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31-OBSTETRICS

changes in mother during preg Hartman sign(implantation blding)-d6 uteroplacental circulat complete-d12(w2) hPL appear in maternal sr-w3 Palmer sign(reg&rhythmic uterine contraction)-w4-8 Goodell sign(softening cx)-w6 Ladin sign(softening mid uterus ant at jn of uterus&cx)-w6 Hegar sign(softening isthmus)-w6-10 Piskacek sign-unequal growt of uterus Jacquemier/Chadwick sign(dusky hue vestib& ant vag wall)-w8

↑ Osiander sign( pulsat felt at lat fornix)-w8 placenta replaces ovary-w8(8-10) max hCG(100-200IU/l)-w8-10 Braxton Hicks contractions-w12 colostrum secretion start-w12 min hCG(10-20IU/l)-w16 uterine souffle-w16 active fetal movement(quickening)-w16 linea nigra-w20 palpation of fetal part-w20 external ballotment-w20 FHS by stethoscope-w20 notch in uterine a doppler disapp-w22 sr Fe min-w28-32 max CO-w32 peak hPL-w34-36

wt gain=10-14kg(12kg,24lbs) vag pH=3.5-6 cx secretion become copius

↓ O2 carrying capacity↑ ts O2 demand by 40%

→ ↓ a v O2 gradient↑ → bld vol fr 4000 5500ml(+30-40%)

↑ pl vol by 40-50%↑ RBC mass by 20%↑ neutrophil (max=20000cell/mm³ immed PP)↑ total prot

↓ pl prot conc↓ → colloid oncotic press fr 20 18mmHg(–14%)

↑ globulin↓ → A/G ratio fr 1.7:1 1:1↑ → fibrinogen fr 200-400mg/dl 300-600 mg/dl(+50%)

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↓ bld clotting factor except XI,XIII↓ PLT by 15%

↓ bld viscosity ECG-LAD, heart moves up,rotates out

↑ CXR-straight lt heart bord, card silhouette heart size-no change apex beat-4th ICS ventric&atrial extrasystole

↑ → CO fr 4.6 6.26l/min(+40%)(max-immed PP> 2nd stage labour> w28-32)↑ → stroke vol fr 65 75ml(+27%)↑ → heart rate fr 70 88/min(+20%)

S1,S2-loud, physiological S3 heard ejection systolic/flow murmer grade2 salt,H2O retention(E) extra H2O retain=6.5l

↓ pl osmolality by 10mosmol/kg↓ sr Na

↓ systemic vasc resistance by 21%↓ SBP,DBP (E,P)

CVP,MAP,PCWP-no change uterine bld supply=750ml/min uteroplacental supply=90%=450-650ml/min ovarian pedicle dilates by 3time

↑ BMR by 10-20%↑ BUL by 15-20mg%

↑ insulin↓ sensitivity of insulin receptor (hPL) by 44%

↑ sr cortisol↑ kidn size by 1cm

↑ renal pl flow by 50-75%↑ GFR by 50%

↓ BUN,sr creat↓→ ren threshold glu glucosuria

↓ → Peristalsis(P), dextrorotated uterus compresses rt>lt ureter at pelvis brim hydroureter& hydronephrosis

↑ GI transit time gastric emptying time-no change

↑ gastric secretion↑ gastric reflux (P)

preg tm-pyogenic granuloma(bn vasc lesion on mucosa, skin, gum, nasal septum)↑ cholestasis, sr bile acid(E)↑ ALP(placenta) by 5time

↓ AST,ALT↑ calorie req by 350kcal/d

1st trim=+150kcal/d 2nd trim=+350kcal/d hyperlipidemia total Fe req=1000mg 1st½=3-4mg/d 2nd½=6-7mg/d

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I2 req=200μg/d VC,FEV1,IRV,RR-no change

↑ → tidal vol fr 475 675ml(+40%)↓ ERV

↓ → residual vol fr 965 765ml(–20%)↑ total lung capacity

diaphr rise by 4cm↑ transv thoracic diam by 2cm

↑ →↑ depth (P sensitivity of resp centre to CO2)↓ pCO2 ,mild resp alkalosis↑ pH bld by 0.02(resp alkalosis)

↑ HCO3 excret (compensatory metab acidosis)↑ pulm min ventil by 40%

P at term=250mg/d E max at term-E2

amnion fetal ectoderm, innermost memb, no vess, no n, no lymphatamniotic fluid <w12-ultrafiltrate of mat plasma w12-20-transudate across fetal skin >w20-fetal urine pH=7(7-7.5),alk carb-glu osmol=250mosmol/l H2O=99% H2O replaced-after 3h turnover rate at term=500-800ml/d POG(w)-vol(ml) 20-250 32-1000 40-800 42-200

AFI=5-24cm polyhydram-AFI>24cm, AF vol>2000ml

oligohydram-AFI<5cm, AF vol<200ml colour-cause straw/colourless-norm

→ → meconium stain[green, 1st to stain-umbilical cord(2h) nail(6h) →vernix/skin(12h) placenta]-fetal distress

thick+flake(pea soup)-c/c fetal distress golden-Rh incompatibility greenish yellow(saffron)-postmaturity dark-concealed hge dark brown(tobacco juice)-IUD purulent-chorioamnionitis

chorion frondosum-placenta leave-fuse with amnion

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transvag chorioscentesis report karyotyping-fetal loss≥3%, ≥10w(11-13w), 1%abortion, ≤9w-limb defect amnioscentesis ≥15w(16-18w), safest, fetal loss=0.25- 0.5%, report-10-14d, ts-amniocyte/dermal fibroblast, not use-fetal skincordoscentesis cord end towards placenta, ≥20w(>18w)

anencephaly USG Dx-w14

placenta hemochorial chorion frondosum+decidua basalis placent:fetal wt=1:6 mat side=20lobe(1lobe=3-5lobule/cotyledon-fnal unit placenta, supplied by truncal a) spiral arteriole=120/intervillous space O2 saturat=65-75% pO2=35-40mmHg umbilic v pO2=30-32mmHg O2 delivery rate=8ml/min/kg bld flow in intervillous space=500-600 ml/min uter a BP=70-80mmHg uter v BP=8mmHgfn hepatic renal pulm

→ endocrine-TRH, CRH, GHRH, GnRH, hCG, hPL, E3(fetal DHEAS sulfatase, aromatase-fetal well being), P(precursor-mat LDL cholesterol), GH, PTH, inhibin, activin, relaxin TSH, PTH, calcitonin, erythropoietin dont cross placenta velamentous placenta-vess separate before reaching margin placenta succenturiata-missing lobe, PPH, sepsis, subinvolution

blighted ovum-avasc villi

most sensitive pregn test-FIA> RIA> ELISA= IRMA> radioreceptor assayurine hCG preg test min detect≥5mIU/l hCG-8d PF

fetal cardiotocography EArly deceler(dip in FHR opposite to uter contraction)-hEAd compression LAte deceler(dip in FHR beyond uter contraction)-c/c pLAcentaL insuff vaRiable deceler(dip abrupt)-coRd compress(<2min) sinusoidal pattern-fetal anem, fetomat hge, fetal hypoxia

ANC visit min=4 ideal=7-9

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screening Down synd 1st trimest USG-11-13+6w-nuchal translucency≥3mm

↑ ↓ marker-11-13w-dual test- hCG+ PAPP 2nd trimest USG-15-20w-nuchal fold thickn≥6mm

↑ ↓ ↓ marker-15-20w triple test- hCG+ AFP+ E3 quadruple test(15-22w) HCG,inHibinA-High

aLp fetoprotein,unconjugated estrioL-Low chance of recurrence=1%

AFP norm-macrosomia

screening Turner synd 2nd trim-nuchal fold thickn≥5mm

apt test source-mat/neonat bld add 1%NaOH destroy HbA, but not HbF quaLitative +ve-bld of fetal originKleihaur Betke test source-mat add citricacidP destroyHbA, but not HbF quanTitative report estimate ml of fetal bldSinger test vasa previa

abortion preg loss<20w,<500g missed-os close, PV blding, pain, USG-cardiac activity– threatened-os close, PV blding, pain, CA+ inevitable-os open, PV blding, pain complete-os close, PV blding, pain, complete expulsion of product of conception

→ incomplete-os open, PV blding, pain, product of conception seen by cx suction evacuation induced- 1st trimest-OPD medical abortion-mifepristone+ misoprostol-done upto-7w, safe upto-9w

D1-200mg oral mifepristone D3-400μg oral/vag misoprostol D15-observation suction evacuation-7-12w, safe upto 15w, Karman cannula, press=600mmHg

2nd trimest-misoprostol, MTP-extra amniotic ethacrydine lactate, dilatation&suction evacuation, manual vacuum aspiration- 12w-60ml syringe,660mmHg

cx incompetence

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prophylactic cx circlage(12-14w)-classic h/o incompetence, cx lth<2.5cm(2nd trimest) emergency circlage-cx dilated, bulging memb into cx canal remove stitch-37w

→ MC sutur-McDonald(purse string) modified Shirodkar(mersilene tape)→ → →Ix-T(close os) Y V U(incompet os)

twin type-separation time fr d of fertilization diamniotic dichorionic<3d diamniotic monochorionic=4-8d monoamniotic monochorionic>8d siamese/conjoint≥13d

risk-Gn>clomiph citrate>GnRH agonistIx-USG-twin peak/lambda sign-10-14w(dichorionic), thickn of dividing memb≥2mm twin-twin transfusion synd

MCDA-deep A-V anast, 1twin-polyhydramn, other-oligohydramn(fetus papyraceous/stuck twin)Mx-fetoscopic laser-ablation of anast

→ → monoamniotic-cord entanglement vasospasm of both baby deathMx-32w-CS embryonic reduction-2fetus-11-13w

APHabruptio placenta vitB9 def Couvellaire uterus-not indicated for hysterectomy type-mixed, concealed, revealed Page classif 0-retrospective Dx(Dx after delivery) 1-pain+PV bld

↓ 2-pain+PV bld+ FHR 3-pain+PV bld+maternal shock+IUD

placenta previa 1-placenta reach lower uterine seg(<2cm fr int os) A-ant,B-post

2(marginal)-placental edge reach margin of int os A-ant,B-post

3(incompl)-part cover int os, but move away as os dilate 4(compl)-completely cover int os minor-1,2A-VD,CS major-2B,3,4-CS dangerous-2B

Rx-MacCaffee protocol bed rest monitor mother,fetus <w34-steroid mild contract-tocolytic

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indication for termination of preg(TOP) unstable vital of mother fetal distress continue to bld ≥37w active labour IUD GCA

adherent placenta Accreta-Attatch to myometrium, intervening decidua, Nitabuchs memb(fibrinoid degeneration) absent INcreta-INvade myomet PErcreta-PEnetrat myomet ,reach serosal surf highest risk-present placenta previa>prev CS

gest HTN BP≥140/90mmHg(mild), ≥160/110mmHg(severe) on 2occas 4h apart >20w POG no evidence of proteinuria BP return to norm<12w PPpre-eclampsia gest HTN proteinuria(>300mg/24h urine,+1dipstick)/any1 of following- PLT<1lac/mm³ liver enzyme>2time sr creat>1.1mg/dl pulm edema cerebral/visual sympt

eclampsia pre-eclampsia sz[GTCS-AP(MC), intrapartum, PP(worst)-1st fit<48h PP]c/c HTN in preg BP≥140/90mmHg<20w POG, >12w PPc/c HTN with superimposed preeclampsia c/c HTN in preg worsen BP new onset proteinuria end organ damageimpending eclampsia pre-eclampsia epigastric pain(subcapsular hematoma liver) headache/dizziness(cerebral hypoxia/edema) blurring/scotoma/diplopia/blindness[(reversible-occipital lobe hypoxia) (irrevers-retinal detachment)] HELLP synd recur rate=24%Rx gest HTN/mild pre-eclampsia-TOP at 37w severe pre-eclampsia-TOP at 34w eclampsia

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Pritchard-LD=4g IV MgSO4(over 10min)+ 10g IM(5g in each buttock), MD=5gIM(every 4h in alternate buttock) upto 24h after delivery/last sz whichever later Zuspan regim(IV)

Sibai regim(IV) MgSO4(NMDA agonist) therapeutic bld level=4-7mEq/l patellar reflex disapp≥10mEq/l resp arrest≥15mEq/l cardiac arrest≥30mEq/l antidote-IV Ca gluconate(10%)10ml

indication of TOP irrespective of POG impending eclampsia eclampsia abruption HELLP synd uncontrol BP reversed end diastolic bldflow in umbilical a doppler

heart ds in preg highest mortality≥50% 1-Marfan synd+aortic root involvement 2-COA+AV involvement 3-Eisenmenger synd 4-aortic dissection(GA) abortion advise 1,2,3 ejection fraction<40% NYHA-3,4 severe MS(<1.5cm²) severe AS(<1cm²)

CS 1,2,4 vag delivery any heart ds except 1,2,4 EA c/i severe AS severe AR cyan HD HOCM

Mx-VD>CS, induction/ARM not c/i, inj methergin c/i→ → → heparin-6 12w, warfarin-18 36w, heparin-36w onset of labour, restart

anticoag-6h after VD, 24h after CS aspirin stop 7d bef labour

DM in preggestational DM derange bld sugar Dx 1st time in preg 1-2step(ACOG)

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→ → 1st-screen test-GCT(24-28w)-50g glu 1h bld glu≥140mg/dl-+ve→ → → → 2nd-3h OGTT-fasting 100g glu 1h 2h 3h

Carpenter Cousten value-fasting≥95, 1h≥180, 2h≥155, 3h≥140mg/dl ≥2value derange-+ve

single step test(WHO/IAPOSG)→ → → 2h OGTT-screen+Dx-fasting 75g glu 1h 2h, fasting≥92, 1h≥180, 2h≥153mg/dl

≥1value derange-+ve→ →overt DM-hyperglycemia free radical inj GCA in fetus

risk of GCA(%)-HbA1C<6.5-norm, 6.5-8.5-mild(3), >9%-high(22) Pederson hypothesis-mat insulin does not cross placenta fetal erythropoietin-fetal liverMx-target capillary bld glu(mg/dl) F<95, 1h<140, 2h<120, mean capill bld glu<100mg/dl, HbA1C<6% TOP-39w CS-birth wt≥4.5kg(DM mother), >5kg(non DM mother)

↑ ↓ insulin req in preg , in labour↑ neonat- RBC, RDS, ketotic hypoglycem, obesity, future DM

ectopic preg intrauterine preg angular-uter lies med to attachm of round lig cornual-rudimentary horn of bicornuate uterus

heterotopic preg=intrauterine+extrauterineDx-16wMx-salpingectomy/KCl/salpingostomy/hyperosmolar glu in ectopic sac cx preg-Rubin criteria, Palman criteria-no pain,blding-Mx-medical abD preg-StuDDiforD criteria-pain+no blding-Mx-Sx ovarian preg-Spigelberg criteria-Mx-Sx FT preg Ampulla> isthmus> infundibular> intramural/interstitium Abortion(w8)-rupture(w6)-abort-rupt(w12) after tubal ligation-ectopic preg(30%)

Dx 1st test-urine preg test(99%) TVS-empty uterine cavity+extrauterine gestat sac+cardiac activity USG-hCG critical titre(IU/l) TVS-1500

TAS-6500↑ hCG doubling time

gold std-laparoscopy sr P<5ng/ml(IU preg>25ng/ml)Mx expectant-hemodynamic stable, sac<3cm, hCG<200IU/l&falling, no cardiac activity medical-hemodynamic stable, sac size<4cm, hCG<5000IU/l-inj

→ → ↓ →mtx-D1-50mg/m²IM D4 D7(hCG by 15%), if not nullip-partial salpingectomy+ tubal reanastomosis, multip-complete salpingectomy Sx-unstable, fail med Mx, rupture, complete family, infertility-laparoscopic salpingostomy(take off product by hydrodissection, 1cm long incision along

→antimesentery bord)> salpingotomy hemostasis not achieved/>5cm size-salpingectomy

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active genital HSVMx-LSCS

nonimmune fetal hydrops accumulation of extracellular fluid in ts&serous cavities in condition other than Rh incompatibility

preterm labour-cx lth<1.5cm 24w<2.5cm

ECV-after 36w

Philpot&Castle Cervicograph alert line begin at 4cm

Leopold maneovre face the face-3rd Leopold-1st pelvic grip face the foot-4th Leopold-2nd pelvic grip

fetal attitude-relation of 1part of fetus to other

phase of parturition(QASI) 1-Quiescence-contractile, unresponsive, cx softening 2-Activation-uterine preparedn for labor, cx ripening 3-Stimulation-uterine contraction, cx dilatat, fetal&placenta expulsn(3 stage of labor) 4-Involution-uterine involution, cx repair, BF

LABOURfalse

↑ no in freq, intensity, duration, show(bld+cx mucus), no effacem(thin, softening)& ↓dilatation of cx, no rupture of memb, pain on sedation

labour analgesia epidural 0.25%bupivacaine-T10-L1 prolonged 1st stage(active phase)-1h, 2nd stage-25min

→1st Stage-beginning of true labour pain full dilatation of cx(10cm) latent phase=0-5cm dilatation, cx effacem≥15mm norm-primi=12h, multip=8h

prolong-primi>20h, multip>14h active phase≥6cm dilatation rate of cx dilat-primi=1.2cm/h, multip=1.5cm/h rate of descent of head-nullip=1cm/h, multip=2cm/h arrest-no change in cx dilat>4h of adeq uterine contraction

cx ripening cerviprime/dinoprostone(PGE2) gel max dose-3applic(1.5mg or 15ml)PV/24h, 6h apart, prev CS-1applic misoprostol(PGE1)

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cx ripening+initiate uter contraction-25μg PV every 4h until onset of contraction abs c/i-prev CS

→2nd Stage-full dilat of cx expulsion fetus norm-primi=1h, mutip=30min prolong-primi>2h, multip>1h arrest primi-no descent>3h, multi-no descent>2h after adeq contraction in absence of analgesia primi>4h, multip>3h in presence of analgesia unstable lie-lie change after 37w engagement-BPD cross pelvic inlet/brim primi-37w, multip-onset of labour engaging diam transverse biparietal=9.5cm(constant) bitemporal=8cm bimastoid=7.5cm(shortest)

vertex AP=suboccipitobregmatic=9.5cm face AP=submentobregmatic=9.5cm brow AP=mentovertical=14cm(largest) deflex head AP=occipitomental=13.5cm

cardinal step of labour engagement descent flexion head rotate by 2/8&come in AP diam shoulder rotate by ⅛&come in obliq diam extension-head born extern rotation of head, restitution of shoulder lat flexion at waist&baby born

aNt asynclitism-Naegle obliquity post asynclitism-Litzman obliquity

Caldwell&Malloy type of pelvis gynaecoid-50%(MC)-inlet-circular, side wall-parallel, ischeal spine-blunt, shallow pelvis, subpubic angle-obtuse(90-100°) anthroPoid-25%-inlet-AP oval-negroid race-Persistent occiPitoPost position, face to Pubis delivery android-20%-inlet-heart shape-occipitopost position-sidewall-convergent, pelvis-narrow, ischeal spine-sharp, deep transv arrest, subpubic angle-a/c(85°) funnel-obstructed labour platypeloid-5%-inlet-transv oval-broad flat-short sacrocotyloid diam-face presentation-transv lie-successful trial of labour Naegle-oNe ala cong absent roberT-Two ala cong absent rachitic-rickets triradiate-vitD def

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pelvic inlet diam/conjugate diagonal-lower border pubic symph-sacral promontary=12cm obstetric-inner border pubic symph-sacral promontary=DC–1.5cm=10.5cm true/anatomical-upper inner border pubic symph-sacral promontary=11cm

pelvic cavity smallest diam=interspinous diam=10.5cm pelvic outlet smallest diam=intertuberous diam=11cm contracted pelvis inlet-OC<10cm, DC<11.5cm cavity-interspinous diam<8cm outlet-intertuberous diam<8cm

assessm pelvis-trial of labour> MRI> CT> radiopelvimetry primi-37w multip-onset of labour

push uterine contraction, pacemaker-rt>lt cornua, contraction rate=2cm/s, depolarises entire uterus in 15s, fundal predominance palpable=10mmHg painful=15mmHg cx dilat=15mmHg moderate=fundus cant be indented with finger=40mmHg adequate=3contraction in 10min lasting 45s= 220montevideo unit 1st stage-onset=25, end=50mmHg 2nd stage=80mmHg tachysystole>5contraction in 10min hyperstimulation=tachysystole+fetal distress

no routine episiotomy done

↑ cephalhematoma-subperiosteal bld, not cross suture line, appear after birth, 1st 72h caput succedaneum-cross suture line, improve in 72h moulding 1-parietal bone just touch each other 2-overlap, manually separate 3-overlap cant separate manually

breech Lovset-extended arm Pinard-extended leg Burns Marshal-aftercoming head delivered by flexion Mauriceau Smellveit-aftercoming head, Malar flexion, Shoulder traction Prague-dorsopost breech Piper forceps-dorsoant breech Duherson-aftercoming head preterm-incision at-2,10'O clock position

deep transverse arrestMx-abnorm pelvis-CS, norm pelvis-manual rotation,Killands forceps,vacuum device

persistent occipitopost position/face to pubis delivery-delivery of head by extension

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Mx-CS>forceps

face presentationMx-MA-VD, MP-CS(MPSC)

brow presentationMx-CS

transverse lie shoulder presentation-grid iron feet-P/VMx-transv lie, 37w, fundal placenta, pelvis adeq-ECV transv lie in labour-CS neglected shoulder presentation-fetal distress/IUD-CS

corpora conduplicata-old preterm dead, folded, doubled up, come out of vag

instrumental delivery forceps CNVII palsy, brachial plex inj, ICH outlet(station≥+3)-Wrigley, SaMPson(Primi, Mould), TuckeR(mulTi, Round head) low-station=+2 midcavity-station=0-+2 diameter-occipitomental

Wrigley short curve, 1blade inside other, English lock, 27.5cm lth, cant be use in aftercoming head breech direction of pull

→ → OA-horiz forward upward→ → OP-horiz forward backward

Piper long(44.5cm), curve b/n shaft&blade, English lock, aftercoming head breech

Killand long(40cm), sling lock, no pelvic curve, straight, ant blade goes 1st(other forceps-lt blade goes 1st) SiMPson long(36cm), Moulded head, English lock, Primi Das long(37cm), curved, aftercoming head

ventouse/vacuum ≥6cm cx dilatat, CNVI palsy, retinal inj, cephalhematoma

cup-flexion pt 3cm ant to post fontanelle, 6cm post to ant fontanelle, diam cup=50 -70mm, plastic(bell shape)/rigid(mushroom shape), press generated=0.8kg/cm²= 600mmHg c/i-preterm, hgic ds, brow presentat failed vacuum-3attempt-no descent of head

→ppt labour-onset expulsion time<3h

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shoulder dystocia>1min delay of delivery of shoulder after delivery of head→ →Mx-call for help empty UB,episiotomy McRoberts manoevre(sudden flexion&

→abduction of mat thigh on abdomen+ suprapubic press) Woods corkscrew,Rubins → →manoevre Zavanelli procedure(push back head CS)

3rd Stage-15-20min prevent PPH-10IU oxytocin(<1min PP) delayed cord clamp>1min[1(80ml)-3(100ml)] extra bld=50mg Fe to baby-norm, preterm, HIV+ve mother early cord clamp-if resuscitation req, Rh incompatibility controlled cord traction-mod Brandt Andrew meth routine fundal massage not done Schultz(Shiny-memb/fet side present at vulva-retroplacental clot) 80% Mathews Duncan(Dirty-cotyleDon/Maternal side present at vulva-no retroplacental clot)-20%

4th Stage=1h

prev CS classical CS-verticle incision LSCS-transv/pfannential/Munroe Kerr(ROR=0.2-1.5%) LSCS-verticle/Kronig(1-7%)

abs c/i of VBAC classical CS(4-9% risk of rupture) ≥2prev LSCS prev h/o rupture(classical-32%, LSCS-6%) h/o hysterectomy, myomectomy CPD in current preg

indications of classical CS ca cx, dense adhesions(UB&low uterine seg), fibroid low seg uterus, ant placenta previa, PM, VVF repair, preterm time of rpt CS-37w(bef onset of norm labour), ≥2prev LSCS-39w ideal time of rpt conception after prev CS≥18mth, min time≥6mth

uterine rupture impending rupture

↑ ↓ most consistent sign-FHR (1st change), (MC change)↑ mat HR

tenderness at scar site suprapubic pain vag bld

Mx-emerg CS scar dehiscence all layer except serosa separated

uterus rupture all layer including serosa separatedMx-emerg laparotomy

early term=37-38w6d term=39-40w6d

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late term=41-41w6d post term≥42w post date>40w

PP change in mother urine voiding-h4 diuresis-d2-5 regeneration of endometrium begin-d7 uterus wt(500g)-w1 uterus wt(300g)-w2 uterus pelvic organ-w2(d10-12) uterus wt(100g)-w3 uterus retain prepreg wt-w4>6 prepreg CO-w4 ovulat nonlactation fem-w4 involution uterus-w6(1.25cm/d)

PPH delivery-bld loss(ml) vag delivery<500 twin vag delivery<1000 CS<1000 ceasarean hysterectomy<1500 fall in hematocrit<10%

prim PPH<24h PP sec PPH-24h-w12 PP shock index=HR/SBP, norm=0.5-0.7, immed resuscitation≥0.9 complic-kidn inj suture on uterus-B lynch, brace, cho², Hayman(uterus not open), Pereira(combinat vert+ horiz suture)

↓ b/l int iliac a ligation- pelvic press by 85%, effective in 50% pt uterine sandwich=balloon tamponade+B lynch

pudendal n(S2,3,4) block vag approach, perineal approach, does not abolish sensation of ant perineum, 1% lignocaine inj 1cm postmed ischeal spine

paracervical block 4,8,2,10'O clock position

→ 3,9'Oclock-desc cervic a br of uterine a 1cm deep into cx ts onset of action=2-5min Frankenhauser ganglion(T10-L1)

perineal tear 1°-skin&/or vag mucosa 2°-mucosa+m 3°-A<50% ext anal sphincter

B>50% ext anal sphincter C-int+ext anal sphincter

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4°-rectal mucosaRx-1°,2°-repair in LR, 3°,4°-repair in OT

↓ done <24h or after 6w in OT SA/EA→ → seq of repair-rectal mucosa int sphincter ext sphincter(end-end anast,

→overlapping techn) episiotomy

uterine inversion→ →Rx-manual reposition(Johnson meth) hydrostatic press(O'Sullivan meth)

laparotomy(Haultain meth)

Lochia(RSA) vag disch for 1st fortnight fishy smell, aLkaLine Rubra=1-4 Serosa=5-9 Alba=10-14

ischeal spine station 0 levator ani m insertion pudendal n block given curve of Carus(forward curve taken by fetus while travelling through maternal pelvis) internal rotation occur vag pessary in prolapse is put

Abbreviations a-artery, AA-amino acid, abtc-antibiotic, AI-autoimmune bef-before, bel-below, b/l-bilateral, bld-blood, b/n-between, bn-benign, br-branch, Bx-biopsy ca-carcinoma, carb-carbohydrate, c/i-contraindication, c/l-contralateral, conc-concentration, cong-congenital, Cx-cervix d-day, def-deficient, ds-disease, d/t-due to, Dx-diagnosis E-estrogen fem-female, fr-from gld-gland, glu-glucose h-hormone idiop-idiopathic, i/l-ipsilateral, inf-infection, inj-injury lig-ligament, LL-lower limb, l/t-leading to m-muscle, maj-major, mal-male, MC-most common, met-metastasis, min-minor, mtx-methotrexate, Mx-management n-nerve, norm-normal P-progesterone, pl-plasma, prot-protein, pt-patient Rx-treatment SCC-squamous cell carcinoma, sr-serum, Sx-surgery, sz-seizure tm-tumour, ts-tissue UL-upper limb, u/l-unilateral vag-vagina, VC-vocal cord, vel-velocity, vert-vertebra, vit-vitamin, vol-volume w-week, wt-weight Xr-X ray y-year

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#-fracture °-degree

THESE NOTES ARE ONLY FOR THE PURPOSE OF GUIDANCE AND HELP TO PG ASPIRANTS, NOT FOR COMMERCIAL OR OTHER PURPOSE. REFERENCE HAS BEEN TAKEN FROM VARIOUS STANDARD TEXTBOOKS.

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