Cervical Polyp?

→ Remove it

IUFD? → Break BAd News (advanced preparations)

↑NT? → Chromosomal Anomaly > Cardiac

A1C vs. NT → A1C (→Congenital anomaly) NT (→Chromosomal anomaly)

OCP OR Pregnancy → brown face mask = Melasma/Chloasma

Vaginal bleeding+loss of pregnancy symptoms+falling hCG and denies passage of fetus tissue w/ no fetus on U/S
= Anembryonic Pregnancy → follow up

1st ANC visit? → Identify Risk Factors

Bacterial Vaginosis? → no recommended screening

HBV concer? → wear condom

Endometrioma (ground-glass)? → caused by infertility

Organ Not Affected by blocking Pudendal N.? → Rectum

Pregnancy? → ↑ Estriol (Estrogen)

RF → severe MR → forceps

Sexual Abuse? → 6” Hymen Penetration

>20wkGA + tachycardia + dizzy + nausea = Supine Hypotension Syndrome → Tx by Maternal Positioning

Preconception

Birth Defect Prevention

- 1ry → PREconception
- 2ry → POSTconception
- 3ry → Intervention

Supplementation
- Folic Acid
- ↓ risk? → 0.4mg
- m risk? → 1 mg
- ↑ risk? → 4mg (Hx of NTD)

Drugs
- A+B → Safe
- C → Benefit > Risk ? → Give it
- D+X → Unsafe

Teratogenic Viruses
→ GIVE MMR PRECONCEPTION PREVENT SAB
→ Rubella Exposure During Pregnancy?
→ Reassurance

Vaccines (for childbearing potential)

- Routine → Tdap, Influenza
- Circumstantial
- HAV
- HBV
- HiB (if asplenic)
- Pneumococcal (T2/3)
- Unrecommended
- HPV
- MMR (avoid conception for 4wks)
- Varicella (avoid conception for 4wks)
- Live Attenuated Intranasal Influenza (avoid conception for 4wks)
- Smallpox
- Meningococcal (9-21yo)

ANC
1. First Visit? → most important in 1st visit
2. Dating
- Hx? LMP (1. Regular Cycle. 2. No Contraceptive 3. No Lactation)
EDD = Mo (Subtract 3 mo) + D (Add 7 ds)
- Ex? Symphysis → Fundus
- U/S? T1 → CRL
T2 → FL, BPD
3. T
- <20wk → Bleed? = Miscarriage
- >20wk → Bleed? = APH
- <37wk → PTL, PPROM
- >37wk → Term
4. Prenatal Diagnosis
→ Screen Tests?
- T1 → Combined Test = NT + hCG + PAPP-A
- T2 → Quadruple Test= hCG+Inhibin + Estriol+AFP
→ Positive?
→ Diagnostic Tests?
- T1 → CVS (11-14wk)
- T2 → AC (15-16wk)

Screening (Fetal Well Being)

→ non stress test
→ BPP (non stress PLUS U/S → breathing, movement, tone, HR, amniotic fluid)
→ Contractions Test (by giving Oxytocin)
→ late deceleration?
→ C/S

Drugs
- Contraindications
- ACEi (Renal Agenesis, Oligo), Alcohol (Cardiac defect, Microcephaly, retardation)
- Blood thinner (Warfarin → nasal hypoplasia, stippled epiphyses) ABx (Tetracycline →
Dental Enamel Hypoplasia)
 - Chloroquine (Choeioretinitis, Deafness)
- DES (vaginal adenoCa, Uterine Malformations), Deafness (Retinoids → give OCP if she takes it)
- Epilepsy (V. Acid → normal tube, facial characters, Phenytoin → cardiac defect, cleft palate digital
hypoplasia)
- Fucked in the head (Li → cardiac ‘epstein')
- Ionizing Radiation esp 8-15th wk(3% retardation, microcephaly/ 15% SAB)
- Nitrofurantoin (Last Month)
- Indications
- Amoxicillin (Safest Abx)

Amniotic Embolism = Sudden SOB, FHR Brady, DIC after ROM (during labor) → emergency C/S

HG = severe, persistent N/V w/ >5% wt. loss of pre-pregnancy weight

- Dx → HypoK HypoCl Metabolic Alkalosis w/ ketonuria

HyperT (↑TSH)? → START PTU in all T’s (Methimazole only T2/3)

CVS (Like MS in RF) → most critical is immediate postpartum

→ Critical Stage in Heart Disease + 2nd Stage of labor?
→ Epidural (↓pain) + Operative Delivery (vacuum, forceps → speed up)

Down’s (↑↑ing risk w/ mother age)

→ Screen
- T1 → Combined Test (11-14wk) = +ve → ↑NT(>5mm) + ↑ hCG + ↓ PAPP-A
- T2 → Quadruple Test (15-18wk) = +ve → hCG+Inhibin are HIgh + Estriol+alpha fEtoprotein are
dFfieicnt
→ Positive?
→ Karyotyping (rule out tests)
- T1 → CVS
- T2 → Amniocentesis

VTE
- DVT Hx in pregnancy? → LMWH (Enoxaparin)
- sob, Hypoxia post c/s? → LMWH (Clexane)

Amnion Polyhydramnios vs. Oligohydramnios

- Oligo = <500mL OR AI <5 (renal Atresia)
- Poly = >2L OR AL >25 (GI Atresia)

<20wk bleed (T1 → mc is chromosomal mc is Trisomy, T2 → mc is cervical incompetence)

Molar Pregnancy (80% benign, 15% invasive, 5% mets ‘Lung’)

- PE (Clues) (is symptomatic it’s usually complete mole)
- Bunch of Grapes w/ Bleed in T1/2
- hCG very ↑, levels aren't 0 after abortion/miscarriage
- Dx U/S snowstorm
- PTE before T3
- Hyperthyroid Function
- HG
- Cx
Complete Partial
 Karyotype 46XX 69XXY

Fetal Tissue No Yes

hCG ↑↑↑ ↑

Neoplasia Risk 28% 4%

- Mx?
→ dilation & curettage
→ RhoGAM
→ serial hCG q1wk until 3 are -ve
→ Plateau OR not 0?
→ suspect invasive mole, choriocarcinoma
→ MTX OR Dactinomycin
- Mx of Met GTD?
→ Risk (Hx molar pregnancy, Hx abortion)?
→ Irregular Vaginal Bleed + Enlarged Uterus + Pelvic Pain 8wk postpartum?
→ quantitative hCG (confirmation)
→ malignant GTD
→ Cough, hemoptysis, Chest Pain? = Choriocarcinoma
→ CXR
→ lesion?
→ CT abdomen, pelvis + MRI brain
→ Locally Invasive = Invasive GTD

Ectopic = (Ampulla>Isthmus>Fimbriae>Ovary>Abdomen>Cervix)
- RF
- Hx PID mc (PID → damage cilia)
- Hx ectopic most important (recurrence? 15% if 1 Hx, 20% if 2 Hx) → Offer IVF if too many Hx
- Hx surgery tube/ovary
- Dx?
→ <20wk Pain, Amenorrhea, Bleed, +ve hCG + Palpable Adnexal Mass?
→ Stable?
→ No → Exploratory Laproscopy
→ Yes
→ TVUS
→ Adnexal Mass → Tx Ectopic
→ Intrauterine Pregnancy
→ Nondiagnostic
→ serum hCG
→ >1500 IU/L → repeat hCG + TVUS in 2ds
→ <1500 IU/L → repeat hCG in 2 ds
- Tx?
→ Stable?
→ hCG <5000, Size <3.5 cm, no fetal heart rate?
→ MTX (must be near hospital, Far? → admit)
→ hCG after 1 wk
→ Unstable, C/I MTX, Fail MTX (↑ or plateau hCG despite MTX) , hCG >5000, Size >3.5, renal?
→ Laparoscopy (Laparotomy if critically unstable)
→ Salpingectomy IF ruptured tube, >3cm
→ Salpingostomy IF unruptured, <3 cm
→ hCG weekly (follow up)
→ remain detectable after surgery?
→ MTX
SAB = Pregnancy Termination <20wkGA OR fetus weighs <500g
- ET
- T1 → chromosomal abnormalities (Trisomy 16)
- T2 → cervical incompetence
- Missed → fetal death w/o expulsion w/ closed cervix
→ RhoGAM
→ T1 → dilatation and curettage (Cx asherman ‘obliteration of cavity nxt
amenorrhea, infertility’, perforation, infection, bleed)
→ T2 → Misoprostol
- Threatened → Bleed w/ cervical closed w/o expulsion
→ RhoGAM
→ Reassurance
- Inevitable → Bleed w/ cervical open and pain w/o expulsion
→ RhoGAM
→ w/w or misoprostol
→ Heavy bleed?
→ D&C (Perforation>Bleeding, Infection, Asherman’s)
- Incomplete → Bleed w/ expulsion and open cervix
→ RhoGAM
→ w/w or misoprostol
→ Septic OR Heavy bleed?
→ D&C
- Complete → Bleed w/ expulsion and closed cervix
→ RhoGAM
→ serial hCG until it’s 0
- Missed → Incidental by USG no Heart Beat
→ w/w or misoprostol
→ Fail?
→ D&C
- Recurrent → >2 consecuitive abortions
- ET
- Fetal → Chromosomal Anomalies
- Maternal
- Uterus
- Cervical incompetence
- submuCosal fibroid
- Commonly uterine septum
- Cavity asherman’s
- Medical
- Thyroid
- DM
- PCOS
- SLE (APS)
- Thrombophilia
- Rh
- Infection → CMV, BActerial Vaginosis
- Septic → Infection Cause Misscrraige
→ IV broad Abx
→ D&C

PTL = 1. Labor (>3 contractions last >30 sec in 3 min w/ >2cm dilation OR 80% effacement) 2. <37+>20wk
- Mx
 → RF: Hx PTL, PPROM, PROM OR Multi Gestation OR Cigarettes, short Cervix, Cervix surgery, late wks
sex
→ Labor <37wk + >20wk?
→ Mother Positioning (Lateral Decubitus) w/ bed rest, fluids, O2
→ Fail (to stop contractions)?
→ No (HTN, DM, ROM, dilatation >4cm, HD, Bleed, )?
→ GA? (Tocolytics → nifedipine > indomethacin)
→ <32? →Tocolytics+Betamethasone+MgSO4+Penicillin
(MgSO4 w/ indomethacin → if expected delivery w/i 24hr = neuroprotection ‘cerebral palsy’)
→ >32? →Tocolytics+Betamethasone+Penicillin
→ >34? → Betamethasone+Penicillin
- Prevention
→ Hx of PTL
→ Yes
→ IM Progesterone
→ TVUS-cervix
→<25mm?→Cerclage (at 13-16 wk) w/ serial TVUS-CL until 24wk
→>25mm?→Serial TVUS-CL until 24wk
→ No
→ TVUS-cervix
→<25mm?→Vaginal progesterone
→N?→routine ANC
- CC → PPROM, Prematurity (killer)

PROM vs. PPROM (normal ROM occur at 8 cm dilation)

- PROM ROM before labor
→ “gush” fluid per vagina/bleed per vagina?
→ Sterile Speculum Ex (w/ USG for anomalies, GA)
→ Pooling, Ferning, +ve Nitrazine Test (blue paper = basic fluid)?
→ >37wkGA (no labor >16hr after ROM) OR chorioamnionitis OR CTG distress?
→ <34?
- Abx (Ampicillin OR Penicillin)
- Tocolytic + Steroid
→ Chorioamnionitis (fever+tender uterus → near delivery)?
→ amnion culture and G-stain
→ Ampicillin PLUS Gentamicin (while awaiting results)
→ induce labor (otherwise labor is spontaneous after ROM)
- PPROM ROM before labor before 37wkGA (90% deliver w/i 7 days)
→ “gush” fluid per vagina/bleed per vagina?
→ Sterile Speculum Ex (w/ USG for anomalies, GA)
→ Pooling, Ferning, +ve Nitrazine Test (blue paper = basic fluid)?
→ GA?
→ <34wk? →Give Abx PLUS Steroid then Deliver by 34wk
→ >34wk? →Give Abx then Deliver

Isoimmunization (Mom Rh+ve + Dad Rh-ve → 50% Hetero, 0% Homo)

→ Rh -ve Mother & Rh +ve Father (or unknown Rh)?
→ Screen anti-D Ab
→ +ve (sensitized) → observe
→ -ve (not sensitized)
→ RhoGAM Upon 28wkGA (300ug, 1500 IU)
→ Delivery (or trauma, abortion, stillbirth, ectopic, amniocentiecis, CVS, ECV)
→ KB test (determine dose of RhoGAM)
→ RhoGAM w/i 72 hr
CTG → VEAL CHOP
- Variable deceleration → Cord compression/prolapse
→ Mx?
→ Mother Positioning (Lateral Decubitus) PLUS stop Oxytocin
→ Fail?
→ Amnioinfusion
→ 10 cm dilated?
→ Operative Delivery
- Early deceleration → Head compression ‘position’ (vagal response)
- Acceleration → Ok
- Late deceleration → Placental insufficiency (Problem)
→ Mx?
→ Mother Positioning (Lateral Decubitus)
→ Stop Oxytocin
→ IV fluids w/ Face Mask O2
→ not in active labor w/ uterine tachysystole (>5 contractions 10 min)
→ Tocolytic (Ritodrine OR MgSO4)
→ Emergency C/S

→ Fetal Bradycardia?
→ Station?
→ +1, +2, +3? → Forceps
→
reduced variability
- Mg-Sulfate
- Sleep Pattern
- Opidiod
- Prematurity
- Hypoglycemia
- Fetal Hypoxia
- Cord Prolapse

Anemia = T1,3 (Hb<11) T2 (Hb<10.5) → ferritin level is most specific

Infections

Varicella → microcephaly, chorioretinitis, skin defect

Rubella → defect 25% in T1 → CVS PDA, Pulmonary Stenosis

GBS
- Screen? 35-37 wkGA rectovaginal culture
- Tx? IF ↓ by IV Penicillin G 4hr before V/D and if ROM on C/S
- GBS disease Hx in infant
- GBS bacteriuria
- GBS UTI
- GBS +ve 5wk prior to labor
- GBS unknown status PLUS >1:
- <27 wk
- Intrapartum Fever
- ROM for >18hr
Pox
- Hx of Pox? → give mom MMR before pregnancy
- Pox perinatal (5ds before or 2 ds after)? → give baby varicella-Zoster Ig
HSV
→ Acyclovir maximize chance of V/D
→ Labor?
→ Speculum Exam
→ Active Lesion? → C/S
→ No Lesion? → V/D
HIV
- Transmission → highest during delivery
- 24% if no prophylaxis
- 8% if w/ prophylaxis
- Mx
- Prenatal → 2 NRTI PLUS 1 NNRTI or protease inhibitor (most important prevention)
- Opportunistic Prophylaxis if CD <200
- No Amniocentesis until viral load undetectable
- Intrapartum
- Mom not on HAART? → Zidovudine
- Viral Load <1000? → Zidovudine PLUS V/D
- Viral Load >1000? → Zidovudine PLUS C/S
[no artificial ROM Or instrumentation]
- Postnatal
- Mother → Continue HAART
- Infant → Zidovudine for >6 wks PLUS serial HIV PCR testing
HTN (mc → IUGR)
- Gestational = >20 wkGA >140/>90 mmHg → give Methyldopa
- Preeclampsia = BP >140/>90 PLUS proteinuria >300 mg/24hr
- Severe? = >1 of:
- Brain → Cerebral, Visual Symptoms
- Lung → Pulmonary Edema
- Heart → BP (>160/110) on 2X 4hr apart
- Liver → ↑ transaminases
- Kidney → Cr >1.1 mg/dL OR doubling
- Blood → PLT <100K
→ PTE? Must deliver
→ w/o severe features?
→ <34 wkGA? → observe (OPD)
→ >34 wkGA? → induce delivery
→ w/ severe features?
→
→ >34 wkGA?
→ MgSO4 (drips intraP)
→ AntiHTN
- Hypetensive Moms Need Love
- Hydralazine
- Methyldopa
- Nifedipine (2nd)
- Labetalol (1st)
→ Delivery (only cure for PTE)
→ Continue MgSO4 for 24hr postpartum
→ hyporeflexia followed by hypotension?
→ STOP MgSO4
- HELLP = Hemolysis + Elevated Liver enzymes + Low PLT
 → PTE + N/V + RUQ pain?
→ HELLP?
→ Stabilize (AntiHTN ‘Labetalol, Hydralazine’ and/or MgSO4 ‘prevents seizure’)
→ Delivery ( at >34 wkGA OR any GA w/ abomral baby test or severe/worsening mom)
[Hypertensive w/ Low PLT? → General Anesthesia]
- Eclampsia = Clinical Dx = preeclampsia w/ grand mal seizure
- Chronic = <20 wkGA OR <pregnancy

CC
- Maternal?
- GDM
- superimposed PTE
- PPH
- Placental Abruption
- C/S
- Fetal?
- IUGR
- Preterm Delivery
- Oligo

DM → T1 highest risk to develop organogenesis 1st CNS is NTD

- GDM = DM >20 wkGA
- Dx (best prognostic test A1C ; if ↑ risk abortion, anomalies)
→ Risk?
→↑ (FHx, GDM Hx, Obese, Big Baby Hx, PCOS, Steroid, Polyuria, Polydipsia)
→ screen by FPG+A1C at 1st visit (16 wk GA)
→ negative?
→ DO 24-28wK
→↓→ screen at 24-28wk
→ 50g glucose (initial)
→ >140 mg/dL?
→ 100g glucose (confirm)
→ >140 mg/dL? (>2 abnormal results? = GDM)
→ GDM?
→ Lifestyle modification
→ FPG > 95 OR OGTT > 140 OR?
→ Insulin
→ refuse insulin?
→ Metformin (safest), glyburide
→ Poor Control/Complication?
→ delivery (C/S if >4.5 kg baby)
- diet? → 41 wkGA
- Meds? → 38+ wkGA
- insulin?→ 37-39 wkGA
- Cx → ↑ing risk for : HTN, PTE, C/S
→ Maternal Hyperglycemia?
→ T1 → CHD, NTD, SAB
→ T2/3→ Fetal Hyperglycemia
→ Fetal Hyperinsulinemia
→ ↑ demand
→ Fetal Hypoxemia
→ ↑ EPO
→ Polycythemia
→ Organomegaly
 → Macrosomia
→ Shoulder Dystocia
→ Birth Injury
→ Neonatal Hypoglycemia

Antepartum Bleed (Thirdtrimester bleed, bleed >20wk)

- Placental Abruption w/ DIC? → Correct DIC then vaginal delivery
Placenta Previa Placental Abruption

Hx Previa HTN 50%

Hx C/S Smoking

Risk Hx Fibroid

Old Mom Trauma

PPROM

Cause Abnormal Placentation Premature Separation

Onset Sudden Sudden

Pain Painless Bleed Painful Bleed

- Mx?
→ Bleed >20wk? (Do speculum ‘Confirm bleed’ followed by TVUS ‘Evaluate Placenta’)
→ Abdominal Pain?
→ Yes (Placental Abruption)
→ Stable Mother and Fetus? → V/D after 36wk
→ Unstable Mother? → C/S unless V/D impending
→ No
→ BEFORE ROM (Previa) → admit then C/S after 37wk
→ AFTER ROM (Vasa w/ctg → emergent C/S

→ Severe Placental Abruption?

→ Hypovolemic Shock PLUS DIC
→ Shock?
→ Aggressive Fluids
→ Stabilized?
→ Yes → Lateral Position
→ No → Blood Transfusion
→ DIC? → Corrected
→ Deliver

PPH = >500mL V/D/>1000mL C/S/bleed causing shock (1ry w/i 24hr/2ry >24hr + <12wk)
- ET → 4T’s
- 80% Tone (Uterine Atony)
- 20% Trauma (laceration, inversion)
- 10% Tissue (retained placenta)
- Accreta 80% (Attached to myometrium)
- Increta 15% (Invade myometrium)
- Percreta 5% (Perforates myometrium)
Dx?
 → Clinical (PPH upon manual separation of the placenta)
→ Initial U/S
→ Confirm Doppler U/S
→ Best MRI

- 1% Thrombin
- bleeding diathesis
- DIC
- Placental Abruption
- Amniotic Embolism
- Prolonged fetal death
Uterine Atony
- ET → AEIOU
- Anatomic Abnormalities
- Exhausted myometrium
- Prolonged labor
- Oxytocin use
- Halogen Anesthesia
- MgSO4
- >5 multiparity
- Leiomyoma
- Chorioamnionitis
- Infections
- Overdistended Uterus → (twin, poly, macro)
Trauma
- ET
- Iatrogenic injury
- Instrumental delivery
- Cervical laceration: most commonly caused by forceps use
- Lower vaginal trauma: most commonly due to episiotomy
- cesarean delivery → Uterine Rupture

- Mx
- Prevent → Active Mx (no C/S or V/D)
→ Oxytocin (Once Shoulder delivered)
→ Fundus Massage
→ Cord Pulling
→ Controlled Cord Clamping
→ Bimanual Massage & External Compression
- Acute
→ Large IV bore, Face Mask, Monitor Vitals, Send CBC
→ Cause?
- Tone?
→ IV Oxytocin w/ Bimanual Massage
→ Fail?
→ ↑ Oxytocin Dose to 40
→ Add Carboprost OR Methergine OR PG1 OR misoprostol
- Oxytocin → C/I in hypersensitivity
- Carboprost → C/I in asthma, active heart dis. Liver dis. Kidney dis.
- Methergine → C/I in HTN, HIV, Heart Disease
→ Fail?
→ Tranexamic acid (w/i 3hr of PPH)
→ Fail?
→ Surgical
 → C/S?
→ Lacerations?
→ Yes → suture ligation
→ No → B-Lynch (compression suture)
→ V/D? → Start Medical, Message
→ Fail?
→ Hysterectomy (definitive)
(embolization if stable only)
- Tissue?
→ remove placenta manually
→ curettage under anesthsia
→ accreta, increta, percreta?
→ hysterectomy
- Trauma (inversion)
→ Reduce Uterus Manually
→ Anesthesia for pain
→ IV fluid & oxytocin
- Thrombin
- CC
- Anemia
- Brain → Sheehan (Hot and Hyped Actress Have Fixed Post With Income in Dollars)
- Hot Hot Flushes
- Hyped Hypotension
- Actres Agalactia
- Have HypoT
- Fixed Fatigue
- Post PPH
- With Weight Gain
- IncomeInsipidus
- Dollars Decreased Libido
- Transfusion reaCtion
- Mother, Baby Death
- VTE
- inFection

2ry PPH Mx
→ PPH >24hr (delayed)?
→ Stable?
→ No → Exploratory Laparotomy
→ Yes
→ Hx, Ex, Labs
→ Endometritis? (Fever ,tender uterus, Foul lochia, Leukocytosis)
→ Yes → IV clindamycin + IV aminoglycoside such as gentamicin
→ U/S
→ No
→ Pelvic U/S doppler
→ Tissue Retained?
→ Yes → Curettage
→ No → U/S (look for vascular, aneurysm)

Twins (↑ing risk w/ monochorionic)

- ET
- Induction (highest risk)
- Age
 - Race
- Weight
- Mx
→ Presentation? (Best → breech-breech Or Cephalic-Cephalic, Worst → breech-cephalic)
→ 1st Twin Cephalic? → V/D
→ 1st Twin Breech? → C/S
- CC (mc is prematurity)

Labor (Assessed by Descending part of head OR partogram 'dilation’)

- Stages?
→ 0 → 6 cm (latent)
→ >20hr NP, >14hr MP?
→ Yes → Rest, Hydration, Analgesics
→ Fail?
→ Oxytocin
→ No
→ 6 → 10 cm (active)
→ >6 cm PLUS ROM PLUS no cervical change >4hr in contraction, >6hr in no contraction?
→ Yes → C/S
→ No
→ 10→ Birth
→ >2hr NP, >1hr MP w/o birth?
→ Yes → Engagement?
→ Yes → Oxytocin if no Contraction, Forceps if Contractions
→ No → C/S
→ No
→ Birth → Placenta
→ >30 no placenta?
→ Yes → Curettage → Fail? → Hysterectomy

- Shoulder Dystocia?
→ McRoberts (flex thighs) OR Apply Suprapubic Pressure
→ Fail?
→ C/S
- Bad Uterine Contractions? → Oxytocin
- ECV (if EVC fail OR <37 wk baby goes down → C/S otherwise wait it will turn spontaneously)
- Do → >37 wk w/ breech presentation wishes V/D
- Don’t
- Antepartum bleed, Active labor
- Baby anomalies, Placental abnormalities (low lying)
- Constriction (oligohydramnios)
- Explosion (ROM), Extended fetus neck
- Fetus non reassuring CTG
- Had C/S before
- Anesthesia?
- Epidural? → Early Stage (<3 cm dilatation) most common+most safe
- Pudendal? → Late Stage (3+ cm dilatation)
(Active Stage? → Epidural)
- Spinal? → non Urgent C/S
- General? → ↓BP OR Risk Bleed (↓PLT) CHOICE for Urgent C/S
(90% effacement, 4cm dilatation ‘active’, baby distress?
→ emergency C/S ‘use general anesthesia’)

OVD
 - Do’s
- Long Stage 2 (Failure of baby head rotation, mom heart D. Or exhausted)
- Leg (breech ‘forceps’)
- bad fetaL CTG (brady, decelerations)
- Don'ts
- Unengaged Head
- Bleeding Disorder
- Bullets
- Stage 2 (full dilatation) exhausted? → Vacuum
- CC → Perineal Tear
- 1st Skin + Subcutaneous perineum + vagina epithelium
- 2nd Skin + Perineal Muscle ‘body’
- 3rd External anal sphincter + internal
- 4th ALL (1st, 2nd, 3rd) + rectal mucosa

C/S → indications? Give Abx before C/S

- Primary C/S
- Placenta previa totalis
- Refractory HELLP OR severe PTE
- Infection in premature birth
- Malpresentation (Breech not corrected)
- Abnormal anatomy (Myoma)
- Relative → CVS, uncontrolled DM
- Multiple pregnancY w/ difference in weight
- Secondary C/S (after PROM and/or phase 1 onset)
- Prolonged Labor
- Premature birth
- Position (breech)
- IntraPartum intraamniotic infection
- MATERNAL EXHAUSTION
- EMERGENCY C/S?
- SEVERE vaginal bleeding
- SUSPECTED uterine rupture
- FETUS BRADYCARDIA on CTG
- FETUS ACIDOSIS (lost variability)

Cord Prolapse
→ Presentation (Breech), Polyhydramnios, Premature birth
→ Umbilical Cord btw presenting part and Pelvic wall?
→ ROM followed by CTG bradycardia, deceleration
→ Trendelenburg position
→ fetus is pushed back into the uterus
→ immediate tocolysis using β2-mimetics (fenoterol)
→ emergency C/S

Postpartum

Postterm vs Late-term Pregnancy

- pregnancy >41wkGA = Late-term → consider induction PLUS start BPP
- Pregnancy >42wkGA = postterm → recommend induction (to prevent CC ‘dystocia’)
- Induction
→ Do’s?
- Postterm (>42wk)
- PPROM >34
 - PROM
- PTE (HTN, Preeclampsia, Eclampsia, HELLP)
- Pig baby (mother w/ DM)
- Popped baby (IUFD)
→ Bishop (assess cervix likelihood for V/D)
- Bishop 0 1 2 3
- Iffacement <30% <50% <70% >80%
- Station -3 -2 0,-1 +1,+2
- Hard, soft? firm mod soft/ripe
- Opening close 1-2cm 3-4cm >5cm
- Position (crvx) post midline ant -
→ Score?
→ <6
→ unfavorable for V/D
→ Per-Vagina Induction (PgE1,2 ,Catheter, Amniotomy ‘when cervix is 4cm’)
→ >8
→ favorable for V/D
→ IV Oxytocin w/ CTG
- CC
- HypoNa
- HypoBP
- Tachysystole

- Don’ts
- Hx ruPture uterus
- Placenta previa, vasa Previa
- Position (Transverse)
- cord Prolapse
- Active genital maternal herPes
- Nonreassuring Pump (CTG)

Postpartum Fever = T >38C for >2ds consecutive

- Cause
- Wind (pneumonia, atelectasis) → 1st Day
- Water (UTI) → 2nd Day
- Wound (C/s, episiotomy) → 3rd Day → Cephalosporin
- Walk (DVT, PE) → 4th day → Enoxaparin
- Womb (endometritis) → 5th day → Clindamycin + Gentamicin
- Wean (mastitis, abscess)
- Wonder drugs

Postpartum Blues, Depression, Psychosis

Blues Depression Psychosis

Prevalence +++ ++ +

Onset <10 days >10 days days-weeks

Symptoms Severe Delusions, Hallucinations

Mild
Suicidal, Guilt,
Psychomotor

Anti-dep, psych
 Tx reassurance Antidepressant not left alone

Breastfeeding
- Counselling? → before conceiving
- Colostrum? 1st expelled milk (yellow) ↑ protein
- Contraception?
- Progestin Only Pills (Best)
- Sterilization
- Barriers
- IUD
- Combined OCP (pass in milk + ↓ milk)
- Contraindications
- Maternal
- Active Alcohol/Drug abuse, Active untreated TB (breastfeed 2wk after antiTB)
- HIV, HSV breast lesion (HBV, HCV not a contraindication unless niplle crack or bleed)
- Varicella infection 5ds before or 2ds after delivery
- CTX, RTX
- Common Problems
- Engorgement
→ Bilateral Tender Symmetric Fullness w/o erythema and fever
→ Cool Compressor w/ NSAIDS, Acetaminophen (improves w/ regular feeding, pumping)
- Mastitis
→ Staph A
→ Unilateral tender swollen erythema w/ Fever
→ Continue breastfeeding (to prevent abscess), Analgesics, Cold Compressors
→ dicloxacillin or cephalexin
→ no response, fluctuating mass?
→ Abscess
→ stop breastfeeding & I/D

Breech
→ Head palpated at fundus?
- Frank flexed hips and extended knees
- Complete flexed thighs and legs
- Single Foot 1 hip flexed
- Double Foot 2 hips extended
→ TAUS
→ no placenta previa OR active lesion
→ ECV (if not C/I)
→ Fail?
→ C/S at 39 wk

Chorioamnionitis (intra-amniotic infection)

→ Prolonged ROM (>18hr btw ROM to Birth), Prolonged labor, Pervaginal pathogen?
→ Fever PLUS >1:
- >100 bpm (mother), >160 bpm (CTG)
- >15K WBC
- Uterine Tenderness
- Smelly Purulent vaginal discharge
→ Broad Abx then Oxytocin to Deliver V/D

Apgar Score