Abrar DMC OSPE DU Gynae & Obs

OSPE OBS AND GYNAE
Instrument ................................................................................................................................ 4
Sim’s Double bladed posterior vaginal speculum ............................................................. 4
Ques no ................................................................................................................................. 4
Cusco’s bivalve Self retaining vaginal speculum .............................................................. 5
Self-retaining bi-channel Foley’s catheter .......................................................................... 6
Uterine Sound ....................................................................................................................... 8
Uterine Curette ..................................................................................................................... 9
Sponge holding forceps......................................................................................................10
Ayre’s spatula with cytobrush ............................................................................................11
MR Syringe with cannula ....................................................................................................12
MVA Syringe with cannula ..................................................................................................13
Vulsellum .............................................................................................................................15
Obstetric forceps and Ventouse.........................................................................................16
Episiotomy scissor..............................................................................................................18
Disposable cord clamp .......................................................................................................19
Contraceptives and drugs ......................................................................................................20
OCP ......................................................................................................................................20
IUCD .....................................................................................................................................21
Implanon ..............................................................................................................................22
DMPA....................................................................................................................................22
Mifepristone + Misoprostol MTP kit (MM Kit).....................................................................23
Labetalol ..............................................................................................................................24
Misoprostol ..........................................................................................................................25
Inj. Oxytocin .........................................................................................................................26
Inj. Ergometrine ...................................................................................................................27
Inj. MgSO4 ............................................................................................................................27
Anti-D immunoglobulin .......................................................................................................28
Hydralazine ..........................................................................................................................29
Specimen .................................................................................................................................30
Ovarian tumor ......................................................................................................................30
Dermoid cyst of ovary .........................................................................................................31
Fibroid uterus ......................................................................................................................32
Placenta with fetal membranes and umbilical cord ..........................................................33
1
Hydatidiform mole ...............................................................................................................34
Unruptured ectopic tubal pregnancy .................................................................................35
Anencephaly ........................................................................................................................36
Hydrocephalus ....................................................................................................................37
Pictogram ................................................................................................................................38
Carcinoma cervix.................................................................................................................38
Bicornuate uterus ................................................................................................................39
Uterovaginal prolapse .........................................................................................................40
Placenta previa ....................................................................................................................41
Abruptio placentae ..............................................................................................................42
Breech presentation ............................................................................................................43
Data/Scenario ..........................................................................................................................44
Obstetrics ............................................................................................................................44
APH ...................................................................................................................................44
PPH ...................................................................................................................................45
Abruptio placentae ..........................................................................................................45
Pre-Eclampsia ..................................................................................................................47
Eclampsia .........................................................................................................................48
Obstructed labor ..............................................................................................................49
Ruptured uterus ...............................................................................................................50
Gynecology ..........................................................................................................................50
Vaginitis ............................................................................................................................50
Incomplete abortion .........................................................................................................51
Septic abortion .................................................................................................................51
Ruptured ectopic pregnancy...........................................................................................52
Carcinoma cervix .............................................................................................................53
Counselling Stations ..............................................................................................................54
Gynecology ..........................................................................................................................54
Myomectomy in a fibroid patient ....................................................................................54
Molar pregnancy ..............................................................................................................55
OCP ...................................................................................................................................56
IUCD and CU-T .................................................................................................................57
Norplant/Implanon ...........................................................................................................58
Contraceptive for newly married couple ........................................................................59
Hysterectomy ...................................................................................................................59
2
Obstetrics ............................................................................................................................60
ANC ...................................................................................................................................60
Placenta Previa ................................................................................................................62
IUD ....................................................................................................................................63
PNC ...................................................................................................................................64
Breast feeding and EBF ...................................................................................................65
Breaking bad news ..............................................................................................................67
CA Cervix..........................................................................................................................67
Partograph...............................................................................................................................69
Procedure stations..................................................................................................................71
MVA ......................................................................................................................................71
Dilatation and curettage ......................................................................................................72
Mechanism of normal labor ................................................................................................73
2nd stage of labor management ..........................................................................................74
Immediate/Routine care of newborn ..................................................................................76
Active management of 3rd stage of labor ...........................................................................77
NVD ......................................................................................................................................77
Examination of newborn .....................................................................................................78
Resuscitation of a baby with perinatal asphyxia...............................................................79
Breast feeding .....................................................................................................................79
3
Instrument
Sim’s Double bladed posterior vaginal speculum
Ques Question Answer
no
1 Identify the supplied Sim’s Double bladed posterior vaginal speculum

photograph (DU)
2 Mention the parts of this 2 blades

instrument
One handle
Groove in between
What structures can be Cervix

examined by it? (DU)
Vaginal wall
Gynecological use (DU) 1. Operation: vaginal hysterectomy, VVF repair,

pelvic floor repair
2. Diagnosis of VVF, genital prolapse
3. Insert + remove IUCD
4. Collect vaginal/cervical discharge and specimen
for cytology and microbiology
Obstetric use (DU) 1. Diagnosis of PROM

2. diagnose genital tear
3. Repair tear
4. Examine vagina and cervix after delivery
3 Mention 4 1. Dilatation, evacuation and curettage

procedures/operations where 2. Anterior colporrhaphy
it is used? (DU) 3. Vaginal hysterectomy
4. VVF: local repair by flap splitting
5. Insertion, removal of IUCD
4 What are the advantage 1. Can inspect cervix

2. Can inspect anterior vaginal wall
4
5 What are the disadvantages of 1. It is not self-retaining
this instrument? (DU) 2. It needs assistant
3. Both wall of vagina cannot be retracted
simultaneously
6 How is this instrument Autoclaving

sterilized? (DU)
7 Pathological conditions ➢ VVF

diagnosed by it (DU) ➢ genital prolapses
➢ PROM
➢ tear in the genital tract
Cusco’s bivalve Self retaining vaginal speculum

Ques no Ques: Answer
1. Identify the instrument (DU) Cusco’s bivalve Self retaining vaginal speculum
2. 2 gynecological 1. Cervical lesion diagnosis: cervical erosion,

polyp, cervicitis, CIN, Ca cervix
2. Collection of cervical biopsy by scraping
3. Operation in cervix: LEEP, LLETZ
4. High vaginal swab for c/s
5. MVA
6. Insertion + removal of IUCD
5
7. 2 obstetric 1. Diagnosis of PROM
2. Diagnosis of genital tear
3. Repair genital tear
4. Examine vagina and cervix after delivery
8. Mention advantages of this 1. It is self retaining

instrument (over sims – DU) 2. Doesn’t need assistant
3. Simultaneously retract both anterior and
posterior vaginal wall
9. Mention disadvantages of this Cannot inspect vaginal wall – only inspect cervix
instrument well
10. How is this instrument sterilized? Autoclave

(DU)
Self-retaining bi-channel Foley’s catheter

Ques no Question Answer
1. Identify the instrument (DU) Self-retaining bi-channel Foley’s catheter
2. Mention its purpose (DU) 1. Continuous drainage of bladder

2. Used to inject dye in saline infusion
sonography (SIS) and
Hysterosalpingography (HSG)
6
3. Why are there 2 channels? (DU) 1. One channel for collection of urine
2. Other channel for pushing water to
inflate the balloon
4. Mention 4 indication of its use 1. To prevent VVF after obstructed

labor
2. Following repair of VVF
3. Chronic urinary retention
4. Monitor urine output in critical
patient
5. 4 obs use (DU) To monitor urine output in

➢ Pregnant woman with retention of
urine
➢ Obstructed labor
➢ Labor patient in shock
➢ Uterine rupture
➢ Eclampsia
➢ Administration of MgSO4
➢ During PPH
➢ During obstetric operation such as
LUCS
6. 4 gynae use (DU) ➢ Any gynecological patient with
retention of urine
➢ Prevention of VVF
➢ To monitor urine output after
gynecological operation
➢ Drainage of pus from vagina
(hematocolpos)
7. Complications of this instrument (DU) 1. UTI
2. Injury to urethra
3. Urethral stricture
4. Urethral rupture
5. Creation of false passage
8. Write down the complication that may 1. UTI

occur if kept for a prolonged period 2. Urinary retention (due to loss of
(DU) bladder tone)
3. Difficulty in removal
4. Urethral stricture
9. How is this sterilized? (DU) 1. Ethylene oxide (chemical)

2. Gamma radiation
7
10. How long can it be kept in situ for ➢ After LUCS: 24-48 hour
different operation? (DU) ➢ Obstructed labor: 10-14 days
➢ After Repair of VVF: 21 days
➢ TAH: 24-48 h
➢ VH: 5 days
Uterine Sound
Ques Question Answer

no
8
1. Identify the instrument (DU) Olive pointed Malleable Graduated Metallic Uterine
Sound
2. Why is this instrument curved? To adapt to the position of the uterus (anteverted)
(DU)
3. Mention its uses (DU) 1. Determine position of uterus

2. Measure length of uterus and cervix
3. Acts of first dilator of uterine canal
4. To sound the uterine cavity to detect foreign
body (such as IUCD)
4. What will the complication of this Perforation of uterus `

instrument If not carefully used?
Hemorrhage
(DU)
5. How is this sterilized? (DU) Autoclaving
Uterine Curette
1. Identify this instrument (DU) Uterine curette
2. Mention the use of this instrument (DU) Curettage of endometrium – diagnostic and
therapeutic
9
3. Mention the complications of using this 1. Perforation
instrument (DU) 2. Hemorrhage
3. Subsequent infertility
4. Asherman’s syndrome
4. How is this instrument sterilized? (DU) Autoclaving
Boiling
Sponge holding forceps

1. Identify this instrument (DU) Sponge holding forceps
2. 2 gynecological conditions where it 1. Antiseptic painting before gynecological

is used (DU) operation
2. Hold lips of cervix during DnC
3. Clean vulva, perineum
10
3. 2 obstetrical condition where it is ➢ Explore uterus during PPH
used (DU) ➢ During LUCS ➔ catch cut margin of uterus
➢ Repair genital tract tear
4. How is this instrument sterilized? Autoclaving
Ayre’s spatula with cytobrush

1. Identify the instruments (DU) Ayre’s spatula with cytobrush
2. In which procedure are these instruments Collection of cervical smear for

used? (DU) cytology (pap smear test)
3. What is the purpose of this procedure? (DU) Screening of cervical carcinoma at a

pre-invasive stage
4. Mention three prerequisites for this 1. No sexual intercourse 5 days

procedure (DU) prior to examination
2. No lubrication
3. No pelvic examination
4. Patient should come at mid
cycle
5. Mention the interpretation of pap 1. ASCUS (atypical squamous

test/grading of Papanicolaou’s smear (DU) cell of undetermined
significance)
2. AGUS (atypical glandular cells
of undetermined
significance)
3. CIN-1
4. CIN-II
5. CIN-III
6. CIS
11
7. Invasive Ca cervix
6. What will be the next step if positive result 1. Colposcopy guided biopsy
comes in this procedure? (DU)
7. What are the methods for screening of 1. VIA (visual inspection by

Carcinoma cervix? (DU) acetic acid)
2. Pap’s smear (cytology)
3. Colposcopy guided biopsy
4. HPV DNA testing
8. What is VIA? (DU) Visual inspection of acetic acid ➔

application of 5% acetic acid to cervix
➔ then visualization ➔ acetowhite
areas indicate areas of lesion
MR Syringe with cannula

1. Identify this instrument (DU) MR syringe/Karman’s syringe

with Karman’s Cannula/MR
cannula
2. Uses of MR syringe (DU) 1. Menstrual regulation
12
2. Management of
incomplete abortion
3. Taking endometrial
sample for biopsy
3. Mention a procedure where this 1. Menstrual regulation

instrument is used (DU)
4. Prerequisites of this procedure 1. Regular menstruating

(DU) woman
2. Less than 14 days have
passed since last missed
period
3. Pregnancy has not been
confirmed
4. Consent, counselling,
privacy, exposure, 3rd
party
5. Logistics ensured
MVA Syringe with cannula

13
1. Identify this instrument (DU) Manual vacuum aspiration syringe (MVA syringe)
with MVA cannula
2. Mention the uses of this instrument 1. Aspiration of uterine contents in

(DU) incomplete, missed, septic abortion
2. Molar pregnancy
3. Endometrial sampling for biopy
4. Menstrual regulation
3. Indication of this instrument (DU) 1. Incomplete abortion

2. Missed abortion
3. Septic abortion
4. Molar pregnancy
14
4. 4 Advantages of this procedure over 1. Quick procedure
D &C (DU) 2. Less chance of uterine perforation
3. Minimal cervical dilation needed
4. Can be done in OPD
5. Can be done with Local anesthesia
6. Less traumatic
5. 4 Complication of this procedure 1. Uterine perforation

(DU) 2. hemorrhage
3. Injury to cervix
4. Secondary amenorreha
5. Future infertility
6. Pelvic infection
Vulsellum
1. Identify the Vulsellum forceps

instrument (DU)
2. Mention its use (DU) 1. To grab the anterior lip of cervix during
a. Dilatation and curettage
b. Menstrual regulation
c. Manual vacuum aspiration
d. Insertion of IUD
2. To grab the posterior lip of cervix
a. Drainage of Pouch of douglus
b. In ruptured ectopic pregnancy
c. In pelvic infection
3 How can you sterilize 1. Autoclaving

this instrument (DU) 2. Boiling
Q. Arrange the logistics for D&C
15
Ans:
D&C set
1. Gallipot
2. Sponge holding forceps
3. Swabs
4. Povidone iodine solution
5. Sim’s double bladed posterior vaginal speculum
6. Vulsellum forceps
7. Uterine sound
8. Hegar’s cervical dilator
9. Ovum holding forceps
10. Uterine curette
Obstetric forceps and Ventouse

1. Identify this instrument Short curved obstetric forceps/Wrigley’s forceps

(DU)
2. Name the parts of this 1. Blade

instrument (DU) 2. Shank
3. Lock
4. Handle
3. Mention the prerequisites 1. Head engaged

for its use (DU) 2. Rotation of head complete
3. Cervix fully dilated
4. Membrane ruptured
5. Pelvis adequate
6. No CPD
7. Baby must be alive
8. Bladder should be emptied
4. Mention 4 indications of 1. Maternal: inadequate bear down effect

delivery with this 2. Fetal: fetal distress at 2nd stage, cord prolapse at
instrument (DU) 2nd stage
3. Other: prolonged 2nd stage, when we want to cut
short 2nd stage
16
5. 4 Complications of this 1. Maternal
instrument (DU) a. Injury to birth canal
b. PPH
c. Puerperal sepsis
2. Fetal
a. Facial palsy
b. Asphyxia
c. Intracranial hemorrhage
6. Mention 3 advantages of 1. Less failure rate

this instrument over 2. Less neonatal complication
ventouse (DU) 3. Sage for preterm babies
4. Can be used in face presentation
5. Can be used in after coming head of breech
6. Can be used in fetal distress in 2nd stage
1. Identify this instrument (DU) Silastic Ventouse cup with traction device
2. Mention the 4 common indication (DU) 1. Maternal: inadequate bear down

effect
2. Fetal: delivery of 2nd twin when
head is high up
3. Other: prolonged 2nd stage, when
we want to cute short 2nd stage
3. Mention 4 important prerequisites for 1. Head engaged

this to be used (DU) 2. Presentation must be vertex
3. Fetus must be at term
4. Cervix fully dilated
5. Membrane ruptured
6. Pelvis adequate
7. No CPD
8. Baby must be alive
17
9. Bladder should be emptied
10. Mention 3 contraindication (DU) 1. (just vice verca)
11. 4 Advantage of this instrument over 1. Can be used in mal rotated head
forceps (DU) 2. Less skill needed
3. Less complication to mother
4. No need of maternal
analgesia/anesthesia
5. Less traction force given
6. Less space occupying
12. Mention 4 compilation of this instrument 1. Fetal complication

(DU) a. Formation of chignon
b. Scalp abrasion
c. Scalp sloughing
d. Cephalhematoma
e. Hemorrhage
2. Maternal complication:
uncommon, minor injury to birth
canal
Episiotomy scissor
Identify this instrument Episiotomy scissor

Identifying points Head bent
Short and curved
Structures cut during episiotomy Posterior vaginal wall ➔ superficial + deep
perineal musucle ➔ fascia covering the
muscle ➔ pudendal vessels ➔ nerves ➔
subcutaneous tissue ➔ skin
3 indications of episiotomy Rigid perineum
Perineum threatening to tear
Breech delivery
Instrumental delivery
Previous episiotomy
Scar in perineum
18
Disposable cord clamp
What is it Disposable cord clamp

Mention its use Clamp umbilical cord after delivery of baby
Site of application 1st tie: 2 finger from abdominal wall of the
baby
2nd tie: 1 finger away from 1st tie
3rd tie: 4 finger away from 2nd tie
Why is it applied at that level? To secure bleeding from umbilical cord
Prevent infection of umbilical cord
(omphalitis)
Mention the normal contents of umbilical cord Wharton’s Jelly
2 umbilical artery
1 umbilical vein
19
Contraceptives and drugs
OCP
Identify this strip (DU) This is a strip of combined oral

contraceptive pill
Mention the composition of this (DU) In case of সুখী it is:
White tablet (28) contains:
1. Estrogen (Ethinyl estradiol)
2. Progesterone (Desogestrel)
Red/brown tablet (7) contains: Fe (Iron)
Mention 4 mechanisms of action (DU) 1. Suppression of ovarian follicle
maturation (E)
2. Suppression of ovulation (P)
3. Make cervical mucus thick, scanty,
viscid (P)
4. Endometrial unfavorable for
implantation (P)
On which day of menstrual cycle should it be 1st day
started? (DU)
Mention 4 indications of this (DU) 1. As a contraceptive method
2. DUB
3. Endometriosis
4. PID
5. Poly cystic ovarian disease
6. ovulatory pain
7. pre-menstrual syndrome
Mention 4 adverse effects of this (DU) 1. Nausea, vomiting
2. Weight gain
3. Irregular p/v bleeding
4. DVT, PE
5. Hypertension
6. Jaundice
4 Contraindication of this (DU) 1. History of stroke, DVT, PE
2. Liver disease
3. Heart disease
4. Thromboembolism (DVT, PE)
5. 6 months postpartum in
lactating mother
20
IUCD
Identify this device (DU) This is Intra Uterine Contraceptive device (IUCD) :
CU-T 380A
Mention 4 mechanisms of action (DU) Copper:
➢ Cellular + biochemical reaction
➢ Change composition of cervical mucus
➢ Alteration of sperm motility
All IUCD ➔ foreign body reaction ➔ change in
endometrium ➔ unfavorable endometrium
Ideal time of insertion (DU)
i. within 1st 5 days of menstruation
ii. post abortal (immediately)
iii. NVD: within 48 hours of delivery
iv. If not within 48 hour then after 6 weeks of
delivery during LUCS
v. after c/s
Mention 4 adverse effects of this (DU) 1. Perforation of uterus ➔ shock
2. Abdominal pain
3. Spontaneous explusion
4. Abnormal uterine bleeding
5. risk of ectopic pregnancy
6. failure (pregnancy)
4 Contraindication of this (DU) 1. PID
2. Undiagnosed bleeding from genital tract
3. Uterine anomaly
4. Suspected pregnancy
5. Severe dysmenorrhea
6. previous hx of ectopic pregnancy
21
Implanon
Identify this device (DU) Implanon NXT sudermal implantable

contraceptive
Mention the composition of this (DU) It contains 1 silastic tube containing 68 mg
etonogestrel (progestogen)
Mention 4 mechanisms of action (DU) ⮚ Inhibition of ovulation
⮚ Inhibits implantation: endometrium
made unfavorable
⮚ Thickens cervical mucus
⮚ Decreases tubal motility
Mention the time of implantation of this ⮚ Within day 5 of menstrual cycle
device (DU) ⮚ Within 5 days after abortion
➢ 3 weeks after delivery
Mention the duration of action (DU) 3 years
Mention 4 adverse effects of this (DU) ⮚ Irregular bleeding (breakthrough)
⮚ Headache
⮚ Weigh gain
⮚ Acne
4 advantages of this as a contraceptive (DU) ⮚ High efficacy
⮚ Long term method
⮚ Doesn’t interfere with sexual
intercourse
⮚ No effect on breastfeeding
⮚ No risk of forgetting
⮚ Prompt return of fertility after removal
DMPA
22
Identify this device (DU) This is a vial containing injectable
contraceptive Depo-Provera (স্বস্তি)
Mention 4 indications of this (DU) ⮚ Lactating mother
⮚ Women in whom estrogen
contraindicated
⮚ Unreliable pill user
⮚ Presence of disease which doesn’t
allow estrogen use: sickle cell
disease, endometrial carcinoma,
endometriosis
Mention 4 adverse effects of this (DU) (same ⮚ Irregular bleeding (breakthrough)
as Implanon)
⮚ Headache
⮚ Weigh gain
⮚ Acne
4 Contraindication of this (DU) ⮚ Suspected pregnancy
⮚ Undiagnosed abnormal p/v bleeding
⮚ Liver disease
⮚ Thromboembolic condition
Mifepristone + Misoprostol MTP kit (MM Kit)
Identify Packet containing Mifepristone and

misoprostol as medical termination of
pregnancy kit
Composition Miferpristone (200 mg)
Misoprostole (200 mcg)
Indication 1. Menstrual regulation
2. Medical termination of pregnancy
(within 63 days)
4 common side effect 1. Abdominal pain
23
2. p/v bleeding
3. shock
4. sepsis
5. nausea, vomiting
6. headache
2 contraindications 1. ectopic pregnancy
(suspected/confirmed)
2. IUCD in situ
3. Liver disease
Labetalol
Identify Strip containing Tablet labetalol 200 mg

What type of drug it is Anti hypertensive drug
Combined alpha and beta blocker
Indication Pre-eclampsia
Severe pre-eclampsia
Eclampsia
Route of administration Oral
IV infusion
Contraindication Asthma
DM
Heart failure
Liver disease
Name some other drugs with same indication Nifedipine
Hydralazine
Alpha-methyl dopa
24
Misoprostol
What is it this is a strip containing Tablet Cytomis, 200

microgram, which is Misoprostol 200
microgram
mechanism of action (DU) Increases sensitivity of uterine muscle to
oxytocin
4 important use Abortion, ectopic pregnancy, hydatidiform
mole
Induction
Augmentation
Ripening of cervix
PPH: prevention and management
Advantage o Very cheap
o Available widely
o Doesn’t need refrigeration
o Effective in early pregnancy (oxytocin
isn’t)
Disadvantage o Nausea, vomiting, diarrhea
o Precipitate labor
o Uterine rupture
o Effect irreversible (unlike oxytocin)
o Fetal distress
o Fetal hypoxia
Contraindication o Asthma
o Glaucoma
o Rupture uterus
o HTN
o Cardiac dss
o Renal dss
25
Inj. Oxytocin
Identify this ampoule (DU) This is an ampoule containing synthetic

preparation of oxytocin (5IU/mL)
Mention its use in obstetrics/obstetric ⮚ Early pregnancy: abortion,
indication (DU) hydatidiform mole
⮚ Late pregnancy: induction of labor,
Augmentation of labor
⮚ AMTSL
⮚ Prevention and management of PPH
Name some other uterotonic drugs (DU) ⮚ Prostaglandin
⮚ Ergometrine
Mechanism of action (DU) causes physiological contraction of uterus
releases prostaglandin
Mention the doses of oxytocin (DU) Induction of labor: start at 2 mIU/min IV ➔
upto 8 mIU/min IV
AMTSL: 10 IU on thigh (5+5) within 1 minute

of delivery
PPH: 20 IU in 1L
Contraindication (DU) Hypersensitivity
Scar in uterus upper segment
Cardiac: hypotension
Pulmonary: asthma
Hepatic: jaundice
Renal: renal failure
26
Inj. Ergometrine
Identify + generic name Inj. Ergometrine

3 common uses AMTSL
PPH management
PPH prevention
Abortion management
3 contraindications Multiple pregnancy
Previous uterine scar
Severe pre-eclampsia
Eclampsia
Name of other uterotonic drugs Oxytocin
Prostaglandin analog
Inj. MgSO4
1 Identify this ampule This is an ampoule containing 5 mL Magnesium sulphate

(DU)
2 What type of drug It is an anticonvulsant and anti tocolytic drug

is it?
3 Write down its ⮚ Eclampsia

indication (DU) ⮚ Severe pre eclampsia
⮚ As tocolytic in preterm birth
⮚ Fetal neuroprotection in preterm birth
4 What are the ⮚ Respiratory rate ≥ 16 breaths/minute

parameters seen ⮚ Urine output <30 mL/hour
⮚ Deep tendon reflexed must be present
27
before its
application (DU)
5 Write down its Dose of MgSO4: (1 ampoule of MgSO4 contains: 2.5 g or 5

dosage schedule mL of MgSO4)
(DU)
⮚ Loading dose: total 10 g
o 4 g MgSO4 + 12 mL Distilled water: IV
slowly over 15-20 mins
o 3 g+3g: IM in each buttock
⮚ Maintenance dose
o 2.5 g, every 4 hourly, IM in alternating
buttock
o Continue for 24 hours from
▪ The last convulsion
▪ Or delivery of the baby
6. Contraindication ⮚ Urine output <30 mL/hour
(DU) ⮚ Respiratory rate <16 breath/min
⮚ Absence of deep tendon reflex
7 Antidote (DU) Injection calcium gluconate 10%
Anti-D immunoglobulin
Identify the drug/vial Vial containing antiD/Rh immunoglobulin

Indication of its use Prevent development of antibody against Rh
antigen in mother’s body following
Childbirth
Abortion
Ectopic pregnancy
Molar pregnancy
Purpose of using the drug Same
28
When it is used/optimum time to give it Within 72 hours of delivery/abortion/ectopic
pregnancy management/mole evacuation
Complications if this drug is not used Maternal:
PE, E
Big baby
Polyhydramnios
Fetal:
Congenital hemolytic anemia
Icterus gravis neonatorum
Hydrops fetalis
Principles of prevention of Rh immunization ➢ Avoid mismatched transfusion
in an Rh negative mother ➢ Prevent feto maternal bleeding
➢ Administer anti D within 72 hours of
delivery/abortion/mole
evacuation/ectopic pregnancy
Hydralazine
What is it? Vial containing hydralazine

Mention its indication in labor Pre eclampsia
Severe PE
Eclampsia
(to control HTN)

Mechanism of action Smooth muscle relaxation ➔ relaxes
vascular smooth muscle ➔ vasodilatation ➔
reduce TPR ➔ reduce BP
Side effects of its use Throbbing headache
Postural hypotension
Tachycardia
Palpitation
Diarrhoea
Nausea
Vomiting
29
Specimen
Ovarian tumor
Identify Bilateral ovarian tumor with uterus and fallopian

tube
Diagnosis Benign cystic neoplasm of ovary
Points in favor of dx ➢ Enlarged ovary
➢ Intact capsule
➢ Smooth surface
➢ Cystic consistency
➢ No engorged vessel seen
➢ No adhesion
➢ No peritoneal deposit
3 common benign tumor of this organ ➢ Dermoid cyst
➢ Serous cystadenoma
➢ Mucinous cystadenoma
➢ Clear cell tumor
Clinical feature of dx ➢ Heaviness in lower abdomen
➢ Slowly increasing mass
➢ In large tumor: mechanical distress
➢ Cystic swelling in abdomen ➔ groove
felt between mass and uterus ➔
movement of mass per abdomen fails to
move cervix per vaginally
d/d of benign ovarian tumor ➢ Fibroid uterus
➢ Pregnancy
➢ Full bladder
➢ Tubo-ovarian mass
➢ Appendicular lump
Investigations to confirm dx USG of Whole abdomen + color doppler
Trans vaginal USG
Tumor marker (CA 125, Beta HCG, AFP, LDH)
Biopsy and histopatholoy
Abdominal CT scan
30
Complications if left untreated Torsion of cyst
Hemorrhage in cyst
Rupture of cyst
Degeneration of cyst
Necrosis of cyst
Conversion to malignant ovarian tumor
Dermoid cyst of ovary
Identify Specimen of a dermoid cyst of ovary showing

hair and teeth
What type of tumor is it Benign
Germ cell tumor
Characteristic features of this tumor Benign tumor
Cystic in nature
Contains tissue from all three germ layers
Ectoderm: teeth, hair, skin, sebaceous
material
Endoderm: thyroid
Mesoderm: muscle, bone, cartilage
Complications Torsion of cyst
Hemorrhage in cyst
Rupture of cyst
Degeneration of cyst
Necrosis of cyst
Conversion to malignant ovarian tumor
Treatment options Small size + family incomplete = ovarian
cystectomy
31
Large tumor + family incomplete + opposite
ovary healthy = unilateral oophorectomy
Both ovaries affected + family complete +

cannot exclude malignancy + post
menopausal = TAH+BLSO
Fibroid uterus
Identify Jar containing uterus and fallopian tube (and

ovary) of both sides, uterus enlarged,
irregular nodular growth confined to body of
the uterus
Diagnosis Fibroid uterus
Type of tumor Benign tumor of smooth muscle
Identifying points ➢ Uterus enlarged
➢ Multiple nodular growth seen
➢ Cut surface white
➢ Whorled appearance
➢ Tube appears normal
Presenting complaints Progressive menorrhagia
Lump in abdomen
Per abdominal findings Firm mass ➔ well defined margin ➔ cannot
get below swelling ➔ mobile from side to
side not from above downwards ➔ no groove
between uterus and abdomen
Investigations ➢ USG of abdomen
➢ TVS USG
➢ MRI
➢ Hysterosalpingogram
➢ Hysteroscopy
Effects of it on pregnancy ➢ Infertility
➢ Abortion
➢ IUGR
32
➢ Preterm labor
➢ Malpresentation/position
➢ Obstructed labor
➢ PPH
Treatment option/modality Medical: mifepristone, danazol, GNRH
analog and antagonist
Surgery:
➢ Conservative: myomectomy (family
incomplete, <40)
➢ Definitive: total abdominal
hysterectomy (>40 y) + BLSO (>45 y)
What operation if multipara/42 years old Total abdominal hysterectomy
Why this operation, mention this point in favor ➢ Multipara
of your surgery ➢ Family complete
➢ Age >40 years
3 complications if she is left untreated ➢ Torsion
➢ Hemorrhage
➢ Degeneration
➢ Necrosis
➢ Infection
➢ Ascites
➢ Malignant transformation
Placenta with fetal membranes and umbilical cord
Identify Specimen of placenta with umbilical cord

(and membranes, if present)
4 important functions of it ➢ Nutrient function
➢ Barrier function
➢ Immunological function
➢ Endocrine function
Sources of its development Fetal part: chorion frondosum
33
Maternal part: decidua basalis
When is its development completed At 12 weeks of gestation
Usual site of attachment Functional layer of endometrium ➔ in the
body ➔ close to fundus ➔ either in anterior
or posterior wall
Hormones produced by it HCG
Human placental lactogen
Estrogen
Progesterone
Cortisol
Common types of abnormalities in it Placenta previa
Placenta succenturiata
Velamentous placenta
Battle-dore placenta
Circumvallate placenta
Importance of its examination after delivery To see any missing bits, lobes, torn vessels
➔ to prevent PPH due to retained bits of
placenta
2 causes of bleeding, related to its structure Placenta previa
during pregnancy Abruptio placenta
1 complication that may occur after delivery PPH
Hydatidiform mole
Identify the supplied specimen Jar containing specimen of hydatidiform mole

2 identifying points Multiple grapes like vesicles
Vesicles are whitish, of different size
Clinical features Amenorrhea
Per vaginal bleeding
Passage of grape like vesicles per vagina
34
Exacerbation of features of pregnancy
(nausea, vomiting)
3 important per abdominal findings Size of uterus: more than age of gestation
Uterus: dougy
Fetal part: absent
FHS: absent
Investigation ➢ USG:
snowstorm appearance of uterus
bilateral enlarged ovaries
➢ Beta HCG: increased
➢ Thyroid function test
➢ Biopsy and histopathology
Treatment General: treatment of anemia
Specific:
suction and evacuation
Hysterectomy
Commonest surgical intervention Suction and evacuation
Mention follow up schedule At least 2 years
Weekly until 3 consecutive normal beta HCG
level
Then monthly for 6 months
Then 3 monthly upto 2 years
Complications of it ➢ Hemorrhage
➢ Shock
➢ Sepsis
➢ DIC
➢ Pre-eclampsia
➢ ARDS
➢ Pulmonary embolism
➢ Air embolism
➢ Malignant transformation
(choriocarcinoma)
Unruptured ectopic tubal pregnancy
Identify specimen Unruptured tubal ectopic pregnancy
35
2 important clinical features Short period of amenorrhea
Uneasiness in flank
Tender mass in the lower abdomen
PV bleeding: absent/slight
Features of shock: absent usually
Mention the name of surgery in such a case Salpingotomy
Salpingostomy
Salpingectomy
Anencephaly
Identify the supplied specimen Anencephaly

What type of defect/anomaly is this Neural tube defect
Which part of body is deficient in this Vault of skull + cerebrum of brain
condition?
But face is intact
Investigation for diagnosis AFP level in amniotic fluid: high
USG
Complication Polyhydramnios
Pre-mature labor
Prolonged labor
Obstructed labor
Malpresentation
How to prevent this condition Folic acid supplementation of all women of
reproductive age group
(at least 1 month before pregnancy up to 12

weeks of gestation)
36
Hydrocephalus
Identify Enlarged head, prominent veins, sunsetting

appearance of eyes
Diagnosis Hydrocephalus
Causes/mechanism ➢ Increased production of CSF
➢ Decreased drainage
➢ Blockage in CSF circulation
Diagnosis of this condition in late pregnancy ➢ Uterus large than age of gestation
➢ Large globular head may be palpated
➢ Confirmed by USG
➢ Failure to engage head
➢ Malpresentation (breech presentation)
Treatment in severe cases ARM/oxytocin ➔ induction of labor ➔
decompression of head by sharp
scissor/needle
37
Pictogram
Carcinoma cervix
Diagnosis Carcinoma cervix

Clinical features Irregular menstruation
Contact bleeding
Post coital bleeding
Excessive p/v offensive/bloody discharge
Advanced: bowel, bladder symptoms, pelvic

pain, symptoms of lung metastasis
Growth in cervix ➔ hard, fixed, friable, bleeds

to touch
4 cardinal signs Hard
Fixed
Friable
Bleeds to touch
Different treatment modalities ➢ Surgery: wertheim’s (radical)
hysterectomy
➢ Radiotherapy
➢ Chemotherapy
➢ Combined
➢ Palliative therapy
Complications ➢ Hemorrhage
➢ Fistula: VVF, VCF (vesico-cervical),
RVF (recto-vaginal)
➢ Due to urinary blockage:
Hydronephrosis
CKD
➢ Pyometra
Causes of death Hemorrhage
Sepsis
38
CKD
Hydronephrosis
Metastasis to distant organs
Bicornuate uterus
Identify Bicornuate uterus

Why this condition develops Due to failure of complete fusion between
mullerian ducts
How to confirm dx ➢ Ultrasonography
➢ Hysterosalpingography
➢ Hysteroscopy
➢ Laparoscopy
Mention its effect on pregnancy ➢ Defective placentation
➢ Abortion (mid trimester abortion)
➢ Cornual pregnancy
➢ Cervical incompetence
➢ Preterm labor
➢ Retained placenta
➢ Inadequate uterine contraction
➢ IUD
➢ IUGR
➢ LBW baby
39
Uterovaginal prolapse
What is shown in the picture Utero-vaginal prolapse

How will you differentiate 2nd degree from 3rd 2nd degree: anterior and posterior wall of
degree vagina cannot be apposed between fingers +
cervix will be palpable between these walls
(cannot get above the swelling)
3rd degree: can be apposed (get above the

swelling)
What pre-operative investigations will you do GA fitness + USG
for the patient?
➢ CBC
➢ Blood grouping
➢ Rh typing
➢ Serum creatinine
➢ Chest xray
➢ RBS
➢ Urine RME
➢ ECG
➢ HBSAg
➢ USG of whole abdomen
Mention three predisposing factors ➢ Trauma during vaginal delivery
➢ Imperfect repair after injury to genital
tract
➢ Spina bifida
➢ Inborn weakness/genetic
3 complications associated with this condition Decubitus ulceration

Vagina: drying ➔ surface keratinization
Cervix: elongation + ulceration
Bladder: hypertrophy of bladder wall
Kidney: hydronephrosis, CKD
40
Placenta previa
What does this picture show with diagnosis Placenta implanted in the lower uterine
segment totally covering the internal os
Diagnosis: placenta previa (central type)

What are the symptoms History of amenorrhea
Per vaginal bleeding: painless, apparently
causeless, recurrent
No history of trauma
Anemia, shock in proportion to hemorrhage
Investigation USG of whole abdomen
CBC
Blood grouping and Rh typing
Complications Mother:
Hemorrhage
Shock
Coagulopathy
DIC
APH followed by PPH
Subinvolution
Malpresentation
Baby:
Fetal distress
Perinatal asphyxia
IUGR
IUD
Preterm baby
LBW
41
Treatment/preferred mode of delivery Resuscitation (IV fluid, blood) ➔ if baby,
mother good and no active bleeding ➔
expectant management
If not ➔ definitive ➔ in this case (central
placenta previa) ➔ USG to confirm ➔
delivery by C/S (cesarean section)
Abruptio placentae
Probable diagnosis Abruptio placentae

Causes of abruptio placentae ➢ Sudden decompression: multiple
pregnancy, polyhydramnios
➢ Pre-eclampsia
➢ Eclampsia
➢ Trauma
➢ Short code
➢ Multiparity
➢ ARM
4 investigations USG of whole abdomen
CBC
Coagulation profile
Bedside urine test
Treatment options Resuscitation (IV access, fluid, blood) ➔ if
patient in labor, close to 37 weeks, bleeding
continued ➔ termination of pregnancy (ARM
and oxytocin ➔ NVD ➔ if failed ➔ C/S)
42
Small percentage: not in labor, no bleeding,
away from term ➔ in them ➔ expectant
management
Complications Hemorrhage
Shock
DIC
PE
AKI
PPH
IUD
IUGR
Fetal distress
LBW baby
Breech presentation
Identify Breech presentation

Types of breech presentation Complete breech
Incomplete breech
➢ Frank breech
➢ Knee presentation
➢ Footling presentation
5 complications of delivery in breech Prolonged labor
presentation Obstructed labor
Fetal distress
IUD
Still birth
Injury to organs of the baby
Injury to the genital tract and organs of the
mother
Methods of vaginal breech delivery Delivery of the lower limbs
43
Then delivery of head after coming of breech
by:
➢ Burns marshal method
➢ Forceps delivery
➢ Malar flexion and shoulder traction
method
Data/Scenario
Obstetrics
APH
A primi gravida at 35 weeks of gestation with history of labor pain and P/V bleeding. Hb 8
gm/dL, HCT <32%
Diagnosis Antepartum hemorrhage with anemia
Investigations USG of whole abdomen
CBC
Outline of management General: resuscitation (IV access, infusion of
fluid, blood transfusion), correction of anemia
Condition of fetus, mother, whether active

bleeding is present or not ➔ determine if
expectant management or termination of
pregnancy
USG to localize placenta ➔ decide if NVD or
C/S
How will you correct anemia Blood transfusion
Iron supplementation
Iron containing food
Complications Maternal:
Hemorrhage
Shock
DIC
Coagulopathy
PE
Sepsis
Preterm labor
Fetal:
Fetal distress
IUD
IUGR
Perinatal asphyxia
Stillbirth
Premature birth
LBW
44
PPH
Multiparous lady….severe p/v bleeding…following delivery at home….1 hour back
Diagnosis Post-partum hemorrhage
6 vital signs to assess her Pulse
Blood pressure
Respiratory rate
Temperature
Urine output
Dehydration
Oxygen saturation
Mental status
1st line management of PPH Shout for help ➔ IV access and
catheterization ➔ draw blood sample for
grouping and Rh ➔ send for blood ➔ IV fluid
infusion and blood transfusion ➔ oxytocin 20
IU in 1 L saline started at 40-60 drops/min
Uterotonic drugs to use Inj. Oxytocin
Inj. Ergometrine
Inj. Misoprostol (prostaglandin)
Abruptio placentae
Pregnant lady….34 weeks….lower abdominal pain + PV bleeding….o/e uterus hard and
contracted
Probable diagnosis Antepartum hemorrhage due to abruptio
placentae
Clinical feature + examination Feature:
➢ Pregnancy for 34 weeks
➢ p/v bleeding: painful, scanty, dark
colored
➢ abdomen hard, contracted, tender
➢ anemia, shock out of proportion to
bleeding
examination:
➢ SFH: may be more
➢ Palpation: hard, tense, tender
➢ Fetal parts, FHS: not felt
➢ Meconium stained liquor present
Treatment Resuscitation (IV access, fluid, blood) ➔ if

management
45
A pregnant lady at 37 weeks of gestation with lower abdominal pain and history of p/v
bleeding. O/E BP was 150/90 mmHg. Urine examination showed albumin
Probable diagnosis Abruptio placentae with Pre-eclampsia
1 investigation to see fetal well being Ultrasonography to see fetal movement and
fetal cardiac activity
Important complications this patient may ➢ Hemorrhage
suffer from ➢ Shock
➢ DIC
➢ Coagulopathy
➢ PE
➢ Sepsis
➢ Preterm labor
Complication of the fetus Fetal:
➢ Fetal distress
➢ IUD
➢ IUGR
➢ Perinatal asphyxia
➢ Stillbirth
➢ Premature birth
➢ LBW
4 impending sings of severe PE ➢ Headache
➢ Blurring of vision
➢ Hypertension >160/110 mm Hg
➢ Severe Upper abdominal pain
➢ Sudden scanty urinary output
➢ Rapidly progressing edema
➢ Rapidly progressing proteinuria
Treatment of a case of severe PE ➢ Diet: salt, fluid restriction, protein
supplementeation
➢ Anti-hypertensive: nifedipine,
labetalol, hydralazine
➢ 37 weeks, BP persistently high,
severe PE ➔ refer to higher center ➔
MgSO4 ➔ termination of pregnancy
irrespective of gestational age
➢ ** Pt <34 weeks ➔ BP well controlled

➔ send home
➢ <34 weeks ➔ not well controlled ➔
corticosteroid for lung maturation ➔
try upto 37 weeks, if not terminate at
34 weeks
]
Treatment of AP Resuscitation (IV access, fluid, blood) ➔ if
46

management
Pre-Eclampsia
Primi gravida…37/38 weeks pf pregnancy…severe headache and blurring of vision. o/e BP is
200/120 mm Hg. Proteinuria ++++
Diagnosis Severe pre-eclampsia
4 impending signs of severe PE ➢ Headache
➢ Hypertension >160/110 mm Hg
➢ Severe Upper abdominal pain
➢ Sudden scanty urinary output
➢ Rapidly progressing edema
➢ Rapidly progressing proteinuria
Investigations USG
Serum uric acid
Urine RME
Serum Creatinine
CBC, PBF (H, P)
AST, ALT (EL)
Coagulation profile (LP)
Maternal complications Eclampsia
Brain hemorrhage
Dimness of vision
ARDS
Cardiac arrest
HELLP syndrome
AKI
Preterm labor
PPH
Shock
Complication of fetus Fetal distress
IUD
IUGR
Stillbirth
Premature baby
LBW
Perinatal asphyxia
Principals of general management ➢ Diet: salt and fluid restriction, protein
supplementation
➢ Antihypertensive: nifedipine,
hydralazine, labetalol
➢ Monitor maternal and fetal status
Obstetric management Patient is near term and has s/s of severe
pre-eclampsia ➔ give MgSO4 to prevent
47
progression to eclampsia ➔ refer to center
with feto-maternal care ➔ immediate
termination irrespective of gestation age and
condition of baby ➔ if baby alive ➔ NICU
management
Monitor mother for post partum complication:
PPH, PP. eclampsia
Eclampsia
18 year old primi….34 weeks of pregnancy….convulsion….O/E BP 160/110 mmHg,
proteinuria +++
Diagnosis Eclampsia
Complications Injury
Tongue bite
Fracture
Fall
Bruising
Brain hemorrhage
ARDS
Aspiration pneumonia
Pulmonary embolism
ALVF
Liver necrosis
AKI
DIC
Shock
PPH
Fetal distress
IUD
IUGR
Perinatal asphyxia
Stillbirth
Pre-term baby
LBW baby
Principles of management Resuscitation
Protection from fall (eclamptic position)
Control of convulsion
Control of hypertension
Deliver within 6-8 hours
Prevent + mx complications
Care in post partum period
Drugs used in control of convulsion MgSO4
Diazepam
Dose schedule of the most common drug MgSO4:
Loading dose: 4g (8 mL) + 12 mL distilled
water = slow IV infusion over 15-20 mins
3g + 3g = 6g IM on each buttock
48
Maintenance: 2.5 g/1 ampoule MgSO4, every
4 hour, in alternating buttock
Parameters need to be checked before giving Urine output >30 mL/hour
the most common drug Respiratory rate >16 breath/min
Ankle jerk and knee jerk: present
Obstructed labor
Primigravida at term….labor pain for 24 h at home…..o/e pt exhausted, dehydrated FHR 100
beats/min. P/V examination….cervix fully dilated and vagina hot, dry
Diagnosis Obstructed labor
Etiological factors Passenger:
Big baby
Hydrocephalus
Macrosomia
Anencephaly
Malformed
Twin baby
Passage:
CPD
Contracted pelvis
Pelvic tumor
Perineal scar
Uterine fibroid
Treatment of the condition Resuscitation (IV fluid, electrolyte, antibiotic,
transfusion) ➔ stabilized ➔
Baby dead ➔ VD (destructive operation)
Early detection + baby alive ➔ c/s delivery
Late detection + baby alive + head low down

➔ forceps/ventouse ➔ assisted VD
Send baby to NICU
3rd stage management to prevent PPH
Continuous catheterization for 10-14 days ➔

to prevent VVF
Complications if left untreated Rupture of uterus

Severe dehydration
Severe ketoacidosis
Shock
PPH
Lactation failure
VVF
Death
49
Fetal distress
Perinatal asphyxia
Stillbirth
Ruptured uterus
35 year….6th gravida…term pregnancy, labor pain for 18 hours. She had severe pain in
abdomen, suddenly the pain intensity became less. She had also developed respiratory
distress. Then she was referred to a tertiary care hospital
Most probable diagnosis Ruptured uterus following
prolonged/obstructed labor
Findings in general examination Hypotension
Tachycardia
Tachypnea
Rapid thready pulse
Cool periphery
Low urine output
Patient exhausted
Dehydrated
Acetone breath
Findings in abdominal examination Abdomen hard and contracted
Palpation of 2 distinct mass in the abdomen
Fetal parts well palpated
FHS absent
General measures to offer for her Resuscitation: immediate wide bore IV
access ➔ infusion of fluid ➔ collection of
blood for grouping and cross matching ➔
send for blood ➔ transfuse as soon as
available ➔ monitor urine output
O2 inhalation
Antibiotic
Analgesic
Definitive treatment in this case 35 year and 6th gravida….most likely family
complete ➔ laparotomy ➔ deliver the baby
(dead usually) ➔ hysterectomy ➔
continuous catheterization for 10-14 days to
prevent VVF
Gynecology
Vaginitis
Married lady of 35 years….GOPD….excessive p/v discharge and itching
2 Possible diagnosis Vaginitis, probably
➢ Trichomoniasis
➢ Vaginal candidiasis
Types of vaginal discharge in this 2 Trichomoniasis: fishy odor, frothy,
conditions greenish/yellowish, pH >5
50
Candidiasis: curd like, pH<4.5
Risk factors for developing the clinical DM
conditions Immune-suppression
Pregnancy
Steroid use
Injudicious use of antibiotic
Drugs to treat the condition Trichomoniasis: metronidazole….800 mg
TDS for 7 days
Candidiasis: Clotrimazole, Miconazole,
Ketoconazole
What advice will you give to this lady Personal hygiene maintain
Treat partner as well
Use barrier method
Incomplete abortion
20 year old lady….8 weeks amenorrhea….severe lower abd pain…p/v expulsion of fleshy
mess. P/V bleeding still continuing
25 year old lady…h/o expulsion of fleshy mess p/v…colicky abd pain, persistent p/v bleeding.
Anemic, size of uterus smaller than period of amenorrhea
Diagnosis Incomplete abortion
Clinical findings in favor of diagnosis Amenorrhea
Lower abdominal pain
p/v expulsion of fleshy mass
continuing abd pain
continuing p/v discharge
uterus smaller than period of amenorrhea
patient anemic
Investigations to confirm diagnosis USG (pregnancy profile): some products of
conception remaining, Fetal heart activity
usually absent
Beta HCG
Treatment options of this case General: treatment of anemia and shock (if
present)
Evacuation:
Medical: mifepristone + misoprostol

Surgical:
If <12 weeks: MVA, DnC
If >12 weeks: Oxytocin, Expulsion under G/A
Give anti-D antibody if mother is Rh-ve
Septic abortion
30 year old woman, Para 3+0…h/o amenorrhea for 33 months, introduction of stick p/v 5 days
back. Now … foul smelling + blood stained vaginal discharge, fever, severe abd pain
Most probable diagnosis Septic abortion
51
Investigations CBC (raised WBC)
Coagulation profile
USG
High vaginal swab for c/s
Complications if untreated Hemorrhage
Infection
Sepsis
Shock
AKI
DIC
Late:
Infertility
Ectopic pregnancy
PID
Treatment Antibiotic
Analgesic
Antipyretic
IV fluid
Blood transfusion
Tetanus and gas gangrene prophylaxis
Localized in uterus: evacuation of content

w/n 24 hours
Parametrium involvement: evacuation after
48 hours
Distal involvement: lapartomoy
If abscess: Incision and drainage

(colpotomy)
Ruptured ectopic pregnancy

28 year old….Para 1 VD….amenorrhea for 8 weeks…lower abd pain….slight p/v bleeding. Hx
of fainting in the morning. O/E, anemia ++, BP 60/30, abdomen distended and muscle guard
present.
Diagnosis Ruptured ectopic pregnancy with shock
How will you diagnose it clinically Sym:
Amenorrhea
p/v bleeding
lower abdominal pain
Sign:
patient in shock
abdomen distended, tender, muscle guarding
urine output diminished
Risk factor Previous DnC
Previous ectopic pregnancy
PID
IUCD
52
Tubal surgery
Salpingitis
d/d Acute appendicitis
Torsion of ovarian tumor
Torsion of fibroid
Acute pyelonephritis
Diverticulitis
What investigations to confirm diagnosis USG: empty uterus, tube dilated
Beta HCG: less than the normal value seen
in pregnancy, failure to increase at normal
rate
Management of this patient General: resuscitation (IV access, infusion,
transfusion, urine output monitor, antibiotic,
analgesic)
Definitve: salpingectomy/salpingo-
oophorectomy (if ovary damaged as well)
If mother Rh-ve: anti D antibody w/n 72 hours

of delivery
Definitive treatment See above
Carcinoma cervix
Patient of 50 years… post coital bleeding…..foul smelling p/v discharge….3 months. O/E
growth seen in anterior lip of the cervix
Diafnosis Carcinoma of cervix
Risk factor Early marriage, sexual intercourse, child
Poor genital hygience
Partner with HPV infection, partner with
multiple sexual partner
Use of non barrier methods (OCP)
Smoking
Cardinal features of this growth Hard
Fixed
Friable
Bleeds to touch
3 findings per speculum Inspection: ulcerative/cauliflower like growth
Hard
Fixed
Friable
Bleeds to touch
Confirmation of the diagnosis Biopsy and histopathology
Treatment options Surgery (radical/wertheim’s hysterectomy)
Radiotherapy
Chemotherapy
Combined
Palliative
Preventive measures of this condition ***risk factor ulta kore dao****
53
Counselling Stations
Gynecology
Myomectomy in a fibroid patient
1. Greetings + self-introduction
2. Inform about diagnosis
i. you have a benign tumor/fibroid in uterus
ii. this is causing heavy bleeding
iii. this may the cause of your infertility
3. inform about treatment options
i. medical management (only medicine)
ii. myomectomy (resection of only the tumor)
iii. hysterectomy
4. best option for her
we have determined that myomectomy is the perfect option for you

5. Inform about operation (myomectomy)
(only the tumor will be removed ➔ rest of the uterus will remain)
6. Advantage of procedure
(reproductive function + menstrual function will remain preserved/intact)
7. Disadvantage of the procedure
i. Myomectomy can convert into hysterectomy
ii. Fibroid may recur
iii. Infertility may persist
8. Exclude other factor of infertility
i. AUB
ii. PID (lower abd pain + purulent vaginal discharge)
iii. TB history
iv. Previous hx of DnC
9. Pre-requisite before procedure
i. Semen analysis of husband
ii. Keep blood ready
iii. Some other investigation needed for G/A fitness
10. Warning and consent
i. Myomectomy may turn into hysterectomy
ii. Consent taken with full information about the risks
11. Post-operative advice
i. Avoid heavy work: 6 weeks
ii. Avoid coitus/sexual intercourse: 6 weeks
iii. Avoid pregnancy: 3 moths (12 weeks)
iv. Next delivery must be in the hospital
12. Cost
i. Keep some money at hand (5-6k taka)
13. Query + thanks
54
Molar pregnancy
1. Greetings + self-introduction
2. Tell about diagnosis
You are having features of pregnancy ➔ but unfortunately you are not carrying a
baby ➔ instead there is benign tumor in your uterus ➔ causing excess nausea,
vomiting, P/V passage of grape like cluster and P/V bleeding ➔ it has been
confirmed by USG and other investigation
3. Tell about the treatment
For this condition you will need treatment ➔ called suction and evacuation ➔ we
will take out the mass from your uterus
4. Prerequisite for treatment
Admit in hospital ➔ keep blood ready
5. After S&E
In most cases (90-95%) it will be cured ➔ rarely (5-10%) become worse and
malignant ➔ so follow up is needed
6. Regular follow up ➔ at least 2 years
7. During follow up, doctor will ask about
➢ Irregular p/v bleeding / amenorrhea
➢ Cough, breathlessness, hemoptysis
➢ Hematemesis, melaena
➢ Examine abdomen and vagina
➢ Investigation: Beta HCG and Chest X ray
8. Come weekly ➔ will do Beta HCG test ➔ 3 consecutives normal ➔ then
come monthly for 6 month ➔ then come 3 monthly
9. If you had hemoptysis/chest pain ➔ you may need to do Chest x ray
10. Advice During 2 years follow-up
➢ Avoid conception
➢ Use barrier method
➢ Don’t use OCP, IUCD
55
OCP
1. Greetings + Self introduction
2. Contraceptive history
3. Mens + Obs hx
➢ number of child + Age of last child
➢ Menstrual cycle
➢ LMP
4. Ask about Past clinical history (and also mention the contraindication)
i. HTN
ii. DM
iii. Liver disease
iv. Migraine
v. Smoking history
5. OCP advantages
i. Highly effective
ii. Cheap
iii. Convenient to use
iv. No interference with sexual activity
v. Quick Reversibility after stopping use
vi. Additional non contraceptive benefits
6. Side effects
i. Nausea
ii. Vomiting
iii. Weight gain
iv. Breakthrough bleeding/irregular P/V bleeding
7. Procedure
i. Start white pill from the 1st day of menstruation
ii. Take one pill at night at the same time for 21 days
iii. Take the red pill (iron pill) for the next 7 days
iv. Withdrawal bleeding will occur during these 7 days
v. After 7 red pill ➔ start new strip again
8. Missed pill
i. miss 1 pill ➔ take it as soon as you remember ➔ continue rest as
usual
ii. miss 2 pills ➔ take both as soon as you remember ➔ continue the
rest + barrier method for next 7 days
iii. miss 3 pills ➔ discard the current strip ➔ use barrier method ➔
period starts again, ➔ start a new strip
9. danger sign/when to stop and return

i. Chest pain
ii. Respiratory distress
iii. Leg pain
iv. Hypertension
v. Jaundice
Return immediately ➔ consult ➔ choose another method
10. Ask for query + thanks
56
IUCD and CU-T
(1st 4 points same)
3. Mens + Obs hx
➢ Menstrual cycle
➢ LMP
4. Ask about Past clinical history
i. PID
ii. Past ectopic pregnancy
iii. Genital malignancy
iv. DM
v. Liver disease
5. Show patient the IUCD device
i. Advantage of IUCD
ii. Long acting + reversible (LARC)
iii. CU-T-380A: 10 year duration of action
iv. High efficacy
v. No interference with sexual intercourse
vi. Fertility return immediately after removal
6. mechanism of action
i. foreign body reaction
ii. prevents implantation of zygote
iii. copper has spermicidal action
7. disadvantage/ complication
i. lower abd pain
ii. dysmenorrhea
iii. irregular p/v bleeding
8. contraindication
i. suspected pregnant
ii. past h/o ectopic pregnant
iii. AUB
iv. PID hx/present
9. time of insertion
i. within 1st 5 days of menstruation
ii. post abortal
iii. NVD: within 48 hours of delivery
iv. If not within 48 hour then after 6 weeks of delivery during LUCS
10. Instruction
i. Check for thread during each menstruation
ii. Come back immediately if thread not found
11. Follow up
i. Come back once in next 1 month
ii. Then once in next 3 months
iii. Then once in next 6 months
iv. Then once yearly
v. Remove after expiration/wish to remove
57
12. Ask for any query + give thanks
Norplant/Implanon

3. Mens + Obs hx
➢ Menstrual cycle
LMP
4. Ask about Past clinical history
i. DM
ii. Liver disease
iii. Thromboembolism
5. Show her the Implanon/Norplant device
6. Advantage of Implanon
i. LARC (long acting reversible contraceptive)
ii. Duration of action: 3 years
iii. High efficacy
iv. No interference with sexual intercourse
v. Prompt return of fertility after removal
7. Mechanism
i. Inhibition of ovulation
ii. Inhibits implantation
iii. Thickens cervical mucus
iv. Decreases tubal motility
8. Disadvantage/side effects
i. Irregular p/v bleeding
ii. Headache
iii. Weight gain
iv. Acne
9. Contraindication
i. Suspected pregnancy
ii. AUB
iii. Liver disease
iv. Thromboembolism
10. Procedure
Small incision made on skin ➔ tube inserted ➔ later taken out by same procedure
11. Instruction
Check for local pain ➔ consult if any discomfort/side effects
12. Query + thanks
58
Contraceptive for newly married couple
Greetings + introduction ➔ Contraceptive hx ➔ obs and mens hx ➔ past clinical history (mainly
like OCP) ➔ options for them: Condom/barrier method + OCP (since newly married) ➔
Condom: advantage disadvantage ➔ OCP: advantage, disadvantage, contraindication,
how to take pill, what to do in missed pill ➔ query + thanks
Condom advantage Condom disadvantage

Cheap High failure rate
Simple Interference with intercourse
Easy to use Latex allergy
Non contraceptive benefit: against STD, PID,
HPV, Ca Cervix
Hysterectomy
1. Greeting and self introduction 0.5

2. Explanation about disease 1
There is a malignancy/…./anything that is mentioned in the scenario

3. Treatment options 1
i. There is conservative treatment
ii. There is definitive treatment (hysterectomy)
4. Best available option for her 1
i. We have determined that the best option for you is hysterectomy
ii. Because you have completed your family
iii. Without this treatment your health condition will worsen
iv. After this treatment you will be cured
5. Pre-requisite of the operation 1
i. Keep blood ready
ii. Pre-operative investigations needed (blood, urine, Chest xray, ECG)
6. Complication during operation (may happen, but we will do our best to 1
avoid)
i. Hemorrhage
ii. Injury to structure
iii. Complication due to anesthesia
7. Immediate post-operative complication (may occur, we will try our best to 1
avoid)
i. Bleeding
ii. Urinary infection
8. Consequences of the operation 1
i. No more menses
ii. No future pregnancy
9. Treatment cost: 7-10 k taka 1
10. Hospital stay: 14 days
11. Query + thanks giving 0.5
Total 10
59
Obstetrics
ANC
A mother has come to you for her 1st ante natal visit. How will you counsel her, regarding her
ante natal care? (ANC counselling)
1. Greetings and self-introduction

2. Schedule future ante natal visits
You will come to us minimum 4 times. Please take this card:
1st at 16 weeks
2nd at 24-28 weeks
3rd at 32 weeks
4th at 36 weeks
3. Advice
Rest
a.
⮚ Sleep 8-10 hours at night and 1-2 hours at noon

⮚ If you don’t feel sleepy during the day, lie down and rest
Diet
b.
⮚ You have to eat high calorie nutritious diet containing: meat, fish, egg,
milk, fruits, vegetables
⮚ Drink plenty of water
Personal
c. hygiene
⮚ Always stay clean

⮚ Bathe regularly
⮚ Wear clean and comfortable dress
⮚ Take care of your breasts, clean them during bathing properly
Sexual
d. Aintercourse:
Avoid sexual intercourse during
➢ 1st 3 months (upto 12 weeks)
➢ the last 2 months (7 months/28 weeks onwards)
Care
e. of bowel bladder
⮚ Drink adequate water

⮚ Frequent evacuation of bladder
⮚ Eat fiber containing foods to avoid constipation
Comfort
f. of mother
60
⮚ Don’t do heavy work
⮚ Don’t wear high heels
⮚ Don’t travel further distance
Immunization
g.
Are you vaccinated for Tetanus➔ if not we will vaccinate you. Once at 5
months, once at 6 months
Drugs
h.
Regularly take
➢ Iron
➢ Calcium
➢ Folic acid tablet
Don’t take any medications without doctor’s prescription
Plan
i. of delivery
⮚ Decide place of delivery: home/hospital

⮚ If you decide to deliver at home, arrange for a skilled birth attendant
⮚ If hospital arrange:
a. Money
b. blood donor
c. transportation
d. attendant who will care for you
Danger
e. 2 sign: Please note the following danger signs
➢ Headache
➢ Convulsion
➢ Per vaginal bleeding
➢ Severe lower abdominal pain, fever (chorioamnionitis)
➢ Dysuria
If you note these problems, urgently consult the doctor
4. Thank the mother and ask for queries
61
Placenta Previa
28 years, 2nd gravida, at 36 weeks of pregnancy with placenta previa, diagnosed by USG, family
anxious and worried, counsel her about the condition
1. Greetings + self introduction

2. Details about current pregnancy
i. Age of pregnancy
ii. Any complications other than the presenting problem
iii. Whether any/How many ANC she had
3. Obstetric + menstrual history
i. Para, gravida, ALC, past delivery details
ii. LMP
iii. Menstruation prior to pregnancy
4. Inform about the current diagnosis
You presented with p/v bleeding ➔ from assessment + USG we have confirmed you
have placenta previa ➔ it means your placenta is attached lower than normal
5. Reassure about the condition
This is unfortunate for you ➔ but we are well equipped to treat you ➔ please be
assured
6. Why you need treatment: complication of mother (complication is rare ➔ we
will try best to prevent any complication)
i. More p/v bleeding ➔ patient will worsen
ii. Preterm labor
iii. PPH
iv. Rarely, there is threat of life
7. Why you need treatment Complication of baby (complication is rare ➔ we
i. Low birth weight
ii. Premature
iii. Failure to breath
iv. Rarely, baby may die (IUD/stillbirth)
8. Some investigation necessary to monitor you + for treatment
i. Hb%
ii. Blood group
iii. USG
9. Plan of treatment: you are 36 weeks, only 1 week away from term ➔ so we
advise you to be admitted now
You are 36 weeks ➔ if you are healthy, baby healthy, no more bleeding, everything ok
➔ we will continue upto 37 weeks ➔ then terminate pregnancy ➔ based on USG ➔
we will determine whether NVD/CS will be needed
If you/baby are in danger or bleeding is severe ➔ we won’t wait till 37 weeks but
terminate immediately by NVD/CS according to USG
10. Advice during this time
i. Absolute bed rest
ii. Bathroom privilege (do toilet with potty in bed)
62
iii. Arrange blood donor
iv. Avoid sexual intercourse
11. You must need delivery at hospital
12. Any query + thanks
IUD

2. Details about current pregnancy
i. Age of pregnancy
ii. Any complications other than the presenting problem
iii. Whether any/How many ANC she had
3. Obstetric + menstrual history
i. Para, gravida, ALC, past delivery details
ii. LMP
iii. Menstruation prior to pregnancy
4. Inform about the current diagnosis
You presented with absence/less movement of baby ➔ also you felt s/s of pregnancy
going away ➔ from assessment + USG we have found that ➔ your baby’s heart beat
and movement is absent ➔ we have diagnosed that your baby has died in utero
5. Reassure about the condition
This is very much unfortunate for you ➔ but it is fortunate that you are in great health ➔
but you need further treatment to ensure no complications occur
6. Cause explanation
This may have happened due to some health condition of you ➔ or due to some defect
of the baby ➔ we will assess you further to know cause ➔ so that we can prevent this
in future pregnancy
7. Why you need treatment: complication of mother (complication is rare ➔ we
i. Dangerous infection
ii. Blood coagulation (DIC)
iii. Severe bleeding (PPH)
8. Some investigation necessary to monitor you + for treatment
i. Hb%
ii. Blood group
iii. Blood test for coagulation (aPTT, fibrinogen)
iv. USG
v. X ray of abdomen
9. Plan of treatment:
The dead baby will be expelled spontaneously within 2 weeks ➔ if not we will deliver it
by NVD
We will insert a catheter in your genital tract ➔ please lightly pull on the catheter from
time to time ➔ this will help expulsion of baby [Intra cervical catheter]
10. Support
i. We will provide you with psychological support
63
ii. After NVD, you can get pregnant again within 6 months
iii. We will assess you to prevent this in next pregnancy
iv. Do proper ANC in the next pregnancy
11. Any query + thanks
PNC
PNC counselling (advice on discharge
1. Greetings and self-introduction.
2. Advice
Rest
a)
⮚ You should sleep 10 hours per day

⮚ 7-8 hours at night
⮚ 1-2 hours during the daytime
⮚ It will be better if you sleep when the baby sleeps
⮚ Avoid heavy work for 6 weeks (NVD)/3 months (C/S)
Diet
b)
➢ You have to eat more than before (add 500 kCal if lactating)
➢ Eat nutritious diet containing: meat, fish, egg, milk, fruits, vegetables
➢ Avoid junk food
Personal
c) hygiene
⮚ Always stay clean

⮚ Bathe regularly
⮚ Wear clean and comfortable dress
⮚ Don’t wear high heels
⮚ Don’t travel further distance
⮚ Apply vulval pad and change regularly till lochial discharge occurs
Care
d) of bowel bladder
⮚ Drink adequate water

⮚ Don’t hold urine for long
⮚ Eat more vegetables
⮚ Eat fiber containing foods to avoid constipation
⮚ Use high commode
⮚ In case of presence of episiotomy wound due to NVD: wash the wound
after acts of defecation and micturition
Post
e) natal exercise
We will teach you some exercise. You should do them regularly
64
Danger
f) signs
Please note the following danger signs:
⮚ Excessive bleeding
⮚ Seizure
⮚ Fever
⮚ Foul smelling per vaginal discharge
If you note these, urgently consult physician
3. Advice for newborn
a. Exclusive breast feeding
⮚ Feed the baby breast milk

⮚ Nothing else, not even a drop of water
⮚ Exclusive BF for the 1st 6 months
⮚ Feed baby as often as it wants
⮚ Maintain proper positioning and attachment
⮚ Start supplementary feeding from 6 months
⮚ Continue breastfeeding up to 2 years
b. Immunization
⮚ Give baby BCG vaccine within 14 days

⮚ Bring baby for vaccination when it is 6 weeks old
⮚ Continue your TT vaccination
4. Contraceptive advice
⮚ Avoid sexual intercourse for 6 weeks

⮚ If lactating ➔ avoid OCP and use POP from 6 months
⮚ Birth spacing for 2 years
5. Follow up
⮚ Post-natal care schedule

a. 1st visit: within 24 h of delivery
b. 3rd: 4th-7th day/during discharge
c. 3rd : after end of 6 weeks
6. Thank the mother and ask for queries
Breast feeding and EBF
1. Greeting and self-introduction
65
2. Directions for breastfeeding
⮚ Initiate breastfeeding within 1 hour

⮚ Exclusive breastfeeding for the 1st 6 month
⮚ Not even a drop of water
⮚ Feed baby as many times as it wants
3. Education about proper positioning and attachment
Please follow the positions that we have shown you
4. Benefit to mother
⮚ uterus will return to normal size

⮚ prevent excessive hemorrhage
⮚ natural contraceptive
⮚ protection from breast cancer, uterine cancer
5. Benefit to baby
⮚ complete and ideal food for baby

⮚ easily digestible
⮚ development of the brain and intellectual development
⮚ protect from infection
⮚ increase bonding
6. No need to buy artificial formula ➔ economic benefit

7. Weaning
⮚ Introduce supplementary food from 6 months

⮚ Such as: khichuri, rice, dal, vegetable, meet, egg etc.
⮚ Continue breast feeding up to 2 years
8. If you don’t follow EBF for 1st 6 months
⮚ difficulty in digestion
⮚ malnutrition
⮚ immunity will decrease
⮚ obesity
⮚ future ➔ diabetes
9. Ask about query + thanks
66
Breaking bad news
CA Cervix
The lady sitting in front of you is 52 years old. She came with complaints of foul smelling vaginal
discharge and post coital bleeding. You have examined the patient and taken biopsy from the
cervix. Report shows squamous cell carcinoma of the cervix. Now break the bad news and
counsel her regarding the treatment.

SPIKES = for
breaking bad
news
S = Set up 2. Want to speak alone/alongside a family member/close relative?
environment
P=Perception 3. What do you know about your current health condition?
of patient
about Did you consult any other doctor ➔ what did they tell you?
condition Did you discuss it with anyone ➔ what did they tell you?
Did you try to find out yourself ➔ what did you find out (books, internet
research)
I = If patient 4. Are you prepared and eager to know about the nature of your
want to know condition? What you hear may not be a happy news, so you need
about her mental preparation
condition
K= 5. We took a biopsy from your cervix (জরায়ু মুখ) ➔ we are very
knowledge to much sad to let you know that you have been diagnosed with
the patient Cervical cancer
about the
condition
E = Empathy 6. It is a very difficult situation for you ➔ please be patient and
+ emotional bear with us ➔ we are well equipped to deal with this condition
support and hopefully with your assistance ➔ we will overcome this
S = Strategy 7. Some further examination needed to assess spread
+ next plan i. Abdominal examination
ii. Vaginal examination
iii. Chest examination
8. Some further investigations needed to assess spread
i. USG
ii. Chest X ray
iii. CT scan of abdomen
iv. MRI of pelvis
9. Treatment modalities
i. Surgery: hysterectomy (radical)
ii. Radiotherapy
iii. Chemotherapy
10. Why you need treatment: complication
With prompt treatment ➔ you may remain healthy and live a better life ➔
but if untreated ➔ complication:
➢ Bowel, bladder problem
➢ Urinary fistula (VVF)
67
➢ Spread to distal organs
➢ Untimely avoidable death
11. Cost
We will try our best to provide best treatment with lowest cost ➔
however please keep in mind that in some cases treatment might
not be cheap ➔ for that family support is needed ➔ if unable let
us know ➔ we will arrange financial support from social welfare
ministry
12. Psychological support
13. Query + thanks
68
Partograph
69
70
Procedure stations
MVA
30 year old woman para 2 presented to you with 9 weeks of pregnancy and per vaginal
bleeding. USG shows blighted ovum. You have decided to treat her with MVA. The patient has
been adequately counseled, consent taken, general anesthesia given, put in lithotomy position,
aseptic wash and draping complete. What are the next steps?
1. Check logistics
i. Cusco’s bivalve self-retaining vaginal speculum
ii. Vulsellum
iii. MVA cannula: 4 mm, 5mm, 6 mm (for cervical dilatation + aspiration)
iv. MVA syringe
v. Oxytocin
2. Prepare MVA syringe
i. Assemble it
ii. Close pinch valve
3. Create vacuum in the MVA syringe
4. Bimanual examination
Confirm size + position of uterus
5. Cusco’s speculum: retract vaginal walls
6. Vulsellum: catch anterior lip of cervix
7. Dilate cervix gradually: with MVA cannula
i. At 1st by 4 mm cannula
ii. Then by 5 mm cannula
iii. Lastly by 6 mm cannula
8. Insert cannula into uterine cavity through cervix
9. Attach MVA syringe to other end of cannula ➔ release pinch valve ➔
vacuum transferred into uterine cavity
10. Back and forth + rotatory movement of cannula ➔ evacuate contents of the
uterus
11. Ensure Complete evacuation, indicated by
i. Appearance of blood + bubbles
ii. No more aspiration occurring
iii. Gritty sensation (cannula is passing over uterine walls)
iv. Uterus feeling to be contracted around cannula
12. Close pinch valve ➔ slowly withdraw cannula and MVA syringe
13. Remove vulsellum ➔ remove cusco’s speculum
14. Examine evacuated mass
15. USG to confirm completion of aspiration
16. Oxytocin administration
17. Wash vulva + cover patient
18. Reassure the patient
71
Dilatation and curettage
(almost same as MVA, the differences are underlined)
1. Check logistics
i. Sim’s double bladed vaginal speculum
ii. Vulsellum
iii. uterine sound
iv. Hegar’s dilator/Cervical dilator
v. Curette
vi. Oxytocin
2. Patient anesthetized ➔ lithotomy position ➔ sponge holding forceps to clean
vagina and perineum ➔ draping with sterile sheet
3. Bimanual examination
Confirm size + position of uterus
4. Sim’s speculum: retract vaginal walls
5. Vulsellum: catch anterior lip of cervix
6. Uterine sound:
Measure length of uterine cavity (pass the sound into uterus)
7. Dilate cervix gradually: with Hegar’s dilator (8 mm) (metallic)
8. Introduce curette ➔ clockwise curettage of whole uterine cavity
9. Collect the curetted material
10. Ensure Complete evacuation, indicated by
i. Appearance of blood + bubbles
ii. Gritty sensation (cannula is passing over uterine walls)
iii. Uterus feeling to be contracted around curette
11. Gently withdraw curette
12. Remove vulsellum ➔ remove cusco’s speculum
13. Examine curetted mass
14. USG to confirm evacuation
15. Oxytocin administration
16. Wash vulva + cover patient
17. Reassure the patient
72
Mechanism of normal labor
1. Baby in left occipito-anterior position 1
Occiput is against the left pubic tubercle

Engagement of baby (bi-parietal diameter) along right oblique diameter
2. Engagement ➔ 1
3. Descent of head ➔
4. Flexion of head ➔
5. Head touches pelvic floor ➔ internal rotation ➔(anti-clockwise) occiput behind 1
symphysis pubis ➔ crowing
6. Delivery of head by extension 1
(occiput under Symphysis pubis and nose on the side of buttock of mother)
7. Restitution 1
(baby’s head rotates clockwise in such way that nose now comes towards right thigh of
mother
8. External rotation of the head due to internal rotation of the shoulder 1
(clockwise…..along the same direction of restitution ➔ babies head now totally

horizontal ➔ nose against right thigh and occiput against left thigh ➔ shoulder now
along antero-posterior diameter of pelvic outlet……left shoulder under symphysis pubis
and right shoulder under buttock)
9. Delivery of anterior shoulder (left) ➔ delivery of posterior shoulder (right) 1
10. Delivery of rest of the body by lateral flexion 1
Total 10
73
2nd stage of labor management
(what doctor will do during each steps of the mechanism of labor)
A patient is in the 2nd stage of labor and about to deliver. Demonstrate delivery of the baby on
the model
Corresponding to
which step of labor
1. greeting, assurance & encouragement
2. Position:
Position of choice
dorsal position with 15 degree left lateral tilt

(preferable/recommended)
3. Prerequisite
i. Check logistics
ii. Ensure bladder is empty ➔ if full ➔
catheterize
iii. Aseptic preparation of doctor
iv. Sterile wash of vulva and perineum
4. Per vaginal examination ➔ check cervical dilatation ➔

check baby’s position, presentation
5. Perform episiotomy if required
6. Keep baby’s head flexed with 2 fingers ➔ controlled extension

delivery of the head
descent
flexion
internal rotation
crowning
7. Support the perineum ➔ head delivered by extension Delivery of the head

by extension
8. Suction + clean baby’s mouth and nose
9. Check if umbilical cord is around baby’s neck
➔ If loose ➔ take it over baby’s head

➔ If tight ➔ clamp in 2 places ➔ cut between them
10. Allow the baby's head to turn spontaneously Restitution
74
11. Head turned ➔ place 2 hands over each ear of baby ➔ tell +
mother to bear down with each contraction
External rotation of
head due to internal
rotation of shoulder
12. Press baby’s head downwards ➔ delivery of anterior delivery of anterior

shoulder shoulder
13. Lift baby’s head upwards ➔ delivery of posterior delivery of posterior

shoulder shoulder
14. Support the baby while rest of the body delivered Delivery of rest of the
body by lateral
flexion
15. Record the time of the delivery + sex of the baby
16. Immediate care of newborn (see below)
At least …place on abdomen ➔ dry baby ➔ wrap with dry

cloth ➔ clamp cord ➔ cut cord ➔ eye wash ➔ breast
feeding advice
17. Prepare for AMTSL
75
Immediate/Routine care of newborn
1. Place the baby on a dry sterile cloth over abdomen of mother 1

2. Dry baby with that cloth 1
3. Discard wet clot 1
4. Cover the baby with another dry sheet 0.5
5. Maintain skin to skin contact with mother 0.5
6. Check whether baby is crying/breathing spontaneously + color + 1
movement
7. Clamp the cord at three specific sites 0.5
(214)
1st tie: 2 finger from abdominal wall of the baby
2nd tie: 1 finger away from 1st tie
3rd tie: 4 finger away from 2nd tie
8. Cut the cord (with sterile blade/scrissor) between 2nd and 3rd tie ➔ after 1 0.5
minute but within 3 minutes
1 finger away from 2nd tie, between 2nd and 3rd tie
9. Apply 7.1% chlorhexidine solution to the umbilical stump 1
Empty 1 whole bottle over the stump

10. Clean the eye with Erythromycin 0.5
Swipe from medial to lateral aspect of the eye

11. Put the baby to mother’s breast + encourage early breastfeeding within 1 1
hour
12. Thanks, and assure the mother 0.5
Total 10
76
Active management of 3rd stage of labor
1. Assure + inform patient about what you are going to do
(you and your baby are going to be fine. Stay strong and we will be done in a few
minutes)
2. Clamp + cut the cord close to the vulva/perineum
3. Palpate abdomen of the mother to exclude 2nd baby
4. After exclusion of 2nd baby’s presence….
Inj. IM 10 IU Oxytocin (5+5) on both thighs within 1 minute

5. Controlled cord traction with simultaneous counter traction
i. Right hand: hold cord + clamp (artery forceps) and keep pulling downwards
(traction) (pull while the uterus contracts, if contraction passes, wait for next
contraction)
ii. Left hand: palmar surface against symphysis pubis: push downwards and
backwards (counter traction)
6. Placenta visible ➔ cup with both hands ➔ rotate it ➔ delivery of placenta +
membrane
7. Uterine massage
8. Check placenta for missing bits/lobes/torn vessels
9. Check genital tract for tear and injury
NVD
(2nd stage + Immediate care of newborn + AMTSL)
1. Greeting + introduction + encouragement

2. Explain about the procedure and reassure
3. Mother placement:
i. Mother lies on sterile rubber cloth
ii. Sterile drape 3 pieces: 1 under buttock, 1 over abdomen, 1 to receive the
baby
iii. Doctor ➔ wash hands ➔ wear gloves
4. 2nd stage of labor (see above)
5. Immediate care of newborn (see above)
6. AMTSL (see above)
77
Examination of newborn
Sequence:
Greetings/Introduction ➔ consent to examine the baby ➔ color, appearance, respiratory rate,
heart rate, temperature (Vitals) ➔ Weight, length, Occipito-frontal circumference
(anthropometry) ➔ head ➔ eye ➔ ear ➔ nose ➔ mouth ➔ neck ➔ chest ➔ abdomen ➔
umbilicus ➔ hand ➔ leg ➔ genitalia ➔ anal canal ➔ back ➔ ask mother (breast feeding,
bowel bladder)
Things to note:
What abnormalities to look for

Color Jaundice
Cyanosis (central, peripheral)
Appearance Facies of cretinism, down’s syndrome, turner’s syndrome
Head Cephalhematoma
Caput
Bulged fontanelle
Anencephaly
Microcephaly
Eye Congenital cataract
Discharge
Ear Congenital anomaly
Low set ear (turner)
Nose Deformity
Mouth Cleft lip
Cleft palate
Tongue tie
Chest Ectopia cordis
Congenital anomaly
Auscultate precordium ➔ dextrocardia
Chest ➔ lung function
Abdomen Any lump/swelling
Hernia
Umbilicus Omphalocele
Omphalitis
Stump infection
Hand Polydactyli
Syndactyli
Amelia
Phocomelia
Leg DDH/CDH
Club foot
Genitalia Hypospadias
Epispadias
Undescended testis
Ambiguous genitalia
Anus Imperforate anus
Back Spina bifida
Meningocele
78
Sacrococcygeal teratoma
Resuscitation of a baby with perinatal asphyxia
1. Dry the baby with clean cloth

2. Wrap the baby with another dry clothe
3. Suction
Clean the mouth + nose by sucker
4. Position: Neck extend + Chin lift + jaw thrust
(Place a folded cloth just under the back of the supine baby)
5. Again suction
6. Stimulation:
Baby left lateral ➔ rub back with ulnar border of right hand ➔ left hand to support
the baby
7. Place umbo bag mask in proper way (with right hand)
i. Thumb and index finger on the mask + middle finger on the chin
ii. Ring and little finger on angle of the jaw
8. Press UMBO bag with left hand 40 times per minute
1001…..1002….1003……………………………..1040
9. If not breathing still ➔ recheck ➔ suction ➔ position ➔ umbo bag press firmly
10. If not ➔ check HR (stetho/cord pulsation) ➔
If HR >100 ➔ continue UMBO bag until respiration returns

If HR <100 ➔ CPR + continue UMBO ventilation ➔ refer + arrange for consultation
CPR: for 3 breaths, 1 chest compression
Breast feeding
Greetings + introduction ➔ EBF (only breast milk, nothing else not even 1 drop of water, day
and night, as per demand of baby) ➔ continue breast feeding for 2 y + weaning from 6 months
➔ proper positioning ➔ proper attachment ➔ always ensure baby drinks fully from one breast
(foremilk + hind milk) ➔ query + thanks
Positioning Attachment
Body held close to mother Mouth wide open
Whole body supported Chin touching the breast
Head and body in a straight line Lower lip turned outward
Baby facing toward breast, nose opposite More areola visible above than below
nipple
79

Abrar DMC OSPE DU Gynae &amp; Obs

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Abrar DMC OSPE DU Gynae &amp; Obs

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OSPE OBS AND GYNAE

1 Identify the supplied Sim’s Double bladed posterior vaginal speculum

2 Mention the parts of this 2 blades

What structures can be Cervix

Gynecological use (DU) 1. Operation: vaginal hysterectomy, VVF repair,

Obstetric use (DU) 1. Diagnosis of PROM

3 Mention 4 1. Dilatation, evacuation and curettage

5. Insertion, removal of IUCD

4 What are the advantage 1. Can inspect cervix

6 How is this instrument Autoclaving

7 Pathological conditions ➢ VVF

Cusco’s bivalve Self retaining vaginal speculum

2. 2 gynecological 1. Cervical lesion diagnosis: cervical erosion,

8. Mention advantages of this 1. It is self retaining

10. How is this instrument sterilized? Autoclave

Self-retaining bi-channel Foley’s catheter

1. Identify the instrument (DU) Self-retaining bi-channel Foley’s catheter

2. Mention its purpose (DU) 1. Continuous drainage of bladder

4. Mention 4 indication of its use 1. To prevent VVF after obstructed

5. 4 obs use (DU) To monitor urine output in

5. Creation of false passage

8. Write down the complication that may 1. UTI

9. How is this sterilized? (DU) 1. Ethylene oxide (chemical)

Ques Question Answer

3. Mention its uses (DU) 1. Determine position of uterus

4. What will the complication of this Perforation of uterus `

5. How is this sterilized? (DU) Autoclaving

1. Identify this instrument (DU) Uterine curette

4. How is this instrument sterilized? (DU) Autoclaving

Sponge holding forceps

1. Identify this instrument (DU) Sponge holding forceps

2. 2 gynecological conditions where it 1. Antiseptic painting before gynecological

Ayre’s spatula with cytobrush

1. Identify the instruments (DU) Ayre’s spatula with cytobrush

2. In which procedure are these instruments Collection of cervical smear for

3. What is the purpose of this procedure? (DU) Screening of cervical carcinoma at a

4. Mention three prerequisites for this 1. No sexual intercourse 5 days

5. Mention the interpretation of pap 1. ASCUS (atypical squamous

7. What are the methods for screening of 1. VIA (visual inspection by

8. What is VIA? (DU) Visual inspection of acetic acid ➔

MR Syringe with cannula

1. Identify this instrument (DU) MR syringe/Karman’s syringe

2. Uses of MR syringe (DU) 1. Menstrual regulation

3. Mention a procedure where this 1. Menstrual regulation

4. Prerequisites of this procedure 1. Regular menstruating

MVA Syringe with cannula

2. Mention the uses of this instrument 1. Aspiration of uterine contents in

3. Indication of this instrument (DU) 1. Incomplete abortion

5. 4 Complication of this procedure 1. Uterine perforation

1. Identify the Vulsellum forceps

3 How can you sterilize 1. Autoclaving

Q. Arrange the logistics for D&C

Obstetric forceps and Ventouse

1. Identify this instrument Short curved obstetric forceps/Wrigley’s forceps

2. Name the parts of this 1. Blade

3. Mention the prerequisites 1. Head engaged

4. Mention 4 indications of 1. Maternal: inadequate bear down effect

6. Mention 3 advantages of 1. Less failure rate

Ques no Question Answer

2. Mention the 4 common indication (DU) 1. Maternal: inadequate bear down

3. Mention 4 important prerequisites for 1. Head engaged

10. Mention 3 contraindication (DU) 1. (just vice verca)

12. Mention 4 compilation of this instrument 1. Fetal complication

Identify this instrument Episiotomy scissor

Abrar DMC OSPE DU Gynae & Obs

Abrar DMC OSPE DU Gynae & Obs