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CASE 1

1. Primary Diagnosis

• Fundal height 10 cm above pubis: expected. At delivery the fundus is at the umbilicus (~18 cm above pubis). It descends approximately 1 cm/day by uterine involution. By day 3 it should be ~15 cm; 10 cm is well within the normal range, reflecting satisfactory involution.
• Uterus is hard (well-contracted): normal; prevents PPH.
• Temperature 36.6°C: afebrile, no puerperal sepsis.
• Lochia rubra: expected on day 3 (red discharge, lasting days 1-4 postpartum).
• Soft breasts with normal lactation: expected on day 3 (colostrum transitioning to milk; engorgement usually begins day 3-4).
• Perineum normal: no perineal sepsis or wound complications.

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2. Classification of Lochia

• Lochia persistently rubra beyond day 10 suggests subinvolution or retained products of conception.
• Offensive/foul-smelling lochia at any stage suggests puerperal endometritis.
• Lochia purulenta: frankly purulent discharge indicating infection.

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3. Differentiation Between Colostrum and Mature Milk

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CASE 2

1. Does It Need Medical Intervention?

• Reassurance and explanation to the patient and parents.
• Iron supplementation if any degree of anaemia.
• If still bothersome: Cyclic progesterone (medroxyprogesterone acetate 10 mg for 10-12 days per month) to regulate shedding.
• Combined OCP (low dose) if progesterone alone insufficient - also provides contraceptive cover (relevant in older adolescents).
• NSAIDs (mefenamic acid) to reduce flow.

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2. If the Same Girl Comes with Heavy Bleeding - Possible Reasons

1. Anovulatory DUB / AUB-O (HPO axis immaturity) - same mechanism but more severe; estrogen breakthrough bleeding.

• Polyp (AUB-P): rare at this age but possible
• Leiomyoma: extremely rare in adolescents
• Malignancy: rare but must exclude in severe/refractory cases

• Coagulopathy (AUB-C): THIS IS THE MOST IMPORTANT DIAGNOSIS TO EXCLUDE IN AN ADOLESCENT WITH HEAVY MENSTRUAL BLEEDING.
  • Von Willebrand disease (most common inherited bleeding disorder in females; presents at menarche with severe menorrhagia)
  • Thrombocytopenia (ITP, leukemia)
  • Platelet dysfunction
  • Factor deficiencies
  • Studies show up to 20% of adolescents presenting with severe menorrhagia at menarche have an underlying coagulopathy
• Ovulatory dysfunction (AUB-O): anovulation (as above)
• Thyroid disorders: Hypothyroidism causes heavy, irregular bleeding (TSH should always be checked)
• Hyperprolactinemia
• Endometrial causes (AUB-E): primary endometrial disorders (rare in adolescents)
• Iatrogenic (AUB-I): medications

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3. If a Woman in Reproductive Age Group Comes with Heavy Bleeding - Reasons

• P - Polyp (AUB-P): Endometrial or cervical polyps causing intermenstrual or heavy bleeding
• A - Adenomyosis (AUB-A): Endometrial glands within myometrium; causes heavy, dysmenorrhic bleeding; classic "globular, tender, woody-hard uterus"
• L - Leiomyoma (AUB-L): Uterine fibroids, especially submucous (Type 0, 1, 2) - most common cause of HMB in reproductive age
• M - Malignancy/Hyperplasia (AUB-M): Endometrial hyperplasia (especially with complex atypical hyperplasia), endometrial carcinoma, cervical carcinoma

• C - Coagulopathy (AUB-C): VWD, ITP, liver disease, anticoagulant use
• O - Ovulatory dysfunction (AUB-O): PCOS (most common cause of anovulation in reproductive age), thyroid disorders, hyperprolactinemia, hypothalamic dysfunction (stress, exercise, weight loss), premature ovarian insufficiency
• E - Endometrial (AUB-E): Primary endometrial disorders - impaired endometrial hemostasis, endometritis
• I - Iatrogenic (AUB-I): Anticoagulants, hormonal contraceptives, IUD (copper IUD - increases flow by 30-50%), SSRIs, antipsychotics (via hyperprolactinemia), chemotherapy
• N - Not yet classified (AUB-N): Arteriovenous malformations, isthmocele (caesarean scar defect)

• Pregnancy complications: threatened/incomplete abortion, ectopic pregnancy, gestational trophoblastic disease (must always exclude with beta-hCG)
• Endometriosis (AUB-O component and local peritoneal inflammation)
• PCOS (most common endocrinopathy; anovulatory heavy bleeding)

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CASE 3

1. Primary Diagnosis

• 20-year-old primipara, 32 weeks gestation
• Leaking clear amniotic fluid from vagina
• On vaginal examination: amniotic fluid leaking confirmed
• Uterus soft and non-tender (no labour, no abruption)
• Cervix: posterior, 3 cm long, firm, external os admits fingertip, internal os closed (Bishop score approximately 1-3 - see below)
• FHR 144 bpm: normal
• Afebrile: no clinical chorioamnionitis at present

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2. Bishop Score Estimation

• Dilation: external os admits fingertip = approximately 1 cm → Score 1
• Effacement: length 3 cm; normal cervix = 3.5-4 cm, so ~20-25% effaced → Score 0
• Station: non-engaged presenting part → Score 0
• Consistency: Firm → Score 0
• Position: Posterior → Score 0

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3. Plan of Investigations

1. Pooling of amniotic fluid in posterior fornix on speculum examination (already confirmed on vaginal exam)
2. Ferning test: amniotic fluid on slide dries in a fern-like pattern (arborization) due to NaCl crystallization
3. Nitrazine/pH test: amniotic fluid is alkaline (pH 7.0-7.5); turns nitrazine paper from yellow to blue (note: false positives with blood, urine, semen)
4. IGFBP-1 (Actim PROM test) or PAMG-1 (AmniSure): highly sensitive and specific immunoassays for amniotic fluid markers - the gold standard confirmatory test
5. Ultrasound (USG): to confirm oligohydramnios (AFI < 5 cm or deepest vertical pool < 2 cm), fetal presentation, estimated fetal weight, placental location, fetal biometry (confirm 32 weeks)

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4. Appropriate Management

Immediate:

• Admit to hospital; bed rest (not strict)
• Do NOT perform digital vaginal examination (increases risk of infection and precipitates labour) - use speculum only
• Hydration: IV fluids

Corticosteroids (PRIORITY):

• Betamethasone 12 mg IM, two doses 24 hours apart (or Dexamethasone 6 mg IM, 4 doses 12 hours apart)
• Indication: 24-34 weeks; reduces RDS, IVH, NEC - reduces neonatal morbidity significantly
• At 32 weeks this is standard of care (Williams Obstetrics, Creasy & Resnik)

Antibiotics (MANDATORY):

• Prophylactic antibiotics prolong latency and reduce chorioamnionitis
• Regimen (ORACLE trial / ACOG): Ampicillin 2 g IV q6h + Erythromycin 250 mg IV q6h for 48 hours, followed by Amoxicillin 250 mg PO q8h + Erythromycin 333 mg PO q8h for 5 days
• Avoid Amoxicillin-Clavulanate (co-amoxiclav) - associated with increased risk of NEC
• GBS prophylaxis: if GBS swab positive or unknown status at delivery - IV Penicillin G

Tocolysis:

• Short-term tocolysis (24-48 hours) to allow corticosteroids to take effect
• Nifedipine or Indomethacin (the latter <32 weeks preferred; avoid after 32 weeks - risk of premature closure of ductus arteriosus and oligohydramnios)
• Do NOT use long-term tocolysis in PPROM - does not improve outcomes and may mask infection signs

Magnesium Sulphate:

• If delivery is anticipated within 24 hours at <34 weeks: MgSO4 for fetal neuroprotection (reduces risk of cerebral palsy)
• Loading dose 4 g IV over 20-30 min, then 1 g/hour maintenance

Monitoring:

• Daily: maternal temperature, pulse, uterine tenderness, character of amniotic fluid (clear vs. cloudy/foul)
• Daily: fetal heart rate, CTG
• Weekly: CBC, CRP
• Ultrasound every 1-2 weeks for AFI and fetal growth

Delivery:

• Deliver at 34 weeks if remaining stable (ACOG/SOGC guidelines)
• Immediate delivery if: chorioamnionitis, non-reassuring fetal heart rate, cord prolapse, abruptio placentae, active labour, fetal compromise
• Mode of delivery depends on presentation and obstetric indications

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CASE 4

1. Preliminary Diagnosis

• Fundal height 10 cm above pubis (satisfactory involution - expected ~1 cm descent/day from umbilicus at delivery)
• Uterus dense (well-contracted)
• Temperature 36.6°C (afebrile)
• Vaginal discharge - bloody (lochia rubra, expected days 1-4)
• Perineum satisfactory
• Bowel - stool passed, gases passed - normal return of bowel function
• Urination free and painless - no urinary retention
• Lactation present

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2. Terminology for a Woman During Pregnancy, Delivery, and the Postpartum Period

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3. Classification of the Postpartum (Puerperium) Period

By Time:

1. Immediate puerperium: First 24 hours after delivery
   • Critical period for PPH, shock, eclampsia
   • Uterus should remain contracted; vital signs monitored closely
2. Early (Remote) puerperium: Day 2 to Day 7
   • Involution progresses; lochia rubra transitioning to serosa
   • Lactation established
   • Most puerperal infections present here
3. Late puerperium: Day 8 to Day 42 (6 weeks)
   • Lochia serosa then alba
   • Menstruation may return (if not breastfeeding: ~6-8 weeks; if exclusively breastfeeding: variable, often 6+ months)
   • Pelvic floor recovery; perineal healing

Physiological Changes in Puerperium:

• Involution of uterus: Uterus weight: 1000g at delivery → 500g by day 7 → 100g by 6 weeks (non-pregnant weight). Rate: ~1 cm/day fundal descent.
• Involution mechanism: Autolysis of myometrial cells (proteolytic enzymes digest myofibril proteins), ischaemia, phagocytosis of dead tissue by macrophages.

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4. Lochia - Definition and Classification

1. Lochia Rubra ("red lochia")

• Days 1-4
• Bright red, then dark red
• Composition: Fresh blood, decidual tissue, fetal vernix, lanugo, meconium traces, amniotic debris
• A sudden increase in lochia rubra after it had lightened = "lochia return" - may indicate over-exertion (should decrease with rest) or subinvolution/retained POC

2. Lochia Serosa ("pink/serous lochia")

• Days 4-10 (some authorities: days 4-8)
• Pink-brown to brownish-yellow
• Composition: Serous fluid, old blood, leukocytes (predominantly), cervical mucus, microorganisms, decidual tissue fragments

3. Lochia Alba ("white lochia")

• Day 10 to 4-6 weeks
• Pale yellow to white
• Composition: Mainly leukocytes, decidual cells, mucus, bacteria, fat, epithelial cells; virtually no RBCs

• Lochia rubra persisting beyond day 10: subinvolution, retained products of conception → investigate with USS; treat with methylergometrine/surgical evacuation if needed
• Offensive/foul smell at any stage: chorioendometritis/puerperal sepsis → high vaginal swab, blood cultures, broad-spectrum antibiotics
• Lochia purulenta: frankly purulent → puerperal sepsis

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5. Differences Between Colostrum and Mature Breast Milk

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CASE 5

1. Primary Diagnosis

• G5P4 (grand multipara) - major risk factor (previous uterine distension scars the lower segment, leading to abnormal placentation)
• Painless vaginal bleeding at 37 weeks - the cardinal feature of placenta previa ("placenta previa bleeds without pain")
• Fetal head high above pelvic brim - the placenta occupying the lower uterine segment physically prevents engagement of the presenting part
• Cephalic presentation, soft non-tender uterus - distinguishes it from abruptio (which would have a hard, tender, board-like uterus)
• Good fetal movements and FHS 150/min (mildly elevated but fetal heart rate can be reactive with maternal tachycardia of 100 bpm)
• Maternal tachycardia (pulse 100): mild haemodynamic compromise from bleeding

• Minor previa = Type I and IIa
• Major previa = Type IIb, III, IV

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2. Plan of Investigations

1. Ultrasound (Transabdominal + Transvaginal):
   • TVS is the gold standard for precise placental localisation (safe in placenta previa - probe does not reach internal os)
   • Confirm placental position, type of previa, presence of vasa previa
   • Placenta accreta spectrum evaluation (increased with grand multiparity and prior CS)
   • Fetal biometry, presentation, AFI
2. MRI Pelvis (if USS inconclusive, especially if accreta suspected)

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3. Management

Immediate Resuscitation:

• IV access with two large-bore (16-18G) cannulas
• IV crystalloids (Hartmann's/Normal saline) for haemodynamic stabilisation
• Blood transfusion if Hb <8g/dL or haemodynamic instability
• Oxygen by face mask (maintain SpO2 >95%)
• Foley catheter for urine output monitoring
• Monitor: continuous pulse oximetry, CTG, BP, urine output

Definitive Management - Delivery at 37 Weeks:

• Elective Caesarean Section (CS) is mandatory
• A placenta completely or partially covering the os cannot allow safe vaginal delivery (fatal haemorrhage risk to mother and fetus)
• CS should be performed by a senior obstetrician in a well-equipped theatre
• Cross-matched blood must be available (minimum 4 units, often more for grand multipara with possible accreta)
• Uterotonic agents (oxytocin, misoprostol, ergometrine) prepared
• If placenta accreta spectrum (increta/percreta) suspected: multidisciplinary team - interventional radiology for possible internal iliac artery balloon occlusion, urology (risk of bladder involvement), intensive care

• Vaginal delivery may be attempted if presenting part is below placental edge and bleeding stops
• Continuous CTG monitoring
• Theatre and blood ready
• Amniotomy (ARM) at full dilatation: presenting part descends and acts as a "plug" reducing bleeding

Subsequent care:

• Post-CS uterotonics to prevent PPH (high risk with placenta previa as lower segment contracts poorly)
• B-Lynch suture or balloon tamponade if uterine atony
• Internal iliac artery ligation or emergency hysterectomy if uncontrolled haemorrhage
• Anti-D immunoglobulin 300 mcg IM if Rh-negative mother

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CASE 6

1. Are These Pelvis Measurements Normal?

• <14 cm = thin-boned (asthenic); correction factor: add 3 cm to measured external conjugate to get true conjugate
• 14-15 cm = medium (normosthenic); correction factor: subtract 9 cm from external conjugate

• 15 cm = large-boned (hypersthenic); correction factor: subtract 10 cm from external conjugate

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2. Conjugata Vera (True/Obstetric Conjugate) Calculation

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3. Methods to Estimate the True Conjugate (4 Methods)

1. External measurement (Baudelocque's method):
   • Measure Conjugata Externa (from anterior superior border of symphysis pubis to sacral spine of L5 / depression below L5 spinous process)
   • CV = CE - 9 cm (medium build)
   • CE normal = 20 cm; CV normal = 11 cm
   • Limitation: indirect; does not account for thickness of bony structures
2. Diagonal Conjugate (Internal measurement by vaginal examination):
   • Clinician inserts two fingers vaginally to reach sacral promontory; measures from the lower border of symphysis pubis to sacral promontory
   • Diagonal Conjugate (DC) normal = 12.5 cm or more
   • CV = DC - 1.5 cm (or DC - 1 to 2 cm depending on symphysis pubis angle)
   • DC = 12.5 cm → CV = 11 cm (normal)
   • This is the most reliable clinical method (Williams Obstetrics)
   • Limitation: if DC cannot be reached (>12.5 cm), the conjugate is assumed adequate
3. Radiological pelvimetry (X-ray pelvimetry):
   • Lateral pelvic X-ray: directly measures true conjugate
   • CT pelvimetry: most accurate; lower radiation
   • MRI pelvimetry: no radiation; gold standard for bony measurements
   • Currently used mainly when clinical pelvimetry is inconclusive or in trial of scar/unusual presentations
   • Largely fallen out of routine use (no proven outcome benefit by RCT)
4. Ultrasonographic (USS) estimation:
   • 3D pelvimetry using ultrasound
   • Less widely available; not yet standard of care
   • Can estimate conjugata vera and transverse diameter in some hands

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CASE 7

1. Diagnosis

• 27-year-old woman
• Married for 5 years; used contraception for first 3 years
• 2 years of regular unprotected intercourse with NO conception
• No previous pregnancies → PRIMARY infertility
• WHO/FIGO definition: infertility = failure to achieve pregnancy after 12 months of regular unprotected intercourse (in women <35 years). After 35 years, the threshold is 6 months.

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2. All Causes of Primary Infertility

Female Factor (~40-50% of all infertility):

• PCOS (most common - anovulation, hyperandrogenism, insulin resistance)
• Hyperprolactinemia (prolactinoma, drugs, hypothyroidism)
• Hypothyroidism (subclinical or overt)
• Hypothalamic dysfunction: functional hypothalamic amenorrhoea (stress, low body weight/BMI, excessive exercise, eating disorders)
• Premature Ovarian Insufficiency / Premature Ovarian Failure
• Congenital hypogonadotropic hypogonadism (Kallmann syndrome)
• Luteal phase deficiency (progesterone deficiency in second half of cycle - poor implantation)
• Obesity-related anovulation

• Previous PID (pelvic inflammatory disease) - most common cause of tubal damage; Chlamydia trachomatis is the leading pathogen
• Post-surgical adhesions (after appendicectomy, myomectomy, ovarian cystectomy)
• Endometriosis (particularly moderate-severe; peritoneal inflammatory cytokine environment, adhesions, tubal occlusion)
• Salpingitis isthmica nodosa
• Congenital tubal abnormalities
• Tuberculosis (genital TB) - a significant cause in developing countries; causes tubal occlusion and frozen pelvis

• Submucous fibroids (impairs implantation, alters uterine cavity)
• Endometrial polyps (mechanical obstruction, altered endometrial receptivity)
• Asherman's syndrome (intrauterine adhesions from previous D&C, curettage, myomectomy, endometritis)
• Congenital uterine anomalies: arcuate, subseptate, bicornuate uterus (associated with recurrent miscarriage more than infertility per se)
• Müllerian agenesis (Mayer-Rokitansky-Küster-Hauser - presents as primary amenorrhoea, not typical infertility)
• Endometritis (chronic)

• Hostile cervical mucus (poor mucus receptivity to sperm)
• Anti-sperm antibodies in cervical mucus
• Cervical stenosis (post-LEEP/LLETZ, cone biopsy, severe cervicitis)
• Anatomical abnormalities

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Male Factor (~30-40% of all infertility):

• Azoospermia: obstructive (post-vasectomy, epididymal block, vas deferens absence) or non-obstructive (Klinefelter syndrome 47XXY, Y chromosome microdeletions, maturation arrest)
• Oligozoospermia: <15 million/mL (WHO 2021 criteria) - idiopathic most common
• Asthenozoospermia: reduced motility
• Teratozoospermia: abnormal morphology
• Varicocele (most common correctable cause of male infertility; impairs spermatogenesis via increased testicular temperature)
• Endocrine: hypogonadotropic hypogonadism, hyperprolactinemia, thyroid disorders
• Infections: mumps orchitis, STIs causing epididymo-orchitis
• Immune: anti-sperm antibodies
• Erectile/ejaculatory dysfunction: retrograde ejaculation (diabetic neuropathy), psychogenic ED
• Drugs: chemotherapy, anabolic steroids, sulfasalazine, nitrofurantoin
• Environmental: heat exposure, radiation, toxins, occupational hazards (pesticides, solvents)
• Genetic: Klinefelter (47,XXY), Y microdeletion, CFTR mutations (bilateral absence of vas deferens)

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Combined Factor (~20%): Both male and female factors present simultaneously

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3. Tactic of Medical Investigation (Infertility Workup)

History:

• Duration of infertility; previous pregnancies (even with other partners), previous contraception
• Menstrual history (cycle regularity, dysmenorrhoea, intermenstrual bleeding)
• Sexual history: frequency, timing, dyspareunia
• Previous STIs, PID, surgery
• Medical conditions (thyroid, PCOS, DM, TB)
• Family history of premature menopause, chromosomal disorders
• Lifestyle: BMI, smoking, alcohol, occupation

Basic Investigations (First line - both partners simultaneously):

1. Semen analysis of partner (even during female workup - cost-effective to exclude male factor early)
2. Day 2-3 FSH, LH, AMH, Estradiol: Ovarian reserve assessment
   • FSH >10 mIU/mL = poor reserve; FSH:LH ratio >3 suggests ovarian failure
   • AMH: most reliable ovarian reserve marker (not cycle-dependent)
3. Mid-luteal phase Progesterone (Day 21 of 28-day cycle): If >5 ng/mL = ovulation occurred (>10 ng/mL = adequate corpus luteum)
4. TSH: Hypothyroidism causes anovulation, hyperprolactinemia
5. Prolactin: Elevated levels cause anovulatory infertility
6. Testosterone, DHEAS, 17-OHP: If signs of hyperandrogenism (PCOS, late-onset CAH)
7. Fasting glucose, insulin: Insulin resistance (PCOS)
8. Antral follicle count (AFC) on transvaginal USS: Day 2-5; reflects ovarian reserve
9. Thyroid antibodies (if TSH borderline)
10. Karyotype (if AMH very low, premature ovarian insufficiency suspected)

• Serial ovarian follicle tracking by TVS (folliculometry): Days 10, 12, 14 to confirm follicular development and ovulation
• Basal body temperature (BBT) chart: low sensitivity/specificity
• LH urine kits (ovulation predictor kits)

Tubal and Uterine Assessment:

1. Hysterosalpingography (HSG):
   • Contrast radiography of uterine cavity and tubes
   • Outlines uterine cavity anomalies (polyps, fibroids, adhesions, septa)
   • Shows tubal patency - bilateral spillage of contrast confirms patent tubes
   • Best done days 7-10 of cycle (post-menstruation, pre-ovulation)
   • Also mildly therapeutic (oil-based contrast slightly improves subsequent pregnancy rates - Van der Houwen meta-analysis)
2. Sonosalpingography / Saline Infusion Sonohysterography (SIS):
   • Saline instilled via cervix during TVS
   • Assesses uterine cavity (polyps, fibroids, adhesions) and tubal patency (with echo contrast - HyCoSy)
3. Laparoscopy and chromopertubation ("Lap and Dye"):
   • Gold standard for tubal patency and peritoneal disease (endometriosis, adhesions, ovarian pathology)
   • Methylene blue dye injected through cervix - observed spilling from fimbrial ends confirms patency
   • Mandatory if HSG shows tubal occlusion, if endometriosis suspected, or after failed IUI/IVF
   • Allows simultaneous therapeutic procedures (adhesiolysis, endometriosis ablation, ovarian drilling)
4. Hysteroscopy:
   • Direct visualisation of uterine cavity
   • Diagnoses and treats: polyps, fibroids, adhesions (Asherman's), septa
   • Often done concurrently with laparoscopy
5. Endometrial biopsy:
   • If chronic endometritis or TB suspected (histopathology, culture, PCR for MTB)
6. Antichlamydial antibody titre:
   • If positive: suggests previous tubal infection; strengthens indication for laparoscopy
7. Karyotyping:
   • Indicated if recurrent miscarriage, POI, or suspected Turner mosaic

Male:

1. Semen Analysis (WHO 2021 criteria):
   • Volume ≥1.4 mL, pH 7.2-8.0
   • Concentration ≥16 million/mL
   • Total motility ≥42%, progressive motility ≥30%
   • Morphology ≥4% normal (Kruger strict criteria)
   • Viability ≥54%
   • Repeat after 2-3 months if abnormal
2. Scrotal USS + Doppler: Varicocele, obstruction
3. Hormones: FSH (elevated in primary testicular failure), LH, testosterone, prolactin
4. Karyotype + Y chromosome microdeletion if azoospermia/severe oligospermia
5. CFTR mutation if bilateral absence of vas deferens
6. Post-ejaculate urine if low volume/retrograde ejaculation suspected

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CASE 8

1. Primary Diagnosis

• 20-year-old nullipara, 39 weeks
• Cephalic presentation on Leopold maneuvers ✓
• FHR 136-138/min - normal ✓
• Abdominal circumference 99 cm, fundal height 38 cm - term-sized baby ✓
• On VE: nose and lips of fetus are palpated = face presentation confirmed
  • In vertex presentation, the posterior fontanelle, sagittal suture, and anterior fontanelle are felt
  • In face presentation, the orbital ridges, nose, mouth, chin (mentum) and malar bones are palpated
  • The mouth has a distinctive feel of gum ridges (as opposed to the anus in a breech - the anus has a "gripping" muscular feel and no bony surrounds; the fetal mouth has gum ridges and zygoma)
• Cervix: mid-position, 1.5 cm long, soft, 1 finger dilated externally, internal os closed
• Bishop Score: Dilated ~1 cm (Score 1), effacement ~50-60% (Score 1-2), mid position (Score 1), soft (Score 2), non-engaged (Score 0) = approximately 5-6 - not quite favourable but cervix is beginning to ripen
• Presenting diameter: submento-bregmatic (9.5 cm) in mento-anterior - same as suboccipito-bregmatic (vertex) - CAN deliver vaginally if mento-anterior

• Incidence: 1 in 500-600 deliveries
• Denominator: Mentum (chin)
• Mento-anterior: chin pointing anteriorly → can deliver vaginally (submento-bregmatic 9.5 cm)
• Mento-posterior: chin pointing posteriorly → cannot deliver vaginally; requires CS (flexion impossible; persistent mento-posterior cannot deliver unless it rotates to anterior)

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2. Plan of Delivery

If Mento-Anterior (MA):

• Trial of vaginal delivery is appropriate in a well-equipped centre with experienced obstetrician
• Allow labour to progress - do not rush with oxytocin augmentation unless indicated
• Continuous CTG monitoring (face presentations have higher risk of cord prolapse, prolonged labour)
• No amniotomy early on (unless indicated) - forewaters help dilate cervix
• Patient should be in left lateral position; avoid supine hypotension
• In second stage: the face presents at the perineum; the chin (mentum) sweeps under the symphysis pubis; birth occurs by flexion of the head (unlike vertex where birth is by extension)
• Episiotomy is usually required (rigid perineum)
• No forceps with face presentation as a general rule unless by experienced operator in very specific settings - Kielland's forceps have been used historically but with high maternal and fetal morbidity; the trend is towards CS for most face presentations
• Ventouse/vacuum delivery is CONTRAINDICATED in face presentation (cup cannot be applied safely on face; risk of severe facial injury)

If Mento-Posterior (MP):

• Elective Caesarean Section is indicated
• Persistent mento-posterior cannot deliver vaginally
• If MP is detected late in second stage with impacted face: immediate CS
• Manual or forceps rotation (Scanzoni maneuver) is hazardous and generally not recommended

Overall Principle:

• If mento-anterior: trial of vaginal delivery with close monitoring and low threshold for CS
• If mento-posterior: CS
• If position cannot be determined: USS to confirm mentum position before proceeding

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3. Complications

Maternal:

1. Prolonged labour: face presentations often have a slower progress due to suboptimal fitting of presenting part
2. Cervical and perineal lacerations: extensive perineal and para-vaginal tearing due to large presenting diameter and deflexed head
3. Postpartum haemorrhage: consequence of prolonged labour and lacerations
4. Uterine rupture (especially in obstructed mento-posterior labour - a dangerous obstetric emergency)
5. Infection: prolonged labour predisposes to chorioamnionitis, puerperal sepsis
6. CS morbidity if operative delivery becomes necessary

Fetal/Neonatal:

1. Facial oedema and bruising: almost universal; the presenting part is the face - extensive soft tissue oedema of lips, eyelids, nose after delivery (reassure parents - resolves in 24-48 hours)
2. Facial nerve injury: from trauma during delivery
3. Laryngeal oedema/tracheal compression: in severe mento-posterior obstructed labour
4. Cord prolapse: face presentation = poorly fitting presenting part with space around it; cord can prolapse alongside
5. Fetal distress / Hypoxia: prolonged labour, cord compression
6. Neonatal asphyxia
7. Skull fractures, intracranial haemorrhage: if difficult forceps attempted
8. Subconjunctival haemorrhages, retinal haemorrhage: from facial trauma
9. Increased perinatal mortality compared to vertex (approximately 3-5x higher in historical series - now much reduced with active management and early CS)

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CASE 9

1. Diagnosis

• Complete cervical dilatation (second stage of labour)
• Head in pelvic cavity
• Fetal distress (muffled heart sounds, FHR 160 bpm = tachycardia, suggesting fetal compromise)

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2. Plan for Management of Labour

1. Maternal stabilisation (prevent further seizures, control blood pressure, prevent aspiration, protect airway)
2. Expedite delivery (the baby is in distress and delivery is the only cure for eclampsia)

• Cervix is fully dilated ✓
• Head is in the pelvic cavity ✓
• Fetus is medium size ✓

1. Stabilise mother (MgSO4, antihypertensives - see below)
2. Ensure prerequisites for forceps are met (see Question 5)
3. Apply forceps under pudendal block/GA
4. Deliver fetus
5. Active management of third stage (PPH risk is very high in eclampsia)
6. Continue MgSO4 for 24 hours post-delivery
7. ICU/HDU monitoring postpartum

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3. Sequence of Events to Help the Mother

1. Call for help - senior obstetrician, anaesthetist, intensivist, neonatologist STAT
2. A - Airway: Protect airway. Turn patient to LEFT LATERAL POSITION (prevents tongue from falling back, reduces aspiration, relieves aortocaval compression). Insert mouth gag/padded tongue depressor (to prevent tongue biting - only during the convulsion itself, not preventatively in a non-convulsing patient). Suction oropharynx of secretions/vomit.
3. B - Breathing: Administer high-flow oxygen (10-15 L/min via face mask). Ventilatory support if apnoea.
4. C - Circulation: IV access with 2 large-bore cannulas. Send blood for: CBC, LFT, RFT, uric acid, coagulation profile, blood sugar, electrolytes. Foley catheter for urine output.
5. D - Drugs to Stop Convulsions (Magnesium Sulphate - DRUG OF CHOICE):
   • Loading dose: MgSO4 4 g IV (as 20% solution) over 10-15 minutes
   • Maintenance: MgSO4 1-2 g/hour IV infusion (continuous)
   • OR Pritchard regimen: 4 g IV + 10 g IM (5g each buttock deep) loading, then 5 g IM every 4 hours alternating buttocks
   • Monitor for MgSO4 toxicity:
     • Respiratory rate must be >12/min
     • Patellar reflexes must be present (loss of DTR is first sign of toxicity)
     • Urine output >30 mL/hour
     • Serum Mg: therapeutic 4-7 mEq/L; respiratory depression >10 mEq/L; cardiac arrest >15 mEq/L
   • Antidote for toxicity: Calcium gluconate 1 g IV (10 mL of 10% solution) slowly over 3-5 minutes
   • If further convulsion despite MgSO4: diazepam 5 mg IV bolus, or thiopentone, or intubation+ventilation
6. Antihypertensive therapy (if BP ≥160/110 mmHg):
   • Labetalol IV: 20 mg IV bolus, can repeat 40 mg, then 80 mg every 10 min (max 300 mg)
   • OR Hydralazine 5 mg IV every 20 minutes (max 20 mg)
   • OR Nifedipine 10-20 mg orally (rapid acting capsule or tablet)
   • Goal: DBP 90-100 mmHg (do NOT drop BP too rapidly - risk of uteroplacental insufficiency)
7. Expedite delivery: as above (forceps)
8. Post-delivery: Continue MgSO4 for 24-48 hours postpartum. BP monitoring and antihypertensives as needed. Watch for pulmonary oedema, HELLP syndrome, DIC, renal failure, cerebral haemorrhage (the classic complications of severe eclampsia).

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4. Stages of an Eclamptic Attack (Clinical Manifestations)

Stage 1 - Premonitory Stage (5-30 seconds):

• Eyes turn to one side, fixed
• Twitching of facial muscles (especially around the mouth)
• Eyes open, eyelids flicker
• Tongue protrudes slightly
• Patient is unresponsive
• May be very short - often not witnessed

Stage 2 - Tonic Stage (30 seconds):

• Whole body goes into tonic spasm (rigid, board-like)
• Arms flexed, legs extended, hands clenched, opisthotonus (arching of back)
• Apnoea - no breathing (dangerous period for fetal hypoxia)
• Face flushed/cyanosed
• Jaw clenched (risk of tongue biting)

Stage 3 - Clonic Stage (1-2 minutes, most dangerous):

• Rapid, violent, rhythmic, clonic convulsions of entire body
• Tongue may be bitten (particularly at start of clonic phase)
• Frothing/foaming at mouth (may be blood-stained if tongue bitten)
• Cyanosis may deepen
• Eyes open, rolling
• Lasts 1-4 minutes
• May result in: tongue bite injury, fractures, fall injury, aspiration pneumonia, intracerebral haemorrhage

Stage 4 - Coma Stage (variable duration):

• After cessation of clonic phase
• Patient becomes deeply unconscious
• Duration: minutes to hours
• Stertorous (noisy) breathing
• May go directly into another convulsion before regaining consciousness
• On regaining consciousness: confusion, headache, disorientation, no memory of event

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5. Conditions and Indications for Forceps

Prerequisites (CONDITIONS THAT MUST ALL BE MET before forceps application):

1. Cervix fully dilated (complete cervical dilatation) ✓ (met in this case)
2. Membranes ruptured (whether spontaneously or artificially) ✓
3. Head must be ENGAGED (in pelvic cavity; head at or below ischial spines = station 0 or below) ✓
4. Exact position of fetal head known (mentum, occiput - must apply blades correctly)
5. Adequate pelvis (no CPD - cephalopelvic disproportion)
6. Bladder and rectum EMPTY (Foley catheter in situ)
7. No contracted pelvis (adequate outlet)
8. Live fetus (if dead: prefer destructive operation or spontaneous delivery in some circumstances)
9. Appropriate anaesthesia available (pudendal block, epidural, spinal, or GA)
10. Obstetrician experienced in forceps application
11. Theatre available for emergency CS if forceps fail
12. Fetal presentation amenable to forceps (vertex, face mento-anterior, aftercoming head of breech)

INDICATIONS FOR FORCEPS (DELIVERY):

• Eclampsia / Severe preeclampsia (this case) - prevent bearing-down efforts, shorten second stage
• Cardiac disease (avoid prolonged second stage and Valsalva)
• Severe respiratory disease
• Second stage exhaustion / inability to push
• Maternal infection/sepsis where prolonged second stage is dangerous

• Fetal distress in second stage (abnormal FHR) ✓ (this case)
• Prolapsed cord (head deliverable)
• Preterm delivery (protective forceps - "bucket forceps/Wrigley's" - protects fragile preterm skull)

• Arrest of head in second stage (failure of progress >1 hour in multiparae, >2 hours in primiparae despite adequate contractions and epidural/no epidural)
• Deep transverse arrest
• High arrest (Kielland's forceps)

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6. Method of Forceps Application (Phantom Description)

• Insert two fingers vaginally, locate the posterior fontanelle and sagittal suture to confirm position (e.g., LOA: occiput at 10 o'clock, sagittal suture oblique)

• Hold the LEFT handle in the LEFT hand (like a pencil, not a fist)
• With RIGHT hand inserted vaginally as a guide (two fingers between head and vaginal wall at 4 o'clock position)
• Introduce the left blade GENTLY along the right guiding hand (blade curves towards left side of maternal pelvis = left side of fetal head)
• The blade is introduced initially pointing nearly vertically, then lowered as it is slid inward
• The handle drops down as blade advances - "handle drops, blade goes to the head"

• Switch hands: hold RIGHT handle in RIGHT hand
• Left guiding hand inserted at 8 o'clock position
• RIGHT blade slides in along the left guiding hand, to the right side of fetal head
• Handle is lowered as blade advances

• Handles come together naturally (if blades applied correctly): lock/articulate at the shank
• Pelvic application check: sagittal suture should be in the midline between the blades; posterior fontanelle should be one finger-breadth above the plane of the shanks; no more than one finger should fit between fenestration of blade and fetal head
• If blades do not come together or one side is higher → remove and reapply

• With contraction and maternal bearing-down effort: traction applied in the axis of the pelvis
• Initially traction is directed downward and outward (Pajot's maneuver: one hand on handles pulls, other hand on shanks provides downward counter-pressure)
• As head crowns and perineum stretches: traction becomes horizontal then upward (delivering the head by extension)
• Episiotomy at crowning (mediolateral, right side)

• Once occiput clears under symphysis: release handles and allow the head to deliver by extension naturally (or gentle upward direction)
• Remove blades one at a time (right first, then left) OR deliver head still in blades if easy delivery expected
• After delivery of head: check for cord around neck, deliver shoulders by usual mechanism

• Inspect for vaginal, cervical, perineal tears
• Active management of third stage (oxytocin 10 IU IM)
• Continue MgSO4
• Repair episiotomy/tears

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CASE 10

1. Primary Diagnosis

• 19-year-old primigravida at 37 weeks
• Lower abdominal pain + vaginal bleeding - the classical duo of abruption
• Uterus FIRM and TENDER - the hallmark finding that distinguishes abruption from placenta previa
  • In abruption: blood tracks between myometrium and placenta → uterine irritability → tonic uterine contraction → "woody-hard, board-like" uterus
  • In placenta previa: uterus is SOFT and NON-TENDER
• FHR 90 bpm (severe bradycardia - normal >110 bpm) = Severe Fetal Distress
• Maternal hypotension (BP 100/60), tachycardia (Pulse 100) = Haemodynamic compromise / Hypovolaemic shock
• Weakness and giddiness: consistent with significant haemorrhage

• Revealed/External: Blood tracks through cervix and appears vaginally (most common - 80%)
• Concealed: Blood accumulates behind placenta, no external bleeding (more dangerous - causes Couvelaire uterus)
• Mixed: Both

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2. Plan of Investigations

Immediate (Bedside/Stat):

1. CBC: Haemoglobin (severity of anaemia), haematocrit, platelets (thrombocytopenia suggests DIC)
2. Blood group and crossmatch: Type and crossmatch URGENTLY - 4-6 units packed RBCs and 4-6 units FFP
3. Coagulation profile (PT, aPTT, fibrinogen, D-dimer): DIC is a major complication of severe abruption; fibrinogen <150 mg/dL is critical
4. Serum fibrinogen: Most sensitive marker for DIC in abruption (normal in pregnancy ≥400 mg/dL; <200 mg/dL = serious coagulopathy)
5. Clot observation test (bedside): Draw 5 mL blood in a plain tube; if clot does not form within 6 minutes = significant coagulopathy (DIC)
6. Urea, creatinine, electrolytes: Renal function; acute tubular necrosis is a complication of severe haemorrhage
7. LFTs, serum uric acid: Baseline; exclude pre-eclampsia/HELLP as co-morbidity
8. Blood glucose
9. Urine output monitoring (Foley catheter): Oliguria <30 mL/hour = renal compromise

Fetal Assessment:

1. CTG (immediate): Continuous electronic fetal monitoring - FHR 90 bpm is ominous (Category III - non-reassuring); assess for late decelerations, variable decelerations
2. Ultrasound:
   • Confirm fetal cardiac activity (is fetus alive?)
   • Identify retroplacental clot (hyperdense/isodense area behind placenta - though USS has poor sensitivity ~50% for acute abruption; diagnosis is clinical)
   • Estimate size of abruption
   • Fetal biometry, presentation, AFI
   • NB: Normal USS does NOT exclude abruption
3. Kleihauer-Betke test if Rh-negative

Additional if haemodynamically stable:

1. CRP - if infection component suspected
2. Serum lactate: Tissue hypoperfusion

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3. Management

Immediate Resuscitation (ABC):

• 2 large-bore IV cannulas (14-16G)
• Aggressive fluid resuscitation: IV crystalloids (Ringer's Lactate / Normal saline) 1-2 L rapidly, then reassess
• Blood transfusion: Packed RBCs as soon as cross-matched blood available; consider uncrossmatched O-negative blood if exsanguinating
• FFP, Cryoprecipitate, Platelets if DIC: fresh frozen plasma 2-4 units (fibrinogen replacement), cryoprecipitate (if fibrinogen <1 g/L), platelets (if <50,000)
• Foley catheter: Target urine output ≥30 mL/hour (0.5 mL/kg/hour)
• Central venous access if severely shocked

Delivery (Definitive Treatment):

• Grade 2-3 abruption with live fetus in distress
• Most rapid route of delivery
• Proceed under GA (if haemodynamically unstable - faster; no time for spinal/epidural)
• Have blood products in theatre
• Anticipate massive haemorrhage (uterotonic agents: oxytocin infusion, misoprostol, ergometrine, carboprost/PGF2α ready)
• Anticipate Couvelaire uterus (blood extravasates into myometrium causing a bruised, purplish, atonic uterus) - may not respond to uterotonics → B-Lynch suture, uterine artery ligation, hysterectomy may be needed
• Neonatologist/NICU team must be present for severely asphyxiated neonate

• Vaginal delivery is preferred (if maternal condition stable) to avoid CS in a coagulopathic patient
• ARM + oxytocin augmentation
• CS only if: impending maternal exsanguination, rapid delivery not imminent, cervix unfavourable, maternal compromise refractory to resuscitation

Management of DIC (if present):

• Replace clotting factors: FFP 2-4 units (each unit raises fibrinogen by ~10 mg/dL)
• Cryoprecipitate 10 units (raises fibrinogen by ~150 mg/dL; preferred for fibrinogen replacement)
• Platelet transfusion if <50,000 with active bleeding or <80,000 with planned CS
• Tranexamic acid 1 g IV (antifibrinolytic - given within 3 hours of haemorrhage onset based on WOMAN trial evidence)
• Haematologist involvement in massive haemorrhage protocol

Post-delivery complications to monitor:

• PPH (uterine atony from Couvelaire uterus, DIC)
• Acute kidney injury (acute tubular necrosis from ischaemia; DIC microthrombi)
• Pulmonary oedema
• Pituitary necrosis (Sheehan's syndrome - if prolonged hypotension)
• ARDS
• Maternal death

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• Williams Obstetrics, 25th Edition (Cunningham et al.)
• Williams Gynecology, 4th Edition
• DC Dutta's Textbook of Obstetrics, 8th Edition
• DC Dutta's Textbook of Gynecology, 7th Edition
• Berek & Novak's Gynecology, 16th Edition
• Creasy & Resnik's Maternal-Fetal Medicine, 8th Edition
• FIGO AUB Classification (PALM-COEIN), 2011/2018All 10 cases have been answered in detail. Here is a quick orientation to what was covered:

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CASE 11

1. Preliminary Diagnosis

• Background of preeclampsia: Preeclampsia is the single most important predisposing cause of abruption. It causes decidual vasculopathy (atherosis of spiral arteries), making the placenta prone to separation.
• Abdominal pain + vaginal bleeding in labour: The hallmark combination of abruption.
• Uterus tense, painful on palpation, not relaxing between contractions ("woody-hard" or board-like uterus): This is the pathognomonic finding. Blood from the retroplacental haematoma infiltrates the myometrium, causing hypertonic uterine contractions that are continuous (tonicospasm/tonic uterine contractions). The uterus does NOT relax between contractions unlike normal labour.
• Asymmetric tenderness (more on the right): Suggests the retroplacental haematoma is predominantly on the right - the separated placental edge bleeds and the clot accumulates there.
• Maternal haemodynamic compromise: Pulse 100 bpm, BP 100/60 - hypovolaemia from blood loss (both external + concealed retroplacental bleeding).
• Fetal heart rate 100 bpm: Severe fetal bradycardia = profound fetal distress (normal FHR in labour = 110-160 bpm; <100 sustained = critical).
• Good news on VE: Cervix fully dilated, membranes absent (ruptured), head in the narrowest part of the pelvis (at ischial spines, approximately station +1 to +2), small fontanelle (posterior fontanelle) to the left and lower = Left Occiput Anterior (LOA) position - a favourable, deliverable position.

• Grade 2: Moderate abruption, fetal distress present, fetus alive - this case fits this grade at minimum.
• Grade 3: Severe, fetal death - fetus here is alive but in severe distress.

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2. Main Etiological Causes of Abruptio Placentae

Primary/Direct Causes:

1. Hypertensive disorders of pregnancy - MOST IMPORTANT CAUSE
   • Preeclampsia/eclampsia (as in this case): decidual vasculopathy, spiral artery atherosis → poor placental bed blood supply → ischaemia and necrosis of decidua basalis → separation
   • Chronic hypertension: 3-5x increased risk
   • Superimposed preeclampsia on chronic hypertension: highest risk
2. Abdominal trauma:
   • Road traffic accidents (most common traumatic cause)
   • Domestic violence / intimate partner violence (must always be asked about)
   • Falls
   • External cephalic version (ECV) - iatrogenic
   • Blunt abdominal trauma (sports, assaults)
3. Sudden decompression of the uterus:
   • Rupture of membranes in polyhydramnios (rapid decompression)
   • Delivery of first twin (second twin at risk)
4. Short umbilical cord (traction on placenta during fetal descent)

Associated Risk Factors (Predisposing):

1. Previous abruption - STRONGEST risk factor; 10-15x increased risk in subsequent pregnancies
2. Multiparity (grand multipara)
3. Advanced maternal age (>35 years)
4. Cigarette smoking: nicotine causes vasoconstriction and decidual ischaemia; carbon monoxide causes placental hypoxia; smokers have 2-3x increased risk
5. Cocaine use: profound vasoconstriction causes placental ischaemia
6. Alcohol and illicit substance use
7. Thrombophilias: Factor V Leiden, antiphospholipid syndrome, protein C/S deficiency, prothrombin gene mutation → thrombosis of decidual vessels
8. Folic acid deficiency / Hyperhomocysteinaemia
9. Anaemia and malnutrition
10. Uterine anomalies / fibroids (especially submucous or retroplacental fibroids)
11. Low socioeconomic status
12. Polyhydramnios
13. Male fetal sex (minor association)

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3. Further Management Plan

Simultaneous Resuscitation and Delivery:

• Call for help: senior obstetrician, anaesthetist, neonatologist/NICU team STAT
• Establish 2 large-bore IV cannulas (16G)
• IV crystalloids (Ringer's Lactate 1-2 L rapid infusion)
• Blood group and crossmatch urgently (4-6 units packed RBCs, FFP)
• Send STAT bloods: CBC, coagulation profile (PT, aPTT, fibrinogen, D-dimer), U&E, serum fibrinogen, clot observation test
• High-flow oxygen via face mask
• Foley catheter, monitor urine output
• Continuous CTG monitoring

• Cervix FULLY dilated ✓
• Membranes absent ✓
• Head at pelvic floor/narrowest part of pelvis ✓ (station +1 to +2)
• LOA position (favourable) ✓
• FHR 100 bpm = severe fetal distress ✓
• Fetus alive ✓

• Preferred: Outlet/Low forceps (Wrigley's or Simpson's) - most controlled
• Episiotomy (mediolateral, right side) to facilitate rapid delivery
• Neonatologist must be present at delivery to resuscitate the asphyxiated neonate

• Oxytocin 10 IU IM immediately after delivery of anterior shoulder (or IV bolus if line in situ)
• Controlled cord traction after signs of placental separation
• Examine placenta: confirm retroplacental clot (confirms diagnosis)
• Inspect for Couvelaire uterus

• FFP (2-4 units for fibrinogen/clotting factor replacement)
• Cryoprecipitate (if fibrinogen <1 g/L)
• Platelet concentrate (if <50,000 with active bleeding)
• Tranexamic acid 1 g IV (within 3 hours of onset - WOMAN trial)

• Continue IV oxytocin infusion (PPH prevention - uterus may be atonic post-abruption/Couvelaire)
• ICU/HDU monitoring
• Continue antihypertensive treatment for underlying preeclampsia (labetalol, nifedipine)
• MgSO4 prophylaxis for eclampsia (already has preeclampsia) - if not already started
• Monitor for: PPH, DIC, AKI (acute tubular necrosis), pulmonary oedema, cortical blindness, Sheehan's syndrome

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4. Can Forceps Be Used Instead of Vacuum (Ventouse)?

• Cervix fully dilated ✓
• Membranes ruptured ✓
• Head at station +1/+2 (pelvic floor/outlet) ✓
• Position known: LOA (posterior fontanelle at left, below anterior = LOA) ✓
• Adequate pelvis (not stated otherwise) - assumed ✓
• Bladder must be emptied (Foley catheter) ✓
• Live fetus ✓
• Fetal distress: INDICATION for forceps ✓

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CASE 12

1. Gestational Age and Expected Date of Delivery (EDD)

• First day of LMP: 18 July 2009
• Naegele's Rule: EDD = LMP + 9 months + 7 days (or LMP - 3 months + 7 days + 1 year)
• July 18 + 9 months = April 18, 2010
• April 18 + 7 days = April 25, 2010
• EDD by LMP = 25th April 2010 ← Interestingly, this is EXACTLY the date she presented to the maternity home, which confirms she is presenting on her due date.

• From 18 July 2009 to 25 April 2010:
  • July 18 to July 31 = 13 days remaining in July
  • August: 31 days; September: 30; October: 31; November: 30; December: 31; January: 31; February: 28 (2010); March: 31; April: 25 days
  • Total = 13 + 31 + 30 + 31 + 30 + 31 + 31 + 28 + 31 + 25 = 281 days = approximately 40 weeks + 1 day
• Gestational age = 40 weeks (term)

• First fetal movement: 12 December 2009
• In a primigravida: first movements (quickening) felt at ~20 weeks
• EDD = Date of quickening + 20 weeks = December 12 + 20 weeks = April 30, 2010 (approximately)
• This confirms term pregnancy (within 5 days of LMP-derived EDD)

• Fundal height 35 cm at term ≈ 35 weeks gestation (by the "finger-width" rule, or SFH in cm ≈ weeks ± 2)
• Note: at term, the head may engage and fundal height may appear slightly less than the gestational age would predict. This is consistent with 39-40 weeks.

• Gestational age = 40 weeks (term)
• Expected Date of Delivery (EDD) = 25 April 2010
• The patient has presented ON her due date - she is in early labour or presenting for assessment at term.

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2. Estimated Fetal Weight (EFW)

• n = 12 if the presenting part is above the ischial spines (not engaged)
• n = 11 if the presenting part is at or below the ischial spines (engaged)

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3. Stages of Labour

Stage 1 - First Stage (Cervical Stage / Stage of Dilatation):

• Primipara: Average 8-12 hours (can range 6-18 hours)
• Multipara: Average 4-6 hours (can range 2-10 hours)

1. Latent phase:
   • Cervical dilatation: 0 to 3-4 cm
   • Slow progress; predominantly cervical effacement and early dilatation
   • Duration: up to 20 hours in primipara; up to 14 hours in multipara
   • Arrest in latent phase is called "prolonged latent phase"
2. Active phase:
   • Cervical dilatation: 4 cm (or 6 cm by modern WHO/FIGO criteria) to 10 cm
   • Rapid progress: ≥1 cm/hour (primipara); ≥1.5-2 cm/hour (multipara)
   • The "active phase begins at 6 cm" (ACOG 2014 consensus) - redefining normal progress
   • Active phase subdivided in Friedman's classic model into:
     • Acceleration phase (4-6 cm)
     • Phase of maximum slope (6-8 cm) - fastest dilatation
     • Deceleration phase (8-10 cm)

Stage 2 - Second Stage (Expulsive Stage / Stage of Expulsion of Fetus):

• Primipara without epidural: up to 2 hours (normal); up to 3 hours with epidural
• Multipara without epidural: up to 1 hour; up to 2 hours with epidural

1. Passive phase (passive descent/latent phase of second stage): Fetal head descends passively; mother has no urge to push yet
2. Active phase (active pushing): Mother has urge to push (ferguson reflex); active bearing-down efforts; delivery imminent

• Primipara: >3 hours without epidural, >4 hours with epidural
• Multipara: >2 hours without epidural, >3 hours with epidural

Stage 3 - Third Stage (Placental Stage):

• Normally 5-30 minutes
• Prolonged third stage: >30 minutes

• After baby delivery, uterus contracts → placenta separates (Schultze mechanism - central separation, fetal surface first; or Matthews-Duncan mechanism - edge separation first, maternal surface delivered first)
• Signs of placental separation: lengthening of cord, gush of blood, fundus rises and becomes globular

• Prophylactic oxytocin 10 IU IM (or IV 5 IU bolus) after delivery of anterior shoulder
• Controlled cord traction (Brandt-Andrews method)
• Uterine fundal massage after delivery of placenta
• Reduces PPH risk by 60%

Stage 4 (some authorities):

• Uterus should remain contracted; lochia rubra; vital signs stable.
• Most PPHs occur in this period.

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CASE 13

1. Diagnosis

• Multipara, second stage of labour (cervix not palpable = fully dilated) ✓
• Mixed breech (footling/complete breech - buttocks AND feet presenting) ✓
• Prolapsed umbilical cord found on VE ✓
• FHR 100/min + muffled heart sounds = severe fetal distress (cord compression compromising umbilical blood flow) ✓
• Buttocks and feet in pelvic cavity = presenting parts descended into pelvis

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2. Plan for Conduct of Labour

Emergency Steps:

• Knee-chest position or Trendelenburg position to shift the presenting part off the cord using gravity
• OR the examiner's hand stays in the vagina to manually elevate the presenting part (buttocks/feet) off the cord - this is maintained until delivery
• Do NOT remove the hand until the baby is delivered
• Keep the cord WARM and MOIST (wrap in warm saline-soaked gauze if it has prolapsed outside the vagina) - do NOT manipulate the cord excessively (vasospasm risk)
• Fill bladder with 500-700 mL warm saline (via Foley catheter) - retrograde bladder filling elevates the presenting part upward

• Senior obstetrician, anaesthetist, neonatologist STAT

• High-flow O2 to mother (10-15 L/min)

• The feet and buttocks are already in the pelvic cavity
• Multipara pelvis has been through previous deliveries (likely adequate)
• Perform assisted breech delivery under episiotomy:
  • Allow buttocks to deliver spontaneously until umbilicus visible (avoid pulling)
  • Once buttocks and trunk delivered to umbilicus: loop the cord to prevent tension
  • Delivery of legs using Pinard maneuver if needed
  • Deliver arms using Lovset's maneuver
  • Deliver aftercoming head using Mauriceau-Smellie-Veit (MSV) maneuver or Burns-Marshall method
  • Forceps to the aftercoming head (Piper's forceps) if available and the head has difficulty delivering
• Neonatologist/resuscitation team at bedside for neonatal resuscitation

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3. What Are the Mistakes? (What Went Wrong in Management)

1. Failure to diagnose cord presentation before membrane rupture: If the cord was adjacent to the presenting part (cord presentation) on admission, it should have been detected by VE or USS before allowing spontaneous membrane rupture. Cord presentation precedes cord prolapse.
2. Allowing spontaneous membrane rupture in a high-presenting or poorly-fitting breech: In breech presentations, the presenting part does not always fit snugly into the pelvis, leaving space for the cord to prolapse. Artificial rupture of membranes (AMNIOTOMY) should ideally have been avoided until the presenting part was well-applied to the cervix, or avoided altogether in favour of CS.
3. Failure to check for cord presentation before ARM or at the time of ROM: After rupture of membranes (spontaneous or artificial), immediate VE should have been performed to exclude cord prolapse.
4. Not monitoring FHR continuously: FHR deceleration (from 140s to 100) signals cord compression; had CTG been monitored continuously, the cord prolapse would have been suspected earlier.
5. Allowing a footling/mixed breech presentation to labour without counselling for CS: Mixed/footling breech is associated with the highest risk of cord prolapse among all presentations (risk ~5-15% vs. ~0.4% for vertex). The current standard of care in most centres is elective CS for footling breech at term.
6. Delayed recognition of the prolapse after FHR deterioration.

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4. Vaginal Delivery with Cord Prolapse - Is Live Birth Possible?

a) Cephalic Presentation with Cord Prolapse:

• Head is at or near the pelvic outlet (advanced second stage, fully dilated, head on the perineum)
• FHR is still present and not severely compromised
• Immediate outlet forceps or vacuum can deliver the head within minutes
• If the head is not at outlet and delivery is not immediately possible → Emergency CS is faster and should be performed

b) Breech Presentation with Cord Prolapse:

• Multipara with fully dilated cervix and presenting parts in pelvic cavity (as in this case)
• Experienced obstetrician capable of breech delivery
• The breech parts can be delivered rapidly enough to salvage the fetus

• Cervix is not fully dilated
• Presenting part is not in pelvic cavity
• Multipara but cervix only partially dilated → Emergency CS is indicated

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5. Aid in Stage 2 with Cord Prolapse

a) Cephalic Presentation, Second Stage:

1. Put patient in knee-chest or Trendelenburg position
2. Manually push presenting part (head) upward off the cord
3. Summon help + neonatologist
4. High-flow oxygen to mother
5. If head at pelvic outlet (station +3 to +4): Immediate outlet forceps or vacuum delivery (fastest)
6. If head not at outlet but cervix fully dilated and head at mid-cavity: Low-mid cavity forceps or vacuum
7. If head not deliverable vaginally immediately: Emergency CS while maintaining manual elevation of presenting part
8. Bladder filling (500-700 mL saline) to help displace head while preparing for CS
9. Keep cord warm and moist if prolapsed outside vagina
10. Neonatologist at delivery for resuscitation

b) Breech Presentation, Second Stage:

1. Trendelenburg/knee-chest position
2. Manually elevate presenting part (breech) off cord
3. High-flow oxygen to mother
4. If buttocks/feet at pelvic floor (as in this case, multipara): Immediate assisted breech delivery
   • Allow spontaneous descent of buttocks; assist delivery of trunk, shoulders, arms, and aftercoming head
   • Piper's forceps to aftercoming head if needed
5. If not in advanced second stage or delivering is not immediate: Emergency CS with hand maintaining elevation of presenting part
6. Neonatologist for neonatal resuscitation (high risk of birth asphyxia)
7. Do not clamp cord until baby delivered (risks further cord traction/compression)

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6. Breech Presentation at 34 Weeks - Management in Antenatal Clinic

• Clinical (Leopold maneuvers) + Ultrasound confirmation
• USS also assesses: placental location, AFI (polyhydramnios/oligohydramnios affect version), fetal biometry, exclude fetal anomaly (hydrocephalus, tumour preventing version), cord position

• At 34 weeks, spontaneous version to cephalic is very likely over the next 2-4 weeks
• No ECV (External Cephalic Version) at 34 weeks - too early; higher rate of reversion if done early
• ECV is performed at 36-37 weeks (after 36 completed weeks in nullipara; 37 weeks in multipara - when it is unlikely to revert spontaneously)

• Explain that 34 weeks breech is common; spontaneous version likely
• Teach the patient to count fetal movements (kick count)

• Review at 36 weeks for repeat presentation assessment

• Offer External Cephalic Version (ECV):
  • Success rate: ~50% in primiparae; ~60% in multiparae
  • Prerequisites: reactive CTG, adequate AFI, no contraindications (placenta previa, previous CS, oligohydramnios, fetal compromise, uterine anomaly, multiple pregnancy)
  • Tocolysis (terbutaline or nifedipine) before ECV improves success
  • Anti-D if Rh-negative
  • CTG monitoring before and after
• If ECV successful: monitor for spontaneous onset of labour; vaginal cephalic delivery
• If ECV fails/declined/contraindicated: counsel regarding planned (elective) CS at 39 weeks (the Term Breech Trial by Hannah et al. 2000 demonstrated significantly lower perinatal morbidity and mortality with planned CS vs. planned vaginal breech delivery for term singletons)

• Knee-chest exercises (10 minutes, 3x/day) - some traditional use; evidence limited
• "Moxibustion" at acupuncture point BL67 - some alternative evidence; not recommended routinely

• Planned CS is the preferred mode at term for breech in most centres
• Vaginal breech delivery is possible under very specific criteria (multipara, flexed breech, adequate pelvis, experienced team) but is increasingly rare in modern practice

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CASE 14

1. Primary Diagnosis

• 18-year-old woman
• Amenorrhoea of 9 weeks by history (LMP-based)
• Nausea and vomiting (classic early pregnancy symptoms)
• Uterus on VE: soft (Hegar's sign - softening of isthmus, pathognomonic of pregnancy) and enlarged to 7-8 weeks (which is slightly less than the 9 weeks of amenorrhoea - uterine size may slightly lag behind gestational age in early pregnancy by clinical palpation)

• Possible dates discrepancy (late ovulation in a long cycle)
• Examination error
• Needs confirmation by USS

• Ectopic pregnancy (but: uterus in ectopic is not enlarged proportionate to amenorrhoea; adnexal mass may be felt; risk of rupture)
• Hydatidiform mole (uterus often larger than dates; snowstorm on USS; very high beta-hCG)
• Fibroid uterus with normal pregnancy

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2. Examinations Needed to Confirm Diagnosis

1. Urine Pregnancy Test (UPT):

• Detects beta-hCG (qualitative)
• Positive from as early as 10-14 days after conception (when beta-hCG >25 mIU/mL)
• At 9 weeks, urine beta-hCG is strongly positive
• Simple, rapid, cheap, first-line test

2. Serum beta-hCG (Quantitative):

• At 9 weeks: expected >50,000-100,000 mIU/mL
• Helps distinguish from ectopic (suboptimal rise), mole (very high), or threatened abortion (falling levels)
• Serial measurements every 48 hours: should double in normal early pregnancy

3. Transvaginal Ultrasound (TVS) - Gold Standard for Confirmation:

• Confirms intrauterine gestational sac (by 5 weeks on TVS)
• Yolk sac visible by 5-6 weeks
• Fetal pole + cardiac activity by 6-7 weeks (heart rate should be >100 bpm by 7 weeks)
• Measures Crown-Rump Length (CRL) - gold standard for first-trimester dating
  • At 9 weeks, CRL ≈ 22-25 mm
• Excludes ectopic, molar pregnancy, missed abortion

4. Complete Blood Count (CBC):

• Baseline; check for anaemia, infection

5. Blood group and Rh typing (Rhesus status):

• Anti-D prophylaxis planning

6. Urinalysis (Urine R/E):

• Exclude UTI (common in pregnancy)
• Check for ketonuria (severity of vomiting/hyperemesis)

7. Blood sugar, LFTs, electrolytes, urea, creatinine:

• Baseline if vomiting is significant (hyperemesis gravidarum can cause electrolyte disturbances, Wernicke's encephalopathy if severe)

8. TSH (Thyroid function):

• Hyperemesis can be associated with transient gestational hyperthyroidism (hCG stimulates TSH receptors)

9. Abdominal / Transabdominal Ultrasound:

• If TVS not available; gestational sac visible by 6-7 weeks transabdominally

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3. Classification of Symptoms of Pregnancy

A. Presumptive Symptoms and Signs (Subjective - reported by the patient):

1. Amenorrhoea - cessation of menstruation (most common first symptom; though anovulation, stress, chronic illness can also cause it)
2. Nausea and vomiting (morning sickness) - due to rising hCG and progesterone; begins 6th week, peaks 8-12 weeks, resolves by 14-16 weeks in most
3. Breast changes: Tingling, tenderness, fullness, nipple pigmentation, Montgomery's tubercles (sebaceous gland hypertrophy on areola)
4. Urinary frequency: Enlarged uterus pressing on bladder; increased GFR; begins early
5. Quickening (fetal movements): Primigravida: ~20 weeks; Multigravida: ~16-18 weeks
6. Fatigue and lethargy
7. Food cravings and aversions (pica)
8. Increased vaginal discharge (leucorrhoea of pregnancy): Due to oestrogen-stimulated cervical gland secretion
9. Mood changes
10. Abdominal enlargement (later)

B. Probable Signs (Objective - detected on examination, highly suggestive):

1. Uterine enlargement (progressive, correlating with gestational age)
2. Hegar's sign: Softening of the isthmus (lower uterine segment) between the cervix and body of uterus; felt bimanually (8-10 weeks); pathognomonic in context
3. Goodell's sign: Softening of the cervix (by 6th week); due to oedema, hypervascularity, and hypertrophy
4. Chadwick's sign (Jacquemier's sign): Bluish/violet discolouration of vagina and cervix due to hypervascularity (by 6-8 weeks)
5. Osiander's sign: Pulsation felt in lateral vaginal fornices (from increased uterine blood flow)
6. Ballottement sign: At 16-20 weeks, a sharp tap on the uterus causes the fetus to float up and then sink back (internal or external ballottement)
7. Braxton Hicks contractions: Irregular, painless uterine contractions felt from 16 weeks onward
8. Skin changes: Linea nigra, melasma (chloasma), striae gravidarum - due to elevated MSH and progesterone
9. Positive pregnancy test (urine/serum beta-hCG)

C. Positive (Diagnostic) Signs - Absolute Confirmation:

1. Fetal heart sounds (FHS) heard on auscultation: By Pinard stethoscope at 20-22 weeks; by Doppler at 10-12 weeks
2. Fetal movements felt by the examiner (active fetal movements on palpation): Usually from 20-22 weeks
3. Ultrasound visualisation of the fetal parts, cardiac activity:
   • Gestational sac + yolk sac on TVS: 5-6 weeks
   • Fetal cardiac activity: 6-7 weeks
   • This is now the gold standard positive sign
4. Fetal skeleton on X-ray (from 16 weeks; outdated/not used due to radiation)
5. Fetal electrocardiography (ECG): fetal cardiac electrical activity on electronic monitoring

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CASE 15

1. Primary Diagnosis

• Regular, painful uterine contractions causing progressive cervical effacement and dilatation
• Discharge of blood-stained mucus show
• Contractions do not cease with sedation or hydration

• If contractions are true labour but progress is very slow, and cervix has not reached active phase (4-6 cm dilatation) after >20 hours in a primigravida or >14 hours in a multigravida

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2. Appropriate Management

Step 1 - Confirm with re-examination:

• If uncertain, observe for 1-2 more hours and repeat vaginal examination
• If no cervical change over 1-2 hours of observation with the described contraction pattern = false labour confirmed

Step 2 - Non-pharmacological Reassurance and Counselling:

• Reassure the patient extensively - false labour is common, especially in primigravidae at term
• Explain the difference between Braxton Hicks and true labour
• Encourage walking (ambulation may precipitate true labour or relieve false labour contractions)
• Hydration: oral fluids; some false labours resolve with simple hydration (an empty bladder and adequate hydration reduces Braxton Hicks)

Step 3 - Sedation / Therapeutic Rest:

• A therapeutic sedative (morphine 10-15 mg IM or pethidine 100 mg IM) can be given to allow rest
• In true labour, contractions PERSIST despite sedation (may slow slightly but continue)
• In false labour, contractions STOP with sedation
• This serves both diagnostic (differentiates true vs. false) and therapeutic (rest) purposes
• After 4-6 hours rest, reassess

Step 4 - Outpatient vs. Admission:

• If false labour confirmed with no cervical change → DISCHARGE HOME with:
  • Clear instructions on when to return (regular contractions every 5 minutes for ≥1 hour; rupture of membranes; reduced fetal movements; bleeding)
  • Kick count monitoring
  • Reassurance that spontaneous labour will begin soon (she is at 40 weeks)

Step 5 - If truly prolonged latent phase (contractions ARE progressive but slow):

• Await spontaneous progression with supportive care
• Cervical ripening if cervix is persistently unfavourable:
  • Prostaglandin E2 (Dinoprostone gel 0.5 mg intracervically or 1-2 mg vaginally)
  • Misoprostol 25-50 mcg vaginally/orally
  • Foley catheter balloon (mechanical cervical ripening)
• Oxytocin augmentation after cervical ripening is NOT indicated until active phase
• Amniotomy (ARM) can be performed if Bishop score ≥6

Step 6 - Fetal Wellbeing:

• CTG (Non-stress test): Confirm reactive FHR pattern
• If post-dates (>41 weeks) or reduced fetal movements: biophysical profile, Doppler

Step 7 - Post-dates Management:

• At 40 weeks, if no spontaneous labour within the next week: plan for elective induction at 41 weeks (some guidelines recommend at 40+5 or 41+0 weeks)
• Membrane sweeping (stripping) can be offered at 40 weeks: reduces incidence of formal induction

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CASE 16

1. Diagnosis

• Term, 5th pregnancy, G5P4 (grand multipara)
• Fetal head felt on the right side of the abdomen (dorso-superior or dorso-inferior transverse lie)
• FHT at umbilicus level, 136 bpm - in transverse lie, FHT is heard at the umbilicus (not in flanks)
• Membranes ruptured 30 minutes ago
• Cervix 6 cm dilated
• No presenting part determined on VE - in transverse lie, no pole enters the pelvis; the shoulder/flank presents at the inlet, or if cord/arm prolapsed, these may be the first structures felt
• Head not reachable, no bony deformations

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2. Plan of Management

Immediate Assessment:

1. Assess fetal condition: CTG, auscultation - is fetus alive?
2. Assess for cord prolapse: carefully on VE (without causing further cord compression)
3. Assess for arm prolapse: is an arm felt in the vagina?
4. Assess maternal vital signs: BP, pulse (exclude shock)
5. Assess labour progress: regular contractions (active labour with 6 cm dilatation confirmed)

Management:

• Transverse lie with ruptured membranes: cannot deliver vaginally safely
• 6 cm dilated in active labour = delivery is imminent if not managed - dangerous
• Grand multipara with transverse lie is classically associated with neglected shoulder/arm presentation if not managed urgently
• Risk of uterine rupture increases rapidly with each contraction against an impacted shoulder

1. IV access, resuscitation fluid, cross-match blood
2. Foley catheter
3. Call theatre team for emergency CS
4. Do NOT attempt external version with ruptured membranes (risk of cord prolapse, violent version, uterine rupture)
5. Do NOT attempt internal podalic version (IPV) if cervix is only 6 cm (IPV requires full dilatation)
6. Uterine relaxants (tocolysis - terbutaline 0.25 mg SC or nifedipine) may be given to temporise while preparing for CS
7. Emergency lower segment CS (LSCS)
8. The CS may be complicated: the head may be in the fundus and the back across the incision; a vertical (classical) uterine incision may be needed if the lower segment is poorly formed (preterm) or if the fetus is deeply impacted

• Internal Podalic Version (IPV) followed by breech extraction (if cervix fully dilated)
• Or Embryotomy/Destructive procedure (decapitation + evisceration) - performed only when fetus is dead and vaginal delivery is being attempted; requires skilled operator
• Emergency CS is still preferred even with fetal death if maternal safety allows (risk of uterine rupture outweighs benefits of vaginal delivery in most situations)

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3. Methods of Delivery Possible at Transverse Lie

1. External Cephalic Version (ECV) - ONLY if membranes intact, before labour or early labour:

• External manual rotation of fetus to cephalic or podalic presentation
• Not possible in this case (membranes have ruptured)

2. Internal Podalic Version (IPV) + Breech Extraction:

• Obstetrician inserts hand inside the uterus (internally), grasps a foot, and converts to footling breech, then delivers by breech extraction
• Prerequisites: FULLY dilated cervix, adequate anaesthesia (GA), adequate pelvis, experienced obstetrician, NO placenta previa, no uterine anomaly, no previous uterine scar
• Historically used for transverse lie of SECOND TWIN (after delivery of first twin, first twin's uterus is empty and soft - IPV of second twin is feasible and safe)
• In this case: cervix only 6 cm - NOT applicable

3. Caesarean Section (CS) - PREFERRED in most cases at term:

• Emergency LSCS (Lower Segment Caesarean Section) is the standard treatment for transverse lie at term, especially with ruptured membranes
• Classical (vertical/fundal) uterine incision if lower segment poorly formed

4. Embryotomy / Destructive Operations - ONLY for dead fetus:

• Decapitation: Separation of the fetal head from the body using a decapitation hook or Gigli saw - allows delivery of the trunk first, then the head
• Evisceration: Removal of abdominal and thoracic organs to reduce fetal volume
• These are destructive operations performed exclusively when the fetus is dead and vaginal delivery is attempted to avoid CS
• Requires extreme skill; essentially only used in resource-limited settings where CS is not available

5. Spontaneous Transverse Lie Delivery (Spontaneous Evolution / Denman's / Douglas' spontaneous version):

• Extremely rare; occurs in small macerated dead fetuses in multiparae with very lax uteri
• Should never be awaited in a living fetus at term - universally fatal for the fetus and highly dangerous for the mother
• Never acceptable as a planned management option

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CASE 17

1. Primary Diagnosis

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2. Physiological Changes During Pregnancy

Cardiovascular System:

• Blood volume increases 40-50% by 32-34 weeks (plasma volume increases 50%; RBC mass increases only 25% → dilutional anaemia = Hb falls)
• Cardiac output increases 30-50% (by increased stroke volume + increased heart rate ~15-20 bpm above baseline)
• Heart rate: Increases by 10-20 bpm
• Blood pressure: Systolic and diastolic decrease slightly in the first and second trimesters (peripheral vasodilation due to progesterone and prostaglandins); returns to normal by term
• Systolic flow murmur: Present in >95% of pregnant women (ejection systolic murmur, Grade I-II/VI, best heard at left sternal edge and pulmonary area) due to increased blood volume and flow velocity - PHYSIOLOGICAL. Diastolic murmurs are never physiological and require investigation.
• Apex beat displaced laterally and upward (uterus pushes diaphragm up)
• ECG changes: Left axis deviation (diaphragmatic elevation), sinus tachycardia, ST changes can appear physiologically
• "Supine hypotensive syndrome": Vena caval compression by gravid uterus when supine → reduced venous return → hypotension; resolved by left lateral position

Blood and Haematological Changes:

• Plasma volume increases 50% (by 1200-1500 mL above baseline)
• Red cell mass increases 25-30% (absolute increase by ~300-500 mL)
• Result: Haematocrit falls from ~40% to ~34-38%; Hb falls from ~13 to ~11-12 g/dL - PHYSIOLOGICAL DILUTIONAL ANAEMIA
• Leukocytes: WBC increases to 12,000-15,000/μL (neutrophilia; even 25,000 in labour is normal)
• Platelets: Mild decrease (dilution + increased consumption); average ~200,000 in third trimester (down from ~250,000 non-pregnant)
• Coagulation: Procoagulant state (increased fibrinogen, factors VII, VIII, X; decreased protein S) → increased VTE risk
• ESR increases significantly (plasma proteins increase); not useful for infection diagnosis in pregnancy
• Serum albumin decreases (dilution) - but total proteins maintained by globulin increase
• Iron requirements increase (especially second and third trimester) - daily need increases from 1 mg to 6-7 mg/day

Respiratory System:

• Tidal volume increases 40% (diaphragm splinted up by uterus; but tidal volume compensates)
• Functional residual capacity (FRC) decreases 20% (diaphragm elevation)
• Respiratory rate unchanged (12-14/min)
• Minute ventilation increases 40-50% (progesterone sensitises respiratory centre)
• Arterial PO2 slightly increases, PCO2 falls (chronic mild respiratory alkalosis; PCO2 ≈30 mmHg in pregnancy vs. 40 non-pregnant)
• Compensatory metabolic acidosis: Renal bicarbonate excretion increases; serum HCO3 falls to 18-20 mEq/L
• Nasal congestion (mucosal oedema, hyperaemia) - "rhinitis of pregnancy"

Renal System:

• GFR increases 40-50% by 10-12 weeks (maintained throughout); creatinine and urea fall
• Renal plasma flow (RPF) increases 75% in first trimester (falls slightly by term)
• Serum creatinine falls to 0.5-0.6 mg/dL (normal non-pregnant: 0.6-1.0 mg/dL); a "normal" creatinine in pregnancy may indicate renal impairment
• Physiological glycosuria - due to reduced tubular reabsorption threshold for glucose (not diagnostic of diabetes mellitus alone)
• Proteinuria up to 300 mg/day is physiological (increased GFR + reduced tubular reabsorption)
• Physiological hydronephrosis: Due to:
  1. Progesterone-induced smooth muscle relaxation (ureteric atony)
  2. Mechanical compression by the gravid uterus at the pelvic brim (right side > left side because the sigmoid colon cushions the left ureter)
  3. Dextrorotation of the uterus compresses the right ureter more
  • Results in mild-moderate dilatation of the renal pelvis and ureters bilaterally (right > left)
  • Predisposes to pyelonephritis (ascending infection in static urine)
  • This explains the mild hydronephrosis found on USS in this patient - it is physiological
• Ureteric peristalsis decreases (progesterone effect)

Gastrointestinal System:

• Gastric motility decreases (progesterone); gastric emptying slows; GERD/heartburn common
• Lower oesophageal sphincter tone decreases → reflux → heartburn (common from second trimester)
• Nausea and vomiting (first trimester): due to rising hCG + progesterone
• Constipation: Reduced gut motility + iron supplementation
• Haemorrhoids: Portal vein compression → increased rectal venous pressure
• Cholestasis: Increased lithogenicity of bile; gallstones common in pregnancy
• Liver: Alkaline phosphatase increases (placental origin); albumin decreases; γ-GT, AST, ALT remain normal

Endocrine System:

• Thyroid: Thyroid gland enlarges slightly; total T3, T4 rise (increased TBG from oestrogen); free T3, T4 remain normal; hCG has weak TSH-like activity → transient hyperthyroid symptoms in first trimester
• Adrenal: Cortisol and aldosterone increase; contributes to fluid retention
• Pancreas: Insulin resistance increases (especially third trimester); due to HPL (human placental lactogen), oestrogen, progesterone, cortisol → gestational diabetes risk
• Prolactin: Increases throughout pregnancy (from pituitary lactotroph hypertrophy due to oestrogen)
• hCG: Peaks at 8-10 weeks, falls by mid-pregnancy

Musculoskeletal:

• Relaxin (from corpus luteum, placenta): Relaxes pelvic ligaments → "pelvic girdle pain," waddling gait
• Lumbar lordosis increases (to compensate for anterior displacement of centre of gravity by gravid uterus)
• Diastasis recti - midline abdominal muscle separation

Skin:

• Hyperpigmentation: Linea nigra (midline), melasma (chloasma gravidarum - "mask of pregnancy")
• Striae gravidarum (stretch marks): rupture of dermal elastic fibres
• Palmar erythema, spider angiomas: Due to elevated oestrogen
• Excessive sweating, heat intolerance (increased metabolic rate)

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3. Causes of Increased Body Weight During Pregnancy

• Normal BMI (18.5-24.9): 11.5-16 kg (IOM guidelines)
• Underweight: 12.5-18 kg
• Overweight: 7-11.5 kg
• Obese: 5-9 kg

1. Products of conception (fetus, placenta, amniotic fluid): ~4.5-5 kg
2. Uterine and breast hypertrophy: ~1.3 kg
3. Expanded blood and interstitial fluid: ~2.5-3 kg
4. Maternal fat stores (metabolic reserve): ~2-4 kg (variable; obese women gain less fat; underweight women gain more)

• First trimester: 1-2 kg (minimal; nausea may limit intake)
• Second trimester: ~0.4 kg/week (fat deposition + blood volume expansion)
• Third trimester: ~0.4-0.5 kg/week (primarily fetal growth, fluid accumulation)

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CASE 18

1. Primary Diagnosis

• 27-year-old G1P1, 2nd postpartum day
• Fever 38.4°C: Puerperal pyrexia defined as temperature ≥38°C on any 2 of the first 10 postpartum days (excluding the first 24 hours) OR temperature ≥38.5°C on any occasion
• Tachycardia (PS 100): Consistent with infection/sepsis
• Lower abdominal tenderness: Uterine tenderness - endometritis
• Foul-smelling lochia (offensive lochia): This is the most specific sign of endometritis - normal lochia is inodorous; offensive smell = bacterial infection of the endometrium
• Breasts soft: Excludes mastitis/breast engorgement as cause of fever
• No mention of UTI symptoms (urinary frequency/dysuria) or chest signs - points to pelvic source

• Prolonged labour or PROM (even if not documented)
• Multiple vaginal examinations
• Genital tract colonisation (GBS, anaerobes, E. coli)
• Caesarean section is the most powerful risk factor (but this was vaginal delivery)
• Bacterial vaginosis

• Anaerobes: Bacteroides spp., Peptostreptococcus spp. (most common causative organisms)
• Gram-negatives: E. coli, Klebsiella, Proteus
• Group B Streptococcus (GBS)
• Enterococcus
• Chlamydia (less common in acute postpartum endometritis)

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2. Plan of Investigations

1. Blood Investigations:

• Full Blood Count (CBC): Leukocytosis (WBC >15,000; in severe sepsis can be >20,000 or paradoxically low); neutrophilia; left shift (bands)
• C-Reactive Protein (CRP) and Procalcitonin: Elevated; useful for monitoring response to treatment
• Blood cultures × 2 (before starting antibiotics): Essential if sepsis suspected; identifies bacteraemia and guides targeted therapy
• Serum electrolytes, urea, creatinine: Renal function (AKI in severe sepsis)
• LFTs, coagulation profile: Assess organ function; DIC can complicate severe sepsis
• Blood glucose: Sepsis-induced hyperglycaemia
• Serum lactate: If ≥2 mmol/L = sepsis; ≥4 mmol/L = septic shock

2. Microbiological:

• High vaginal swab (HVS): Culture and sensitivity of vaginal secretions
• Endocervical swab: Culture (aerobic, anaerobic, Chlamydia NAAT/PCR, GBS)
• Lochia culture: Swab of offensive lochia; culture for aerobic and anaerobic organisms
• Urine R/E + Culture (MC&S): Exclude concurrent UTI/pyelonephritis (can co-exist)

3. Imaging:

• Transvaginal Ultrasound (TVS) / Transabdominal USS:
  • Look for retained products of conception (RPOC) - echogenic material within uterine cavity
  • Uterine subinvolution
  • Parametrial involvement, pelvic abscess
  • Free fluid in the Pouch of Douglas (pelvic peritonitis)
• CT scan of abdomen and pelvis (if USS inconclusive, sepsis worsening, or pelvic abscess suspected):
  • Better for parametrial/pelvic sidewall involvement
  • Identifies tubo-ovarian abscess, pelvic thrombophlebitis

4. Additional:

• Chest X-ray: If respiratory symptoms; exclude aspiration pneumonia or endocarditis (in severe bacteraemia)
• Echocardiography: If persistent bacteraemia with S. aureus → rule out infective endocarditis
• Pelvic vein Doppler / CT venography: If septic pelvic thrombophlebitis suspected (fever persisting >72 hours despite antibiotics, without another identifiable focus)

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3. Management

A. General Supportive Care:

• Hospitalisation
• IV access, hydration (IV fluids if febrile/tachycardic)
• Vital sign monitoring: temperature, HR, BP, RR, SpO2, urine output (Foley catheter)
• Sepsis six bundle if sepsis criteria met: O2, IV fluids, blood cultures, lactate, antibiotics within 1 hour, urine output monitoring

B. Antibiotics (CORNERSTONE of treatment):

1. Clindamycin 900 mg IV q8h + Gentamicin 5 mg/kg IV q24h (or 1.5 mg/kg q8h)
   • This is the gold standard regimen for postpartum endometritis
   • Cure rate >90%
   • Clindamycin: excellent anaerobic + gram-positive coverage
   • Gentamicin: gram-negative coverage
   • If enterococcal infection suspected or no response after 72 hours: ADD Ampicillin 2 g IV q6h
2. Alternative: Piperacillin-tazobactam 3.375-4.5 g IV q6-8h (broad spectrum, covers anaerobes)
3. Alternative: Ampicillin-sulbactam 3 g IV q6h
4. If penicillin allergy: Clindamycin + Aztreonam (renal-dose adjusted)

• Continue IV antibiotics until the patient is afebrile for 24-48 hours AND clinically improved
• Then NO oral antibiotics needed (ACOG recommendation - continuation of oral antibiotics does not reduce treatment failure)
• If RPOC present: proceed to surgical evacuation (see below)

C. Surgical Management (if Retained Products of Conception):

• Suction curettage / Manual vacuum aspiration (MVA) under antibiotic cover
• Oxytocin/methylergometrine before or after procedure (to firm uterus, reduce bleeding)
• Send evacuated material for histopathology and culture

D. Management of Septic Pelvic Thrombophlebitis (if suspected):

• Fever persisting despite adequate antibiotics for 72 hours with no focus
• Diagnosis: CT venography or MRI
• Treatment: Therapeutic anticoagulation (heparin IV infusion, adjusted to maintain therapeutic aPTT)
• Antibiotics continued

E. Breastfeeding:

• Most antibiotics used are compatible with breastfeeding (penicillins, cephalosporins, clindamycin, metronidazole in standard doses)
• Gentamicin: Very little in breast milk; compatible with breastfeeding
• Encourage continued breastfeeding unless mother is too unwell

F. Monitoring response:

• Temperature should fall within 48-72 hours of antibiotics
• If no improvement in 72 hours → review diagnosis → consider: RPOC, pelvic abscess, pelvic thrombophlebitis, drug-resistant organism, incorrect antibiotic selection

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CASE 19

1. Primary Diagnosis

• Wrist = 14 cm → medium build → subtract 9 cm from Conjugata Externa
• CV = 15 - 9 = 6 cm

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2. Mode of Delivery

1. Conjugata Vera of 6 cm means the minimum AP diameter for engagement of a term fetal head (diameter ~9.5 cm suboccipitobregmatic) is not available - engagement is physically impossible.
2. Estimated fetal weight 3.5 kg (normal-sized baby) with a severely contracted pelvis = absolute CPD.
3. No trial of labour is warranted when CV <7.5 cm (absolute disproportion). In mild contraction (CV 9.5-11 cm) a trial of labour is appropriate; in moderate contraction (7.5-9.5 cm) a very carefully supervised trial may be considered, but in severe/absolute contraction it is dangerous.
4. Attempting vaginal delivery risks: uterine rupture, obstructed labour, fetal distress, neonatal death, maternal vesicovaginal fistula (from prolonged obstructed labour) - catastrophic consequences.

• Confirm by ultrasound: fetal presentation, EFW, AFI, placental location
• Obstetric conjugate by vaginal examination (diagonal conjugate -1.5 cm to cross-check)
• Consent: Explain findings and rationale for CS
• Elective LSCS (Lower Segment Caesarean Section) under spinal anaesthesia
• Timing: Admit, pre-operative assessment, blood group & crossmatch, nil by mouth 6 hours, then CS
• Paediatrician present at delivery
• Post-operative care standard

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CASE 20

1. Diagnosis

• Occiput Anterior (OA) position (small fontanelle - posterior fontanelle - in front of symphysis = occiput is anterior) ✓
• Head at pelvic floor (outlet plane) ✓
• Sagittal suture in outlet plane ✓
• Fetal heart rate 105-110/min, dull, arrhythmic = Category III / Severe Fetal Distress ✓
• Prolonged labour: 10 hours total, 4 hours after ARM → question of second stage duration

• Cervix fully open (complete dilatation) ✓
• Membranes ruptured 4 hours ago ✓
• Labour 10 hours total, primipara - within normal range, but the fetal distress makes this an emergency

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2. Tactic of Management

Step 1 - Confirm and assess:

• Immediate VE (already done per case): head at outlet, OA, cervix fully dilated ✓
• Is fetal cord pulsation present? (confirm alive)
• Ensure bladder is empty (catheterise if not)
• Confirm exact position of head (OA confirmed by posterior fontanelle at front)

Step 2 - Summon help:

• Senior obstetrician, anaesthetist, neonatologist STAT

Step 3 - Maternal preparation:

• Position: lithotomy position on delivery table
• High-flow oxygen to mother
• Perineal preparation and draping
• Anaesthesia: pudendal nerve block (10 mL 1% lignocaine each side bilaterally at ischial spines) + perineal infiltration
• (Or epidural top-up if epidural in place)

Step 4 - Instrument selection and delivery:

• Cervix fully dilated ✓
• Membranes ruptured ✓
• Head at pelvic floor/outlet (station +3/+4) ✓
• Position known: OA ✓
• Bladder empty ✓
• Fetal distress: INDICATION ✓
• Live fetus ✓
• No severe CPD (not mentioned; assume adequate pelvis given she is in second stage with head at outlet)

• Head is at outlet in OA → ideal for outlet forceps
• Faster than vacuum in acute fetal distress (no cup placement delay)

• Left blade first (Wrigley's left blade to the left side of fetal head): insert blade along guiding right hand at 4 o'clock, then lower handle as blade advances
• Right blade: along left guiding hand at 8 o'clock
• Blades articulate/lock in the midline
• Check application: sagittal suture midline between blades; posterior fontanelle one fingerbreadth above shank plane
• Traction: With contraction; traction directed posteriorly and downward initially (Pajot's maneuver), then horizontal, then upward as occiput appears under symphysis
• Episiotomy at crowning (right mediolateral)
• Deliver the head by controlled upward traction/extension
• Neonatologist for immediate neonatal resuscitation

Step 5 - After delivery:

• Neonatologist: Apgar score at 1 and 5 minutes; immediate resuscitation (bag-mask ventilation, intubation if needed, chest compressions if HR <60)
• Active management of third stage (Oxytocin 10 IU IM)
• Inspect for perineal, vaginal, cervical lacerations; repair
• Send cord blood gases (umbilical artery pH; pH <7.0 = severe acidosis = asphyxia)
• Document all findings

Alternative - Ventouse (Vacuum Extractor):

• If forceps not available or operator not trained in forceps: apply vacuum cup to flexion point (3 cm anterior to posterior fontanelle) in OA; build negative pressure to 0.6-0.8 kg/cm²; traction with contractions
• Can be used at outlet in OA; adequate for this case

If delivery NOT imminent or instrumental delivery fails:

• Emergency CS (grade 1 CS - immediate threat to maternal or fetal life)
• But given head at pelvic floor in OA: instrumental delivery should be achievable rapidly

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• Williams Obstetrics, 25th Edition (Cunningham, Leveno, Bloom et al.)
• DC Dutta's Textbook of Obstetrics, 8th Edition (Hiralal Konar)
• DC Dutta's Textbook of Gynecology, 7th Edition
• Berek & Novak's Gynecology, 16th Edition
• Creasy & Resnik's Maternal-Fetal Medicine, 8th Edition
• ACOG Practice Bulletins (Intrapartum Fetal Heart Rate Monitoring, PPROM, Postpartum Haemorrhage)
• WHO Guidelines for Intrapartum CareAll 10 cases are answered. Here is a quick orientation to what each case covered:

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• CASE 11 - Abruption + preeclampsia: 4 sub-questions answered (diagnosis, aetiology table, management plan, forceps vs vacuum)
• 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
• 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)
• CASE 14 - Early pregnancy/hyperemesis: 3 sub-questions (diagnosis, investigations, classification of pregnancy symptoms into Presumptive/Probable/Positive with all signs listed)
• CASE 15 - False labour: 2 sub-questions (diagnosis with comparison table true vs false labour, full stepwise management)
• CASE 16 - Transverse lie with ruptured membranes: 3 sub-questions (diagnosis, management, all 5 possible delivery methods explained)
• CASE 17 - Physiological anaemia/murmur/hydronephrosis: 3 sub-questions (diagnosis, all physiological changes by system, weight gain components table)
• CASE 18 - Puerperal endometritis: 3 sub-questions (diagnosis, full investigation plan, antibiotic regimens and surgical management)
• CASE 19 - Contracted pelvis: 2 sub-questions (all pelvic measurements analysed, CV calculated as 6 cm = absolute CS)
• CASE 20 - Fetal distress at outlet OA: 2 sub-questions (diagnosis, full forceps delivery steps)

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CASE 10

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1. Primary Diagnosis

• 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

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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)

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3. Management

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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

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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)

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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

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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)

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D. POSTOPERATIVE/POST-DELIVERY CARE

1. PPH (uterine atony from Couvelaire uterus, DIC) - most immediate danger
2. 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
3. DIC (may worsen or develop post-delivery)
4. Pulmonary oedema (from massive transfusion, fluid overload, or pre-eclampsia)
5. Sheehan's Syndrome (anterior pituitary necrosis from prolonged hypotension - presents weeks/months later as failure of lactation, amenorrhoea, adrenal/thyroid insufficiency)
6. ARDS (Acute Respiratory Distress Syndrome) - from shock, massive transfusion
7. 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

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CASE 20

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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

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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

• 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)

1. Cervix fully dilated ✓ (complete dilatation confirmed on VE)
2. Membranes ruptured ✓ (absent 4 hours)
3. Head at pelvic floor/outlet (station +3/+4) ✓
4. Position KNOWN: Direct Occiput Anterior (posterior fontanelle anterior, sagittal suture AP) ✓
5. Bladder empty ✓ (catheterised)
6. Anaesthesia administered ✓
7. Fetal distress: INDICATION ✓
8. Fetus alive ✓
9. No CPD (head already at outlet - by definition adequate outlet)
10. Experienced operator ✓
11. 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

• 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)
• Phase 2 (as head descends to perineum): Direction becomes HORIZONTAL
• Phase 3 (as occiput appears at vulva under symphysis): Direction becomes UPWARD (toward ceiling) - the head delivers by EXTENSION over the symphysis
• Traction is applied with CONTRACTIONS and maternal pushing - "Pull WITH her, not against her"
• Between contractions: release traction but keep blades in position
• Traction should be STEADY and CONTROLLED, never jerky or rotational
• 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

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• 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