Obstetrics

• Cervical position (posterior, intermediate, anterior)
• Consistency (firm, intermediate, soft)
• Effacement (<30%, <50%, <80%, >80%)
• Dilation (<1cm, 1 - 2cm, 3 - 4cm, >5cm)
• Station (-3, -2, -1 or 0, 1 or 2)

• Modified score:
• + 1 for pre-eclampsia or each previous vaginal delivery
• - 1 for post-dates, nulliparous, PPROM

• < 5 = induction likely
• < 6 require cervical ripening
• >8 = likely to acheive vaginal birth
• > 9 likely to labour spontaneously
• maximum 13

• 1. onset of regular painful contractions
•      latent phase <4cm
•      established phase >4cm dilated

2. full dilation to delivery of the baby

3. delivery of the baby to delivery of the placenta

37 completed weeks - 42 completed weeks

• < 37 weeks counts as premature
• > 42 weeks may require induction

From 0 - 4cm dilation of the cervix

May last 2 - 3d in primiparous women or 8h in multiparous

• -3 = 3cm above spines
• -2
• -1
• 0 = ischial spines = halfway point
• 1 = 1cm below
• 2
• 3 = scalp/PP at perineum

Dilation to delivery

• 1 hour passive descent
• 2 hours or 1 hour of pushing (nulliparous or multiparous)

• Dr - define risk
• C - contractions
• BR - baseline rate
• A - accelerations >15bpm for >15s
• VA - variation >5
• D - deccelerations
• O - overview

• Inflammatory response:
• - increased PG and oxytocin receptors on uterus
• - decreased progesterone

• strong regular contractions (> 2:10)
• rupture of membranes (confirmed by staff)
• operculum "show" (mucus plug that drops out as cervix dilates and mucus thins)

if no contractions, wait up to 48h then induce labour

vaginal discharge post-partum (may last 4 - 6 weeks) = blood, mucus and placental tissue

• 3 stages:
• 1. rubra/cruenta = red, 3 - 5 days
• 2. serosa = thin, brown/pink, exudate + RBC, WBC, mucus. Persisting for weeks suggests late PPH
• 3. alba/purulenta = white or yellow, 2 - 6 weeks, fewer RBC, mainly WBC, epithelium, cholesterol, fat, mucus. More than 6 weeks may suggest genital lesion.

• Offensive odour = infection
• Lochiostasis/lochioschesis = lochia retained in uterus
• Lochiometra = distension of uterus
• Lochiorrhea = excessive flow, may be infection

= artificial rupture of membranes

20 week detailed scan of fetal anomaly

Each organ, limb deformities, liquor volume, position of placenta

Abdo circumference checking size of liver - 1st sign of starvation/IUGR is decreased AC:HC

bleeding after 24 weeks

Appearance (blue or pale all over / acrocyanosis, blue extremities and pink middle / pink all over)

Pulse rate (absent / less than 100 / 100 or more)

Grimace (no response to stimulation / grimace or feeble cry / cry and pull away)

Activity (no muscle tone / some flexion / flexed limbs resist extension)

Respiration (absent / weak, irregular gasps / strong lusty cry)

placental sample taken before 16 weeks for chromosomal analysis

• serum screening triple test (14 - 18 weeks) = alpha-fetoprotein, HCG, unconjugated oestrogen
• +
• nuchal translucency (11  -13 weeks)

for Down's syndrome

• Ultrasound to date the pregnancy around 12 weeks
• Also look for location of embryo, number, viability (double check with HCG > 1000)

Foetal heart is visible on scan from 5/40

fitting due to raised blood pressure, proteinuria and elevated liver enzymes

when breech is turned to cephalic

from 12 weeks

• 1 = 0 - 12 weeks
• 2 = 13 - 28 weeks
• 3 = 29 weeks +

• Haemolysis
• Elevated Liver Enzymes
• Low Platelets

may develop from pre-eclampsia?

blood test to find amount of fetal blood cells in the maternal blood

manual removal of retained placenta - under anaesthetic in theatre

morbid attachment of the placenta to the uterus, particularly where there is uterine scar tissue

pelvic pain during pregnancy

Ideally 8 - 12 weeks

0 - 28 days

Health visitor takes over care after 28 days until school age.

• 12 weeks - dating, location, number, viability
• 2nd scan screening?
• 20 - anomaly
• 4th scan of foetal well-being iff problems in previous scans

1st degree = vaginal mucosa only

2nd degree = subcutaneous

3rd degree = into external anal sphincter

4th degree = through EAS into rectal mucosa

• Mediolateral = 45 degrees to posterior forchette on one side
• - less trauma, less blood loss, less infection, worse pain

• Midline = vertical from posterior forchette towards rectum
• - hastens delivery, severe trauma involving EAS

a surgical incision made in the perineum to facilitate delivery

> 30% vaginal deliveries

preparation for operative delivery, shoulder dystocia

no benefit to the mother

• Maternal:
• - exhaustion
• - inadequate expulsion (spinal cord injury, neuromuscular disorder)
• - avoiding expulsive effort (cardiac disease, cerebrovascular disease)

• Foetal:
• - foetal distess/non-reassuring CTG

• Other:
• - prolonged second stage
•      > 3 hours in nulliparous with analgaesia
•      > 2 hours in nulliparous women without
•      > 2 hours in parous with analgesia
•      > 1 hour in parous without

• Maternal:
• - analgesia
• - consent
• - lithotomy position
• - empty bladder
• - adequate pelvimetry

• Foetal:
• - engaged vertex presentation
• - station > +2
• - known foetal position and attitude, caput and moulding

• Uteroplacental:
• - fully dilated
• - ruptured membranes
• - r/o placenta previa

• Other:
• - experienced operator
• - capability for EmCS if needed

• Relative:
• prematurity
• fetal macrosomia
• suspected fetal coagulation disorder

• Maternal:
• - perineal injury - especially rotational forceps, not really increased in ventouse

• Foetal:
• - forceps
•       - facial bruising or laceration
•       - facial nerve palsy
•       - skull fractures
•       - cervical spine injury
•       - intracranial hamorrhage
• - ventouse:
•      - caphalohaematoma (scalp bleeding)
•      - scalp lacerations
•      - possibly intracerebral haemorrhage?

occipitomental or mentovertical

extended head

13cm diameter

• AF is anterior/central
• PF is very anterior

submentobregmatic

• hyperextended head
• 9.5cm

AF very anterior or no fontanelles

• occipitofrontal
• deflexed or partially extended head

11.5cm

• central AF
• very anterior PF

• suboccipitobregmatic
• well-flexed head

9.5cm

• central or anterior PF
• very posterior AF

• suboccipitofrontal
• may associated with OP

10 - 10.5cm

• PF anterior
• AF posterior

1. Engagement - the widest diameter passes the pelvic inlet (biparietal 9.5cm in vertex presentation) - usually by 36/40

2. Descent

3. Flexion

4. Internal rotation - presenting part moves from transverse to AP, asynclitic then even

5. Extension (of head over symphysis pubis)

6. Restitution (extenal rotation of the head to match the torso)

7. Expulsion - anterior shoulder over symphysis, then posterior shoulder, then body

• Volume > 2ml
• pH > 7.2
• concentration >20million per ml
• total > 40 million per ejaculate
• motility >50% a or b
• morphology > 30% normal forms

2 out of 3 of:

1. oligo or anovulation

2. clinical or biochemical increased androgens

3. USS polycystic ovaries: 12+ follicles of 2 - 9mm each OR >10cm cubed overall volume

• AND
• r/o Congenital Adrenal Hyperplasia, androgen-secreting tumour, Cushing's

• Presentation: menorrhagia, subfertility
•     if large: peripheral oedema (obstructed venous return), urinary incontinence (compression)

Risk Factors: Afro-Carribean, overweight, forties, fertile

• PV bleeding
• abdominal pain
• missed periods/positive pregnancy test
• painful dysuria and painful BO
• shoulder tip pain (blood under diaphragm)

• - menorrhagia
• - dysmennorhoea
• - dyspareunia
• - chronic pelvic pain (adhesions)
• - nulliparity (infertility or abstinence due to pain)
• - cyclical haematuria
• - haemoptysis
• - painful, cyclical expanding masses in a pelvic scar

benign change in endometrium associated with presence of chorionic tissue.

Cells appear malignant but aren't. Characterised by nuclear enlargement, +/- irregular nuclear membrane, granular chromatin, centronuclear vacuolisation, pseudonuclear inclusions

• vessels coming from cord travel away from the placenta in the membranes and overlie internal os
• risk of tear during dilation
• 1 in 3000
• clinical diagnosis
• high foetal mortality (it is foetal blood being lost)
• low maternal risk

abnormal CTG + <500ml painless PV bleeding

• immediate CS
• foetal transfusion

• HIV (NB. not HBV/HCV alone)
• primary genital HSV in 3rd trimester
• placenta previa major
• twins with first twin breech
• singleton breech at term where ECV failed or contraindicated