1. Pap smear
   • Purpose and screening role
   • Indications, timing, technique of collection
   • Bethesda reporting system
   • Interpretation and follow-up of abnormal results
2. Outlet forceps delivery
   • Definition and prerequisites
   • Indications and contraindications
   • Procedure, safety checks, complications
   • Aftercare and documentation
3. Deep transverse arrest
   • Definition, causes and diagnosis
   • Clinical findings and management options
   • Role of manual rotation, rotational forceps, vacuum, and caesarean delivery
   • Maternal and fetal complications
4. Episiotomy
   • Definition, types and indications
   • Technique, repair and postoperative care
   • Complications
   • Why routine episiotomy is not recommended
5. Medical termination of pregnancy (MTP)
   • Legal provisions and indications
   • Methods in first and second trimester
   • Consent, counseling and follow-up
   • Complications and post-abortion contraception

1. Pap Smear

Definition

Objectives

• Detect cervical intraepithelial neoplasia (CIN) before invasion occurs.
• Detect early invasive cervical carcinoma.
• Reduce mortality from carcinoma cervix through screening and treatment of precursor lesions.
• Identify infections or reactive cellular changes incidentally.

Principle

Indications

• Screening of asymptomatic women for carcinoma cervix.
• Follow-up after treatment of CIN or cervical cancer.
• Follow-up of a previous abnormal cytology result.
• Women at increased risk:
  • Early onset of sexual activity
  • Multiple sexual partners
  • Immunosuppression, including HIV
  • Previous CIN or carcinoma cervix
  • Smoking
  • History of sexually transmitted infections

Timing and preparation

• Ideally taken in the mid-menstrual period.
• Avoid taking during menstruation, preferably wait until bleeding has stopped.
• Avoid vaginal intercourse, douching, vaginal medications, lubricants, and spermicides for 24-48 hours before the test.
• Treat severe cervicitis or vaginal infection first if it obscures the sample.
• In pregnancy, screening may be done when indicated, but endocervical curettage is contraindicated.

Technique of collection

1. Explain the procedure and obtain consent.
2. Place the woman in lithotomy position.
3. Introduce a warmed Cusco's speculum without excessive lubricant.
4. Visualize the cervix and note ectropion, erosion, discharge, ulcer, growth, or bleeding.
5. Collect cells from the transformation zone using:
   • Ayre's spatula, rotated through 360 degrees around the external os, and/or
   • Cytobrush or endocervical brush for endocervical cells.
6. Spread the material evenly on a labelled glass slide and immediately fix it in 95% ethanol, or place the sampling device in liquid-based cytology medium.
7. Send the specimen with relevant clinical details.

Cytological reporting: Bethesda system

A. Negative for intraepithelial lesion or malignancy

• Normal cytology
• Inflammation or reactive cellular changes
• Atrophy
• Organisms such as Candida, Trichomonas, bacterial vaginosis, or herpes-related changes may be reported.

B. Squamous-cell abnormalities

• ASC-US: Atypical squamous cells of undetermined significance
• ASC-H: Atypical squamous cells, cannot exclude high-grade lesion
• LSIL: Low-grade squamous intraepithelial lesion, usually corresponding to CIN 1
• HSIL: High-grade squamous intraepithelial lesion, corresponding to CIN 2 or CIN 3
• Squamous-cell carcinoma

C. Glandular-cell abnormalities

• Atypical glandular cells
• Adenocarcinoma in situ
• Adenocarcinoma

Management of abnormal cytology

• ASC-US: Reflex high-risk HPV testing, repeat cytology, or colposcopy according to age and local guideline.
• HPV-positive ASC-US, LSIL, ASC-H, HSIL, or glandular abnormality: Colposcopic evaluation is generally indicated.
• HSIL: Requires urgent colposcopy with directed biopsy. Excisional treatment may be required after appropriate assessment.
• Cytology is a screening test. Definitive diagnosis of CIN requires colposcopy-directed biopsy.

Advantages

• Simple, inexpensive, outpatient procedure.
• Acceptable and relatively noninvasive.
• Detects preinvasive lesions with a long latent period.
• Has substantially reduced incidence and mortality of cervical cancer where organized screening is implemented.

Limitations

• Sampling error and interpretative error can produce false-negative results.
• It does not diagnose invasive cancer with certainty.
• A visible suspicious cervical lesion requires colposcopy and biopsy even if the Pap smear is negative.
• Screening intervals and test choice increasingly depend on HPV-based screening policies.

Conclusion

2. Outlet Forceps Delivery

Definition

Classification

• The fetal head is on the pelvic floor.
• The scalp is visible at the introitus without separating the labia.
• The sagittal suture lies in the anteroposterior diameter or in right/left occipitoanterior or occipitoposterior position, with rotation not exceeding 45 degrees.
• The fetal head is at or below the pelvic floor.

Indications

Maternal indications

• Prolonged second stage of labour due to inadequate expulsive efforts.
• Maternal exhaustion.
• Conditions where bearing down should be shortened or avoided:
  • Severe cardiac disease
  • Severe hypertension or eclampsia
  • Certain neurological disorders
  • Severe respiratory disease
• Need to shorten the second stage due to maternal distress.

Fetal indications

• Non-reassuring fetal heart rate in the second stage, when immediate vaginal delivery is feasible.
• Fetal distress with head low in the pelvis.
• After-coming head of breech, using suitable forceps in selected cases.

Prerequisites

1. Cervix fully dilated.
2. Membranes ruptured.
3. Vertex presentation.
4. Exact fetal head position known.
5. Head engaged and at outlet or low station.
6. No cephalopelvic disproportion.
7. Adequate pelvis clinically assessed.
8. Bladder emptied by catheterization.
9. Adequate analgesia or anaesthesia.
10. Informed consent from the woman.
11. Trained operator, assistant, neonatal resuscitation facility, and readiness to abandon the procedure if it fails.
12. Facilities for immediate caesarean delivery should be available if necessary.

Contraindications

• Cervix not fully dilated.
• Membranes intact.
• Unengaged head or high head.
• Unknown fetal position.
• Suspected cephalopelvic disproportion.
• Brow presentation or transverse lie.
• Inadequate pelvis.
• Fetal bleeding disorder or severe thrombocytopenia, if known.
• Inexperienced operator.

Instruments

• Outlet forceps, usually Wrigley's forceps or Simpson's forceps depending on local practice.
• Bladder catheter.
• Episiotomy and repair set.
• Neonatal resuscitation equipment.

Procedure

1. Explain the procedure, obtain consent, and ensure aseptic precautions.
2. Position the woman in lithotomy position.
3. Confirm full dilatation, rupture of membranes, station, position, and absence of disproportion by vaginal examination.
4. Empty the bladder.
5. Give appropriate analgesia or pudendal block. Perform episiotomy only if indicated.
6. Identify the left and right blades. Each blade should lie over the corresponding side of the fetal head, with the pelvic curve following the curve of the maternal pelvis.
7. Introduce the left blade first, guided by the operator's hand, followed by the right blade.
8. Lock the blades gently. Easy locking confirms appropriate application. If locking is difficult, remove and reassess position.
9. Check:
   • No maternal tissue is caught between blade and fetal head.
   • Sutures and fontanelles are consistent with the diagnosed position.
   • Blades are symmetrically applied.
10. Apply traction only during uterine contractions and maternal expulsive effort:

• Initially downward and backward to follow the pelvic axis.
• Then horizontally.
• Finally upward and forward as the head crowns.

1. Remove forceps when the head is crowning or after delivery of the head, according to operator preference and clinical circumstances.
2. Deliver shoulders and body in the usual manner.
3. Inspect cervix, vagina, and perineum carefully. Repair episiotomy or tears and assess for postpartum haemorrhage.

Rules of safe traction

• Traction must be intermittent and synchronized with contractions.
• Traction should follow the pelvic axis.
• Never use excessive force.
• Do not rotate the forceps in a simple outlet forceps delivery.
• If there is no descent with properly applied traction, abandon the procedure and reassess. Do not persist with repeated attempts.

Complications

Maternal

• Cervical, vaginal, and perineal tears.
• Extension of episiotomy.
• Third- or fourth-degree perineal tear.
• Postpartum haemorrhage.
• Bladder or urethral trauma.
• Pelvic floor injury and, rarely, later urinary or anal incontinence.

Fetal

• Facial marks or bruising.
• Facial nerve palsy.
• Scalp injury or laceration.
• Cephalhaematoma.
• Skull fracture or intracranial haemorrhage, rarely.
• Eye trauma, rarely.

Conclusion

3. Deep Transverse Arrest

Definition

Mechanism

Etiology

1. Inefficient uterine action.
2. Deflexion of the head, causing poor adaptation to the pelvis.
3. Android pelvis or contracted mid-pelvis, especially prominent ischial spines.
4. Persistent occipitotransverse position.
5. Relative cephalopelvic disproportion.
6. Large fetus.
7. Epidural analgesia may be associated with prolonged second stage, though it is not an independent diagnosis.
8. Pelvic floor factors preventing normal rotation.

Clinical features

• Prolonged second stage of labour.
• Maternal exhaustion and ineffective bearing-down efforts.
• Slow or absent descent of the head despite good uterine contractions.
• Increasing caput succedaneum and moulding.
• Fetal distress may occur if obstruction is prolonged.

Diagnosis

Abdominal examination

• Head is deeply engaged and may not be palpable abdominally.
• Anterior shoulder may be prominent above the symphysis.
• Fetal back may be felt laterally.

Vaginal examination

• Cervix fully dilated.
• Membranes ruptured.
• Head engaged, usually at +1 or +2 station.
• Sagittal suture lies transversely.
• Posterior fontanelle lies toward one lateral pelvic wall and anterior fontanelle toward the opposite side.
• Caput and moulding may make diagnosis difficult.
• Clinical assessment must exclude cephalopelvic disproportion.

Differential diagnosis

• Persistent occipitoposterior position.
• Brow presentation.
• Deflexed occipitotransverse head without arrest.
• Obstructed labour due to cephalopelvic disproportion.
• Malposition mistaken because of severe caput or moulding.

Management

Initial measures

• Confirm diagnosis and assess fetal well-being with continuous fetal heart monitoring.
• Ensure full dilatation and rupture of membranes.
• Catheterize the bladder.
• Give adequate analgesia or regional anaesthesia.
• Correct dehydration and maternal exhaustion.
• Assess pelvic capacity and exclude disproportion.
• Call an experienced obstetrician and ensure neonatal resuscitation readiness.

A. Expectant management

• Maternal and fetal condition are reassuring.
• Contractions are adequate.
• Head is low and there is ongoing descent.
• No significant caput, moulding, or disproportion is present.

B. Manual rotation followed by forceps or vacuum

• Head is engaged and low.
• Pelvis is adequate.
• Exact position is known.
• There is no disproportion.
• The operator is experienced.

• Under adequate anaesthesia, the hand is introduced vaginally.
• The occiput is rotated anteriorly toward the symphysis during a contraction.
• Once rotation is maintained, delivery may be completed by forceps or vacuum, depending on clinical circumstances and operator competence.

C. Rotational forceps delivery

• Full dilatation.
• Ruptured membranes.
• Engaged head.
• Exact position known.
• Adequate pelvis.
• No cephalopelvic disproportion.
• Skilled operator and immediate availability of caesarean delivery.

D. Caesarean delivery

• There is suspected cephalopelvic disproportion.
• The head is high or not safely accessible for vaginal operative delivery.
• Severe caput and moulding make position uncertain.
• Fetal distress is present and safe instrumental delivery is not immediately feasible.
• Manual rotation or instrumental delivery fails.
• Skilled rotational-forceps delivery is unavailable.

Complications

Maternal

• Exhaustion, dehydration, ketosis.
• Obstructed labour.
• Chorioamnionitis.
• Postpartum haemorrhage.
• Cervical, vaginal, or perineal tears.
• Uterine rupture in neglected obstruction.
• Bladder injury or fistula in prolonged obstructed labour.

Fetal

• Fetal hypoxia and acidosis.
• Birth asphyxia.
• Scalp oedema, cephalhaematoma.
• Intracranial haemorrhage or trauma after difficult instrumental delivery.
• Stillbirth in neglected cases.

Prevention

• Proper assessment of pelvic capacity and fetal size.
• Accurate diagnosis of fetal position during labour.
• Judicious use of oxytocin.
• Timely identification of poor progress in the second stage.
• Early referral to a suitably equipped centre when operative vaginal delivery may be required.

Conclusion

4. Episiotomy

Definition

Types

1. Midline or median episiotomy

• Incision starts at the posterior fourchette and extends directly towards the anus.
• Common in some countries.

• Less blood loss.
• Easier to repair.
• Less pain.
• Better healing.

• Higher risk of extension into the anal sphincter and rectum, causing third- or fourth-degree perineal tear.

2. Mediolateral episiotomy

• Incision begins at the posterior fourchette and extends laterally, usually at an angle of about 45-60 degrees from the midline.
• In India, right mediolateral episiotomy is commonly performed.

• Lower risk of extension into the anal sphincter and rectum.

• More blood loss.
• More painful.
• More difficult to repair.
• Delayed healing and dyspareunia may be more common.

3. Lateral episiotomy

• Incision is made laterally from the vaginal introitus.
• Rarely used because of risk of injury to Bartholin gland, vessels, and pudendal nerve branches.

4. J-shaped episiotomy

• Begins in the midline and curves laterally.
• Rarely used.

Indications

Maternal indications

• Rigid or scarred perineum likely to impede delivery.
• Instrumental vaginal delivery, especially forceps delivery, when additional space is necessary.
• Need to shorten the second stage of labour in a woman with serious cardiac, neurological, or respiratory disease.
• Imminent severe irregular perineal tear in selected situations.

Fetal indications

• Fetal distress requiring rapid delivery, when vaginal delivery is imminent.
• Breech delivery, especially for delivery of the after-coming head.
• Shoulder dystocia, to facilitate manoeuvres. Episiotomy itself does not relieve bony impaction.
• Certain operative vaginal deliveries.
• Prematurity, only in selected circumstances, not routinely.

Timing

• The perineum is thinned out and bulging.
• The fetal head is crowning, usually visible about 3-4 cm at the introitus.
• It should not be done too early because it increases blood loss and pain.

Procedure: mediolateral episiotomy

1. Explain the need and obtain consent whenever possible.
2. Ensure aseptic precautions and adequate analgesia, commonly local infiltration with lignocaine if no effective regional anaesthesia is present.
3. Support the perineum.
4. Introduce two fingers between the fetal head and perineum to protect the head.
5. During a contraction, make an incision from the posterior fourchette laterally at about 45-60 degrees to the midline.
6. The incision is generally about 3-5 cm long initially and may be extended if necessary.
7. After delivery of placenta, inspect the vagina, cervix, and perineum for extensions or associated tears.

Repair

Steps

1. Identify apex of the vaginal incision and secure haemostasis.
2. Repair vaginal mucosa with continuous absorbable suture.
3. Approximate perineal muscles, especially bulbocavernosus and transverse perineal muscles, with interrupted or continuous absorbable sutures.
4. Repair skin using subcuticular or interrupted absorbable sutures.
5. Perform rectal examination after repair to exclude rectal injury or a transfixing suture.

Postoperative care

• Inspect for bleeding, haematoma, infection, and wound gaping.
• Maintain local hygiene and keep the area clean and dry.
• Give analgesics and ice packs during the initial period if required.
• Stool softener and adequate fluids may be given to prevent painful constipation.
• Encourage early ambulation and pelvic floor exercises after recovery.
• Advise return if there is fever, increasing pain, foul discharge, urinary difficulty, wound separation, or faecal incontinence.

Complications

• Pain and oedema.
• Excessive bleeding and perineal haematoma.
• Extension into third- or fourth-degree perineal tear.
• Wound infection.
• Wound dehiscence.
• Delayed healing.
• Dyspareunia.
• Scar tenderness.
• Rarely rectovaginal fistula or anal sphincter dysfunction following severe extension.

Evidence and present recommendation

Conclusion

5. Medical Termination of Pregnancy (MTP)

Definition

Objectives

• Prevent maternal morbidity and mortality due to unsafe abortion.
• Provide safe, legal termination of unwanted pregnancy.
• Terminate pregnancy when continuation poses a threat to the woman's physical or mental health.
• Provide post-abortion contraception and counselling.

Legal grounds for MTP in India

1. Therapeutic ground
   Risk to the life of the pregnant woman or grave injury to her physical or mental health.
2. Eugenic ground
   Substantial risk that, if the child were born, it would suffer from serious physical or mental abnormality.
3. Humanitarian ground
   Pregnancy alleged to have resulted from rape. The anguish of pregnancy resulting from rape is presumed to cause grave injury to mental health.
4. Contraceptive failure
   Failure of any contraceptive method or device used by a woman or her partner for limiting children or preventing pregnancy. The resulting anguish is presumed to constitute grave injury to mental health.
5. Socioeconomic circumstances
   The actual or reasonably foreseeable social or economic environment may be considered while assessing risk to mental health.

Gestational limits and medical opinion

Consent

• Consent of the pregnant adult woman is essential.
• Husband's consent is not required.
• For a woman below 18 years of age or a mentally ill woman, written consent of the guardian is required.
• Confidentiality of the woman's identity must be maintained, except where disclosure is legally authorized.

Who can perform MTP?

Place where MTP can be performed

• A government hospital, or
• A place approved by the government or district-level authority for MTP services.

Pre-abortion assessment

1. Confirm pregnancy.
2. Determine gestational age:
   • Menstrual history
   • Clinical examination
   • Ultrasonography when indicated
3. Exclude ectopic pregnancy.
4. Assess medical disorders, anaemia, bleeding risk, and allergies.
5. Blood group and Rh status. Administer anti-D immunoglobulin to Rh-negative unsensitized women as indicated.
6. Screen and treat infection where required.
7. Explain available methods, expected bleeding, pain, possible complications, follow-up, and contraceptive options.
8. Obtain informed written consent.

Methods of MTP

A. First trimester

1. Medical method

• Mifepristone blocks progesterone receptors, causing decidual breakdown and cervical softening.
• Misoprostol is a prostaglandin E1 analogue that produces cervical ripening and uterine contractions.

2. Vacuum aspiration

• Manual vacuum aspiration or electric vacuum aspiration.
• Usually preferred for surgical evacuation in early pregnancy.
• Suction evacuation is safer than dilatation and curettage.

B. Second trimester

• Medical induction using mifepristone and misoprostol according to approved protocol.
• Dilatation and evacuation is an option in an appropriate setting with an experienced provider.
• In later gestation, induction methods are commonly used and the woman requires close observation.

Complications

Immediate complications

• Incomplete abortion.
• Excessive haemorrhage.
• Failed abortion or continuing pregnancy.
• Uterine cramps and pain.
• Nausea, vomiting, diarrhoea, fever, or chills with prostaglandins.
• Cervical injury.
• Uterine perforation, especially with surgical methods.
• Anaesthetic complications.
• Infection or sepsis.

Late complications

• Menstrual disturbance.
• Intrauterine adhesions, uncommon with modern vacuum aspiration.
• Subfertility is uncommon after an uncomplicated safe abortion.
• Psychological distress in some women, particularly where there is coercion, stigma, violence, or inadequate support.

Management of complications

• Incomplete abortion: Vacuum aspiration or medical completion as appropriate.
• Haemorrhage: Assess for retained products, genital tract injury, atony, or coagulopathy; resuscitate and treat the cause.
• Sepsis: Broad-spectrum antibiotics, evacuation when indicated, and intensive supportive care.
• Uterine perforation: Observation or surgical exploration depending on instrument, clinical condition, and suspected visceral injury.
• Continuing pregnancy after medical abortion: Reassess and offer appropriate termination; counsel about potential fetal risks from drug exposure.

Post-abortion care

• Confirm completion of abortion clinically, by pregnancy test, ultrasonography, or other appropriate follow-up method.
• Explain warning signs:
  • Heavy bleeding
  • Persistent severe abdominal pain
  • Fever
  • Foul-smelling discharge
  • Continuing pregnancy symptoms
• Provide counselling and contraception. Most contraceptive methods can be started immediately after abortion.
• Offer emotional support and screen for coercion or violence where appropriate.

Conclusion