OBGYN: Cardiotocograph

CTG (Cardiotocograph)

- Graphical record of fetal heart sounds, uterine contractions and fetal movements.

The CTG Machine:

- Has 1 screen and 3 probes

1. Cardio probe: to detect fetal heart sounds.
2. Toco Probe: detects strength and frequency of uterine contractions
3. Fetal movement probe: The mother is asked to press a button each time she feels her baby move.

Fetal heart rate (FHR):

- Normal: 120-160 beats/min (Range of the baseline fetal heart rate)

- FHR < style="">Bradycardia

- FHR > 160 beats/min is Fetal Tachycardia

Acceleration: An increase in FHR of at least 15 beats/min lasting for at least 15 seconds

Deceleration: A decreased in FHR of at least 15 beats/min lasting for at least 15 seconds. There are three types of deceleration, Types I, II and III.

Toco: Uterine Contractions:

- Range: 0 to 100 mm H₂O

- 20 to 40 mm H2O- Mild contractions

- 40 to 60 mm H2O- Moderate contractions

- 60-100 mm H2N- Severe contractions

Note: Uterine contractions are recorded at # of contractions/10 minutes.

The time between two dark red lines on the CTG paper is taken as 10 minutes.

Indications for CTG:

1. Done at the time of admission
2. Done again at the time of induction of labor

OBGYN: Postpartum Hemorrhage

PPH (Postpartum Hemorrhage)

- Excessive blood loss from the female genital tract starting at the time of the 3^rd stage of labor until 42 days after the delivery of the baby.

Note: Normal blood loss after NVD: upto 500 ml

Normal blood loss after a C-Section: upto 1000 ml

Primary PPH: Blood loss within 24 hours of the 3^rd stage of labor.

Secondary PPH: Blood loss starting after 24 hours of the delivery of the baby until 42 days post-partum.

Causes of Primary PPH:

I. Uterine atony (accounts for 90% of the cases of Primary PPH)

- Myometrial and Placental causes of Uterine atony.

II. Genital tract trauma (7%)

III. Coagulopathies (3%)

I. Uterine Atony: The uterus is unable to contract.

Myometrial causes of Uterine atony:

1. In multipara females, the uterus is over-distended as a result of multiple pregnancies.
2. The uterine muscle is replaced by fibrous tissue in some areas.
3. Prolonged 1^st and 2^nd stage of labor
4. Fibroid uterus

Placental causes of uterine atony:

1. Placental retention
2. Placenta Accreta
3. Placenta Previa
4. Placenta Abruptio

II.Genital tract trauma (Accounts for 7% PPH cases)

1. Deep episiotomy
2. Perineal tears
3. Cervical tears
4. Uterine tears
5. Wound dehiscence

III.Coagulopathies (Account for 3% PPH cases)

1. Thrombocytopenic purpura
2. DIC
3. Pre-eclampsia
4. HTN

OBGYN: Mechanism of Labor

Mechanism of Labor

- Series of changes in the attitude and position of the presenting part of the baby during its passage through the birth canal.

Attitude: relationship of parts of the baby to one another.

Position: Relationship between the fixed part of the maternal pelvis and the fixed part of the baby.

Denominator: Baby’s fixed part (varies with presentation).

Example: the chin is the denominator when the presentation is the face, sacrum is the denominator when the presentation is breech and occiput is the denominator when there is vertex presentation.

Note: Iliopectineal line is taken as an ANTERIOR point.

Sacroiliac joint is taken as a POSTERIOR point.

Pelvic Inlet:

- AP diameter = 11.5cm

- Transverse diameter = 13.5cm

- Therefore, Trasverse diameter > AP diameter (at the pelvic inlet)

- And so the baby enters the pelvis in the trasverse position

Pelvic Outlet:

- AP diameter = 13.5cm

- Transverse diameter = 11.5 cm

- AP diameter > Transverse diameter (at the pelvic outlet)

- The baby is delivered in the AP position

Steps of the Mechanism of Labor:

1. Descent and engagement
2. Flexion
3. Internal Rotation
4. Extension
5. Restitution
6. External Rotation

= Delivery of the baby!!!

OBGYN: Patient with c/o Menorrhagia

Questions to ask from a patient who presents to the clinic with complains of Menorrhagia:

- Since when? (onset)

- How many pads does she use each day? (Assess flow)

- How soaked are they?

- Is there any soaking of clothes?

- Does she see any clots?

- How many days does she bleed?

- Is there any dysmenorrhea?

- Does she get weak? Feel dizzy?

- How do her heavy periods affect her daily life: Is she still able to continue with her house chores? Does she miss school or work because of her periods?

D/Ds of Menorrhagia:

1. Uterine fibroids (doctor might feel a mass in the abdomen on examination)
2. Endometriosis
3. Endometrial hyperplasia/ cancer
4. IUD contraceptive use
5. Hormone producing tumor of the ovary
6. PID (pelvic inflammatory disease)
7. Anticoagulant therapy (Ask about easy bruisiblity)
8. Vitamin K deficiency
9. Von Willebrand factor deficiency
10. Hormonal imbalance such as Cushing’s or Thyroid abnormalities (Ask the patient about recent weight gain? Weight loss? Heat and cold intolerance?)
11. Stress

GYN: History Taking

GYN: History taking

Name:

Husband’s name:

Age:

Time since marriage:

Address:

LMP:

Parity:

Presenting Complaint:

Examples

- Amenorrhea: secondary amenorrhea is when the patient hasn’t had her periods for more than 6 months.

- Menorrhagia: Heavy menstrual flow but normal duration.

- Dysmenorrhea: painful periods.

- Oligomenorrhea: cycle is prolonged (more than 35 days)

- Polymenorrhea: the cycle is less than 21 days and so the patient has periods more than once in one month.

Normal Menstrual Cycle is approx: 21-35 days long

Normal amount of blood loss: 5-80 ml

Length of periods: 1-8 days

HOPC:

- onset

- duration

- associated symptoms

- aggravating and relieving factors

Menstrual History:

- Age at menarche

- Cycle

- Flow

- Dysmenorrheal?

- Intermenstrual bleeding?

- Post-coital bleeding?

- Contraceptive use?

- Has she ever had a PAP Smear taken?

- LMP

Obstetrics History:

- Ask about each pregnany: Duration of pregnancy? Complications? Outcome?

- Ask about each delivery: Mode of delivery? Place of delivery? Complications at the time of delivery?

- Ask about each baby: Birth weight of baby? Was the baby breast fed?

Past History:

- Past medical: HTN, Diabetes, TB, Seizures, Asthma etc..

- Past Surgical

- Blood Transfusions

- Is her vaccination up-to-date?

Personal History:

- Appetite

- Sleep

- Bowel

- Micturition

- Recent weight gain/weight loss

- History of any addictions (such as smoking, naswaar, hooka etc..)

- History of any allergies to foods or medicines?

Family History:

- Is the marriage consanguineous?

- History of breast cancer, ovarion cancer, uterine cancer etc..

- History of HTN, Diabetes etc..

Social History:

- # of family members

- # of earning members

- Approximate income?

- Use of boiled water at home?

Obstetrics: History taking

Obstetrics: Science and art of dealing with a pregnant female.

Obstetrics: History Taking

Name:

Husband’s Name:

Time since marriage:

Gravida:

Parity:

LMP:

EDD:

Presenting Complaint:

- Gestational age in weeks

- Reason for coming today?

History of Presenting Complaint:

- Was the pregnancy planned and spontaneous?

- How did she know she was pregnant?

- How did she confirm the pregnancy?

1^st Trimester

- Ask about nausea? vomiting?

- Other associated symptoms such as fever? Abdominal/pelvic/back pain? Burning micturition?

- Vaginal discharge?

- Bleeding per vaginum?

- Use of folic acid tablets? (small yellow colored pills)

- Was an ultrasound done at 6 or 7wks (Dating scan)

2^nd Trimester

- Ask about regular use of folic acid, iron and calcium supplements?

- Ultrasound at 18-22wks (Anomaly scan)?

- Quickening: fetal movements? (normally felt around 20 weeks gestation)

- Fever? Rash? Abdominal pain?

3^rd Trimester

- Tetanus toxoid vaccine at 28 wks and 32 wks?

- Regular doctor checkups?

- Ultrasound?

- Booked case?

Post-natal History:

- Are you breast feeding the baby?

- Have you passed feces and urine?

- Ask about lotia/bleeding?

- How is the baby doing?

- How is the mother doing?

Past Obstetrics History

1. Pregnancy:

- Gestational age at time of delivery?

- Outcome of preganancy?

2. Labour/delivery:

- Normal vaginal delivery? C-section?

- Labor- Normal? Prolonged?

- Length of labor?

- D&E?

- D&C:

- Place of delivery? (at home or at the hospital?)

- Any other complications?

3. Perperium:

- Any complications?

4. Baby:

- Gender of baby?

- Age of baby?

- Breast fed? Length of breast feeding?

- Birth weight?

Menstrual History:

- Age at menarche

- Cycle

- Flow

- Dysmenorrheal?

- Intermenstrual bleeding?

- Post-coital bleeding?

- Contraceptive use?

- Has she ever had a PAP Smear taken?

- LMP

Past History:

- Past medical: HTN, Diabetes, TB, Seizures, Asthma etc..

- Past Surgical

- Blood Transfusions

- Is her vaccination up-to-date?

Personal History:

- Appetite

- Sleep

- Bowel

- Micturition

- Recent weight gain/weight loss

- History of any addictions (such as smoking, naswaar, hooka etc..)

- History of any allergies to foods or medicines?

Family History:

- Is the marriage consanguineous?

- History of breast cancer, ovarion cancer, uterine cancer etc..

- History of HTN, Diabetes etc..

Social History:

- # of family members

- # of earning members

- Approximate income?

- Use of boiled water at home?

Stages and Management of Labor

Stages of Labor

Labor: [After 37 weeks of gestation] Progressively increasing uterine contractions (in intensity and duration), leading to cervical dilatation and effacement, resulting in the delivery of the fetus and the placenta.

Signs and Symptoms of Labor:

- Severe intermittent pain starts from the back and radiates to the lower abdomen.

- Show (Mucus plug of cervix).

- Rupture of amniotic fluid

I. First Stage of Labor

- Lasts for approximately 8-12 hours

- Primigravida < 12 hours

- Multigravida < 8 hours

The first stage of labor is further divided into two phases:

1. Latent Phase: From the time of the start of uterine contractions until the cervix if 3cm dilated.
2. Active Phase: Lasts until the cervix is 10cm dilated.

II. Second Stage of Labor

- From the full dilatation of the cervix until the delivery of the baby.

- Primigravida < 2 hours

- Multigravida < 1 hour

The second stage of labor is further divided into: Passive and Expulsive phases

1. Passive Phase: When the patient’s cervix is fully dilated but she does not have the urge to push.
2. Expulsive Phase: The patient’s cervix is fully dilated and she has the urge to push.

1. Make sure the patient is comfortable lying in bed in the Lithotomy position
2. Monitor fetal heart sounds with each uterine contractions to make sure that the baby does not go into fetal distress (Fetal distress: FHR< 120 beats per minute).
3. Use an “in and out catheter” to empty the patient’s bladder.
4. Empty the patient’s rectum if needed.

III. Third Stage of Labor

- From the time of the delivery of the baby until the delivery of the placenta.

- Normal length < 30 minutes

- Uterine contractions originating in the fundus will result in the delivery of the placenta.

Three Signs of the 3^rd Stage of Labor:

1. Gush of blood.
2. Lengthening of cord
3. Fundus becomes globular

Active Management of the 3^rd stage of Labor:

- Give the patient oxytocin (parenterally) to prevent PPH (post-partum hemorrhage). Ocytocin will act to increase the contractions and prevent blood loss.

Complications of 3^rd Stage of Labor:

- Primary PPH

- Shock

- Severe trauma

- Pulmonary embolism

- Amniotic embolism

7 Things to do when a patient is in Labor:

1. History
2. Examination incl. Vitals, General physical, Abdomen examination
3. Per vaginal Exam:

- Use sterile gloves and lubricant

- Assess cervical effacement and dilatation. (Note: Normal length of a cervix is 10cm).

- Check to see if the membranes are intact (If the membranes are ruptured, then labor should start within 12 hours).

- Check the color of the amniotic fluid

- Assess Station: Presenting part of the baby in relationship with the ischial spine. If the presenting part is at the level of the ischial spine, the Station = 0. If the presenting part is 1cm above the ischial spine, the Station = -1. If the head of the baby is seen, Station = +2

4. Enema
5. Order new labs
6. CTG to assess fetal heart sounds
7. Counsel the patient and provide tender loving care

Things to do when a patient is in ACTIVE LABOR:

1. Maintain an IV line
2. Ask the patient to only eat light foods.
3. Take the vitals of the patient (BP, Temp, Pulse, R/R)
4. Abdominal examination
5. Augmentation: to increase frequency of contractions and to decrease the duration of labor (Pharmacological and Mechanical).

Pharmacological Augmentation: give the patient Oxytocin (Syntocinol).

- Note: 1 Ampule= 1ml = 5 units

- In a primigravida patient: Give 10 units of oxytocin in 1000ml of Ringer’s solution at 10 drops/minute.

Mechanical Augmentation:

- Artificial rupture of membranes using a Koker’s forcep.

History taking of vaginal discharge

Vaginal Discharge

Causes of vaginal discharge:

1. Candida infection (Yeast infection): White, curd like discharge associated with intense itching. More common in immunosupressed states such as diabetes mellitus or patients using antibiotics.

2. Cervical cancer

3. Trichomoniasis: Green colored frothy discharge associated with intense itching.
4. Leukorrhea: Colorless discharge. Dries up to leave a yellowish-brown stain. Usually pre-menstrual.

5. PID (Pelvic Inflammatory Disease): Pussy mucopurulent discharge.

Possible causes: Chlamydia, Gonorrhea, Superimposed saprophytic infections, Infection because of an IUD.

6. Bacterial Vaginosis: Homogenous, fishy smelling discharge. A lot in amount.

Questions to ask when taking a history from a patient with complaints of VAGINAL DISCHARGE:

1. Duration
2. Color
3. Smell
4. Consistency/frequency
5. Quantity
6. Relationship with menstrual cycle
7. Associated symptoms: fever, itching, menorragia etc..
8. Contraceptive use
9. Antibiotic use

D/Ds of Something Coming out of the Vagina:

1. Uterine prolapse
2. Tumor
3. Chronic uterine inversion: A result of trauma due to the pull of the placents (mismanagement in the 3^rd stage of labor).
4. Fibrinoid polyp

Questions to ask when taking a history from a patient with complaints of SOMETHING COMING OUT OF THE VAGINA:

1. Does the mass go back in spontaneously?
2. Does it go back in with pressure?
3. Does an increase in intra-abdominal pressure (coughing, defecationg) worsen the prolapse?
4. Does this problem interfere with sexual activity?
5. Ask about backache? Is the backache relieved on lying down?
6. Ask about urination: burning micturition? Incontinence? Increased frequency?
7. Intermenstral bleeding? Post-coital bleeding? (Esp. important to ask when the patient has cervical polyps)

Antenatal Examination

Antenatal Examination

General Physical

1. BP: usually falls during the first 2 trimesters. The decrease in diastolic blood pressure is greater than the decrease in systolic BP. Pregnancy related hypertension is after 20 weeks of gestation.
2. Temperature: Fever may indicate infection.
3. Pulse: Possible causes of tachycardia in a pregnant patient maybe due to anxiety, fever (due to a TORCH infection) or anemia.
4. Respiratory Rate: Increases in pregnancy because of metabolic acidosis. And in late pregnancy the increase is due to the compression of the diaphragm by the enlarged uterus.
5. Jaundice
6. Anemia
7. Cyanosis
8. Edema: Pedal edema is normal in late pregnancy.
9. Lymph nodes

Breast Examination

1. Check for breast tenderness.
2. Check for the presence of lumps.
3. Identify any nipple deformities/problems that may interfere with breast feeding.

Abdominal Examination

Exposure: Must be up to pubic symphysis so that the Pfenenstiel’s scar (if present) is clearly visible.

Inspection:

1. Make sure that abdominal distention is consistent with the period of gestation.
2. Check for the presence of any scars, pigmentation, or visible pulsations.
3. Can fetal movements be seen?

Palpation:

1. Guarding
2. Rigidity
3. Tenderness
4. Palpate the liver, spleen and kidneys.

Percussion:

1. Liver span
2. Fluid thrill
3. Shifting dullness

Antenatal Obstetric Examintation:

1. Measure the symphysio-fundal height: Move your hand down from the xiphoid process to the first area of resistance. Measure this in Inches and then convert it into centimeters.

Note: After 14 weeks gestation the symphysio-fundal height in centimeters = Number of weeks of gestation + 3 cm.

2. Check the lie of the baby: Relationship between the long axis of the maternal and fetal spine.
3. Presentation (Breech, Cephalic, Shoulder)
4. Engagement of the fetal head: When the widest part of the fetal head has crossed the pelvic brim, the head is said to be engaged.
5. Listen to fetal heart sounds
6. Leopole’s Maneuver: Fundal grip, Lateral grip, Pelvic grip, Pawlik’s grip.

Puddle sign

Puddle sign procedure and its interpretation:

Ask the patient to lie prone for 5 minutes and then, to rise upon elbows and knees as shown in the figure below.

The middle portion of the abdomen will become dependent and pendulous. Apply stethoscope to this dependent portion of the abdomen and flick the near flank region with finger.

Move stethoscope away from yourself (the examiner). Sound loudness increases at the farther edge of puddle. This augmentation of sound intensity is indicative of Ascites.

This test is able to detect as little as 140 mL of fluid. Clinical manifestations of Ascites usually become evident after 500 mL of fluid accumulation.

Puddle sign has a sensitivity of 50 % and specificity of 70%.
On the other hand, shifting dullness has a sensitivity of 90% and specificity of 60%.