Obstetrics 11

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prem.sigdel7
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Obstetrics 11
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2015-01-23 12:26:02
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Female pelvis Persentation Mechanism labor Episiotomy Obstructed
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  1. What is false pelvis? [IOM 04]
    Area above pelvic brim is called as false pelvis
  2. What are the various types of pelvis?
    • Gynecoid - most common
    • Anthropoid  
    • Platypelloid - most rare type [KERELA 99]
    • Android

    [Female type pelvis @ GAP in the order of most common to least common]

  3. What position do the  Anthropoid and platypelloid pelvis predispose to?
    • Anthropoid  - predispose to Occiput posterior position [AI 93, 95, UP 97] 
    • Platypelloid  - predisposes to  Occiput transverse position

    • [@ ANthrOPoid - ANteroposterior diameter is greater than transverse diameter, and OP signifies Occipito Posterior positions are more common with anthropoid type of pelvis.
    • See the space in pelvis type, in platypelloid, its oval with more transverse length, so head stays in occipito transverse]
  4. What is Naegele's pelvis and Robert's pelvis?
    • Naegele's pelvis - absent of one sacral ala. [AI 01, AIIMS 91]


    Robert's pelvis - absence of both sacral ala. [AI 92]

    [@ RoBert - Both ala absent]
  5. What is Anatomical conjugate, Obstetric conjugate and Diagonal conjugate?
    1. Anatomical conjugate - Distance between the midpoint of sacral promontory to the inner margin of the upper border of symphisis pubis. It measures 11cm. 

    • 2. Obstetric conjugate - Distance between midpoint of  sacral promontory to prominent bony projection in the midline on the inner surface of the symphysis  pubis.
    • It measures  10 cm.
    • It is the shortest antero-posterior diameter in anteroposterior plane of inlet. [AI 91,UP 96] 

    3. Diagonal conjugate - Distance between the lower border of of symphysis pubis to the midpoint on the sacral promontory.[UP 93]   It measures 12 cm.

    • [Note: 4= Shortest conjugate (shortest distance) is lower border of symphysis pubis to lower border of sacrum]
  6. What is the maximum diameter of pelvic inlet? [UP 00]
    Transverse diameter.

    It measures 13 cm.
  7. What is the most common lie of fetus?
    Longitudinal lie
  8. What is the most common presentation of fetus? 
    Cephalic 
  9. What is the  diameter of presentation in
    - Brow presentation. [UP 93,97]
    - Completely extended presentation. [UP 96]
    Brow presentation - Mentovertical 

    Completely extended presentation - Submentobregmatic.

  10. What are various important  transverse diameters of fetal skull?
    • Bi-Mastoid  - 7.5cm-  shortest. [AI 91] 
    • Bi-Temporal - 8cm-  second shortest. [UP 93, AI 97] 
    • Bi-Parietal diameter - 9.5cm

    [@MTP]

  11. What is the most common causes of Breech presentation?  [AI 94,97,03]
    Prematurity
  12. What are the kinds of Breech presentation?
    • 1. Frank breech - it is not going  to change and thus stable, thus, can be delivered vaginally. Most common type. [AI 91]
    • - Flexed hip, extended knee, with feet near head
    • [@ Frank kisses his own foot]
    • 2. Footling  breech  
    • 3. Knee presentation - thighs extended, but knee flexed, bringing knees down to present at the brim
    • 4. Complete breech - also called as unstable breech presentation because if it keeps its foot down, it becomes the footling presentation. 



    [Note: Incomplete breech includes Frank breech, footling breech and knee presentation; the latter two are rare.]
  13. Which of the breech presentation can be delivered vaginally?
    Frank breech
  14. What is star gazing breech presentation?
    Breech presentation with hyperextended neck – should never be vaginally delivered because the head is hyperextended, and to be delivered vaginally, the  head should be flexed.

  15. What is the most common position of fetal head in early/late labor at  delivery?
    • Early – Left occipito transverse 
    • Late – Occiputo anterior
  16. What  is the most common attitude of fetal head?
    Vertex  -  chin against the chest – flexed.
  17. What is the difference in composition of the uterus and cervix?
    • Uterus – Smooth muscle
    • Cervix – Collagen (Inner OS has 75% collagen, external OS has 90%  collagen)
  18. What is the mechanism  of softening of uterus?
    Release of PG causes break of disulfide collagen links. Water enters into the  bonds and water content increases. Thus, instead of becoming firm or hard, it becomes soft.  (nose changes to lips]
  19. What are the components of Bishop score? [JIPMER 01, KARNATAKA 00,AI 07]
    • 1. Dilatation of cervix -  most important
    • 2. Effacement of cervix (cervical length)     
    • 3. Station of head
    • 4. Consistence of cervix
    • 5. Os position of cervix
    • [@ DESCO]

    • Score of ≥6 is favorable.
    • Score of ≤5  suggests that labour is unlikely to start without induction.
  20. What are the cardinal movements of labor?
    • Engagement
    • Descent
    • Flexion 
    • Internal rotation 
    • Crowning
    • Extension (for delivery of head)
    • Restitution
    • External rotation
    • Lateral flexion (delivery of shoulders and trunk)

    @Every Decent Fellow In Crowded Earth Reproduces, Eats, Lives]

  21. A lady presents at 37 weeks of gestation with uterine contraction and pain suggestive of labor for 10 hours. On examination, cervix is persistently 1 cm dilated and uneffaced. What should be the next line of treatment? [AI 11]
    A) Sedation and wait 
    B) Augmentation with oxytocin and amniotomy 
    C) Caesarian section
    D) Induction with rupture of membranes
    A) Sedation and wait

    Presence of pain suggestive of labor without progressive dilatation and effacement of cervix suggests a diagnosis of false labor pains.
    False labor pains at 37 weeks of gestation are best managed by sedation and watchful waiting to prevent prematurity.
    (this multiple choice question has been scrambled)
  22. What are the various stages of labor?
    • First stage -  starts from the onset of true labour pain and ends with full dilatation of cervix. [JIPMER 98]
    • Second stage - starts from  full dilatation of cervix and ends with expulsion of fetus from the birth canal. 
    • Third stage - starts after expulsion of fetus and ends with expulsion of placenta and membranes. [IOM 11] 
    • Fourth stage - stage of observation for at least one  hour after expulsion of the after-births.
  23. What are the substages of stage 1 of labor?
    • Latent phase – Effacement of  cervix 
    • Active phase – Dilatation of cervix
  24. How do you diagnose Prolonged latent phase of labor?
    Cervical dilatation <3cm, and duration  >20hrs in primigravida and >14hrs in multigravida.
  25. What is the cause of  prolonged latent phase?  How do you manage?
    • Injudicious analgesia, Hypotonic  (contraction frequency  decreased) or hypertonic ( contractions are intense, lasts  for less duration)  uterine contractions.
    •   Management is therapeutic rest and sedation -  when she wakes up, cervix may be dilated.  Not C/S.
  26. How do you diagnose prolonged/arrested active phase?
    • Cervical dilatation ≥3cm  with Inadequete cervical  change/hr --Primigravida <1.2cm, mutipara <1.5cm
    • No cervical change ≥2hrs.
  27. What are the causes of prolonged /arrested active phase?
    • 3P:
    • Passenger-  fetal size or orientation
    • Pelvis – mothers bony pelvis 
    • Powers  - Uterine contractions
    • (these are the causes of Prolonged second stage of labor also)
  28. How can you manage prolonged/arrested active phase?
    • Among 3 P – the  thing that we can change  is  Power. First we ascess the  quality of contraction (frequency, duration, and intensity).
    • It should be at least a contraction every 3  minutes,  lasting 45-60 seconds, cannot indent the  contracted uterus.
    • If the contraction is adequate, the management is C/S, and if the contractions  are not adequate, give   Oxytocin.
  29. How do you diagnose Prolonged  second stage of labor?
    • ≥ 2hrs without Epidural 
    • ≥ 3hrs with Epidural
  30. When can the mother push the baby?
    Only in second stage of labor
  31. How can you manage Prolonged second stage of labor?
    • Ascess Uterine contractions.
    • Oxytocin if no adequate contractions.
    • If head engaged, forcep or Vacuum extraction.
    • If not, C/S.
  32. What is the most common cause of  prolonged third stage of labor?
    Inadequete uterine contractions.
  33. What is the weight of  mature placenta? [AI 96]
    about 450 gms
  34. What are the components of active management of third stage of labor? [IOM 11,13,AI 10,12]
    Administration of uterotonic soon after birth of baby. Oxytocin is the uterotonic of choice. If oxytocin not available, ergometrine may be used. 

    Delayed cord clamping and cutting. [AI 10] 

    Controlled cord traction for delivery of placenta followed by uterine massage. 


    Active management of third stage of labor reduces the PPH incidence by 30-60%. [IOM 11]
  35. What should be the timing of cord clamping?
    • Current evidence shows that delayed cord clamping is beneficial for the baby.
    • Immediate cord clamping has been shown to increase the incidence of iron deficiency anemia.
    • For premature and low birth weight babies, immediate cord clamping can also increase the risk of intraventricular hemorrhage and late onset sepsis.
  36. What are the contraindications of Ergometrine?
    • Suspected multiple pregnancy
    • Organic cardiac diseases
    • Severe preeclampsia and eclampsia
    • Rh- negative mother [IOM 09] - more chance of feto-maternal micro-transfusion
  37. A 22 yrs old woman at term has been 2 cm for 3 hrs with no change, Normal fetus on sono, cephalic presentation, normal EFM tracing, Management?
    Observation, therapeutic rest and sedation.
  38. A 22yr G1 P0 at term has gonne from 4 to 7 cm over the past 2 hrs, with no change in station, Fetus is normal on sono, cephalic presentation,  and normal EFM tracing, Management?
    She is in active phase of first stage of labor, so, we  do not expect descent of fetus, and she is dilating 1.3cm/hr, which is normal, so management  is observation.
  39. A 22 yrs woman at term  has been 6cm for 3 hrs with no cervical change,  Normal fetus on sono, cephalic presentation, and normal EFM tracing, management?
    Cervix has not been dilated for >2hrs, so there  is problem in 3P, but we can only change the Power, so if there are inadequate contractions, use Oxytocin, if not, C/S.
  40. A 22 yr  woman at term  presents with regular Uterine contractions  at 7cm dilatation , No presenting part can  be palpated, through the bulging membranes, Management?
    Sonogram to identify the lie, presentation and fetal  normality.
  41. A 22yr woman at term has 10cm and pushing for 3 hrs, with no change in station, normal fetus on sonogram, cephalic presentation and normal EFM tracing, Management?
    She is stage 2, there should be change in station and baby should be  delivered baby in 2hrs. So, it is prolonged stage 2. The defect is on 3 P. We can only change power. So, if the contraction  is not adequate,  use Oxtocin or forceps. If adequate, do C/S.
  42. 22 yrs old woman presents at 6 cm dilatation with no presenting fetal part. Sono shows transverse lie. Risks if membranes  are ruptured?
    Prolapsed Umbilical cord -  donot  rupture the membrane unless the presenting part is well against the  fetal membranes.
  43. A lady G3P1A1 is admitted to the labour room at term. Cervix is 4 cm dilated, membrane are intact and head is palpable 3/5 per abdomen. After 4 hours, repeated examination is done and cervix is 5 cm dilated, station is unchanged and the cervicograph remains on the right side of alert lens. Which of the following statements about the progress of labor is true? [AI 12]
    A) The head was engaged at the time of presentation
    B) The cervicograph progress is satisfactory
    C) The cervicograph status suggest that intervention is likely to be required
    D) The cervicograph on repeat examination would touch the action line
    C) The cervicograph status suggest that intervention is likely to be required

    The patients cercix has dilated only 1 cm in 4 hours after entering the active phase (4 cm dilatation) indicating a very slow rate of progress of labor. The cervicograph line if plotted will be seen to lie to the right of 'alert line'closely approaching the action line indicating a high likelihood that an intervention will be required.
    Head is likely to be engaged when the portion above the brim is represented by less than 2 finger or less (<2/5 per abdomen). Since the head is palpable 3/5 per abdomen on admission, it is not engaged at the time of admission.
    (this multiple choice question has been scrambled)
  44. What are the signs of  third stage of labor?
    Gush of blood, lengething of cord, Balling up of uterus.
  45. What are the factors that cause the  internal rotation of  fetal  head?
    • Uterine contractions 
    • Resistance of levator ani muscle
  46. Define engagement? 
    Passage of biparietal diameter through the pelvic inlet. 
  47. What change do you find in Umbilical cord prolapse?
    Variable Deceleration.
  48. What is the most common cause of Prolapsed Cord? 
    Membrane ruptured with head unengaged. 
  49. What is the management of prolapsed cord?
    Elevate fetal head take to operating room and Emergency C/S.
  50. What are the steps in management of shoulder dystocia? [AI 10,11]
    Steps include HELPERR algorithm:

    • H: Call for Help; Shoulder dystocia is called if shoulders cannot be delivered with gentle traction
    • E: Evaluate for Episiotomy: Not routinely indicated; maybe needed when attempting intra-vaginal maneuver

    • L: Legs (McRoberts): Hyperflexion and abduction of hips—initial maneuver
    • - causes tilting of pelvis, and increases pelvic space

    • P: (Suprapubic Pressure):
    • No fundal pressure; combination of McRoberts and suprapubic pressure resolves most shoulder dystocias

    • E: Enter (Internal Maneuvers):
    • i. Woods maneuver: Insert hand into posterior vagina and rotate posterior shoulder clockwise or counterclockwise
    • ii. Rubin: Push posterior or anterior
    • shoulder toward fetal chest to adduct shoulders

    R: Remove/delivery posterior arm

    R: Roll the patient to her hands and knees

    • [Note: if none of the above succeeds, we go for SALVAGE METHODS, which include
    • 1. Posterior axillary sling
    • 2. Zavanelli maneuver
    • 3. Fracture clavicles
  51. What is Zavanelli maneuver?
    • It is a salvage method for shoulder dystocia. It includes:
    • - tocolytics is used to relax the uterus, 
    • - pushing back the delivered head into the birth canal
    • - performing emergency CS
  52. What are the degrees  of Obstetrical  lacerations?
    • First degree – Only perineal mucosa. 
    • Second degree – perineal body muscles. 
    • Third degree – Rectal sphincter involved, rectal mucosa not involved. 
    • Fourth degree - Rectal mucosa involved.

    [@ mucosa, muscle, muscle, mucosa]
  53. A woman presented on 7th day after 3rd degree of perineal tear.  When do you repair it?
    • Recent tear should be repaired immediately following the delivery of the placenta. This reduces the chance of infection and minimizes the blood loss. 
    • In case of delay beyond 24 hrs, the repair is to be withheld. Antiseptic dressing is prescribed and the wound is allowed to heal by granulation tissue  or repaired after the infection is controlled. 
    • The complete tear (3rd degree tear) should be repaired after 3 months if delayed  beyond 24 hours. 
  54. What are the indications of Episiotomy?
    • Shoulder dystocia 
    • Fetal bradycardia 
    • Forceps delivery
  55. What are the structures cut in medio-lateral episiotomy? [SGPGI 03]
    • Posterior vaginal wall
    • Superficial and deep transverse perineal muscles, bulbospongiosus and part of levator ani
    • Fascia covering those muscles
    • Transverse perineal branches of pudendal vessels and nerves
    • Subcutaneous tissue and skin
  56. In which condition do you find Bandl ring? [MP 01]
    Obstructed labor
  57. What is Mauriceau Smellie Veit Maneuver?
    • Mauriceau Smellie Veit maneuver:
    • With fetus resting on hand and forearm, the operator's index and middle fingers lift up the fetal maxillary prominences and an assistant applies suprapubic pressure.
    • It is used to deliver the aftercoming head in a breech delivery.



    [Note: Other methods for delivery of aftercoming head of breech include: Burns-Marshall maneuver and Forceps application]

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