1. Obstetrics Phase 3a Vishal Ram
The Peer Teaching Society is not liable for false or misleading information…

2. Topics to cover Normal labour Complications & Emergencies Prematurity
Puerperium
Exam Qs and Tips
The Peer Teaching Society is not liable for false or misleading information…

3. Normal labour
First Stage: Time between onset of regular contractions and full dilation of the cervix.
Uterine contractions
Cervical ripening = softening
Cervical effacement = change in shape of cervix from bulb to flat
Cervical dilation = normal rate is 1-3cm/hr
Pink/white mucus (+ liquor) secretion from cervix
Latent phase = 0-4cm
Full dilation of cervix to 10cm
Descent, flexion and internal rotation of the baby
The Peer Teaching Society is not liable for false or misleading information…

4. Normal labour Second Stage: From full dilation to delivery
Descent, flexion and internal rotation completed followed by extension of the baby’s head as it delivers.
Passive phase = head reaches pelvic floor (engagement, rotation and flexion are complete) – mum experiences a desire to push.
Active phase = mum pushes (valsava manoeuvre) – due to pressure of the head on the pelvic floor.
Delivery:
Perineum stretches and often tears!
Restitution = head rotates 90o into transverse position – in which it entered the pelvis
Next contraction = shoulder delivered
The Peer Teaching Society is not liable for false or misleading information…

5. Normal labour Types of tear during delivery:
1st degree = minor damage to the fourchette
2nd degree = tear involving the perineal muscles
3rd degree = tear affecting the anal sphincter
4th degree = tear involving the anal mucosa
The Peer Teaching Society is not liable for false or misleading information…

6. Normal labour
Third Stage: Time from delivery of fetus to delivery of placenta (approx. 15 mins)
Delivery of placenta and membranes and the control of bleeding
During this time uterine contractions occur to compress the blood vessels supplying the placenta.
The Peer Teaching Society is not liable for false or misleading information…

7. Antepartum Haemorrhage
Complications & Emergencies
Antepartum Haemorrhage
= Bleeding after 24 weeks gestation
Causes:
Placenta Praevia
Placental Abruption
Vasa Praevia
The Peer Teaching Society is not liable for false or misleading information…

8. Complications & Emergencies
Placenta Praevia:
Low-lying placenta – common at 2o weeks – but moves ‘upwards’ as pregnancy continues
Classification = proximity of placenta to internal os of cervix:
Major = covers the internal os
Minor = in lower segment (but does not cover internal os)
The Peer Teaching Society is not liable for false or misleading information…

9. Complications & Emergencies
Placenta Praevia:
Clinical Features:
-Intermittent PAINLESS bleeding – red/profuse
-Often an incidental finding on ultrasound scan.
-Breech pregnancy + transverse lie are common (fetal head not engaged – its high)
(Note: vaginal examination can provoke a massive bleed – NEVER performed unless placenta praevia excluded)
Investigations:
-Ultrasound – confirms diagnosis
Management:
-Delivery = Elective c-section at 39 weeks (if major = c-section, if minor = aim nvd unless 2cm from internal os).
The Peer Teaching Society is not liable for false or misleading information…

10. Complications & Emergencies
Placental Abruption:
Part/all of the placenta separates from the lining of the uterus before delivery of the fetus (occurs after 24 weeks)
Main complications:
-Fetal death (common)
-DIC
-Renal failure
-Maternal death
Main causes
-IUGR
-Pre-eclampsia
-Maternal smoking
-Cocaine usage
-PH of placental abruption
-Multiple pregnancy
The Peer Teaching Society is not liable for false or misleading information…

11. Complications & Emergencies
Placental Abruption:
Clinical Features:
-PAINFUL bleeding – blood behind placenta + in myometrium – blood often DARK
-May be concealed (pain, no blood) or revealed (pain with blood).
-On examination = Tachycardia, hypotension (MASSIVE blood loss), tender uterus. In severe – uterus is ‘woody’ – fetus difficult to feel.
(Note: volume of blood is not proportional to the severity)
Investigations:
-CTG (ultrasound not useful unless to exclude placenta praevia)
Management:
-IV fluids and steroids, blood transfusion considered, opiate analgesia
-Delivery = Fetal distress = urgent c-section; if no fetal distress = elective c-section (after 37 2wweeks)
The Peer Teaching Society is not liable for false or misleading information…

12. Complications & Emergencies
Vasa Praevia:
Umbilical cord inserts into the membrane (choriamniotic membrane) NOT the placenta – known as velamentous cord insertion
This leads to vulnerable vessels which are prone to rupture when membranes break during delivery.
Lead to copious bleeding and stillbirth
Diagnostic triad:
Membrane rupture
Painless vaginal bleeding
Fetal bradycardia
Treatment = immediate emergency c-section (following rupture of membranes)
The Peer Teaching Society is not liable for false or misleading information…

13. Postpartum Haemorrhage (PPH)
Complications & Emergencies
Postpartum Haemorrhage (PPH)
Primary PPH = 1st 24hrs after delivery; blood loss > 500ml
-Causes = Uterine atony (reduced tone), uterine rupture, clotting disorders
(RFs for atony = PMH, uterine abnormality, large placenta, placenta praevia/abruption)
-Management = Oxytocin, bimanual compression, blood transfusion
Secondary PPH = Excess blood loss after 24hrs
-Causes = Retained placental tissue, clot
-Management = USS to identify retained products, give ampicillin and metronidazole as secondary infection is common, careful curette of uterus – histology for choriocarcinoma.
The Peer Teaching Society is not liable for false or misleading information…

14. Postpartum Haemorrhage (PPH)
Complications & Emergencies
Postpartum Haemorrhage (PPH)
For causes remember the 4 Ts:
-TONE = atomy
-TRAUMA = from delivery
-TISSUE = retention of the placenta
-THROMBIN = coagulation disorders
The Peer Teaching Society is not liable for false or misleading information…

15. Complications & Emergencies
Shoulder Dystocia
Shoulder cannot be delivered after the head has been delivered = anterior shoulder is stuck behind the symphasis pubis
Causes:
Diabetes mellitus
Fetal macrosomia
Maternal obesity
Prolonged labour
Too much oxytocin (increased uterine contractions)
Abnormal fetal lie
The Peer Teaching Society is not liable for false or misleading information…

16. Complications & Emergencies
Shoulder Dystocia
The mothers pelvis constricts the baby’s chest, and there is also often cord compression, thus asphyxiation is the main risk.
-Usually acidosis and asphyxiation will set in after about 4-5 minutes in the shoulder dystocia position.
Management:
-Get mum into McRobert’s position
-Try other manoeuvres – Rubin , Woodscrew
-Maternal Symphisiotomy
-Push the head back in – emergency c-section (last choice)
The Peer Teaching Society is not liable for false or misleading information…

17. Prematurity Risk Factors: Smoking Cervical weakness
Genital infection (e.g. BV, UTI)
PH of prematurity
Pre-eclampsia
Gestational diabetes
The Peer Teaching Society is not liable for false or misleading information…

18. Prematurity Primary Prevention: Reducing population risk:
Smoking/STD prevention
Cervical Assessment at 20 weeks (1. Transvaginal cervical ultrasound 2. Qualitative fetal fibronectin test)
Reducing multiple pregnancies
Secondary Prevention: Methods to diagnose and treat existent disease
Tertiary Prevention: Treatment after diagnosis
Prompt diagnosis and referral
Drugs = Tocolytics (terbutaline, nifedipine, progesterone)
Corticosteroids
The Peer Teaching Society is not liable for false or misleading information…

19. Prematurity Complications Developmental delay
Chronic lung disease  Respiratory distress syndrome due to a lack of surfactant (give IM corticosteroids)
Cerebral palsy
Visual/hearing impairment
The Peer Teaching Society is not liable for false or misleading information…

20. Puerperium Postnatal care – 6 weeks following birth
Common problems = Perineum damage, urinary incontinence (approx. 50%), constipation and haemorroids, mastitis, backache and postnatal depression.
Serious maternal health problems:
Postnatal Psychosis = mania or depression
PPH
Postnatal anaemia (common and overlooked)
Puerperal pyrexia
Thromboembolism (more common following c-section = DVT/PE)
The Peer Teaching Society is not liable for false or misleading information…

21. Exam tips What we had: MEQ: EMQ: Abdominal pain during pregnancy
Abdominal mass, pain, vaginal bleeding
EMQ:
Treatment for infertility and sexual dysfunction
Diagnosis of breast lump
Diagnosis of vaginal discharge
Diagnosis of medical conditions in pregnancy
Management of complications in pregnancy
-Diagnosis of abnormal vaginal bleeding in pregnancy and puerperium
The Peer Teaching Society is not liable for false or misleading information…