Solve the following tasks... make sure you use obgyn books like Williams Gynecology and Obstetrics and DC dutta as your bases of information.. proper medical books . Answer these like you are a md ms obgyn. Detailed answers with explanations. CASE № 1 Patient 22 years old, primapara, three days ago she had normal labor, weight of new born - 3,5kg, breast are soft, lactation is normal; fundus of uterus is 10 cm above pubis, uterus is hard, temperature – 36.6о С. Discharge from vagina is red; perineum is normal 1. Primary diagnose? 2. Classification of lochia. 3. Differentiation between milk and colostrums by constitution. CASE № 2 A young 12 year old girl who has attained menarche (first menstruation) 6 months back comes with bleeding coming on every 15 days. The flow is not heavy, but it is bothersome and the girl is not able to concentrate in her studies. 1. Does it need medical intervention? 2. If the same girl comes with heavy bleeding, what could be the reason? 3. If a woman in the reproductive age group comes with heavy bleeding what could be the reason? CASE № 3 A 20 years old primipara patient presents at 32 weeks of gestation with complaints of lower abdominal pain and leaking of clear amniotic fluid from vagina. On objective examination: Ps – 80, BP – 110/70 mm Hg, T – 36.7. Uterus is enlarged up to 32 weeks, soft and non-tender. Lie of the fetus – longitudinal, cephalic presentation. FHR – 144 bpm. On vaginal examination: Position of the cervix – posterior, lenth – 3cm, consistency – firm, external os admits tip of finger, internal os is closed, presenting part is non-engaged; leaking of clear amniotic fluid is present. 1. What is your primary diagnosis? 2. Estimate cervical maturity by Bishop score 3. What is your plan of investigations? 4. What is the appropriate management? CASE № 4 Patient 20 years old, primipara, three days ago, was a normal delivery. Fetal weight - 3,5 kg. The breasts are soft, lactation. Fundal height - 10 cm above the womb, the uterus is dense. Body temperature - 36.6 ° C. Vaginal discharge - bloody, perineum in a satisfactory condition. The stools was unremarkable. Gases passed out. Urination is free, painless and adequate. 1. The preliminary diagnosis. 1. The preliminary diagnosis. 2. What do doctors call a woman during pregnancy, delivery and the postpartum period? 3. Classification of post-partum period. 4. What is lochia, their classification? 5. What is different between colostrum and milk? CASE №5 A G5P4 patient presents with complaints of painless vaginal bleeding at 37 weeks of gestation, appreciates fetal movements well. On examination: Ps – 100, BP – 120/70 mm Hg. Uterus is soft ad non-tender. Presentation is cephalic, fetal head is high above the pelvic brim. FHS – 150/min. 1. What is your primary diagnosis? 2. What is your plan of investigations? 3. Management? CASE № 6 A pregnant woman has following sizes of pelvis: Distancia interspinarum – 26 cm, Distancia intercristarum – 28 cm, Distancia intertrochanterica – 32 cm, Conjugata externa – 20.5 cm, Wrist circumference – 14 cm. 1. Has this woman normal sizes of pelvis? 2. What is the conjugata vera for this pregnant woman? 3. What are the methods used for estimate true conjugate (4 methods)? CASE № 7 The Woman, 27 years old, came to the Consultation with complaints to impossibility to be pregnant during last 2 years. She is married from 22 years old. First 3 years of married life she used condoms and oral pills, but 2 years ago she finished to do it without effect. She has normal menstrual cycle - it came when she was 12 years old, length is 28 days, length of the menstruation 3-5 days and volume of blood loss about 80-100 ml. She never was pregnant before. 1. What is your diagnosis? 2. Describe all reasons which could present at that disorder. 3. Describe tactic of medicine investigation. CASE № 8 Patient 20 years old, nullipara, has 39 weeks of pregnancy; by Leopold maneuvers – cephalic presentation; cardiac tone of fetus 136-138 per minute; abdominal circumference 99 cm, fundus length is 38 cm. Vaginal examination – cervix in the middle of pelvis, length 1, 5 cm, soft, external os goes to 1 finger, nose and lips of fetus are palpated. 1. Primary diagnose? 2. Plan of delivery. 3. What complications may be? CASE № 9 Primipara woman 20 years old was send to the labor room with a full-term pregnancy in a state of sopor. At home and on the road was three attack of eclampsia. BP 180/100. Labor after 2-3 minutes. The opening of the cervix is complete, head into the pelvic cavity. Fetus is medium size. Fetal heartbeat muffled, 160 bpm. 1. Diagnosis. 2. Plan for the management of labor. 3. List the sequence of events to help the mother in this case. 4. List the major clinical manifestations of an attack of eclampsia according to stages. 5. Condition and indications for forceps. 6. Show on the phantom method to operate forceps. CASE №10 A 19-year-old primigravida at 37th week of gestation presents with lower abdominal pain, vaginal bleeding, weakness and giddiness. On examination: Ps – 100, BP – 100/60 mm Hg. Uterus is firm and tender. FHR – 90, weak. 1. What is your primary diagnosis? 2. What is your plan of investigations? 3. Management?
CASE №11 In primigravida women, whose pregnancy proceeded with moderate preeclampsia, during labor arise stomach pain, weakness, dizziness, bleeding from the genital tract. Pulse increased to 100 bpm, blood pressure 100/60 mmHg. The uterus is tense, painful on palpation, more on the right, between labor attempts not relaxed. The fetal head in the pelvic cavity. Fetal heart rate - about 100 bpm. Vaginal examination: a complete opening of the cervix, the amniotic sac is not present, the fetal head in the narrowest part of the pelvis, a small fontanelle at the left womb, located below the big one. 1. Make a preliminary diagnosis. 2. What are the main etiological cause of this disease? 3. Further management plan. 4. Is it possible in this case, the use of forceps instead of vacuum? CASE № 12 White women 26 years old, primapara, came to the maternity home in the 25 of April 2010, first day of last menstrual cycle was 18 of July 2009, and first movement of fetus was 12 of December 2009; abdominal circumference 101 cm, height of uterus 35 cm. 1. How many weeks of pregnancy of this patient, and the expected day of labor. 2. Calculate the fetal weight. 3. Stages of labor? CASE № 13 Multipara woman in the second stage of labor with mixed breech presentation of fetus, marked decrease in the fetal heart rate up to 100 beats / min and decrease of the heart sounds. At vaginal examination, cervix is not noted, buttocks and feet of the fetus are in the pelvic cavity, prolapse of umbilical cord found. 1. Diagnosis. 2. Plan for the conduction of labor. 3. What are the mistakes? 4. Is it possible to give birth to a living fetus with umbilical cord prolapsed by vaginal delivery: a) in the cephalic presentation, and b) for breech presentation? 5. What kind of aid should be provided to women in the II stage of labor when there is prolapse of umbilical cord: a) cephalic presentation, and b) in breech presentation? 6. At 34 weeks revealed breech presentation of fetus, further tactics of doctor of women consultation clinic. CASE № 14 Patient 18 years old has complains – amenorrhea about 9 weeks, nausea and vomiting. By vaginal examination uterus is soft and enlarged to 7-8 weeks. 1. Primary diagnose? 2. Which examinations you need to confirm you diagnose? 3. Classification of symptoms of pregnancy? CASE №15 A 20-year-old G1 patient at 40th week of gestation presents with mild labor pain since last 20 hours. The pain is located in lower abdomen, intensity and duration of pain remains unchanged. Vaginal discharge is absent. On vaginal examination: the cervix is uneffaced, 3cm in lenth, external os admits tip of finger. 1. What is your primary diagnosis? 2. What is the appropriate management? CASE № 16 A pregnant woman was admitted into the hospital 6 hour’s after the beginning of uterine contractions. The amniotic sac was not ruptured. Term pregnancy 5, delivery 5. All previous pregnancies and deliveries proceeded without complications. The size of the pelvis is normal. Through palpation of the abdominal wall, the head of the fetus is felt on the right side, transverse lie of the fetus is felt. Heart beat of the fetus is clear at level umbilicus 136 beats/minutes, rhythmical. 30 minutes after admission, the amniotic sac ruptured. In vaginal examination: cervix dilation was 6cm, without presence of amniotic sac, presenting part is not determined. The head is not reached, bone deformations are not present. 1. Diagnosis 2. Plan of management 3. What methods of delivery are possible at transverse position of a fetus? CASE № 17 White women 32 years old, primapara, 27 weeks of pregnancy; by physical examination uterus vertex, cephalic presentation, fetal heart rate 136-138 per minute . During auscultation was found systolic murmurs, Pls – 78 per minute, BP 110/70 mm Hg. Gestational body weight 9 kg. During ultrasound examination of kidneys was found mild hydronephrosis. Laboratory analysis: Er - 3,6x1012 Hb – 108g/l, Ht – 39%, Leukocyte – 7,3x10 9, Thrombocyte – 240x10 9. 1. Primary diagnose. 2. Physiological changes during pregnancy. 3. Due to what the increased body weight during pregnancy, can be explained? CASE №18 A 27-year-old G1P1 patient presents on the 2nd postpartum day after unremarkable spontaneous delivery with complaints of lower abdominal pain, high fever, and weakness. On examination: T – 38.4*C, PS – 100, BP – 110/70 mm Hg, both breasts are soft, there is lower abdominal tenderness and foul smell lochia. 1. What is your primary diagnosis? 2. Make plan of investigations? 3. Management. CASE №19 A 20-year-old primigravida with full term pregnancy was admitted because labor onset. Pelvimetry: 22 – 24 – 27 – 15, wrist index – 14cm. Estimated fetal weight – 3.5 kg. 1. What is your primary diagnosis? 2. Select delivery mode. CASE № 20 Primipara in labor 10 hours, rupture of amniotic sac 4 hours ago. Contractions regular, for 50 sec, every 1 min . The heartbeat of the fetus dull, arrhythmic beats 105-110 in min. At vaginal examination: the opening of the cervix complete, head of the fetus in the pelvic floor, sagittal suture in exit plane, a small fontanel in the front from the symphysis. 1. What is your diagnosis? 2. Tactic of management. Do the same for these
Where are the complete answers ?
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CASE 11 - Abruption + preeclampsia: 4 sub-questions answered (diagnosis, aetiology table, management plan, forceps vs vacuum)
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CASE 12 - Dating/EDD/fetal weight/stages: 3 sub-questions with Naegele's calculation, quickening confirmation, Johnson's + Dare's formula, full 3-stage classification with Friedman's curve
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CASE 13 - Cord prolapse in breech: 6 sub-questions answered (diagnosis, management plan, mistakes listed, vaginal delivery feasibility for both vertex and breech, stage 2 aid for both presentations, 34-week breech tactics)
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CASE 14 - Early pregnancy/hyperemesis: 3 sub-questions (diagnosis, investigations, classification of pregnancy symptoms into Presumptive/Probable/Positive with all signs listed)
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CASE 15 - False labour: 2 sub-questions (diagnosis with comparison table true vs false labour, full stepwise management)
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CASE 16 - Transverse lie with ruptured membranes: 3 sub-questions (diagnosis, management, all 5 possible delivery methods explained)
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CASE 17 - Physiological anaemia/murmur/hydronephrosis: 3 sub-questions (diagnosis, all physiological changes by system, weight gain components table)
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CASE 18 - Puerperal endometritis: 3 sub-questions (diagnosis, full investigation plan, antibiotic regimens and surgical management)
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CASE 19 - Contracted pelvis: 2 sub-questions (all pelvic measurements analysed, CV calculated as 6 cm = absolute CS)
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CASE 20 - Fetal distress at outlet OA: 2 sub-questions (diagnosis, full forceps delivery steps)
Can u show me the long answers. I am not able to see them
Generate 1 to 10 long answers and 20th again
Only generate task 10 amd 20 again
CASE 10
1. Primary Diagnosis
| Grade | Description |
|---|---|
| Grade 0 | Clinically silent; retroplacental clot found after delivery |
| Grade 1 (Mild) | External bleeding, mild uterine tenderness, no maternal or fetal compromise |
| Grade 2 (Moderate) | Moderate bleeding (external + concealed), definite uterine tenderness, fetal distress but fetus alive |
| Grade 3 (Severe) | Massive haemorrhage, board-like uterus, maternal shock, fetal death |
- Revealed (External): Blood tracks through cervix and is visible vaginally - accounts for ~80% of cases
- Concealed: Blood trapped behind placenta, no external bleeding - accounts for ~20%; the most dangerous type as blood loss is underestimated
- Mixed: Both external and concealed components
2. Plan of Investigations
Immediate Bedside/STAT Investigations:
- Haemoglobin and Haematocrit: assess severity of anaemia
- Platelet count: thrombocytopenia suggests developing DIC (Disseminated Intravascular Coagulation)
- WBC: baseline; elevated with stress response
- Type and screen URGENTLY
- Crossmatch minimum 4-6 units packed red blood cells and 4-6 units Fresh Frozen Plasma (FFP)
- If exsanguinating and crossmatched blood not available: O-negative uncrossmatched blood
- Prothrombin Time (PT) and INR
- Activated Partial Thromboplastin Time (aPTT)
- Serum Fibrinogen - THE most important test; fibrinogen is consumed early in DIC
- Normal in pregnancy: ≥400 mg/dL (pregnancy is a hypercoagulable state with elevated baseline fibrinogen)
- Fibrinogen 200-400 mg/dL: early coagulopathy
- Fibrinogen <200 mg/dL: significant DIC
- Fibrinogen <100 mg/dL: severe DIC, major haemorrhage risk
- D-dimer: Elevated in DIC (fibrin degradation products)
- Thrombin time
- Draw 5 mL blood into a plain glass tube; observe
- Normally a firm clot forms within 6 minutes
- If no clot forms in 6 minutes or clot is soft/lysed = significant DIC
- A RAPID, cheap bedside test - available even in resource-limited settings
- Williams Obstetrics and DC Dutta both emphasise this test in managing abruption
- Assess renal function
- Acute Tubular Necrosis (ATN) is a recognised complication of severe abruption - from renal cortical ischaemia due to hypovolaemia + DIC microthrombi in glomerular capillaries
- In severe cases: Bilateral Renal Cortical Necrosis (catastrophic, irreversible)
- Exclude HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) as a co-existing condition or mimicker
- Serum uric acid (elevated in preeclampsia)
- Hypoglycaemia can complicate shock
- Insert Foley catheter immediately
- Target urine output ≥30 mL/hour (0.5 mL/kg/hour)
- Oliguria is the earliest sign of renal compromise
- Lactate ≥2 mmol/L = sepsis/tissue hypoperfusion
- Lactate ≥4 mmol/L = septic/haemorrhagic shock with poor tissue perfusion
- Guides resuscitation adequacy
Fetal Assessment:
- Connect immediately
- FHR of 90 bpm sustained is a Category III (non-reassuring/pathological) pattern
- Look for: late decelerations, variable decelerations, sinusoidal pattern, absent variability
- Confirms degree of fetal compromise and urgency for delivery
- Confirm fetal cardiac activity - is the fetus alive? (This guides whether vaginal or CS delivery is selected)
- Identify retroplacental clot: echogenic/hypoechoic area behind placenta - though USS has only ~50% sensitivity for acute abruption (fresh blood is isodense with placenta on USS)
- Estimate size of the haematoma
- IMPORTANT: A normal USS does NOT exclude abruption - the diagnosis is CLINICAL
- Confirm fetal presentation, AFI, placental location (to exclude co-existing placenta previa)
- Fetal biometry (estimated fetal weight)
- If mother is Rh-negative: quantify feto-maternal haemorrhage (FMH) to calculate correct dose of anti-D immunoglobulin
- Qualitative: confirms FMH occurred (maternal blood contains fetal cells)
3. Management
A. IMMEDIATE RESUSCITATION
- Ensure patent airway
- Supplemental oxygen via non-rebreather face mask at 10-15 L/min
- Maintain SpO2 >95%
- If unconscious or GCS falling: intubation and ventilation
- Monitor respiratory rate and SpO2
- If pulmonary oedema develops (from massive transfusion or pre-existing pre-eclampsia): positive pressure ventilation
- Two large-bore peripheral IV cannulas (14-16 gauge) - do both simultaneously
- IV Fluid resuscitation: Ringer's Lactate or Normal Saline 1-2 litres rapidly, then reassess vital signs
- Blood transfusion: Start packed red blood cells (pRBCs) as soon as crossmatched blood available; use 1:1:1 ratio (pRBC : FFP : platelets) if massive transfusion protocol activated
- If blood not immediately available and patient exsanguinating: O-negative uncrossmatched blood
- Target: Systolic BP ≥90 mmHg, HR <100, urine output ≥30 mL/hour, Hb ≥8 g/dL
- Insert immediately; strict monitoring of urine output hourly
- Oliguria (<20 mL/hour) = renal compromise; escalate management
- Continuous pulse oximetry
- Continuous CTG
- BP every 15 minutes
- Urine output hourly
- Repeat CBC, coagulation profile every 2-4 hours until stable
B. MANAGEMENT OF DIC (if present)
- Massive tissue factor (thromboplastin) release from the damaged decidua and placenta activates the coagulation cascade
- Simultaneous fibrinolysis consumes clotting factors
- Result: paradoxical simultaneous thrombosis (microthrombi) and bleeding (factor depletion)
- Fresh Frozen Plasma (FFP): 2-4 units IV (each unit contains all clotting factors; 1 unit raises fibrinogen by ~10 mg/dL)
- Cryoprecipitate: 10 units IV (rich in fibrinogen, factor VIII, vWF; 10 units raise fibrinogen by ~150 mg/dL; preferred when fibrinogen <1 g/L)
- Platelet Concentrate: Transfuse if platelets <50,000/μL with active bleeding; aim to keep >80,000 if CS planned
- Tranexamic Acid 1 g IV over 10 minutes (antifibrinolytic; the WOMAN trial demonstrated significantly reduced death from PPH when given within 3 hours of haemorrhage onset)
- Haematologist involvement in massive haemorrhage protocol
- Do NOT give heparin in obstetric DIC (worsens bleeding)
C. DELIVERY - MODE AND TIMING
If Fetus is ALIVE with Fetal Distress (this case):
- Term fetus (37 weeks), alive but in severe distress (FHR 90, weak)
- Vaginal delivery is not imminent (cervical status not stated, but abruption may or may not be in labour; even if some dilatation is present, the fetal distress requires immediate delivery)
- CS delivers the fetus in the shortest possible time
- Grade 2-3 abruption with live fetus = indication for immediate CS in most guidelines
- If haemodynamically stable: Spinal anaesthesia (faster onset than epidural, avoids maternal airway manipulation)
- If haemodynamically unstable or coagulopathy present: General Anaesthesia (GA) - faster to induce; avoids risks of spinal in hypovolaemic patient (profound hypotension) and unsafe if coagulopathy (epidural haematoma risk)
- Couvelaire Uterus (Uteroplacental Apoplexy): Blood infiltrates into the myometrium between muscle fibres, giving the uterus a bruised, purple-blue, mottled appearance. Named after the French obstetrician Alexandre Couvelaire. The Couvelaire uterus is atonic - it does NOT contract well, setting the stage for severe PPH.
- Retroplacental clot: Found on the maternal surface of the placenta; confirms diagnosis
- Uterine atony post-delivery: Uterus feels "boggy" and fails to contract despite oxytocin
- Oxytocin infusion: 20-40 IU in 500 mL NS, run over 4-8 hours after delivery of anterior shoulder
- Ergometrine 0.2-0.5 mg IV (caution in hypertension)
- Carboprost (PGF2α) 0.25 mg IM every 15 minutes (max 8 doses) - avoid in asthma
- Misoprostol 800-1000 mcg PR or SL
- B-Lynch suture: Compression suture around the uterus - first-line surgical option for atony at CS
- Uterine artery ligation (O'Leary stitch)
- Internal iliac artery ligation
- Peripartum hysterectomy: Last resort for uncontrolled haemorrhage - life-saving. Higher risk in Couvelaire uterus.
- Balloon tamponade (Bakri balloon): Can be used at CS if uterus is closing and still oozing
If Fetus is DEAD (Grade 3 with absent cardiac activity on USS):
- Artificial Rupture of Membranes (ARM) if not already done
- Oxytocin augmentation (20-40 IU in 500 mL NS)
- Allow labour to progress with close monitoring
- Most patients deliver within 6-8 hours
- CS reserved for: maternal exsanguination not responding to resuscitation, unfavourable cervix with expected prolonged labour, other obstetric indication (e.g. obstruction)
D. POSTOPERATIVE/POST-DELIVERY CARE
- PPH (uterine atony from Couvelaire uterus, DIC) - most immediate danger
- Acute Kidney Injury / Acute Tubular Necrosis:
- From renal ischaemia (prolonged hypotension) + DIC (glomerular microthrombi)
- In severe cases: Bilateral Renal Cortical Necrosis (irreversible, requires dialysis)
- Monitor urine output strictly; renal replacement therapy if oliguria persists despite adequate resuscitation
- DIC (may worsen or develop post-delivery)
- Pulmonary oedema (from massive transfusion, fluid overload, or pre-eclampsia)
- Sheehan's Syndrome (anterior pituitary necrosis from prolonged hypotension - presents weeks/months later as failure of lactation, amenorrhoea, adrenal/thyroid insufficiency)
- ARDS (Acute Respiratory Distress Syndrome) - from shock, massive transfusion
- Maternal death - severe abruption with DIC and shock is one of the leading causes of direct maternal mortality
- Received massive transfusion
- DIC present
- Haemodynamic instability
- Oliguria/AKI
- Explain the diagnosis and what happened to the patient and family
- Recurrence risk in subsequent pregnancy: approximately 10-15x increased risk of abruption in next pregnancy
- Counsel regarding modifiable risk factors: smoking cessation, blood pressure control, aspirin prophylaxis in next pregnancy (if hypertensive disorders co-existed)
- Psychological support if fetal death occurred
CASE 20
1. Diagnosis
- Cervix fully dilated (10 cm) = second stage ✓
- Membranes ruptured 4 hours ago ✓
- Contractions every 1 minute for 50 seconds = hyperstimulation/very frequent, strong contractions
- This pattern (contractions every 1 minute) is abnormal - normal active labour has contractions every 2-3 minutes. Contractions this frequent reduce the diastolic relaxation phase → reduced uteroplacental blood flow between contractions → fetal hypoxia accumulates
- FHR 105-110: borderline bradycardia (normal 110-160 bpm)
- Dull/muffled: Reduced amplitude of heart tones = fetal cardiac depression from hypoxia/acidosis
- Arrhythmic: Loss of normal beat-to-beat variability + irregular rhythm = profound hypoxia-acidosis causing cardiac depression; variability loss is the most ominous CTG sign
- Combined: this is a fetus in severe acute asphyxia
- 10 hours total labour in a primipara = not prolonged (within normal limits for first stage)
- The issue is not prolonged labour per se - the issue is acute fetal distress with the head already at the outlet
2. Tactic (Plan) of Management
Step 1 - Call for Emergency Help
- Senior obstetrician
- Anaesthetist
- Neonatologist/Paediatrician - essential; this neonate will need immediate resuscitation for birth asphyxia
- Scrub nurse/midwife
- Inform NICU to be ready
Step 2 - Immediate Maternal Management
- High-flow oxygen: 10-15 L/min via non-rebreather mask to maximise oxygen delivery to the fetus via placenta
- Maternal position: Left lateral decubitus (left lateral tilt) - relieves aortocaval compression by the gravid uterus; improves venous return and cardiac output; increases uteroplacental blood flow
- IV access (if not already in situ): 16-18G cannula
- Stop oxytocin (if it was running): Hyperstimulation (contractions every 1 minute) must be stopped immediately. Oxytocin should be discontinued or reduced to allow uterine relaxation between contractions. If uterine hyperstimulation is the cause of fetal distress, this single intervention may temporarily improve FHR.
- Tocolysis for acute fetal resuscitation (if time permits): Terbutaline 0.25 mg SC (beta-2 agonist) causes uterine relaxation, improving uteroplacental blood flow during preparation for delivery. Used as a temporising measure ONLY - not a substitute for delivery.
- Empty the bladder: Foley catheter if not already done. A full bladder obstructs head descent and complicates instrumental delivery.
Step 3 - Position the Patient for Delivery
- Lithotomy position on the delivery table/bed
- Legs in lithotomy stirrups, buttocks slightly off the edge of the table
- Perineum cleansed with antiseptic (Betadine/chlorhexidine)
- Sterile draping
Step 4 - Anaesthesia
- Landmark: Ischial spine (felt on VE)
- 10 mL of 1% lignocaine on each side, injected posterior to the ischial spine
- The pudendal nerve (S2, S3, S4) supplies sensation to the perineum, vulva, and lower vagina
- Onset: 3-5 minutes; provides adequate analgesia for episiotomy and instrumental delivery
- Plus: perineal infiltration of 5-10 mL 1% lignocaine subcutaneously at the planned episiotomy site
- Top-up epidural block immediately
Step 5 - Instrument Selection
| Feature | Forceps | Vacuum |
|---|---|---|
| Speed | Traction begins immediately after locking | 2-3 minutes needed to build negative pressure; cup positioning |
| Fetal distress | Preferred - fastest delivery | Relatively slower |
| OA at outlet | Perfect indication for outlet forceps | Vacuum also works at outlet OA |
| Scalp trauma | None | Chignon, cephalhaematoma, subgaleal haematoma risk |
| Failure rate | Low at outlet | Low at outlet |
| Operator skill | Requires experience | Less technically demanding |
| Neonatal asphyxia | Does not worsen (fast delivery) | Slight delay in negative pressure build-up |
- Wrigley's forceps (outlet forceps) - short handles, short blades; ideal for outlet OA delivery
- Simpson's forceps - longer blades; used for low-outlet deliveries with minimal moulding
- Anderson's forceps - similar to Simpson's
Step 6 - Application of Forceps (Step-by-Step)
- Cervix fully dilated ✓ (complete dilatation confirmed on VE)
- Membranes ruptured ✓ (absent 4 hours)
- Head at pelvic floor/outlet (station +3/+4) ✓
- Position KNOWN: Direct Occiput Anterior (posterior fontanelle anterior, sagittal suture AP) ✓
- Bladder empty ✓ (catheterised)
- Anaesthesia administered ✓
- Fetal distress: INDICATION ✓
- Fetus alive ✓
- No CPD (head already at outlet - by definition adequate outlet)
- Experienced operator ✓
- Theatre available if forceps fails ✓
- Hold the LEFT handle in the LEFT hand (thumb on top, fingers wrapping the handle - held like a pen, not a fist)
- Insert the RIGHT hand into the vagina as a guiding hand (two fingers between the fetal head and the left lateral vaginal wall, at approximately 4 o'clock position)
- The LEFT blade (which goes to the LEFT side of the maternal pelvis and the LEFT side of the fetal head) is introduced with the handle pointing VERTICALLY upward initially
- The toe of the blade is guided toward the left side of the fetal head, sliding along the guiding right hand
- As the blade advances, the HANDLE IS LOWERED (drops toward the horizontal) - this is the classic teaching: "handle falls as blade rises to the head"
- The blade should lie between the fetal head and the vaginal wall, following the curve of the head
- Remove the right guiding hand; leave the left handle in position
- Switch: hold RIGHT handle in RIGHT hand
- Insert LEFT guiding hand into vagina at 8 o'clock (right lateral side)
- The RIGHT blade slides in along the left guiding hand to the right side of the fetal head
- Handle lowered as blade advances
- In DOA, both blades should be introduced symmetrically
- The two handles come together naturally (if correctly placed)
- The SHANKS LOCK at the articulation point (English lock for Wrigley's/Simpson's)
- If the shanks do not come together without force, or one side is higher → the blades are malpositioned → REMOVE both blades and re-examine before re-applying
- The sagittal suture should lie MIDWAY between the two blades (in the midline) - confirms symmetric application
- The posterior fontanelle should lie ONE FINGER-BREADTH ABOVE the plane of the shanks - confirms flexion/correct cephalic application
- No more than one finger should fit between the fenestration of the blade and the fetal head - confirms blades are not too far lateral or slipping
- Both blades should feel equally applied to the head
- Right mediolateral episiotomy at the point of crowning/maximal perineal distension
- Incision: from the posterior fourchette, angled 45-60 degrees to the right, 3-4 cm in length
- Use scissors or scalpel; cut at peak of a contraction when tissues are thinned
- This protects the perineum and sphincter, provides room for the forceps blades and fetal head
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Phase 1 (initial traction): Directed POSTERIORLY AND DOWNWARD (toward the floor)
- This follows the outlet of the pelvis: the head must clear the coccyx/sacrum inferiorly first
- Pajot's maneuver: Right hand grasps the handles and applies traction; left hand rests on the shanks and applies downward counter-pressure (this converts horizontal traction on handles into a downward-outward vector following pelvic axis)
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Phase 2 (as head descends to perineum): Direction becomes HORIZONTAL
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Phase 3 (as occiput appears at vulva under symphysis): Direction becomes UPWARD (toward ceiling) - the head delivers by EXTENSION over the symphysis
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Traction is applied with CONTRACTIONS and maternal pushing - "Pull WITH her, not against her"
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Between contractions: release traction but keep blades in position
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Traction should be STEADY and CONTROLLED, never jerky or rotational
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In DOA, NO ROTATION is needed - the head is already in the ideal position
- As the occiput clears under the symphysis: handle the forceps gently upward
- The head delivers by extension
- Once the widest diameter of the head (biparietal) passes the vulval ring: RELEASE the handles
- Allow the head to deliver slowly and gently over the perineum (reduces third and fourth degree tear risk)
- Alternatively: some operators remove the blades just as the head crowns and allow the head to deliver naturally - reduces pressure on the perineum
- Check for cord around neck immediately
- Delivery of shoulders: gentle downward traction on the head to deliver the anterior shoulder first; then upward to deliver posterior shoulder
- Deliver body by assisted mechanism
Step 7 - Immediate Neonatal Care
- Apgar score at 1 and 5 minutes (and every 5 minutes if <7 until >7 twice)
- This neonate is expected to have a LOW Apgar score (1-3) given FHR 105, dull, arrhythmic
- Neonatal Resuscitation Protocol (NRP):
- Dry, stimulate, position
- Assess breathing and heart rate at 30 seconds
- If not breathing or gasping, HR <100: Bag-mask ventilation (BMV) with room air (or 21% O2 initially; escalate to 100% O2 if no response)
- If HR <60 despite 30 seconds of effective BMV: Chest compressions (2-thumb technique; 3:1 ratio with ventilations)
- If HR <60 despite CPR: Epinephrine (IV via umbilical venous catheter or endotracheal) 0.01-0.03 mg/kg
- Intubate if prolonged resuscitation or if BMV ineffective
- Cord blood gas sampling (from umbilical artery): Send for pH, pCO2, pO2, base excess
- pH <7.0 and base deficit >12 mmol/L = significant metabolic acidosis = hypoxic-ischaemic insult
- This guides further neonatal management (Therapeutic Hypothermia / Cooling if birth asphyxia confirmed)
- Therapeutic Hypothermia (Cooling Protocol): If neonate meets criteria for hypoxic-ischaemic encephalopathy (HIE):
- Gestational age ≥36 weeks
- Cord pH <7.0 or base deficit ≥16
- Encephalopathy signs (abnormal tone, seizures, depressed consciousness)
- Cooling to 33-34°C core body temperature for 72 hours (reduces neuronal death)
- MUST be started within 6 hours of birth to be effective
- Transfer to NICU level III
Step 8 - Active Management of Third Stage
- Oxytocin 10 IU IM immediately after delivery of the anterior shoulder (or IV 5 IU bolus)
- Controlled cord traction (Brandt-Andrews technique) after signs of placental separation
- Uterine massage after placental delivery
- Examine placenta and membranes for completeness
Step 9 - Inspection and Repair
- Thorough inspection of:
- Episiotomy site: Repair in layers (vaginal mucosa, perineal muscle, skin)
- Vaginal walls: Lateral vaginal lacerations from forceps blades - most common in outlet forceps
- Cervix: Examine with ring forceps (post-instrumental delivery, cervical lacerations are common)
- Perineal body: Degree of tear (first through fourth degree)
- Rectum and anal sphincter: Examine carefully per rectum to exclude occult 3rd/4th degree tear
- Repair all lacerations under adequate anaesthesia
Step 10 - Post-delivery Monitoring
- Vital signs every 15-30 minutes for 2 hours (immediate puerperium)
- Monitor for PPH: uterine tone, lochia amount, BP
- Urinary output monitoring (catheter in situ 24 hours post-instrumental delivery)
- Analgesia: diclofenac/ibuprofen + paracetamol regularly; opioids if needed
- Thromboprophylaxis: LMWH 6-12 hours post-delivery (if no bleeding); TED stockings
- Stool softeners (lactulose) to avoid straining against the repair
- NICU admission if Apgar <7 at 5 minutes
- Monitor for HIE, seizures, respiratory distress, hypoglycaemia, hypocalcaemia
- Cooling protocol if HIE criteria met (as above)
- Inform parents: explain what happened, what is being done, prognosis
- Williams Obstetrics, 25th Edition (Cunningham, Leveno, Dashe et al.)
- DC Dutta's Textbook of Obstetrics, 8th Edition (Konar)
- Berek & Novak's Gynecology, 16th Edition
- Creasy & Resnik's Maternal-Fetal Medicine, 8th Edition
- ACOG Practice Bulletin No. 154: Operative Vaginal Delivery
- ACOG Practice Bulletin: Abruptio Placentae
- NRP (Neonatal Resuscitation Program) Guidelines, 8th Edition