PERINEAL LACERATIONS

1
Extends through vagina &
degree perinea skin
2nd
Extends into soft tissue of
degree perineum (bulbocavernous
and perineal muscle)
3rd
Through anal sphincter
degree
4th
Through rectal mucosa
degree
st

TYPES OF SPONTANEOUS ABORTION

BLEEDI ABD. PAIN
CERVI POC
NG
X
THIRD TRIMESTER
THREATE
Minimal BLEED
Possible
Close No
PAINLESS
BLEEDING
NED
POC
PLACENTA PREVIAexpell
Mechanism
Abnormal placental
ed
implantation
INEVITAB Profuse Severe
Openin close
No
proximity,
extending
LE
POCor
covering the cervix
expell
Risk factors
Multiparity, multiple
ed
gestation,
advance
INCOMPL Profuse Minimal/sev
Open
Some
maternal
age,
previous
ETE
ere
POC
placenta previa, previous
expell
cs
ed
Source of bleeding
Maternal Open
blood All
COMPLET
Minimal Minimal
Management
No vaginal exam,POC
stabilize
E
patient with premature
expell
fetus, emergencyed
CS
MISSED
None
No pain
Close No
PAINFUL BLEEDING
POC
ABRUPTIO PLACENTA
expell
Mechanism
Premature separation
ed of
placenta
SEPTIC
Abortion resulting in uterine infection.
Risk factors Presents with fever,
Hypertension,
chills and abdominal
peritoneal signsor pelvic trauma,
premature rupture of
membrane, previpus
placenta abruptia, tobacco
of cocaine use
Source of bleeding
Management
Stabilize patient and
manage expectantly if
with premature fetus,
emergency CS

VASA PREVIA
Rupture of fetal vessel
that cross placental
membrane overlying the
cervix
Multiple gestation,
velamentous cord
insertion, accessory lobe
of placenta
Fetal blood
Emergency CS

UTERINE RUPTURE
Laceration of uterine wall
Previous uterine scar,
excessive oxyytocin, over
distended uterus

Emergency CS

OB GYN HISTORY
CC,HPI, PMHx, FHx and ROS plus:
HPI:
gravidity (# or pregnancies including the current one (tiwns =1/1)
parity (# of births beyond 24 wks aog or <24 if alive)
EDD: use nageles rule
LMP
Naegeles rule:
Add 7 days to 1st day of LMP
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Subtract 3 months
Add 1 year
Example:
LMP-------------------------------------sept.14, 2007
Add 7 days-----------------------------sept. 21, 2007
Subtract 3 months------------------june 21, 2007
Add 1 yr------------------------------ june 21, 2008
EDC------------------------------------june 21, 2008
TERMS
RELATED TO
PREGNANCY
STATUS
Term
Definition
Para
# of pregnancy that reached viability
Gravid
A woman who is or has been pregnant
Primigravida
One who is pregnant for the first time
Multigravida
Pne who has been pregnant previously
Multipara
One who has carried two or more pregnancies to
viability
Nulligravida
A woman who has never been and is not currently
pregnant
Menstrual history

menarche (age when periods began)/ menopause

Cycle (interval between the 1st 2 consecutive periods)- any
change in cycle, duration of period.
Subjective assessment of flow: pads/tampons
Dysmenorrhea and timing of pain
PMS (premenstrual syndrome)

Obstetric history

Parity where, when and outcome

Gestation, birthweight, sex, mode of delivery
Complications ante/intra/postpartum
Feeding.
Ex. G1-1990, LFT baby boy via NSD at CSM hospital; BW= 6.7lbs; no
complications

Gynecological history
Note previous surgical procedures
Cervical smears (normal, tx?)
Previous gynaecological problems and any surgery (e.g. PID or
endometriosis)
Intermenstrual/postcoital/postmenopausal bleeding
Vaginal discharge; color, smell, amount, itch
Abdominal or pelvic pain site, duration, radiation, associated
factors
Contraceptive history
Details of contraceptive use. The method used, duration of use,
acceptance,
Current method, side effects and plan for the future

Sexual history

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Coitarche (1st sexual intercourse)

# of sexual partners
Inquire if sexually active
Dyspareunia, libido, arousal and satisfaction
Timing of coitus and desire for pregnancy
Previous STI
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PHYSICAL EXAMINATION
Abdominal examination
INSPECTION
Note the distention of the abdomen that may indirectly indicate the
shape and size of the uterus. Note also any symmetry of the abdomen
Note any fetal movement observed
Note any surgical scars e.g. pfannenstiel ( correlate to
previous surgical and gynaecological history)
Cutaneous signs of pregnancy:
Linea nigra - dark pigmented line stretching from
just below xiphisternum through the
umbilicus to the suprapubic area.
Striae gravidarum - aka stretch marks of pregnancy;
red lines or bands that sometimes
appear on the abdomen during pregnancy
striae albicans silvery white and are evidence of previous parity
FUNDIC HEIGHT
AOG
FUNDIC LEVEL
12wks
Just above symphysis
16 wks Halfway between symphysis and umbilicus
20 wks Level of umbilicus
26 wks 2 to 3 fingers above the umbilicus
32 wks Midway between umbilicus and xiphoid
process
36 wks At the level of costal margin
40 wks 1-2 fingers below the costal margin

PALPATION
Measure fundic height and do leopolds maneuvers
1. Position patient semi
recumbent with bladder
empty
2. Palpate to determine fundus
with two hands, ensure the
abdomen is soft (not
contracting).
3. Place the zero mark of the
tape measure at the
uppermost border of the
symphysis pubis. Measure
from the top of the
symphysis pubis (a) to the
top of the fundus (b) make

Conditions when the fundic

height is not compatible with
the expected gestational age
Shorter than normal measurement:
- Fetus descent into the pelvis
(normal 2-4 wks before delivery)
- Estimated date of conception is
incorrect
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Large
-

Small but healthy fetus

Oligohydramnios
Fetus positioned sideways
Breech
Fetus is small for gestational age

Polyhydramnios
Large for gestational age
Hydatiform mole

1st maneuver
PRESENTATION
The uterine fundus is palpated to determine which fetal part occupies the uterine
fundus
Fetal head is hard, firm, round, and moves independently of the trunk
Buttocks is soft, symmetric, has small bony processes moves with the trunk
2nd maneuver
FETAL LIE
Palpate each side of the maternal abdomen to determine which side is fetal back
and whick is the extremities
Fetal back will feel firm and smooth.
Fetal extremities will feel like small irregularities and protrusions
3rd maneuver
ENGAGEMENT
Palpate the area above the symphysis pubis to determine the presenting part and if
the fetus is engaged. This will validate the findings of the 1 st maneuver
Floating- presenting part can be gently pushed back and forth
Engaged presenting part immovable
4th maneuver
Palpate in the direction of pelvic inlet using 3 fingers of each hand and determine
the presenting part. This maneuver is less informative if the presenting part is
breech
Vertex cephalic prominence is on the same side as the small parts
Face cephalic prominence is on the same side as the back.
Abdominal examination cont....
Palpation cont...
Lie of the fetus - referes to the positon of the spinal column of the fetus in
relation to the spinal column of the mother.
TYPE OF FETAL LIE
Longitudinal fetal spine is parallel to the long axis of the mother
Transverse - fetal spine is perpendicular (90O) to the long axis of the mother

Fetal attitude or posture - characteristic posture which the fetus assumes inside
the uterus during the 3rd trimester

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COMPLETE
FLEXION

MODERATE
FLEXION

POOR
FLEXION

HYPEREXTENS
ION

NORMAL : moderate flexion of head, flexion of arms unto chest and flexion of legs
to abdomen
Presentation the part of the fetus that overlies the pelvic brim
TYPICAL TYPES OF FETAL PRESENTATIONS

VARIOUS VERTEX PRESENTATIONS

1. The first letter of the code tells which side of the pelvis the fetus reference point
is on (R for right L for left)
2. the second letter tells what reference point on the fetus is being used (occiput-O,
fronto-F , mentum-M, breech-S, shoulder- Sc or A)
3. the last letter tells which half of the pelvis the reference point is in (anterior A,
posterior P, tranverse or in the middle-T)
4. Each presenting part are normally recognized for each position using occiput
as the reference point.

Most common
Note: also shown are the positions of the large and small fontanelles and the frontal,
sagittal, and lambdoidal suture that determines the position of the vertex.

TYPES OF BREECH PRESENTATION

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AUSCULATATION
-

At about 20 wks, the heartbeat can be heard without Doppler amplification.

Use of fetoscope or the bell of a regular stethoscope and press firmly into
patients abdomen
The heartbeat is best hard over the babys back (locate using leopolds
maneuvers)
After the fetal heart beat is located, count for 30 seconds then multiply is by
2 to obtain the number of beats per minute (bpm)
Remember to check the womans pulse against the fetal sounds. If rate is the
same, readjust the Doppler or fetoscope.
FREQUENCY OF AUSCULATION
Low risk
High risk
women
women
1st stage
Latent
Every 1 hr
Every
phase
Every 30 mins
30mins
Active
Every
phase
15mins
2nd stage
Every 15mins
Every 5mins

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Note: normal FHR usually is between 120160bpm

Percussion generally not used in obstetric examination

Internal examination
A. estimating pelvic inlet

True conjugate (11cm)

Obstetric conjugate (10cm)
Diagonal conjugate (12cm)
1. Insert the gloved 2 fingers into the vagina until the tip reaches sacral
promontory.
2. Mark with the finger of the other hand where the inferior border of
symphysis pubis meets the examining hand.
3. Compare the hand measurement to a ruler to determine the diagonal
conjugate diameter.
note: an estimate of the obstetrical conjugate is obtained by
subtractiong 1.5 -2 cm from the diagonal conjugate.

TYPE OF PELVIS

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GYNECOID PELVIS
(most common type in women)
- Blunted ischial spine
- Straight side walls
- Pelvic brim is a transverse ellipse (nearly circle)
- Wide subpubic arch
- Most favourable for delivery
PLATYPELLOID PELVIS
- Blunted ischial spine
- Straight side walls
- Pelvic brim is flattened anteroposteriorly
- Wide subpubic arch
ANDROID PELVIS
- Prominent ischial spines
- Convergent side walls (widest posteriorly)
- Pelvic brim is heart shaped
- Narrow subpubic arch
ANTHROPOID PELVIS
- Prominent ischial spines
- Straight sidewalls
- Pelvic brim is an anteroposterior ellipse
- Narrow subpubic arch
B. MEASURING CERVICAL DILATATION AND EFFACEMENT
Cervical dilatation is assessment of how open the cervix at the level of
internal os. To gauge cervical dilatation, place the index and middle fingers
against the cervix and determines the size the opening. Measurement range
from 0 cm ti 10 cm or fully dilated.
Cervical effacement is assessment of how effaced (thinned out) the cervix
becomes as the presenting part pushes on it. Measurement is reported in
percent.
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C. MEASURING FETAL STATION

Fetal station is the position of the presenting part in relation to the
maternal ischial spine. The most commonly used measurement divides the
distances from pelvic inlet to ischial spine and ischial spine to introitus into 3
parts each. Station is negative if it is above the ischial spine and positive if it
is below
D. SPECULUM EXAMINATION, BIMANUAL EXAMINATION, AND
RECTOVAGINAL EXAMINATION

OBSTETRICS
ECTOPIC PREGNANCY
1.
2.
3.
4.
5.

Signs and Symptoms

Abdominal or pelvic pain
Amenorrhea with abnormal uterine bleeding
Signs of early pregnancy
Vaginal bleeding
Low BP when bleeding is severe

1.
2.
3.
4.
5.
6.
7.

Risk Factors
Previous tubal surgery
Previous Ectopic pregnancy
In utero diethylstilbestrol exposure
Previous genital infection
Infertility
Current smoking
Previous IUD use

1.
2.
3.
4.
5.
6.
7.

Differential Diagnosis
Acute appendicitis
Miscarriage
Ovarian torsion
Pelvic Infammatory Disease
Ruptured corpus luteum
Tuboovarian abscess
Urinary stones

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ECTOPIC PREGNANCY

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