Week 3 and week 4 assessment

1. Acute obs and gyne condition

a. Obs
i. Shoulder dystocia
1. Complications
a. Fetal
i. Hypoxia, cerebral palsy
ii. Brachial plexus injury
iii. Fracture of clavicle or humerus
iv. Intracranial haemorrhage
v. Cervical spine injury
vi. Fetal death (rare)
b. Maternal
i. PPH
ii. Genital tract trauma incl. 3rd and 4th degree perineal tears
2. Risk factors
a. BW > 4kg
b. Previous h/o
c. Macrosomia
d. BMI >30 and excessive wt gain in pregnancy
e. DM
f. Post-term
g. Poor progress in late first or second stage of labor
3. Mx
a. H – call for help
b. E – Episiotomy
c. L – Legs into McRoberts (as far back toward stomach as possible)
d. P – Suprapubic pressure to posterior aspect of anterior shoulder, if fails 
rocking movement
e. E – Enter pelvis for inter maneuvers
i. Rubin II – pressure on posterior aspect of anterior shoulder to adduct and
rotate
ii. Woods’ screw – Rubin II + pressure on anterior aspect of posterior shoulder
iii. Reverse Woods’ screw
f. R – release of posterior arm by flexing elbow, getting hold of fetal hand,
sweeping fetal arm across chest and face to release posterior shoulder
g. R – Roll over to ‘all fours’ (Gaskin maneuver)

ii. Obstetric Hemorrhage

 1. Antepartum
a. Placenta abruptio
b. Placenta previa
c. Severe chorioamnionitis or septicaemia
d. Severe pre-eclampsia
e. Retained dead fetus
2. Intrapartum
a. Abruptio
b. Uterine rupture
c. Amniotic fluid embolism
d. Complications of Cesaeran: angular or broad ligament tears
e. Morbidly adherent placenta (accreta/percreta)
3. Postpartum
a. Primary
i. Tone – uterine atony
ii. Trauma – genital tract trauma
iii. Thrombin - coagulopathy
iv. Tissue – retained POC
b. Secondary
i. Infection
4. Consequences of hemorrhage
a. Hypovolemia
b. Sudden and rapid cardiovascular decompensation
c. DIC
d. Blood transfusions
e. Pulmonary edema
f. Transfusion reactions
g. ARDS
h. Sheehan’s syndrome
5. Mx
a. Call for help
b. ABC
c. Catheter for urine output
d. Blood transfusion
e. Tx according to cause

iii. Disseminated intravascular coagulopathy (DIC)

 1. Causes
a. Massive haemorrhage (depletion of fibrinogen, platelets and coag factors
b. Can occurs with other condition such as amniotic fluid embolism
2. Ix
a. Fibrin degradation products (FDPs)
b. Fibrinogen
c. Partial thromboplastin time (PTT)
d. APTT
3. Mx
a. Senior haematologist
b. FFP: contains all clotting factors
c. Cryoprecipitate: more fibrinogen but lacks antithrombin III which is often
depleted in massive obstetric hemorrhages
d. Platelet concentrates
e. Recombinant activated factor VII
f. Tranexemic acid 1g IV

iv. Amniotic Fluid Embolism (rare but fatal)

1. Occurs
a. With spontaneous or artificial rupture of membrane
b. During delivery or within 48hr
c. Rarely, during or after TOP, manual removal of placenta or amniocentesis
2. Characteristics
a. Acute onset of hypoxia and respiratory arrest
b. Hypotension
c. Fetal distress
d. Convulsions
e. Shock
f. Altered mental status
g. Cardiac arrest
3. Risk factors
a. Multiple pregnancy
b. Older maternal age
c. Cesarean or instrumental delivery
d. Eclampsia
e. Polyhydramnios
f. Placenta previa
g. Placenta abruptio
h. Cervical laceration
i. Uterine rupture
j. Medical induction of labor
4. Mx
a. Resuscitation incl CPR (ABC: SaO2 close to 100%, fluids, vasopressors,
inotropic support
b. Admission to ICU
c. Pulm. Artery wedge pressure
d. Deliver the fetus
v. Uterine inversion
 1. Risk factors
a. Strong traction on umbilical cord with excessive fundal pressure
b. Abnormal adherence of placenta
c. Uterine anomaly
d. Fundal implantation of placenta
e. Short cord
f. Previous uterine inversion
2. S/S
a. Hemorrhage
b. Severe lower abd pain in 3rd stage
c. Shock
d. Uterine fundus not palpable abdominally or just felts as a dimple at the
fundus
e. Mass in the vagina
3. Mx
a. Call for help
b. Immediate replacement by pushing up the fundus thru the cervix with the
palm (Johnson maneuver)
c. IV access
d. Blood for FBC, Coag, Crossmatch
e. Fluids
f. Cont monitor V/S
g. Transfer to OT and arrange analgesia
h. If placenta still attached, left in situ to minimize bleeding, removal attempted
after replacement
i. Tocolytics
j. If manual reduction fails  hydrostatic repositioning (O’Sullivan’s technique)
k. If fails  laparotomy (Haultain’s or Huntingdon’s procedure)

vi. Cord Prolapse

 1. Predisposing factors
a. Abn lie or presentation
b. Multiple pregnancy
c. Polyhydramnios
d. Prematurity
e. High head
f. Unusually long umbilical cord
2. Mx
a. Deliver fetus as rapid as possible (instrumental or CS)
b. Prevent further compression
i. Knee to chest position
ii. Fill bladder with 500mL warm NS to displace the presenting part upwards
c. Prevent spasm by avoiding exposure of cord. Reduce cord into vagina to
maintain body temperature. Insert a warm swab to prevent coming back out.
d. Avoid handling of cord as much as possible to prevent spasm
e. Tocolytics during transfer to CS; tackle with oxytocics if uterine atony
f. Neonatal team

vii. Uterine rupture

1. Causes
a. Severe direct violence
b. Weakness of wall d/t old scars (CS, curettage)
c. Weakness of wall d/t abnormal placentation (increta)
d. Abnormal thinning of wall (sacculation, diverticula, rudimentary horns)
2. S/S
a. Severe lower abdominal pain then no pain
b. Collapse
3. Mx
a. Laparotomy
b. Repair or remove uterus accordingly

b. Gynecology
i. Incomplete miscarriage – retention of POC inside uterus
1. S/S
 a. Passage of part(s) of POC
b. Continuous bleeding
c. Enlarged Uterus size less than POA
d. Cervix os is open and retained contents may be felt
2. USG: retained contents
3. Tx: Evacuation

ii. Septic abortion – any abortion associated with infection of uterus and its content
1. S/S
a. Fever >24hr, +/- chills and rigors
b. Offensive or purulent vaginal discharge
c. Other evidence of pelvic infection: lower abd pain and tenderness
d. H/o unsafe termination by unauthorized person
e. Looks sick and anxious
f. Persistent tachycardia >90bpm
g. Hypothermia <36oC
h. Abd pain or chest pain
i. Tachypnea >20/min
j. Impaired mental state
k. Diarrhea +/- vomiting
l. Renal angle tenderness
2. Ix
a. Cervical or high vaginal swab prior to internal examination
i. Culture & sensitivity
ii. Gram stain
b. Blood for Hb, TWC & differentials, ABO, Rh grouping
c. Urine analysis, culture
d. USG pelvis and abdomen for retained POC, free fluids, foreign body
e. Blood culture if chills and rigors
f. Serum electrolyte, CRP, serum lactate (>4mmol/L indicate ts hypoperfusion)
g. Coag profile
h. Xrays: abdomen, chest.
3. Mx
a. Bed rest
b. IV line + Fluids
c. Monitor V/S
d. Abx: Ampicillin/Cephalosporin + Gentamycin + Metronidazole
e. Oxytocin to control bleeding and enhance expulsion of POC
f. Surgical evacuation can be done after 6hr of IV therapy. Can be earlier if severe
bleeding or deteriorating condition in spite of therapy
g. May need hysterectomy if endotoxic shock not responding to treatment d/t
gas gangrene

iii. Acute ectopic pregnancy

1. S/S
a. Lower Abd pain: Unilateral, acute.
 b. Preceded by amenorrhea
c. PVB
d. Vomiting, fainting d/t reflex vasomotor disturbance from peritoneal irritation
d/t hemoperitoneum
e. Look quiet, conscious, blanched, pale
f. Features of shock: tachycardia, hypotension, cold extremities
g. Abdomen examination: tense and tender. No mass felt. Shifting dullness (+).
h. Pelvic examination usually contraindicated d/t extreme pain and may
precipitate an unruptured to rupture
2. Dx
a. USG and serum b-hCG
3. Mx
a. Resuscitation
b. Laparotomy or laparoscopy
i. Salpingotomy
ii. Salpingostomy
iii. Salpingectomy

iv. PID
v. Torsion of pedicle

2. Irregular vaginal bleeding

a. Structural causes (PALM)
i. Polyp
 ii. Adenomyosis
iii. Leiomyoma
iv. Malignancy and hyperplasia
b. Nonstructural systemic causes (COEIN)
i. Coagulopathy
ii. Ovulatory dysfunction
iii. Endometrial
iv. Iatrogenic
v. Not yet identified
c. Table of DDx AUB
d. Ix
i. FBC
ii. GXM
iii. Pregnancy test
iv. Coag profile
v. Pap smear
vi. Thyroid profile
vii. Wet prep for motile trichomonas
viii. Imaging
1. TVS for uterus anatomy, thickness
2. Saline infusion sonography
3. Hysteroscopy – Dx and Tx
4. MRI as second line procedure for adenomyosis
ix. Histological confirmation of pathology
1. Biopsy
e. Management
i. Tx underlying causes

3. Post-Partum Hemorrhage
a. Table of Ts and associated risk factors
b. Mx
 i. Resuscitation: ABC, IV access warmed crystalloid
ii. Blood GXM
iii. FBC, coag profile
iv. V/S every 15 min
v. Tx as per underlying causes
1. Uterine atony
a. Rubbing the uterus fundus
b. Ensure bladder is empty (catheter)
c. Oxytocin 5 IU IV
d. Ergometrine 0.5mg slow IV or IM (contraindicated in HTN) OR
e. Oxytocin infusion (40 IU in 500mL isotonic crystalloids at 125mL/hr) OR
f. Carboprost 0.25mg IM q15min to max 8 doses (cautious in asthma) OR
g. Misoprostol 800mcg S/L
h. Blood transfusion
i. Surgical
i. Intrauterine balloon tamponade
ii. Step-wise uterine artery ligation (uterine, utero-ovarian and
hypogastric vessel ligation) Bilateral ligation of internal iliac arteries
iii. Brace suture (B-lynch/Hayman)
iv. Artery embolization
2. Trauma
a. Inspect perineum, vagina and cervix
b. Apply pressure to bleeding areas
c. Repair either in labor ward or OT
3. Tissue (retained POC)
a. If placenta delivered, check for obvious missing tissue
b. Examine the mother vaginally for adherence of placenta
4. Thrombin
a. Rare
5. Secondary PPH
a. Usually associated with endometritis (+/- retained POC)
b. ABX
c. Surgical evacuation of retained POC