1. Obstetrics: 64 questions
   Pregnancy physiology and diagnosis; fetal surveillance; labor and delivery; malpresentations; hypertensive disorders; miscarriage and preterm birth; maternal medical diseases; obstetric hemorrhage; infections and sepsis; postpartum care; Rh incompatibility.
2. Gynecology: 64 questions
   Reproductive anatomy; menstrual and endocrine disorders; infertility and assisted reproduction; contraception and abortion; gynecologic infections; endometriosis and fibroids; pelvic organ prolapse; benign and malignant gynecologic tumors; diagnostic procedures.
3. Emergency care and practical procedures: 64 questions
   Obstetric and gynecologic emergencies, operative techniques, examinations, delivery maneuvers, and newborn care.

• Types of obstetric hospitals. Structure of a municipal maternity hospital under Russian Ministry of Health Order No. 1130n. Key performance indicators of an obstetric inpatient facility.
• The perinatal period and perinatal mortality: definition, incidence, structure, causes, and modern methods for assessing fetal well-being in utero.
• Anatomy and physiology of the female reproductive system.
• Polyhydramnios and oligohydramnios: amniotic-fluid exchange, etiology, diagnosis, and management of pregnancy and labor.
• Diagnosis of early and late pregnancy. Methods of antenatal fetal-weight estimation.
• Hemolytic disease of the newborn: etiology, pathogenesis, clinical forms, and treatment.

1. Obstetrics: 64 questions
   Pregnancy physiology and diagnosis; fetal surveillance; labor and delivery; malpresentations; hypertensive disorders; miscarriage and preterm birth; maternal medical diseases; obstetric hemorrhage; infections and sepsis; postpartum care; Rh incompatibility.
2. Gynecology: 64 questions
   Reproductive anatomy; menstrual and endocrine disorders; infertility and assisted reproduction; contraception and abortion; gynecologic infections; endometriosis and fibroids; pelvic organ prolapse; benign and malignant gynecologic tumors; diagnostic procedures.
3. Emergency care and practical procedures: 64 questions
   Obstetric and gynecologic emergencies, operative techniques, examinations, delivery maneuvers, and newborn care.

• Types of obstetric hospitals. Structure of a municipal maternity hospital under Russian Ministry of Health Order No. 1130n. Key performance indicators of an obstetric inpatient facility.
• The perinatal period and perinatal mortality: definition, incidence, structure, causes, and modern methods for assessing fetal well-being in utero.
• Anatomy and physiology of the female reproductive system.
• Polyhydramnios and oligohydramnios: amniotic-fluid exchange, etiology, diagnosis, and management of pregnancy and labor.
• Diagnosis of early and late pregnancy. Methods of antenatal fetal-weight estimation.
• Hemolytic disease of the newborn: etiology, pathogenesis, clinical forms, and treatment.

Obstetrics: English translation of the exam topics

1. Organization of obstetric care and maternal-perinatal health
   • Types and structure of maternity hospitals
   • Hospital performance indicators
   • Perinatal and maternal mortality
   • Initial antenatal assessment and risk groups
2. Normal pregnancy, fetus, placenta, and amniotic fluid
   • Female reproductive anatomy and physiology
   • Fertilization, embryogenesis, fetogenesis
   • Placenta and hormonal regulation of pregnancy
   • Amniotic fluid and its diagnostic importance
   • Polyhydramnios and oligohydramnios
   • Fetal anatomy, head measurements, and fetal-weight estimation
3. Maternal pelvic anatomy and obstetric examination
   • Obstetric pelvis and pelvic measurements
   • External obstetric examination
   • Vaginal examination during labor
   • Anatomically and clinically contracted pelvis
4. Normal labor and delivery
   • Physiology and regulation of labor
   • Stages of labor
   • First, second, and third stages of labor
   • Mechanism of labor in occiput-anterior and occiput-posterior positions
   • Perineal protection, placental separation, and physiologic blood loss
5. Fetal malpresentation and multiple pregnancy
   • Breech presentation: diagnosis, management, and mechanism of labor
   • Multiple pregnancy and chorionicity
   • Management of pregnancy and delivery in twins or higher-order multiples
6. Postpartum period and birth trauma
   • Normal puerperium
   • Perineal incision and lacerations
   • Maternal and neonatal birth trauma
   • Prevention of postpartum infection
7. Pregnancy complications and pregnancy loss
   • Hyperemesis gravidarum
   • Miscarriage and recurrent pregnancy loss
   • Preterm labor
   • Post-term pregnancy
   • Fetal hypoxia and neonatal asphyxia
8. Hypertensive disorders of pregnancy
   • Edema, proteinuria, and hypertension in pregnancy
   • Preeclampsia
   • Eclampsia
   • Severity assessment, treatment, and obstetric management
9. Abnormal labor
   • Abnormal uterine activity
   • Pathological preliminary period
   • Precipitous labor
   • Uterine inertia
   • Discoordinated labor
10. Pregnancy with maternal medical disease

• Diabetes mellitus and diabetic fetopathy
• Chronic hypertension
• Kidney disease
• Heart disease
• Indications or contraindications for continuing pregnancy

1. Obstetric hemorrhage and critical care

• Bleeding during pregnancy
• Placenta previa
• Placental abruption
• Postpartum hemorrhage, including uterine atony/hypotonia
• Disseminated intravascular coagulation
• Hemorrhagic shock
• Uterine rupture

1. Obstetric infection and sepsis

• Postpartum purulent-septic diseases
• Endometritis, pelvic peritonitis, and peritonitis after cesarean section
• Toxic shock and obstetric sepsis
• Lactational mastitis

1. Fetomaternal blood-group incompatibility

• Rh isoimmunization
• Hemolytic disease of the fetus and newborn
• Sensitization pathways, prevention, and pregnancy management

Sample translation, Questions 1-10

1. Types of obstetric inpatient facilities. Structure of a municipal maternity hospital according to Russian Ministry of Health Order No. 1130n. Main performance indicators of an obstetric inpatient facility.
2. The perinatal period and perinatal mortality: definition, incidence, structure, causes, and modern methods for assessing fetal well-being in utero.
3. Anatomy and physiology of the female reproductive system.
4. Polyhydramnios and oligohydramnios: amniotic-fluid exchange, etiology, diagnosis, and management of pregnancy and labor.
5. Diagnosis of early and late pregnancy. Methods of antenatal estimation of fetal weight.
6. Hemolytic disease of the newborn: etiology, pathogenesis, clinical forms, and treatment.
7. Physiological changes in a woman’s body during pregnancy. Hormonal regulation of the gestational process.
8. Breech presentations: causes, classification, diagnosis, and management of pregnancy.
9. Physiology of pregnancy. The placenta as a “new” endocrine gland: definition, functions, and structure.
10. Mechanism of labor in breech presentation. Contemporary principles of labor management.

1. Obstetrics: 64 questions
   Pregnancy physiology and diagnosis; fetal surveillance; labor and delivery; malpresentations; hypertensive disorders; miscarriage and preterm birth; maternal medical diseases; obstetric hemorrhage; infections and sepsis; postpartum care; Rh incompatibility.
2. Gynecology: 64 questions
   Reproductive anatomy; menstrual and endocrine disorders; infertility and assisted reproduction; contraception and abortion; gynecologic infections; endometriosis and fibroids; pelvic organ prolapse; benign and malignant gynecologic tumors; diagnostic procedures.
3. Emergency care and practical procedures: 64 questions
   Obstetric and gynecologic emergencies, operative techniques, examinations, delivery maneuvers, and newborn care.

• Types of obstetric hospitals. Structure of a municipal maternity hospital under Russian Ministry of Health Order No. 1130n. Key performance indicators of an obstetric inpatient facility.
• The perinatal period and perinatal mortality: definition, incidence, structure, causes, and modern methods for assessing fetal well-being in utero.
• Anatomy and physiology of the female reproductive system.
• Polyhydramnios and oligohydramnios: amniotic-fluid exchange, etiology, diagnosis, and management of pregnancy and labor.
• Diagnosis of early and late pregnancy. Methods of antenatal fetal-weight estimation.
• Hemolytic disease of the newborn: etiology, pathogenesis, clinical forms, and treatment.

1. Organization of obstetric care and maternal-perinatal health
   • Types and structure of maternity hospitals
   • Hospital performance indicators
   • Perinatal and maternal mortality
   • Initial antenatal assessment and risk groups
2. Normal pregnancy, fetus, placenta, and amniotic fluid
   • Female reproductive anatomy and physiology
   • Fertilization, embryogenesis, fetogenesis
   • Placenta and hormonal regulation of pregnancy
   • Amniotic fluid and its diagnostic importance
   • Polyhydramnios and oligohydramnios
   • Fetal anatomy, head measurements, and fetal-weight estimation
3. Maternal pelvic anatomy and obstetric examination
   • Obstetric pelvis and pelvic measurements
   • External obstetric examination
   • Vaginal examination during labor
   • Anatomically and clinically contracted pelvis
4. Normal labor and delivery
   • Physiology and regulation of labor
   • Stages of labor
   • First, second, and third stages of labor
   • Mechanism of labor in occiput-anterior and occiput-posterior positions
   • Perineal protection, placental separation, and physiologic blood loss
5. Fetal malpresentation and multiple pregnancy
   • Breech presentation: diagnosis, management, and mechanism of labor
   • Multiple pregnancy and chorionicity
   • Management of pregnancy and delivery in twins or higher-order multiples
6. Postpartum period and birth trauma
   • Normal puerperium
   • Perineal incision and lacerations
   • Maternal and neonatal birth trauma
   • Prevention of postpartum infection
7. Pregnancy complications and pregnancy loss
   • Hyperemesis gravidarum
   • Miscarriage and recurrent pregnancy loss
   • Preterm labor
   • Post-term pregnancy
   • Fetal hypoxia and neonatal asphyxia
8. Hypertensive disorders of pregnancy
   • Edema, proteinuria, and hypertension in pregnancy
   • Preeclampsia
   • Eclampsia
   • Severity assessment, treatment, and obstetric management
9. Abnormal labor
   • Abnormal uterine activity
   • Pathological preliminary period
   • Precipitous labor
   • Uterine inertia
   • Discoordinated labor
10. Pregnancy with maternal medical disease

• Diabetes mellitus and diabetic fetopathy
• Chronic hypertension
• Kidney disease
• Heart disease
• Indications or contraindications for continuing pregnancy

1. Obstetric hemorrhage and critical care

• Bleeding during pregnancy
• Placenta previa
• Placental abruption
• Postpartum hemorrhage, including uterine atony/hypotonia
• Disseminated intravascular coagulation
• Hemorrhagic shock
• Uterine rupture

1. Obstetric infection and sepsis

• Postpartum purulent-septic diseases
• Endometritis, pelvic peritonitis, and peritonitis after cesarean section
• Toxic shock and obstetric sepsis
• Lactational mastitis

1. Fetomaternal blood-group incompatibility

• Rh isoimmunization
• Hemolytic disease of the fetus and newborn
• Sensitization pathways, prevention, and pregnancy management

Sample translation, Questions 1-10

1. Types of obstetric inpatient facilities. Structure of a municipal maternity hospital according to Russian Ministry of Health Order No. 1130n. Main performance indicators of an obstetric inpatient facility.
2. The perinatal period and perinatal mortality: definition, incidence, structure, causes, and modern methods for assessing fetal well-being in utero.
3. Anatomy and physiology of the female reproductive system.
4. Polyhydramnios and oligohydramnios: amniotic-fluid exchange, etiology, diagnosis, and management of pregnancy and labor.
5. Diagnosis of early and late pregnancy. Methods of antenatal estimation of fetal weight.
6. Hemolytic disease of the newborn: etiology, pathogenesis, clinical forms, and treatment.
7. Physiological changes in a woman’s body during pregnancy. Hormonal regulation of the gestational process.
8. Breech presentations: causes, classification, diagnosis, and management of pregnancy.
9. Physiology of pregnancy. The placenta as a “new” endocrine gland: definition, functions, and structure.
10. Mechanism of labor in breech presentation. Contemporary principles of labor management.

1. Questions 1-16: Normal pregnancy and obstetric anatomy
   Antenatal care, perinatal mortality, female reproductive physiology, placenta, amniotic fluid, fetal development, pelvis, fetal head, and obstetric examination.
2. Questions 17-25: Normal labor and postpartum care
   Stages and mechanism of labor, management of delivery, placental stage, blood loss, neonatal birth trauma, physiological puerperium, and episiotomy.
3. Questions 26-37: Pregnancy and labor complications
   Hyperemesis, hypertensive disorders, preeclampsia/eclampsia, labor abnormalities, contracted pelvis, and maternal mortality.
4. Questions 38-50: High-risk pregnancy and fetal conditions
   Antenatal screening, multiple pregnancy, pregnancy loss, preterm and post-term birth, fetal hypoxia, neonatal asphyxia, diabetes, hypertension, kidney disease, and heart disease.
5. Questions 51-64: Obstetric hemorrhage, infection, and Rh disease
   Placenta previa, abruption, postpartum hemorrhage, DIC, shock, uterine rupture, postpartum infection, sepsis, mastitis, and Rh alloimmunization.

Obstetrics Oral-Exam Answer Sheet

1. Obstetric facilities and maternity-hospital indicators

2. Perinatal period and perinatal mortality

3. Female reproductive anatomy and physiology

4. Polyhydramnios and oligohydramnios

5. Diagnosis of pregnancy and estimated fetal weight

6. Hemolytic disease of the newborn

7. Physiological changes during pregnancy

8. Breech presentation

9. Placenta as an endocrine organ

10. Mechanism and management of breech birth

11. Amniotic fluid and rupture of membranes

12. Fertilization and fetal development

13. Female pelvis in obstetrics

14. Fetus as the object of labor

15. Obstetric examination

16. Physiology and stages of labor

17. First stage of labor

18. Second stage and perineal protection

19. Mechanism of labor in occiput-anterior position

20. Mechanism of labor in occiput-posterior position

21. Fetal birth trauma and caput succedaneum

22. Third stage of labor

23. Physiological blood loss

24. Normal puerperium

25. Perineal incisions in childbirth

26. Vomiting in pregnancy

27. Hypertensive disorders: pathogenesis and classification

28. Hypertensive disorders: clinical features and treatment

29. Preeclampsia

30. Eclampsia

31. Abnormal labor activity

32. Pathological preliminary period

33. Precipitous labor

34. Uterine inertia

35. Discoordinated labor

36. Contracted pelvis

37. Maternal mortality

38. First antenatal visit

39. Multiple pregnancy

40. Recurrent pregnancy loss

41. Spontaneous miscarriage

42. Preterm birth

43. Post-term pregnancy

44. Intrauterine fetal hypoxia

45. Neonatal asphyxia

46. Diabetes mellitus in pregnancy

47. Maternal birth trauma

48. Chronic hypertension in pregnancy

49. Renal disease and pregnancy

50. Heart disease in pregnancy

51. Bleeding during pregnancy

52. Placental abruption

53. Placenta previa

54. Early postpartum hemorrhage

55. Obstetric disseminated intravascular coagulation

56. Hemorrhagic shock in obstetrics

57. Uterine rupture

58. Postpartum purulent-septic diseases and postpartum ulcer

59. Postpartum endometritis and related infections

60. Postpartum pelvic peritonitis and post-cesarean peritonitis

61. Toxic shock syndrome

62. Obstetric sepsis

63. Lactational mastitis

64. Rh isoimmunization

• English translation of the question
• A clear oral-answer structure: definition, etiology, classification, clinical features, diagnosis, management, complications, and key examiner points
• Important distinctions and short memory aids
• A brief rapid-revision summary at the end

Obstetrics topic map

1. Questions 1-5: Obstetric services, perinatal mortality, reproductive anatomy, amniotic-fluid disorders, diagnosis of pregnancy and fetal-weight estimation
2. Questions 6-10: Hemolytic disease, maternal physiological changes, breech presentation, placenta, breech delivery
3. Questions 11-15: Amniotic fluid, embryology, obstetric pelvis, fetal skull, obstetric examination
4. Questions 16-20: Physiology of labor and mechanisms of vertex delivery
5. Questions 21-25: Birth trauma, third stage, blood loss, puerperium, episiotomy
6. Questions 26-30: Hyperemesis, hypertensive disorders, preeclampsia, eclampsia
7. Questions 31-37: Abnormal labor, contracted pelvis, maternal mortality
8. Questions 38-45: Antenatal care, multiple pregnancy, miscarriage, preterm/post-term birth, fetal hypoxia, neonatal asphyxia
9. Questions 46-50: Pregnancy complicated by diabetes, hypertension, kidney disease, and heart disease
10. Questions 51-57: Antepartum and postpartum hemorrhage, abruption, previa, DIC, shock, uterine rupture
11. Questions 58-64: Puerperal infection, sepsis, mastitis, Rh isoimmunization

Obstetrics Questions 1-5: Oral-Exam Preparation

1. Types of obstetric facilities. Structure of a city maternity hospital. Performance indicators

Translation

A. Types of obstetric care facilities

1. Outpatient care
   • Antenatal clinic or women's health clinic
   • Pre-pregnancy counseling, pregnancy registration, routine antenatal surveillance
   • Identification and referral of high-risk pregnancies
2. Inpatient obstetric facilities
   • Maternity units within general hospitals
   • Maternity hospitals
   • Interdistrict or regional obstetric hospitals
   • Perinatal centers
3. Levels of care
   • Level I: Low-risk pregnancies and uncomplicated term births.
   • Level II: Moderate-risk pregnancies; facilities for operative delivery, anesthesia, neonatal observation/intensive care.
   • Level III: Perinatal center for high-risk mothers and fetuses, severe maternal disease, very preterm birth, major fetal anomalies, and advanced maternal/neonatal intensive care.

B. Structure of a maternity hospital

• Admission and triage unit
• Antenatal pathology department for pregnant women requiring admission
• Labor and delivery unit, including individual delivery rooms
• Operating theater for cesarean section and other obstetric surgery
• Anesthesiology and intensive-care facilities
• Postpartum ward
• Neonatal unit, with resuscitation and intensive care where indicated
• Laboratory, ultrasound, blood-bank or transfusion-service access
• Infection-control and isolation facilities
• Consultation services: obstetrician, anesthesiologist, neonatologist, physician specialists

C. Main performance indicators

• Maternal mortality ratio
• Severe maternal morbidity or maternal near-miss events
• Postpartum hemorrhage rate
• Eclampsia and severe preeclampsia rate
• Cesarean delivery rate
• Operative vaginal delivery rate
• Obstetric trauma, including third- and fourth-degree perineal tears
• Postpartum infection and sepsis rate

• Stillbirth rate
• Perinatal mortality rate
• Early neonatal mortality rate
• Preterm birth rate
• Low-birth-weight rate
• Apgar scores, neonatal asphyxia, birth trauma
• Transfer of newborns to intensive care

• Number of deliveries
• Bed occupancy rate
• Average length of stay
• Bed turnover
• Cesarean section rate
• Referral and transfer rates

Examiner points

• Do not say that cesarean rate alone indicates quality. Both an unnecessarily high and an inappropriately low rate may be problematic.
• The central concept is the right patient in the right level of care at the right time.
• Maternal and perinatal death review is a quality-improvement process, not merely a statistical exercise. WHO describes maternal and perinatal death surveillance and response as a system for identifying causes and preventable factors in deaths. See WHO MPDSR guidance.

2. Perinatal period and perinatal mortality. Fetal assessment

Translation

A. Definition of the perinatal period

• Late fetal deaths from 28 completed weeks of gestation, plus
• Early neonatal deaths from birth through day 6 of life.

B. Perinatal mortality rate

C. Structure of perinatal mortality

1. Stillbirths
   • Antepartum stillbirth: fetal death before labor
   • Intrapartum stillbirth: fetal death during labor
2. Early neonatal deaths
   • Death during the first 7 completed days of life

D. Major causes

1. Maternal causes
   • Hypertensive disorders, especially preeclampsia
   • Diabetes mellitus
   • Severe anemia
   • Infection and sepsis
   • Chronic kidney, heart, or autoimmune disease
   • Smoking, alcohol, drugs, malnutrition
2. Placental and cord causes
   • Placental insufficiency and fetal growth restriction
   • Placental abruption
   • Placenta previa with severe hemorrhage
   • Cord prolapse, true knot, cord compression
   • Chorioamnionitis
3. Fetal causes
   • Prematurity
   • Congenital malformations
   • Chromosomal abnormalities
   • Fetal anemia and Rh hemolytic disease
   • Intrauterine infection
4. Intrapartum and neonatal causes
   • Acute fetal hypoxia/asphyxia
   • Birth trauma
   • Meconium aspiration
   • Respiratory distress syndrome and complications of prematurity
   • Neonatal infection

E. Methods of antenatal fetal assessment

1. Maternal fetal-movement assessment

• Reduced or absent fetal movements may be an early warning sign.
• The mother should seek urgent evaluation if movements are clearly reduced from her usual pattern.

2. Ultrasound

• Viability and fetal cardiac activity
• Gestational age
• Fetal anatomy
• Growth and estimated fetal weight
• Amniotic-fluid volume
• Placental location and appearance

3. Fetal biometry and growth monitoring

• Head circumference
• Abdominal circumference
• Femur length
• Estimated fetal weight
• Growth trend is more informative than one isolated measurement.

4. Doppler velocimetry

• Umbilical artery Doppler
• Middle cerebral artery Doppler
• Ductus venosus Doppler in severe cases

5. Cardiotocography, CTG or non-stress test

• Baseline fetal heart rate
• Variability
• Accelerations
• Decelerations
• Uterine contractions

6. Biophysical profile, BPP

• Fetal breathing movements
• Gross body movements
• Fetal tone
• Amniotic-fluid volume
• Non-stress test

Examiner points

• Perinatal mortality is a sensitive measure of both obstetric and neonatal care.
• Do not rely on CTG alone. Use the full clinical picture: gestational age, maternal condition, fetal movements, ultrasound, Doppler, and CTG.
• Abnormal umbilical-artery Doppler is associated with adverse outcomes in placental insufficiency.

3. Anatomy and physiology of the female reproductive system

Translation

A. Anatomy

External genital organs: the vulva

• Mons pubis
• Labia majora
• Labia minora
• Clitoris
• Vestibule of the vagina
• External urethral opening
• Vaginal opening
• Greater vestibular, Bartholin, glands

Internal genital organs

• Fibromuscular canal, approximately 7-10 cm in length
• Extends from vulva to cervix
• Anterior, posterior, and lateral vaginal fornices surround the cervix
• Functions in intercourse, menstrual outflow, and childbirth

• Pear-shaped muscular organ in the pelvis
• Parts: fundus, body, isthmus, cervix
• Layers:
  • Endometrium: inner mucosa, undergoes cyclical changes
  • Myometrium: smooth-muscle layer, responsible for labor contractions
  • Perimetrium: outer serosal covering

• Lower cylindrical part of uterus
• Has internal os, cervical canal, and external os
• Produces cervical mucus
• During pregnancy it remains closed; during labor it effaces and dilates

• Four parts: interstitial/intramural, isthmus, ampulla, infundibulum with fimbriae
• Fertilization usually occurs in the ampulla
• Transport the oocyte and embryo to the uterus

• Produce oocytes and hormones
• Main hormones: estrogen, progesterone, inhibin, and anti-Müllerian hormone
• Contain ovarian follicles at different stages of development

B. Pelvic supports

• Pelvic floor muscles, especially levator ani
• Endopelvic fascia
• Uterosacral ligaments
• Cardinal or transverse cervical ligaments
• Pubocervical fascia

C. Physiology: hypothalamic-pituitary-ovarian axis

1. Hypothalamus releases pulsatile GnRH
2. Anterior pituitary releases FSH and LH
3. Ovarian follicles produce estrogen
4. Ovulation follows the mid-cycle LH surge
5. The ruptured follicle becomes the corpus luteum
6. Corpus luteum produces mainly progesterone

D. Menstrual cycle

• Causes endometrial proliferation
• Makes cervical mucus thin, clear, and stretchable near ovulation
• Supports development of secondary sexual characteristics

• Converts proliferative endometrium into secretory endometrium
• Thickens cervical mucus
• Raises basal body temperature
• Reduces myometrial contractility
• Supports early pregnancy

Examiner points

• Fertilization occurs most often in the ampulla.
• Implantation normally occurs in the uterine endometrium, usually in the upper posterior wall.
• Ovulation occurs about 14 days before the next menstrual period, not always on day 14.
• The myometrium is the essential contractile layer in labor.

4. Polyhydramnios and oligohydramnios

Translation

A. Normal amniotic fluid: formation and circulation

• Fetal urine, the principal source
• Fetal lung fluid
• Transmembranous transfer from maternal circulation

• Fetal swallowing and gastrointestinal absorption
• Intramembranous absorption into fetal blood vessels in the placenta
• Small contribution from transmembranous flow

• Protects against trauma
• Allows fetal movement and musculoskeletal development
• Allows normal lung development
• Maintains temperature
• Prevents umbilical-cord compression
• Facilitates labor and cervical dilation

B. Assessment by ultrasound

1. Single deepest vertical pocket, DVP/MVP
   • Oligohydramnios: <2 cm
   • Polyhydramnios: ≥8 cm in a singleton pregnancy
2. Amniotic-fluid index, AFI
   • Oligohydramnios: commonly ≤5 cm
   • Polyhydramnios: commonly ≥24-25 cm

C. Polyhydramnios

Definition

Etiology

1. Maternal
   • Diabetes mellitus, especially poorly controlled diabetes
2. Fetal
   • Gastrointestinal obstruction preventing swallowing: esophageal or duodenal atresia
   • Central nervous system anomalies affecting swallowing
   • Neuromuscular disorders
   • Fetal anemia or hydrops fetalis
   • Chromosomal abnormalities
3. Placental/fetal conditions
   • Twin-to-twin transfusion syndrome, in the recipient twin
   • Chorioangioma of the placenta
4. Idiopathic
   • Many mild cases have no identifiable cause

Clinical features

• Uterus large for dates
• Maternal dyspnea, abdominal discomfort, edema, reflux
• Difficulty palpating fetal parts
• Fetal heart sounds may be distant
• Increased risk of preterm contractions

Complications

• Preterm labor and preterm rupture of membranes
• Malpresentation and unstable lie
• Cord prolapse after membrane rupture
• Placental abruption due to sudden uterine decompression
• Uterine atony and postpartum hemorrhage

Management

• Confirm diagnosis and severity by ultrasound.
• Search for cause: detailed anatomy scan, diabetes testing, fetal growth assessment, assessment for anemia or infection when indicated.
• Fetal surveillance according to severity and associated disease.
• Treat the underlying disorder.
• Severe symptomatic cases may require specialist interventions, such as therapeutic amnioreduction in selected circumstances.
• During labor: confirm presentation, use caution during amniotomy because rapid drainage can precipitate cord prolapse or abruption, and anticipate postpartum hemorrhage.

D. Oligohydramnios

Definition

Etiology

1. Rupture of membranes
   • Prelabor rupture of membranes is a common cause.
2. Placental insufficiency
   • Fetal growth restriction
   • Hypertension and preeclampsia
   • Post-term pregnancy
   • Maternal vascular disease
3. Fetal renal and urinary-tract abnormalities
   • Bilateral renal agenesis
   • Polycystic kidney disease
   • Obstructive uropathy
4. Drugs
   • ACE inhibitors
   • Angiotensin-receptor blockers
   • Prolonged NSAID exposure, particularly later in pregnancy
5. Twin-to-twin transfusion syndrome
   • Oligohydramnios in the donor twin

Clinical features

• Uterus may be small for dates
• Fetal parts easily palpable
• Reduced maternal perception of movements may occur
• Usually diagnosed on ultrasound

Complications

• Cord compression and variable decelerations in labor
• Fetal growth restriction and chronic hypoxia
• Meconium-stained liquor
• Pulmonary hypoplasia and limb deformation when severe and early
• Increased cesarean delivery for fetal compromise

Management

• Confirm gestational age, membrane status, and fetal wellbeing.
• Assess fetal anatomy, growth, placenta, Doppler studies, and maternal disease.
• Manage the cause, for example hypertension or ruptured membranes.
• Perform fetal surveillance when appropriate.
• Timing of delivery depends on gestation, severity, fetal growth, Doppler/CTG findings, and membrane status.
• In labor, continuous fetal monitoring is often appropriate because of cord-compression risk.

Examiner points

• Polyhydramnios: think “too much production or too little swallowing.”
• Oligohydramnios: think “membrane rupture, placental insufficiency, or absent/reduced fetal urine.”
• Sudden rupture of membranes with polyhydramnios can lead to cord prolapse and placental abruption.
• Severe early oligohydramnios can cause pulmonary hypoplasia.

5. Diagnosis of early and late pregnancy. Antenatal estimation of fetal weight

Translation

A. Diagnosis of pregnancy

1. Presumptive signs

• Amenorrhea
• Nausea and vomiting
• Breast enlargement and tenderness
• Fatigue
• Urinary frequency
• Perception of fetal movement, quickening

2. Probable signs

• Enlarged uterus
• Positive urine or serum hCG
• Goodell sign: soft cervix
• Hegar sign: soft uterine isthmus
• Chadwick sign: bluish discoloration of cervix and vagina
• Braxton Hicks contractions
• Ballottement

3. Positive or diagnostic signs

• Visualization of an intrauterine embryo/fetus by ultrasound
• Fetal cardiac activity detected by ultrasound
• Fetal heart sounds detected by Doppler or fetoscope
• Fetal movements palpated by the examiner

B. Early diagnosis

• Urine hCG becomes positive after implantation, often around the time of missed menstruation.
• Serum quantitative hCG is more sensitive and useful in early-pregnancy assessment.

• Confirms intrauterine pregnancy and viability.
• Used with serial hCG and clinical findings when ectopic pregnancy or early pregnancy loss is suspected.

C. Late diagnosis and assessment of gestational age

• Reliable last menstrual period, LMP
• First-trimester ultrasound, the most accurate ultrasound method for dating
• Fundal-height measurement after approximately 20 weeks
• Timing of quickening: often around 18-20 weeks in nulliparous women and sometimes earlier in multiparous women
• Fetal heart activity and fetal movements
• Second- and third-trimester ultrasound are less accurate for dating than first-trimester ultrasound

D. Estimation of fetal weight

1. Clinical methods

• From around 20-36 weeks, fundal height in cm roughly corresponds to gestational age in weeks in a singleton pregnancy.
• Accuracy is reduced by obesity, fibroids, multiple pregnancy, abnormal fluid volume, and fetal growth disorders.

• Leopold maneuvers assess lie, presentation, position, engagement, and approximate fetal size.
• Less accurate than ultrasound.

[ \text{Estimated fetal weight in grams}

2. Ultrasound estimation

• Biparietal diameter, BPD
• Head circumference, HC
• Abdominal circumference, AC
• Femur length, FL

Examiner points

• Most accurate method of pregnancy dating: first-trimester ultrasound using crown-rump length.
• Most reliable clinical sign of pregnancy: fetal heart activity detected by ultrasound or Doppler.
• Ultrasound fetal weight is an estimate, not an exact weight.
• In suspected growth restriction, assess not only estimated fetal weight, but also growth velocity, amniotic fluid, Doppler, and fetal surveillance.

Rapid revision: 10 high-yield points

1. Perinatal mortality = late fetal deaths plus early neonatal deaths per 1,000 total births.
2. Perinatal period for international WHO reporting: from 28 weeks gestation to day 6 after birth.
3. Fetal wellbeing assessment: movements, ultrasound, growth, Doppler, CTG, and BPP.
4. Fertilization most commonly occurs in the ampulla of the tube.
5. Progesterone maintains the secretory endometrium and reduces uterine contractions.
6. Polyhydramnios: diabetes, impaired fetal swallowing, fetal anomaly, anemia/hydrops, or TTTS.
7. Oligohydramnios: membrane rupture, placental insufficiency, renal anomaly, post-term pregnancy.
8. Oligohydramnios is DVP/MVP <2 cm; polyhydramnios is DVP/MVP ≥8 cm.
9. First-trimester ultrasound is the best ultrasound method for pregnancy dating.
10. Ultrasound estimated fetal weight is based mainly on HC/BPD, AC, and FL, with meaningful error margins.

Obstetrics Questions 6-10: Oral-Exam Preparation

6. Hemolytic disease of the fetus and newborn

Translation

A. Definition

B. Etiology

1. Rh incompatibility

• Mother: RhD-negative
• Fetus: RhD-positive
• Mother has been sensitized and produces anti-D IgG antibodies.

2. Other red-cell antigen incompatibilities

• Kell
• c antigen
• E antigen
• Duffy and Kidd antigens, less commonly

3. ABO incompatibility

• Mother has blood group O
• Fetus has group A or B

C. Pathogenesis

1. Fetal Rh-positive red cells enter maternal circulation.
2. The Rh-negative mother becomes sensitized and produces anti-D antibodies.
3. In a subsequent Rh-positive pregnancy, maternal IgG antibodies cross the placenta.
4. They bind fetal red blood cells and cause hemolysis.
5. Hemolysis causes:
   • Fetal anemia
   • Increased erythropoiesis and hepatosplenomegaly
   • High-output cardiac failure
   • Hypoproteinemia and edema
   • Hydrops fetalis
   • In severe untreated disease, intrauterine fetal death

D. Routes of maternal sensitization

• Previous delivery of an Rh-positive infant
• Miscarriage, ectopic pregnancy, or induced abortion
• Antepartum hemorrhage
• Placental abruption
• Abdominal trauma
• Invasive procedures: amniocentesis, chorionic-villus sampling, fetal blood sampling
• External cephalic version
• Manual removal of placenta
• Rh-incompatible blood transfusion

E. Clinical forms

1. Anemic form

• Pallor
• Anemia
• Mild hepatosplenomegaly
• Jaundice may be absent or mild

2. Icteric form

• Jaundice within the first 24 hours of life
• Anemia
• Hepatosplenomegaly
• Raised unconjugated bilirubin
• Positive direct antiglobulin test, DAT or direct Coombs test

3. Edematous form, hydrops fetalis

• Generalized edema
• Ascites
• Pleural and pericardial effusions
• Severe anemia
• Cardiomegaly and heart failure
• Hepatosplenomegaly
• Placental edema and polyhydramnios may occur

F. Antenatal diagnosis and surveillance

At the first antenatal visit

• Determine maternal ABO and RhD blood group.
• Perform an antibody screen, indirect Coombs test.
• Repeat screening according to local protocol, especially in RhD-negative women.

If maternal antibodies are present

• Identify the antibody and measure antibody level or titre.
• Determine whether the father carries the relevant antigen.
• If available, use fetal genotyping from maternal blood for fetal RhD or other relevant antigen status.
• Refer to fetal-medicine specialists if there is significant antibody level, rising titre, or prior affected pregnancy.

Fetal anemia assessment

• An MCA-PSV above approximately 1.5 multiples of the median suggests moderate to severe fetal anemia.
• Severe fetal anemia may require fetal blood sampling and intrauterine transfusion in a specialist center.

G. Prevention

• Routinely during late pregnancy, according to national protocol
• Within 72 hours after delivery of an RhD-positive infant
• After a potentially sensitizing event: bleeding, miscarriage, ectopic pregnancy, trauma, invasive procedure, or external cephalic version

H. Treatment

Antenatal treatment

• Serial antibody surveillance and MCA Doppler
• Intrauterine red-cell transfusion for significant fetal anemia
• Timely delivery in a fetal-medicine center when indicated

Neonatal treatment

• Cord blood testing: group, RhD status, hemoglobin, bilirubin, DAT
• Intensive bilirubin monitoring
• Phototherapy
• Intravenous immunoglobulin in selected immune hemolysis cases
• Red-cell transfusion for anemia
• Exchange transfusion when severe hyperbilirubinemia or anemia requires it

Examiner points

• Maternal IgG, not IgM, crosses the placenta.
• Rh disease usually becomes more severe in subsequent antigen-positive pregnancies.
• Anti-Kell disease can be severe because it suppresses fetal erythropoiesis as well as causing hemolysis.
• Anti-D prophylaxis prevents sensitization but does not treat an already sensitized patient.

7. Physiological changes in pregnancy and hormonal regulation

Translation

A. General principle

B. Cardiovascular changes

• Blood volume increases by about 40-50%.
• Plasma volume rises more than red-cell mass, causing physiological dilutional anemia.
• Cardiac output rises by about 30-50%.
• Heart rate usually rises by approximately 10-20 beats/minute.
• Systemic vascular resistance falls.
• Blood pressure may decrease in mid-pregnancy and return toward baseline near term.
• The enlarging uterus may compress the inferior vena cava when the woman lies supine, causing supine hypotensive syndrome.

C. Hematological and coagulation changes

• Increased red-cell mass, but a greater increase in plasma volume
• Mild reduction in hemoglobin and hematocrit
• Mild leukocytosis, especially during labor
• Platelet count may fall slightly, called gestational thrombocytopenia
• Increased fibrinogen and several clotting factors
• Reduced fibrinolytic activity

D. Respiratory changes

• Progesterone stimulates respiration.
• Tidal volume and minute ventilation increase.
• Functional residual capacity decreases because the diaphragm is elevated.
• Mild compensated respiratory alkalosis develops:
  • Lower PaCO₂
  • Renal bicarbonate loss as compensation
• Oxygen consumption increases.

E. Renal and urinary changes

• Renal plasma flow and glomerular filtration rate increase by about 40-50%.
• Serum creatinine and urea normally become lower than in non-pregnant adults.
• Physiological dilation of the renal pelvis and ureters, more often on the right, predisposes to urinary stasis and pyelonephritis.
• Frequency of urination is common.
• Mild glycosuria can occur because of increased filtration and reduced tubular reabsorption.

F. Gastrointestinal changes

• Nausea and vomiting, usually early in pregnancy
• Reduced lower-esophageal sphincter tone causing reflux
• Delayed gastric emptying
• Reduced gut motility causing constipation
• Gallbladder stasis, increasing gallstone risk
• Hemorrhoids due to venous pressure and constipation

G. Endocrine and metabolic changes

Carbohydrate metabolism

• Early pregnancy: increased insulin sensitivity and glycogen storage
• Late pregnancy: insulin resistance, increased lipolysis, higher glucose availability for fetus

Thyroid physiology

• Increased thyroxine-binding globulin due to estrogen
• Total T4 and T3 increase
• hCG can mildly stimulate the TSH receptor in early pregnancy, lowering TSH
• Interpretation requires trimester-specific reference ranges

H. Reproductive and breast changes

• Uterus enlarges by hypertrophy and hyperplasia of myometrial cells.
• Uterine blood flow markedly increases.
• Cervix becomes soft, vascular, and cyanotic.
• Breasts enlarge; ducts and lobules proliferate.
• Colostrum may be expressed late in pregnancy.

I. Hormonal regulation of pregnancy

Examiner points

• hCG maintains the corpus luteum in the first trimester.
• By about 8-12 weeks, the placenta becomes the main source of progesterone.
• Progesterone maintains uterine quiescence.
• Estrogen increases uterine growth and promotes expression of oxytocin receptors toward term.
• Pregnancy is hypercoagulable and insulin-resistant.

8. Breech presentation

Translation

A. Definition

B. Classification

1. Frank breech

• Hips flexed
• Knees extended
• Feet lie near the fetal head
• Buttocks present first
• Most common type at term

2. Complete breech

• Hips flexed
• Knees flexed
• Fetus appears “sitting cross-legged”
• Buttocks present first

3. Incomplete breech

• Footling presentation: one or both feet present below the buttocks
• Kneeling presentation: rare

C. Etiology and risk factors

Maternal and uterine factors

• Uterine malformations
• Fibroids, especially in the lower uterine segment
• Uterine scar
• Multiparity
• Pelvic tumor

Placental and fluid factors

• Placenta previa
• Polyhydramnios
• Oligohydramnios

Fetal factors

• Prematurity
• Multiple pregnancy
• Fetal growth restriction
• Congenital anomalies, especially CNS, neuromuscular, or skeletal disorders
• Short umbilical cord in rare cases

D. Diagnosis

Clinical examination

• A hard, round, ballotable fetal head in the fundus
• A softer, irregular breech mass above the pelvic inlet
• Fetal heart sounds often heard above the umbilicus

Vaginal examination during labor

• Sacrum
• Ischial tuberosities
• Anus
• External genitalia
• Feet in footling presentation

Ultrasound

• Type of breech
• Fetal head attitude, especially flexion versus hyperextension
• Fetal growth and estimated weight
• Placental location
• Amniotic-fluid volume
• Structural anomalies
• Number of fetuses

E. Course of pregnancy

1. External cephalic version
2. Planned cesarean delivery
3. Planned vaginal breech birth in carefully selected circumstances

F. External cephalic version, ECV

• It is usually offered at or after 36-37 weeks in a singleton breech pregnancy, depending on local policy.
• Fetal heart rate is checked before and after the procedure.
• It should be performed where emergency cesarean delivery is available.

• Any contraindication to vaginal delivery
• Placenta previa
• Multiple pregnancy, except selected cases
• Major fetal compromise
• Significant uterine anomaly
• Certain cases of ruptured membranes or vaginal bleeding

G. Delivery planning

Planned cesarean delivery

Planned vaginal breech birth

• Experienced obstetrician and team
• Facility with immediate cesarean and neonatal-resuscitation capability
• Frank or complete breech
• No contraindication to vaginal birth
• Estimated fetal weight in an acceptable range according to local protocol
• Flexed or neutral fetal head, not hyperextended
• Adequate maternal pelvis
• No fetal compromise
• Informed patient consent

Examiner points

• The most common type at term is frank breech.
• Ultrasound is essential before delivery planning.
• Footling presentation carries a high risk of cord prolapse.
• External cephalic version is considered late in pregnancy if no contraindication exists.
• Vaginal breech birth is not automatically forbidden, but requires strict selection and experienced staff.

9. Physiology of pregnancy. Placenta as a new endocrine gland

Translation

A. Definition of placenta

B. Structure

Fetal part

• Chorionic plate
• Chorionic villi
• Umbilical cord with:
  • Two umbilical arteries
  • One umbilical vein
  • Wharton’s jelly

Maternal part

• Decidua basalis
• Intervillous space containing maternal blood

C. Main placental functions

1. Respiratory function

• Transfers oxygen from mother to fetus
• Transfers carbon dioxide from fetus to mother

2. Nutritional and transport function

• Glucose by facilitated diffusion
• Amino acids by active transport
• Fatty acids, vitamins, electrolytes, and water

3. Excretory function

4. Metabolic function

• Glycogen
• Cholesterol
• Fatty acids
• Hormones and enzymes

5. Protective and immunological function

• Selective barrier, not an absolute barrier
• Maternal IgG crosses placenta, especially later in pregnancy, providing passive neonatal immunity
• Some drugs, viruses, alcohol, nicotine, and other harmful agents can cross
• Promotes maternal immune tolerance of the semiallogeneic fetus

6. Endocrine function

D. Placental hormones

1. Human chorionic gonadotropin, hCG

• Produced by syncytiotrophoblast
• Detected in pregnancy tests
• Maintains corpus luteum in early pregnancy
• Supports progesterone production before the placental takeover
• Peaks in the first trimester

2. Progesterone

• Initially produced by the corpus luteum
• Later produced mainly by placenta
• Maintains decidua and pregnancy
• Decreases myometrial contractility
• Supports breast alveolar development
• Contributes to smooth-muscle relaxation

3. Estrogens

• Produced through cooperation between fetus and placenta
• Promote uterine enlargement and uteroplacental blood flow
• Promote breast ductal development
• Near term, help prepare uterus for labor by increasing gap junctions and oxytocin receptors

4. Human placental lactogen, hPL

• Produces maternal insulin resistance
• Promotes lipolysis
• Makes more glucose available to the fetus
• Contributes to breast development

5. Placental growth hormone

• Contributes to changes in maternal metabolism and insulin resistance

6. Relaxin, inhibin, activin, CRH, and prostaglandins

• Contribute to cervical ripening, uterine activity, fetal development, and adaptation to pregnancy

E. Placental circulation

• Deoxygenated fetal blood travels from fetus to placenta through two umbilical arteries.
• Oxygenated, nutrient-rich blood returns to the fetus through one umbilical vein.
• Maternal blood enters the intervillous space through spiral arteries.

Examiner points

• The placenta is both an exchange organ and an endocrine organ.
• Maternal and fetal blood are normally separated by the placental barrier.
• hCG maintains the corpus luteum early in pregnancy.
• Placenta is the main source of progesterone after the first trimester.
• hPL is responsible for maternal insulin resistance and helps supply glucose to the fetus.

10. Biomechanism of breech delivery and modern principles of labor management

Translation

A. General principle

B. Denominator and positions

• Left sacroanterior, common
• Right sacroanterior
• Left sacroposterior
• Right sacroposterior
• Sacral transverse positions

C. Mechanism of labor in frank breech presentation

1. Engagement of the breech

2. Descent and internal rotation of the buttocks

3. Delivery of buttocks and lower limbs

4. Descent and delivery of trunk

5. Delivery of shoulders

6. Delivery of arms

7. Delivery of the after-coming head

D. Modern management principles

1. Before labor

• Confirm breech type and fetal head position by ultrasound.
• Assess estimated fetal weight, fetal anomaly, placental location, amniotic fluid, and maternal pelvis.
• Discuss external cephalic version if appropriate.
• Counsel about risks and benefits of planned cesarean versus planned vaginal breech birth.
• Plan delivery at a center with experienced obstetric, anesthesia, and neonatal teams.

2. Criteria for planned vaginal breech birth

• Term singleton pregnancy
• Frank or complete breech
• Flexed or neutral fetal head
• No major fetal anomaly
• Adequate maternal pelvis
• Fetal weight within locally accepted limits
• No fetal compromise
• Skilled clinician present
• Immediate availability of cesarean delivery and neonatal resuscitation
• Informed maternal consent

3. In labor

• Continuous fetal heart-rate monitoring.
• Avoid premature pushing before full dilation.
• Avoid unnecessary manipulation or traction on the fetus.
• Allow spontaneous descent and delivery as far as possible.
• Maintain readiness for urgent cesarean delivery.
• Avoid artificial rupture of membranes unless there is a clear indication because of cord-prolapse risk.
• Assess labor progress carefully. Failure of descent, fetal compromise, or unfavorable findings requires cesarean delivery.

4. Cesarean delivery is generally indicated when

• Footling or kneeling presentation
• Hyperextended fetal head
• Fetal compromise
• Major fetal anomaly
• Suspected fetopelvic disproportion
• Previous poor obstetric history suggesting risk
• Inadequate facilities or no experienced vaginal-breech operator
• Failure of labor progress

E. Main complications of breech delivery

• Cord prolapse
• Cord compression and acute hypoxia
• Birth asphyxia
• Entrapment of the after-coming head
• Nuchal arms
• Birth trauma: fractures, brachial plexus injury, intracranial hemorrhage

• Cervical and vaginal lacerations
• Postpartum hemorrhage
• Operative delivery complications

Examiner points

• Sacrum is the denominator in breech presentation.
• The sequence is: breech, trunk, shoulders/arms, then head.
• Do not pull on the fetus before spontaneous delivery has progressed as far as possible.
• The greatest danger is delayed delivery of the after-coming head.
• Vaginal breech delivery is a specialized procedure and should only occur with appropriate selection, expertise, and immediate cesarean capability.

Rapid revision: Questions 6-10

1. HDFN results from maternal IgG antibodies crossing the placenta.
2. The most severe form of HDFN is hydrops fetalis.
3. MCA-PSV Doppler is used to screen for significant fetal anemia.
4. Anti-D immunoglobulin prevents Rh sensitization in unsensitized RhD-negative women.
5. Pregnancy causes increased blood volume, cardiac output, GFR, minute ventilation, insulin resistance, and hypercoagulability.
6. hCG maintains the corpus luteum; progesterone maintains uterine quiescence; hPL causes insulin resistance.
7. Frank breech is the most common breech type at term.
8. Footling breech has a high risk of cord prolapse.
9. Placenta performs respiratory, nutritional, excretory, immune, metabolic, and endocrine functions.
10. In breech delivery, the sacrum is the denominator and the after-coming head is the major risk point.

Obstetrics Questions 11-15: Oral-Exam Preparation

11. Amniotic fluid: volume, composition, significance, diagnostic role. Timely and premature rupture of membranes

Translation

A. Definition and normal volume

• At 10 weeks: about 30 mL
• At 20 weeks: about 300-400 mL
• At 36-38 weeks: maximum, about 800-1,000 mL
• At 40 weeks: around 600-800 mL
• Volume normally decreases after term.

B. Composition

• Electrolytes
• Proteins
• Glucose
• Lipids
• Hormones
• Enzymes
• Urea, creatinine, uric acid
• Fetal epithelial cells
• Vernix caseosa
• Lanugo hairs
• Meconium, if passed by the fetus

C. Functions of amniotic fluid

1. Mechanical protection: cushions the fetus against external trauma.
2. Allows fetal movement: supports normal musculoskeletal development.
3. Promotes lung development: fetal breathing movements and fluid support pulmonary growth.
4. Maintains temperature stability.
5. Prevents cord compression.
6. Protects against adhesions between the fetus and amnion.
7. Facilitates labor: the forewaters form a hydrostatic wedge that helps cervical dilation.
8. Has diagnostic value: volume, color, and biochemical/cellular content can reflect fetal condition.

D. Diagnostic importance

1. Volume

• Oligohydramnios suggests membrane rupture, placental insufficiency, fetal growth restriction, fetal renal anomaly, or post-term pregnancy.
• Polyhydramnios suggests maternal diabetes, fetal anomaly impairing swallowing, fetal anemia/hydrops, infection, or multiple pregnancy.

2. Color

• Clear or slightly opalescent fluid is normal.
• Meconium-stained liquor may indicate fetal maturation or fetal stress/hypoxia, particularly if thick.
• Blood-stained fluid may occur with placental abruption, vasa previa, trauma, or cervical bleeding.
• Foul-smelling fluid suggests intra-amniotic infection.

3. Amniocentesis

• Fetal karyotype/genetic testing
• Infection
• Fetal anemia in selected situations
• Lung maturity testing, now rarely used because clinical timing is more important
• Biochemical indicators of fetal disease

E. Rupture of membranes

Timely rupture of membranes

Early rupture of membranes

Prelabor rupture of membranes, PROM

Preterm prelabor rupture of membranes, PPROM

Delayed rupture of membranes

F. Diagnosis of ruptured membranes

• History of sudden gush or continuous leakage of fluid
• Sterile speculum examination: pooling of fluid in the posterior vaginal fornix
• Nitrazine or pH testing, with false positives possible from blood, semen, or infection
• Microscopy for ferning
• Commercial biochemical tests where available
• Ultrasound may show low fluid volume but cannot alone confirm rupture

G. Management principles

At term PROM

• Confirm diagnosis and assess mother and fetus.
• Assess for infection, fetal compromise, and labor.
• Delivery is generally planned rather than prolonged expectant management, according to local protocol.

PPROM

• Admit or closely monitor.
• Confirm rupture and gestational age.
• Assess for chorioamnionitis, abruption, labor, and fetal wellbeing.
• Consider antibiotics, antenatal corticosteroids, magnesium sulfate for fetal neuroprotection at appropriate gestations, and delivery if infection, fetal compromise, placental abruption, or advanced labor occurs.

Examiner points

• Main sources: fetal urine and lung fluid.
• Main routes of removal: fetal swallowing and intramembranous absorption.
• PROM means rupture before labor.
• PPROM means PROM before 37 weeks.
• Excessive vaginal examination after ruptured membranes increases infection risk.

12. Fertilization and development of the conceptus. Embryonic and fetal periods

Translation

A. Fertilization

Site

Main stages

1. Capacitation of sperm
   • Functional maturation of sperm within the female reproductive tract.
   • Enables sperm to penetrate the oocyte coverings.
2. Passage through corona radiata
3. Acrosome reaction
   • Enzymes released from the sperm acrosome help penetrate the zona pellucida.
4. Fusion of sperm and oocyte membranes
5. Cortical reaction
   • Prevents polyspermy, meaning entry of more than one sperm.
6. Completion of meiosis II by the oocyte
7. Formation and fusion of male and female pronuclei
8. Formation of the zygote
   • Restores the diploid chromosome number: 46 chromosomes.

B. Early development

1. Cleavage

2. Morula

• Forms approximately 3 days after fertilization.
• A solid ball of about 16 cells.

3. Blastocyst

• Forms around day 4-5.
• Consists of:
  • Embryoblast, inner cell mass: forms the embryo
  • Trophoblast, outer layer: contributes to placenta and membranes
  • Blastocyst cavity

4. Implantation

• Begins about day 6-7 after fertilization.
• Normally occurs in the endometrium of the uterine fundus, often on the posterior wall.
• Trophoblast differentiates into:
  • Cytotrophoblast
  • Syncytiotrophoblast

C. Germ layers

D. Periods of intrauterine development

1. Pre-embryonic period

• Fertilization
• Cleavage
• Blastocyst formation
• Implantation
• Formation of bilaminar embryonic disc

2. Embryonic period

• Organogenesis
• Formation of major body structures
• Maximum vulnerability to structural teratogens

3. Fetal period, fetogenesis

• Growth
• Functional maturation of organs
• Development of body proportions
• Increasing fetal viability with advancing gestation

E. Important developmental dates

• Fertilization: day 0
• Morula: about day 3
• Blastocyst: day 4-5
• Implantation begins: day 6-7
• Fetal heartbeat detectable by ultrasound: usually around 5.5-6 weeks of gestational age
• Embryonic period ends: 8 weeks after fertilization
• Fetal period begins: 9 weeks after fertilization

Examiner points

• Fertilization occurs in the ampulla.
• Implantation starts around day 6-7.
• Trophoblast forms the fetal part of the placenta.
• Organogenesis occurs mainly from week 3 to week 8 after fertilization.
• Gestational age is conventionally counted from the first day of the last menstrual period, about 2 weeks before fertilization.

13. Female pelvis in obstetrics

Translation

A. Divisions of the pelvis

• Two innominate bones
• Sacrum
• Coccyx

• Ilium
• Ischium
• Pubis

1. Greater pelvis, false pelvis
2. Lesser pelvis, true pelvis

B. Greater pelvis

External pelvic measurements

C. Lesser pelvis, true pelvis

1. Pelvic inlet
2. Pelvic cavity
3. Pelvic outlet

D. Planes and dimensions of the true pelvis

1. Plane of the pelvic inlet

• Sacral promontory posteriorly
• Arcuate lines laterally
• Upper border of pubic symphysis anteriorly

2. Plane of greatest pelvic dimensions

• Anteroposterior diameter: approximately 12.5 cm
• Transverse diameter: approximately 12.5 cm

3. Plane of least pelvic dimensions

• Anteroposterior diameter: about 11.5 cm
• Transverse diameter, interspinous diameter: about 10-10.5 cm

4. Plane of pelvic outlet

• Straight anteroposterior diameter: about 9.5 cm
• Functional anteroposterior diameter during delivery: about 11-11.5 cm, because the coccyx moves backward
• Transverse diameter, intertuberous diameter: about 11 cm

E. Pelvic inclination

• Approximately 55-60 degrees
• The pelvic axis is curved and follows the curve of the sacrum.

F. Obstetric pelvic types

Examiner points

• The true pelvis forms the birth canal.
• The obstetric conjugate is the key AP diameter of the pelvic inlet.
• The narrowest transverse diameter is the interspinous diameter, about 10-10.5 cm.
• Gynecoid pelvis is the most favorable pelvic type for vaginal birth.
• Do not diagnose cephalopelvic disproportion by pelvimetry alone. Labor progress and fetal condition are decisive.

14. Fetus as the object of labor: skull, sutures, fontanelles, head diameters, circumferences, and segments

Translation

A. Fetus as the object of labor

B. Fetal skull

1. Vault
2. Base
3. Face

Main vault bones

• Two frontal bones
• Two parietal bones
• Occipital bone

C. Sutures

D. Fontanelles

Anterior fontanelle, bregma

• Diamond-shaped
• At junction of sagittal, coronal, and frontal sutures
• Larger than posterior fontanelle
• Identifying it on vaginal examination suggests an extended or incompletely flexed head.

Posterior fontanelle, lambda

• Triangular
• At junction of sagittal and lambdoid sutures
• Identifying it helps diagnose a well-flexed vertex presentation and occiput position.

E. Important fetal-head diameters

F. Circumferences of the head

G. Fetal-head segments

1. Small segment
   • Suboccipitobregmatic diameter
   • Presented in well-flexed vertex presentation
   • Most favorable for vaginal birth
2. Medium segment
   • Occipitofrontal diameter
   • Presented with incomplete flexion
3. Large segment
   • Mentovertical diameter
   • Presented in brow presentation
   • Usually too large for vaginal delivery at term

Molding

Examiner points

• Posterior fontanelle is triangular; anterior fontanelle is diamond-shaped.
• The most favorable diameter in vertex birth is suboccipitobregmatic, 9.5 cm.
• Brow presentation presents the largest AP diameter, mentovertical, 13.5 cm.
• The biparietal diameter is about 9.5 cm.
• The sagittal suture helps identify fetal head position.

15. External obstetric examination. Vaginal examination in labor

Translation

A. Purpose of external obstetric examination

• Uterine size and gestational age
• Fetal lie
• Presentation
• Position
• Attitude
• Engagement of the presenting part
• Fetal heart rate
• Amniotic-fluid volume, indirectly
• Contractions and uterine tenderness

B. Preparation

• Explain procedure and obtain consent.
• Ensure privacy and a comfortable warm environment.
• Ask the woman to empty her bladder.
• Position her semi-recumbent with a slight left lateral tilt to avoid supine hypotension.
• Expose only the abdomen.
• Warm hands before examination.

C. Inspection and measurements

1. Inspection

• Abdominal size and shape
• Surgical scars
• Striae gravidarum
• Visible fetal movement
• Umbilical hernia
• Signs of edema or skin disease

2. Fundal height

3. Abdominal circumference

D. Leopold maneuvers

First maneuver: fundal grip

• Head: hard, round, ballotable
• Breech: softer, irregular, less ballotable

Second maneuver: lateral grip

• Back: smooth, firm, resistant surface
• Limbs: small, irregular, mobile parts

Third maneuver: Pawlik grip, first pelvic grip

• If mobile, the presenting part is not engaged.
• If fixed, engagement may have occurred.

Fourth maneuver: second pelvic grip

• Descent and engagement of presenting part
• Degree of flexion of the fetal head

E. Fetal heart auscultation

• Use Doppler or Pinard stethoscope.
• In cephalic presentation, fetal heart sounds are usually loudest below the umbilicus.
• In breech presentation, they are usually heard above the umbilicus.
• Record fetal heart rate, rhythm, and regularity.

F. Vaginal examination in labor

Indications

• On admission in labor, if appropriate
• To confirm labor progress and cervical dilation
• To identify presentation, position, and station
• To assess membrane status
• Before procedures such as amniotomy, instrumental birth, or induction decisions
• Suspected cord prolapse
• Fetal bradycardia or abnormal fetal heart-rate pattern
• Urge to push or suspected second stage
• Suspected malpresentation or obstructed labor

Contraindications or precautions

• Significant antepartum bleeding until placenta previa is excluded
• Suspected placenta previa
• Known vasa previa
• PPROM when it is not essential
• Active genital herpes lesions, unless birth is imminent and examination is necessary
• Severe infection-control concerns

G. Technique

1. Explain procedure and obtain consent.
2. Ensure privacy and appropriate position, usually lithotomy or dorsal recumbent with knees flexed.
3. Perform hand hygiene and use sterile gloves.
4. Inspect external genitalia.
5. Separate labia gently with non-dominant hand.
6. Insert index and middle fingers gently during a contraction-free interval.
7. Assess systematically.
8. Withdraw fingers slowly and inspect glove for blood, meconium, liquor, or foul-smelling discharge.
9. Document findings and communicate them clearly.

H. What to assess

1. Cervix

• Position: posterior, mid-position, anterior
• Consistency: firm, medium, soft
• Effacement: percentage or length
• Dilation: 0-10 cm
• Presence of edema

2. Membranes and amniotic fluid

• Intact, bulging, or ruptured
• If ruptured: color, odor, amount, and time of rupture

3. Presenting part

• Vertex, breech, face, brow, shoulder, cord, or hand
• Identify sutures/fontanelles in vertex presentation
• Identify denominator and position

4. Station

• Ischial spines: station 0
• Above spines: negative stations, for example -1 to -3
• Below spines: positive stations, for example +1 to +3

5. Pelvis

• Sacral curve
• Ischial spines
• Sidewalls
• Subpubic angle
• Diagonal conjugate, if needed
• Evidence of obstruction or soft-tissue mass

6. Caput and molding

• Caput succedaneum
• Degree of molding
• Severe caput/molding with no descent may suggest obstruction.

Examiner points

• Leopold maneuvers assess lie, presentation, position, and engagement.
• In vertex presentation, fetal heart sounds are usually below the umbilicus.
• The ischial spines are station 0.
• Assess cervix, membranes, presenting part, position, station, pelvis, caput, and molding during vaginal examination.
• Never perform a digital vaginal examination in significant late-pregnancy bleeding until placenta previa has been excluded.

Rapid revision: Questions 11-15

1. Amniotic fluid is formed mainly by fetal urine and fetal lung fluid.
2. PROM = rupture before labor; PPROM = rupture before labor and before 37 weeks.
3. Fertilization occurs in the ampulla; implantation begins around day 6-7.
4. Embryogenesis from weeks 3-8 is the main period of organogenesis and teratogenic risk.
5. The obstetric conjugate is approximately 10.5-11 cm.
6. The interspinous diameter is the narrowest transverse diameter of the pelvis.
7. Posterior fontanelle is triangular; anterior fontanelle is diamond-shaped.
8. A well-flexed vertex presents the suboccipitobregmatic diameter of 9.5 cm.
9. Leopold maneuvers determine fetal lie, presentation, position, and engagement.
10. In vaginal examination, assess the cervix, membranes, presenting part, position, station, caput, molding, and pelvis.

Obstetrics Questions 16-20: Oral-Exam Preparation

16. Physiology of labor. Regulation of uterine contractions. Preparatory period. Stages and duration of labor

Translation

A. Definition of labor

Features of true labor

• Contractions become regular, stronger, longer, and more frequent.
• Pain commonly begins in the back or lower abdomen and radiates forward.
• There is progressive cervical effacement and dilation.
• The presenting part descends.

False labor contractions

• Irregular and variable in intensity.
• Usually do not progressively increase.
• Often resolve with rest, hydration, or change in activity.
• Do not cause progressive cervical change.

B. Causes and regulation of labor

1. Uterine activation near term

• Increased oxytocin receptors in the myometrium
• Increased prostaglandin production
• Increased gap junctions between myometrial cells, especially connexin-43
• Cervical ripening and remodeling
• Increased uterine sensitivity to uterotonics

2. Role of progesterone and estrogen

• Maintains uterine quiescence throughout pregnancy.
• Reduces myometrial excitability.
• Reduces prostaglandin effects.

• Increase near term.
• Increase myometrial excitability.
• Increase oxytocin receptors and gap junction formation.
• Promote prostaglandin synthesis.

3. Prostaglandins

• Ripen and soften the cervix.
• Increase myometrial contractility.
• Contribute to membrane rupture and labor progression.

4. Oxytocin and Ferguson reflex

• It stimulates rhythmic uterine contractions.
• Its receptors increase greatly near labor.
• Cervical and vaginal stretching causes neuroendocrine stimulation of further oxytocin release, called the Ferguson reflex.

5. Fetal and placental contribution

• The fetal hypothalamic-pituitary-adrenal axis matures near term.
• Fetal cortisol promotes placental CRH activity and estrogen production.
• Placental CRH and inflammatory mediators contribute to uterine activation and cervical ripening.

C. Uterine contractions

• Involuntary nature
• Fundal dominance: contractions begin near the uterine fundus.
• Polarity: upper uterine segment contracts and retracts; lower uterine segment becomes progressively thinner and more distensible.
• Triple descending gradient: contraction begins in the fundus, is strongest in the fundus, and spreads downward.

Retraction

• Thickens the upper uterine segment.
• Pulls the cervix upward.
• Promotes cervical effacement and dilation.
• Helps fetal descent.
• Assists placental separation after birth.

D. Preparatory or prodromal period

Clinical features

• Irregular uterine contractions, often painless or mildly uncomfortable
• “Lightening,” or descent of the presenting part
• Increased pelvic pressure
• Backache
• Passage of cervical mucus plug or “bloody show”
• Cervical softening, shortening, and centralization
• Possible mild weight loss or reduced edema

Clinical importance

E. Stages of labor

First stage: cervical dilation

1. Latent phase
   • Cervical effacement and early dilation
   • Current practice commonly considers active labor to begin at about 5-6 cm dilation.
   • Duration is highly variable.
2. Active phase
   • More rapid dilation from approximately 5-6 cm to full dilation.
   • Requires ongoing assessment of maternal condition, fetal status, contraction pattern, and labor progress.

Second stage: expulsion of fetus

• Passive phase: full dilation before active maternal pushing, with descent due to uterine contractions.
• Active expulsive phase: maternal urge to push and active bearing-down efforts.

Third stage: delivery of placenta

Fourth stage, often described clinically

F. Duration of labor

Examiner points

• True labor causes progressive cervical change.
• Oxytocin, prostaglandins, estrogen, fetal cortisol, and inflammatory mediators participate in labor.
• The upper segment contracts and retracts; the lower segment stretches and becomes thinner.
• The first stage ends at complete cervical dilation.
• The second stage ends with birth of the fetus.
• The third stage ends with delivery of the placenta.

17. First stage of labor: course and management. Forces of labor. Cervical dilation in primiparas and multiparas

Translation

A. Definition

• Cervical effacement
• Cervical dilation
• Formation of the lower uterine segment
• Descent and engagement of the presenting part

B. Phases of the first stage

1. Latent phase

• Cervix softens, shortens, and begins dilating.
• Contractions are becoming regular but may still be variable.
• The phase is often prolonged in primiparas and can be managed expectantly if mother and fetus are well.

2. Active phase

• Begins at approximately 5-6 cm dilation in contemporary labor care.
• Contractions become stronger, longer, and more frequent.
• Cervical dilation and fetal descent become more apparent.

C. Forces of labor

1. Primary powers

• Cervical effacement and dilation
• Formation of the lower uterine segment
• Fetal descent
• Placental separation in the third stage

2. Secondary powers

• Most important in the second stage.
• Should not be encouraged before complete dilation because early pushing can cause cervical edema, fatigue, and ineffective descent.

D. Cervical effacement and dilation

Effacement

• In a nulliparous woman, the cervix typically effaces first, then dilates.
• In a multiparous woman, effacement and dilation often occur simultaneously.

Dilation

E. Management of the first stage

1. Admission assessment

• Confirm labor and gestational age.
• Obtain maternal history and identify risk factors.
• Assess blood pressure, pulse, temperature, pain, hydration, and bladder status.
• Abdominal examination: lie, presentation, position, engagement, contractions, fetal heart rate.
• Vaginal examination only when indicated and safe.
• Assess membrane status and liquor if membranes are ruptured.

2. Ongoing maternal monitoring

• Vital signs
• Pain and coping
• Oral fluids and nutrition as appropriate
• Urine output and bladder emptying
• Frequency, duration, and strength of contractions
• Vaginal bleeding and membrane status
• Emotional support and informed communication

3. Fetal surveillance

• Intermittent auscultation in low-risk labor, according to local protocol.
• Continuous CTG for significant risk factors or abnormal fetal heart-rate findings.
• Assess fetal heart rate after contractions when indicated.

4. Monitoring labor progress

• Cervical dilation
• Fetal head descent
• Contractions
• Fetal heart rate
• Liquor and molding
• Maternal pulse, blood pressure, temperature, and urine

5. Vaginal examination

• Perform with consent, aseptic technique, and clinical indication.
• In uncomplicated active labor, WHO recommends about 4-hourly vaginal examination, while minimizing unnecessary examinations.
• Examine sooner if there is an urge to push, fetal concern, altered contraction pattern, bleeding, suspected cord prolapse, or poor progress.

6. Pain relief

• Continuous support and non-pharmacologic methods
• Inhaled analgesia where available
• Systemic analgesia
• Neuraxial analgesia, such as epidural analgesia

7. Avoid unnecessary intervention

• No routine early amniotomy.
• No routine oxytocin augmentation.
• No routine continuous CTG in low-risk spontaneous labor.
• No unnecessary restriction of movement or oral intake, unless clinically indicated.

F. Abnormal findings requiring reassessment

• Power: inadequate or excessive contractions
• Passenger: fetal size, position, presentation, flexion
• Passage: maternal pelvis or soft-tissue obstruction

• Membrane rupture and infection
• Bladder distension
• Epidural effect
• Placental abruption
• Uterine scar complication
• Fetal hypoxia

Examiner points

• Primary powers are uterine contractions.
• Secondary powers are abdominal-muscle pushing efforts.
• In primiparas, effacement usually precedes dilation.
• In multiparas, effacement and dilation are usually simultaneous.
• The key evidence of labor is progressive cervical dilation and effacement.
• Monitor labor with a partograph or Labor Care Guide, not by time alone.

18. Second stage of labor. Perineal protection

Translation

A. Definition

1. Passive phase
   • Cervix is fully dilated.
   • The woman may not yet have a strong urge to push.
   • Fetal descent continues due to uterine contractions.
2. Active expulsive phase
   • The woman has an urge to push.
   • Maternal expulsive effort contributes to birth.

B. Physiology and course

• Uterine contractions are strong and frequent.
• The presenting part descends through the pelvis.
• The pelvic floor stretches.
• The fetal head undergoes cardinal movements.
• Maternal pushing increases intra-abdominal pressure.

C. Management of the second stage

1. Preparation

• Confirm full dilation before active pushing.
• Assess fetal presentation, position, station, and fetal heart rate.
• Prepare equipment for birth and neonatal resuscitation.
• Ensure a skilled attendant is present.
• Encourage a comfortable birth position chosen by the woman when clinically appropriate.
• Ensure the bladder is empty.

2. Maternal pushing

• Encourage the woman to follow her spontaneous urge to push.
• Avoid prolonged breath-holding or rigid coached pushing in a low-risk woman unless clinically indicated.
• With epidural analgesia, delayed pushing may be considered if mother and fetus are well and local resources permit monitoring.

3. Fetal surveillance

• Assess fetal heart rate regularly, particularly after contractions and pushing.
• Continuous CTG is appropriate if high-risk features, abnormal fetal heart rate, oxytocin augmentation, or other indication exists.

4. Assess progress

• Descent of the head
• Rotation
• Caput and molding
• Maternal exhaustion
• Fetal status
• Duration in context of parity and epidural analgesia

D. Perineal protection

Purpose

• Control the speed of head delivery.
• Allow gradual stretching of tissues.
• Reduce uncontrolled perineal tears.
• Support delivery of the head in a controlled manner.

Main principles

1. Communication
   • Tell the woman when to stop pushing or pant during crowning.
   • Obtain consent before touching or applying compresses.
2. Control of head extension
   • Support the perineum with one hand.
   • Use the other hand to control the speed of head extension.
   • Deliver the head slowly between contractions if necessary.
3. Support of the perineum
   • Gentle “hands-on” guarding can be used.
   • Warm compresses may reduce severe perineal trauma.
   • Perineal massage may be used according to patient preference and clinician skill.
4. Delivery of shoulders
   • Check for nuchal cord.
   • Allow restitution and external rotation.
   • Gentle downward traction delivers the anterior shoulder, then upward movement delivers the posterior shoulder.
   • Avoid forceful traction.

Episiotomy

• Need to expedite birth for fetal compromise
• Instrumental vaginal delivery
• Rigid scarred perineum preventing delivery
• Selected cases of shoulder dystocia or complicated breech delivery

Do not do

• Do not apply routine fundal pressure, also called the Kristeller maneuver.
• Do not perform routine episiotomy.
• Do not pull forcefully on the fetal head or shoulders.

Examiner points

• Second stage begins at full dilation and ends with birth.
• Confirm complete dilation before encouraging active pushing.
• Controlled head delivery and support of the perineum reduce trauma.
• Routine episiotomy and fundal pressure are not recommended.
• Warm compresses and perineal support are evidence-based options to reduce severe tears.

19. Biomechanism of labor in left occiput-anterior position

Translation

A. Definition

• Presentation: vertex
• Denominator: occiput
• Leading point: posterior fontanelle
• Presenting diameter: suboccipitobregmatic diameter, 9.5 cm
• Presenting circumference: suboccipitobregmatic circumference, approximately 32 cm

B. Cardinal movements in occiput-anterior labor

1. Engagement

• The sagittal suture usually lies in an oblique diameter.
• In LOA, the occiput is directed toward the left anterior quadrant of the maternal pelvis.

2. Descent

3. Flexion

• The chin approaches the chest.
• The suboccipitobregmatic diameter, 9.5 cm, presents.
• This is favorable for passage through the pelvis.

4. Internal rotation

5. Extension

1. Occiput
2. Bregma
3. Forehead
4. Face
5. Chin

6. Restitution

7. External rotation

8. Delivery of shoulders and trunk

• The anterior shoulder delivers under the pubic symphysis.
• The posterior shoulder delivers over the perineum.
• The rest of the body follows by lateral flexion.

C. Summary sequence

Examiner points

• In vertex presentation, the denominator is the occiput.
• In a well-flexed vertex, the presenting diameter is suboccipitobregmatic, 9.5 cm.
• In LOA, internal rotation brings the occiput beneath the pubic symphysis.
• The head delivers by extension.
• The shoulders deliver after restitution and external rotation.

20. Biomechanism of labor in occiput-posterior position

Translation

A. Definition

• Left occiput posterior, LOP
• Right occiput posterior, ROP

B. Predisposing factors

• Android or anthropoid pelvis
• Deflexed fetal head
• Nulliparity
• Large fetus
• Epidural analgesia, association rather than direct causation
• Reduced uterine efficiency
• Pelvic-floor characteristics

C. Clinical features

• Severe back pain, “back labor”
• Slow cervical dilation or delayed descent
• Persistent transverse position
• Prolonged second stage
• Increased molding and caput
• Maternal exhaustion
• Increased risk of operative vaginal birth or cesarean birth

• Posterior fontanelle is directed posteriorly.
• The anterior fontanelle may be more easily palpable because the head is often less flexed.
• Sagittal suture may lie in an oblique or transverse diameter.

D. Mechanism when occiput rotates anteriorly

1. Engagement

2. Descent and flexion

3. Long anterior internal rotation

4. Delivery as occiput anterior

• Extension of the head
• Restitution
• External rotation
• Delivery of shoulders and body

E. Persistent occiput-posterior delivery

Mechanism

1. Engagement and descent occur.
2. The occiput remains directed toward the sacrum.
3. The head may undergo only a short internal rotation.
4. The anterior part of the head, usually the bregma or forehead, becomes fixed under the pubic symphysis.
5. The head is born by a greater degree of flexion, with the occiput sweeping over the perineum.
6. Restitution, external rotation, and shoulder delivery follow.

F. Management principles

Antenatal and early labor

• Confirm position clinically and by ultrasound if uncertain.
• Encourage maternal mobility and comfortable positions if appropriate.
• Give adequate analgesia and hydration.
• Monitor progress and fetal status.

In established labor

• Avoid diagnosing arrest too early.
• Reassess contractions, fetal size, flexion, station, pelvic adequacy, caput, and molding.
• Correct uterine hypocontractility if appropriate and safe.
• Consider manual rotation or rotational instrumental birth only with suitable prerequisites and an experienced operator.
• Perform cesarean delivery for arrest of descent/rotation, failed operative vaginal delivery, fetal compromise, or suspected cephalopelvic disproportion.

Examiner points

• In OP, the occiput must make a long anterior rotation of 135 degrees to become anterior.
• If anterior rotation occurs, delivery continues as an occiput-anterior birth.
• Persistent OP can deliver face-to-pubis but is associated with prolonged labor and perineal trauma.
• Persistent OP may lead to fetal distress, maternal exhaustion, operative vaginal birth, or cesarean delivery.

Rapid Revision: Questions 16-20

1. Labor is regular uterine contractions causing progressive cervical effacement and dilation.
2. Uterine contractions are regulated by oxytocin, prostaglandins, estrogen, functional progesterone withdrawal, fetal cortisol, and inflammatory mediators.
3. Primary powers are uterine contractions; secondary powers are maternal pushing efforts.
4. First stage: onset of established labor to full dilation. Second stage: full dilation to birth. Third stage: birth to placental delivery.
5. In primiparas, effacement usually occurs before dilation. In multiparas, they often occur together.
6. Do not use a fixed 1 cm/hour dilation rate as the sole criterion for intervention.
7. Routine episiotomy and fundal pressure are not recommended.
8. Vertex OA mechanism: engagement, descent, flexion, internal rotation, extension, restitution, external rotation, delivery.
9. In occiput-anterior labor, the occiput rotates under the pubic symphysis.
10. In occiput-posterior labor, successful anterior rotation is about 135 degrees.

Obstetrics Questions 21-25: Oral-Exam Preparation

21. Fetal birth trauma. Caput succedaneum. Prevention of neonatal birth trauma

Translation

A. Definition

• Congenital anomalies
• Hypoxic-ischemic injury
• Neonatal infection
• Genetic or metabolic disease

B. Risk factors

Maternal and labor-related

• Cephalopelvic disproportion
• Contracted pelvis
• Prolonged or obstructed labor
• Precipitous labor
• Uterine hyperstimulation
• Malpresentation or malposition
• Shoulder dystocia
• Operative vaginal delivery, especially difficult forceps delivery
• Inadequate or incorrect obstetric maneuvers

Fetal factors

• Macrosomia
• Prematurity
• Breech presentation
• Fetal anomalies
• Fetal bleeding disorder

C. Classification of neonatal birth trauma

1. Soft-tissue injuries

• Caput succedaneum
• Bruising, petechiae
• Skin abrasions or lacerations
• Subcutaneous fat necrosis

2. Scalp and cranial injuries

• Cephalohematoma
• Subgaleal hemorrhage
• Skull fracture
• Intracranial hemorrhage

3. Peripheral nerve injuries

• Brachial plexus palsy, including Erb palsy
• Facial nerve palsy
• Phrenic nerve injury

4. Skeletal injuries

• Clavicle fracture
• Humerus fracture
• Femur fracture

5. Internal-organ injury

• Hepatic rupture
• Splenic rupture
• Adrenal hemorrhage

6. Spinal cord injury

D. Caput succedaneum, “birth tumor”

Definition

Features

• Present at birth
• Located over the presenting part of the scalp
• Soft and pitting
• Poorly demarcated
• Crosses suture lines
• May be associated with bruising
• Usually resolves spontaneously within 24-48 hours

Differential diagnosis

Clinical significance

• Prolonged labor
• Malposition
• Cephalopelvic disproportion
• Obstructed labor

E. Prevention of neonatal birth trauma

1. Careful antenatal risk assessment:
   • Identify macrosomia, malpresentation, fetal anomalies, and maternal pelvic problems.
2. Correct assessment of labor:
   • Monitor cervical dilation, descent, fetal heart rate, caput, and molding.
   • Recognize obstructed labor early.
3. Appropriate choice of delivery method:
   • Timely cesarean delivery for true disproportion, fetal compromise, inappropriate presentation, or failed labor.
4. Safe operative vaginal delivery:
   • Use forceps or vacuum only with correct indication, known fetal position, adequate dilation, engaged head, and an experienced operator.
   • Avoid sequential use of forceps and vacuum whenever possible.
5. Skilled breech management:
   • Avoid unnecessary traction.
   • Use trained assistance and timely cesarean birth when indicated.
6. Immediate neonatal examination:
   • Examine scalp, clavicles, limbs, neurologic status, and breathing.
   • Observe infants after difficult instrumental delivery for subgaleal bleeding, anemia, shock, or jaundice.

Examiner points

• Caput succedaneum is edema and crosses sutures.
• Cephalohematoma is subperiosteal and does not cross sutures.
• Subgaleal hemorrhage can cause severe blood loss and shock.
• Prevention depends mainly on correct labor management and timely recognition of obstruction.

22. Third stage of labor. Methods and signs of placental separation

Translation

A. Definition

B. Physiology of placental separation

C. Types of placental separation

1. Schultze mechanism

• Separation begins centrally.
• A retroplacental hematoma forms.
• The fetal surface of the placenta appears first.
• Membranes usually peel off and follow behind.
• External bleeding may be minimal until the placenta is delivered.

2. Duncan mechanism

• Separation begins at the placental edge.
• Maternal surface appears first.
• Blood may escape externally earlier.
• Membranes may be more likely to be retained.

D. Signs of placental separation

1. Schröder sign

• Uterus becomes firm, globular, and rises in the abdomen.
• Often deviates to the right.

2. Alfeld sign

• The visible segment of umbilical cord lengthens outside the vagina.

3. Küstner-Chukalov sign

• With pressure above the pubic symphysis:
  • If the placenta has separated, the cord does not retract.
  • If it has not separated, the cord retracts upward.

4. Klein sign

• Ask the woman to bear down.
• If the placenta is separated, the cord lengthens and does not retract after she stops pushing.

5. Mikulicz-Radetsky sign

• The woman experiences an urge to push because the placenta has descended into the vagina.

Other supportive signs

• A small gush of blood
• Lower uterine segment becomes more prominent
• Placenta may become visible at the introitus

E. Management of the third stage

Active management of the third stage of labor

1. Give a prophylactic uterotonic after birth, usually oxytocin according to local protocol.
2. Delay cord clamping when the newborn does not need immediate resuscitation, according to current neonatal policy.
3. Use controlled cord traction only by a trained clinician and only after signs of placental separation, with uterine countertraction.
4. Assess uterine tone and blood loss after placental delivery.

Inspection after delivery

• Placental maternal surface for completeness of cotyledons
• Membranes for completeness
• Umbilical cord vessels, normally two arteries and one vein
• Maternal genital tract for tears
• Uterine tone and vaginal bleeding

F. Complications

• Retained placenta
• Retained placental fragments or membranes
• Uterine atony
• Postpartum hemorrhage
• Uterine inversion, especially after inappropriate cord traction
• Genital tract trauma
• Infection

Examiner points

• The third stage is from birth of the baby to delivery of placenta.
• Never apply cord traction before placental separation and uterine contraction.
• Schultze: fetal surface first. Duncan: maternal surface first.
• A firm, globular, elevated uterus and lengthening cord suggest placental separation.
• Always inspect placenta and membranes for completeness.

23. Physiological blood loss in childbirth. Methods of determining blood loss

Translation

A. Physiological blood loss

• Up to 0.5% of maternal body weight
• Usually not more than about 400-500 mL in an uncomplicated vaginal birth

Important modern point

B. Why postpartum blood loss is dangerous

Treat the woman, not only the number of milliliters.

C. Methods of estimating or measuring blood loss

1. Visual estimation

• Quick but inaccurate.
• Commonly underestimates large blood loss.
• Should not be the sole method in suspected hemorrhage.

2. Direct measurement

• Simple
• More objective
• Allows early recognition of excessive bleeding

3. Gravimetric method

• Swabs
• Pads
• Linen
• Drapes
• Clots where possible

4. Suction-volume measurement

5. Laboratory and clinical assessment

• Hemoglobin and hematocrit
• Coagulation studies
• Fibrinogen
• Lactate
• Urine output
• Shock index:

D. Causes of excessive postpartum blood loss

Examiner points

• Physiological blood loss is traditionally up to 0.5% of maternal body weight.
• Objective measurement is preferred over visual estimation.
• Gravimetric rule: 1 g of additional weight is approximately 1 mL of blood.
• Severe hemorrhage may occur before hypotension is apparent.
• Always think of the 4 Ts.

24. Physiological postpartum period. Prevention of puerperal purulent-septic infection

Translation

A. Definition

• Immediate postpartum period: first 24 hours
• Early postpartum period: first 7 days
• Late postpartum period: up to 6 weeks

B. Physiological changes in puerperium

1. Uterine involution

• Immediately after birth: fundus near the umbilicus
• It descends roughly 1 cm or one fingerbreadth each day
• By 10-14 days: usually no longer palpable abdominally
• By 6 weeks: near pre-pregnant size

2. Lochia

• Foul odor
• Persistent heavy red bleeding
• Large clots
• Increasing bleeding after initial reduction
• Fever or uterine tenderness

3. Cervix and vagina

• Cervix gradually closes but the external os remains slit-like after vaginal birth.
• Vaginal rugae and pelvic-floor tone gradually recover.
• Perineal wounds heal over days to weeks.

4. Breast and lactation

• Colostrum is produced initially.
• Mature milk usually comes in around days 2-4.
• Prolactin stimulates milk production.
• Oxytocin causes milk ejection.

5. Cardiovascular and urinary changes

• Diuresis is common in the first days postpartum as excess pregnancy fluid is mobilized.
• Blood volume and cardiac output gradually normalize.
• The hypercoagulable state persists in the early postpartum period, so venous thromboembolism risk remains increased.

6. Menstruation and fertility

• Ovulation can occur before the first menstruation.
• Exclusive breastfeeding may delay menstruation but is not completely reliable contraception unless strict lactational amenorrhea criteria are fulfilled.

C. Management of the normal puerperium

Immediate postpartum monitoring

• Pulse, blood pressure, temperature, respiratory status
• Uterine tone and fundal height
• Amount and character of bleeding
• Perineum, vagina, cesarean wound if applicable
• Pain control
• Urination and bladder emptying
• Breastfeeding and newborn feeding
• Emotional wellbeing and mental health

General care

• Early mobilization when safe
• Adequate hydration and nutrition
• Perineal hygiene
• Bowel care and prevention of constipation
• Thromboprophylaxis for women at increased risk
• Breastfeeding support
• Counseling about warning symptoms and postpartum contraception

D. Prevention of postpartum purulent-septic infection

Main risk factors

• Cesarean birth
• Prolonged labor
• Prolonged rupture of membranes
• Chorioamnionitis
• Multiple vaginal examinations
• Retained placental tissue
• Postpartum hemorrhage
• Operative vaginal delivery
• Perineal trauma
• Diabetes, obesity, anemia, immunosuppression

Prevention measures

1. Hand hygiene and aseptic technique
   • Strict hand hygiene for all personnel.
   • Sterile technique for vaginal examinations and invasive procedures.
2. Minimize vaginal examinations
   • Perform only when indicated.
   • Use sterile gloves and document findings.
   • Reduce examinations after membrane rupture.
3. Timely management of ruptured membranes and prolonged labor
   • Monitor for chorioamnionitis.
   • Avoid unnecessary delays where maternal or fetal risk is increasing.
4. Antibiotic prophylaxis when indicated
   • Cesarean birth requires prophylactic antibiotics.
   • Additional prophylaxis depends on procedure and local policy.
5. Safe surgical and perineal-wound care
   • Correct repair of lacerations and episiotomy.
   • Prompt treatment of hematoma, wound infection, or dehiscence.
6. Early recognition and treatment
   • Investigate fever, uterine tenderness, foul lochia, tachycardia, wound pain, or systemic illness.
   • Treat suspected postpartum infection promptly.

Examiner points

• Puerperium lasts about 6 weeks.
• Lochia progress: rubra → serosa → alba.
• A foul smell, fever, uterine tenderness, or heavy persistent bleeding is abnormal.
• Most important infection-prevention measures: hand hygiene, asepsis, minimizing vaginal examinations, antibiotic prophylaxis for cesarean birth, and early treatment of infection.

25. Perineal incision during childbirth: indications, postpartum care, and complications

Translation

A. Definition

Terminology

• Episiotomy: incision beginning at the posterior vaginal commissure and extending laterally.
• Perineotomy: usually a midline incision directed toward the anus. In some regions, terms may be used differently.

B. Types of episiotomy

1. Mediolateral episiotomy

• Begins at the posterior vaginal commissure.
• Directed laterally, usually at about 45-60 degrees from the midline at crowning.
• Commonly preferred in many settings because it may reduce extension into the anal sphincter.

2. Midline episiotomy

• Incision is directed straight toward the anus.
• Easier repair, less blood loss, often less pain.
• Higher risk of extension into the anal sphincter and rectum.

3. Lateral episiotomy

• Begins lateral to the midline.
• Less commonly used because of possible injury to vessels, glands, and nerves.

C. Indications

1. Need to expedite birth because of fetal compromise.
2. Operative vaginal delivery, especially forceps delivery.
3. Rigid, scarred, or non-distensible perineum obstructing delivery.
4. Selected complicated breech deliveries.
5. Selected shoulder dystocia situations where more room is needed for internal maneuvers.
6. Imminent severe uncontrolled perineal tear in selected cases.

D. Timing and basic principles

• Perform only when the perineum is thinned and stretched by the presenting part, usually at crowning.
• Obtain consent whenever possible.
• Ensure adequate analgesia or anesthesia.
• Use sterile technique.
• Make the incision only for a clear indication.
• After birth of placenta, inspect carefully for extension, bleeding, and associated vaginal/cervical tears.
• Repair in layers using appropriate absorbable sutures.

E. Postpartum care after episiotomy

1. Inspect the wound:
   • Hemostasis
   • Anatomical alignment
   • Extension into anal sphincter or rectum
   • Hematoma
2. Pain management:
   • Cold packs in the immediate period if appropriate
   • Oral analgesia
   • Local care according to hospital policy
3. Hygiene:
   • Keep perineum clean and dry.
   • Change pads regularly.
   • Hand hygiene before and after perineal care.
4. Bowel care:
   • Adequate fluids and fiber.
   • Stool softeners if needed, especially after significant tears.
5. Follow-up:
   • Review wound healing, pain, infection, urinary symptoms, bowel control, and dyspareunia.
   • Pelvic-floor exercises after recovery.

F. Complications

Early complications

• Bleeding
• Hematoma
• Wound infection
• Wound dehiscence
• Edema and severe pain
• Extension to third- or fourth-degree perineal tear
• Injury to anal sphincter or rectum

Late complications

• Persistent perineal pain
• Dyspareunia
• Cosmetic dissatisfaction
• Pelvic-floor dysfunction
• Anal incontinence if sphincter injury occurred
• Scar tenderness
• Psychological distress

Examiner points

• Episiotomy is selective, not routine.
• Mediolateral episiotomy has lower risk of extension into the anal sphincter than midline episiotomy.
• Perform at crowning when the perineum is stretched, with analgesia and asepsis.
• Always inspect for extension into the anal sphincter and rectum.
• Major complications: bleeding, hematoma, infection, dehiscence, severe tears, dyspareunia, and anal incontinence.

Rapid Revision: Questions 21-25

1. Caput succedaneum is scalp edema that crosses sutures and resolves spontaneously.
2. Cephalohematoma does not cross sutures; subgaleal hemorrhage may cause life-threatening blood loss.
3. Third stage begins after birth of the baby and ends after placental delivery.
4. Schultze mechanism: fetal surface first. Duncan mechanism: maternal surface first.
5. Signs of placental separation: firm globular uterus, uterine rise, cord lengthening, and small blood gush.
6. Physiological blood loss is traditionally up to 0.5% of maternal body weight, commonly up to 400-500 mL.
7. Quantified blood loss is more accurate than visual estimation.
8. The puerperium lasts about 6 weeks; lochia progress rubra → serosa → alba.
9. Prevent puerperal infection by hand hygiene, asepsis, minimizing unnecessary examinations, and timely antibiotics when indicated.
10. Episiotomy is selective, not routine.

• Exact English translation of each question
• Definition and core concepts
• Etiology, classification, pathogenesis where relevant
• Clinical features and diagnosis
• Management and obstetric tactics
• Complications and prevention
• “Examiner points” and rapid-revision boxes
• Tables, formulas, and memory aids where useful
• A final high-yield revision section

• Management details would be aligned with broadly accepted current guidance, while clearly flagging areas governed by local Russian protocols or supervised procedural training.
• I would preserve the same level of detail across all questions, including obstetric hemorrhage, hypertensive disorders, sepsis, pregnancy loss, maternal medical disease, and Rh alloimmunization.