sexually transmitted diseases.

 Birth Control Pills: Birth control pills are taken daily

 Depo-Provera: Depo-Provera is an injection given by doctor that
prevents pregnancy for three months.
 Lunelle:Lunelle is an injection given by the health care provider that prevents
pregnancy for one month.
 NuvaRing/Vaginal Ring: NuvaRing, or vaginal ring, is a flexible ring that is
inserted into the vagina for three weeks, removed for one week, and then
replaced with a new ring. The ring releases estrogen and progesterone into
the body.
  Ortho Evra Patch/Birth Control Patch: The birth control patch is placed
directly on the skin.
 Intrauterine Device (IUD): The IUD is a small plastic device containing
copper or hormones and is inserted into the uterus by a medical professional.
The IUD does not stop the sperm from entering into the uterus, but rather it
changes cervical mucus decreasing the probability of fertilization and it
changes the lining of the uterus preventing implantation should fertilization
occur.

5-Withdrawal & Sterilization: Neither withdrawal nor sterilizations prevent

transmission of sexually transmitted diseases.
 Withdrawal: Withdrawal involves the removal of the erect penis from the
vagina prior to ejaculation.
 Sterilization:
o Female: Sterilization involves the surgical closing of the fallopian
tubes which carry the eggs from the ovaries to the uterus This
procedure is referred to as a tubal ligation
o Male: Sterilization involves the surgical closing of tubes that carry
sperm. This procedure is referred to as a vasectomy

Assisted reproductive technology

1-Fertility medication
 Gonadotropin-releasing hormone: GnRH stimulates the release of
gonadotropins (LH and FSH) from the anterior pituitary in the body.
 Oestrogen antagonists: inhibiting the negative feedback of estrogen at the
hypothalamus so the hypothalamus secretes GnRh which in turn stimulates
the anterior pituitary to secrete LH and FSH which help in ovulation
 Gonadotropins
 Human chorionic gonadotropin

2- Artificial insemination: Artificial insemination involves sperm being placed into a

female's uterus (intrauterine) or cervix (intracervical) using artificial means rather
than by sexual intercourse. This can be a very low-tech process, performed at home
by the woman alone or with her partner. Conception devices, such as a conception
cap may be used to aid conception by enhancing[vague] the natural process.
Conception caps are used by placing semeninto a small conception cap, then placing
the cap onto the cervix. This holds the semen at the cervical os, protecting the
semen from the acidic vaginal secretions and keeping it in contact with the cervical
mucus. Sperm donors may be used where the woman does not have a male partner
with functional sperm.

3- Surrogacy: Surrogacy, where a woman agrees to become pregnant and deliver a

child for a contracted party. It may be her own genetic child, or a child conceived
throughnatural insemination, in vitro fertilization or embryo transfer using another
woman's ova. Surrogacy via a gestational carrier is an option when a patient's
medical condition prevents a safe pregnancy, when a patient has ovaries but no
uterus due to congenital absence or previous surgical removal, and where a patient
has no ovaries and is also unable to carry a pregnancy to full term.

4-In vitro fertilization: It is the technique of letting fertilization of the male and
female gametes (sperm and egg) occur outside the female body. Techniques usually
used in in vitro fertilization include: Transvaginal ovum retrieval (OCR) is the process
whereby a small needle is inserted through the back of the vagina and guided via
ultrasound into the ovarian follicles to collect the fluid that contains the eggs. Embryo
transfer is the step in the process whereby one or several embryos are placed into
the uterus of the female with the intent to establish a pregnancy.
The main risks of assisted reproductive techniques are:
 Genetic disorders
 Low birth weight
 Preterm birth
 Membrane damage
 Postpartum depression

Finances
Family planning is among the most cost-effective of all health interventions.
"The cost savings stem from a reduction in unintended pregnancy, as well as a
reduction in transmission of sexually transmitted infections, including HIV".
42. Uterine curettage

Definition:

 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.

Procedure:

 Lithotomy position
 Anesthesia (local or general)
 Insert Speculum
 Insert smooth rods to dilate the cervix
 We perform curettage by inserting the curate and we start to remove the
endometrium lining.

Reasons for Dilation and Curettage

 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, oruterine cancer. A sample of uterine tissue is
viewed under a microscope to check for abnormal cells.

Complications

 Perforation
 Ashermans’s syndrome – infertility
 Infection
 Cramping
 Spotting or light bleeding