O&G OSCE by Maddy

OBSTETRICS
AND
GYNECOLOGY
OSCE Sheet
Prepared By
Madeleine Joseph
2008
1
Obstetrics
2
What is obstetrics?
Obstetrics is the specialty of medicine
concerned with the care of women during
pregnancy, parturition, and puerperium.
Parturition- child birth
Puerperium-period from the termination of
labour to complete involution of the uterus,
usually defined as 42 days.
3
Obstetric History
Name: Past Surgical History:
Date of Birth: Drug History:
Age: Family History:
Occupation: Social History:
Last Menstrual Period: Review of Systems:
Expected Date of Delivery (via LMP or USS): • Central nervous system review
Gestational Age: • Cardiovascular system review
Presenting Complaint: • Respiratory system review
History of Presenting Complaint: • Gastrointestinal system review
1st Booking: • Genitourinary system review
Gestational Age at Booking: • Gynaecological Review of system
Booking Parameters: Summary:
Number of Antenatal Visits: On Examination:
Past Obstetric History: Assessment:
Past Gynaecological History: Plan:
Past Medical History:
4
Obstetric Forceps
Obstetric forceps are instruments used for
assisting the delivery of the fetal head.
1. Incidence
2. Types of Forceps
3. Indications
4. Conditions which must apply
5. Complications
5
Obstetric Forceps
Incidence
There are varying rates to the use of obstetric
forceps globally. Rates are higher in centres
with higher epidural rates. Instrumental
delivery rates at:
• Queen Charlotte’s, UK incidence in 1997 was 20% forceps
deliveries
• Chelsea Hospital, UK in 1997 was 40% forceps deliveries
• Mount Hope Hospital, Trinidad in 1997 was <5%
• Czech Republic 1.5% of deliveries
• Australia and Canada are 15%
6
Obstetric Forceps
Types of Forceps
The basic instrument has three parts:

1.The blade
2.The shank end
3.The handle
7
Obstetric Forceps
The blades-the blades are curved to fit
the fetal head-cephalic curve. Some
curves are designed to fit the curve of
the pelvis. For example, the Wrigley’s
forcep used vaginally to deliver the head
at the time of a has no pelvic curve.
8
Obstetric Forceps
Forceps application can be classified into two
broad subgroups:
1. Midcavity Forcep
2. Outlet Forcep
Midcavity Forcep
These are applied when the head is at the level of the ischial spines or
below. There are different types of midcavity forceps:
1. Simpson’s
2. Neville Barnes
3. Keiland’s
9
Obstetric Forceps
Midcavity Forceps
1. Simpson’s Forcep
– Midcavity traction forceps
– Sturdy frame
– Long shank
– Marked pelvic curve
10
Obstetric Forceps
Midcavity Forcep
2. Neville Barnes Forcep
• Midcavity traction forceps
• Used for the delivery of the after
coming head of the breech
• Does not allow for rotation
11
Obstetric Forceps
Midcavity Forcep
3. Kielland’s Forceps
– Designed for both traction and rotation of the fetal head
– Facilitates delivery when the fetal head is above station
zero
– Used especially in instances of deep transverse lie
– Requires skill and should be performed in operating
theater with readiness for caesarean section
– Requires generous episiotomy because perineal damage is
inevitable.
12
Obstetric Forceps
Midcavity Forcep
3. Kielland’s Forceps
– This forcep has a
• Long shank
• Cephalic curve
• Absence of significant pelvic curve
• Sliding lock allows correction of asynctlitism
• A knob on the shoulder of the instrument
which allows for identification of the occiput
during rotation.
13
Obstetric Forceps
Outlet Forceps
1. Piper’s Forceps
– Obsolete
– Designed to control the delivery and maintain the
flexion of the after coming head of the breech. This
provides protection for the head during its descent and
minimizes the effects of the sudden pressure changes
– Marked curvature of the shank
14
Obstetric Forceps
Outlet Forceps
2. Wrigley’s Forceps
– Permits the delivery when the head
is below the level of the ischial
spines. That is, below station zero
– It can be applied easily and
painlessly
– Light frame
– Short shank
– Fixed/English lock
– Cephalic curve present
– Pelvic curve more pronounced
15
Obstetric Forceps
Outlet Forceps
Wrigley’s Forceps
16
Obstetric Forceps
Indications
Maternal Indications
– Maternal Illness requiring a shortened second stage of labour. e.g.
– Cardiac disease
– Pre-eclampsia
– Eclampsia
– Maternal distress
– Prolonged 2nd stage or failure to progress in the 2nd stage of labour
which should be 1 hour in a primagravida and 30 minutes in a
multigravida. Prolonged labour may be due to:
– Malpositions
– Deep transverse lie
– Ineffective uterine contractions
17
Obstetric Forceps
Indications
Fetal Indications
–Fetal Distress
–Prematurity
–The after coming head of the breech
18
Obstetric Forceps
Conditions Which Must Apply
For Forcep Delivery
• No cephalopelvic disproportion. The biparietal diameter must

be able to pass through the pelvic brim
• The head should be at station zero
• The position of the head must be known. Position of the head
ascertain by vaginal examination.
• Cervix must be fully dilated.
19
Obstetric Forceps
Conditions Which Must Apply
For Forcep Delivery
• Membranes must be ruptured.
• Bladder and rectum must be empty
• Patient in lithotomy position with adequate anaesthesia or
analgesia.
• Patient must have a generous episiotomy with lignocaine
infiltration
• Neonatologist must be in attendance at the delivery with
facilities for resuscitation
Obstetric Forceps
Conditions Which Must Apply For Forcep Delivery
F-full dilatation of the cervix

O-outlet adequate
R-ruptured membranes/rectum empty
C-contractions good/catheterize bladder
E-engaged head/episiotomy
P-position known/paediatrician in attendance
S-Suitable presentation
21
Obstetric Forceps
Complications
Maternal Complications
• Perineal tears
• Vaginal tears
• Cervical tears
• Uterine rupture
• Fistula formation
22
Obstetric Forceps
Complications
Fetal Complications
• Facial Nerve Palsies
• Scalp injuries-including lacerations and crush
injuries
• Cephalhematoma
• Intracranial haemorrhage
23
Vacuum Extraction
(Ventouse)
The vacuum Extractor (Ventouse) is used for assisted
vaginal delivery of a fetus. It provides traction and allows
rotation of the fetal head in conjunction with maternal effort.
Vacuum Extraction can be performed with simple anaesthesia

such as perineal infiltration with local anaesthetic or a
pudendal block.
Failure rates are higher than with forceps and are in the region
of 10-20%
25
Vacuum Extraction
(Ventouse)
Features:
a. Suction cap
b. Handle and tubing
c. Hand pump (older systems
used a vacuum bottle)
26
Vacuum Extraction
(Ventouse)
Incidence
–Queen Charlotte’s and Chelsea
Hospital in 1997 preference for the
Ventouse at least 60% to 40% of
the instrumental deliveries
27
Vacuum Extraction
(Ventouse)
Types
a. Silc Cup-this is a silastic device best applied when easy delivery is
expected and:
– the head is in the occipito-anterior position
– well flexed vertex presentation,
– no caput
– an average sized baby is expected
a. Bird Anterior Cup-applied when a more difficult delivery is anticipated.
There may be caput. The head is well flexed and in the occipito-anterior
position
b. Bird Posterior Cup-deflexed head in the occipito-posterior position
 Always apply the largest cup
 Build vacuum up to 0.8kg/cm3 over 1-2 minutes
28
Vacuum Extraction
(Ventouse)
Maternal Indications
– Maternal Illness requiring a shortened second stage of labour. e.g.
– Cardiac disease
– Pre-eclampsia
– Eclampsia
– Maternal distress
– Prolonged 2nd stage or failure to progress in the 2nd stage of labour
which should be 1 hour in a primagravida and 30 minutes in a
multigravida. Prolonged labour may be due to:
– Malpositions
– Deep transverse lie
– Ineffective uterine contractions
29
Vacuum Extraction
(Ventouse)
Fetal Indications
–Fetal Distress
–Prematurity
30
Vacuum Extraction
(Ventouse)
Advantages
• Recourse to general and regional anaesthesia is likely to be
used with Ventouse delivery
• Can be used to facilitate rotation of the head instead of using
pernicious instruments such as Kielland’s forcep
• Allows autorotation during traction
• Safer for the delivery of the second twin
• The amount of pressure applied can be controlled
• Reduced maternal morbidity
 Fewer birth canal injuries with the Ventouse.
 Ventouse occupies less space.
31
Vacuum Extraction
(Ventouse)
Disadvantages
• Cervical lacerations
• Interval between application to delivery tends to be longer with the
Ventouse than with the forceps.
• Higher failure rate of 10-20% as compared with 2-10% for forceps
 Failure occurs when the cup has slipped off more than three times or
when there is no progress of the head after 20 minutes of traction
• Ventouse should be avoided in the preterm infant of less than 36 weeks
because of the softness of the calvaria.
• Large caput-the artificial caput or chignon. Superficial necrosis may occur.
This is likely in prolonged traction.
• 5-20% may develop Cephalhematomas. Cephalhematoma are likely if
traction exceeds 20 minutes.
32
Induction of Labour
What is labour?
Labour is the process by which the products of conception
(e.g. fetus, umbilical cord, liquor, membranes and placenta)
are expelled after the 28th week of gestation through the
vaginal route by rhythmic contractions of the uterus.
In established labour, there is effacement of the
cervix with dilatation of 3-4cm. There is at least
one contraction occurring every ten minutes
lasting 45-60seconds with a pressure of 25-
100mmHg.
Induction of Labour-stimulation of the onset of labour by
artificial means during the third trimester of pregnancy, in an
attempt to secure a vaginal delivery.
33
Induction of Labour
Obstetric management of a patient classified
into:
a) Time of delivery
b) Mode of delivery
Time of delivery
Time of delivery is immediate and the mode is vaginal or
abdominal if placental function tests indicate deterioration of
the integrity of the feto-placental unit.
if there is no contra-indication to vaginal delivery, then labour

should be induced. 34
Induction of Labour
Indications
a) Essential Hypertension i) Premature rupture of the
b) Pre-eclampsia membranes
c) Eclampsia j) Chorio-amnionitis
d) Diabetes mellitus k) Intrauterine demise
e) Postdate pregnancies l) Congenital anomalies e.g.
anencephalus
f) Abruptio placenta
g) Sickle cell disease
h) Rhesus iso-immunization
35
Induction of Labour
Contra-indications To Induction of Labour
a) Transverse Lie
b) Cephalopelvic Disproportion
c) Grand multiparity-careful use of Syntocinon infusion in a
highly parous woman because she may respond in an erratic
manner to the Syntocinon.
d) Previous Caesarean Section-if the pelvis is adequate and the
uterine scar has healed, then careful use of Syntocinon
infusion should be employed.
e) Previous Operation on the Cervix-e.g. amputation or cone-
biopsy
f) Unengaged Head
g) Maternal cardiac disease
36
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Induction of Labour
Preparing the Patient
• Complete history and examination of the patient. Ascertain:
» Obstetric history from the patient
» Lie of the fetus
» Presentation of the fetal head
• An indication for induction must be present
• An abdominal ultrasound should be performed to the placental location
• The patient should be admitted to hospital prior to the proposed date of
induction if she is not already in the hospital
• Small and gentle enema given in the evening
• Mild sedative is prescribed
• Vaginal examination is performed to determine whether or not the cervix is
ripe
38
Induction of Labour
Cervical Ripening
The Bishop Scoring System is used to
differentiate between a cervix that is
unprepared and requires priming and a cervix
in which the ripening process has already
occurred.
• Bishop Score of 9 or > indicates greater likelihood of a
successful induction
• Bishop Score of 4 or < indicates likely failure of
induction. Cervical priming is therefore indicated in
those with a low Bishop Score.
39
Induction of Labour
Score
Factor 0 1 2 3
Dilatation 0 1-2 3-4 5-6

(cm)
Effacement 0-30 40-50 60-80 80
(%)
Station -3 -2 -1,0 +1, +2
Consistency Hard Medium Soft -
Position Posterior Middle Anterior -
The Bishop Score: Numerical System used to evaluate

inducibility of the cervix 40
9/18/2019 41
Induction of Labour
Cervical Ripening
An ideal priming agent should fulfill the following
criteria:
a) It must be safe and practical
b) It must not affect maternal well-being such as
nausea, vomiting, and diarrhea
c) It must not affect uterine blood flow or feto-
placental unit
d) It should be economical
42
Induction of Labour
Methods of Cervical Ripening
Methods of Cervical Ripening to induce cervical

softening and dilatation:
a) Mechanical
» Foley’s Catheter
» Hygroscopic Dilator
b) Chemical
» Intravaginal Hormones
» Prostaglandins
43
Induction of Labour
a) Mechanical
• Foley’s Catheter
• A Foley’s catheter with a 25-30mL balloon is passed
into the endocervix above the internal os using tissue
forceps. The balloon is then inflated with sterile
saline, and the catheter is withdrawn gently to the
level of internal os. This causes separation of the
membranes and consequent release of
prostaglandins.
• This method induces cervical ripening over 8-12
hours. The cervix will be dilated 2-3cm when the
balloon fallouts.
44
Induction of Labour
a) Mechanical
• Hygroscopic Dilator
• Laminaria tents are made from desicated
stems of the coldwater seaweed Laminaria
digitata (processed dried seeweed) or L
japonica
• When placed in the endocervix for 6-12 hours,
the laminaria increases in diameter three to
fourfold by extracting water from cervical
tissues, gradually swelling and expanding the
cervical canal. 45
9/18/2019 46
Induction of Labour
a) Chemical
• Intravaginal Hormones
• Natural relaxin is a polypeptide hormone that is produced in the
human corpus luteum, decidua, and chorion. Purified protein
relaxin, 2mg in tylose gel, given vaginally or intracervically to
induce cervical ripening in 80% of cases and labour in about one-
third of patients over 12 hour period.
• Purified porcine relaxin when used causes the release of

proteases which destroy the link proteins in the cervix and
produce a disorganization of the collagen fibers.
• Estradiol vaginal gel causes in an increased collagenolytic

activity of the cervix. 47
Induction of Labor
a) Chemical
• Prostaglandins
• Two forms of prostagladins are commonly
used for cervical ripening prior to induction at
term:
1. Misoprostol (PGE1)-NOT FDA approved
for cervical ripening.
2. Dinoprostone (PGE2)-FDA approved for
cervical ripening.
48
Induction of Labor
a) Chemical: Prostaglandins
Dinoprostone (Prepidil , Cervidil)
• comes packaged in single dose syringe containing 0.5mg of PGE2
in 2.5mL of viscous gel of colloidal silicon dioxide in triacetin.
• The prostaglandin is inserted by intracervical, vaginal or extra-
amniotic means.
• Intracervical method is more efficacious. Intravaginal method is
a safer route because it does not carry the risk of rupturing the
membranes or introduction of infection.
• Expensive
49
Induction of Labor
Dinoprostone (Prepidil , Cervidil)
Contra-indications to the use of Dinoprostone :
• Contraindicated in patients with a history of asthma
• Glaucoma
• Myocardial infarction
• Unexplained vaginal bleeding
• Chorio-amnionitis
• Ruptured membranes
• Previous caesarean section
50
Induction of Labor
a) Chemical
• Prostaglandins
Misoprostol (Cytotec)
• Not FDA approved for cervical ripening
• Cheaper alternative to Dinoprostone
• Manufactured in 100mcg unscored and 200mcg scored tablets
which can be administered orally, vaginally, and rectally.
• Up to 50mcg-100mcg can be inserted vaginally to a primigravida
and 25mcg-50mcg to a multigravida.
• 12 hours should be allowed for cervical ripening after which
Oxytocin induction should be started.
51
Induction of Labor
Adverse Effect:
• Fetal heart rate deceleration
• Fetal distress
• Emergency caesarean section
• Uterine hyper tonicity
• Uterine rupture
• PPH
• Nausea
• Vomiting
• Fever
• Peripartum infection
52
Induction of Labor
Technique
• The prostaglandin pessary is inserted in the posterior
fornix of the vagina
• Patient remains supine for at least one hour to thirty
minutes to minimize leakage
• Patient is observed for a period of 2 hours for uterine
activity and fetal heart rate
• Oxytocin induction is delayed for about 10 hours
because the effects of prostaglandin E2 are exaggerated
with Oxytocin.
53
Induction of Labor
Standard methods of induction of labor are:
a) Pharmacological : Oxytocin
b) Non phramacological : Membrane sweep,
Amniotomy, Nipple stimulation.
A Syntocinon infusion is commenced on the morning of
induction and proceed to artificial rupture of the membranes 4
to 6 hours later
Amniotomy is used as an adjunct rather than by itself.
This combination of methods reduces induction to delivery

time interval considerably 54
Induction of Labor
Oxytocin
Clinical response to Syntocinon infusion depends on
the parity of the patient and the period of gestation.
Caution must be taken in highly parous patients
and in those in advanced gestational age.
– The myometrium in highly parous patients is more

sensitive to Oxytocin than in primigravida
– The closer to term, the more likely will the uterus respond
to an Oxytocin infusion
55
Induction of Labor
Oxytocin
Oxytocin is naturally produced by the posterior pituitary. It is
also produced synthetically as Syntocinon or Pitocin.
Mechanism of Action:
Oxytocin receptors are found in the myometrium. Oxytocin exaggerates
the inherent rhythmic pattern of uterine motility. It also promotes the
ejection of milk by stimulating smooth muscle contraction.
Indications:
– Augmentation of labor
– Induction of labor
– Promotion of milk ejection
– Reduction of PPH
56
9/18/2019 57
Induction of Labor
Oxytocin
Dose:
induction of labor: 10 units in 1000mL of Normal Saline or Dextrose 5%
in water at an infusion rate of 2milliunits/minute. The infusion rate can be
increased to a maximum of 32 milliunits/minute. Increments can be made
at 15 minute intervals
For uterine contraction/postpartum bleeding, 10 units intramuscularly or

10-40 units in 1000mL Normal Saline with an infusion rate of 20-40
milliunits/minute
Adverse Effects:
– Uterine hyperstimuization ->Uterine rupture
– subarachnoid hemorrhage
– Hypotension
– Arrhythmias
58
Induction of Labor
Oxytocin
59
Induction of Labor
During an Oxytocin infusion, it is important to
measure:
– The frequency and intensity of uterine contractions. When
contractions of 50-60 mmHg occur at 2.5-4 minute
intervals, the Oxytocin dose should not be increased any
further.
– Fetal heart rate and rhythm
– Maternal vital signs (e.g. blood pressure, pulse rate,
respiratory rate, and temperature)
Once the cervix has dilated to about 3-4cm, it is advisable to
perform an amniotomy. The patient is in active labour.
60
Augmentation of Labour
Amniotomy
An amniotomy is the artificial rupture of
the membranes. Amniotomies are
performed with hook or Kocher’s
Forceps.
Amniotomy is an effective way to induce

labor in selected patients with a high
Bishop Score . Release of amniotic fluid
shortens the muscle bundles of the
myometrium.
The strength and duration of the

contractions are increased and a more
rapid contraction sequence follows.
61
Induction of Labor
Amniotomy
The membranes should be ruptured with an amniotomy hook.
The forewater rupture of the membranes should be performed.
It is intended to induce or accelerate labor.
No effort should be made to strip the membranes and do not

displace the head upward to drain off amniotic fluid. It is wise
to wait for the onset of active labor to perform the procedure.
Early and variable deceleration of the fetal heart rate is noted

to be common with amniotomy.
62
Induction of Labor
Hazards of Induction of Labor
1. Premature delivery
2. Fetal distress
3. Maternal distress
4. Infection
5. Uterine rupture
6. Precipitate labor
7. Unusual uterine activity from Oxytocin
a) Hypertonic
b) Tachysystole
c) hyper stimulation
8. Failure
9. Neonatal hyperbilirubinemia 63
Induction of Labor
1. Premature delivery
• The expected date of delivery has to be correctly
calculated from the patient’s history of her last period
to avoid an induction in a preterm pregnancy.
• Also establish fetal pulmonary maturity by either

clinical, biophysical or biochemical means.
Lecithin/sphingomyelin ration in amniotic fluid is
recommended.
64
Induction of Labor
2. Fetal Distress
• Fetal compromise arising from frequent and intense uterine
contractions induced by Oxytocin. Fetal anoxia can occur if the
tetanic uterine contractions give little time for recovery.
3. Maternal Distress
• Maternal distress can occur if labor is prolonged.
4. Infection
• Chorio-amnionitis bears a direct relationship to the duration of
ruptured membranes and the frequency of vaginal examinations.
65
Induction of Labor
5. Uterine Rupture
• Oxytocin infusion has be en a factor in uterine rupture in the
past.
• Caution should be exercised in highly parous women, in those
with previous caesarean section and myomectomy scars, and in
patients with borderline cephalopelvic disproportion.
6. Precipitate Labor
7. Unusual uterine activity from Oxytocin
• Hypertonic: contractions lasting >90 seconds
• Tachysystole: more than 5 contractions per 10 minute period
• Hyper stimulation: exaggerated uterine response with type dips
or fetal tachycardia
66
Induction of Labor
Hazards of Induction of Labour
8. Failure of Induction
• Failure of induction of labour is considered when the combined
Oxytocin and amniotomy technique has not achieved significant
progress over a reasonable length of time providing that there are
adequate uterine contractions.
• Progress of labour is judged by descent of the presenting part and
dilatation and effacement of the cervix.
• If this induction fails, proceed to caesarean section.
9. Neonatal Hyperbilirubinemia
• It is believed that when Oxytocin is used to induce labor, neonatal
jaundice may ensure.
• The mechanism of action is swelling of the red cells which become
readily destroyed resulting in hyperbilirubinemia in the newborn.
67
Ultrasound In Obstetrics
Ultrasound is a non-invasive technique that produces images of thin
sections of the body by generating high frequency sound waves in the
range of 3.5 to 5.0MHz. The sound waves are beamed into the body by a
transducer in close contact with the skin.
Echoes are produced at the boundaries between tissues of different density.

The returning echoes are captured by crystals in the transducer and
converted to electrical currents which are amplified and processed to build
up an image of the tissue plane on a screen.
Pure fluid produces no returning echoes, while inhomogeneous solid tissue

produces multiple echoes
68
Types of Scanners
Two basic types of scanners used in obstetrics:
1. B Scanners
2. Real-time Scanners
B-Scanners produce a static image on the screen with each
passing of the transducer on the body.
Real-Time Scanners produce a continuous image of a section

of the body as long as the transducer is held in contact with the
skin. The real-time scanner permits direct observation of
movement of tissue with the body and are more useful in
obstetrics than static scanners.
69
• Biological Effects
• At high intensities ultrasound energy can cause
destruction of tissue by the cavitation mechanism but
there is no proof. It is therefore considered to be a safe
and non-invasive technique.
• Examination Technique
• During the first trimester, the patient must have a full
bladder. This displaces the gas-filled bowel upwards
out of the pelvis and provides a clear fluid filled
acoustic window between the skin and the uterus. This
permits visualization of minute detail within the uterus.
70
• Later on in pregnancy, moderate filling of the bladder is
useful to help identify the placenta in relation to the
internal os.
• Scans are carried out in longitudinal and transverse
planes .
• A thin film of acoustic gel is applied to the skin to
enable the head of the transducer to make perfect
contact and exclude all air bubbles which would
seriously degrade the image.
71
• Echogenicity of tissues refers to the degree of
brightness of the returning echoes from the tissue.
• Tissue is hyper-echoic if its displayed brightness has

increased beyond the normal range or if it is being
compared with less echogenic adjacent tissue.
• Hypo-echoic is when the tissue displays brightness that

is reduced beyond the normal range.
72
Indications
First Trimester
• Diagnosis of Pregnancy
• Gestational Age
• Fetal Demise
• Threatened Abortion
• Ectopic Pregnancy
• Hydatidiform Mole
• Uterine Myoma
73
Indications
First Trimester
• Diagnosis of Pregnancy
– The earliest evidence of pregnancy is the visualization of a fluid-filled
sac within the uterus surrounded by a rim of bright echoes.
– This fluid-filled sac can be seen as early as 5th week of gestation
– By the 6th week of gestation a small fetal pole is usually visible within
the sac.
– The shape of the sac is round but it may be flattened by the overfilled
bladder or distorted by submucous fibroids
– Cardiac pulsation can be seen at the 7th week
– Fetal movement can be seen by the 10th week
74
Indications
First Trimester
• Gestational Age
– Accurate assessment of gestational age is very important in clinical
practice. Reasons include:
• Correct timing for cervical suture
• Irregular menstruation
• Discrepancy between uterine size and the date given by the
patient
• an early estimate of gestational age is important when the margin
of error is less than a week may prove to be useful in later
pregnancy if problems like intrauterine growth retardation or post
maturity are suspected.
75
Indications
First Trimester
• Gestational Age
• Before 7th week of gestation, the only method of estimation of
gestational age is by measuring three diameters of the gestation
sac, taking the average and using a table of gestational age and sac
diameters.
• From weeks 7 to 13, the measurement of crown-rump length (CRL)
with a margin of error of + 4 days.
• Multiple pregnancy can also be diagnosed by the 6th week if more
than one gestational sac is present and by the 8th week if there is
only one sac.
• From week 12, the bi-parietal diameter (BPD) of the fetal head.
76
Indications
First Trimester
• Fetal Demise
• Lack of fetal cardiac activity and the absence of fetal
movement indicate fetal demise.
• Cardiac activity is the most sensitive sign and with a
real time scanner should detect fetal demise within
seconds, while fetal movement may need several
minutes of patient observation.
77
Indications
First Trimester
• Fetal Demise
– Complete abortion
• Scans show uterine enlargement but no gestational sac.
• There might be some widening of the line of bright echoes in the
middle of the uterus representing thickening of the decidual lining
of the uterine cavity.
– Missed abortion
• Scans show a gestation sac which is smaller than expected
• The sac is deformed to some extent and the surrounding bright
ring of echoes tends to be less well defined than in a normal sac
• Within the sac, fetal remnants are visible
78
Indications
First Trimester
• Fetal Demise
– Blighted Ovum
• Scans show a gestation sac which is small-for-dates.
• The sac may preserve a round shape and is often
deformed at some point
• The surrounding bright echoes is usually less distinct
than in a normal sac
79
Indications
First Trimester
• Threatened Abortion
• A scan is reassuring to both mother and the
obstetrician
• The most important factor is fetal well being
• There should be a thorough check for fetal demise
80
Indications
First Trimester
• An ultrasound when an ectopic pregnancy is suspected will determine
the presence or absence of an intrauterine gestational sac
• Care must be taken to distinguish a true gestational sac or a pseudo
sac which is a common finding in tubal pregnancies
• A true gestational sac has a double outline over part of the sac
representing the uterine decidua overlying the buried sac
• This double line is absent in a false sac which is due to endometrial
thickening and fluid accumulation within the uterine cavity.
• If a true intra-uterine gestational sac is found, then the diagnosis of
tubal pregnancy can be excluded
81
Indications
First Trimester
• In tubal pregnancy before rupture, findings include the
presence of an adnexal mass and slight enlargement of
the uterus
• If leakage from rupture has occurred, then free fluid
will be found in the cul-de-sac.
• In chronic ectopic pregnancy, a large complex mass may
be found adherent to the uterus or displacing the
uterus
82
Indications
First Trimester
• Hydatidiform Mole
• An ultrasound scan will show an enlarged uterus filled
with a mass of homogenous echoes producing the
“snow storm” effect
• In some scans, the texture is broken up by cystic spaces
of varying sizes representing collections of blood or clot
formation
• In most scans, NO FETUS is visible
• Multilocular bilateral lutein cysts may be imaged in half
of the molar pregnancies
83
Indications
First Trimester
• Uterine Myoma
– Most common pelvic masses associated with pregnancy
– If they are subserous and lie in the upper segment, they may not
produce any harmful effects and are usually easily identifiable on
scanning
– A large myoma in the lower segment may interfere with normal
delivery and a repeat scan at 36 week gestation is advisable.
– Multiple intramural and subserous myomas in the first trimester of
pregnancy will lead to a clinical diagnosis of :large-for-date”.
– A scan will demonstrate the typical rounded hyper or hypo echoic
masses with the uterus
– In the first 8 weeks of pregnancy, the uterine cavity may be so
distorted that a gestation sac may be lost among fibroid masses
84
Indications
Second and Third Trimester
• Diagnosis of pregnancy
• Viability of the Fetus
• Fetal Presentation
• Fetal Maturity or Gestational Age
• Reasons For The Estimation of Gestational Age
– Unsure of Dates
– Large-For-Dates
– Small-For-Dates
• Elective Caesarean Section
• Post maturity
• Fetal Abnormality
• Placenta
• Sex Determination
85
Indications
• Diagnosis of pregnancy
– Sometimes pregnancy has to be confirmed in the second
trimester
– In some of these cases, the problem is pseudocyeisis
where the patient acquires symptoms of pregnancy
including increasing abdominal girth and fetal movement.
An ultrasound scan may convince the patient of her non-
pregnant state.
86
Indications
• Viability of the Fetus
– Before real time scanners signs of intra uterine death
included apparent lack of movement on of the fetus on
static scanners, overlapping of fetal skull bones (the
Spalding Sign on radiograph), a rolled-up attitude of the
fetus, gross edema of the scalp and thorax
– The real time scanners now can establish all stages of
pregnancy with 100% accuracy by observing cardiac
pulsation
87
Indications
• Fetal Presentation
– Although clinical examination can determine the fetal presentation
there might still be some doubt particularly in obese patients
– Real time ultrasound provides rapid and precise information on both
the lie and the presenting part
– If an abnormal presentation is observed, the most likely cause is to
exclude are:
• placenta previa
• fetal abnormality
• multiple pregnancy,
• uterine myoma and
• polyhydramnios
88
Indications
– Bi-parietal Diameter (BDP)
• The earliest and most widely used parameter for
estimation of gestational age in the 2nd and 3rd
trimester is measurement of the bi-parietal diameter of
the fetal skull.
• A bi-parietal diameter should be done early in
pregnancy because the margin of error increases with
advancing gestational age.
89
Indications
– Bi-parietal Diameter (BDP)
In this can in this scan it is important to note the following:
a) Fetal skull is oval with the occipital bones at one end of the long axis
and the frontal bone at the other
b) The scan represents widest diameter between the parietal eminences,
and is taken at the level of the thalami
c) A central bright line of echoes representing the falx and other midline
structures is symmetrically placed w.r.t. the anterior and posterior
parietal bones
d) The BPD is measured from the outer table of the near parietal bone to
the inner table of the distal parietal bone
90
Indications
• Other Parameters-can be measured and are useful. They
include:
– Abdominal diameters and circumference
– Femur , tibia, humerus, and ulna lengths
– The distance between the outer margins of the two orbit is known as
the binocular distance
– Cardiac and renal size are not in general use
91
Indications
– Unsure of Dates-in women with irregular periods and in those who fail
to keep record may have no idea of when they become pregnant
– Large-for-Dates-clinical examination may suggest that the uterus is
large for dates as calculated from the menstrual date. Causes of large
for dates include:
• Wrong dates
• Unsuspected multiple pregnancy
• Uterine myoma
• Ovarian cyst
• Polyhydramnios
• Fetal macrosomia
• And certain fetal abnormalities
92
Indications
• Small-For-Dates-
– an ultrasound should be requested when clinical
examination suggests that the fetus welfare is at stake.
– The scan may indicate a normal fetus with a reduced
estimate of gestational age by 4 or even 8 weeks
clearly indicates wrong dates.
– Fetal death can also be identified on a real time
scanner
93
Indications

• Small-For-Dates
-Intrauterine growth retardation usually manifests by
32 weeks gestations
94
Indications
Elective Caesarean Section

 serial ultrasounds are needed if the decision for an
elective caesarean section is made in early pregnancy
to estimate gestational age.
 The first scan should be done between 8 and 12 weeks
and another scan done by 21 weeks followed by one at
31 weeks.
95
Indications
Fetal Abnormality
 Cranial
 Anencephaly is the most recognizable cranial defect on ultrasound.
This is recognized by the absence of the cranial vault and with
prominent cranial features being the two knob-like petrous bones.
 Hydrocephaly is where the cranium is grossly enlarged and reduced in

thickness. The size of the cranium may or may not be enlarged.
Cranial enlargement can be diagnosed by comparing head and
abdominal diameters. The ratio should be close to 1, with the head
slightly larger in the first two trimesters. The reverse is true in the last
trimester. If the diameter of the head is greater than the abdominal
diameter by more than 9mm, the HYDROCEPHALUS must be
diagnosed.
96
Indications
Fetal Abnormality
 Cranial
 Microcephaly may be diagnosed if the biparietal diameter is smaller
than the abdominal diameter by 9mm or more.
 Encephalocele is recognizable by an outgrowth from the cranium

while amniotic band syndrome may be suspected if there is gross
deformity of the head.
97
Indications
Placenta
 Appearance
 The placenta appears as a thick layer of homogenous echoes
attached to the uterine wall and covered on its internal surface by a
well defined bright line of echoes known as the chorionic plate.
 As the placenta ages, it undergoes noticeable changes. Its surface

becomes indented. The indentations usually reach the basal layer.
Fibrosis and calcification appear and multiple cystic spaces are
often seen.
98
Indications
Placenta
 Localization
 Antepartum Haemorrhage. Placenta Previa has to be excluded. A
longitudinal midline scan with a full bladder will allow the
internal os to be identified and the relationship of the placenta to
the os to be established. If the placenta is low lying up to the
second trimester it may migrate in the last trimester.
 A scan should be repeated 32-34 weeks to assess its location to
decide on a mode of delivery.
 In some cases, it is possible to demonstrate the separation of the
placenta with the uterine wall and the intervening zone of blood or
clots shows as a well demarcated hypo-echoic zone.
99
Indications
Placenta
 Abnormal lie. Whenever an abnormal lies is found on clinical examination, an
ultrasound scan should be requested to excluded to exclude the possiblity of
placenta previa.
 Amniocentesis. Ultrasound is used during this procedure to localize the
placenta. After localization, the placement of the needle can be adjusted to
avoid damage to the placenta.
Sex Determination
 Ultrasound is not used officially to determine the sex of the fetus but it can be
done after 26th week gestation.
 In the male, demonstration of the scrotum and testes is usually a reliable sign
of the fetus being a male. It is difficult to diagnose confidently the female sex
but demonstration of the vulva with a central bright line instead of a scrotal sac
is possible.
100
Retained Placenta
A retained placenta is one that remains

attached to the uterus >30minutes following
delivery or abortion, posing an increased
risk of bleeding or infection.
101
Retained Placenta
The placenta may be retained due to faulty technique in conducting the third
stage of labour or due to morbidly adherent placenta.
Incidence
Retained placenta occurs in 2% of deliveries. Frequency increases at
the gestational ages of <26 weeks and up to 37 weeks. At term, 90% of
placentas will be delivered within 15 minutes. Once 30 minutes has
passed during the third stage of labour there is a 10-fold increase in the
risk of haemorrhage.
Normally, syntometrine is given intramuscularly with the birth of the

anterior shoulder of the baby. If given too late, it may result in the
entrapment of the placenta in the uterus partially or completely.
Occasionally, excessive traction on the cord results in snapping of the
cord, thus leaving the placenta in utero.
102
Retained Placenta
The distinction is made on the thickness of the myometrium that
is involved.
There are three grades of adherent placenta:

1. Placenta accreta-this is the mildest form.
2. Placenta increta
3. Placenta percreta-the serosa has been reached.
103
Retained Placenta
Causes of Retained Placenta include:
1. Previous trauma to the uterus from manual removal of the

placenta, caeserean section or curettage
2. Defective decidual reaction probably hormonal in origin
3. Previous myomectomy
4. Submucous fibroids
104
Retained Placenta
There are three grades of adherent placenta:
1. Placenta accreta-this is the mildest form. The villi are

attached to the myometrium.
2. Placenta increta-the villi are invading the
myometrium.
3. Placenta percreta-the serosa has been reached. the
villi are beneath or have penetrated through the uterine
serosal surface.
Each entity may be focal, partial or total.
105
Retained Placenta
 Completely Adherent Placenta-bleeding is minimal as the main site of bleeding is from

the placental bed.
 Partially Separated Placenta-this is usually accompanied by heavy blood loss.
 Completely Separated Placenta-it may occupy the lower segment leaving the upper
segment free to contract, thus significantly limiting blood loss.
If there is heavy bleeding with an undelivered placenta, immediate intervention

is needed. Placental tissue remaining in the uterine cavity prevents adequate
contraction and retraction, and predispose to excessive bleeding. Cord traction
should be tried once more but if that fails, then manual removal of the placenta
is undertaken.
106
Retained Placenta
Manual Removal of the Placenta
1. Should be undertaken in the operating theater under general anaesthesia.

2. Patient is placed in the lithotomy position.
3. Vulva is cleaned with antiseptic solution.
4. The bladder is emptied.
5. One hand is introduced into the vagina and the placenta is located by
following the cord. The other hand must perform the function of steadying
the fundus through the abdominal wall.
6. Having located the placenta, the periphery is sought and using the ulnar
border of the hand, a plane of cleavage is established.
7. Keeping the fingers together, the placenta is steadily separated from the
uterine wall, and cupped in the hand which is then withdrawn. NO
CLAWING OF THE PLACENTA.
8. If the placenta is morbidly adherent in any part, it is impossible to remove
it without leaving shreds of tissue behind. As much placental tissue is
removed, digitally, and to control haemorrhage by an oxytocin transfusion.
9. Blood transfusion and prophylactic antibiotics are necessary.
107
10.In severe cases, a hysterectomy may be required as a last resort.
Caesarean Section
Definition:
A caesarean section is a procedure that involves making an incision through
the abdominal wall and the uterus for extraction of the fetus.
There has been an increase in the caesarean section rates over the last few
decades. In Trinidad in 1976 were 2.2% but have increased to 7.4% in 1997.
The rates may have increased because of:
1. Medical malpractice litigation

2. Reduced family size and at a later maternal age. The precious
pregnancy.
3. Electronic fetal monitoring
4. A reduction in the use of rotational forceps for mid-cavity vaginal
deliveries, and the consequent lack of Obstetricians with the necessary
skill to perform these types of deliveries.
5. Socio-economic and demographic factors e.g. Short stature.
6. Reluctance to allow vaginal birth.
108
Caesarean Section
Indications
A caesarean section may be elective or emergent. Indications may be maternal,
placental/cord, fetal or failure to progress/cephalopelvic disproportion.
Indications for a Caesarean Section:
Maternal:
1. Tumors
2. Previous myomectomy
3. Previous caesarean section(s)
4. Previous classical caeserean section
5. Vaginal repair operations
6. Previous traumatic vaginal delivery
7. Pelvic contractions
8. Unfavourable cervix
9. Vertical infections
109
Caesarean Section
Indications
Placental/Cord:
1. Placenta Previa
2. Abruptio placenta
3. Cord Prolapsed
Fetal:
1. Presumed fetal distress
a) Meconium stained liquor may suggest fetal distress
b) Cardiotocographic abnormalities
c) Severe intra-uterine growth restriction
d) Abnormal scalp blood pH
2. Abnormal presentation/Lie
a) Oblique lie
b) Transverse lie
c) Compound presentation
d) Brow/face presentation
e) Breech presentation (large, premature, footling, extended head)
3. Fetal Macrosomia
4. Multiple pregnancy (when twin A is breech, when twin B is in distress after twin A has
been delivered, triplets and higher order multiple gestation).
5. Gross fetal anomaly e.g. hydrocephaly
110
Caesarean Section
Indications
Failure to progress/Cephalopelvic
Disproportion:
A caesarean section should only be considered in

a primigravida after an amniotomy has been
performed and there are adequate contractions
with or without a Syntocinon infusion provided
that there are no other indications for a c-section.
111
Caesarean Section
Procedure
Preparation of Patient
1.Mother is admitted to hospital the day before surgery.

2.Informed written consent is obtained and reviewed.
3.Anaesthetist discusses the type of anaesthetic procedure that will be used (general, spinal
or epidural).
4.Blood is drawn for FBC, group and cross match 2 units of whole blood.
5.Oral ranitidine is administered.
6.Nil per os from midnight
7.On the morning of surgery, her pubic area is shaved
8.A Foley’s catheter is inserted for continuous bladder drainage.
9.The paediatric team is informed.
10.Premedication
a) Atropine sulphate 0.6mg I.M.
b) Ranitidine hydrochloride 50mg I.M/I.V.
c) An oral antacid e.g. Sodium citrate 30ml.
Narcotic analgesics, such as Pethidine are contraindicated as they cross the placental
barrier and can cause fetal respiratory depression.
112
Caesarean Section
Operative Procedure
The Skin Incision: a vertical sub-umbilical midline or Pfannenstiel (transverse

suprapubic) incision in employed.
The Vertical Incision:

i. Allows very rapid entry into the abdominal cavity. The incision is easy
to extend to allow greater exposure of the abdominal contents if
required; easier to perform a classical section; easier to perform a
caesarean hysterectomy if necessary.
ii. The main disadvantages are weaker scar with a greater incidence of
burst abdomen and a less cosmetically acceptable scar.
113
Caesarean Section
Operative Procedure
The Pfannenstiel Incision:

i. The advantages include
a) More cosmetically acceptable
b) Less risk of incisional hernia
ii. The main disadvantages are that it takes more time to perform; surgical
exposure can be difficult in certain women and it is not easy to extend
if more room is needed; there is greater incidence of wound
haematoma.
The Uterine Incision:
• Vertical Upper Segment (classical)
• Vertical Lower Segment
114
Caesarean Section
Operative Procedure
The Classical Caesarean Section

After the abdomen is opened in layers, a vertical incision is made in the anterior upper
uterine segment.
Indications:
1. Lack of access to the lower segment as a result of uterine fibroids, dense adhesions,
lower segment of a preterm uterus may not be wide enough to allow delivery of th
preterm fetus safely.
2. Post mortem to salvage a live fetus.
3. Transverse lie (dorso-inferior)
4. Elective caesarean hysterectomy
5. Major placenta previa
Disadvantages to this type of incision:

1. Increased hemorrhage
2. Weaker uterine scar
3. Greater risk of rupture in subsequent pregnancy, which can occur during the
antenatal period.
4. Difficult surgical re-approximation of the uterine incision
5. Increased morbidity e.g. Puerperal infections, longer hospitalization, greater need
115
for blood transfusion
Caesarean Section
Operative Procedure
The Lower Segment Caesarean Section:
1.The abdomen is opened in layers. Layers of the abdominal wall are:

1. Skin
2. Camper’s fascia- fatty superficial layer
3. Scarpa’s fascia- deep fibrous layer
4. External Oblique muscle
5. Internal oblique muscle
6. Transverse abdominal muscle
7. Transversalis fascia
8. Peritoneum
2.A large moistened abdominal pack is placed in each para-colic gutter to
prevent soiling of the abdominal contents by amniotic fluid, blood or
meconium.
3.The lower segment is identified by a loose fold of peritoneum superior to the
bladder (the utero-vesical fold). This fold is grasped with a non-toothed
dissecting forceps and a transverse incision is made.
116
Caesarean Section
The Lower Segment Caesarean Section

4. The bladder is now reflected off the lower segment in a caudal direction.
5. A doyen bladder retracter is inserted to protect the bladder by exposing the
lower segment.
6. A transverse incision is made with a scalpel and the amniotic membranes
are exposed.
7. The membranes are then ruptured.
8. The fetus is delivered with the aid of uterine fundal pressure and sometimes
obstetrics forceps.
9. To aid in placental separation and to reduce blood loss, one ampoule of
Syntometrine or Syntocinon intravenously as soon as the cord is clamped.
10. An infusion of 40 units of Syntocinon 1 litre of 5% Dextrose water to
keep the uterus contracted.
117
Caesarean Section
The Lower Segment Caesarean Section

11. After the placenta and membranes are delivered, the uterine cavity is
explored with a large swab to remove any additional membranes.
Submucosal fibroids or congenital anomalies can also be detected at this
time.
12. Green armytage clamps are then applied to the lateral angles of the
incision and to the edges if there are any large bleeding vessels.
13. The incision is closed in two layers with the first for haemostasis and the
second layer covers the raw edges of the first while adding tensile strength
to the incision.
14.The visceral and abdominal peritoneum are repaired after the pelvic
structures are inspected.
15.The abdominal incision is closed in layers.
16. The vagina is then swabbed to remove any clots. This is done to identify
any subsequent post-operative bleeding.
17. The urine in the collecting tubing and bag are inspected for colour and
amount.
118
Caesarean Section
Post-Operative Care for Uncomplicated Cases
First 24 Hours:
1. Vital signs every 15 minutes for the first hour, every hour for the next
four hours and then every four hours for 24 hours.
2. 3 litres of I.V. Fluids e.g. 5%Dextrose water/normal saline.
3. Input/output charting. Foley’s catheter is left in continuously for the
first 24 hours.
4. Analgesia. Pethidine 100mg I.M. Every 4 hours for 6 doses.
5. Anti-emetic. Gravol 50mg I.M. For 2-3 doses.
6. Intravenous broad spectrum antibiotics.
Caesarean Section
Day 1 Post Op:
1. The vitals chart is checked along with the input/output chart.

2. General examination is performed with emphasis for venous
thrombosis, pulmonary embolism and the presence of bowel sounds.
3. Sips of clear fluids are started and if tolerated, the I.V line can be
discontinued.
4. Physiotherapy and gentle ambulation are commenced.
5. The Foley’s catheter is removed on Day 1.
6. Oral analgesia is started and oral antibiotics can be prescribed.
7. Breastfeeding is encouraged
8. An indirect Coombs test is performed if she is Rhesus negative on the
mother. Direct coombs test from the cord blood.
Caesarean Section
Day 2-3:
1. Soft food diet and normal diet on the third day.

2. Hb is checked.
3. If she has not passed stool by this time, a Dulcolax rectal suppositories
can be administered.
4. Dressing is changed.
5. She is discharged and is made to return on day 7 to have sutured
removed.
6. An appointment is made for a postnatal visit in 6 weeks. At this visit, a
general examination is done and she receives contraception and is
advised to have future antenatal care at a tertiary institution as any
subsequent pregnancy is at a higher risk for obstetric complications.
Caesarean Section
Complications
1.Anaesthetic complications
Anaesthetic complications are increased when general
anaesthesia is used. Mendelson’s Syndrome is acid aspiration. It
can be reduced by the use of cricoid pressure and reducing gastric
pH contents. If it occurs, there is a high mortality rate.
2.Haemorrhage is a common complication. Blood flow through
the uterine vessels at term is about 400-800ml/min. Reactionary
haemorrhage can occur as a result of a slipped ligature or oozing
from the edges of the uterine cavity when the blood pressure rises.
Secondary haemorrhage may present 1-2 weeks following surgery
as a result of post-operative endometritis.
3.Trauma-may occur to bowel, bladder and the uterus. The fetus
may be at risk of scalpel injury on making the uterine incision.
Caesarean Section
Complications
4. Sepsis-peritonitis can occur especially in the presence of

chorioamnionitis and with retroperitoneal haematoma formation.
Superficial infections occur frequently, especially with a
Pfannenstiel incision which is prone to haematoma collection.
Reduce infection by using intraoperative antibiotics.
5. Thromboembolism can cause maternal death. Prevention
with pneumatic compression stockings intraoperatively, early
ambulation and heparin therapy in selected cases.
6. Paralytic Ileus is rare but may occur following
contamination of the abdominal contents by infected blood.
Caesarean Section
Vaginal Birth After Caesarean Section (VBAC)
Trial of Scar which implies that the obstetrician is testing the integrity of the scar
with the end point being rupture of the uterus instead of a vaginal delivery.
Success rate of 60%-80% has been reported for a VBAC.
Before embarking on a VBAC it is important that:

1. There is no gross cephalopelvic disproportion
2. There was no previous endometritis following the previous caesarean
section which can result in a weaker scar.
3. The scar was in the lower segment and the presentation is cephalic.
4. Facilities are available for a repeat caesarean section. The mother is
labelled high risk. There must be close maternal and fetal surveillance.
IV access must be sited and blood cross matched.
5. Obstetrician and paediatrician must be available on site. The mother
must be kept nil per oral except for antacids.
6. There should be early recourse to c-section especially if she has been in
established labour for more than 6 hours.
Caesarean Section
Vaginal Birth After Caesarean Section (VBAC)
Complications:
Uterine rupture or scar dehiscence, loss of uterine activity, signs of

hypovolaemic shock, bright red vaginal bleeding, ascent of the
presenting part of the pelvis, and scar tenderness.
Caesarean Section
Instruments
Doyen’s Retractors
Uses:
1. Retracts the urinary bladder during a Caesarean section
Features:
1. Retractor is wide and has a deep curve
2. Effective in pulling the bladder away
Caesarean Section
Instruments
Green Armytage Clamps
Uses:
1. Placed at the lateral edges of a uterine incision made at caesarean section, especially at the
angles if there are any bleeding vessels.
2. Use sponge forceps if the Green Armytage is not available but there is danger of suturing
through the hole.
Features:
1. Non-traumatic (atraumatic to the tissue)
2. Haemostatic
3. Broad based for a wide area of haemostasis
Cervical Cerclage
Mersilene Tape
128
Cervical Cerclage
Mersilene Tape
Features:
1. White
2. Polyester suture
3. Sterile
4. 5mm wide
5. 30cm in length
6. Attached to an aneurysmal needle
7. Used for the placement of a McDonald or
Shirodkar suture in a patient with cervical
incompetence.
8. Applied at 14-16 weeks gestation 129
Cervical Incompetence
History of abortions:
1. Recurrent
2. Midtrimester
3. Complete
4. Quick
5. Painless
6. Bloodless
130
Diagnosis of cervical incompetence may be confirmed :

1. Easy painless passage of a No. 8 Hegar dilator through the cervical
canal of a non-pregnant unanaesthetised woman; start with a
number 12 and work downward.
2. Hysterography in the nonpregnant patient. It demonstrates reflux dye
through the cervical canal. The diameter is measured; if it is greater
than 8mm an incompetent cervix is diagnosed.
3. By observing painless effacement and dilatation of the cervix over
several weeks in the midtrimester. The membranes eventually dilate
the cervix and bulge.
4. With serial ultrasonography during early pregnancy to determine the
length of the cervix, and the shape and the width of the cervical
canal.
131
Treatment of Cervical Incompetence
The treatment of cervical incompetence is the placement of a suture around the internal
os of the cervix at the end of the first trimester of pregnancy. This is called a cervical
cerclage.
Time of Insertion: 14-18 weeks gestation
Prior to a cerclage, an ultrasound is needed to:

1. to assess the fetus for any cardiac activity
2. maturity
3. exclude any fetal anomalies e.g. anencephaly
Methods of Cervical Cerclage:

1. McDonald
2. Shirodkar
3. Benson and Durfee
4. Lash
132
McDonald Technique: Mersilene Tape is encircled through the internal os in

an in/out fashion of the cervical mucosa and underlying tissues.
Shirodkar Technique: A transverse incision is made on the anterior surface

of the portio-vaginalis at the level of the internal os and a similar incision is
made in the posterior fornix at the level of the insertion of the uterosacral
ligaments. Using an aneurysmal needle, Mersilene tape or black silk or
another non-absorbable material is directed submucosally through the anterior
incision, close to the cervix and emerges posteriorly; the other end of the stitch
is passed round the opposite side of the cervix and emerges posteriorly. The
suture is then tied, leaving the ends long to facilitate removal. The vaginal
mucosa is then closed with catgut sutures.
133
Postoperatively Treatment:
1. Tocolytic agent e.g. Indomethacin rectally, Salbutamol, or
Depo Provera is given to dampen uterine contractions.
2. Bed rest
3. NO SEXUAL INTERCOURSE!
4. Sedation
134
Cervical Cerclage
Complications of Cervical cerclage:

1. Bucket handle tear
Removal of the Suture:

1. Electively removed at 38 weeks
2. Missed abortion
3. Fetal anomaly
4. Antepartum Haemorrhage
5. Preterm Labour
6. Spontaneous Rupture of Membranes
7. Intrauterine Demise
135
Magnesium Sulphate
Magnesium Sulphate is used in obstetrics as an anticonvulsant in the
management of eclampsia and also as a tocolytic agent to prevent preterm
labour.
Anticonvulsant:
Magnesium sulphate is centrally acting. It blocks neuromuscular contraction
by presynaptic inhibition at the myoneuronal junction. It also blocks the
stimulation of catecholamine release from the adrenal medulla. It produces
peripheral vasodilatation and decreases responsiveness of the vascular smooth
muscle to sympathomimetic amines. It has minimal hypotensive effects. It
does not produce sedation.
Tocolytic:
Magnesium Sulphate exerts its tocolytic effect by interfering with intracellular
calcium formation
136
Magnesium Sulphate
Dose:
Anticonvulsant: Loading dose of 4g (20ml of a 20% solution) IV over 3-5
minutes. Maintenance dose of 1-3g/hour IV or IM. Antidote for Magnesium
sulphate is Calcium Gluconate 10ml of a 10% solution given over 3 minutes.
Tocolytic: Infusion 0f 20g of Magnesium sulphate in 1Litre of 5% Dextrose-

water at a rate of 7ml/minute for 1 hour then 4ml/minute for 1 hour followed by
2ml/minute as maintenance dose for ~12hours after cessation of uterine
contractions.
Magnesium Sulphate
Adverse Effects:
1. Respiratory depression
2. Cardiac arrest
3. Loss of tendon reflexes
4. Slurred speech
5. Muscle paralysis
6. Somnolence
7. Warm flushing
8. ECG changes
Monitor: patients on magnesium sulphate should be monitored to ensure that:

1. Pulse >60 beats/minute
2. Respiratory rate >12 breaths/minute
3. Deep tendon reflexes are present
4. Urine output >30ml/hour
5. Serum magnesium 4-7mg/dl
Magnesium Sulphate has a narrow therapeutic index:

• Therapeutic range 4-7mg/dl
• Reflexes disappear at 10-12mg/dl
• Respiratory arrest occurs at 15mg/dl
• Cardiac arrest occurs at 30mg/dl 138
Magnesium Sulphate
Magnesium Sulphate Toxicity
(Levels in mg/dl)
 1.5-3 Normal
 4-7 Therapeutic Levels
5-10 ECG Changes
8-12 Loss of patellar reflex/warm flushing
10-12 Somnolence/Slurred Speech
15-17 Muscle Paralysis/ Respiratory Difficulty
≥30 Cardiac Arrest
139
Magnesium Sulphate
140
Salbutamol
(Ventolin)
Salbutamol is a beta two adrenergic agent.
Mechanism of action:
beta adrenergic receptors are situated on the outer surface of the cell
membrane in the myometrium. When the receptors are stimulated by a beta
adrenergic agonist, relaxation of the uterus ensues. This occurs because of the
release of the enzyme adenylcyclase which catalyses the conversion of the ATP
to AMP. AMP that stimulates the activity of a group of enzymes responsible
for protein phosphorylation in the cell membrane. The uptake and
sequestration of intracellular calcium is increased, intracellular calcium levels
fall and contractile state of the myometrium is interfered with resulting in
relaxation.
Indications for use:

1. Tocolytic
2. Bronchodilator
141
Salbutamol
Dose:
IV infusion of 5mg in 500ml of Dextrose water. When
contractions cease, continue orally 4mg po TID.
Contraindications:
1. Bradycardia
2. Hypotension
3. Heart block
Adverse Effects:
1. Bradycardia
2. Decreased blood pressure
3. Hyperglycaemia
142
Salbutamol
143
Syntometrine
(5iu Oxytocin and 0.5mg ergometrine)
Produces a sustained tetanic contraction of the myometrium that reduces blood
loss from the vessels at the placental site. It also promotes contraction of the
uterine corpus. Given with the birth of the anterior shoulder.
Indications:
a) Promotes sustained uterine contractions during the 3rd stage of labour
b) Treatment of post partum haemorrhage due to uterine atony. Given IV.
c) Given after delivery of a retained placenta. Given IV.
d) During caesarean section after delivery of the infant.
e) Given prophylacticly for post partum haemorrhage or post partum
shock
a) Previous post partum haemorrhage
b) Grand multiparity
c) Anaemia
d) Hydramnios
e) Twin delivery, after delivery of twin B
f) Incomplete abortion
g) Evacuation of a hydatidiform mole 144
Syntometrine
(5iu Oxytocin and 0.5mg ergometrine)
Dose:
1 ampoule of Syntometrine contains 5units
of Syntocinon plus 0.5mg Ergometrine.
Onset of action:
IM 2-3minutes
IV 30-60seconds
145
Syntometrine
Contraindications:
1. Hypertensive disorders of pregnancy
2. Cardiac disease in pregnancy
3. Twin pregnancy after delivery of twin A
4. Vaso-occlusive disease (e.g. Sickle cell
disease)
Adverse Effects:
1. Increased incidence of retained placenta
2. Post partum pain
3. Tetanic contractions 146
Augmentin
(Amoxicillin + Clavulanic Acid)
Amoxicillin is bactericidal. It is a natural penicillin that binds to the beta

lactam ring, hydrolyzes it via enzymatic activity causing death to the bacteria.
The bacteria interferes with the last step of bacterial cell wall synthesis.
Clavulanic acid is a beta lactamase inhibitor. It doesn’t have much antibiotic
from enzymatic inactivation.
Indications:
1. Prevention of chorioamnionitis
2. Respiratory tract infections
3. Prophylactic for patients with prosthetic valves by the dentists
4. Urinary tract infection
5. Uncomplicated sinusitis/complicated sinusitis
6. Pharyngitis
7. Otitis media
8. Skin infections 147
Augmentin
Dose:
1 vial contains 1g Amoxicillin/200mg Clavulanic Acid.
875mg po BID or 500mg po TID or 90mg/kg/day
Adverse Effects:
1. Nausea
2. Diarrhea
3. Vomiting
4. Interstitial nephritis
5. Neurotoxicity
6. Platelet dysfunction
7. Hypersensitivity
148
Augmentin
149
Gonodotrophin Releasing Hormone Analogues
Gonadotrophin Releasing Hormone Analogues
(Goserelin, Buserelin, and Leuprolide)
Inhibit ovulation for 4-9 months to prevent cyclic stimulation of the
endometrial implants. GnRH analogues acts as an inhibitors of GnRH.
These are effective in suppressing the production of gonadal hormones.
Indications:
Conservative/Non-operative management of Endometriosis and Fibroids
1. Prostate Cancer
2. Endometriosis
3. Fibroids
4. Precocious Puberty
• The GnRH analogues cause climacteric side effects, that is
Pseudomenopause.
• To prevent/reduce climacteric side effects, use add back regime (add
minimal amount of estrogen & biphosphonates)
Goserelin
(Zoladex)
GYNAECOLOGY
What is gynaecology?
Gynaecology is the medical specialty
that is concerned with diseases of the
female genital tract, as well as
endocrinology and reproductive
physiology of the female.
152
Gynaecological History
Name:
Date of Birth:
Age:
Occupation:
Presenting Complaint:
History of Presenting Complaint: include
– Abnormal menstrual loss
– Pattern of bleeding-regular, irregular
– Intermenstrual bleeding
– Amount loss
– Number of pads
– Clots? Or flooding
– Pelvic pain
– Vaginal discharge
• Amount, Blood, Odor, Color
– Usual cycle
• Menarche, Duration, Cycle Length
• Last Menstrual Period
153
Past Gynaecological History:
– Surgical gynaecological treatment
– Last pap smear? Result?
Past Obstetric History:
– Number of pregnancies, birth weight, puerperium, ages of children
Sexual and Contraceptive History:
– Coitarche and Number of sexual partners
– Sexually transmitted diseases
– Dysparenuia
– Bleeding during intercourse
– Use of contraception and Type
Past Medical History:
Past Surgical History:
Drug History:
Family History:
Social History:
154
Review of Systems:
• Central nervous system review
• Cardiovascular system review
• Respiratory system review
• Gastrointestinal system review
• Genitourinary system review
• Gynaecological Review of system
Summary:
On Examination:
Assessment:
Plan:
155
Dilatation and Curettage
Dilatation and Curettage is dilatation of the cervix and

curettement of the endometrium.
Indications for Dilatation:

1. Cervical stenosis
 Dysmenorrhoea
 Haematometra
 Pyometra
 Infertility
2. Insertion of IUCD
3. Hegar dilator test for cervical incompetence
4. Prior to Hysterosalpingography
5. Intrauterine radium packing 156
Indications: Diagnostic and Therapeutic

Diagnostic Indications for D &C:
1. Menorrhagia
2. Intermenstrual bleeding due to an endometrial polyp
3. Genital tuberculosis
4. Infertility-Test for ovulation (Day 24 endometrial biopsy)
5. Post menopausal bleeding (EUA and fractional curettage)
6. Prolonged uterine bleeding
7. Endometrial hyperplasia/adenocarcinoma
8. Amenorrhea? Asherman’s syndrome
9. Prior to Manchester operation/Le Fort Operation
10.Aria Stella phenomenon with suspected ectopic pregnancy
11.Recurrent abortions-uterine anomalies
157
Indications: Diagnostic and Therapeutic
Therapeutic Indications for D &C:

1. Evacuation of retained products of conception
• Incomplete abortion
• Missed abortion
• Septic incomplete abortion
• Hydatidiform mole (suction followed by
sharp curettage)
2. Endometrial polypectomy
3. Menorhagia (deep curettage)
4. Removal of lost IUCD
158
Procedure
1.General anaesthesia
2.Patient in lithotomy position
3.Aseptic technique, empty bladder with a Jake’s catheter
4.Examination under anaesthesia
5.Insertion of the Aurvard’s Weighted Speculum
6.Pass the uterine sound to determine depth of uterine cavity
7.Dilatation with Hegar dilator
8.Curettage with uterine curette
9.Histological analysis of endometrial curetting
159
Complications of Dilatation and Curettage:
1.Asherman’s Syndrome occurs when

overzealous curetting of the endometrium
damages the basal layer leading to fibrosis and
adhesions. This leads to amenorrhea and
infertility.
2.Bleeding
3.Infection
4.Air emboli
160
Uterine Curette
O
Uterine Curette
Uses:
1. Dilatation and curettage
2. To obtain uterine samples for analysis
3. To remove products of conception
Features:
1. Sharp curette-used in a non-pregnant patient and
used for diagnostic purposes.
2. Blunt curette-used in a gravid uterus because it is
less likely to perforate. A blunt curette is also
used therapeutically in incomplete abortions.
Hegar Dilators
Hegar Dilator
Uses:
1. To dilate the cervix in
• Dilatation and curettage
• Hysteroscopy
• Hysterosalpingography
• Diagnosis of cervical incompetence in a
nonpregnant patient
• Cervical stenosis
Features:
1. Comes in varying sizes starting from 8mm-14mm
Complications:
1. Trauma to the uterus leading to cervical incompetence
later.
164
Uterine sound
165
Uterine sound
Uses:
1. To assess uterine size prior to dilating the cervix.
2. Prior to insertion of an IUCD
3. Prior to a dilatation and curettage
4. Measures the depth of the uterus
Features:
1. Calibrated for length
Complications:
1. Uterine perforation
2. Infection
166
Pap Smear Apparatus
Pap smear:
 Exfoliative cytology of cervix
 Annual screening for all sexually active women is
recommended by the American College of
Obstetrics and Gynecology
 The American Cancer Society recommends
screening of women with a Pap Smear every
three years
 Detects dysplastic cells
Dyskaryosis
Hyperchromatic
Koilocytosis
167
Pap Smear Apparatus
Cytobrush
Features:
1. Plastic
2. Contains nylon bristles
Function:
1. To obtain exfoliating cells from the endocervix
168
Pap Smear Apparatus
Ayres Spatula
Features:
1. Wooden
2. Two ends:
• One for nulliparous women
• Two for multiparous women
Function:
• to obtain exfoliating cell from the ectocervix
169
Pap Smear Apparatus
Cusco’s Speculum
Uses:
1. Used to visualize the cervix and lateral walls of the vagina
2. Allows for Pap Smear, cervical biopsy, endometrial
aspiration, take swabs for and endocervical smear and a
high vaginal smear
Features:
1. Two blades
• Upper (anterior)
• Lower (posterior)
2. Only the bottom blade moves
3. Handle
4. Various sizes: small, medium, and large
170
Pap Smear Apparatus
Other apparatus include:

1. Gloves
2. Lubricating jelly
3. Fixative spray
4. Microscope slide
5. Pap smear form
171
Pap Smear
How to perform a pap smear?
1. Patient instructed not to have intercourse night prior to Pap smear

2. Patient should not be menstruating
3. Ensure that the requisition form is completed.
4. Label the slide with a pencil a the frosted end.
5. The patient is placed in the lithotomy position with her legs in the
stirrups.
6. Do not perform bimanual vaginal examination prior to Pap smear
7. External genitalia is examined.
8. Speculum of appropriate size is passed.
9. Lubricate speculum with warm water. Do not use lubricating jelly.
10. Cervix is identified and the position of the transformation zone is
assessed.
11. Rotate the spatula once through 360̊ and keep it well applied.
12. Insert the Cytobrush gently and turn 180̊ . Do not use in pregnancy.
13. Apply each sample on one half of the slide.
14. Fix the sample immediately and allow to dry before closing.
172
Pap Smear
Papanicoloau Classification
Negative
I. Normal
II.Inflammatory
Positive
III.Mild Dyskaryosis
IV.Moderate to severe dyskaryosis
V.Malignant cells seen
Pap Smear
The Bethesda System
1. Benign Cellular Changes
a) Infection
b) Reactive
2. EPITHELIAL CELL ABNORMALITIES
• SQUAMOUS CELL
•Atypical squamous cells of undetermined significance (ASC-US)
•Low grade squamous intraepithelial lesion (LSIL)
encompassing: HPV/mild dysplasia/CIN 1
•High grade squamous intraepithelial lesion (HSIL)
encompassing: moderate and severe dysplasia, CIS/CIN II and
CIN III
•Squamous cell carcinoma
• GLANDULAR CELL
•Atypical glandular cells of undetermined significance (AGCUS)
•Adenocarcinoma
Cervical Intraepithelial Neoplasia
Management:
•Based on
•Type of lesion
•Patient’s reproductive ambition
•Follow-up
•CIN I or II treatment options
•Local ablation
•Cryocautery
•Electrocautery
•CO2 laser
•Excisional removal
•Loop diathermy
•Cold knife
•Therapeutic cone biopsy
•CIN I may be left alone & managed conservatively (may revert to normal)
•CIN III (severe dysplasia & carcinoma-in-situ) or microinvasive disease
•If reproductive ambition complete  extended hysterectomy
•If reproductive ambition incomplete  therapeutic cone biopsy
•Follow-up  regular routine re-screening with Pap smear & Colposcopy
Diathermy Loops
(LLETZ)
Diathermy Loops are used in the treatment of cervical intraepithelial

neoplasia II and III.
Cervical Carcinoma
History:
•Asymptomatic with risk factors
•Age 35-45
Early coitarche
Multiple sexual partners
Promiscuity
Association with sexual partners that are high risk
(e.g. presence of HIV)
Sexually transmitted diseases (e.g. herpes virus
type 2)
Smoking cigarettes
Cervical Carcinoma
•Symptomatic
Prolonged or heavy bleeding
oIntermenstrual bleeding
oPost-coital bleeding
oPost-menopausal bleeding
Vaginal discharge  foul-smelling & blood stained (in later stages)
Pain
oChronic low back pain or pelvic pain
oDeep dyspareunia
Constitutional symptoms
oAnemia
oAnorexia
oCachexia
oUremia
oWeight-loss
oMalaise
Late/metastatic symptoms
oFrequency
oDysuria
oHematuria
oEdema
oConstipation/diarrhea
oUrinary/fecal incontinence
oChronic renal failure due to hydronephrosis (terminal stages)
Cervical Carcinoma
Examination:
•General
•Anemia
•Cachexia
•Supraclavicular lymphadenopathy (terminal disease)
•Abdominal
•Palpable abdominal mass
•Hard
•Irregular
•Hepatomegaly (metastases)
•Vaginal examination
•Fungating mass in vagina or at introitus
•Speculum
•Blood coming out of os
•Cervix bleeds readily & is friable
•Fungating, ulcerating, infected, necrotic or exophytic mass
•Bimanual examination
•Consistency of uterus & cervix
•DRE  parametrial involvement
Cervical Carcinoma
Investigations:
•Hb – for anemia
•Screening test  Pap smear
•Diagnostic tests  biopsy
•Colposcopy
•Cone biopsy
•Staging tests
•Ultrasound scan of pelvis
•Intravenous pyelogram  detects hydronephrosis
•Barium enema & proctoscopy  spread to bowels
Staging of Cervical Cancer
Stages:
•Stage 0: carcinoma-in-situ
•Stage I: cancer confined to cervix
Ia1: < 3 mm involvement from basement membrane
Ia2: 3-5 mm involvement from basement membrane
Ib: involves cervix or only to body of uterus
•Stage II: cancer involving upper 2/3 of vagina as well
IIa: not involving parametrium
IIb: involving parametrium but not pelvic wall
•Stage III: cancer involving whole vagina
IIIa: lower third of vagina
IIIb: parametrium as far as pelvic wall
•Stage IV: cancer involving bladder/rectal mucosa or extension
outside true pelvis
Staging of Cervical Cancer
Management:
•Depends on stage
Stage 0-Ia1
oIf patient has reproductive ambitions
Cone excisional biopsy (in diagnosing)
Nothing further if lesion is completely removed
Regular follow up with cervical smears & colposcopy
Extended hysterectomy as soon as family complete
oRegular follow up with vaginal smears & colposcopy
oIf no reproductive ambitions  extended hysterectomy
Stage Ia2: Wertheim’s operation (radical hysterectomy + pelvic
lymphadenectomy) or radiotherapy
Stage Ib-IIa: radical hysterectomy or radiotherapy or both
Stage IIb-IV
oRadiotherapy
oChemotherapy
Grave’s Speculum
Grave’s Speculum
Uses:
– Colposcopy (examination of the cervix and vagina by means of endoscopy)
– Used to visualize vaginal walls
– Allows access for a pap smear
– Used during a cervical biopsy
– Used during endometrial aspiraiton
– Used to view the cervix to collect endometrial swabs or high vaginal swabs
Features:
– Opens in two planes
– May be plain, ebonized or insulated
– Both blades can move
– Lower (posterior) blade is longer
Punch Biopsy Forceps
Uses:
– Used during outpatient Colposcopy
– Used for cervical biopsies
Features:
– Designed to take biopsies from the most critical areas
– Endocervical forceps are angled to take a precise biopsy of the endocervical
canal (site of the most common lesion).
– The jaws of both instruments have been designed to give the maximum size of
tissue bite.
– The cutting action is superior to conventional forceps, giving grip and a smooth
clean cut without the need to twist or pull the forceps from the tissue.
Colposcopy:
– Procedure done after abnormal Pap smear to confirm CIN by visualizing
abnormal areas in cervix & upper vagina
– The endocervical canal extends beyond the field of vision in 12-15% of
premenopausal women and in a higher percentage of post menopausal women
– Procedure
• 5% acetic acid sprayed on cervix
• Abnormal areas show:
– Punctate stippling
– Mosaicism
– Aceto-white appearance
– Abnormal vascular pattern
• Abnormal areas are biopsied with the punch biopsy forceps for histological
diagnosis:
– CIN I – lower 1/3
– CIN II – lower 2/3
– CIN III – severe/whole (carcinoma-in-situ)
Assessment of Tubal Patency In Female Infertility
Tubal Cause of Infertility:

•Evaluate in pre-ovulatory phase (day 7 to 10)
•Methods
•Tubal insufflation
•Hysterosalpingography (HSG)
•Endoscopy
189
Assessment of Tubal Patency In Female Infertility
Tubal insufflation
•Administer CO2 through Jarcho’s cannula applied to cervix &
record pressures
•Normal pressures: rises to 80 mmHg & drops to 20-30 mm Hg
•In tubal stenosis, pressure rises to: 180-200 mmHg
•Disadvantages
•If tubes blocked, cannot tell site of occlusion
•Can not tell if one or both tubes are blocked
•Risk of air embolism if air used instead of CO2
•Failure of CO2 passage could mean tubal spasm
190
Hysterosalpingography
Indications
•Tubal patency
•Recurrent abortions
•Location of lost IUCD
•Evaluation of integrity of uterine scar
•Asherman’s syndrome
Advantage
•Can diagnose site of occlusion
•Outlines uterine cavity
•Outlines cervical canal
•General anesthesia not required
•Out-patient procedure
191
Hysterosalpingography
Procedure
•Jarcho’s cannula fitted into cervical canal & attached to syringe
containing radio-opaque dye (e.g. Hypaque, Ethiodol, Salpix)
•Control film taken
•Fractional injections of 5-10 ml at a time injected & films taken
•1st film shows uterine cavity
•2nd film shows spill
Complications
•Oil granulomas
•Shoulder-tip/abdominal pain
•Pelvic endometriosis
•Peritonitis
•Cornual spasm  false negative
•Anaphylactic shock
•Radiation risks
•Trauma to cervix
192
Laparoscopy
Veress needle
193
Perform operative procedures
Laparoscopy
Plan:
•Definition
•Indications
Diagnostic
Therapeutic
•Contra-indications
•Advantages
•Technique
•Complications
Definition:
•Invasive endoscopic procedure
•Allows
Visualization of entire pelvic cavity
•Perform operative procedures
Laparoscopy
Indications:
•Diagnostic
•Pelvic tumors or unknown pelvic masses
•Biopsy
•Staging & spread
•Precocious puberty - ovarian masses
•Absence of menstruation - absent ovaries or uterus
•Acute/chronic pelvic pain - to determine cause
•Infertility
•Visualize tubal adhesions
•Secondary to PID
•Secondary to endometriosis
•Test Tubal patency with methylene blue
•Look for outflow of dye
•See pearly white cysts on ovary of polycystic ovarian
disease
Laparoscopy
Indications:
•Diagnostic
•Tuberculosis – gumma formation
•Endometriosis
•Visualize deposits
•Chocolate cysts on ovaries
•Flame shaped hemorrhages
•Blue blobs on peritoneum
•Extent of disease
•Location
•Involvement of tubes
•Visualize adhesions caused by endometriotic deposits
•Ectopic pregnancy
Laparoscopy
Indications:
Therapeutic (4 C’s)
•Cancer/tumors
•Aspiration of ovarian cysts
•Removal of subserosal fibroids
•Contraception
•Removal of foreign bodies (e.g. lost IUCD)
•Tubal ligation
•Conception
•Treatment of infertility
•Lyse adhesions on tubes
•In-vitro fertilization – retrieve oocytes
Laparoscopy
Indications:
Therapeutic
•Complaints of pain/bleeding
•Ectopic pregnancy
•When < 3 cm
•Endometriosis
•Lyse adhesions
•Cauterize deposits
•Laser vaporization
•Second look to aid in evaluation of
treatment
•Treatment of PID
Laparoscopy
Contra-indications: (A CHASE)
•Acute abdomen
•Contra-indications to anesthesia
•Hiatus hernia
•Abdominal mass > 12/40 size
•Severe or moderate cardiorespiratory distress
•Extreme obesity
Laparoscopy
Advantages: (MD DEAL)

•More cosmetically appealing
•Day-case procedure
•Done under GA/LA
Local  for diagnostic procedures &
sterilization
•Easy to perform
•Minimal Adhesion formation
•Low post-operative morbidity
Laparoscopy
Technique:
1. Informed Consent
2. Patient is anaesthetized
3. Patient in Lithotomy position
4. Vaginal preparation
• Empty bladder with Jake’s catheter
• Examination Under A naesthesia
• Vaginal cleansing
• Cervix is exposed and a Vulsellum is attached to the anterior lip of the
cervix while a cervical cannula is introduced and locked into place.
5. Antiseptic cleansing of abdomen
6. 1 cm sub/intraumbilical incision is made after infiltration with 1% Xylocaine
7. Patient placed in a 45̊ Trendelenburg position and a Veres Needle is inserted
into the peritoneal cavity. The abdomen is inflated with Carbon Dioxide until
an abdominal pressure of 40cm of water
8. Uterine manipulation
9. The Veres Needle is removed and incision extended.
10. Insert trocar, then laparoscope at a 45̊ to the skin in the direction of the pelvis.
11. When finished, relieve pneumoperitoneum.
12. Instruments are removed in reverse order
13. Discuss results with patient
Laparoscopy
Veres Needle
Laparoscopy
Veres Needle
Uses:
• Used for the instillation of gas (usually carbon dioxide into
the abdomen during laparoscopy)
• Up to 3L of gas
• Carbon dioxide is safe
• It is not combustible
• Low risk of air embolism
• Forms a pneumoperitoneum
• 40-45cm of water pressure
• 25mmHg pressure used to insert trocar
• 15mmHg pressure needed to operate
Features:
• Spring-loaded which leads to the prevention of perforation
of abdominal viscera
Laparoscopy
Disadvantages:
•Major procedure
•Anesthetic complications
•Trauma to bladder, bowel, blood vessels, cervix
•Cystitis
•Pelvic adhesions
Complications: (CHASE E)
•Aggravate Cardiorespiratory compromise
•Hernias
•Anesthetic
•Shoulder-tip pain
•Gas Embolism
•Parietal Emphysema
Contraception & Sterilization
Contraceptive methods:
•Physical methods
•Mechanical barriers
•Spermicides
•Intra-uterine devices
•Oral contraceptives
•Injectable contraceptives & progestogen implants
•Sterilization procedures
Physical methods:
•Rhythm safe period
Intercourse avoided during fertile period of cycle
Basal body temperature
oRise of 0.3-0.5 oC (0.5-1.0 oF) after ovulation
oIntercourse avoided for 5 days afterwards
Cervical mucus method
•Coitus Interruptus
Withdrawal of penis from vagina prior to ejaculation
oResumed for 7 days before menses
Mechanical barriers:
•Condom or sheath
Protects against venereal disease
Decreases sexual satisfaction
•Diaphragm
Inserted in vagina 2 hours before intercourse
Spermicidal cream used to increase
effectiveness
Should not be removed for 6-8 hours after
intercourse
Vaginal Spermicides:
•Foams & creams inserted high into vagina
using applicator prior to intercourse
•Used as adjunct to mechanical barriers
Condom
Condom
Advantages:
•Provides protection against pregnancy and sexually transmitted
diseases.
•Condoms have a slight tourniquet effect on the outer veins of the
penis. This may be beneficial for men who have trouble keeping an
erection.
•The condom frequently prolongs a man's ejaculation.
Safety: 98% safe. Pearl Index of 3-14
Disadvantages:
•A few men can not maintain an erection
•Friction of the condom may reduce clitoral stimulation and reduce
lubrication, making intercourse less enjoyable or even
uncomfortable.
•Intercourse may be less pleasurable since the man must withdraw
his penis immediately after ejaculation.
•Latex Allergies to latex condoms are rare, but they do occur.
(Alternatives are polyurethane or animal membranes.)
Intra-uterine contraceptive device (IUCD):
•Plastic device inserted into uterus to prevent pregnancy
•Indications
•If OCP is contra-indicated
•History of venous-thromboembolism
•History of liver disease
•Uncontrolled hypertension
•Migraine headaches
•Patients unwilling to use OCP’s because of lack of
convenience
•Emergency contraception
Types
•First Generation-Inert (e.g. Lippes loop)
•Second Generation-Copper-bearing devices (e.g. Copper T,
Copper 7, Copper 250)
•Third Generation-Hormone-releasing devices
•Progestasert
•Mirena (levonorgestrel)
•Mechanism of action
•Induces foreign body reaction
•Stimulates inflammatory reaction
•Interference with enzyme systems
•Copper ions – spermicidal
•Hormone-releasing  create secretory endothelium
(unreceptive to implantation)
Intra-uterine contraceptive device (IUCD)
Complications:
•Expulsion
•Perforation of uterus
•Bleeding – menorrhagia & intermenstrual bleeding
•Pain – low backache & uterine cramps
•Infection – PID, sepsis
•Failed contraception & risk of ectopic pregnancy
•Lost IUCD
Intra-uterine contraceptive device (IUCD)
Contra-indications:
•Active PID
•Large fibroids
•Abnormal uterine bleeding
•Pregnancy
•History of previous ectopic pregnancy
•Valvular or congenital heart disease (susceptibility to bacterial
endocarditis)
•Malignant changes of
•Cervix
•Endometrium
•Ovary
•Recently expelled hydatidiform mole
•Allergy to copper & Wilson’s disease  for copper-containing
devices
Intrauterine Contraceptive Device (IUCD)
Locating lost IUCD
•Speculum examination to confirm
•X-ray of pelvis to locate
•If extra-uterine  laparoscopic removal may be
necessary
•If intra-uterine
•Removal hook
•Curettage
•Hysteroscopic removal
Intrauterine contraceptive Device
Introducer
Introducer
Intrauterine Contraceptive Device
Oral Contraceptives
Types
•Combined preparations
•Monophasic
•Biphasic/sequential (no longer used because of endometrial
carcinoma association)
•Triphasic
•Progestogen-only pill (mini-pill)
Oral Contraceptives
Mechanism of action
•Inhibits ovulation
•Thickens cervical mucus – impenetrable to sperm
•Creates unreceptive endometrium for implantation
•Alters myometrial & tubal muscular activity – interfere with
sperm transport & accelerated propulsion of zygote
Oral Contraceptives
Benefits
•Decreases menstrual flow – used in menorrhagia &
anemia
•Relief of dysmenorrhea
•Improvement in skin texture
•Enlargement of breasts
•Increased sexual satisfaction
•Decreases risk of fibroids, PID, endometriosis &
ectopic pregnancy
•Protects against benign breast disease & simple
ovarian cysts
•Reduced risk of ovarian & endometrial carcinoma
•Rapid return to normal fertility
Oral Contraceptives
Side effects:
Estrogenic
•Premenstrual tension
•Weight-gain; fluid retention
•Nausea & vomiting
•Cervical erosion
•Menorrhagia
•Chloasma
•Venous thromboembolism
Oral Contraceptives
Side Effects:
Progestogenic
•Premenstrual depression
•Weight-gain; increased appetite
•Tiredness
•Dry vagina
•Oligomenorrhea
•Greasy hair & acne
•Breast fullness
Oral Contraceptives
Complications
• Thrombo-embolic events
• Venous thrombosis
• Thrombotic stroke
• Cerebrovascular hemorrhage
• Hypertension
• Benign liver tumor
Oral Contraceptives
Contraindications
• History of thrombo-embolic disease
• Severe hepatic dysfunction
• Sickle-cell anemia
• Breast or endometrial carcinoma
• Severe diabetes mellitus
• Moderate to severe hypertension
• Disturbances of lipid metabolism
• Pregnancy
• Idiopathic jaundice/cholestasis of pregnancy
• Herpes of pregnancy
• Undiagnosed abnormal uterine bleeding
Oestrogen Only Pill
Premarin
• Contains 0.625mg of oestrogen

• Add back menopausal symptoms
• Prevents hypertrophy of the endometrium
• Advanced inoperable metastic breast and prostatic
carcinoma
• postmenopausal osteoporosis
• Treatment of uterine bleeding from hormonal imbalance
• To treat oestrogen deficiency in
• Female hypogonadism
• Ovariectomy
• Primary ovarian failure
Oestrogen Only Pill
Premarin
Contraindicated in:
• Thromboembolic disease
• Undiagnosed vaginal bleeding
• Pregnancy
Adverse Effects:
• Headache and Dizziness
• Lethargy and Mental depression
• Nausea
• Anorexia
• Increased appetite
• Hypertension
• Acne
• Breast tenderness
Combined Oral Contraceptive Pill
Cilest
Combined Oral Contraceptives
• Synthetic oestrogens and progesterones
• First Generations
• Norethindrone
• Second Generations
• Levonorgestrel
• Third Generations
• Gestodene (e.g. Minulet)
• Norgestimate
• desogestrel
Combined Oral Contraceptives
Health Benefits
• Reliable birth control
• Menstrual periods are shorter and lighter
• Periods are less painful
• Periods are more predictable
• Less risk of iron deficiency anaemia
• Reduction in ovarian cancer
• Reduction in endometrial cancer
• Decrease in fibrocystic breast disease
• Decrease incidence of functional ovarian cysts
• Reduces endometriosis and fibroids
Combined Oral Contraceptives Pills
Minulet
Injectable contraceptives & Implants
Mechanism – all contain progestogen
•Inhibits ovulation (principally inhibiting LH)
•Thickens cervical mucus
•Makes endometrium unreceptive for
implantation
•Alters tubal transport of ovum
Injectable contraceptives & Implants
Depo-provera (Medroxyprogesterone acetate)

•Intramuscular injection (150 mg)
•Lasts for 3 months
•Indications
•Postpartum patients who want to postpone sterilization
•Women who want no more children & refuse sterilization
•Women > 35
•Mentally retarded
•Those who wish protection from pregnancy for 3 months
•Sickle-cell disease
•Where estrogen preparations are contra-indicated
•Implants & other preparations
Long-acting contraceptives (3 months to 5 years)
Norplant
•Implant is a sustained release system
•Has silastic tubing
•Six capsules each
•34mm in length
•2.4mm in width
•Each capsule contains 36mg of the crystalline form of
Levonorgestrel
•67μg/day for the first year then 30μg/day from the second year
Indications
•Delay in having children for 2-3 years

•Long term contraception
•Difficulty remembering to take a pill every day
•History of anaemia and Menorrhagia
Norplant
Contraindications
•Thrombophlebitis
•Thromboembolic disease
•Breast cancer
•Undiagnosed genital bleeding
•Acute liver disease
•Benign or malignant liver disease
Norplant
Norplant
Introducer
Depo-Provera
• Intramuscular injection (Medroxyprogesterone acetate 150 mg)
• Lasts for 3 months
• Prevents endometrial cancer
• Indications :
• Postpartum patients who want to postpone sterilization
• Women who want no more children & refuse sterilization
• Women > 35
• Mentally retarded
• Those who wish protection from pregnancy for 3 months
• Sickle-cell disease
• Where estrogen preparations are contra-indicated
• Adverse Effects:
• 6lbs per year increase in weight
• Delay in fertility from 6months-12months on cessation of injections
• Persistent menstrual irregularity
• Long term use increases the development of osteoporosis
Depo-Provera
Transdermal Patch
Composed of :
•Estradiol Transdermal Patches 1.8mg releases 50μg/24hours
•Ortho Evra is another weekly contraceptive patch, which contains Norlegestromin
and Ethinyl oestradiol.
•Suitable in women who can use OCP
•No need to remember a daily pill
Emergency contraception
• High-dose combined estrogen-progestogen pill

(“Morning after pill”)
• High-dose progestogen pill
• Intra-uterine contraceptive device (e.g. Copper-T)
• Mifepristone RU-486
Female Sterilization
Counseling
• Irreversible & permanent method
• Failure rate (1 in 200)
• Procedure & complications
• Risk of ectopic pregnancy
• Other methods of contraception & vasectomy
Types
• Postpartum – within 2-3 days of delivery
• Postabortal – occurs after abortion
• Interval – anytime in non-pregnant patient
after puerperium
Tubal Sterilization
Approaches
• Abdominal
• Laparotomy (SUMI incision)
• Mini-laparotomy (Pfannensteil incision)
• Laparoscopy
• Vaginal
• Colpotomy
• Culdoscopy
• Hysteroscopy
Tubal Sterilization
Methods
 Tubal ligation
• Pomeroy
• Irving (Oxford)
• Madlener
• Uchida
• Kroner (fimbriectomy)
Tubal Sterilization
Methods
 Tubal occlusion
• Bipolar electrocautery
• Tubal clips, rings & bands
• Yoon band or Falope ring
• Hulka-Clemens clip
• Tantalum clips
• Filshie clip
• Sclerosant (e.g. Essure). Pain and discharge as adverse
effects. Perform post procedure 3 month hysterogram to
assess the efficacy of the method.
• P-block: silicone rubber
 Cornual resection
 Salpingectomy
Tubal Sterilization
Complications
1. Anesthetic
2. Surgical
 Immediate
• Primary hemorrhage
• Damage to viscera (bladder, bowel, ureters)
 Early
• Infections
• Peritonitis
 Late
• Lower abdominal pain (electrocautery)
• Dyspareunia
• Menstrual irregularities
3. Regrets & demands for reversal
4. Failure rate
5. Conversion of laparoscopy to laparotomy if adhesions or obese
Tubal Sterilization
Babcock
249
Tubal Sterilization
Babcock
Uses:
1. Grasp tubular structures in
• Adhesiolysis
• Appendectomy
• Bilateral tubal ligation
• Salpingectomy in ectopic pregnancy
• Recanalization
• small bowel surgery
2. To hold tissue that you don’t want to damage e.g.
Fallopian tubes
Features:
1. Atraumatic (causes minimal trauma)
250
Sim’s Speculum
Uses:
• Used to visualize and to retract the posterior vaginal
walls
• Used in the diagnosis of utero-vaginal prolapse,
• Used in dilatation and curettage and hysteroscopy
Features:
• Bivalved
• U shaped with vaginal blade and handle
• Available in different sizes
Disadvantages:
• Non-self retaining
• An assistant is required
• An additional instrument is needed to retract the anterior
wall 251
Sim’s Speculum
252
Allis Tissue Forceps
Uses:
– Used to grip tissue with minimal trauma e.g. Skin
Features:
– Light weight
– Fine toothed edges
– Non-ratched but locking
Allis Tissue Forceps
Endometrial Aspirator (Pipelle)
Uses:
• Endometrial aspiration
• For histological biopsy of the uterine mucosal lining
• Sample extraction of uterine menstrual content
• Endometrial cancer screening
• Endometrial dating
• Diagnosis of ovulation and fertility
• 2-3 days secretory phase prior to menstrual bleeding
• Bacterial culturing
• Used to investigate dysfunctional uterine bleeding
Features:
• Plastic
• Narrow bore
• Low volume suction mechanism. Suction via
capillary action.Under negative pressure.
• Length 23.5cm
• Sterile
• Used as an outpatient procedure
Endometrial carcinoma
Histological types:
– Adenocarcinoma
– Adenosquamous
– Squamous
– Adenoacanthoma
– Papillary serous (most aggressive)
Incidence:
– Menopausal
– Mean  65 yr
– 10 %  < 50 yr
Endometrial carcinoma
Etiology:
– Unopposed estrogens  anovulatory cycles
• Early menarche
• Late menopause
• Polycystic ovarian syndrome
• Hyperprolactinemia
– Obesity
• Diabetes
• Hypertension
– Nulliparity
– Hormone replacement therapy (with no progesterone)
Pathophysiology: (because of unopposed estrogens)

– Simple hyperplasia  complex hyperplasia  complex hyperplasia with
atypia  adenocarcinoma
Endometrial Carcinoma
History: (ABCDE)
– Lower Abdominal pain
– Bleeding
• Post menopausal bleeding (PMB)
• Abnormal uterine bleeding
– Irregular bleeding
– Inter-menstrual bleeding (IMB)
– Menorrhagia
– Constitutional symptoms
– Watery stained offensive Discharge
– Extra-uterine symptoms
• Urinary tract infection
• Constipation
Investigations:
– Blood
• Complete Blood Count
• Renal Function Test
• Liver Function Test  for metastases
• Random Blood Sugar
• Group & Rhesus
– Radiological
• Chest x-ray
• Transvaginal ultrasound (TVUS)
– If endometrium > 5 mm  endometrial biopsy & sampling
– Endometrial biopsy & sampling
• Hysteroscopic guided biopsy
• Dilatation & curettage (fractional) – if negative, do hysteroscopic biopsy
Staging: (surgical)
– 0  CIN
– I
• IA  endometrium
• IB  inner myometrium
• IC  outer myometrium
– II  cervix
– III  confined to pelvis
• Ovaries
• Fallopian tubes
• Rectum
• Bladder
• Iliac nodes
– IV  outside pelvis
• Para-aortic nodes
• Liver
• Lungs
Treatment:
– Up to Stage I  Total abdominal hysterectomy (TAH) + bilateral salpingo-
oophorectomy (BSO) + pelvic lymph node dissection
– Stage II  radical hysterectomy + pelvic lymph node dissection
– Stages III & IV  adjuvant therapy
• Pelvic radiation
• Chemotherapy (e.g. cyclophosphamide)
Prognosis: (5 year survival rate)

– IA  95%
– IB & IC  80-90%
– II  70%
– III  30-40%
– IV  10%
Utero-Vaginal Prolapse
Definition: Descent of the uterus through the vagina
Degrees of utero-vaginal prolapse:
First degree: Descent of cervix to introitus (but not outside)
Second degree: Cervix appears outside introitus (but not vagina)
Third degree: Descent of uterus outside introitus (procidentia)
History:
Symptoms
– Feeling of something coming down in the vagina
– Lower back pain
– Dyspareunia
– Bleeding
– Incomplete evacuation (rectocele) & constipation
– Urinary difficulties (obstructive symptoms)
• Acute retention
• Infection
• Stress incontinence
• Patient needs to reduce prolapse to urinate
• Predisposing factors – Gynecologic history
– Obstetric history • Post-menopausal 
• Grand multiparity hypoestrogenic state
• Prolonged labor – Medical history
• Precipitate labor • Chronic cough
• Instrumentation during labor • Bronchitis
• Trauma during labor (e.g. • Increased abdominal
cervical laceration) pressure
• History of large babies • Emphysema
• Bearing down on • Intra-abdominal mass
inadequately dilated cervix • Ascites
• Constipation
• Diabetes mellitus
– Social history
• Smoking
• Carries/lifts heavy objects
– Grandchildren
– Occupation
– Anesthetic assessment
• Co-morbid states (e.g. diabetes, hypertension, cardiac
disease)
Utero-vaginal Prolapse
• Examination:
General
• Mucous membranes – pale (anemia)
• Chest examination – rule out COPD
• Cardiac examination – anesthetic assessment
• Abdominal examination
– Ascites
– Intra-abdominal mass
– Hydronephrosis
• Examination:
Pelvic
• Supine
– Atrophy of vaginal tissue
– Decubitus ulcer or dependent part of procidentia  treat with
premarin cream
– Pap smear
• Sims’ position (patient lie on their left side, left leg extended and
right leg flexed).
– Reduce procidentia
– Look for associated cystocele or rectocele
• Supine
– Assess uterus for
» Size
» Mobility
» Position
• Standing- check for stress incontinence (cough, strain)
• Type of prolapse
– Anterior
• High – cystocele (bladder)  frequency; stress
incontinence
• Low – urethrocele (urethra)
– Posterior
• High – enterocele
• Low – rectocele
Differential diagnosis:
– Urethra  Uretheral diverticulum
– Vulva  Cyst of Gartner’s duct
– Vagina  Soft tumors of the vagina
– Cervix
• Cervical polyp
• Hypertrophy of the portio vaginalis of cervix
Investigations:
– Complete Blood Count
• Anemia
• Urinary tract infection
– Renal function test
– Fasting Blood Sugar/Random Blood Sugar
– Urine
• Microscopy/Culture/Sensitivity
– Chest x-ray and Electrocardiograph
Treatment
• Conservative
– Indications
• Minor prolapse
• Young women with reproductive ambitions
• Poor operative risk
• Antenatal and post partum patients
• Refuse surgery
• Awaiting surgery (especially when there is a decubitus ulcer)
Treatment
– Types
• Pelvic exercise
• Estrogen vaginal cream (e.g. premrin cream)  promotes
healing
• Ring pessary
– Changed every 3 months
– Disadvantages (PV DUE)
» Pressure necrosis
» Vaginitis
» Discharge
» Ulceration
» Elderly women might forget it
Treatment
Ring Pessary
Surgical
– Types
• Manchester repair
– Anterior colporrhaphy
– Amputation of cervix/vaginal hysterectomy
– Posterior colpo-perineorrhaphy
• Vaginal hysterectomy with vaginal wall repair
• Associated stress incontinence
– Vaginal hysterectomy with Kelly buttress sutures
– As separate operations
» Marshall Marchetti Kratz
» Burch colpo-suspension
» Aldridge sling operation
• Moschowitz operation  enterocele
Surgical
– Pre-op investigations
• Blood
–Complete Blood CountBC  Hb
–Group and Crossmatch – 2 units
–Renal Function Test  ureter can be
damaged
• Chest x-ray
• Electrocardiogram
• Post-op management
– Day 0
• Flavin-soaked pack in vagina after operation
– To prevent hematoma formation
– To prevent agglutination of anterior & posterior walls
• Intravenous Fluids – 2-3L/day
• Slates of ice if thirsty
• Foley catheter
– Insert at end of operation
– Continual drainage for 3 days
• Analgesics & antiemetics IM
• Prophylactic antibiotics (ampicillin) for 5 days
– Prevent cystitis
• Post-op management
– Day 1
• Check urine
–Color (hematuria)
–Volume (oliguria)
• Remove flavin pack
• Remove catheter on day 3-4 with one day of spigot
q 4-6 hr before, then check residual volume
–If > 100 ml  re-educate bladder
• Low residue diet and no nocturnal activities
Surgical Treatment
– Complications
• Early
– Damage to bladder, rectum, urethra
– Hemorrhage
– UTI
– DVT
• Late
– Stress incontinence
– Dyspareunia – superficial and deep
• Treat underlying cause
– Smoking
– Ascites
– Constipation
Auvard’s Vaginal Weighted Speculum
Uses:
– Dilatation and curettage
– Vaginal hysterectomy
– Anterior Colporrhaphy
– Cervical cerclage
– Manchester Repair
– LEEP
Features:
– Weighs 1960g
– Self retaining
– Wide blade; good for operation
– No assistance needed
– Gives better exposure of the anterior vagina and cervical os
Disadvantages:
– Lacerations to the posterior vaginal wall
– Operator may still need assistance in retracting anterior vaginal wall
Auvard’s Vaginal Weighted
Speculum
9/18/2019 281
Needle Holder
The needle
holder is, as the
name implies
used to hold a
needle while
suturing.
Vulsellum Forceps
Vulsellum Forceps
Uses:
– To clip the anterior lip of the cervix during dilatation and curettage
Features:
– Multi-toothed
– Applied vertically
– Type of tenaculum
Tenaculum Forceps
Tenaculum Forceps
Uses: Clips the anterior lip of the cervix in
– Laparoscopy
– Hysteroscopy
– Endometrial sampling
– Used in placement of a cervical cerclage
– Insertion of an intrauterine contraceptive device
Features:
– Single tooth forcep
– Best used in early pregnancy
– Less traumatic to the cervix
– Less painful to patient i.e. useful in outpatient setting
– No need for anaesthesia
– Applied horizontally
Sponge Forcep
Sponge Forcep
Uses:
– Alternative used in pregnancy for soft cervix
– Used to hold small 4”x4” swabs for cleaning or swabbing during
surgery
– Used to retract the anterior lip of the cervix or cervical cerclage
– Used for repair of cervical lacerations post partum
– In caesarean section if no green Armytage is present for bleeding
– To remove products of conception in a dilatation and curettage
– Used to clamp infundibulo-pelvic ligament
Features:
– Ratched
– Blunt, non-traumatic tip
– Less traumatic than Vulsellum

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OBSTETRICS

The basic instrument has three parts:

• No cephalopelvic disproportion. The biparietal diameter must

F-full dilatation of the cervix

Vacuum Extraction can be performed with simple anaesthesia

if there is no contra-indication to vaginal delivery, then labour

Dilatation 0 1-2 3-4 5-6

Consistency Hard Medium Soft -

Position Posterior Middle Anterior -

The Bishop Score: Numerical System used to evaluate

Methods of Cervical Ripening to induce cervical

• Purified porcine relaxin when used causes the release of

• Estradiol vaginal gel causes in an increased collagenolytic

Amniotomy is used as an adjunct rather than by itself.

This combination of methods reduces induction to delivery

– The myometrium in highly parous patients is more

For uterine contraction/postpartum bleeding, 10 units intramuscularly or

Amniotomy is an effective way to induce

The strength and duration of the

No effort should be made to strip the membranes and do not

Early and variable deceleration of the fetal heart rate is noted

• Also establish fetal pulmonary maturity by either

Echoes are produced at the boundaries between tissues of different density.

Pure fluid produces no returning echoes, while inhomogeneous solid tissue

Real-Time Scanners produce a continuous image of a section

• Tissue is hyper-echoic if its displayed brightness has

• Hypo-echoic is when the tissue displays brightness that

• Reasons For The Estimation of Gestational Age

Elective Caesarean Section

 Hydrocephaly is where the cranium is grossly enlarged and reduced in

 Encephalocele is recognizable by an outgrowth from the cranium

 As the placenta ages, it undergoes noticeable changes. Its surface

A retained placenta is one that remains

Normally, syntometrine is given intramuscularly with the birth of the

There are three grades of adherent placenta:

1. Previous trauma to the uterus from manual removal of the

1. Placenta accreta-this is the mildest form. The villi are

Each entity may be focal, partial or total.

 Completely Adherent Placenta-bleeding is minimal as the main site of bleeding is from

 Partially Separated Placenta-this is usually accompanied by heavy blood loss.

If there is heavy bleeding with an undelivered placenta, immediate intervention

1. Should be undertaken in the operating theater under general anaesthesia.

1. Medical malpractice litigation

Indications for a Caesarean Section:

A caesarean section should only be considered in

1.Mother is admitted to hospital the day before surgery.

The Skin Incision: a vertical sub-umbilical midline or Pfannenstiel (transverse

The Vertical Incision:

The Pfannenstiel Incision:

The Classical Caesarean Section

Disadvantages to this type of incision:

The Lower Segment Caesarean Section:

1.The abdomen is opened in layers. Layers of the abdominal wall are:

The Lower Segment Caesarean Section

The Lower Segment Caesarean Section

1. The vitals chart is checked along with the input/output chart.

1. Soft food diet and normal diet on the third day.

4. Sepsis-peritonitis can occur especially in the presence of

Before embarking on a VBAC it is important that:

Uterine rupture or scar dehiscence, loss of uterine activity, signs of

Green Armytage Clamps

Diagnosis of cervical incompetence may be confirmed :

Time of Insertion: 14-18 weeks gestation

Prior to a cerclage, an ultrasound is needed to:

O&G OSCE by Maddy

O&G OSCE by Maddy