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📚 OBSTETRICS - COMPLETE LAQ EXAM NOTES

Source: DC Dutta's Textbook of Obstetrics + Standard Obstetrics References

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SECTION 1: LABOUR - NORMAL & ABNORMAL

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Q105. DYSTOCIA

Classification (3 Ps):

DYSTOCIA
    ├── POWERS (Uterine)
    │       ├── Uterine inertia (hypotonic)
    │       ├── Hypertonic dysfunction
    │       └── Cervical dystocia
    ├── PASSENGER (Fetal)
    │       ├── Malpresentations (breech, transverse)
    │       ├── Malpositions (OP, OT)
    │       ├── Macrosomia
    │       └── Fetal abnormalities (hydrocephalus)
    └── PASSAGE (Maternal)
            ├── Bony pelvis (contracted pelvis)
            └── Soft tissue (cervical, vaginal, vulval)

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Q114. PROLONGED LABOUR

Causes:

• Contracted pelvis (most common bony cause)
• Uterine inertia / dysfunction
• Cervical dystocia
• Rigid perineum / vaginal stenosis
• Pelvic tumours (fibroid, ovarian cyst)

• Malpresentation (breech, face, brow)
• Malposition (persistent OP, OT)
• Large baby (macrosomia)
• Hydrocephalus
• Conjoined twins

Clinical Features:

• Labour >18 hrs primigravida / >12 hrs multigravida
• Maternal exhaustion, dehydration, ketosis
• Fever, tachycardia
• Fetal distress (FHR abnormalities)
• Caput succedaneum, moulding of fetal head
• Bandl's ring may appear (sign of impending rupture)

Diagnosis:

• Careful history and partograph monitoring
• Per abdominal examination: head position, descent
• Per vaginal examination: dilation, effacement, station
• USG: fetal size, position, liquor

Maternal Complications:

• Dehydration, ketoacidosis
• Exhaustion
• Infection / sepsis
• PPH (atony)
• Uterine rupture
• Obstetric fistula (VVF, RVF)
• Death

Fetal Complications:

• Fetal distress
• Birth asphyxia
• Birth trauma
• IUFD
• Neonatal sepsis

Management:

PROLONGED LABOUR MANAGEMENT
         │
         ▼
ASSESS CAUSE
         │
    ┌────┴────────────┐
    │                 │
Uterine inertia    CPD/Obstruction
    │                 │
Augmentation       Caesarean section
(Oxytocin drip)
         │
    Monitor with
    Partograph + CTG

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Q115. OBSTRUCTED LABOUR

Causes:

• Contracted pelvis (most common)
• Pelvic tumours
• Vaginal stenosis / septum

• Hydrocephalus
• Shoulder dystocia
• Locked twins
• Fetal macrosomia
• Malpresentation

Clinical Features:

Diagnosis:

• Clinical: Bandl's ring (pathological retraction ring) at junction of upper and lower uterine segments
• Moulding grade 3+ on VE
• Partograph shows arrest of descent and dilation

Maternal Complications:

• Uterine rupture (most serious)
• Obstetric fistula (VVF/RVF)
• Sepsis
• PPH
• Shock
• Maternal death

Fetal Complications:

• Fetal distress
• IUFD
• Birth asphyxia
• Birth injuries

Management:

• Immediate resuscitation: IV fluids, antibiotics, catheterize
• Empty bladder (prevents further obstruction)
• Deliver by safest route:
  • Live fetus: Emergency LSCS
  • Dead fetus: Destructive operation (craniotomy, decapitation)
• Post-delivery: Repair fistula, manage PPH, antibiotics

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Q122/123. CONSTRICTION RING vs RETRACTION RING

Constriction Ring (Pathological contraction ring / Bandl's ring):

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Q125. PRECIPITATE LABOUR

Complications:

• Perineal lacerations (1st, 2nd, 3rd degree tears)
• Cervical lacerations
• PPH (atony)
• Amniotic fluid embolism
• Uterine inversion

• Intracranial haemorrhage (rapid compression-decompression)
• Birth asphyxia
• Birth trauma
• Aspiration

Management:

• If in hospital: do NOT restrain labour
• Monitor FHR continuously
• Be ready for perineal support
• Repair all lacerations
• Active management of 3rd stage
• Neonatal resuscitation ready

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Q126. UTERINE INERTIA

Types:

1. Primary (Hypotonic) Inertia: Present from onset of labour
   • Contractions <3 in 10 min, lasting <45 sec, intensity <25 mmHg
2. Secondary Inertia: Starts well, then weakens
   • Usually from obstruction or exhaustion
3. Hypertonic Inertia: Painful but ineffective contractions (spasm)
   • Rare, fundal dominance lost

Management:

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Q127. CONTRACTED PELVIS

Types of Contracted Pelvis:

1. Flat pelvis - reduced AP diameter
2. Android pelvis - funnel-shaped, narrowed outlet
3. Anthropoid pelvis - reduced transverse diameter
4. Platypelloid - very flat, reduced AP

Muller-Munro Kerr Method (Assessment):

• Two hands on fetal head, push it into pelvis
• Third finger of one hand on symphysis pubis
• If head overlaps symphysis = significant CPD

Diagonal Conjugate:

• Measured per vaginum
• True conjugate = DC - 1.5 cm
• If true conjugate <10 cm = contracted inlet

Diagnosis:

• History: short stature, rickets, polio, deformity
• General: height <145 cm suggestive
• Pelvi-metry: clinical + imaging
• X-ray pelvi-metry (Thoms' method)
• MRI pelvi-metry (most accurate, no radiation)

Types of Pelvis Differentiation:

Management:

• If mild CPD + good contractions: Trial of labour
• Moderate-severe CPD: Elective LSCS
• Obstructed: Emergency LSCS
• Dead fetus: Craniotomy

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Q128. TRIAL OF LABOUR

Contraindications:

• Severe CPD
• Previous classical CS scar
• Previous uterine surgery (myomectomy entering cavity)
• Bad obstetric history
• Elderly primigravida
• Fetal macrosomia >4 kg
• Malpresentation
• Placenta previa

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SECTION 2: ANTEPARTUM HAEMORRHAGE (APH)

Note: Some texts now use 20 weeks as the threshold.

Classification:

APH
├── PLACENTAL CAUSES
│       ├── Placenta Previa (20%)
│       └── Abruptio Placentae (30%)
└── NON-PLACENTAL CAUSES
        ├── Local causes (cervical erosion, polyp, carcinoma)
        ├── Vasa previa
        └── Marginal sinus rupture

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Q116/117. BREECH PRESENTATION

Types:

1. Frank/Extended breech (most common, 65%) - thighs flexed, legs extended
2. Complete/Flexed breech (25%) - thighs and legs flexed
3. Footling/Incomplete breech (10%) - one or both feet presenting

Clinical Findings:

• Fundal height = 36 weeks for breech
• Hard, round, ballottable head at fundus
• Soft, irregular, non-ballottable breech at lower pole
• FHS heard at or above umbilicus

• Soft irregular mass at os
• Feel sacrum, anus, ischial tuberosities
• Do NOT confuse anus with mouth (anal sphincter = tone; mouth = hard gums, tongue)

Maternal Complications of Breech:

• PPH
• Perineal tears
• Operative delivery

Fetal Complications:

• Birth asphyxia (cord compression, head entrapment)
• Intracranial haemorrhage
• Erb's palsy, fractured clavicle
• Spinal cord injury
• IUFD

Management of Breech:

BREECH MANAGEMENT
        │
        ▼
Antenatal: Offer ECV at 36-37 weeks
        │
    Success?
    ┌───┴───┐
   YES      NO
    │       │
Cephalic  Assess for vaginal breech vs LSCS
delivery     │
         ┌───┴──────────┐
         │              │
    Vaginal Breech    LSCS
    (if criteria met)   (preferred in modern practice)

• Frank breech
• Adequate pelvis
• Normal fetus (no hydrocephalus, no macrosomia)
• Experienced obstetrician available
• Spontaneous onset of labour

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Q118. TRANSVERSE LIE

Causes:

• Multiparity (lax uterus) - most common
• Prematurity
• Placenta previa
• Polyhydramnios
• Pelvic tumour
• Uterine anomaly (bicornuate)
• Contracted pelvis

Per Abdominal Findings:

• Uterus broad/low
• No fetal pole at fundus or lower pole
• Fetal head on one side, breech on other
• FHS at umbilical level

Per Vaginal Findings:

• Presenting part absent or shoulder felt
• Sometimes arm may prolapse (shoulder presentation)

Management in Hospital:

• Antenatal: Correct cause if possible; ECV at 37 weeks
• In labour:
  • Early (before membranes rupture): ECV + ARM
  • After membranes ruptured: LSCS (live fetus)
  • Dead fetus: Decapitation or bipolar version

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Q119. EXTERNAL CEPHALIC VERSION (ECV)

Indications:

• Breech at 36-37 weeks
• Transverse lie at term

Contraindications:

• Previous LSCS scar
• Placenta previa
• APH
• Multiple pregnancy
• Oligohydramnios
• Fetal distress / IUGR
• Uterine anomaly
• Hypertension / pre-eclampsia

Complications:

• Placental abruption
• Cord entanglement
• Fetal distress
• Premature labour
• Fetomaternal haemorrhage
• Uterine rupture (rare)

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SECTION 3: POSTPARTUM HAEMORRHAGE (PPH)

Types:

• Primary PPH: within 24 hours of delivery
• Secondary PPH: >24 hours to 6 weeks

Causes - 4 Ts:

4 Ts OF PPH
├── TONE (70%)    → Uterine atony
├── TISSUE (10%)  → Retained placenta/membranes
├── TRAUMA (20%)  → Lacerations, uterine rupture, inversion
└── THROMBIN (1%) → Coagulopathy (DIVC, AFE)

Risk Factors:

• Grand multiparity
• Prolonged labour
• Macrosomia / polyhydramnios
• Antepartum haemorrhage
• Previous PPH
• Uterine fibroids
• Coagulopathy

Management of PPH:

PPH MANAGEMENT (HAEMOSTATIC APPROACH)
         │
         ▼
Call for HELP + Resuscitate (IV access x2, fluids, O2)
         │
         ▼
Identify cause (4 Ts)
         │
    ┌────┼────────────┐
    │    │            │
  TONE TRAUMA      TISSUE
    │    │            │
Bimanual  Repair     Manual removal
massage   lacerations of placenta
    │
Uterotonic drugs:
1st: Oxytocin 10 IU IM + 20 IU IV infusion
2nd: Ergometrine 0.2 mg IM/IV
3rd: Misoprostol 800 mcg SL
4th: Carboprost (15-methyl PGF2α)
    │
If bleeding continues:
Balloon tamponade (Bakri balloon)
    │
Brace suture (B-Lynch)
    │
Uterine artery ligation
    │
Internal iliac artery ligation
    │
Hysterectomy (last resort)

Management of Labour in PPH:

• Active management of 3rd stage (AMTSL): oxytocin 10 IU IM immediately after delivery
• Controlled cord traction
• Uterine massage after placental delivery

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SECTION 4: PUERPERAL COMPLICATIONS

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Q106/107. PUERPERAL PYREXIA & PUERPERAL SEPSIS

Puerperal Pyrexia:

Causes (WINDSHIELD mnemonic):

• Wound infection (perineal)
• Infection (UTI)
• Necrotizing fasciitis
• Deep vein thrombosis
• Septic phlebitis
• Hematoma (pelvic)
• Infection (chest, mastitis)
• Endometritis
• Local (episiotomy)
• Drug reaction

Prophylaxis:

• Aseptic technique during labour
• Minimum VEs
• Avoid prolonged labour
• Treat anaemia antenatally
• Antibiotics for PROM, prolonged rupture
• Clean cord care

---

Puerperal Sepsis:

3 Predisposing Factors:

1. Anaemia - diminished immunity
2. Prolonged labour / PROM - ascending infection
3. Traumatic delivery - breach in defence

Mode of Spread:

• Endometritis → myometritis → parametritis → pelvic abscess → peritonitis
• Lymphatic spread to pelvic veins → septic thrombophlebitis → septicemia
• Direct spread through fallopian tubes → peritonitis

Clinical Features:

• Fever (38°C+), chills, rigors
• Tachycardia, tachypnea
• Uterine tenderness, subinvolution
• Foul-smelling lochia
• Lower abdominal pain
• Septic shock in severe cases

Investigations:

• HVS culture + sensitivity
• Blood culture
• CBC (leukocytosis)
• CRP, procalcitonin
• USG pelvis (rule out retained products, abscess)

Management:

• IV antibiotics: Amoxicillin + Metronidazole + Gentamicin (triple therapy)
• Supportive: IV fluids, antipyretics
• Retained products: suction evacuation
• Abscess: surgical drainage
• Septic shock: ICU, vasopressors

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Q108. ACUTE MASTITIS

Clinical Features:

• Pain, swelling, redness of breast (usually one quadrant)
• Fever, malaise
• Tender, firm area
• Organism: Staphylococcus aureus (most common via cracked nipple)

Complications:

• Breast abscess (if untreated)
• Septicaemia
• Milk stasis / cessation of lactation

Management:

• Do NOT stop breastfeeding (key point!)
• Antibiotics: Flucloxacillin/Cloxacillin 500 mg QID x 10 days
• Supportive: analgesics, breast support
• If abscess: incision and drainage

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Q109. CRACKED NIPPLES

Causes:

• Poor attachment/latch during breastfeeding
• Flat/inverted nipples
• Vigorous suckling
• Thrush infection (Candida)
• Improper breast care

Treatment:

• Correct positioning and latch
• Nipple shield
• Apply expressed breast milk to nipple
• Lanolin cream (Jelonet)
• Dry nipples after feeding
• Treat underlying Candida if present

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Q110/170. SUB-INVOLUTION

Clinical Features:

• Uterus larger than expected for days postpartum
• Excessive, prolonged lochia
• Irregular bleeding
• Pelvic pain
• Tenderness on bimanual examination

Causes:

• Retained products of conception
• Endometritis / pelvic infection
• Uterine fibroids
• Ovarian tumour
• Full bladder
• Previous multiparity

Management:

• Ergometrine 0.5 mg TDS x 5 days (to promote involution)
• Antibiotics if infection present
• Remove retained products (suction evacuation)
• Treat underlying cause

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SECTION 5: ABNORMAL PREGNANCY

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Q138/139/140/141. ABORTION

Types:

ABORTION TYPES
├── Threatened Abortion
├── Inevitable Abortion
├── Incomplete Abortion
├── Complete Abortion
├── Missed Abortion
├── Septic Abortion
├── Habitual (Recurrent) Abortion (≥3 consecutive)
└── Carneous Mole

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Threatened Abortion (Q140):

• Bleeding per vaginum <20 weeks with CLOSED OS
• No passage of tissue
• Uterus size = dates
• Treatment: Rest, progesterone support, avoid coitus
• 50% proceed to inevitable

Inevitable Abortion:

• Open os, bleeding, no passage yet
• OS is OPEN (key differentiator from threatened)

Missed Abortion (Q139):

• Amenorrhea, then brownish discharge
• Regression of pregnancy symptoms
• Uterus smaller than dates
• Closed cervical os
• USG: absent fetal heart, no fetal movement ("silent uterus")

• DIC / coagulopathy (if retained >4 weeks)
• Infection
• Psychological trauma

• USG confirmation
• Suction evacuation (1st trimester)
• Medical: Mifepristone + Misoprostol
• 2nd trimester: Induction with oxytocin / misoprostol

---

Septic Abortion (Q141):

1. Resuscitate (IV access, fluids)
2. Cultures (blood + HVS before antibiotics)
3. IV antibiotics: Ampicillin + Gentamicin + Metronidazole
4. Evacuate uterus (within 12-24 hrs after antibiotics)
5. Treat complications

• Unsafe/illegal abortion (non-sterile instruments)
• PROM preceding abortion
• Iatrogenic

• Septic shock
• DIC
• Acute renal failure
• Peritonitis
• Death

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Q142. CARNEOUS MOLE

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Q143/144. HYDATIDIFORM MOLE

Types:

Clinical Features:

• Amenorrhea (>4 months)
• Excessive uterine size (>dates)
• Severe hyperemesis
• Hyperthyroidism signs
• Pre-eclampsia before 20 weeks (pathognomonic)
• Bleeding PV + grape-like vesicles passage
• No fetal heart sounds
• Theca lutein cysts (bilateral ovarian cysts)

Investigations:

• Beta-hCG: markedly elevated
• USG: "Snowstorm pattern" (classic)
• Chest X-ray: rule out lung metastasis
• LFT, TFT, CBC

Complications:

• Malignant transformation to choriocarcinoma (15-20% complete mole)
• Trophoblastic embolism
• Pre-eclampsia
• Hemorrhage
• Infection
• Hyperthyroidism

Management:

MOLAR PREGNANCY MANAGEMENT
        │
        ▼
Suction evacuation (method of choice)
        │
        ▼
Send tissue for histopathology
        │
        ▼
Serial beta-hCG monitoring
(weekly until negative x2, then monthly x6)
        │
        ▼
Contraception for 1-2 years (OCPs preferred)
        │
        ▼
If hCG not declining / rising = Gestational Trophoblastic Neoplasia
→ Refer for chemotherapy (Methotrexate)

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Q145. ECTOPIC PREGNANCY

Sites:

ECTOPIC SITES
├── Tubal (97%)
│   ├── Ampullary (55%) - most common
│   ├── Isthmic (25%)
│   ├── Fimbrial (17%)
│   └── Interstitial (3%)
└── Extra-tubal (3%)
    ├── Ovarian
    ├── Abdominal
    └── Cervical

Causes:

• Salpingitis / PID (most common) - ciliary dysfunction
• Previous ectopic
• IUD in situ
• Previous tubal surgery
• Endometriosis
• Infertility treatment (IVF)
• Congenital tubal defects

Clinical Features:

Differential Diagnosis:

• Threatened abortion
• Acute appendicitis
• Ovarian cyst torsion/rupture
• PID
• Corpus luteum haemorrhage

Investigations:

• Urine pregnancy test (positive)
• Serum beta-hCG (lower than expected for dates; does not double in 48 hrs)
• TVS: empty uterus + adnexal mass + free fluid
• Culdocentesis: non-clotting blood (if USG not available)
• Laparoscopy: gold standard

Immediate Complications of MTP (Medical Termination of Pregnancy):

• Haemorrhage
• Incomplete evacuation
• Infection / sepsis
• Uterine perforation
• Cervical trauma
• Anaesthetic complications

Indications of Termination under MTP Act:

• Risk to mother's life/physical health
• Risk to mother's mental health
• Rape/incest pregnancy
• Fetal abnormality (substantial risk)
• Contraceptive failure (married women / now unmarried too per 2021 amendment)
• Up to 20 weeks (24 weeks for special categories per 2021 MTP Amendment Act)

Indications for Salpingectomy vs Salpingo-Oophorectomy:

Management of Ectopic:

ECTOPIC MANAGEMENT
        │
        ▼
Is patient STABLE?
    ┌───┴───┐
   YES       NO
    │        │
    ▼        ▼
Medical Rx  Emergency surgery
(MTX if    (Laparotomy/
criteria   Laparoscopy)
met)       Salpingectomy

• Unruptured ectopic <3.5 cm
• hCG <5000 mIU/mL
• No cardiac activity on USG
• Hemodynamically stable

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Q146. MULTIPLE PREGNANCY

Varieties:

• Dizygotic (fraternal): 2 separate ova + 2 sperm; always dichorionic diamniotic (DCDA)
• Monozygotic (identical): 1 fertilized ovum divides:
  • 0-3 days: DCDA
  • 4-8 days: Monochorionic Diamniotic (MCDA)
  • 8-12 days: Monochorionic Monoamniotic (MCMA)

  • 13 days: Conjoined twins

Diagnosis:

• Hyperemesis
• Large for dates uterus
• Multiple fetal parts
• Multiple FHs heard
• USG: definitive (number of fetuses, chorionicity, amnionicity)

Maternal Complications:

• Hyperemesis
• APH (placenta previa, abruption)
• Pre-eclampsia (3x risk)
• Anaemia
• PROM
• Malpresentation
• Preterm labour
• PPH
• Operative delivery

Fetal Complications:

• Prematurity
• Low birth weight
• TTTS (Twin-to-Twin Transfusion Syndrome) - in MCDA
• Cord entanglement (MCMA)
• Discordant growth
• IUFD
• Congenital anomalies

Management:

• ANC: more frequent visits
• Iron + Folic acid supplementation
• Cervical length monitoring
• Delivery: LSCS if 1st twin non-cephalic; vaginal if both cephalic and uncomplicated
• Active management of 3rd stage

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SECTION 6: HYPERTENSIVE DISORDERS OF PREGNANCY

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Q147. PRE-ECLAMPSIA

Classification:

1. Mild Pre-eclampsia: BP 140-159/90-109 mmHg + proteinuria
2. Severe Pre-eclampsia: BP ≥160/110 mmHg + proteinuria + end-organ features

Clinical Features:

• Hypertension (after 20 weeks)
• Oedema (no longer a diagnostic criterion)
• Proteinuria
• Severe features: headache, visual disturbances, epigastric pain, oliguria, HELLP syndrome

HELLP Syndrome:

• Haemolysis
• Elevated Liver enzymes
• Low Platelets

Complications:

• Eclampsia
• Abruption placentae
• HELLP syndrome
• Acute renal failure
• Pulmonary oedema
• DIC
• Maternal stroke/death
• IUGR
• IUFD

Management:

PRE-ECLAMPSIA MANAGEMENT
        │
        ▼
Mild (outpatient if reliable)
→ BP monitoring, urine PCR, fetal surveillance
→ Antihypertensives if BP >150/100 (Methyldopa, Labetalol, Nifedipine)
→ Delivery at 37 weeks
        │
Severe (admit)
→ Stabilize BP (IV Labetalol / Hydralazine)
→ MgSO4 for seizure prophylaxis
→ Fetal monitoring (CTG, Doppler)
→ Delivery regardless of gestation if severe features

• 1st line: Methyldopa (safe, oral)
• Acute severe: IV Labetalol, IV Hydralazine, oral Nifedipine
• Avoid: ACE inhibitors, ARBs (teratogenic)

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Q148. ECLAMPSIA

Types:

• Antepartum (50%) - most common
• Intrapartum (25%)
• Postpartum (25%) - usually within 48 hrs

Clinical Features:

• Severe headache, visual disturbances (warning signs)
• Hypertension, proteinuria
• Convulsions in 4 stages:
  1. Premonitory (10-15 sec)
  2. Tonic (15-30 sec)
  3. Clonic (1-4 min)
  4. Coma (variable)

Complications:

• Maternal: cerebral haemorrhage, pulmonary oedema, ARF, DIC, aspiration pneumonia, death
• Fetal: fetal distress, IUFD, preterm delivery, IUGR

Management:

ECLAMPSIA IMMEDIATE MANAGEMENT
         │
         ▼
A - Airway (left lateral, O2)
B - Breathing (O2 4-6 L/min)
C - Circulation (IV access x2, fluids cautiously)
D - Drugs
         │
MgSO4 REGIME (Pritchard's)
Loading: 4g IV over 15-20 min + 10g deep IM (5g each buttock)
Maintenance: 5g deep IM every 4 hrs
Until: 24 hrs after last seizure
         │
Monitor: Urine output (>30 mL/hr), Knee jerk, RR (>12/min)
Antidote: Calcium gluconate 1g IV (if toxicity)
         │
Antihypertensive: IV Labetalol / Hydralazine (if DBP >110)
         │
Deliver: Once stabilised (vaginal preferred if possible)
         │
Post-delivery: Continue MgSO4 for 24 hrs

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Q149. ANAEMIA IN PREGNANCY

Classification (DC Dutta):

• Mild: 10-11 g/dL
• Moderate: 7-10 g/dL
• Severe: <7 g/dL
• Very severe: <4 g/dL

Causes:

ANAEMIA IN PREGNANCY
├── NUTRITIONAL (most common in India)
│   ├── Iron deficiency (most common)
│   └── Folate deficiency (Megaloblastic)
├── HAEMORRHAGIC (APH, hookworm, malaria)
├── HAEMOLYTIC (Sickle cell, thalassaemia, G6PD)
└── APLASTIC (rare)

Iron Deficiency Anaemia - Maternal & Fetal Complications:

• Fatigue, dyspnoea
• Increased infection risk
• PPH (uterine atony)
• Cardiac failure (severe anaemia)
• Poor wound healing

• IUGR
• Prematurity
• Low birth weight
• Neonatal anaemia
• IUFD (severe)

General Management:

• Diet: Iron-rich foods (green leafy vegetables, meat, legumes)
• Oral iron: Ferrous sulphate 200 mg TDS (elemental iron ~60 mg/dose)
• Vitamin C with iron (enhances absorption)
• Folic acid 5 mg/day
• If severe / non-compliance: IV iron (Ferric carboxymaltose) or blood transfusion
• Treat hookworm infestation

Megaloblastic Anaemia - Causes:

• Folic acid deficiency (most common in pregnancy)
• Vitamin B12 deficiency
• Drug-induced (methotrexate, phenytoin)
• Treatment: Folic acid 5 mg/day

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SECTION 7: MEDICAL DISORDERS IN PREGNANCY

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Q151. GESTATIONAL DIABETES MELLITUS (GDM)

Complications of Diabetes in Pregnancy:

• Pre-eclampsia
• Polyhydramnios
• Preterm labour
• Increased LSCS rate
• UTI
• Postpartum haemorrhage

• Macrosomia (most common fetal complication)
• Neonatal hypoglycaemia
• Respiratory distress syndrome
• Neonatal jaundice
• Shoulder dystocia
• IUFD
• Congenital anomalies (in pre-existing DM)

General Management in Pregnancy:

• Dietary control (1800-2200 kcal/day)
• Self blood glucose monitoring
• Insulin therapy (oral hypoglycaemics generally avoided, Metformin increasingly used)
• Fetal surveillance: growth scans, BPP, Doppler
• Delivery at 38-39 weeks (if controlled)
• Paediatric team at delivery

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Q147/158. CARDIAC DISEASE IN PREGNANCY

Clinical Features:

• Dyspnoea (grade I-IV NYHA)
• Orthopnea
• Palpitations
• Syncope
• Oedema (early)
• Signs of specific valvular disease

Complications:

• Cardiac failure (most serious - usually at 28-32 weeks peak blood volume)
• Pulmonary oedema
• Subacute bacterial endocarditis
• Thromboembolic events
• Maternal death

Management:

• Team approach: Obstetrician + Cardiologist
• Limit activity, reduce stress
• Iron + folic acid (to prevent anaemia)
• Anticoagulants if indicated (prosthetic valves)
• Antibiotic prophylaxis (if SBE risk)
• Delivery: vaginal preferred (less haemodynamic stress)
• Avoid prolonged pushing (cardiac stage)
• Epidural analgesia beneficial

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Q136. RUPTURE OF UTERUS

Causes:

• Previous LSCS
• Previous myomectomy
• Previous uterine repair

• CPD
• Malpresentation
• Neglected labour

• Injudicious oxytocin use
• Trauma
• Grand multiparity + uterine overdistension

Diagnosis:

• Sudden severe abdominal pain ("ripping" sensation)
• Cessation of contractions (in complete rupture)
• Fetal parts palpable superficially (if complete)
• Fetal heart absent
• Vaginal bleeding
• Signs of shock
• P/V: presenting part ascends up

Complications:

• Haemorrhagic shock
• Vesicovaginal fistula
• Maternal death
• Fetal death

Management:

UTERINE RUPTURE MANAGEMENT
        │
        ▼
RESUSCITATE (IV access, fluids, blood transfusion)
        │
        ▼
EMERGENCY LAPAROTOMY
        │
    ┌───┴──────────┐
    │              │
REPAIR         HYSTERECTOMY
(if edges       (if extensive
clean, patient  tear, uncontrolled
desires more    bleeding, grand
children)       multipara)
        │
        ▼
Closure + Drain + Antibiotics

---

Q137. CERVICAL INCOMPETENCE

Causes:

• Congenital (DES exposure, Mullerian anomaly)
• Traumatic (D&C, forceps, previous cervical surgery - LLETZ, cone biopsy)
• Infective (chorioamnionitis)

Management:

• Cervical cerclage (MacDonald or Shirodkar suture) at 12-14 weeks
• Progesterone therapy (vaginal micronized progesterone 200 mg/night)
• Cervical length monitoring by TVS

---

SECTION 8: OBSTETRIC PROCEDURES

---

Q163. EPISIOTOMY

Types:

1. Median/Midline: Straight back along midline (USA preference)
   • Advantage: Less blood loss, heals better
   • Disadvantage: Risk of extension to 3rd/4th degree tear
2. Mediolateral: At 45° to midline (UK/India preference)
   • Advantage: Less risk of anal sphincter injury
   • Disadvantage: More blood loss, more painful
3. Lateral: Obsolete (complications)
4. J-shaped: Modified mediolateral

Indications (Selective, not routine):

• Fetal distress (need rapid delivery)
• Forceps or ventouse delivery
• Shoulder dystocia
• Preterm baby
• Breech delivery
• Rigid perineum
• Imminent perineal tear (3rd/4th degree threatened)

Complications:

• Haemorrhage
• Haematoma
• Infection
• Wound dehiscence
• Extension (3rd/4th degree)
• Dyspareunia
• Fistula

Management (Repair):

• Continuous suture technique preferred
• Absorbable sutures (Vicryl/Polyglycolic acid)
• 3-layer repair: vaginal mucosa → perineal muscles → skin

---

Q164. CAESAREAN SECTION (LSCS)

Indications:

• Placenta praevia (major)
• Previous classical CS (classical scar)
• Obstructed labour with live fetus
• Active genital herpes

• Fetal distress
• Malpresentation (breech, transverse)
• CPD
• Eclampsia (unfavourable cervix)
• Failed induction
• IUGR with compromised fetus
• Previous 2 LSCS

Maternal Complications:

• Haemorrhage (PPH, bladder/vessel injury)
• Anaesthetic complications
• Urinary tract injury
• Bowel injury

• Infection (wound, endometritis, UTI)
• DVT / pulmonary embolism
• Ileus
• Wound dehiscence

• Uterine scar (rupture in next pregnancy)
• Placenta praevia / accreta in future
• Adhesions

Management:

• Preoperative: consent, CBC, blood group, IV access, catheter, antacid
• Anaesthesia: spinal preferred; GA if urgent
• Technique: Pfannenstiel incision → uterovesical fold dissection → low transverse uterine incision
• Closure: 2-layer uterine closure
• Postoperative: early ambulation, antibiotics, analgesia, thromboprophylaxis

---

Q165. FORCEPS DELIVERY

Varieties:

1. Simpson's forceps - straight shanks, for OA position
2. Neville-Barnes forceps - most commonly used in UK/India
3. Kielland's forceps - rotation forceps, for OP/OT positions
4. Wrigley's forceps - short, for delivery of head at CS
5. Piper's forceps - aftercoming head in breech

Prerequisites (MUST CHECK BEFORE APPLICATION):

1. Fully dilated cervix (10 cm)
2. Head engaged (at or below spines, station 0 or lower)
3. Membranes ruptured
4. Position of head known
5. Pelvis adequate (no CPD)
6. Empty bladder (catheterize first)
7. Adequate analgesia (pudendal block / epidural)
8. Consent obtained
9. Experienced operator

Fetal Complications:

• Cephalohematoma
• Subgaleal haemorrhage
• Facial nerve palsy
• Facial laceration
• Intracranial haemorrhage
• Skull fracture

---

Q168. INDUCTION OF LABOUR

Indications:

• Post-dates pregnancy (>41 weeks)
• Pre-eclampsia / eclampsia
• PROM at term (>37 weeks)
• Diabetes mellitus at 38-39 weeks
• IUGR with compromised fetus
• APH (abruption stabilised)
• Maternal request after 41 weeks
• IUD

Contraindications:

• CPD (major)
• Transverse lie
• Placenta praevia
• Previous classical CS / 2 or more CS
• Active herpes
• Cord presentation
• Vasa praevia

Methods:

1. Bishop Score assessment (assess cervical ripeness)
   • Score <6: Ripen cervix first
   • Score ≥6: Ready for induction
2. Cervical ripening:
   • Prostaglandin E2 (Dinoprostone) gel/pessary
   • Misoprostol 25 mcg vaginally
   • Mechanical (Foley catheter)
3. ARM (Artificial Rupture of Membranes)
4. Oxytocin infusion (after ARM or with ripened cervix)

---

Q169. ARM (Artificial Rupture of Membranes / Amniotomy)

Indications:

• Induction of labour (cervix favorable)
• Augmentation of labour
• Application of internal monitor
• To assess liquor (meconium)
• Cord prolapse management (after securing head)

---

Q162. VERSION

Types:

1. External Cephalic Version (ECV) - from outside (see Q119)
2. Internal Podal Version - hand inside uterus, converts any presentation to footling breech
3. Bipolar Version (Combined) - one hand internal, one external; rarely used

Indications:

• ECV: Breech/Transverse at 36-37 weeks (if no contraindications)
• Internal: 2nd twin in malpresentation during labour (transverse → footling breech)
• Bipolar: occasionally in transverse lie

Contraindications:

• Ruptured membranes (internal version)
• Placenta praevia
• Previous CS
• Oligohydramnios
• Significant CPD

Complications:

• Premature labour
• Fetal distress
• Cord prolapse
• Placental abruption
• Uterine rupture

---

Q166. INDICATIONS FOR D&C (Dilation & Curettage)

• Abnormal uterine bleeding
• Endometrial biopsy
• Assessment of cervical pathology

• Incomplete / inevitable / missed abortion
• Management of hydatidiform mole (suction curettage)
• Retained products of conception post-delivery
• Endometrial polyp removal

---

Q167. HYSTERECTOMY - INDICATIONS IN OBSTETRICS

• Intractable PPH (uterine atony/rupture) unresponsive to conservative measures
• Uterine rupture (extensive)
• Placenta accreta/increta/percreta
• Septic uterus (endometritis not responding to treatment)
• Carcinoma in situ of cervix (found incidentally)

---

SECTION 9: PRETERM LABOUR & PROM

---

Q130. PRETERM LABOUR

Maternal Complications:

• Increased operative deliveries
• PPH
• Infection
• Psychological distress

Fetal Complications:

• RDS (respiratory distress syndrome)
• Intraventricular haemorrhage
• Necrotising enterocolitis
• Retinopathy of prematurity
• Cerebral palsy
• Neonatal sepsis
• Death

Management:

• Tocolysis: Nifedipine (1st line), Atosiban, Indomethacin
• Corticosteroids: Betamethasone 12 mg IM x2 doses 24 hrs apart (lung maturity - give before 34 weeks)
• MgSO4: for neuroprotection if <32 weeks
• Antibiotics: if GBS positive or PROM

---

Q131. PROM (Premature Rupture of Membranes)

Clinical Features:

• Sudden gush / continuous leaking of fluid from vagina
• Wet underclothes / pad
• Speculum exam: pooling of fluid in posterior fornix
• Ferning pattern on microscopy
• Litmus test: turns blue (alkaline - amniotic fluid pH 7.1-7.3)
• USG: oligohydramnios

Management:

• Term PROM: induce within 12-24 hrs (GBS swab, antibiotics if GBS+)
• Preterm PROM (<34 weeks): conservative management, antibiotics (Erythromycin 250 mg QID x10 days), corticosteroids, close monitoring for infection
• Rupture at <26 weeks: counsel for very poor fetal prognosis

---

Q132. POST-MATURITY

Causes:

• Idiopathic (most common)
• Placental sulphatase deficiency
• Anencephaly (absent cortisol trigger)
• Genetic predisposition

Maternal Complications:

• Prolonged labour, dystocia
• Instrumental delivery
• LSCS rate increased
• Perineal trauma
• Psychological stress

Fetal Complications:

• Placental insufficiency (post-mature syndrome / dysmaturity)
• Meconium aspiration
• Oligohydramnios
• IUFD (most feared)
• Macrosomia (shoulder dystocia)

Management:

• Cervical ripening + induction at 41-42 weeks
• Fetal surveillance: NST, BPP, Doppler
• Deliver if: poor BPP, oligohydramnios, absent end-diastolic flow

---

Q133. INTRA-UTERINE DEATH (IUD)

Diagnostic Features:

• No fetal movement (mother's report)
• No FHS on auscultation
• Uterus not growing

USG Findings:

• Absent fetal heart activity
• No fetal movement
• Spalding's sign: overlapping skull bones
• Dewe's sign: fetal spine collapse

X-Ray Findings (Roberts' signs):

• Overlapping skull bones (Spalding's sign)
• Gas in fetal vessels (Robert's sign)
• Exaggerated spinal curvature
• Collapsed fetal skull

Complications:

• Psychological grief
• DIC (if retained >4 weeks - rare)
• Infection

Management:

• Confirm with USG
• Inform patient sensitively
• Allow 48 hrs for spontaneous labour
• Induce with Mifepristone 200 mg + Misoprostol
• Check coagulation profile

---

SECTION 10: INJURIES OF BIRTH CANAL

---

Q134. INJURIES OF BIRTH CANAL

Common Perineal Injuries During Birth:

3 Degrees of Perineal Tear:

Causes of Cervical Tear:

• Precipitate labour
• Forced delivery through undilated cervix
• Instrumental delivery (forceps)
• Large baby
• Rigidity of cervix

Management:

• Repair all lacerations promptly
• 3rd degree: specialist repair under GA/spinal in OT
• Antibiotics, laxatives (avoid constipation), anal sphincter exercises

---

SECTION 11: PLACENTAL COMPLICATIONS

---

Q129. RETAINED PLACENTA

Causes:

• Uterine atony (bladder not emptied)
• Morbidly adherent placenta (accreta/increta/percreta)
• Trapped placenta (cervical closure before placenta delivered)
• Constriction ring formation
• Partial separation (commonest reason for retention)

Management:

RETAINED PLACENTA
        │
        ▼
Empty bladder → Controlled cord traction
        │
If fails → Oxytocin 10 IU in 10 mL N. saline via umbilical vein
        │
If fails → Manual removal of placenta (MROP) under analgesia
        │
If adherent → Laparotomy / hysterectomy

---

Q135. PELVIC HAEMATOMA

Causes:

• Perineal/vaginal lacerations
• After episiotomy repair
• Forceps delivery
• Inadequate haemostasis
• Coagulopathy

Homoeopathic Treatment: (as requested)

• Arnica montana - initial trauma, haematoma
• Hamamelis - venous haemorrhage
• Bellis perennis - deep tissue bruising
• Calendula - prevents infection, promotes healing

---

SECTION 12: NEONATAL TOPICS

---

Q189. ASPHYXIA NEONATORUM

Causes:

• Antepartum: APH, pre-eclampsia, maternal anaemia, IUGR, cord prolapse
• Intrapartum: Obstructed/prolonged labour, fetal distress, meconium aspiration
• Neonatal: Prematurity, RDS, congenital anomalies

APGAR Score:

• 7-10: Normal
• 4-6: Moderate asphyxia
• 0-3: Severe asphyxia

Resuscitation (NRP - ABC):

NEONATAL RESUSCITATION FLOWCHART
        │
        ▼
Dry, Warm, Stimulate (30 sec)
        │
APGAR 7-10? → Routine care
        │
APGAR 4-6?
        │
        ▼
Bag and Mask Ventilation (PPV)
O2 at 21% (room air) initially
30 breaths/min
        │
APGAR 0-3 / No improvement
        │
        ▼
Intubation + Chest compressions (3:1 ratio)
        │
Epinephrine 0.1 mg/kg IV/ET tube
        │
Consider: NaHCO3, volume expansion

---

Q190. NEONATAL JAUNDICE

Physiological vs Pathological:

Causes of Pathological Jaundice:

• Rh incompatibility / ABO incompatibility (haemolytic)
• Sepsis
• G6PD deficiency
• Congenital hypothyroidism
• Biliary atresia (conjugated)
• TORCH infections

Causes of Physiological Jaundice:

• Relatively short RBC lifespan in newborns (70-90 days)
• Immature hepatic conjugation (low UDPGT activity)
• Increased enterohepatic circulation

---

Q191. OPHTHALMIA NEONATORUM

Causes:

Management:

• Gonococcal: IV/IM Ceftriaxone 25-50 mg/kg x1 dose + irrigation
• Chlamydial: Oral Erythromycin x 14 days
• Prevention (Crede's prophylaxis): 1% silver nitrate drops OR Erythromycin 0.5% ointment into both eyes at birth

---

Q192/282. CHARACTERISTICS OF NEWBORN BABY

• Weight: 2.5-4.0 kg (avg 3.4 kg male, 3.3 kg female)
• Length: 48-52 cm
• Head circumference: 33-35 cm
• Chest circumference: 30-33 cm (HC > CC normally)
• Pulse: 120-160/min
• RR: 30-60/min
• Temperature: 36.5-37.5°C

1. Dry and warm immediately
2. Assess APGAR at 1 and 5 minutes
3. Clear airway (suction if needed)
4. Delayed cord clamping (1-3 min)
5. Skin-to-skin contact
6. Vitamin K 1 mg IM (prevents HDN)
7. Eye prophylaxis (Crede's)
8. Initiate breastfeeding within 1 hour
9. Newborn screening (heel-prick test)

---

Q193. WEANING OF INFANTS

• 6 months: Purees, mashed foods (cereals, fruits, vegetables)
• 7-8 months: Soft lumps, finger foods
• 9-12 months: Family foods, mashed

---

Q194. BREASTFEEDING

Advantages:

• Ideal nutrition (changes composition as baby grows)
• Passive immunity (IgA, lactoferrin)
• Reduces SIDS risk
• Lowers allergy risk
• Better cognitive development

• Reduces PPH (oxytocin release)
• Helps uterine involution
• Weight loss
• Reduces breast/ovarian cancer risk
• Lactational amenorrhea (natural contraception)
• Bonding

Contraindications:

• Active tuberculosis (untreated)
• HIV positive mother (in developed countries with safe water - AFASS criteria)
• Maternal medications: chemotherapy, radioactive iodine, certain antivirals
• Herpes simplex lesions on breast
• Galactosaemia in infant (rare)

---

Q196. PRETERM BABY

Maternal Causes:

• Infections (UTI, TORCH, GBS)
• Pre-eclampsia / hypertension
• Multiple pregnancy
• Cervical incompetence
• PROM
• APH

Fetal Causes:

• IUGR
• Fetal distress
• Congenital anomalies
• Multiple gestation

Complications:

• RDS (most common, due to surfactant deficiency)
• Intraventricular haemorrhage
• Necrotising enterocolitis
• Retinopathy of prematurity
• Patent ductus arteriosus
• Apnoea
• Hypothermia
• Hypoglycaemia
• Sepsis

---

Q197/198. IUGR & LBW

Causes:

• Malnutrition
• Anaemia
• Pre-eclampsia
• Smoking, alcohol, drugs
• Chronic illness (diabetes, renal disease)
• Infections

• Congenital anomalies
• Chromosomal abnormalities
• Multiple pregnancy

• Placental insufficiency
• Circumvallate placenta
• Placenta praevia

---

Q199. Rh INCOMPATIBILITY

Mechanism:

Rh-ve mother + Rh+ve fetus
        │
Fetal Rh+ve cells enter maternal circulation
(at delivery, abortion, trauma)
        │
Mother produces anti-Rh IgG antibodies
        │
In NEXT pregnancy: IgG crosses placenta
        │
Haemolyses fetal RBCs → Anaemia → Hydrops fetalis

Complications:

• Jaundice (haemolytic)
• Kernicterus (bilirubin encephalopathy)
• Hydrops fetalis (severe - ascites, oedema)
• Stillbirth

Prevention:

• Anti-D immunoglobulin (RhoGAM) 300 mcg IM:
  • At 28 weeks (prophylactic)
  • Within 72 hrs of delivery (if baby Rh+ve)
  • After abortion, ectopic, amniocentesis

---

SECTION 13: CONGENITAL ABNORMALITIES

---

Q200. ANENCEPHALY

Causes:

• Folic acid deficiency (most important preventable cause)
• Genetic (multifactorial)
• Valproate exposure
• Diabetes mellitus
• Hyperthermia in early pregnancy

---

Q201. HYDROCEPHALUS

Causes:

• Aqueductal stenosis (most common)
• Spina bifida (Arnold-Chiari malformation)
• Dandy-Walker malformation
• TORCH infections (Toxoplasma, CMV)
• Intraventricular haemorrhage

---

Q203. DOWN'S SYNDROME (Trisomy 21)

Features:

• Flat facial profile, slanted eyes
• Epicanthal folds, Brushfield spots
• Low-set ears
• Single palmar crease (Simian crease)
• Short neck, hypotonia
• Intellectual disability
• Congenital heart defects (40-50%)

Associations:

• Increased risk with advanced maternal age (>35 years)
• Risk at 35 = 1:350; at 45 = 1:30

Screening:

• 1st trimester: Nuchal translucency + PAPP-A + free beta-hCG (combined test)
• 2nd trimester: Triple test (AFP, estriol, beta-hCG)
• Cell-free fetal DNA (cfDNA / NIPT) - most sensitive

---

SECTION 14: PUBLIC HEALTH OBSTETRICS

---

Q204. PERINATAL MORTALITY

Causes:

• Asphyxia (most common)
• Prematurity
• Birth trauma
• Infections (sepsis, TORCH)
• Congenital anomalies
• APH, PPH

Predisposing Factors:

• Low SES
• Poor ANC attendance
• Grand multiparity
• Extremes of age
• Multiple pregnancy
• Anaemia
• Hypertensive disorders

Prevention:

• Good ANC (detect high-risk pregnancies)
• Skilled birth attendance
• Emergency obstetric care
• Neonatal resuscitation training
• Corticosteroids for preterm
• Safe delivery practices

---

Q207. SAFE MOTHERHOOD

Pillars (4 Pillars of Safe Motherhood):

1. Family planning
2. Antenatal care
3. Clean/safe delivery
4. Essential obstetric care (EmOC)

Key Initiatives:

• JSY (Janani Suraksha Yojana) - India
• JSSK (Janani Shishu Suraksha Karyakram) - India
• LaQshya programme
• Pradhan Mantri Matru Vandana Yojana

---

Q208. MATERNAL MORTALITY

Causes:

• PPH (most common direct cause globally)
• Hypertensive disorders (eclampsia)
• Sepsis
• Obstructed labour
• Unsafe abortion

• Anaemia
• Cardiac disease
• Hepatitis
• Malaria

Steps to Reduce Maternal Mortality:

1. Improve ANC coverage
2. Skilled birth attendance at every delivery
3. 24/7 emergency obstetric care
4. Blood transfusion facilities
5. Postnatal care
6. Family planning access
7. Female education
8. Iron/folate supplementation
9. Prevention of unsafe abortion (MTP Act)

---

Q210/211. MEDICOLEGAL ASPECTS

Q210: Sex Determination Act (PCPNDT Act):

• Pre-Conception and Pre-Natal Diagnostic Techniques Act, 1994
• Prohibits sex determination of fetus
• Bans sex-selective abortion
• All ultrasound centres must register
• Punishment: 3-5 years imprisonment + fine
• Form F mandatory for every ultrasound

Q211: MTP Act Indications:

• Up to 20 weeks: Any registered practitioner with reason
• Up to 24 weeks: Two practitioners required, for specified categories:
  • Survivors of rape/sexual assault
  • Minors
  • Change in marital status
  • Fetal anomaly (major)
  • Physically disabled women
  • Mentally ill women
  • Emergency
• After 24 weeks: Only for substantial fetal anomaly (Medical Board approval)

---

SECTION 15: BASIC OBSTETRICS

---

Q253. PLACENTA

Structure:

• Fetal side: Smooth, covered by amnion, umbilical cord attaches
• Maternal side: Rough, 15-20 cotyledons separated by septa
• Size: 18-20 cm diameter, 2-3 cm thick, weight 500-600 g (1/6th fetal weight)

Functions:

1. Nutrition (glucose, amino acids transfer)
2. Respiration (O2 transfer, CO2 removal)
3. Excretion (urea, bilirubin)
4. Hormone production:
   • hCG (from 6-8 weeks, peaks at 10 weeks)
   • hPL (from 6 weeks, increases throughout)
   • Progesterone (from 10 weeks, takes over from corpus luteum)
   • Oestrogen
5. Barrier function (partial - cannot stop all pathogens)
6. Storage (glycogen, iron, Ca²⁺)

---

Q254. AMNIOTIC FLUID

Physical Features:

• Clear, slightly yellowish
• Volume: 800-1000 mL at term
• pH: 7.1-7.3 (alkaline)
• Specific gravity: 1.008
• Osmolality: 255-260 mOsm/L

Composition:

• Water (98-99%)
• Dissolved proteins
• Glucose, lipids
• Fetal cells (used in amniocentesis)
• Lanugo, vernix

Functions:

• Protects fetus from trauma
• Prevents cord compression
• Maintains temperature
• Allows fetal movement (limb development)
• Lung development (fluid breathing)
• Maintains amniotic pressure

---

Q257. DIAMETERS OF FETAL SKULL

---

Q264. EDD (EXPECTED DATE OF DELIVERY) - NAEGELE'S FORMULA

• USG: most accurate in 1st trimester (CRL measurement)
• Quickening: 18-20 weeks (para); 20-22 weeks (primigravida)
• Fundal height: at 20 weeks = umbilicus level

---

Q270. ANTENATAL CARE (ANC)

Aims:

1. Promote, protect, restore maternal and fetal health
2. Early detection and treatment of complications
3. Prepare mother for labour, delivery, and puerperium
4. Ensure a live, healthy mother and baby

Procedure at 1st ANC Visit:

• Complete history (obstetric, medical, family, drug)
• Examination (general, obstetric, P/V)
• Blood: CBC, blood group/Rh, VDRL, HIV, HBsAg, rubella immunity
• Urine: routine, culture
• USG: dating scan (8-12 weeks), NT scan (11-14 weeks)
• Start: Folic acid 5 mg/day (started before conception ideally), Iron, Calcium

Subsequent Visits:

• Monthly until 28 weeks
• Fortnightly 28-36 weeks
• Weekly from 36 weeks

Important Investigations for Fetal Well-being (Late Pregnancy):

• USG fetal growth scan (28, 34, 36 weeks)
• BPP (Biophysical Profile)
• NST (Non-stress test)
• Doppler (umbilical artery)
• Amniocentesis (if needed)
• Kick count (10 movements/12 hrs)

---

Q278. PUERPERIUM & LOCHIA

Normal Puerperium:

• Period of 6-8 weeks after delivery when reproductive organs return to pre-pregnancy state.

Types of Lochia:

Clinical Assessment of Uterine Involution:

---

Q279. LACTATION & COLOSTRUM

Colostrum:

• Yellowish fluid secreted 2-4 days before and after delivery
• High in protein, IgA, lactoferrin, macrophages
• Low in fat and lactose
• Very valuable - do not discard!

4 Stages of Lactation:

1. Mammogenesis: Breast development during pregnancy (estrogen + progesterone + prolactin)
2. Lactogenesis I: Colostrum production (from 16 weeks gestation)
3. Lactogenesis II: Milk "coming in" (2-3 days post-delivery after progesterone withdrawal)
4. Galactopoiesis: Maintenance of milk supply (prolactin + suckling reflex + oxytocin)

---

Q256. FETAL CIRCULATION & CHANGES AT BIRTH

Fetal Circulation (Special Features):

• Ductus venosus: Bypasses liver (umbilical vein → IVC)
• Foramen ovale: Bypasses lungs (RA → LA)
• Ductus arteriosus: Bypasses pulmonary circulation (PA → Aorta)
• Fetal Hb (HbF) has higher O2 affinity
• Blood PO2 is low (~30 mmHg) but adequate due to HbF

Changes at Birth:

AT BIRTH
Lungs expand → Pulmonary resistance ↓ → Pulmonary blood flow ↑
                                              │
                                              ▼
                                    LA pressure rises
                                              │
                                     Foramen ovale CLOSES
                                              │
                        Cord cut → Umbilical vessels constrict
                                              │
                              Ductus venosus closes (becomes ligamentum venosum)
                              Ductus arteriosus closes (becomes ligamentum arteriosum)
                              Umbilical arteries (→ lateral umbilical ligaments)
                              Umbilical vein (→ ligamentum teres)

---

Q260-262. SIGNS & SYMPTOMS OF PREGNANCY BY TRIMESTER

1st Trimester (< 12 weeks):

2nd Trimester (12-28 weeks):

• Quickening (18-20 weeks primigravida; 16-18 weeks multigravida)
• Reduction in nausea
• Breast tenderness

• Visible uterine enlargement
• FHB by fetoscope (20 weeks), Doppler (12-14 weeks)
• Ballottement

• Anatomy scan (18-20 weeks)
• GCT/OGTT for GDM (24-28 weeks)
• Triple test (15-18 weeks)

3rd Trimester (28-40 weeks):

---

Q263. DIFFERENTIAL DIAGNOSIS OF PREGNANCY

---

SECTION 16: MANAGEMENT OF LABOUR IN SPECIAL SITUATIONS

---

Q177. MANAGEMENT OF LABOUR IN APH

Principles:

• Admit immediately
• IV access x2, cross-match blood, Foley catheter
• Do NOT do vaginal examination before USG (rule out placenta praevia)
• Monitor fetal wellbeing (CTG)
• Stabilise mother

• LSCS is route of delivery in major praevia
• Vaginal delivery possible in minor grades

• If fetal distress: immediate LSCS
• If mild abruption + alive fetus + cephalic + favourable cervix: augment and deliver
• Dead fetus: vaginal delivery preferred; correct coagulopathy

---

Q174. ECLAMPSIA MANAGEMENT DURING PREGNANCY, LABOUR, POSTNATAL

During Pregnancy (Antenatal Eclampsia):

1. MgSO4 loading + maintenance (Pritchard's or Zuspan's regimen)
2. Antihypertensives (IV Labetalol / Hydralazine)
3. Stabilise ≥4 hrs, then deliver
4. LSCS if: unfavourable cervix, fetal distress, failed induction

During Labour (Intrapartum Eclampsia):

1. Continue MgSO4
2. Shorten 2nd stage (forceps/ventouse)
3. Monitor urine output, reflexes, RR closely
4. Paediatrician at delivery

Postnatal (Postpartum Eclampsia):

1. Continue MgSO4 for 24 hrs after last seizure
2. Antihypertensives until BP settles
3. Fluid balance strictly (risk of pulmonary oedema)
4. Can breastfeed (MgSO4 safe)
5. Contraception: avoid COC (thrombosis risk); use POP or barrier

Zuspan's Regimen (alternative to Pritchard's):

• Loading: 4g IV over 20 min
• Maintenance: 1g/hr IV infusion

---

Q175. SEVERE HYPERTENSION - MANAGEMENT

---

Q171. SEVERE HYPEREMESIS GRAVIDARUM - MANAGEMENT

Management:

1. Admit - IV access, strict fluid balance
2. Rehydration: IV Normal saline / Hartmann's
3. Antiemetics:
   • Cyclizine 50 mg TDS (1st line)
   • Ondansetron 4 mg TDS (caution in 1st trimester re: cleft palate - controversial)
   • Metoclopramide 10 mg TDS
   • Promethazine 25 mg TDS
4. Vitamins: Pyridoxine (B6) + Thiamine (prevent Wernicke's encephalopathy)
5. Thromboprophylaxis (high-risk state)
6. Enteral nutrition (if <3 kg weight loss); TPN rarely needed

---

• PPH 4 Ts: Tone, Tissue, Trauma, Thrombin
• MgSO4 Pritchard's: 4g IV + 10g IM loading; 5g IM 4-hrly maintenance
• Antidote to MgSO4 toxicity: Calcium gluconate 1g IV
• APGAR: Appearance, Pulse, Grimace, Activity, Respiration
• Naegele's formula: LMP + 9 months + 7 days
• Types of perineal tears: 1st (skin), 2nd (muscles), 3rd (sphincter), 4th (rectal mucosa)
• Ectopic most common site: Ampulla of fallopian tube
• Molar pregnancy USG: "Snowstorm pattern"
• Down's syndrome: Trisomy 21, increased with advanced maternal age
• Rh incompatibility prevention: Anti-D within 72 hours of delivery
• Active management 3rd stage (AMTSL): Oxytocin 10 IU IM immediately after delivery

---

📚 OBSTETRICS - REMAINING LAQ ANSWERS (Part 2)

Source: DC Dutta's Obstetrics + Standard References

---

SECTION 1: REMAINING LABOUR TOPICS

---

Q116. CLINICAL, PER ABDOMINAL & VAGINAL FINDINGS - BREECH PRESENTATION

Per Abdominal Examination:

Per Vaginal Examination:

---

Q120. HOMOEOPATHIC REMEDIES - BREECH MANAGEMENT

• Pulsatilla: Most important remedy; corrects malpresentation; suited to mild, yielding women; given at 34-36 weeks
• Cauphyllum: Ineffective uterine contractions with malpresentation
• Arnica: After correction, to prevent soreness
• Nux vomica: Breech with constipation and irritability

---

Q121. HOMOEOPATHIC REMEDIES IN MALPRESENTATIONS & MALPOSITIONS

• Pulsatilla 200/1M: Classic remedy for all malpresentations (breech, transverse, OP)
• Cauphyllum: Cervical dystocia, ineffectual pains
• Kali carb: Persistent OP position, back labour (backache ++, pains go to buttocks)
• Sepia: Bearing down pains, prolapse tendency
• Gelsemium: Rigid os, nervous patient, no uterine force

---

Q124. TYPES OF CERVICAL DYSTOCIA

Types:

1. Constriction of Internal Os:
   • Most common type
   • Fibrous tissue replaces muscle
   • Causes: previous cauterisation, amputation, cervicitis
2. Constriction of External Os:
   • Rarely obstructs labour
   • May cause annular detachment
3. Carcinoma of Cervix:
   • Rigid, infiltrated cervix
4. Rigid Undilated Cervix (Primary):
   • No organic cause
   • Young primigravida
   • Response to oestrogen poor
5. Cervical Fibrosis:
   • After previous surgery (cone biopsy, LLETZ, Shirodkar suture)

Management:

• Await spontaneous dilation with good contractions
• If no progress: LSCS

---

Q113. ABNORMAL DELIVERY - REMEDIES (Homoeopathic)

• Cauphyllum: Exhausting, ineffective, irregular contractions; cervix rigid; great exhaustion
• Cimicifuga (Actaea racemosa): Sharp, erratic pains flying across abdomen; nervous, fearful patient
• Kali carb: Labour pains in back; cutting pains from back to thighs; exhaustion
• Arnica: After instrumental delivery; bruised, sore feeling
• Bellis perennis: Deep tissue trauma
• Secale cornutum: Prolonged, exhausting contractions; thin, cachectic women; danger of gangrene
• China: After haemorrhage with exhaustion; restlessness

---

Q112. ABNORMAL PREGNANCY - REMEDIES (Homoeopathic)

• Pulsatilla: Malpresentation; emotional, weepy patient
• Sepia: Morning sickness all day; bearing down sensation; indifferent to family
• Nux vomica: Morning sickness <10 AM; irritable, ambitious patient; constipation
• Ipecac: Persistent nausea not relieved by vomiting; clean tongue
• Symphytum: Bone pain in pregnancy; fractured coccyx
• Calcarea carb: Obesity in pregnancy; sweaty head; fearful; leucorrhoea

---

Q111. REMEDIES FOR NEW BORN (Homoeopathic)

• Arnica: For trauma of birth; bruising; protects against haemorrhage
• Opium: Asphyxia neonatorum (pale, unconscious, no reaction)
• Antimonium tartaricum: Mucus rattle in chest; difficulty breathing at birth
• Carbo veg: Near-dead neonate; cold, cyanosed, only fan-blowing revives
• Chamomilla: Irritable, crying baby; neonatal colic
• Aconite: High fever, restlessness in newborn

---

SECTION 2: REMAINING PLACENTAL/POSTPARTUM TOPICS

---

Q129. RETAINED PLACENTA - CAUSES (Detailed)

Causes:

RETAINED PLACENTA
├── PARTIAL SEPARATION (most common)
│   ├── Inadequate uterine contractions
│   └── Failure of 3rd stage mechanism
├── TRAPPED PLACENTA
│   └── Cervix closes before placenta descends
├── MORBIDLY ADHERENT PLACENTA
│   ├── Placenta accreta (chorionic villi adhere to myometrium)
│   ├── Placenta increta (invade into myometrium)
│   └── Placenta percreta (penetrate through serosa)
└── CONSTRICTION RING
    └── Cervical spasm traps placenta

• Previous LSCS (most important)
• Previous uterine surgery
• Placenta praevia overlying a scar
• Grand multiparity
• Previous uterine curettage

---

Q133. IUD - DIAGNOSTIC FEATURES (Complete)

• Absent fetal cardiac activity
• No fetal movements
• Macerated fetus appearance
• Spalding's sign: overlapping skull bones
• Collapsed fetal skull
• Oligohydramnios

• DIC / Coagulopathy (if >4 weeks)
• Infection / Sepsis
• Psychological trauma / Grief
• Maceration of fetus

---

Q134. INJURIES OF BIRTH CANAL (Complete with Homoeopathic Remedies)

Homoeopathic Remedies:

• Arnica: First remedy for all birth canal injuries; reduces bruising and haematoma
• Calendula: Promotes healing of torn perineum; prevents infection; use as wash
• Bellis perennis: Deep muscular injury; bruised sore perineum
• Staphysagria: Lacerated perineum with sharp cutting pains; injury from surgical incision (episiotomy)
• Hamamelis: Venous bleeding from tears; vulval varicosities
• Hypericum: Nerve-rich areas injury (perineal region); shooting nerve pains after tear

---

SECTION 3: REMAINING ABORTION TOPICS

---

Q138. ABORTION - C/F, INVESTIGATIONS, HOMOEOPATHIC REMEDIES

Clinical Features by Type:

Investigations:

• Urine beta-hCG
• Serum beta-hCG (serial)
• USG (TVS most sensitive)
• CBC, blood group, Rh
• Coagulation profile (for missed/septic)
• HVS culture (septic)

Homoeopathic Remedies for Abortion:

• Sabina: Most important remedy; bright red bleeding + clots; pain from sacrum to pubis; threatened abortion at 3rd month
• Secale cornutum: Dark, offensive blood; thin cachectic patients; bleeding continuous
• Ipecac: Bright red gushing bleeding with nausea
• Trillium pendulum: Bright red bleeding; better by binding hips tightly
• Viburnum opulus: Threatened abortion; cramping pains extending to thighs
• Cauphyllum: Habitual abortion; weakness of uterus
• Cimicifuga: Abortion at 3rd month; rheumatic tendency
• Pulsatilla: Retained POC after incomplete abortion

---

Q144. MOLAR PREGNANCY - INVESTIGATIONS & D/D

Investigations:

Differential Diagnosis:

---

SECTION 4: HYPERTENSIVE DISORDERS (Remaining)

---

Q173. SEVERE PRE-ECLAMPSIA - MANAGEMENT

• BP ≥160/110 on two occasions
• Proteinuria ≥5g/24hrs
• Oliguria <500 mL/24hrs
• Pulmonary oedema / cyanosis
• Epigastric/RUQ pain (hepatic capsule distension)
• Headache / visual disturbances
• Platelet count <100,000
• Impaired liver function (ALT/AST >2x normal)
• IUGR

Management:

SEVERE PRE-ECLAMPSIA MANAGEMENT
            │
            ▼
ADMIT to HDU/ICU
            │
   ┌────────┼──────────────┐
   │        │              │
CONTROL  SEIZURE        DELIVER
  BP     PROPHYLAXIS
   │        │              │
IV Labetalol MgSO4     After
20 mg IV  4g IV over  stabilisation
then      20 min +    (aim within
40-80 mg  1g/hr infusion 24-48 hrs)
q10 min   (Zuspan)
OR
Hydralazine
5 mg IV q20 min
OR
Nifedipine
10-20 mg oral
            │
     Monitor EVERY 4 HOURS:
     - BP
     - Urine output (>25 mL/hr)
     - Reflexes
     - RR (>12/min)
     - Oxygen saturation
     - FHR (CTG)
            │
     Fluid restriction: 80-100 mL/hr
     (prevent pulmonary oedema)
            │
     Corticosteroids if <34 weeks
     (for fetal lung maturity)

---

Q172. PUERPERAL SEPSIS - MANAGEMENT

MANAGEMENT PROTOCOL:

PUERPERAL SEPSIS MANAGEMENT
            │
            ▼
Step 1: CULTURES first (blood + HVS + urine)
            │
Step 2: ANTIBIOTICS (BROAD SPECTRUM)
Triple therapy:
• Ampicillin 2g IV 6-hrly
• Gentamicin 5 mg/kg IV 24-hrly
• Metronidazole 500 mg IV 8-hrly
            │
Step 3: SUPPORTIVE CARE
• IV fluids (maintain urine output >0.5 mL/kg/hr)
• Antipyretics (Paracetamol)
• Analgesics
• Heparin (if septic pelvic thrombophlebitis)
            │
Step 4: REMOVE SOURCE
• Retained products → Suction evacuation
• Pelvic abscess → Surgical drainage
• Peritonitis → Laparotomy
• Perineal wound infection → Remove sutures, clean
            │
Step 5: COMPLICATIONS
• Septic shock → ICU, vasopressors, organ support
• DIC → FFP, platelets, cryoprecipitate
• ARF → HDU, fluids, dialysis if needed

---

SECTION 5: REMAINING MEDICAL DISORDERS

---

Q152. RETENTION OF URINE - CAUSES

Causes in Obstetrics:

• Retroverted gravid uterus (10-14 weeks - most classic cause)
• Fibroid pressing on urethra
• Ovarian cyst impacted in pelvis
• Urethral stricture

• Perineal pain/oedema (reflex retention - most common)
• Perineal haematoma
• Pudendal nerve damage
• Prolonged labour (bladder atony)
• Epidural analgesia (most common iatrogenic cause)
• Spinal anaesthesia
• PPH causing hypotension → reduced bladder sensation

Management:

• Catheterize (relieve acute retention)
• Treat underlying cause
• Pelvic floor exercises
• Trial of void after 24-48 hrs

---

Causes of Increased Frequency of Micturition in Pregnancy:

• Growing uterus pressing on bladder
• Increased blood volume → increased renal filtration
• hCG effect

• Engagement of head → pressure on bladder
• Reduced bladder capacity

• UTI (must rule out)
• Diabetes mellitus (polyuria)
• Gestational diabetes

---

Q157. HYPERTHYROIDISM IN PREGNANCY - COMPLICATIONS

• Graves' disease (autoimmune - most common)
• Hyperemesis gravidarum (hCG stimulation of TSH receptors)
• Hydatidiform mole
• Toxic nodular goitre

Complications:

• Thyroid storm (obstetric emergency)
• Cardiac failure / arrhythmia
• Pre-eclampsia
• Preterm labour
• Miscarriage
• Anaemia

• IUGR
• Prematurity
• Neonatal hyperthyroidism (TSI crosses placenta)
• Neonatal goitre
• Fetal tachycardia

Management:

• Propylthiouracil (PTU) - preferred in 1st trimester
• Carbimazole - 2nd and 3rd trimester (PTU causes liver toxicity with prolonged use)
• Beta-blockers (Propranolol) for symptom control
• Surgery: 2nd trimester if needed
• Radioactive iodine: CONTRAINDICATED in pregnancy

---

Q159. MANAGEMENT OF ASTHMA IN PREGNANCY

Principles: (treat asthma aggressively - uncontrolled asthma more dangerous than drugs)

• Salbutamol (SABA) - safe all trimesters
• Budesonide (ICS) - preferred
• Ipratropium - safe
• Oral prednisolone - safe (small increased risk cleft palate 1st trimester)

• NSAIDs (aspirin-sensitive asthma)
• Non-selective beta-blockers (e.g., propranolol)

Homoeopathic Remedies for Asthma in Pregnancy:

• Arsenicum album: Asthma at midnight-3 AM; restlessness; burning in chest; worse cold
• Natrum sulphuricum: Asthma worsens in damp weather; every cold goes to chest
• Ipecac: Asthma with nausea; loose rattling cough with vomiting
• Sambucus nigra: Asthma in infants and pregnant women; sudden attacks at night
• Blatta orientalis: Chronic asthma; obese patients

---

Q160. MANAGEMENT OF EPILEPSY IN PREGNANCY

Key Issues:

• AEDs (anti-epileptic drugs) are teratogenic but seizures also harm baby
• Goal: seizure control with minimum teratogenic risk

Safe AEDs Preferred:

Avoid if possible:

Management:

• Folic acid 5 mg/day (before conception + throughout)
• USG screening for anomalies at 18-20 weeks
• Vitamin K 10 mg/day in last 4 weeks (enzyme-inducing AEDs → neonatal bleeding)
• Neonatal: Vitamin K 1 mg IM at birth
• Breastfeeding: allowed (AED levels in milk low)

Homoeopathic Remedies:

• Belladonna: Sudden, violent convulsions; hot, red face; staring eyes
• Cicuta virosa: Convulsions with distorted postures; head thrown back
• Cuprum metallicum: Convulsions starting in fingers/toes; clenched thumbs
• Nux vomica: Convulsions from digestive disturbance; irritable, chilly patient

---

Q161. TB IN PREGNANCY - INVESTIGATIONS & MANAGEMENT

Investigations:

• Sputum AFB (3 samples) - most important
• Sputum culture (LJ medium - takes 6-8 weeks)
• GeneXpert (rapid - 2 hrs)
• Mantoux test (positive does not mean active disease)
• CXR (with shielding after 1st trimester)
• CBC, LFT (baseline before anti-TB drugs)

Management:

• Allowed (small amounts in milk, not harmful)
• Give Isoniazid prophylaxis to newborn if mother sputum-positive

---

Q158. CVD (CARDIOVASCULAR DISEASE) IN PREGNANCY - C/F, COMPLICATIONS, MANAGEMENT

NYHA Classification:

Danger Periods:

1. 28-32 weeks (maximum blood volume increase)
2. During labour (each contraction adds 300-500 mL blood to circulation)
3. Immediately postpartum (auto-transfusion of 500-800 mL)

Clinical Features:

• Dyspnoea on exertion → rest
• Orthopnoea (2-3 pillow)
• PND (paroxysmal nocturnal dyspnoea)
• Haemoptysis
• Cyanosis, clubbing
• Raised JVP
• Pulsating neck veins
• Murmurs (mitral stenosis most common in India)

Complications:

• Cardiac failure (main complication)
• Pulmonary oedema
• SBE (Subacute Bacterial Endocarditis)
• Pulmonary hypertension
• Thromboembolic events
• Maternal death

Management:

• Antenatal: Iron + folate, limit activity (NYHA III-IV = bed rest), diuretics if failure, anticoagulants (prosthetic valves), antibiotic prophylaxis
• Labour: Left lateral position, O2, epidural analgesia (reduces cardiac work), shorten 2nd stage (forceps/ventouse), avoid bearing down
• Delivery: Vaginal preferred; LSCS only for obstetric indication
• Postpartum: Watch 24-48 hrs (redistribution); diuretics if signs of failure; contraception: avoid OCP (thromboembolic risk); IUCD with caution

---

SECTION 6: REMAINING PROCEDURES

---

Q162. VERSION - COMPLETE

Internal Podal Version:

1. Hand inserted into uterus
2. Fetal foot grasped
3. Brought down to vagina → footling breech
4. Breech extraction performed

• Contracted pelvis
• Ruptured uterus threatened
• Ring constriction
• Fetal distress (then direct delivery)

---

Q163. EPISIOTOMY - COMPLETE

TYPES with Diagram:

                CLITORIS
                   |
         ──────────┼──────────
        |                    |
   URETHRA                  |
        |                   |
   VAGINAL ────────────────
   ORIFICE
        |
    ────┼─────── Mediolateral (45°)
        |
        │  ← Median/Midline
        │
     ANUS

Timing of Episiotomy:

• Cut ONLY when head distends perineum 3-4 cm (crowning)
• Too early → excessive blood loss
• Too late → tear still occurs

Repair Technique:

1. First: Vaginal mucosa - continuous interlocking suture
2. Second: Deep perineal muscles - interrupted sutures
3. Third: Skin - subcuticular continuous suture (best cosmetic result) OR interrupted

---

Q164. CAESAREAN SECTION (LSCS) - HOMOEOPATHIC REMEDIES POST-CS

• Staphysagria: Main remedy after surgical incision; cutting/stinging pain along scar; grief/violation feeling
• Arnica: Post-operative soreness and bruising; promotes healing
• Calendula: Promotes wound healing; prevents keloid
• Bellis perennis: Deep tissue healing post-CS; soreness in pelvis
• Hypericum: Nerve pain along scar
• China: Post-CS blood loss + exhaustion + flatulence

---

Q165. FORCEPS - COMPLETE

Application Steps (Neville-Barnes):

1. Catheterize bladder
2. Confirm position of head
3. Introduce left blade first (along left hand guide)
4. Introduce right blade
5. Lock the blades
6. Check correct application (sagittal suture midway, posterior fontanelle 1 finger above shanks)
7. Traction in axis of pelvis (Pajot's manoeuvre for outlet forceps)
8. Episiotomy at crowning
9. Remove forceps before delivery of face

Conditions Contraindicating Forceps:

• Head not engaged
• CPD
• Cervix not fully dilated
• Position unknown
• Live fetus with hydrocephalus
• Coagulopathy (relative)

---

SECTION 7: SPECIAL MANAGEMENT SITUATIONS

---

Q178. MANAGEMENT OF LABOUR IN MULTIPLE PREGNANCY

Antenatal:

• Increased monitoring (fortnightly scans)
• Iron + folic acid
• Cervical length monitoring
• Tocolytics if preterm
• Corticosteroids if <34 weeks

Intrapartum:

MULTIPLE PREGNANCY LABOUR MANAGEMENT
            │
Check presentation of Twin 1
            │
    ┌───────┴────────┐
    │                │
Cephalic       Non-cephalic
    │                │
Vaginal        LSCS
delivery
possible
    │
IV access x2, blood available
CTG monitoring for both twins
            │
After Twin 1 delivered:
Check presentation of Twin 2 (USG)
            │
    ┌───────┴────────┐
    │                │
Cephalic       Transverse/breech
    │                │
Augment        ECV or internal
with           podal version
oxytocin       then vaginal delivery
            │
3rd stage: AMTSL (high risk PPH)
Active: Oxytocin 10 IU IM + 20 IU IV infusion

---

Q179. MANAGEMENT OF LABOUR IN OLIGOHYDRAMNIOS

Causes:

• Post-dates pregnancy
• IUGR/placental insufficiency
• PPROM
• Fetal renal agenesis (Potter's sequence)
• Bilateral renal agenesis

Management in Labour:

• Continuous CTG monitoring
• Amnioinfusion (saline infusion into amniotic cavity via intrauterine catheter) - reduces cord compression
• Low threshold for LSCS (fetal distress likely)
• Have neonatal team ready

---

Q180. MANAGEMENT OF LABOUR IN POLYHYDRAMNIOS

Causes:

• Idiopathic (most common)
• Fetal anomalies (esophageal atresia, anencephaly, neuromuscular disorders)
• Gestational diabetes
• Multiple pregnancy (TTTS)
• Hydrops fetalis

Complications in Labour:

• Malpresentation / malposition
• Cord prolapse (on AROM)
• PPH (uterine atony)
• Abruption (sudden decompression)
• Premature labour

Management:

• Cautious ARM (controlled - remove small amount of fluid slowly)
• Keep hand on presenting part during ARM (prevent cord prolapse)
• Immediate delivery if fetal distress
• Active 3rd stage management (PPH risk)
• Indomethacin (reduces AFI - used antenatally, not in labour)

---

Q181/182. MANAGEMENT OF LABOUR IN SEVERE ANAEMIA / ASTHMA / CVD / HIV

Severe Anaemia (Hb <7 g/dL):

• Blood transfusion before labour (aim Hb >10 g/dL at delivery)
• If in active labour with severe anaemia:
  • Packed red cells transfusion with IV Furosemide (prevent cardiac overload)
  • Oxygen supplementation
  • Avoid prolonged labour (increases oxygen demand)
  • Instrumental delivery to shorten 2nd stage
  • Active 3rd stage (PPH risk high)
  • Antibiotics (susceptible to infection)

HIV in Pregnancy:

• PREVENTION OF MOTHER-TO-CHILD TRANSMISSION (PMTCT):
  • ART (triple therapy) to ALL HIV+ pregnant women regardless of CD4 count
  • Continue ART lifelong (Option B+)
  • LSCS if viral load >1000 copies/mL at 36 weeks
  • Vaginal delivery acceptable if viral load undetectable
  • Avoid ARM / FBS / scalp electrodes (increase transmission)
  • Neonatal prophylaxis: Nevirapine syrup from birth x 6 weeks
  • Breastfeeding: Avoid if safe alternatives available (India: breastfeeding with ART is now recommended given safe water access issues)

---

Q183. MANAGEMENT OF LABOUR IN ELDERLY PRIMIGRAVIDA

Risks:

• Higher rate of pre-eclampsia, GDM
• Chromosomal abnormalities (Down's, etc.)
• Placenta praevia
• Fibroids
• Higher LSCS rate

Management in Labour:

• Elective IOL at 39-40 weeks (many units)
• Continuous CTG monitoring
• Low threshold for LSCS
• Active 3rd stage
• Neonatal team (risk of chromosomal abnormality)
• Offer prenatal diagnosis (amniocentesis/NIPT)

---

Q184. MANAGEMENT OF LABOUR WITH BAD OBSTETRIC HISTORY

Causes:

• Antiphospholipid antibody syndrome (APAS)
• Thrombophilia
• Cervical incompetence
• Uterine anomaly
• Genetic factors
• Infections
• Endocrine disorders (hypothyroidism, PCOS)

Management in Labour:

• High-risk unit delivery
• Continuous CTG
• IV access early
• Paediatrician at delivery
• Active management of 3rd stage
• Extra vigilance for PPH

---

Q185/186. LABOUR WITH FIBROIDS / UTERINE PROLAPSE

Fibroids (Uterine Leiomyomata):

• Malpresentation (distorts uterine cavity)
• Obstruction (cervical/lower segment fibroids)
• Inefficient uterine contractions
• PPH (atony, invasion of cotyledons)
• Retained placenta

• Continuous CTG
• Fibroid may "red degenerate" in labour (very painful)
• LSCS if fibroid at lower segment / cervix obstructs passage
• Do NOT remove fibroid at CS (risk of uncontrollable haemorrhage)

Uterine Prolapse:

• Obstructed labour (prolapse may worsen)
• Rupture of prolapsed tissue
• Infection
• PPH

• LSCS usually safest
• If vaginal: careful progress monitoring
• Pessary removed before labour
• Post-delivery: pelvic floor repair

---

SECTION 8: FETAL DISTRESS & BIRTH INJURIES

---

Q187. FETAL DISTRESS - CAUSES

Causes:

FETAL DISTRESS CAUSES
├── MATERNAL CAUSES
│   ├── Supine hypotension (aortocaval compression)
│   ├── Severe anaemia (Hb <7 g/dL)
│   ├── Pre-eclampsia / eclampsia
│   ├── Haemorrhage (APH, PPH)
│   ├── Hypotension (epidural, haemorrhage)
│   └── Prolonged labour / obstructed labour
├── PLACENTAL CAUSES
│   ├── Abruption
│   ├── Placenta praevia
│   ├── Placental insufficiency (post-maturity, IUGR)
│   └── Placenta infarction
└── FETAL/CORD CAUSES
    ├── Cord prolapse (most acute)
    ├── True knot / tight nuchal cord
    ├── Vasa praevia
    ├── Prematurity
    └── Fetal anaemia (Rh incompatibility)

Signs of Fetal Distress:

• FHR abnormalities:
  • Baseline tachycardia (>160 bpm)
  • Baseline bradycardia (<110 bpm)
  • Late decelerations (most ominous)
  • Variable decelerations (cord compression)
  • Reduced beat-to-beat variability (<5 bpm)
• Meconium-stained liquor (Type 2 or Type 3 = thick)
• Reduced fetal movements
• Abnormal FBS (pH <7.2 = acidosis)

---

Q188. BIRTH INJURIES IN NEWBORN - CAUSES

Types and Causes:

---

Q258. CAPUT SUCCEDANEUM

Mechanism of Formation:

• During labour, presenting part is enclosed within ring of os
• Venous and lymphatic flow distal to ring is obstructed
• Oedema forms in subcutaneous tissue of scalp
• Fluid is serosanguineous

Characteristics:

Importance:

• Indicates vertex presentation
• Indicates engagement
• Shows direction (position) of delivery - position of caput = occiput
• Usually resolves in 24-48 hrs
• No treatment needed

---

SECTION 9: REMAINING NEONATAL TOPICS

---

Q190. NEONATAL JAUNDICE - COMPLETE

Investigations:

• Serum bilirubin (total, direct, indirect)
• Blood group and Rh (baby and mother)
• Direct Coombs' test (DCT) - for isoimmune haemolysis
• CBC + peripheral smear
• G6PD assay
• TFT (hypothyroidism)
• TORCH titres (if infection suspected)
• USG abdomen (biliary atresia)

Treatment:

NEONATAL JAUNDICE TREATMENT
            │
        Bilirubin level?
            │
    ┌───────┴────────────┐
    │                    │
  <15 mg/dL         >15-20 mg/dL
  (full term)        (full term)
    │                    │
  Phototherapy       Exchange transfusion
    │                if rising rapidly
  "bili-lights"      despite phototherapy
  (decomposes
  bilirubin in skin)

---

Q195. ARTIFICIAL FEEDING - COMPLICATIONS

Complications:

• Aspiration (incorrect positioning)
• Over/underfeeding
• Gastroenteritis (formula contamination with unsafe water)
• NEC (necrotising enterocolitis) - higher risk than breastfed

• Diarrhoeal disease (major cause of infant mortality in developing countries)
• Respiratory infections
• Cow's milk protein allergy
• Constipation (formula more constipating)

• Obesity
• Type 2 diabetes
• Lower IQ
• Reduced bonding
• Higher allergy risk
• Reduced maternal benefits (no protection from cancer)

---

Q202. EXOMPHALOS - RISK FACTORS

Risk Factors:

• Chromosomal abnormalities (Trisomy 13, 18, 21) - in 50%
• Beckwith-Wiedemann syndrome
• Pentalogy of Cantrell (with cardiac defects)
• Advanced maternal age
• Low folic acid intake
• Maternal smoking / alcohol

---

Q205. STILL BIRTH - CAUSES

Causes:

CAUSES OF STILLBIRTH
├── MATERNAL (30%)
│   ├── Pre-eclampsia / eclampsia
│   ├── Diabetes mellitus
│   ├── Severe anaemia
│   ├── Antiphospholipid syndrome
│   └── Systemic infections (malaria, syphilis)
├── FETAL (25%)
│   ├── Congenital anomalies
│   ├── Chromosomal abnormalities
│   ├── IUGR
│   └── Infection (TORCH)
├── PLACENTAL (25%)
│   ├── Abruption (most acute)
│   ├── Placenta praevia
│   ├── Cord prolapse
│   ├── True cord knot
│   └── Velamentous cord insertion
└── UNEXPLAINED (20%)

---

Q206. NEONATAL DEATHS

Causes:

Prevention:

• Antenatal corticosteroids for preterm
• Skilled birth attendance
• Neonatal resuscitation training (NRP)
• Kangaroo Mother Care (KMC) for preterm
• Breastfeeding promotion
• Infection prevention (cord care, eye care, Vitamin K)

---

Q209. METHODS TO MINIMISE MEDICOLEGAL PROBLEMS

Documentation:

• Maintain accurate, legible, contemporaneous records
• Document all discussions, consents, complications
• Record fetal heart rate on CTG - label with patient ID, date, time
• Document drug doses, timing, signatures

Consent:

• Informed written consent for all procedures
• Explain risks and benefits
• Allow time for questions
• Consent for LSCS must include: reason, type, risks of surgery and anaesthesia, blood transfusion possibility

Communication:

• Inform patient and family of all findings
• Document conversations
• Explain adverse outcomes honestly (duty of candour)
• Never dismiss patient complaints

Protocols:

• Follow standard institutional protocols
• If deviation: document reason
• Maintain skills and training (CTG interpretation courses, drills)
• Call senior help promptly and document time called

Specific to Obstetrics:

• Birth register maintained
• Partograph for every labour
• Neonatal birth record complete
• Register all births (CMO office)
• If maternal death: report to CMO, conduct audit

---

SECTION 10: REMAINING BASIC OBSTETRICS

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Q247/248. OOGENESIS & SPERMATOGENESIS

Oogenesis - Stages:

OOGENESIS
            │
Oogonium (2n) → Mitosis → Primary oocyte (2n)
            │
            ▼ (starts in fetal life, arrested at PROPHASE I of meiosis I)
Primary oocyte (46 chromosomes, 4n DNA)
            │
            ▼ (Resumes at puberty with LH surge, just before ovulation)
Secondary oocyte (23 chromosomes) + 1st polar body
            │
            ▼ (Arrested at METAPHASE II of meiosis II until fertilization)
If fertilized → Ovum (23 chromosomes) + 2nd polar body
If not fertilized → Degenerates

• 7 million oogonia at 20 weeks gestation
• 2 million primary oocytes at birth
• 400,000 at puberty
• ~400 actually ovulated in lifetime
• First meiotic division = unequal (one large secondary oocyte + tiny 1st polar body)

---

Spermatogenesis - Stages:

SPERMATOGENESIS (in seminiferous tubules)
            │
Spermatogonium (2n) → Mitosis → Primary spermatocyte (2n)
            │
            ▼ Meiosis I
Secondary spermatocyte (n) x2
            │
            ▼ Meiosis II
Spermatid (n) x4
            │
            ▼ Spermiogenesis (transformation)
Spermatozoa x4

---

Q249. MECHANISM OF OVULATION & HORMONAL REGULATION

Hormonal Regulation:

HYPOTHALAMUS
    │ GnRH (pulsatile)
    ▼
ANTERIOR PITUITARY
    │
    ├── FSH → Follicle development → Oestrogen ↑
    │
    ├── Oestrogen ↑ → POSITIVE FEEDBACK → LH SURGE
    │
    ▼
LH SURGE (36-40 hrs before ovulation)
    │
    ▼
OVULATION (Day 14 in 28-day cycle)
    │
    ▼
Corpus Luteum forms → Progesterone + Oestrogen
    │
No fertilization → CL degenerates → P4 + E2 ↓
    │
    ▼
Menstruation

Mechanism of Ovulation:

• LH surge → increased prostaglandins, proteolytic enzymes
• Follicular wall weakens and ruptures
• Secondary oocyte + corona radiata released
• Trapped by fimbriae

---

Q250. DECIDUA - LAYERS & FUNCTIONS

Layers:

Functions:

• Forms maternal component of placenta (decidua basalis)
• Nutritive role (decidual cells = glycogen-rich)
• Immunological: prevents rejection of fetus (progesterone-dependent immunosuppression)
• Produces prolactin, IGFBP-1, relaxin
• Protective barrier

---

Q251. CHORIONIC VILLI

Development:

1. Primary villi: Solid cytotrophoblast projections (Week 2)
2. Secondary villi: Mesenchymal core added (Week 3)
3. Tertiary villi: Fetal blood vessels develop inside (Week 4 onward) → functional exchange

Types (based on attachment):

• Anchoring villi: Attach to decidua basalis
• Free (floating) villi: Suspended in intervillous space - main site of exchange

Structure:

• Outer syncytiotrophoblast (no cell boundaries)
• Inner cytotrophoblast (Langhans' cells) - disappears in 3rd trimester
• Mesenchymal core with fetal capillaries

---

Q252. INNER CELL MASS - DEVELOPMENT

Development Sequence:

Fertilization (Day 0)
        ↓
Zygote → Cleavage → Morula (Day 3-4)
        ↓
Blastocyst (Day 5)
        ├── Trophoblast (outer) → Placenta + membranes
        └── ICM (inner) → Embryo proper
                ↓
        ICM differentiates into:
        ├── Epiblast → Ectoderm, Mesoderm, Endoderm (3 germ layers)
        └── Hypoblast → Yolk sac

---

Q255. SYSTEMIC & PHYSIOLOGICAL CHANGES DURING INTRAUTERINE LIFE

Cardiovascular:

• Heart beats at 22 days
• Fetal HR: 120-160 bpm
• High CO (vital for oxygen delivery given low PO2)
• HbF (more O2 affinity than HbA)

Respiratory:

• Fetal breathing movements (FBMs) present from 10 weeks
• Lungs filled with lung fluid (not air)
• Surfactant production: type II pneumocytes start at 24 weeks, adequate by 34-35 weeks
• FBMs are prerequisite for lung development (absent in anencephaly → hypoplastic lungs)

Renal:

• Urine production starts at 10-12 weeks → contributes to amniotic fluid
• Fetal urine = hypotonic (dilute) amniotic fluid

GI:

• Swallowing from 12 weeks
• Meconium present from 16 weeks (green-black - bile + GI secretions)

Immune:

• IgG passively crosses placenta (maternal antibodies protect against infections for first 3-6 months)
• IgA: in breast milk
• Fetal immune system develops but relatively immature at birth

---

Q259. ANTERIOR & TRANSVERSE DIAMETERS OF PELVIC INLET

Anteroposterior Diameters:

Transverse Diameters:

---

Q276. CROWNING & RESTITUTION

Crowning:

• When the widest diameter of the fetal head (biparietal diameter) has passed through the vulva and the head no longer recedes between contractions
• Episiotomy (if needed) is cut at crowning

Restitution:

• After delivery of the head, it rotates 45° back to its natural alignment with the shoulders
• Undoes the internal rotation that occurred during descent
• If head was in OA position: head turns to face directly downward (i.e. L or R)
• This is a PASSIVE movement (no uterine contraction needed)

• Head rotates further 45° as anterior shoulder rotates to AP diameter
• Shoulders now in AP diameter for delivery

---

Q277. CLINICAL ASSESSMENT OF INVOLUTION OF UTERUS

Method:

• Palpate abdomen with bladder empty
• Measure fundal height from symphysis pubis
• Note consistency (firm = good involution; soft = subinvolution)
• Assess lochia (type, amount, smell)
• Bimanual examination (PV) if subinvolution suspected

---

Q280. HOMOEOPATHIC REMEDIES FOR INCREASING MILK SUPPLY

• Ricinus communis: Most specific remedy for increasing milk; agalactia
• Urtica urens: Promotes milk flow; with urticaria history
• Lac caninum: Milky white discharges; alternating symptoms
• Pulsatilla: Variable milk, changeable symptoms; emotional weepy women
• Calcarea carb: Obese women; profuse milk that disagrees with baby
• Phytolacca: Mastitis with hard, lumpy breasts; pain on nursing radiates to whole body

---

Q281. PNC (POSTNATAL CARE) - OBJECTIVES, ADVICE, HOMOEOPATHIC REMEDIES

Objectives:

• Promote physical recovery of mother
• Support breastfeeding establishment
• Neonatal surveillance
• Detect and manage complications (PPH, infection, depression)
• Contraception counselling
• Vaccination (if missed antenatally)
• Rubella vaccination if non-immune

Advice Given to Mother:

• Daily bath; perineal hygiene
• Change pads frequently
• Breast hygiene (clean, dry nipples)

• High protein, iron-rich diet
• Adequate fluids (2-3 L/day) for breastfeeding
• Avoid gas-forming foods initially

• Early ambulation (prevents DVT)
• Pelvic floor exercises from Day 1
• Avoid heavy lifting for 6 weeks
• Sexual intercourse: after lochia stops + wound healed (~6 weeks)

• Progestogen-only pill (safe in breastfeeding; start at 6 weeks)
• IUCD (insert at 6-8 weeks)
• Barrier methods (from day 1)
• Avoid COCP until 6 months postpartum if breastfeeding

Homoeopathic Remedies PNC:

• Arnica: Soreness, exhaustion, bruising post-delivery
• Sepia: Post-natal depression; indifference; bearing down sensation
• Pulsatilla: Weeping, mood swings; insufficient milk; retained lochia
• Staphysagria: After CS or episiotomy; emotional, violated feeling
• China: After blood loss; weakness; anaemia; flatulence
• Natrum muriaticum: Post-natal depression; grief; milk insufficiency

---

Q271. METHODS OF PRENATAL GENETIC SCREENING

Non-Invasive:

Invasive (Diagnostic):

---

Q272. ANC ADVICE GIVEN TO MOTHER

Complete ANC Advice:

• Increase caloric intake by 300 kcal/day
• Iron-rich foods: spinach, jaggery, meat, legumes
• Protein: 70-90 g/day
• Calcium: milk, dairy, green leafy vegetables
• Avoid: raw/undercooked meat, unpasteurised dairy, liver (excess vitamin A), alcohol, raw eggs, sushi, high-mercury fish

• Folic acid 400 mcg/day (or 5 mg if high risk) - ideally pre-conception
• Iron + folate tablet (IFA) from 13 weeks
• Calcium 1g/day (from 20 weeks)
• Low-dose aspirin 75-150 mg/day (if high risk for pre-eclampsia - from 12-16 weeks)

• Moderate exercise safe (30 min/day walking)
• Avoid contact sports, heavy lifting
• Avoid hot tubs, saunas

• Daily bath
• Dental care (gingivitis common in pregnancy)
• Breast care: no nipple preparation needed (research shows no benefit)

• Avoid long-haul air travel after 36 weeks
• Seat belt: below bump, across chest
• DVT prophylaxis for long flights

• Bleeding PV
• Severe headache / visual disturbance
• Reduced/absent fetal movements
• Severe abdominal pain
• Leaking fluid
• Facial/hand oedema (sudden)
• Fever

• Tetanus toxoid: 2 doses (TT1 at first contact, TT2 4 weeks later; or Td)
• Influenza vaccine (safe all trimesters)
• COVID vaccine (recommended)

---

Q273. IMPORTANCE OF ANC

1. Early detection of high-risk pregnancies (hypertension, diabetes, multiple pregnancy)
2. Prevention of complications (anaemia, infections, malnutrition)
3. Screening for congenital anomalies (USG, NIPT, AFP)
4. Health education and counselling
5. Immunisation (TT)
6. Iron and folate supplementation (reduces anaemia by 50%)
7. Birth preparedness (plan for delivery)
8. Reduction in maternal and perinatal mortality
9. Detection and treatment of STIs (VDRL, HIV screening)
10. Psychological support

---

Q274. BACKACHE IN PREGNANCY

Causes:

• Lumbar lordosis (compensatory - to maintain balance with growing uterus)
• Relaxin hormone (ligament laxity → sacroiliac joint instability)
• Weight gain
• Diastasis recti
• Urinary tract infection
• Disc prolapse
• Postural strain

Auxiliary Management:

• Correct posture training
• Firm mattress
• Avoid high heels
• Pelvic support belt
• Physiotherapy / prenatal yoga
• Swimming (offloads weight)

Homoeopathic Therapies:

• Kali carb: Back pain during labour radiating to hips; weakness of back
• Rhus toxicodendron: Backache better on movement, worse at rest; stiffness
• Aesculus hippocastanum: Sacral backache with piles; feeling of fullness in rectum
• Bellis perennis: Backache due to uterine weight; deep muscle soreness
• Nux vomica: Backache associated with constipation; worse at night

---

Q275. PHYSIOLOGICAL CAUSES OF CONSTIPATION DURING PREGNANCY

1. Progesterone effect: Relaxes smooth muscle of bowel → reduced peristalsis → prolonged transit time → increased water absorption → hard stools
2. Displacement of bowel: Gravid uterus compresses colon
3. Iron supplementation: Ferrous compounds cause constipation
4. Reduced physical activity
5. Dehydration (if inadequate water intake)
6. Dietary changes (reduced fibre)

Management:

• Increase dietary fibre (fruits, vegetables, whole grains)
• Increase fluid intake (2-3 L/day)
• Regular exercise (walking)
• Ispaghula husk (Fybogel) - safe
• Lactulose - safe in pregnancy
• Stimulant laxatives (senna) - use cautiously, avoid in 1st trimester

---

Q279. COLOSTRUM - COMPLETE

Colostrum Composition (vs Mature Milk):

• First immunisation (IgA - protects gut)
• Promotes passage of meconium (mild laxative effect)
• High vitamin A
• Growth factors for intestinal maturation

---

Q282/283. PHYSICAL FEATURES OF NEWBORN AT BIRTH & IMMEDIATE CARE

Physical Features in Detail:

• Vernix caseosa: white, cheesy coating (protective; thermoregulation)
• Lanugo: fine downy hair (more in preterm)
• Milia: white sebaceous plugs on nose (not infected)
• Erythema toxicum: benign rash (common, normal)
• Mongolian blue spot: hyperpigmented area (lumbosacral; normal in Asians)

• Fontanelles: Anterior (closes 18 months), Posterior (closes 2-3 months)
• Sutures: separated (allows moulding)

• Blue-grey at birth (true colour at 3-6 months)
• Subconjunctival haemorrhages (common, resolve in 1-2 weeks)

• Umbilical cord: 2 arteries + 1 vein (single umbilical artery = associated anomalies)

• Female: labia minora prominent, hymenal tag normal
• Male: testes usually descended; if not → undescended testes

---

QUICK REVISION FLOWCHART - ALL HIGH-YIELD TOPICS

LABOUR ABNORMALITIES
├── Prolonged: >18 hrs (primi) / >12 hrs (multi)
├── Obstructed: Bandl's ring, moulding 3+, no descent
├── Precipitate: <3 hrs → tears, PPH
└── Uterine inertia: Primary vs Secondary

HAEMORRHAGE
├── APH: Placenta praevia vs Abruption
├── PPH: 4 Ts (Tone 70%, Tissue, Trauma, Thrombin)
└── Treatment: Oxytocin → Ergometrine → Misoprostol → Carboprost → Surgery

HYPERTENSION
├── Pre-eclampsia: BP ≥140/90 + proteinuria after 20 weeks
├── Severe: BP ≥160/110 + end organ damage
├── Eclampsia: Pre-eclampsia + convulsions
└── MgSO4 Pritchard: 4g IV + 10g IM loading; 5g IM 4-hrly

ABORTION
├── Threatened: closed os, bleeding, no POC
├── Inevitable: open os, no POC
├── Incomplete: open os, partial POC
├── Complete: closed os, all POC
├── Missed: closed os, no FHB, no growth
└── Septic: fever + open os + offensive discharge

ECTOPIC
└── Empty uterus + adnexal mass + positive hCG = ECTOPIC until proven otherwise

MOLAR
└── Snowstorm USG + very high hCG + pre-eclampsia before 20 weeks = MOLAR

NEONATAL
├── APGAR: 7-10 normal; 4-6 moderate; 0-3 severe
├── Resuscitation: Dry → PPV → Intubate + CPR → Epinephrine
├── Jaundice: Physiological (>24 hrs, <2 weeks); Pathological (<24 hrs, >12 mg/dL)
└── Asphyxia: APGAR + NRP

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• Write Definition first for every answer
• Use tabular comparisons wherever you can (examiners love tables)
• Draw flowcharts for management questions (saves time + shows clarity)
• Include complications in every answer
• For homoeopathy topics: always mention the KEY remedy first (e.g., Pulsatilla for malpresentation, Sabina for abortion, MgSO4 equivalent = Calcarea carb in homoeopathy)