OSCE on 14/3/2008

Describe gynaecoid pelvis.

It is the most favourable type of female pelvis, well suited for childbearing. The effect
on labour is to facilitate the occipito-anterior position.

 Brim is round.
 Cavity is shallower and more spacious.
 Outlet is larger.
 Sacrum is wider and more curved.
 Pubic arch is wider.
 Sacrosciatic notch is wider.
 Acetabula are further apart.

Describe android pelvis.

It is a narrow-fore male pelvis, which is an unfavourable pelvis & least suited for
childbearing. The effect on labour is to facilitate the occipito-posterior position &
deep transverse arrest is common.

 Brim is heart-shaped.
 Cavity is funnel shaped.
 Outlet is smaller & narrow.
 Sacrum is straight.
 Pubic arch is narrow & subpubic angle is sharp
 Sacrosciatic notch is greater & narrow.
 Ischial spines are prominent.

Describe anthropoid pelvis.

The effect on labour is that the occiput can easily accommodate in the hollow of the
sacrum, which results in direct occipito-posterior position.

 Brim is oval shaped with long antero-posterior (AP) diameter but a reduced
transverse diameter.
 Sacrum is long & deeply concave sacrum.

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 Subpubic angle is usually normal.
 Sacrosciatic notch is greater & wide.

Describe platypelloid pelvis.

It is a flat pelvis. The effect on labour is that the fetal head may engage in transverse
diameter; sometimes result in face or brow presentation.

 Brim is kidney shaped with short antero-posterior (AP) diameter & long
transverse diameter.
 Cavity is shallow.
 Outlet is larger.
 Sacrum is flat.
 Pubic arch is very wide.

What is the boundary of the pelvic brim (true pelvis)? (8%)

8 boundaries of the pelvic brim:

1. sacral promontory
2. alae of the sacrum
3. sacroiliac joint
4. iliopectineal line
5. iliopectineal eminence
6. superior ramus of the pubic bone
7. upper inner border of the pubic bone
8. upper inner border of the symphysis pubis

7 routine antenatal blood test.

1. Haemoglobin level (Hb>11g/dl) & Mean Cell Volume (MCV>80fL):

To detect anaemia & screening of Thalassaemia. If MCV < 80fL, suggest iron
deficiency anaemia or Thalassaemia by further blood tests.
2. Blood group: For cross-matching.
3. Rhesus factor: Rhesus –ve mother need to have anti-D immunoglobulin
injection after delivery to prevent Rhesus isoimmunization.

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4. Rubella antibodies: anti-Rubella –ve mother will be given Rubella
vaccination after delivery & 3 months reliable contraception.
5. Venereal Disease Research Laboratory (VDRL) / Enzyme-
linked Immunosorbent Assay (EIA): To screen for syphilis and start
early treatment.
6. Hepatitis B Surface Antigen (HBsAg): Hepatitis B carrier’s baby will be given
both Hepatitis B Immunoglobulin and Hepatitis B vaccine at birth.
7. Human Immunodeficiency Virus (HIV) antibodies test.

The signs & symptoms of onset of first stage.

1. Regular & painful uterine contractions

2. Show
3. Leaking of liquor
4. Effacement & Dilatation of cervix

Definite onset of labour. (= regular painful UCs + shortening/dilatation of cervix)

The development of regular, painful uterine contractions producing progressive

dilatation of cervix.

The signs of placental separation.

1. Hard, globular & mobile uterus (uterine contraction).

2. A gush of blood from vagina.
3. Lengthening of cord at vulva.
4. Placenta may appear at vulva.

Define active management of 3rd stage of labour.

1. Give oxytocin after delivery of anterior shoulder of baby

2. Early clamping & cutting of cord
3. Controlled cord traction (CCT) to deliver the placenta

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Name 3 kinds of vaccine that the baby will be received.

1. B.C.G. Vaccine
2. Hepatitis B Vaccine-First / Second / Third Dose
3. DTaP-IPV Vaccine-First / Second / Third / Booster Dose
4. MMR Vaccine (Measles, Mumps & Rubella)-First / Second Dose

Define 4 stages of labour.

1st stage - begins from the definite onset of labour to fully dilatation of cervix
latent phase: 0→3cm, active phase: 3→10cm, transition phase: 8→10cm
2 stage – begins when the cervix is fully dilated & ends when the body is born
nd

3rd stage – lasts from the birth of baby until the expulsion of placenta & membranes,
normal duration is 5-10mins
4th stage – the 1st hour postpartum, begins with the birth of placenta

The signs & symptoms of onset of 2nd stage.

Probable signs
1. expulsive uterine contractions
2. involuntary urge to push
3. rupture of membranes
4. trickling of blood
5. gaping of the anus
6. gaping of the vulva
7. bulging of the perineum
8. appearance of the presenting part

Definite sign – cervix is fully dilated, no cervix is felt on the vaginal examination.

Name 3 major procedures that you will carry out during abdominal
examination.

1. Inspection
 Size: uterus = date

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 Shape: ovoid / pendulous
 Skin changes: linea nigra / straie gravidarum
 Scars: previous surgery / caesarean section
2. Palpation – to determine the lie/ presentation/ engagement/ Symphysio-fundal
height/ uterine size ?U=D/ ?polyhydramnios or oligohydramnios
3. Auscultation – to determine the rate and regularity of the fetal heart by Doptone;
to assess the fetal well-being

Significance of vaginal examination during labour. 10.2001 (B.2) (5%)

In antepartum period
1. for taking high vaginal swab (HVS) or Pap’s smear in antenatal visits
2. to assess the cervical status, especially in complicated pregnancy, e.g. antepartum
haemorrhage (any blood clots was seen by speculum examination), premature
rupture of membranes (to confirm leaking of liquor & any meconium stained or
blood stained liquor)

In intrapartum period
1. to confirm the definite onset of labour by the effacement & dilatation of the
cervix
2. identify the fetal presentation & position; the descent of the presenting part; any
caput or moulding; any cord, placenta or membranes was felt
3. to confirm full dilatation of cervix; for the sign of going into the 2nd stage
4. to confirm rupture of membranes & observe the condition of liquor, e.g. any
meconium stained or blood stained liquor
5. to do amniotomy (artificial rupture of membranes(AROM))
6. to examine the genital tract, any oedema or warts
7. to exclude cord prolapse following spontaneous ROM or AROM
8. to assess progress of labour
9. to perform fetal monitoring procedure, e.g. applying fetal scalp electrode or
performing fetal blood sampling
10. to remove the retained product of gestation (RPOG)
11. to confirm the presentation, position, lie & decent of the presenting part of the 2 nd
twin after the delivery of the 1st twin, in order to confirm the mode of delivery,
e.g. normal vaginal delivery or vacuum extraction or caesarean section

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In postpartum period
1. postnatal examination to find out any genital tract trauma after delivery
2. exploration of uterus for retained or incomplete placenta

Name 2 presenting diameters for a vertex presentation with the fetal head well-
flexed.

The fetus is in occipito-anterior (OA) position.

1. Suboccipito-bregmatic diameter (SOB) 9.5cm
2. Biparietal diameter 9.5 cm (fixed)

Define Obstetric conjugate. (2%)

Obstetric Conjugate (OC) is the shortest antero-posterior (AP) diameter of the

pelvic brim (11cm). It is the shortest distance, from sacral promontory to a point
1.25cm down, on the posterior surface of symphysis pubis.

Define restitution. (1%)

A corrective movement of the fetal head after it is born in the antero-posterior (AP)
diameter, to right it in relation to the shoulders.

Name 3 pelvic floor muscles that will be involved when making an episiotomy.

1. Bulbocavernosus muscle
2. Transverse perinea muscle
3. Pubococcygeus muscle

List 3 methods for delivery of placenta.

1. Control cord traction (CCT) with Schultz method – fetal side appears first
2. CCT with Matthew Duncan method – maternal side appears first
3. Manual Removal of Placenta
Define moulding, caput and cephalhaematoma.

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1. Moulding is the ability of the fetal head to change its shape as it passes through
the birth canal.
2. Caput is a localized swelling over the presenting part of the fetal head formed by
the effusion of serum under the scalp.
3. Cephalhaematoma is a swelling due to bleeding between the skull bone & the
periosteum which covers it.

List 3 major differences between a caput succedaneum and a cephalhaematoma.

Caput succedaneum
1. presents at birth
2. does not increase in size
3. soft, pits on pressure
4. swelling can cross suture lines
5. subside gradually; disappears after birth within a few hours to several days

cephalhaematoma
1. appears after birth
2. tends to grow larger
3. soft, circumscribed, does not pit on pressure
4. swelling does not cross suture lines; limit to individual bones, although it may be
bilateral
5. disappears from several weeks to even months

Name 4 different ways that the newborn will loss the body heat after delivery.

Radiation, conduction, evaporation, convection.

State 3 inborn reflexes that aid the newborn to breastfeed.

Rooting, suckling, swallowing reflexes.

Define let-down reflex.

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Let-down reflex (oxytocin reflex) works before or during feed to make milk flow.
Suckling of the baby stimulates the posterior pituitary gland to secrete oxytocin in
blood, which induces the contractions of the smooth muscles of uterus & myo-
epithelial cells around alveoli, and lead to squirting of breast milk.

Identify 3 minor discomforts in pregnancy and briefly describe their causes.

1. Gum bleeding, occurs during or after brushing of teeth. It caused by oestrogen

effect, leading increasing vascularity & proliferation of gingival tissue, so
swollen tissue & increases the bleeding tendency. Its management are using soft
brush; increasing intake of Vitamin C; having regular dental check-up; and
giving education on oral & dental hygiene.

2. Morning sickness (nausea & vomiting), symptoms occurs on rising, preparing

meals & smelling foods. It caused by progesterone & human chorionic
gonadotrophin (HCG) effect, aggravated by fatigue & emotional factors. Its
management are giving reassurance; small and frequent meals; drinking fluid
separately from meal; avoiding strong smell, greasy, gas-forming or high
seasoned food; eating dry biscuits or toast before arising in the morning; taking a
late snack, e.g. biscuits or drinking a warm milk before retires at night; taking
anti-emetics only when prescribed, e.g. Stemetil, Vitamin B supplement.

3. Ankle oedema. It caused by general fluid retention, decreased venous return due
to uterine pressure. Its management are elevating legs when sitting, especially in
afternoon & evening; avoiding wearing constricting panty girdles or knee high
stockings; doing leg exercise; practicing frequent dorsiflexion of feet; exclude
other complication such as pre-eclampsia.

Briefly state the causes and management of a pregnant woman with the following
minor disorders: (1) heartburn; (2) leg cramps.

Heartburn is a burning or irritating sensation in the mediastinal region due to reflux

of gastric content into oesophagus.
It is caused by increased progesterone effect, relax cardiac sphincter & decreases
gastric motility, leads to oesophageal reflux. The mechanical displacement of the
enlarged uterus causes regurgitation.

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The managements are to take small & frequent meals; avoid over-eating and spicy
food; avoid lying down immediately after eating to prevent oesophageal reflux; give
prescribed antacid, e.g. Magnesium trisilicate.

Leg cramps is painful muscle spasm in the calf muscle.

It is caused by pressure effect of gravid uterus and impairs the circulation of lower
extremities. It may be related to the imbalance in calcium & phosphorus.
The managements are to keep dorsiflexion of foot to relieve leg cramps; apply warm
massage to the affected muscles; avoid prolonged standing, walking & over-fatigue;
may give calcium tablets or Vitamin B Complex.

Definition of postpartum haemorrhage.

Postpartum haemorrhage (PPH) is excess bleeding from the genital tract at any
time following birth of the baby till the end of puerperium.
Primary (early) PPH is excessive bleeding from the genital tract of ≥ 500ml during
the 3rd stage or in the first 24 hours after delivery.
Secondary (late) PPH is excessive vaginal bleeding occurs after the first 24 hours
and up to 6 weeks postpartum, usually no precise volume specified.

Define causes of postpartum haemorrhage.

Causes of postpartum haemorrhage (PPH): “4T”

1. Tone (most common cause of early PPH) – Atonic uterus due to
 overdistention of uterus: multiple pregnancy; polyhydramnios; macrosomia
 ↓ uterine contractility: multiparity; precipitate or prolonged labour; oxytocin
augmentation; uterine fibroid or full bladder; placenta praevia or abruptio
placentae; intrauterine manipulation, e.g. MROP, or operative delivery

2. Trauma – Genital tract trauma due to

 Bleeding sites: episiotomy; cervical, vaginal or perineal tear; vulval or vaginal
wall haematoma; rupture of uterus; uterine inversion
 Predisposing factors: macrosomia; instrumental delivery; precipitate labour;
delivery before cervix is fully dilated; rupture of previous uterine scar.
3. Tissue (most common cause of late PPH) – Retained tissue due to
 Retained placenta or retained products of gestation (RPOG) due to

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 unrecognized succenturiate placenta; mismanagement of 3 rd stage; incomplete
emptying from MROP
 Predisposing factors: previous placenta praevia; previous caesarean section or
curettage; morbid adherent placenta, e.g. placenta accreta, increta or percreta;
advanced maternal age or high parity

4. Thrombin – Coagulopathies such as

 Hypofibrinogenaemia, thrombocytopenia or disseminated intravascular
coagulation (DIC)
 Associated conditions: abruptio placentae; severe pre-eclampsia (PET);
prolonged retention in-utero of a dead fetus; amniotic fluid embolism &
septicaemia

Define causes & clinical features of secondary (late) postpartum haemorrhage.

Causes
1. Retained products of gestation (RPOG)
2. endometrial infection
3. rupture of vulval haematoma
4. dehiscence of caesarean scar

Clinical features
1. persistent & recurrent red lochia
2. subinvolution of the uterus
3. +/- fever & chills
4. if blood loss is heavy, may go into shock

Prevention of postpartum haemorrhage.

 Early detection of high risk cases

 Prompt decision & management

1. Correct antenatal anaemia
2. Perform episiotomy only when indicated
3. Active management of 3rd stage
― Give oxytocin after delivery of anterior shoulder of baby

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― Early clamping & cutting of cord
― Controlled cord traction (CCT) to deliver the placenta
4. Early repair of episiotomy or tear
5. Prophylactic oxytocin after delivery

Define 3 non-pharmacological means & 3 pharmacological means of pain relief.

3 non-pharmacological means of pain relief

1. hydrotherapy
2. aromatherapy
3. breathing exercise & relaxation technique

3 pharmacological means of pain relief

1. Entonox inhalation
2. Pethidine intramuscular injection
3. epidural analgesia

Definition of hypertension in pregnancy.

Pregnancy Induced Hypertension (PIH)

 Gestation ≥ 20 weeks
 A systolic blood pressure (BP) ≥ 140 mmHg AND / OR
 A diastolic BP ≥ 90 mmHg (Phase V), respectively on 2 occasions at least 4
hours apart
 A definition changes to “transient” when pressure returns to normal postpartum

State the signs & symptoms of pre-eclampsia. (5%)

The following are also the definition of pre-eclampsia (PET)

1. Gestation ≥ 20 weeks
2. Blood pressure (BP) ≥ 140/90 mmHg on 2 occasions at least 4 hours apart OR
Diastolic BP > 110 mmHg on any one occasion
Returning to normal postpartum
3. Proteinuria ≥ 300 mg in 24 hours OR
2 clean catch mid-stream urine (MSU) 4 hours apart with ≥ 2+ on reagent strip

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State the signs & symptoms of severe pre-eclampsia (PET).

Signs
1. At rest, systolic blood pressure (SBP) ≥ 160 mmHg or diastolic blood pressure
(DBP) ≥ 110 mmHg
2. Proteinuria: ≥ 5 g in 24 hours OR
clean catch mid-stream urine (MSU) with ≥ 3+ on dipstrick
3. Oliguria: < 400 – 500 ml/day
4. serum creatinine > 90 mmol/L
5. HELLP syndrome
 Haemolysis → Jaundice / Anaemia
― total bilirubin > 1.2 mg/dl; LDH > 600IU/L
 Elevated Liver enzymes: AST > 70 IU/L
 Low Platelets: Platelet count < 100,000 per mm3 (used to classify severity)

Symptoms
1. headache
2. blurred vision
3. nausea & vomiting (∵HELLP syndrome)
4. epigastric / right upper quadrant (RUQ) pain (∵HELLP syndrome)
5. hyper-reflexia
6. clonus

State the definition and signs & symptoms of impending eclampsia.

Eclampsia is the development of generalized convulsion & coma in a pre-

eclamptic woman, it probably due to cerebral vasospasm leading to cerebral
hypoxia & cerebral edema. Postpartum eclampsia usually develops within 24
hours of delivery.

signs & symptoms of impending eclampsia

1. +/- marked rise in blood pressure; increase in proteinuria; severe edema
2. visual disturbances
 blurred vision, flashes of light, spots before eyes
3. severe headache

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4. epigastric pain & vomiting due to hepatic haemorrhage
5. increased muscular activity, brisk tendon reflex
6. Oliguria: < 400 – 500 ml/day

Risk factors of pre-eclampsia (PET). (5%)

Maternal risk factors

1. first pregnancy
2. maternal age: <15 or >35
3. obesity
4. family history: mother & sisters have PET during their pregnancies
5. history of PET in previous pregnancy
6. pre-existing medical conditions
 hypertension
 diabetes mellitus
 renal disease
 autoimmune disease

Fetal risk factors

Conditions related to large placental site:
1. multiple pregnancy
2. hydrops fetalis
3. hydatidiform mole

Complications of pre-eclampsia (PET). (5%)

Maternal complications
1. Central Nervous System (CNS)
 Irritability, headache, visual disturbance, eclampsia
 CVA ― stroke, cerebral edema
2. cardiac: ↓plasma volume →↑blood viscosity → congestive heart failure
3. lung: leaky capillaries → pulmonary edema
4. liver: ↑liver enzymes → subcapsular haemorrhage, jaundice, liver failure
5. renal
 ↑urate, urea & creatinine level
 ↓urine output → acute renal failure

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6. uterus
 placenta: ↓uteroplacental blood → poor placental perfusion → infarction and/or
abruptio placentae
7. blood: Disseminated Intravascular Coagulation (DIC)
8. HELLP syndrome
 Haemolysis → Jaundice / Anaemia
― total bilirubin > 1.2 mg/dl; LDH > 600IU/L
 Elevated Liver enzymes: AST > 70 IU/L
 Low Platelets: Platelet count < 100,000 per mm3 (used to classify severity)
 Clinical presentation: right upper quadrant (RUQ) pain, epigastric pain, nausea
& vomiting, 85% hypertension

Fetal complications
1. Intrauterine growth retardation (IUGR) due to
 Placental insufficiency resulting from placental infarction / vascular changes
2. Intrauterine death (IUD) due to
 Acute hypoxia in case of abruptio placentae / eclampsia
3. Prematurity
 ↑incidence of preterm labour
 latrogenic: early termination of pregnancy (TOP)

Complications of eclampsia.

Maternal complications
1. cerebral haemorrhage
2. asphyxia
3. aspiration pneumonia
4. organs failure: kidney, liver, heart
5. injuries: tongue, fracture

Fetal complications
1. hypoxia
2. asphyxia
3. stillbirth

Diagnosis of pre-eclampsia (PET).

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History taking
1. family history of PET: mother & sisters have PET during their pregnancies
2. previous history of PET
3. history of medical problems: HT / renal disease / DM

Clinical features
1. asymptomatic in mild to moderate PET
2. Blood pressure (BP) ≥ 140/90 mmHg on 2 occasions at least 4 hours apart OR
Diastolic BP > 110 mmHg on any one occasion
Returning to normal postpartum
3. Proteinuria ≥ 300 mg in 24 hours OR
2 clean catch mid-stream urine (MSU) 4 hours apart with ≥ 2+ on reagent strip
4. Oedema: no longer a sign of PET, but the presence of generalized edema is
significant
5. Severe PET will have symptoms:
 headache, dizziness
 visual disturbances: blurred vision, diplopia or spots before eyes
 epigastric pain & vomiting due to hepatic haemorrhage (∵HELLP syndrome)
 Oliguria: < 400 – 500 ml/day
 hyper-reflexia

Laboratory investigation
1. High plasma urate & urea level
2. Impaired renal function: ↑creatinine level
3. High haematocrit (↑HCT)
4. HELLP syndrome
 Haemolysis → Jaundice / Anaemia
― total bilirubin > 1.2 mg/dl; LDH > 600IU/L
 Elevated Liver enzymes: AST > 70 IU/L
 Low Platelets: Platelet count < 100,000 per mm3
5. prolonged clotting profile

Other diseases
1. renal disease: urinary tract infection (UTI)
2. Phenochromycytoma
3. Autoimmune disease
List the causes of “high head” at term.

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1. Cephalo- pelvic disproportion (CPD) is the disproportion between the size of
fetal head & that of the maternal pelvis causing difficult labour, e.g. normal size
pelvis & macrosomia or contracted pelvis & average size fetus.
2. Placenta praevia: the placenta had occupied the lower pole of the uterus &
hinder the descent of the head.
3. Fibroid may hinder the descent of the head.
4. Malposition, e.g. occipito-posterior (OP) position, & malpresentation, e.g.
brow or face presentation: the presenting diameter is large in relation to the
pelvic brim, since the head is usually deflexed or extended.
5. Fetal abnormalities such as cojoined twins, hydrocephalus, hydrops fetalis,
which results in disparity between the size of the fetus & that of the pelvis.
6. Wrong date: the gestation may not be actually “term”, so engagement does not
occur.
7. Polyhydramnios may present with a larger fundal height than actual gestation.
8. Parity: as engagement of multiparous women takes place during labour.

Define Preterm Labour.

Onset of regular uterine contractions associated with progressive cervical change after
24 weeks & before 37 weeks of gestation.

State the risk factors of Preterm Labour.

1. Prior preterm delivery

2. Age group: teenage / advanced age
3. Psycho-socio-economic factors: stress / substance abuse / smoking / low
socioeconomic status
4. Overdistension of uterus: multiple pregnancy / polyhydramnios
5. Uterine abnormality: uterine fibroid
6. Cervical abnormality: cervical incompetence
7. Maternal infection: chorioamnionitis, urinary tract infection (UTI), genital tract
infection (GTI)
8. Conditions complicating pregnancy: pre-eclampsia (PET), antepartum
haemorrhage (APH)
9. Fetal factors: intrauterine growth retardation (IUGR) / fetal abnormalities such

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 as hydrops fetalis or hydrocephalus
10. Trauma
11. Unknown

State the problems of preterm babies.

Due to immaturity of body systems

1. CNS: cerebral & intraventricular haemorrhage
2. Respiratory system: pneumonia, respiratory distress syndrome (RDS)
3. CVS: patent ductus arteriosus, hypotension
4. GIT: abdominal distension, necrotizing entercolitis (NEC)
5. Hepatic: neonatal jaundice
6. Renal: fluid & electrolyte imbalance
7. Metabolic: hypothermia, hypoglycemia, hypocalcaemia
8. Immune: neonatal sepsis
9. Haematological: anaemia, coagulation disorders
10. Eyes: retinopathy of prematurity
11. Long term adverse effects: impaired mental development & cerebral palsy

State Premature Rupture of Membranes (PROM) & Preterm Premature

Rupture of Membranes (PPROM).

PROM is ROM prior to the onset of labour irrespective of the gestational age.
PPROM is ROM prior to the onset of labour before 37 weeks of gestation.

State the causes of PROM.

1. Increased intrauterine pressure: polyhydramnios, multiple pregnancy

2. Incompetent cervical os
3. Malpresentation: breech / brow / face
4. Malposition: occipito-posterior (OP) position (high head→ rupture of forewater)
5. Maternal infection: chorioamnionitis
6. Preterm Labour
7. Post amniocentesis
Define Postterm Pregnancy.

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A pregnancy of 42 weeks or more (=294 days) from the first day of the last menstrual
period, with regular 28 days cycle.

Define induction of labour & the common methods used for induction of labour.

Induction of labour is the stimulation of uterine contractions before the spontaneous

onset of labour with or without ruptured fetal membranes for the purpose of
accomplishing birth.
The methods of induction of labour are:
 Medical methods include pessary of Prostaglandin E 2 (PGE2) to ripen the cervix
& Syntocinon infusion to bring about uterine contractions.
 Surgical methods include amniotomy & sweeping / stripping of the cervix.
 Combined method is both medical & surgical methods.
 Complementary methods are sexual intercourse, stimulation of nipples, use of
herbs.

Discuss the indications of induction of labour.

The benefits to the mother or the fetus outweigh those of continuing the pregnancy.
The benefits must be weighed against the potential maternal or fetal risks associated
with this procedure.

Maternal indication
1. Prolonged / Postdate pregnancy
2. Hypertension including Pre-eclampsia
3. Uncontrolled diabetes mellitus (DM)
4. Medical problems such as renal / respiratory / cardiac disease
5. Mild abruptio placentae
6. Chorioamnionitis
7. Poor obstetric history, e.g. previous stillbirth
8. Unstable lie
9. Premature rupture of membranes
10. Maternal request

Fetal indication

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1. Suspected fetal compromise, e.g.
 Intrauterine growth retardation
 Decreased fetal movement
 Abnormal umbilical artery blood flow can be detected by the Doppler ultrasound
2. Intrauterine death
3. Severe fetal abnormality
4. Suboptimal antepartum cardiotocography (CTG)

Factors affecting success of induction of labour. 4.1999 (B.4) (5%)

1. Gestational age
 The closer to 40 weeks of gestation or thereafter, the higher the chances of
success
2. Parity
 Multiparity is more likely to respond to induction of labour than primiparity
3. Favourability or ripeness of the cervix
 A high bishop score (≧6/13) predicts a good response to induction of labour
while a low score implies difficulties
4. The method chosen for induction of labour
 Amniotomy / artificial rupture of membranes (AROM) used alone may result in
unpredictable & long intervals before onset of contraction
 Combined induction (amniotomy / AROM & Syntocinon infusion) used may
result in shorter induction-to-delivery interval
5. Urgency of the condition
 Mother’s life at risk
 Fetal compromise

Risks / complications of induction of labour.

1. Failed induction
 Effective uterine activity cannot be established or maintained
2. Higher rate of operative delivery: vacuum extraction / forceps delivery /
caesarean section
3. Medical induction, e.g. pessary of Prostaglandin E2 (PGE2), Syntocinon
infusion
 Uterine hyperstimulation lead to fetal distress or uterine rupture

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 Drug effect of Syntocinon may lead to neonatal jaundice
 Syntocinon in 5% Destrose infusion may lead to water intoxication
4. Surgical induction, amniotomy / artificial rupture of membranes (AROM),
may lead to intrauterine infection, cord prolapse, abruptio placentae; and
increases the rate of compression & moulding of the fetal head during
uterine contraction
5. Amniotic fluid embolism (rare)

Contraindications to induction of labour.

Absolute contraindications
1. transverse presentation
2. complete or footling breech
3. pelvic disproportion
4. placenta praevia
5. severe abruptio placentae
6. cord presentation or cord prolapse
7. presence of active infection, e.g. genital herpes
8. high risk of uterine rupture, e.g. previous classical caesarean section (CS), 2
previous lower segment caesarean section (LSCS), history of uterine surgery
9. tumours occupying the pelvis

Relative contraindications
1. Medical induction, e.g. pessary of Prostaglandin E2 (PGE2), Syntocinon
infusion
 Syntocinon infusion may cause uterine hyperstimulation in grandmultiparity, and
easily lead to uterine rupture
 Syntocinon infusion may lead to uterine rupture due to the scar of previous
caesarean section

2. Surgical induction, amniotomy / artificial rupture of membranes (AROM)

 AROM increases the rate of infection if the mother has cardiac disease
 Intrauterine death (absolute)

Causes of polyhydramnios. 1.1998 (B.14) (5%)

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Predisposing factors of polyhydramnios. 1.1997 (B.4) (5%)

Polyhydramnios is defined as a quantity of amniotic fluid which exceeds

1500mls, it may not be clinically apparent until it reaches 3000mls. Acute
polyhydramnios is very rare, occurs rapid and suddenly at around 20-24 weeks,
uterine size reaches xiphisternum in 3-4 days. Chronic polyhydramnios is more
common and graduate onset at around 30 weeks.

The causes/ predisposing factors of polyhydramnios are maternal cause such as

gestational diabetes mellitus (GDM), it may due to maternal hyperglycemia, then
lead to fetal hyperglycemia and causes macrosomia & fetal polyurina, so result in
polyhydramnios; fetal causes such as multiple pregnancy, usually in monozygotic
twins with twin twin transfusion; neural tube defect such as Spinal Bifida &
Anencephaly, Spinal Bifida causes increased transudation of fluid from the exposed
meninges into the amniotic cavity then lead to polyhydramnios, Anencephaly will
lack of anti-diuretic hormone and causes increased urination then lead to
polyhydramnios; Oesophageal atresia or duodenal atresia, since the fetus is unable
to swallow the liquor and absorb into its circulation then causes polyhydramnios;
Hydrops fetalis may due to alpha thalassaemia major or Rhesus sensitization;
Placental anomaly such as Chorio-angioma (very rare), which is the tumour of
the placenta.

How to diagnose polyhydramnios? (5%)

Clinical features
1. maternal discomforts from pressure symptoms
2. abdominal distension
3. abdominal pain
4. dyspnoea
5. dysphagia
6. increased edema

Abdominal examination
1. Inspection
 Uterus is larger than the gestational age
 Uterus is globular in shape rather than ovoid
 Abdominal wall is thin & tense

21
 Skin is stretched & shiny with marked striae gravidarum & obvious superficial
blood vessels

2. Palpation
 Uterus is tense
 Fetal parts may be difficult to palpate
 A fluid thrill may be elicited

3. Auscultation
 Fetal heart sound is muffled & difficult to hear

Ultrasonogram
 detection of fetal & placental abnormalities
 estimation of amniotic fluid volume by
→ single largest pocket measurement (the largest pocket measured in 2
perpendicular planes): >8 cm is polyhydramnios
→ amniotic fluid index (AFI) (the summation of the vertical depth of the largest
pocket in 4 uterine quadrants): 20-25 cm is polyhydramnios (> 95% for
gestational age)

Causes of oligohydramnios.

Oligohydramnios is abnormally small amount or absence of amniotic fluid,

usually less than 500mls of fluid.

The causes of oligohydramnios are Prolong Rupture of Membrane; postmaturity;

placental insufficiency which may caused by Pregnancy Induced Hypertension
(PIH), since intense generalized vasospasm causes reduced circulating plasma
volume and lead to end organ ischemia, therefore reduced uteroplacental blood
induces poor placental perfusion and causes placental ischemia, it may result in
placenta-infarction and/or abruptio-placentae, so intrauterine death (IUD) or
intrauterine growth retardation (IUGR) may occur; fetal anomalies such as
renal agenesis, which is absence of kidney, e.g. Potter’s syndrome; Urethral
obstruction or renal dysplasia; and intrauterine death (IUD).

How to diagnose oligohydramnios? (5%)

22
History taking
 any predisposing factors of placental insufficiency, e.g. pregnancy induced
hypertension (PIH), pre-eclampsia (PET)
 reduction of fetal movement

Abdominal examination
1. Inspection
 Small uterine size

2. Palpation
 Uterus is smaller than the gestational age
 Fetal parts are easily felt

Ultrasonogram
 estimation of amniotic fluid volume by
→ single largest pocket measurement (the largest pocket measured in 2
perpendicular planes): <1 cm is oligohydramnios
→ amniotic fluid index (AFI) (the summation of the vertical depth of the largest
pocket in 4 uterine quadrants): <5 cm is oligohydramnios (< 5% for
gestational age)
 Doppler scan revealed intrauterine growth retardation (IUGR)
 Morphology scan shown renal abnormalities & pulmonary hypoplasia
(Potter’s syndrome)

The definition of Naegele’s Rule. 1.1997 (B.1.i) (1%)

A rule for calculating the Estimated Date of Confinement (EDC): subtract 3

months from the first day of the last normal menstrual period (LMP) and add 7 days.

Define Potter’s syndrome.

Potter’s syndrome is a congenital condition & commonly associated with only 2

vessels in the umbilical cord. It is a complication of oligohydramnios, since lack of
intrauterine space causing compression deformities.
Features of Potter’s Syndrome:

23
1. squashed-looking face
2. flattening of nose
3. low-set ears & furrows under the eyes (Potter’s facies)
4. micrognathia
5. talipes
6. skin is dry & leathery in appearance
7. renal agensis (absence of kidney) (rare & fatal condition)
8. pulmonary hypoplasia

Write short notes on amniotic fluid. 4.1998 (B.12) (5%)

Amniotic fluid is the fluid contained in the amniotic sac, also called liquor amnii.
This fluid surrounds and is swallowed by the fetus. It is secreted from the cells of the
amnion, transudate from fetal vessels in the cord and placenta and from maternal
vessels in the decidua. The amount varies from 500 to 1500mls at term.

The fluid allows the fetus to move freely and equalizes pressure, acts as a shock
absorber, equalizes the temperature and provides some nutritive substances for
the fetus.

Write short notes on the definition of perineum. 1.1997 (B.1.v) (1%)

Anatomically, perineum is the area extending from the pubic arch to the coccyx, with
the underlying tissues. Obstetrically, the perineal body is the fibromuscular pyramid
between the lower third of the vagina anteriorly and the anal canal posteriorly, and
ischial tuberosities laterally.

Write short notes on placenta. 1.1997 (B.13) (5%)

It is formed by the 12th week of pregnancy, and is composed of large numbers of

chorionic villi grouped together in cotyledons, and embedded in the decidua basalis of
the uterus. The branches of the umbilical vessels form the umbilical cord. The
insertion of the cord is usually placed centrally of the placenta. There are 2 layers
covering the placenta: amnion & chorion. The placenta expelled after birth. It weighs
approximately 1/6 of the baby’s birth weight at full term.

24
Functions of the placenta:
1. glycogen storage
2. respiration
3. excretion
4. endocrine
5. nutrition
6. partial barrier

Write short notes on Partogram. 4.1999 (B.7) (5%)

It is a graphical record of the progress of labour, particularly the dilatation of the

cervix. Progress can be assessed from the visual patterns of cervical dilatation;
strength, frequency & duration of uterine contractions; descent of the presenting part
(5/5 fifth on abdominal palpation & station on vaginal examination), in conjunction
with the record of maternal and fetal conditions; maternal condition includes vital
signs, urine output & urinalysis, drugs & intravenous fluid given, vaginal examination
findings; fetal condition includes fetal heart rate (FHR) & FHR pattern, colour of
liquor, any caput or moulding found on vaginal examination.
When normal progress does not occur, action such as augmentation with oxytocic
drugs can be taken, so partogram is an early detection of any abnormalities.

Identify 8 risks of advanced maternal age pregnancy. (4%)

Maternal risks
1. medical diseases complicating pregnancy, e.g. diabetes mellitus, hypertension,
cardiac problems, gynecological disorders such as uterine fibroids
2. multiple pregnancy
3. preterm labour may due to high risk of pre-eclampsia
4. increased incidence of antepartum haemorrhage (APH) due to abruptio
placentae caused by pre-eclampsia
5. increased incidence of postpartum haemorrhage (PPH) due to atonic uterus
6. high rate of caesarean section
7. high rate of maternal mortality

Fetal & neonatal risks

25
1. abortion
2. low birth weight / intrauterine growth retardation (IUGR) may due to
preterm labour / mother has medical disease, e.g. hypertension
3. macrosomia if mother of advanced age has gestational diabetes mellitus
(GDM)
4. Higher risk of congenital abnormalities or congenital malformation, e.g.
Down’s syndrome or others; congenital malformation may induce shoulder
dystocia
5. high rate of perinatal mortality

Identify 3 features that indicate a satisfactory labour progress. (3%)

A satisfactory labour progress can be detected by cardiotocography, vaginal

examination & abdominal palpation.

Regular and painful uterine contractions (UC)

1. Contractions & retractions of uterus

2. Relaxation between UC
 To allow the placental blood flow to be resumed
 To avoid muscle fatigue

3. Optimal UC
 Frequency: 3-4 / 10 minutes
 Duration: ~ 40-90 seconds
 Strength: mild / moderate / strong (50-75 mmHg)
 Resting tone: 8-12 mmHg

Descent of the fetus

 Descent of the presenting part takes place with regular & painful UC, so
engagement & increase in station occur.

Progressive effacement & dilatation of cervix

1. Cervical effacement
 Shortening & thinning of the cervical canal
 Caused by pulling up of the internal os & incorporated into the lower uterine
segment

26
2. Cervical dilatation
 The opening or widening of the external os from 0-10 cm
 Progressive cervical dilatation depends on well-fitting presenting part,
regular UC & intact forewater

State the physiological mechanisms to uterine involution during puerperium.

(3%)

Uterine involution is the process whereby the uterus returns to the approximate
pre-pregnant size and position while the placental site of the endometrium heals.

The physiological mechanisms are autolysis, enzymatic digestion & ischaemia.

Autolysis is the digestion of excess muscle fibres by proteolytic enzymes. The
decreased blood supply to the uterus induces atrophy fibrous & elastic tissue, which
are broken down by phagocytosis.

Enzymatic digestion occurs when the proteolytic enzymes, called Lysin, which is a
cell-dissolving substance contained in blood stream, break down muscle fibres and all
these waste products of myometrium are circulated in the blood, and excreted by the
kidneys in urine.

The blood vessels with muscle fibres are interlaced and compressed, so ischaemia
occurs.

The contractions of the arterial smooth muscle and compression of the vessels by
contraction of the myometrium result in hemostasis. The superficial layer
(functional layer) of decidua becomes necrotic and shed in the lochia. The
epithelium of the uterus regenerates, an intact layer (basal layer) will reform at
around Day 7 to Day 10. Development of new endometrium will complete in
around 3 weeks. The placental site takes around 6 weeks to heal.

Diagnosis of cephalopelvic disproportion (CPD). (5%)

CPD should be a retrospective diagnosis, actual diagnosis could only be made

after delivery. We can only suspect a mother with CPD in antenatal period &

27
during labour.

1. History taking of
 Any medical diseases such as any disease or injury of spine, pelvis or lower
limbs, e.g. poliomyelitis; or maternal diabetes mellitus (DM)
 Any obstetric problems such as previous history of difficult labour, prolonged
labour or operative delivery; or macrosomia / big baby
2. Physical examination
 Observation of any abnormal gait, such as limping gait due to shortening of
one leg or deformity of spine or hip joint
 Short stature: body height < 150cm
 Abdominal examination of any malpresentation; big baby; high head at term
or unengaged fetal head at/near term by head fitting test (head engagement
occurs after 36 weeks in primiparous; head engagement usually occurs during
labour in multiparous)
3. Pelvic assessment of
 Reduced diameter clinically / ? inadequate pelvic size
 Whether it is fail to meet the criteria for a clinically adequate size for vaginal
delivery

4. X-ray / CT pelvimetry for actual pelvic size

 Is used to confirm the diagnosis
 To find out any reduced pelvic measurements & abnormal shape of pelvis

5. Ultrasound for estimation of fetal size

 To confirm big baby

State the causes & associated risks of cephalopelvic disproportion (CPD). (5%)

CPD is disproportion between the size of fetal head & that of the maternal pelvis
causing difficult labour, such as normal size of pelvis VS big baby, small size of
pelvis VS average size of baby.

Pelvic causes
1. small pelvis
2. contracted pelvis
Fetal causes of big baby

28
1. hereditary
2. baby of diabetic mother
3. post term pregnancy
4. multiparity
5. fetal abnormality, e.g. hydrocephalic fetus

Associated risks of CPD

1. prolonged labour
2. obstructed labour may lead to uterine rupture
3. malpresentation or malposition
4. early rupture of membranes (ROM) / premature rupture of membranes (PROM)
may lead to cord prolapse
5. maternal & fetal trauma

State the indications & criteria of trial of labour (TOL). (5%)

Indications of TOL
1. mild contracted pelvis
2. suspected mild degree of cephalopelvic disproportion (CPD)

Criteria of TOL
1. cephalic presentation
2. good medical & obstetric history
3. no complicating pregnancy
4. one previous lower segment caesarean section (LSCS) (trial of scar (TOS))

State the factors affecting the outcome of TOL. (5%)

1. the effectiveness of uterine contractions

2. the “give” of pelvic joints
3. flexion of fetal head
4. degree of moulding of the fetal head

State the indications for terminating TOL. (5%)

29
1. no descent of fetal head
 felt by abdominal examination rather than vaginal examination
 false descent may felt ∵excessive moulding → caput

2. no progressive cervical dilatation

3. maternal or fetal distress

Briefly describe the diagnosis of abruptio placentae & placenta praevia. (5%)

Abruptio placentae occurs if premature separation of a normal situated placenta after

24th week of pregnancy.

Diagnosis of abruptio placentae

1. Abdominal pain & hard consistency guarding on abdominal palpation
 Mildest degree of placental separation is relatively pain free
 Excessively painful if concealed haemorrhage lead to couvelaire uterus
→ uterine enlargement, tense uterus with hard consistency
 Fetal parts may not be palpated

2. abnormal cardiotocography (CTG) tracing

3. bleeding from vagina
4. shock if severe bleeding: ↑pulse, ↓BP
5. normal or rapid respiration
6. Ultrasound is used to confirm the diagnosis by detecting the degree of
placental separation.

Placenta praevia occurs if the placenta is partially or wholly implanted in the lower
uterine segment on either the anterior or posterior wall. The anterior location is more
serious than the posterior location because of difficult surgery of caesarean section.

Diagnosis of placenta praevia

1. painless, causeless, recurrent
2. uterus is not tense
3. fetal head is not engaged in primiparous lady
4. malpresentation especially breech
5. oblique or transverse lie

30
6. unstable lie in multiparous lady due to lax abdominal muscle
7. When the lower uterine segment starts to form or the cervix begins to dilate,
the placenta becomes partially separated & this causes maternal bleeding
8. signs & symptoms correlated to the amount of bleeding, e.g. shock if severe
bleeding
9. Ultrasound is used to confirm the diagnosis by detecting the placental
location.

State different degrees of placenta praevia. (5%)

Placenta praevia occurs if the placenta is partially or wholly implanted in the lower
uterine segment on either the anterior or posterior wall. The anterior location is more
serious than the posterior location because of difficult surgery of caesarean section.

Type I
 Majority of placenta is in the upper uterine segment.
 Usually mild blood loss

Type II (Marginal placenta praevia)

 Placenta is partially located in the lower uterine segment & reaching the internal
cervical os
 Usually moderate blood loss
 Fetal hypoxia is more likely if mother is in shock

Type III
 Placenta is located partially over the internal cervical os
 Bleeding is likely to be severe particularly when the lower uterine segment
stretches & the cervix begins to efface & dilate in late pregnancy

Type IV
 Placenta is located centrally over the internal cervical os
 Torrential haemorrhage is very likely

State the classification of abruptio placentae. (5%)

31
Abruptio placentae occurs if premature separation of a normal situated placenta after
24th week of pregnancy.

Revealed type (vaginal bleeding seen)

 Partial placental separation and blood escapes from placental site, separates
the membranes & drains through the vagina

Concealed type (no vaginal bleeding seen)

 Central placental separation and blood is retained behind the placenta &
forced into the myometrium & infiltrates between the muscle fibres of the uterus
→ couvelaire uterus or uterine apoplexy

Mixed type (both revealed & concealed type)

 Visible blood loss is not the guide to the severity of the haemorrhage

What are the causes of obstructed labour in first stage? (5%)

Maternal causes
1. contracted pelvis / cephalopelvic disproportion (CPD)
2. impacted pelvic tumours
 uterine fibroid, cervical fibroid
 large ovarian cyst
 tumour of the pelvic bones

3. undilatable stenosis of the cervix

 cervical dystocia
 cervical cancer
 after surgery (multiple scar formation after repair)

4. congenital thick vaginal septum

Fetal causes
1. very large fetus / macrosomia
2. malpresentation
 shoulder / brow / compound presentation
 face presentation (persistent mentum posterior (PMP) presentation must need

32
 caesarean section)

3. malposition
 persistent occipito-posterior (POP) position may lead to deep transverse arrest, &
must need caesarean section

4. Fetal abnormalities
 Hydrocephalus
 Conjoined / locked twins
 Hydrops foetalis
 Ascitis / abdominal tumour

Signs of obstructed labour. (5%)

Obstructed labour occurs if there is no advance of the presenting part despite

strong uterine contraction. Vaginal delivery is impossible.

Early signs of obstructed labour

1. Labour fails to progress (no or slow) despite of good uterine contraction
 High presenting part
 Slow dilatation of cervix
 Tonic uterine contraction

2. Early rupture of membranes (ROM) due to ill-fitting part

3. Deterioration in maternal condition

 Mother shows tiredness & anxiety

Late signs of obstructed labour

1. Signs of maternal distress
 Dehydration, ketonuria, ↓urine output, low grade fever

2. Signs of fetal distress

 Deceleration of fetal heart rate, unsatisfactory cardiotocography (CTG),
meconium stained liquor (MSL), fetal blood sampling shown acidosis

3. Tonic contraction: stronger & more frequent

33
 Uterus becomes moulded around the fetus & does not relax properly
between contractions
― tetanic contraction → uterine response to overcome obstruction in multiparous
lady
― secondary uterine inertia → uterine exhaustion in primiparous lady, then
uterus cease to contract

4. Abdominal palpation found Bandl’s Ring

 Bandl’s Ring is a visible retraction ring (an oblique ridge) above the
symphysis pubis across the abdomen. This marks the junction between the
thick & short upper uterine segment and the thin & long lower uterine
segment
― Fetal parts are difficult to palpate
― Continuous tonic uterine contraction
→ uterus becomes hard & tender, and fails to relax properly between contractions
→ upper uterine segment is shorter & thicker, which may lead to uterine rupture

5. Vaginal examination
 Vagina: hot & dry
 Cervix: oedema; dilates slowly & loosely applied to the presenting part
 Presenting part: high, excessive moulding, large caput

Physiological changes of the uterus during the first stage of labour. 10.2002 (B.4)
(5%)

The contractions & retractions of the uterine muscles lead to the formation of the
upper & lower uterine segments. The upper uterine segment is dominated by
longitudinal & oblique muscle fibres, which plays more active part during uterine
contractions, and makes itself becomes shorter & thicker.

The lower uterine segment is developed from the isthmus of uterus, which is
dominated by circular muscle fibres, it plays less active part during uterine
contractions, and makes itself becomes longer & thinner.

As the cervix is continuous with lower uterine segment, the effect of retraction is to
pull open or dilate the external cervical os.
The retraction ring gradually rises as the upper uterine segment contracts & retracts &

34
the lower uterine segment gradually thins out to accommodate the descending fetus

State the physiological changes of the 1st stage of labour.

1. contractions & retractions of uterus

2. formation of upper & lower uterine segments
3. effacement & dilatation of cervix
4. general fluid pressure
5. formation of bags of water
6. rupture of membranes
7. fetal axis pressure
8. descent of fetus

State the physiological changes of the 2nd stage of labour.

1. Stronger, longer, expulsive but may be less frequent uterine contractions

2. Ferguson reflex
 Pressure from the presenting part stimulates nerve receptors in the pelvic floor &
lead to urge to push

3. Fetal axis pressure increases the flexion of fetal head

4. Secondary powers lead to contraction of abdominal muscles & diaphragm

5. Displacement of bladder & pelvic floor

 Bladder is pushed upwards, so stretching & thinning of urethra occurs
 Pressure of the advancing head on rectum expels any residual faecal matter
 Perineum is stretched & thinned

6. Uterus, cervix & vagina merged into a single broad channel

7. Expulsion of the fetus

State the physiological changes of the 3rd stage of labour.

35
1. Placental separation
 After delivery of baby, uterus contracts & retracts, and lead to the reduction of
uterine size & placental site
 Placenta becomes compressed, blood in intervillous spaces is forced back into
the spongy layer of deciduas
 The surface area for placental attachment reduces & the non-elastic placenta
begins to peel off the uterine wall
 4 signs of placental separation
― Hard, globular & mobile uterus (uterine contraction).
― A gush of blood from vagina.
― Lengthening of cord at vulva.
― Placenta may appear at vulva.

2. Placental expulsion
 Control cord traction (CCT) with Schultz method ― fetal side appears first
 CCT with Matthew Duncan method ― maternal side appears first

3. Control of bleeding by
 Contraction of living ligatures (oblique muscle fibres)
 Contraction of muscular walls of blood vessels
 Formation of clots at the sinuses

Define daily postnatal assessment (5%)

1. vital signs: blood pressure / pulse / temperature

2. breasts & nipples condition
 breasts engorgement
 sore / cracked nipples
 block ducts / mastitis

3. Uterus: consistency / fundal height / position

 Any signs of subinvolution
→ flabby & poorly contracted
→ persistent backache or pelvic pain
→ heavy vaginal bleeding
→ tenderness

36
4. lochia: amount / colour / consistency / odor
 any signs of infection

5. perineum
 haematoma / bruising / condition of episiotomy wound
 any signs of infection
 haemorrhoid

6. lower limbs
 any thrombophlebitis & deep vein thrombosis (DVT)
 any positive Homan’s sign
→ legs stretched out straight & relaxed, pressure applied on foot (forced
dorsiflexion), pain experienced behind calf or in calf when thrombosis is
present

7. Afterpains
 Occur commonly in multiparity & lactating mothers
∵ uterus of primiparity is able to maintain a well-contracted state

8. nutrition: can tolerate food & fluid

9. elimination
 urinary symptoms (urination should take place within 6-8 hours)
 any constipation

10. psychological adaptation

 general condition
 interaction of the mother & other family with the newborn
 postpartum blue

11. rest & sleep patterns

12. ambulation & exercise
13. self care & newborn care

Common causes of urinary retention during / after delivery. 4.1997 (B.2) (5%)

37
Possible reasons for acute retention of urine during / after delivery. 10.2000 (B.9)
(5%)

Causes of retention of urine in intrapartum period

1. Use of bedpan
2. lack of privacy
3. complication of epidural analgesia
4. Advancing fetal head displaced the bladder and pressed against urethra

Causes of retention of urine in postpartum period

1. Trauma to bladder & urethra, especially occurs in difficult labour, prolonged
labour, precipitated labour, operative delivery such as vacuum extraction /
forceps delivery / caesarean section
2. Complication of epidural analgesia (effect may last for 10-12 hours); spinal or
general analgesia due to caesarean section
3. urinary tract infection
4. fear of micturition due to the painful perineum, vulval or vaginal haematoma
5. lack of privacy

Management of intrapartum / postpartum urinary retention. 10.1999 (B.9) (5%)

Midwifery management in intrapartum period

1. Provide privacy
2. Assist women in a desired position
3. Encourage the women to hear the sound of flowing tap water in order to
stimulate her sense of voiding
4. Catheterize the bladder → to empty the bladder in order to facilitate the descent
of the presenting part

Midwifery management in postpartum period

1. Firstly, assessment must done to find out the reason of postpartum urinary
retention, e.g. distended bladder & uterus displacement by abdominal palpation;
epidural effect; lack of privacy
2. Provide privacy
3. Assist women in a desired position or to void in toilet
4. Encourage the women to hear the sound of flowing tap water in order to
stimulate her sense of voiding

38
5. Drugs, e.g. Panadol or Dologesic, must be administered to relief the pain of
perineum or episiotomy wound
6. Catheterization of the bladder if the woman cannot pass urine for 6-8 hours after
delivery
7. If the woman still cannot pass urine after catheterization of the bladder,
indwelling catheter should kept in situ for 48 hours or according to the doctor’s
prescription, fluid intake & urinary output should be measured & monitored
8. Mid-stream urine (MSU) must be sent for culture to rule out the urinary infection
9. By abdominal palpation, uterus should correct its malposition spontaneously
after empting the bladder
10. After removal of catheter, woman is encouraged for more fluid intake & try
voiding again until the bladder is empty

Symptoms of postpartum depression. 4.2000 (B.8) (5%)

1. Physical symptoms
 Anorexia
 Headaches
 Sleep disturbance
 Difficult to concentrate
2. Tiredness, irritability
3. tearfulness, low mood, despondency
4. Anxious & fear
5. Lack of drive& enjoyment, social withdrawal
6. Loss of control, obsessive thinking
7. Loss of libido, suicidal ideas

Write short notes on Edinburgh Postnatal Depression Scale. 10.2002 (B.6) (5%)

Edinburgh Postnatal Depression Scale (EPDS) is a 10-items self-reported

questionnaire & the best known screening tool for postnatal depression. It has a high
level of reliability & validity. The conventional cut-off point for detecting
depression is 12/13. It is done on 6 weeks postpartum for early detection of
postnatal depression. It is translated & validated Chinese version has been
established & a 9/10 cut-off point is suggested for local use in Hong Kong.
There are increasing prevalence which is >10% and is affecting the mother,

39
family & society. If risk is identified, we need to contact the client & provide follow-
up, refer to obstetrician for further assessment is needed to confirm whether
clinical depression is present or in development. We need to identify the problem
of the client by counseling & provide help. If the condition is not serious, refer to
MCHC or introduce self-help group for further arrangement. If the condition is
serious, refer to psychiatric physician for further treatment.

Definition & prevention of postnatal depression. (5%)

Write short notes on puerperal mental disorder. 10.1996 (B.14) (5%)
Write short notes on postnatal depression. 1.1998 (B.2) / 10.1998 (B.12) (5%)
Write short notes on postpartum blue. 10.2000 (B.11) (5%)

Postnatal depression is a lowering of the spirits; a mood change experienced as

sadness or melancholy after delivery. It is a common puerperal mental disorder
which affects around 10-15% of childbearing women. It common occurs 3-5 days
postpartum. The earliest onset is 2-3 weeks; usually after 6 weeks postpartum;
and can last for several weeks or months; sometimes as long as 1-2 years.

The causes of postnatal depression are probably multi-factorial & a combination of

biological, psychological & social factors.

There are some predictors of postnatal depression:

1. History of previous depression
2. Prenatal anxiety / depression
3. Concurrent life stressors
4. Lack of social support
5. Maternity blues
6. Poverty
7. Marital dissatisfaction

Careful assessment of emotional state in postnatal period is necessary & important.

There are screening tools for the diagnosis of postnatal depression, which are
Edinburgh Postnatal Depression Scale (EPDS) & Beck Depression Inventory
(BDI).

The consequences of postnatal depression are

40
1. Personal suffering of women
2. Marital discord
3. Impaired mother-child relationship
4. Risk of recurrence
5. Child adjustment problems
 Long term studies showed that children of depressed mothers had low levels of
attention & concentration & behavioral problems

Prevention & early detection is important in postnatal depression. The prompt

management of postnatal depression is most vital; which includes medication,
psychotherapy & social support.

Prevention of postnatal depression

1. Antenatal preparation: Midwives should inform the women
 the stresses involved in parenting
 the possible effect of having a baby on the relationship between the couple
 the importance of asking help from partner, & from other relatives
 the advantages of talking about one’s feelings with one’s partner or a close friend
or professional
 the possibility of adverse emotional responses after delivery, & available source
of help
2. Screening programme
 Antenatal screening for women using a checklist of associated risk factors may
be considered
 Screening programme for postnatal depression should be established for all
women by using the screening tool such as Edinburgh Postnatal Depression
Scale (EPDS)
 Counseling & supportive therapy should be arranged for those women at-risk
of suffering postnatal depression

3. Postnatal support & counseling

 Closely monitored women’s emotional responses in postnatal period
 Ensure adequate rest & supervision on baby care
 Explanation, understanding & support are the best treatment for the distressed
mothers
 Midwives should listen to postnatal women, this is not only therapeutic, but will
facilitate the early recognition of women with problems
 Postnatal support groups may be helpful to women who feel isolated & lonely

41
 after childbirth
 Postnatal hotlines or face-to-face individual counseling should be available
 An outreach service can be established to visit women at risks

Identify 4 common health problems after childbirth. (4%)

1. After pains
 Occur during the first 2-3 days, more common in multiparity
 Caused by the myometrial contraction of the uterus
 Pains are accentuated during breastfeed
 Mild analgesic is usually effective, e.g. Ponstan

2. Perineal pain (especially if episiotomy is present)

 Perineal hygiene should be taught
 Application of cooling agents may provide short term pain relief
 Local anaesthetic spray or gel (5% lignocaine) can be of benefit
 Paracetamol is usually effective in controlling mild pain

3. Haemorrhoids
 May become prolapsed & extremely painful after labour
 Analgesia is required, e.g. Anusol cream
 Can be digitally replaced when edema subsided
 Constipation is avoided & high residue diet is encouraged

4. Breast engorgement
 If the produced milk is not adequately removed, the alveoli become
distended resulting in engorgement
 Can be prevented by early initiation of unrestricted feeding & correct
positioning of the baby

What is the pattern of weight gain during pregnancy and what components
constitute the weight gain? (6%)

Weight gain for women whose body mass index (BMI) is

 Low (<19.8): ~ 13-18 kg (28-40 lbs)
 Normal (19.8-26): ~ 11.4-16 kg (25-35 lbs)

42
 High (>26-29): ~ 7-11.4 kg (15-25 lbs)

Weight gain for Chinese women is

 ~ 13-16.7 kg for underweight women
 ~ 11-16.4 kg for women of average body weight
 ~ 7-14.4 kg for overweight women

Average weight gain for women of normal built & height is 11.5-13.5 kg.
 2-3 kg in first 20 weeks
 ~ 0.5 kg/week in last 20 weeks (~ 10 kg till term)

The pattern is not a linear trend:

 Little weight gain ~ 1.6-2.3kg in 1st trimester
 ~ 0.45 kg/week in 2nd trimester
 ~ 0.36 kg/week in 3rd trimester

Maximum weight gain occurs between 17 & 24 weeks of gestation.

Weight loss or fail to gain weight over 2-weeks interval is common in 3 rd trimester,
which is more prevalence of small for gestational age (SGA) infants in this group of
women. Severe weight loss in pre-eclampsia (PET) is due to uterine insufficiency and
may lead to intrauterine growth retardation (IUGR) / preterm labour / intrauterine
death (IUD).

The components constitute the maternal weight gain are

 fetus ~ 3.4 kg
 placenta (1/6 of the weight of uterus) ~ 0.6 kg
 amniotic fluid ~ 1 kg
 uterus ~ 1 kg
 increased blood volume & fluid ~ 3.5 kg
 body changes ~ 3-4 kg
→ total weight gain = ~ 11.5-13.5 kg

Discuss the definition, causes, predisposing factors, clinical features,

investigations & management of puerperal pyrexia. 1.1998 (A.2) (15%)

Puerperal pyrexia is defined as temperature > 37.4℃ on more than 3 occasions

or 38℃ on one occasion.

43
Causes of puerperal pyrexia
1. mild transient pyrexia may be reactionary (within the first 24 hours)
2. mild transient pyrexia may due to breast engorgement
3. antenatal infection

Predisposing factors of puerperal pyrexia

1. intrapartum factors
 repeated vaginal examinations
 prolonged labour
 prolonged rupture of membranes
 operative deliveries, e.g. vacuum extraction, forceps delivery, caesarean section
 intrauterine manipulation, e.g. exploration of uterus or manual removal of
placenta (MROP)
 retained product of gestation (RPOG)

2. infection
 genital tract infection due to laceration of genital tract; perineal, vaginal &
cervical tear
 episiotomy or caesarean section wound infection
 infection of the uterus, e.g. endometritis, may due to the infected placental site
 urinary tract infection (UTI) due to bladder catheterization during labour
 mastitis: non-infective mastitis occurs when milk flow from one segment of the
breast is obstructed; infective mastitis is caused when bacteria enter the breast,
commonly through a crack in the nipple, usually caused by Staphylococcus
aureus
3. Poor nutrition, anaemia, chronic condition

Clinical features of puerperal pyrexia

1. fever, rapid pulse
2. chills & rigor
3. malaise, anorexia
4. uterus is tender & subinvoluted
5. profuse & foul smelling of lochia
6. blood result shown increased WBC & ESR
7. positive culture result
8. episiotomy or caesarean section wound infection: redness, edema, pain, purulent
drainage, gapping of wound

44
9. UTI: frequency of micturition, dysuria, urgency, loin pain or suprapubic pain
10. mastitis: tachycardia, headache, nausea & vomiting, localized pain, swelling,
redness, axillary adenopathy

Investigations of puerperal pyrexia

1. history taking of possible risk factors, e.g. antenatal infection, &
intrapartum factors & symptoms complained by the woman
2. physical examination
 vital signs: temperature, blood pressure, pulse, respiration rate, skin colour
 throat, heart & chest
 postnatal examination: breasts & nipples to rule out breast engorgement & sore
nipples; involution of uterus; condition of abdominal or perineal wound; colour,
amount & smell of lochia to rule out any profuse & foul smelling of lochia; any
swelling & discomfort of the leg to rule out deep vein thrombosis (DVT)

3. laboratory investigations
 Blood studies of CBP, WBC, ESR
 Culture of throat swab, wound swab, high vaginal swab (HVS), blood, mid-
stream urine (MSU)
 Chest X-ray
 Ultrasound (USG) Doppler to rule out DVT

Management of puerperal pyrexia

1. contact isolation in a private & well-ventilated room, universal precaution is
taken to prevent cross-infection
2. identify the source of infection
3. assessment of the severity
4. appropriate antibiotic therapy
 usually start with a broad-spectrum & change to the appropriate one when
result is available
5. general care for febrile patient
 adequate sleep & rest
 oral panadol & analgesia
 high protein diet & hydration
6. prone position to encourage lochia drainage
7. care for specific infection
 episiotomy or caesarean section wound infection: wound care +/- incision &
drainage & resuturing of the wound; advice on personal & perineal hygiene

45
 UTI: antibiotic therapy, e.g. Ampicillin; light & nutritious diet; encourage fluid
intake; monitor intake &output
 Mastitis: antibiotic therapy, e.g. Flucloxacillin; advise mother to continue
breastfeed & gentle massage the breast during feed; help her to express the milk
by pump if feeding is difficult or too painful; supportive measures such as apply
moist warmth before feeding & cold compress after a feed, a larger bra or
different cut or style may provide comfort; prepare the mother for incision &
drainage of abscess if formed.
8. continuous monitoring of the woman’s condition & response to treatment

Pre-requisites of low forceps application. (5%)

1. membranes must be ruptured

2. full dilatation of cervix
3. position & station of fetal head must be known
4. fetal head must engaged
5. no appreciable cephalopelvic disproportion (CPD)
6. empty bladder ∵ no obstruction of uterine contractions after vacuum extraction /
forceps delivery
7. adequate analgesia, e.g. pudendal or epidural block

Advantages of forceps delivery. (5%)

1. instrument is simple & need for assembly

2. shorter deliver time
3. can be used in face (only at mentum-anterior (MA) position) & breech
presentation
4. reduction in neonatal cephalohaematoma & vaginal haemorrhage as compared
with vacuum extraction

Advantages of vacuum extraction. (5%)

1. ease of application
2. can be used before full dilatation of cervix
3. can be used in delivery of second twin

46
4. encourage “auto-rotation” of malpositioned fetal head
5. less frequent & less severe genital tract trauma
6. primary postpartum haemorrhage & puerperal complications are less frequent
7. lower risk of caesarean section following vacuum extraction (especially
borderline cephalopelvic disproportion(CPD))

Indications, contraindications & complications of instrumental delivery (VE /

forceps). (15%)

Maternal indications
1. Prolonged 2nd stage due to
 Maternal distress or exhaustion
 Inability to push effectively, e.g. epidural analgesia

2. Prophylactic shortening of the 2nd stage, such as

 Cardiac or respiratory disease
 Severe hypertension
 Pre-eclampsia (PET)

Fetal indications
1. non-reassuring fetal heart rate pattern / fetal distress in 2nd stage of labour
2. control of after-coming head in breech delivery by the use of forceps
3. vacuum extraction if the head of the 2nd twin is high

contraindications
1. lack of engagement of fetal head
2. inability to accurately diagnose fetal position
3. prematurity of <34 weeks of gestation
4. malpresentation, e.g. face, brow, breech, is contraindicated in vacuum extraction
5. incomplete cervical dilatation; exceptions are second twin vertex, small baby,
urgent delivery for fetal distress or haemorrhage (must under experienced hands)

Maternal complications
1. genital tract trauma & infection
2. bladder or urethral injury
→ postpartum urinary retention
3. haemorrhage

47
Fetal complications
1. ventouse (metal cup) of vacuum extraction will cause
 chignon: scalp edema created by the vacuum extractor at the application area,
usually resolves within 24-48 hours
 scalp bruising / reddened areas may darkened & take several days to resolve
 scalp abrasion / laceration
 subaponeurotic / intracranial haemorrhage

2. forceps will cause

 facial marks
 facial palsy
 fracture of skull bone

Advantages of lower segment caesarean section. (5%)

Lower segment caesarean section (LSCS) is a transverse incision which made in

the lower uterine segment.

Advantages
1. better cosmetic effect
2. incision heals better
3. incision is totally extra-peritoneal
→ minimal risk of intra-peritoneal infection, e.g. peritonitis, & post-operative
complications
4. less likely to have scar rupture in subsequent pregnancies due to superior wound
strength

Advantages, disadvantages & indications of classical caesarean section. (5%)

Classical caesarean section is a vertical incision which made in the upper uterus.

Advantages
1. quicker to perform, suitable for urgent delivery for fetal distress or haemorrhage
2. can be enlarged quickly if needed
3. better visualization of the uterus

48
4. often more appropriate for obese woman

Disadvantages
1. more bleeding & oozing during operation
2. leaking of liquor into the peritoneal cavity
→ peritonitis, adhesions & intestinal obstruction
3. higher risk of scar rupture in subsequent pregnancies

Indications
1. gestation is <32 weeks before the lower uterine segment has formed
2. lower uterine segment is inaccessible, such as
 major placenta praevia
 impacted shoulder
 interlocking twins

3. fibroids distorting the uterus

4. post-mortem caesarean section

Common indications & complications of caesarean section. (5%)

Caesarean section is the surgical birth of the fetus through an incision in the
abdominal wall & uterus.

Indications for elective caesarean section

1. previous uterine scar
 previous classical caesarean section (C/S)
 previous myomectomy
 more than one previous LSCS
― 1/3 cases had previous C/S likely to have a repeat C/S

2. contracted pelvis (CP)

3. moderate to severe degree of CPD
4. malpresentation, e.g. brow, shoulder, breech
5. persistent unstable lie
6. multiple pregnancy
7. major type of placenta praevia
8. maternal active genital herpes or HIV infection

49
9. pressure of some gynaecological conditions such as cervical cancer & pelvic
tumours

Indications for emergency caesarean section

1. antepartum haemorrhage due to placenta praevia or abruptio placentae
2. fulminating pre-eclampsia or eclampsia
3. fetal distress
4. cord prolapse
5. persistent occipito-posterior position
6. failed induction of labour
7. No / slow progress of labour (obstructed labour)
8. failed vacuum extraction or forceps delivery
9. intrauterine infection

Maternal complications
1. haemorrhage during & after operation
2. wound complications such as
 haematoma
 gapped wound or fistula
 wound infection

3. infection
 endometritis
 chest infection
 urinary tract infection (UTI)

4. anaesthetic complications such as

 failed intubation
 Mendelson’s syndrome (acidic gastric juice is inhaled during general anaesthesia
(GA))
 Spinal headache

5. paralytic ileus & intestinal obstruction

6. deep vein thrombosis (DVT) & pulmonary embolism
7. bladder or urethral injury
→ postpartum urinary retention
8. higher risk of uterine rupture in subsequent pregnancies
9. higher risk of repeated C/S

50
Fetal complications
1. transient tachypnoea of the newborn caused by delayed absorption of lung fluid
2. increased incidence of respiratory distress syndrome (RDS)
3. accidental injury

Definition of intrauterine death (IUD) & stillbirth.

IUD is the death of the fetus in utero, including missed abortion & stillbirth.
Stillbirth is a baby born shows no signs of life after the 24 th weeks of gestation (or a
gestational age of 22 completed weeks) or with the birth weight > 500 grams.

Definition of maternal mortality, late maternal death & maternal mortality rate.

Maternal mortality is the death of a woman while pregnant or within 42 days of

termination of pregnancy, irrespective of the duration & the site of the pregnancy,
from any cause related to or aggravated by the pregnancy or its management but not
from accident or incidental causes.

Late maternal death is the death occurring between 42 days & one year after
termination of pregnancy, miscarriage or delivery that are due to direct (e.g. abortion,
PET) or indirect maternal causes (e.g. cardiac or infectious disease).
Maternal mortality rate is the number of maternal deaths per 100,000 total births.

Causes of maternal mortality.

1. haemorrhage of pregnancy & childbirth

2. obstetrical pulmonary embolism
3. amniotic fluid embolism
4. hypertension
5. pregnancy with abortive outcome
6. ectopic pregnancy
7. puerperal infection
8. thrombosis & thromboembolism
9. pre-eclampsia & eclampsia

51
10. genital tract sepsis

Definition of perinatal mortality & perinatal mortality rate.

Perinatal mortality is the death of a fetus after 28 weeks of gestation, including the
stillbirth (birth weight ≧ 1000 grams) & those within the first week (7 days) of life,
i.e. stillbirth + early neonatal death.
Perinatal mortality rate is the number of perinatal deaths per 1000 total births.

Causes of perinatal mortality.

1. congenital abnormalities
2. low birth weight (may due to prematurity)
3. intrauterine hypoxia
4. asphyxia, intracranial injury
5. infection

Factors affecting maternal & perinatal mortality.

1. environmental & social background of the mother

 maternal age
 parity
 marital status
 social class
 substance abuse
2. standard of obstetric & paediatric care
3. places of delivery

Definition of neonatal mortality & neonatal mortality rate.

Neonatal mortality is the death of the newborn in the first 28 days of life.
Early neonatal death occurs in the first 7 days of life.
Late neonatal death occurs in the next 21 days of life.
Neonatal mortality rate is the number of neonatal deaths per 1000 live births.

52
Causes of neonatal mortality.

1. congenital abnormalities
2. low birth weight (may due to prematurity)
3. intrauterine hypoxia
4. asphyxia, intracranial injury
5. infection
6. baby survive beyond the 1st week of life & death because
 neonatal infection
 intraventricular haemorrhage (IVH)
 necrotizing enterocolitis (NEC)
 iatrogenic disorders

Definition of infant mortality & infant mortality rate.

Infant mortality is the death of the newborn in the first year of life, including all
neonatal death & post-neonatal death (death from 4 weeks to 1 year of age).

Infant mortality rate is the number of infant deaths per 1000 live births.

Causes of infant mortality.

1. congenital abnormalities
2. low birth weight (may due to prematurity)
3. intrauterine hypoxia
4. asphyxia, intracranial injury
5. infection
6. baby survive beyond the 1st week of life & death because
 neonatal infection
 intraventricular haemorrhage (IVH)
 necrotizing enterocolitis (NEC)
 iatrogenic disorders
7. acquired after birth
 sudden infant death
 neoplasms
 infections

53
 home accidents

State the control of fetal heart rate (FHR).

1. pacemaker in the sinoatrial node

2. autonomic nervous system
 sympathetic increases FHR; parasympathetic decreases FHR
 cardioregulatory centre in mid-brain
3. receptors
 chemoreceptors in aorta & mid-brain
 baroreceptors in large arteries & aorta
4. other factors: drugs; fetal sleep & activity states; diurnal variation; sex (female >
male)

Define clinical factors, pathological factors, associated risks affecting FHR.

Clinical factors
1. duration of 1st stage of labour
2. maternal fever
3. maternal smoking
4. epidural analgesia
5. infection, e.g. chorioamnionitis
6. medication: Pethidine, Bricanyl

Pathological factors
1. maternal thyrotoxicosis
2. structural abnormalities of fetal heart
3. fetal anaemia / anomalies
4. cord compression accidents
5. oligohydramnios

Associated factors
1. intrauterine growth retardation (IUGR)
2. placental insufficiency, e.g. abruptio placentae, placenta praevia, maternal
hypertension, past term
3. no liquor / thick meconium stained liquor (MSL) at rupture of membranes

54
 (ROM) → ? fetal distress
4. at term / preterm premature rupture of membranes (PPROM)
5. suspicious FHR trace before

Definitions of baseline fetal heart rate, baseline variability, acceleration,

tachycardia, bradycardia, sinusoidal pattern, saltatory pattern.

Baseline fetal heart rate (FHR)

 mean level of a stable FHR in the absence of accelerations & decelerations over
a period of 5-10 minutes
 normal baseline FHR at term: 110-160 bpm
 higher value of baseline FHR in preterm fetuses due to sympathetic system
matures faster

Baseline variability
 degree to which the baseline varies within a particular band width (1cm = 1 min),
excluding accelerations & decelerations
 indicates the integrity of the autonomic nervous system
 normal: 5-25 bpm
 non-reassuring: <5 bpm lasting for ≧40 & <90 mins
 abnormal: <5 bpm lasting for ≧90 mins
 causes of decreased variability: fetal sleep; prematurity; hypoxia; drugs, e.g.
sedatives; congenital anomalies, e.g. CNS OR CVS

Acceleration
 a transient increase in FHR above the baseline level of ≧15 bpm & lasting for
≧15 seconds
 reactive trace: at least 2 accelerations in a 20-minutes period

Tachycardia
 baseline FHR: >160 bpm
 non-reassuring CTG: baseline FHR >160 bpm
 abnormal CTG: baseline FHR >180 bpm
 causes: active fetus; drugs; maternal or fetal infection; hypoxia
Bradycardia
 baseline FHR: <110 bpm
 non-reassuring CTG: baseline FHR <110 bpm

55
 abnormal CTG: baseline FHR <100 bpm
 causes: hypoxia; maternal heart block; drugs; maternal hypotension; cord
prolapse; fetal cardiac anomalies
 prolonged bradycardia / deceleration: an abrupt decrease in FHR to levels below
the baseline & lasts for 60-90 secs
 these decelerations become pathological if they cross 2 contractions, i.e. >3 mins

Sinusoidal pattern
 a trace with smooth rounded sine-wave-like pattern:
1. stable baseline FHR
2. flat baseline variability
3. regular oscillations; an amplitude of 5-15 bpm; amplitude above & below are
equal
4. frequency of 3-5 cycles / min
5. no acceleration

 causes: severe anaemia; severe hypoxia

 healthy fetus suggested by:
1. accelerations of FHR in response to stimulation
2. reactivity or normal baseline variability before & after the acceleration
3. saw-tooth pattern rather than smooth rounded pattern

Saltatory pattern
 excessive baseline variability of >25 bpm
 cause: an increase adrenergic stimulation in response to fetal hypoxia

Define 3 common patterns of deceleration.

Deceleration is a transient episode of slowing of FHR below the baseline level of

≧15 bpm & lasting for ≧15 seconds.

Early deceleration
 begins early in the uterine contraction (UC) cycle, has its nadir at the peak of the
contraction & return to baseline before completion of the contraction
 synchronous with contraction, symmetrical & bell shaped
 usually appear in the late 1st stage & 2nd stage of labour
 usually, but not invariably benign

56
 cause: fetal head compression lead to rise in intracranial pressure (ICP) &
stimulates the vagal nerve
 associated causes: malpresentation (OP / OT position), vaginal examination,
artificial rupture of membranes (AROM)
 in non-hypoxic fetus increased baseline variability +/- rebound acceleration

Late deceleration
 onset of deceleration is usually seen 30 seconds or more after the onset of UC;
the nadir occurs well after the peak of contraction; usually the return to baseline
occurs after the contraction is over
 usually no accelerations seen preceding or following the deceleration
 uniform & symmetrical
 speed of recovery from the deceleration may reflect the degree of fetal
compromise
 usually but not invariably pathological
 condition is more sinister when the baseline variability is reduced (<5 bpm) or
they occur after each contraction
 cause: fetal hypoxia with impaired uteroplacental circulation / poor
uteroplacental perfusion / uteroplacental insufficiency

Variable deceleration
 variable in shape, size & sometimes in timing with respect to UCs
 cause: hypoxia due to umbilical cord compression
 typical variable decelerations have a primary “shoulder”, rapid deceleration to
the nadir, rapid return to the baseline, & a secondary “shoulder”
 healthy fetus with acceleration before & after the deceleration called
“shouldering”
 may or may not indicate hypoxia
 clinical manifestation of variable deceleration (∵ cord compression)
1. compression on vein before artery → initial decrease in venous return →
tachycardia (primary shoulder)
2. when artery also compressed → chemoreceptor & baroreceptor activated →
bradycardia
3. when released of the compression → increase arterial flow → tachycardia
(secondary shoulder)
Atypical variable deceleration
Variable deceleration with any of the following additional components:
 loss of primary or secondary rise in baseline rate (No shoulder)

57
 slow return to baseline FHR after the end of UC
 prolonged secondary rise in baseline rate (prolonged secondary shoulder)
 biphasic deceleration (W shape of the deceleration)
 continuation of baseline rate at lower level

Criteria for a reactive cardiotocography. 4.2000 (B.11) (5%)

Fetal heart rate (FHR)

1. baseline FHR: 110-160 bpm
2. baseline variability: 5-25 bpm
3. acceleration: ≧2 within 20 minutes (≧15 bpm & lasts ≧15 secs), in response to
fetal movements
4. deceleration: abscent
5. to confirm non-reactivity, the trace should run for a period of at least 40 minutes

Uterine contraction (UC)

1. frequency: 3-4 / 10 minutes
2. duration: ~ 40-90 seconds
3. strength: 50-75 mmHg
4. basal tone: 8-12 mmHg

Criteria for a non-reassuring cardiotocography.

1. baseline FHR: bradycardia 100-109 bpm / tachycardia 160-180 bpm

2. baseline variability: <5 bpm lasting for ≧40 & <90 mins
3. deceleration: early / variable / single prolonged ≦3 mins
4. acceleration: absent

Criteria for an abnormal cardiotocography.

1. baseline FHR: bradycardia <100 bpm / tachycardia >180 bpm / sinusoidal

pattern (stable baseline FHR ≧10 mins)
2. baseline variability: <5 bpm lasting for ≧90 mins
3. deceleration: late / atypical variable / single prolonged >3 mins (pathological)
4. acceleration: absent

58
Causes & signs of fetal distress.

Causes of fetal distress

1. decreased maternal oxygenation
 cardiac disease
 chronic pulmonary disease
 severe anaemia
 eclamptic or epileptic convulsions

2. decreased uteroplacental blood supply

 maternal hypertension lead to poor placental perfusion
 maternal hypotension due to epidural analgesia, supine hypotension, antepartum
haemorrhage (APH)
 excessive uterine action
 decreased placental function due to abruptio placentae, postterm pregnancy

3. decreased umbilical blood flow

 intrauterine cord compression due to oligohydramnios, true knots in cord, cord
entanglement
 cord prolapse

4. fetal complication
 anaemia
 prematurity
 congenital abnormalities, e.g. lung hypoplasia
 infection

Signs of fetal distress

1. non-reassuring / abnormal FHR pattern
2. meconium stained liquor (MSL) (when fetus is in cephalic presentation)
3. result of fetal blood sampling (FBS)
 low scalp blood pH: <7.25

Normal value of fetal blood sampling (FBS) & cord blood pH.

59
Results of FBS
 normal scalp blood pH: >7.35 – 7.45
 scalp blood pH in pre-acidotic state: 7.2 – 7.25
 scalp blood pH in acidotic state: <7.2
*** disadvantages of FBS: invasive, infection, haemorrhage

Results of cord blood pH

 normal value: 7.25 – 7.35
 borderline value: 7.2 – 7.25
 metabolic acidemia: <7.2
*** umbilical artery is selected for taking cord blood pH, because its value can
reflect the fetus in acute hypoxia.

Write short notes of meconium-stained liquor detected in labour. (5%)

Meconium stained liquor (MSL) is a traditional sign associated with fetal distress.
If fetal hypoxia occurs, vagal nerve is triggered, which increases the gut peristalsis &
relaxation of anal sphincter, then passage of meconium occurs.

Presence of meconium in liquor may reflect fetal gastrointestinal maturity.

But aspiration of the meconium into the fetal or neonatal lung is associated with
clinical disease ranging from mild transitory respiratory distress to severe respiratory
compromise (meconium aspiration syndrome ― MAS). Prevention of MAS is vital to
improve perinatal mortality & morbidity.

Amnioinfusion is a common procedure done during labour to decrease the risk of

MAS in babies born to the mother with moderate to thick MSL during labour.
Amnioinfusion is done to dilute meconium in the amniotic fluid by normal saline
(NS) to decrease the risk of MAS.

1L NS solution at room temperature is instilled into the uterine cavity via an

intrauterine pressure catheter over a period of about 30 minutes. The procedure is
needed to repeat if undelivered within 4 hours & delivery is not imminent.

State the emotional response of HIV / AIDS.

60
HIV = Human Immunodeficiency Virus
AIDS = Acquired Immunodeficiency Syndrome
= HIV infection + AIDS defining illness

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

Risks of vaginal breech delivery. (5%)

Maternal risks
1. prolonged labour
2. impacted breech → obstructed labour
3. maternal trauma due to higher risk of cervical / vaginal lacerations → genital
tract trauma
4. higher risk of operative delivery, e.g. forceps delivery of the after-coming head
or caesarean section
5. higher risk of infection / sepsis

Fetal risks
1. Hypoxia due to
 Cord compression / cord prolapse
 Delayed head delivery
 Early separation of placenta
 Fetal head entrapment

2. Asphyxia / neonatal pneumonia

3. Intracranial haemorrhage due to rapid decompression of the after-coming head

4. Birth injuries
 Rupture of internal organs due to manipulations, e.g. liver, spleen
 Fracture of humerus / clavicle / femur; transaction of spinal cord
 Nerve injuries, e.g. Erb’s palsy, Klumpke palsy
 Sternomastoid tumour
 Soft tissue damage

61
 Bruising & oedema of the external genitalia
 Oedematous & discoloured of the foot (footling breech)

Write short notes on combined oral contraceptive pills. (5%)

Combined oral contraceptive (COC) pills = estrogen + progesterone

COC pills are prohibited for the women of HT / DM or GDM / DVT / during BF.

Action
1. inhibits ovulation
2. changes in the endometrium preventing implantation
3. altering cervical mucus thick and impenetrable to sperms

Advantages
1. reliable, reversible, convenient, non-intercourse related method
2. relief of premenstrual tension, dysmenorrhoea, reduce menstrual flow
3. regulate menstrual cycle, ↓ blood loss → decrease the incidence of iron
deficiency anaemia
4. decrease occurrence of ovarian cysts & benign breast changes

Side-effects
1. nausea & vomiting
2. fluid retention → minor weight gain, carpel-tunnel syndrome
3. chloasma
4. breast tenderness
5. headache
6. depression & mood changes
7. changes in libido (sexual desire)
8. suppression of lactation

Potential hazards
1. thromboembolism
2. coronary artery or cerebral vascular disease
3. hypertension
4. impaired liver function
5. metabolic effects on glucose tolerance
6. small increase risk for breast & cervical cancer

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Absolute contraindications
1. thrombophlebitis or thromboembolism disorders
2. cerebral vascular or coronary artery disease
3. impaired liver function, liver disease, jaundice
4. malignancy of breast or genitals
5. known or suspected pregnancy
6. undiagnosed abnormal genital bleeding

Relative contraindications
1. chronic systemic disease ― hypertension, diabetes mellitus
2. obesity
3. age > 45 or smokers > 35
4. depression
5. varicose veins

Stop the pills if

1. cramp, pain or swelling in legs
2. sudden severe migraine, or usual headache
3. sudden onset of severe chest pain
4. visual disturbabce
5. 6 weeks before major surgery → ↓ risk of deep vein thrombosis (DVT) post-
operatively

Monthly injectables, e.g. Nonestrol

Mechanism: same as COC, mainly suppression of ovulation

Advantages:
1. effective
2. eliminates first pass effect of the hormone on the liver
3. little effects on lipids, weight, BP & liver function
4. quick return of fertility

Side effects:
1. menstrual problem is common
2. nausea & vomiting
3. fluid retention → minor weight gain, carpel-tunnel syndrome
4. chloasma

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5. breast tenderness
6. headache
7. depression & mood changes
8. changes in libido (sexual desire)
9. suppression of lactation

Follow-up of clients
Women on oral contraceptives or injectables should have an annual follow-up for
1. complete physical examination
2. vaginal examination & Pap smear
3. urine testing for sugar

Write short notes on progesterone only contraceptive pills. (5%)

Action of progesterone only pill (POP)

1. Changes in the endometrium preventing implantation
2. Altering cervical mucus thick and impenetrable to sperms
3. 40% women still ovulates normally
4. duration of action: 2 hours

Indications
1. Women who wish to use oral contraceptive pills, but
 Are not prepared to run the undesirable effects associated with estrogen
 Are unable to tolerate oestrogen
 For whom oestrogen are contraindicated for any reason

2. age > 40 or smokers > 35

3. lactating women
4. women with DM or obesity
5. women with mild HT or where the BP is well-controlled

Advantages
1. acceptable efficacy
2. controlled by women
3. reversible fertility
4. relief of premenstrual tension & dysmenorrhoea
5. side effects are much less than those observed with combined pills

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Disadvantages
1. higher failure rate
2. heavier irregular bleeding
3. acne due to androgenic activity of Levonorgestrel (LNG)

Contraindications
1. thrombophlebitis or thromboembolism disorders
2. cerebral vascular or coronary artery disease
3. impaired liver function, liver disease, jaundice
4. malignancy of breast or genitals
5. known or suspected pregnancy
6. undiagnosed abnormal genital bleeding
7. irregular menstruation
8. current breast cancer
9. < 6 weeks postpartum & breastfeeding
10. not recommended for teenagers

Progesterone only injectables

Slow release progesterone, e.g. Depo-provera

Action:
1. inhibition of ovulation
2. changes in the endometrium preventing implantation
3. altering cervical mucus thick and impenetrable to sperms
4. duration of action: 3 months +/- 2 weeks

Indications:
1. in conjunction with Rubella immunization
2. particularly suitable for
 unreliable pill-takers
 whom oestrogen are contraindicated, e.g. older or lactating women

Advantages:
1. high effectiveness
2. simple & convenient
3. long lasting as only one injection is needed every 3 months
4. no estrogenic side-effects

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5. relief of premenstrual & menstrual symptoms
6. lactation is not suppressed

Disadvantages:
1. drug’s action is irreversible as once given
2. menstrual disturbance ― irregular & heavy bleeding; or oligo-menorrhoea
3. delayed return of fertility
4. prolonged use may result in significant loss of bone density
5. minor side effects
 headache
 mood changes
 breast tenderness
 fluid retention

Contraindications:
1. thrombophlebitis or thromboembolism disorders
2. cerebral vascular or coronary artery disease
3. impaired liver function, liver disease, jaundice
4. malignancy of breast or genitals
5. known or suspected pregnancy
6. undiagnosed abnormal genital bleeding
7. irregular menstruation
8. current breast cancer
9. < 6 weeks postpartum & breastfeeding
10. not recommended for teenagers

Follow-up of clients
Women on oral contraceptives or injectables should have an annual follow-up for
4. complete physical examination
5. vaginal examination & Pap smear
6. urine testing for sugar

Write short notes on condom & femshield (femidom). (5%)

Condoms are made of fine latex rubber, available in various colours & textures,
lubricated and spermicide incorporated.

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Femshield (femidom) is a female condom. It is a soft, pliable polyurethane sheath
which lines the vagina. It has an inner ring which is used for insertion and which
holds the sheath in place beyond the pubic bone and an outer ring which lies flat
against the labia.
It is pre-lubricated and likely to offer a high degree of protection against pregnancy
and all the sexually transmitted diseases (STD).

Action
They prevent spermatozoa from reaching the female upper genital tract.

Advantages of condom
1. simple & easy method to use
2. inexpensive & easily obtained
3. free from medical risks
4. protection against most STD
5. improvement of performance in some patients with premature ejaculation

Disadvantages of condom
1. sexual activity is interrupted
2. some couples complain discomfort or local irritation
3. loss of pleasurable sensation
4. allergy to latex type of condom (rare)

Advantages of femidom
1. free from medical risks
2. protection against most STD
3. women would feel more in control

Disadvantages of femidom
1. expensive
2. slippery to hold & difficult to insert
3. looks awkward as there is something hanging out of the vagina
4. some couples complain discomfort or local irritation
5. loss of pleasurable sensation

Typical appearance of a neonate born to a diabetic mother.

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1. heavy & plump for gestation
2. excessive fat; rounded face; shoulders may be disproportionally broad
3. skin red, abundant hair
4. large placenta & cord
5. if maternal DM is well controlled, the birth weight is relatively normal

Complications of a baby born to a diabetic mother.

1. hypoglycaemia
2. hypocalcaemia
3. polycythaemia (↑RBC)
4. neonatal jaundice
5. respiratory distress syndrome ???

Care of a baby born to a diabetic mother.

1. Paediatrician need to standby at birth

2. Prevention of neonatal hypoglycaemia
 Check haemoglucostix
 Early feeding
 Maintain blood glucose > 2.2 mmol/L
3. Careful examination to exclude congenital abnormalities
4. Watch out for complications, e.g. neonatal jaundice (NNJ)

Screening of GDM: spot sugar, HbA1c (reflect glucose tolerance in these few
months)
Diagnosis of GDM: oral glucose tolerance test (OGTT) (done at 26-28 weeks)
 For 75g glucose load (WHO): fasting >8 mmol/L; 2 hours pp >11 mmol/L

Insulin therapy is needed if she failed to maintain fasting blood sugar ≦5.8
mmol/L or 2 hours pp ≦7.2 mmol/L

Risks factors for gestational diabetes mellitus (GDM).

1. Family history of DM

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2. Obesity
3. Advanced maternal age
4. Multiple pregnancy, e.g. twins
5. Past obstetric history
 GDM
 Big baby / macrosomia
 Recurrent abortion
 Unexplained stillbirth or perinatal death

Effects of GDM on mother.

1. higher infection rate, e.g. UTI, vaginal infection

2. increased incidence of pregnancy complications, e.g.
 pregnancy induced hypertension (PIH)
 polyhydramnios
 preterm labour
3. increased incidence of ketoacidosis during pregnancy & labour
4. higher risk of operative delivery, e.g. VE / forceps / C/S, due to big baby or
macrosomia
5. complications of DM, e.g. retinopathy & nephropathy
*** Time & mode of delivery
 poor controlled GDM / DM, suspected small for gestational age (SGA) or other
complications: IOL at 38 weeks
 EFW > 4kg: caesarean section ?? at 38 weeks
 GDM on diet with good control: IOL at 41 weeks

Effects of GDM on fetus.

1. spontaneous abortion, unexplained stillbirth, ↑perinatal mortality

2. congenital malformations
3. prematurity
4. macrosomia → birth trauma
5. intrauterine growth retardation (IUGR) ∵poor placental perfusion of DM case
Name 2 presenting diameters for a cephalic presentation with the fetal head
deflexed.

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The fetus is in occipito-posterior (OP) position.
1. Occipito-frontal diameter (OF) 11.5cm
2. Biparietal diameter 9.5 cm (fixed)

Name 2 presenting diameters for a face presentation with the fetal head fully-
extended.

1. Submento-bregmatic diameter (SMB) 9.5cm

2. Bitemporal diameter 8.2cm (fixed)

Name 2 presenting diameters for a brow presentation with the fetal head
partially-extended.

1. Mento-vertical diameter (MV) 13.5cm

2. Bitemporal diameter 8.2cm (fixed)

Name the pelvic bones and joints.

The pelvis consists of 4 bones.

2 Innominate bones:
 Ilium
 Ischium
 Pubic bone
1 Sacrum
1 Coccyx

The 4 pelvic joints are

 2 Sacro-iliac joints
 Symphysis pubis
 Sacro-coccygeal joint

Name the bones and sutures of the fetal skull.

Bones of the fetal skull

 2 Frontal bones

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 2 Parietal bones
 1 Occipital bone

Sutures of the fetal skull

 Frontal suture
 Coronal suture
 Sagittal suture
 Lambdoidal suture

Define contracted pelvis.

A pelvis is contracted when one or more diameters are less than the lower limit of
normal, which would interfere with the birth of an average sizes baby.

Lower limit of pelvic diameters:

Transverse diameter of inlet = 11.5cm
Antero-posterior (AP) diameter of inlet = 10cm (Obstetric Conjugate (OC))
Antero-posterior (AP) diameter of outlet = 10cm
Interspinous diameter of outlet = 10cm

Define the different types of perineal trauma.

1st degree tear

 Involves the fourchette only
 Need repair only if active bleeding

2nd degree tear

 Involves the fourchette and superficial perineal muscles (Bulbocavernosus,
transverse perineal muscle) and in some cases the Pubococcygeus
 Equivalent to an episiotomy wound & needs to be repaired

3rd degree tear

 Involves external anal sphincter & the posterior vaginal wall

4th degree tear

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 Tear extends to the anterior wall of rectum & involves the rectal mucosa

State the changes of fetal circulation at birth.

Closure of: Changes in newborn’s circulation:

1. Ductus Venosus → Ligamentum Venosum
2. Foramen Ovale → Fossa Ovale
3. Ductus Arteriosus → Ligamentum Arteriosum
4. Hypogastric Arteries (developed from umbilical arteries & closure at birth)

Four specific feeding techniques you should recommend to a breastfeeding

woman with sore nipples. 10.2002 (B.5) (5%)
Advice given to a lactating mother for prevention of sore nipples. (5%)

Poor positioning or latch-on is the most common cause of sore nipples. The best
prevention of sore nipples is to latch baby properly from the very beginning.

Prevention:
1. We should correct positioning (with most of the areola in the baby’s mouth) &
latch-on problems.
2. The mother should break oral suction before removing from the breast.
3. The mother should apply breast milk on the nipple & areola after each feed and
allow to dry.
4. The mother should avoid using soap on nipples.

Management (specific feeding techniques):

1. We should correct positioning (with most of the areola in the baby’s mouth)
& latch-on problems.
2. We should reassure & encourage her to continue breastfeeding to prevent breast
engorgement.
3. The woman should start with the side of least sore first and can try alternate
feeding positions. She should feed on the sore nipple after let-down reflex
occurs.
4. We should teach her to apply breast milk on the nipple & areola (rub
hindmilk on areola) after each feed to promote healing.
5. We should teach her to expose nipples to air as much as possible.

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6. The mother should take analgesic, e.g. panadol, before breastfeeding if
necessary.
7. We should teach her to express breast milk regularly, manually or by
pumping, while breastfeeding is suspended for severe soreness to prevent
breast engorgement.
8. We should look for other causes such as fungal infection for prolonged soreness.

Management of breast engorgement in a lactating mother. (5%)

It is common when the milk first comes in on the 2 nd to 5th day after birth when the
milk has not been removed efficiently. The best prevention is to encourage
unrestricted frequent feeds from day of birth.

Prevention:
1. Early, frequent & unrestricted breastfeeding is the most effective way of
prevention.
2. We should check positioning (with most of the areola in the baby’s mouth) to
make sure the baby is attached well at the breast.
3. We should avoid supplement.
4. For the sleepy baby, mother should encourage to wake him up frequently for
feeding.

Management:
1. We should check positioning (with most of the areola in the baby’s mouth) to
make sure the baby is attached well at the breast.
2. The number of breastfeeds should not be restricted. She should feed frequently
and whenever the baby wants.
3. The mother should apply warmth before feeding to induce let-down reflex.
4. The mother should gently express milk from the breast to soften the areola and
help the baby to attach.
5. The mother should massage breasts gently during feeding.
6. The mother should apply cold compress after a feed to lessen the pain.
7. We should teach her to wear supportive wireless bra to lessen discomfort. The
mother who is not breastfeeding should wear a well-fitting brassiere or use the
breast binder to lessen discomfort.
8. The mother should take analgesic, e.g. panadol, if necessary.

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Management of a lactating mother with inadequate milk supply. 4.2002 (B.4)
(5%)

Reliable signs when the baby may not be getting enough breast milk:
1. Birth weight not regain after 2 weeks.
2. Poor weight gain of < 500g a month
3. Passing small amount of concentrated urine < 6 times a day.
4. The urine is yellow and strong smelling.

Other possible signs that baby may not be getting enough milk:
1. Baby not satisfied after breastfeeds.
2. Baby cries often.
3. Very frequent breastfeeds.
4. Long feeds.
5. Baby refuses to breastfeed.
6. Baby has hard, dry green stool.
7. Breasts do not enlarge during pregnancy.
8. Breasts do not feel full when milk is expected to come in.

Management:
1. Assess the frequency & length of breastfeeding.
2. Evaluate for any ineffective sucklings, latching-on technique & position.
3. Count the number of wet diapers, and bowel movements per day.
4. Assess baby’s weight gain & growth.
5. Explain that the most important thing is to let her baby suckle more
 Offer her breast at least every 2 hours for an unrestricted length of time.
 Breastfeed on demand.
 Let baby suckle longer than before at each breast.
 Keep baby with her and breastfeed at night.
6. Explain that she should keep her baby near & give plenty of skin-to-skin contact.
7. If for any reason the mother is unable to actively nurse the baby, she should use a
breast pump or manual expression to provide stimulation & milk removal.
8. Reassure & support the mother by giving dietary advice (encourage proper
nutrition & sufficient fluid intake), allowing good rest, providing relevant
information, showing empathy by using simple language, discussing with her
family for support.
9. Dietary advice
 Depending upon the culture heritage, economic situation and food preference, a

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 mother has her choices.
 She should take a well balanced diet as she uses 25% energy output for
breastfeeding. She needs extra 500 calories/day in her meal.
 The lactating mother should eat according to her hunger and drink when she
feels thirsty.
 Introduce locally valued lactogogue if necessary.
 In families with history of allergy, mothers should note that some foods in their
diets affect their babies.
 A vegetarian mother can take supplementary vitamins for her diet.
 Seek special dietary advice for breastfeeding mothers with severe dietary
restriction for religious reasons or medical condition, etc.
10. Encourage breastfeeding by praising her effort in trying and continuing to
breastfeed.
11. Give supplementary feeds if medically indicated.
12. Record the amount of supplement being offered and how it is given.
13. If the baby refuses to suckle on an “empty” breast, help her to find a way to give
the baby milk while he is suckling, e.g. with a dropper or a breastfeeding
supplementer.

Non-pharmacological methods of lactation suppression. 4.1999 (B.14) (5%)

1. Firm support of the breasts, e.g. wear a well-fitting brassiere

2. Avoid nipple stimulation / manual expression of the breasts
3. If breasts become engorged express breast milk to comfort, but do not empty the
breasts completely.
4. Advice mothers to avoid milk galactogogues (milk production food), but not
necessary to restrict fluid intake.
5. Use mild analgesic, e.g. panadol, & apply cold compress on the breast to relieve
discomfort.

*** Weaning breastfeeding should be done gradual to minimize discomfort for

the mother & the baby. Abrupt weaning may lead to breast engorgement & pain.
Gradual weaning: leaving out 1 daily feeding each week & substituted with a bottle.
Abrupt weaning: leaving out 1 daily feeding each day & substituted with a bottle.

Advantages / benefits of breastfeeding. (5%)

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To the mother
1. convenient, less work
2. economical, costs less than formula feeding
3. emotional satisfaction
4. promotes uterine involution, reduce bleeding & may help to prevent anaemia
5. decreasing weight faster, ∵ use up the stored fat
6. delay return of ovulation → delay menstruation → delay a new pregnancy
7. reduce the risk of ovarian cancer & possibly breast cancer
8. better health → less likely to have osteoporosis after menopause

Psychological benefits
1. helps mother & baby to form a close & loving relationship
2. baby cries less & may grow faster
3. mother responds to the baby in a more affectionate way → less likely abuse the
baby
4. help a child develop intellectually → better cognitive development

To the society
1. environmental friendly, less rubbish (bottles, teats, tins, etc.) → less pollution
2. ↓ infant morbidity & mortality ― contributes to the heath & well-being of the
society / nation

To the baby
1. Breast milk contains antibacterial, antiviral, anti-infective & anti-parasitic
factors; hormones; enzymes; specialized growth factors; immunological
properties; enough vitamins.
2. Fat in breast milk is more completely digested & efficiently used / absorbed.
3. Breast milk protects baby against infection since it contains
 all class of immunoglobulins (Ig), e.g. IgA, IgG, IgM, which provide local
intestinal protection against viruses of influenza & bacteria, e.g. E.Coli.
 interferon which can increase macrophage function and antiviral activity.
 lactoferrin which has bacteriostatic effect & can inhibit growth of E.Coli.
 macrophages, lymphocytes, leukocytes which can ingest pathogens
4. Breast milk protects baby against development of food allergy, since it contains
epidermal growth factor (EGF), which is a local protection on the mucous
membranes of gastrointestinal (GI) tract by
 Increasing the size of villi

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 Helping to seal the mucosa so that large molecules cannot penetrate the gut wall.
5. Breast milk is fresh, of correct T℃ & ↓ risk of contamination.
6. Baby who is breastfed, is less likely to develop nappy rash & less likely to be
overweight especially in later life.
7. Benefits of the mechanical action of breastfeeding are optimally exercises the
muscles of the soft palate & helps keep the Eustachian tube open.

Advantages & disadvantages of Pethidine injection during labour.

Advantages
1. simple
2. easy to administer
3. low cost

Disadvantages
To mother:
1. nausea & vomiting
2. suppress respiration
3. drowsiness & disorientation

To fetus & neonate:

1. loss of variability in fetal heart rate (FHR) → flat pattern of FHR
2. respiratory depression of baby → Naloxene (Narcan) 0.1mg/kg of BW can be
given as an antidote for baby
3. decrease in suckling & other neurobehavioral response of baby

Advantages & disadvantages of Entonox inhalation during labour.

Advantages
1. easy to use
2. inexpensive
3. relative harmless to mothers & babies

Disadvantages
1. limited pain relief
2. cause drowsy & confusion, hyperventilation to mother

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3. air pollution

Advantages, disadvantages, complications & contraindications of Epidural

Analgesia (EA).

Advantages
1. effective: total pain relief
2. safe: ↑placental perfusion, no adverse effect on fetus
3. no repeated injections is needed
4. provides EA for emergency caesarean section (Em C/S), especially when general
analgesia (GA) is not advised
5. beneficial for at risk groups
 long & exhausting labour
 breech presentation
 multiple pregnancy
 hypertension (HT)

Disadvantages
1. hypotension ∴pre-loading is given
2. requires expertise / equipment / staffing
3. restrict mobility
4. urinary retention → ↑risk of bladder catheterization
5. catheter misplace / fall out → failure of pain relief
6. absence of Ferguson’s reflex → ↓urge to push → ↑risk of instrumental
delivery, e.g. forceps delivery or vacuum extraction
7. neurological deficit in postpartum
 headache
 urinary retention
 inability to move legs (delay ambulation)

Complications
1. hypotension ∴pre-loading is given
2. bloody tap (intravascular) (puncture of epidural vessel)
→ local anaesthetic toxicity
→ convulsion, cardiac & respiratory arrest

3. dural tap (puncture of dural mater) → leakage of cerebral spinal fluid (CSF)

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4. total spinal block (when the catheter enters the subarachnoid space)
→ cardio-respiratory arrest

Contraindications
1. extreme obesity
2. previous back problems, spinal deformities
3. local or system infection
4. coagulopathy / receiving coagulation therapy
5. certain cardiac disease, e.g. aortic valve disease
6. neurological disease, e.g. multiple sclerosis
7. allergy to anaesthetics

Uses & complications of Spinal Analgesia (SA).

Uses: in operative procedures

1. manual removal of placenta (MROP)
2. caesarean section (C/S)
3. suturing for extensive lower reproductive tract tear

Complications
1. hypotension
2. total spinal block
 respiratory paralysis → cardiac stress
3. pruritis
4. bladder dysfunction

Predisposing factors of Amniotic Fluid Embolism (AFE).

Amniotic fluid contains fetal particulate matter & rich in thromboplastin

triggers clotting system. It forced into the woman’s venous circulation through a
tear in the placental membranes and carried to the woman’s lungs. Fetal
particulate matter in the fluid obstructs pulmonary vessels.

Predisposing factors of AFE

1. multiparity

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2. short labour
3. oxytocin
4. very strong or uterine titanic contractions
5. cervical laceration
6. intrauterine fetal death
7. placenta praevia
8. placenta accrete
9. abruptio placentae
10. polyhydramnios
11. multiple pregnancy
12. macrosomia
13. uterine rupture
14. prolonged labour
15. postterm labour

What is disseminated intravascular coagulation (DIC)? What is its

complications?

An inappropriate overstimulation of normal coagulation in which thrombosis

and haemorrhage occur simultaneously.
Hypercoagulation occurs initially; multiple small clots are formed in the
microcirculation of various organs. This process is followed by fibrinolysis.

Complications of DIC
1. kidney: oliguria / anuria
2. liver: jaundice
3. lung: dyspnoea, cyanosis
4. brain: convulsion, coma
5. retina: blindness
6. pituitary gland: Sheehan’s syndrome (necrosis of anterior pituitary gland)

What are the sources of tissue thromboplastin?

1. tissue ischaemia, e.g. abruption placentae, fetal death, pre-eclampsia (PET)

2. amniotic fluid
3. massive haemolysis, e.g. incompatible transfusion

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4. septicaemia ∵ infection

Coagulation changes in pregnancy & labour.

 Hypercoagulable state during pregnancy, with ↑all procoagulant factors

except clotting factor XI (6) (plasma thromboplastin antecedent) & clotting
factor XIII (8) (fibrin-stabilizing factor).
 Placenta is rich in tissue factor (thromboplastin), which is released when
placental separation occurs.

Fibrinolysis changes in pregnancy & labour.

 ↑ plasminogen levels
 fibrinolytic activity: ↓ during pregnancy ∵↑ inhibitory activity
returns to normal within 1/2 hour of delivery

Diagnosis of DIC.

1. prolonged aPTT, PT, PTT (clotting profile)

2. fibrinogen <1g/L
3. ↑fibrin degradation products (FDP)
4. D-dimer: +ve
5. low platelet count
6. hepatic failure
7. HELLP syndrome (↑BP in HELLP syndrome)
8. thrombocytopenic purpura

Obstetric causes of DIC.

1. abruptio placentae
 liberation of tissue thromboplastins resulting in an associated diffuse
intravascular coagulation → using up fibrinogen
 hypofibrinogenaemia & ↑FDP → inhibit myometrial contractility →

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 haemorrhage

2. intrauterine death (IUD)

 thromboplastins are released from the dead fetal tissue if it has retained in
uterus for more than 3 or 4 weeks → enter the maternal circulation →
depleted the coagulation factors
 not observed in modern obstetric practice ∵labour is induced promptly
following diagnosis of IUD before S/S

3. sepsis, e.g. septic abortion, intrauterine infection, postpartum endometritis

 endotoxin entering the circulation & damaging the blood vessels → release
of thromboplastins
 infections that cause haemolysis of RBCs release thromboplastin, e.g. E coli

4. AFE
 Amniotic fluid is rich in thromboplastins enters into maternal circulation
 Clotting factor is depleted → hypofibrinogenaemia

5. severe PET
 vasospasm & hypoxia → vessel walls damage → release of thromboplastins
→ contact with the surface of the platelets & coagulation-fibrinolysis
process occurs → consumes massive amounts of coagulation-fibrinolysis
factors

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