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Obstetrics for competitive examinations

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Date posted: October 24, 2011

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Non Clinical

Dr T Geetha Prasanth
Medical officer. Department of Homeopathy
Govt. of Kerala
Before beginning to go through the notes on OB and GYN, kindly revise the anatomy of the
female reproductive organs and the process of fertilization.
The OB and GYN part actually start with the physiological changes of mother during pregnancy.
Almost every organ and tissues of a female body undergo physiological changes during

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pregnancy. The metabolic, chemical and endocrine balances of the body gets altered.

Archives
The important changes

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Dr Mansoor Ali

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Changes in UTERUS and CERVIX

1. Increase in weight from 50 gms. To 900 gms
2. Increase in size from 7.5X 5X 2.5 cms to 30X 23X 20 cms
3. Myometrium and endometrium undergo hypertrophy. The endometrium of the pregnant uterus
is called deciduas.
4. Cervix becomes softer.
5. Cervical racemose glands secretes a tenacious mucus forming a plug (operculum) which acts
as a barrier against infections
6. Uterine contractions increases which are irregular, infrequent and painless(Braxton-Hicks
contractions)
CHANGES in VAGINA
1. Vaginal blood supply increases leaving a bluish appearance to mucosa (Jacquemier sign or
Chadwicks sign)
2. the action of oestrogen increases the vaginal secretions
3. Vaginal pH becomes more acidic which helps to prevent infections
CHANGES in The BREAST
Breast changes are more evident in primigravida. The changes are mostly due to oestrogen and

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progesterone. Oestrogen acts more on glands and ducts and progesterone on the secretory
functions of the breast.Breast changes are mostly taking place during second and fifth months.
During

second

month

: Breast increases

in

size, bluish

discolouration

and

more

sensitiveness.errectile nipple, deeply pigmented aerola, and prominent tubercles (Mont Gomerys
tubercles)in the areola are noted.
During fifth month, secondary areola develops, a sticky yellow fluid may be expressed from the
nipple.
CHANGES IN THE SKIN
Mostly due to the action of the MSH of the anterior pituitary.
Depressed pinkish or slightly bluish lines (striae gravidarum) appear on the abdomen and thighs.
Sometimes pigmentation may appear on cheeks,foreheads and around eyes which mostly

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disappear after the pregnancy.
WEIGHT GAIN DURING PREGNANCY
The weight gain during pregnancy is contributed by the enlarging uterus, growing foetus,
placenta, liquor amnii, acquisition of fat and water reduction. It may vary from person to person. In
general the average weight gain is 5 to 9 kg.
HAEMATOLOGICAL CHANGES
1.
2.
3.
4.
5.
6.
7.

Plasma volume increases upto 1.2 litres

RBC volume increases by about 20 to 30 % (upto 350ml)
Leucocytes increases predominantly neutrophils
The total plasma proteins increases
Albumin globulin ratio is decreased to 1:1 (normal 1.7: 1)
Fibrinogen level raised by 50%
ESR level increases

Cardio vascular changes

Cardiac output is raised by 40%.
Femoral venous pressure is increased
The blood flow to the uterus is considerably increased.
Pulmonary and renal blood flow is considerably increased
Due to venous congestion, varicose veins tend to develop more during pregnancy.
CHANGES IN URINARY SYSTEM
1. Increase frequency of micturition due to antiverted uterus during the early weeks of pregnancy
and due to descent of the presenting part in the later part of pregnancy
2. Glycosuria is common but may not be pathological
3. Proteinuria should be investigated thoroughly
DIAGNOSIS OF PREGNANCY
Normal duration of pregnancy
9 months and seven days/ or 280 days or 40 weeks
First trimester first twelve weeks
Second trimester - 13 to 28 weeks
Third trimester - 29 to 40 weeks
SIGNS AND SYMPTOMS
1.
2.
3.
4.
5.

Amenorrhoea
Frequency of micturition
Morning sickness
Breast changes
Skin changes

6. Quickening (usually occurs between 16th and 20th week)

Probable signs
1.
2.
3.
4.

Abdominal enlargement
Changes in uterus
Braxton Hicks contractions
Chadwick sign

5. Ocianders sign (increase pulsation felt in the lateral vaginal fornix by about the 8th week of
pregnancy)
6. Softening of Cervix
7. External and internal ballottement
8. Detection of hCG in urine and blood
Positive signs of pregnancy
1. Foetal parts and foetal movements (apprectiated by 22nd week)
2. Foetal heart sounds. Most conclusive sign of pregnancy heard between 18 20th week for
the first time.
3. Ultra sonic evidence . Gestation sac by 6th week, foetal heart beat -7th week, foetal heart rate
-10th week using Doppler.
4. Malformations detected by 18th week.
CALCULATION OF THE DATE OF DELIVERY (EDD)
By adding 7days to the first day of LMP count back 3 months or count 9months forward to reach
the EDD.
Minor disorders of pregnancy

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1.Morning sickness
Medicines. - Sepia, Puls, Nux vom, Ignatia, Phosph, Ntrum mur, Cocculus, Colchicum,
Ipecac, Symphoricarpus,
2. Acidity and Heartburn
Medicines- Puls, Sepia, Nux vom , Colocynth ,Staphy, Carbo veg, sulphur, Lyco, Ars alb,
Robinia
3.Back ache
Med- Kali bich , Actea, Ammon mur, Arnica, Rhustox, Bryonia, Phosph
5.
6.
7.
8.

Constipation
Varicose veins
Haemorrhoids
Fainting

PHYSIOLOGY OF LABOR
Defined as the process of expulsion of the foetus along with the placenta and the membranes
from the uterus through the birth canal.
NORMAL LABOR
A Labor is normal, if it is
1.
2.
3.
4.
5.
6.

Spontaneous in onset
At term
Vertex presentation
Process completed by natural unaided efforts of the mother
Time for first and second stages does not exceed 18 hours
No complications arise

PROCESS OF LABOR
The exact process of labor is not certain. But humoral and mechanical factors control labor.
Humoral control
1. Oxytocin from posterior pituitary has a stimulating action on the pregnant uterus. Oxytocin
receptors are more in the myometrium.
2. Fall in the level of progesterone which changes the oestrogen progesteron balance
produces uterine contractions in greater amplitude.
3. Increase in prostaglandins increases the rhythmic uterine activity and the hormonal changes
that initiates the parturition.
MECHANICAL
1. Uterine distension
Increase in intra uterine pressure and the resultant tension enforced on uterine muscle fibre
may initiate labor.
The stretching of lower uterine segment by the foetal head and the pressure exerted by it on
the para cervical nerve ganglion may initiate labor.
SIGNS OF LABOR
Pre labor - These signs occur 2 or 3 weeks prior to the onset of labor.
Lightening which is the sinking of the presenting part into the pelvis
False pains- irregular dull pains appearing in the lower abdomen and are not associated with
uterine hardening.
Frequency of micturition
Cervix become soft and dilated
Signs of True Labor
1. True labor pains- the uterine contractions become painful which are cotrolled by the nervous
system and endocrine factors.
2. Dilatation of Cervix and cervical canal. After a dilatation of 3cms has occurred, further
dilatation occurs at the rate of 1 cm per hour.
3. Show- blood stained mucoid discharge due to the detachment of chorion is seen within two
hours of starting the labor.
4. Formation of bag of water- stretching of lower uterine segment causes a detachment of
membrane . the presenting part fix into the cervix and divide the amniotic fluid into two. The
presenting part forces the bag of membrane during contraction which may lead to early
rupture of the membrane.

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STAGES OF LABOR
STAGE 1 - Onset of true labor pain to full dilatation of cervix.
STAGE 2 - Full dilatation of cervix and expulsion of foetus
STAGE 3- Expulsion of foetus to expulsion of placenta and its membranes
MECHANISM OF NORMAL LABOR
1. Engagement
2. Flexion of head
3. Internal rotation of head
4. Crowning
5. Delivery of head by extension
6. Restitution of head
7. External rotation of head
8. Delivery of shoulders and trunk by lateral rotation
DURATION OF LABOR
Depends on
1. Primigravida or multipara
2. Type of pelvis
3. Size and presentation of foetus
4. Strength and frequency of uterine contractions
Usually in primigravida first stage last for about 12 hours, second two hours, third one fourth of an
hour. In multipara, it is 6 hours, half and hour and one fourth of an hour respectively.
COMPLICATIONS OF THE THIRD STAGE OF THE LABOR
POST PARTUM HAEMORRHAGE pph. pph is severe bleeding during the third stage of labor or
within 24 hours of expulsion of placenta.
Causes:
1. Atonic uterus
2. Traumatic causes
3. Blood coagulation disorders.
Signs of PPH
Bleeding /vagina
Rapid pulse
Pallor
Collapse
Management
1. Stimulation of uterus to contract by massaging
2. Emptying of uterus fully
3. Blood transfusion if necessary
4. Traumatic causes should be repaired
Homoeopathic Medicines
Caulophyllum, Actea, Pulse,Arnica, Bell, Phosoph, Ipecac, Sabina, Secale Cor.
RETAINED PLACENTA
Placenta is said to be retained, if it is not expelled even after 30 minutes of the birth of the baby.
Causes:
1. Poor bearing down efforts
2. Distended uterus
3. Prolonged labor
4. Uterine atonicity
5. Hour glass contraction of uterus
6. Adherent placenta
MANAGEMENT
1. Empty the bladder with a catheter
2. Retained placenta should be removed
Adherent Placenta (placenta accuate) it is a rare condition in which the placenta is directly
embedded into the uterine muscles . the spongy layer of decidua is absent here.

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COLLAPSE AND SHOCK
It is due to hypovolumic shock associated with haemorrhage.
Signs:
1. Pulse is rapid, soft and thready
2. Fall in blood pressure
3. Marked pallor
4. Shallow respiration
MANAGEMENT
Restoration of the blood volume
Medicinal management
PUERPERIUM
It is the period which begins with the termination of the third stage of labor and last till the genital
organs have assumed their pre-pregnancy stage which last for 6-8 weeks.
CHANGES IN UTERUS
1. Reduction in weight to 60 gms
2. Reduction in size
3. Arteries at the placenta site undergo constriction.
4. Decidua left after delivery undergoes necrosis and entire endometrium is restored by the third
week.
THE LOCHIA
The vaginal discharge during puerperium is called lochia which may extend up to 3 weeks.
Persistence of red lochia and excessive amount of lochia should be considered seriously.
The cervix never returns to the non gravid state, the external os is always patulous in a multipara.
The vaginal outlet is markedly relaxed , hymen replaced by small tabs of tissue which cicatrise
(carunculae myrtiformis) which is a characteristic sign of parity. The perineum is relaxed,pelvic
floor regain tone with a certain amount of gaping of vulva.
The puerperal bladder has a very much increased capacity and there is oedema and hyperaemia
of the bladder mucosa. Striae gravidarum appear in the abdominal wall with a certain amount of
laxity and flabbiness of the abdominal muscles if proper exercises are not observed.
Milk is secreted by the mother only by the second or third day of delivery. Breast become larger,
fuller, and veins become more prominent. The thin liquid secreted from the breast during the first
48 hours is rich in fat globules, lactalbumin and lactglobulin is called cholestrum.
Return of menstrual cycle takes place after about 10 weeks of pregnancy in most lactating
mothers; whereas in non lactating mothers it may be as early as 4 weeks.
MANAGEMENT OF NORMAL PUERPERIUM
1. Restoration of health of mother
2. To prevent infection
3. Promotion of breast feeding
4. Motivation for adopting contraceptive measures
COMPLICATION OF PUERPERIUM
1. Puerperal sepsis: It is an infection of genital tract occurring as a complication or abortion or
child birth
Clinical features:
Pyrexia
Tachycardia
Brownish,profuse,foul smelling lochia
Large and soft uterus which is tender to touch
Treatment
1. Adequate rest and sleep
2. Diet should be high in calories and vitamins
3. Adequate fluid and electrolyte balance
4. Correction of anaemia
Medicinal Management
SUBINVOLUTION : Slowing of the process of involution is known as subinvolution.

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Causes:
1. Retained products of conception
2. Fibroids
3. Overdistension
4. Caesarian section
5. Prolapse of uterus
6. Retroversion of uterus
7. Local uterine infections
Treatment : Treatment of the underlying cause and medicinal management
URINARY TRACT INFECTIONS
Causes: Infections due to catheterization during labor or retention of urine
clinical features:

Fever with Chills and Rigor, Frequency of micturition, Dysuria, Anorexia,

Nausea and Vomiting.

Treatment: Increase fluid intake, Medicinal management
RETENTION OF URINE
The causes are bruising and oedema of the urethra and bladder
Prolonged second stage of labor
Treatment : Women should be encouraged to pass urine within 12 hours of delivery
Medicinal management
BREAST COMPLICATION
Acute Mastitis: Is the inflammation of the breast which may progress into a breast abcess if not
treated.
Clinical features: Fever with general malice and head ache, throbbing pain and tenderness in the
breast
Treatment: Frequent feeding of the baby.
Medicinal management
VENOUS THROMBOSIS
This is characterized by formation of thrombi in the veins which may be superficial or deep.
PULMONARY THROMBO EMBOLISM
A piece of thrombus may become detached in the veins of the pelvis or lower limbs and travels by
the inferior venacava to the right side of the heart and via the pulmonary artery to the lungs.
Clinical features: Sudden chest pain with respiratory distress, haemoptysis, cyanosis,
hypotension, collapse, respiratory failure and cardiac arrest. Death may occur from shock or vagal
inhibition.
HYPEREMISIS GRAVIDARUM
The term hyperemisis gravidarum is applied to the excessive vomiting which persists beyond 4
months and very little nourishment is retained.
TOXAEMIAS OF PREGNANCY
1. A/c toxaemia of pregnancy (onset after the 24th week)
Pre eclampsia which may be mild or severe characterized by oedema, albuminura and
hypertension.
Eclampsia characterized by the above symptoms with convulsion or coma
2. C/C HYPERTENSIVE DISEASE WITH PREGNANCY
1. Without superimposed a/c toxaemia
i.
ii.

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hypertension known to have antenatal pregnancy

hypertension observed inpregnancy

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b. c/c hypertensive vascular disease with superimposed toxaemia
3. Unclassified toxaemia
A/C MATERNAL VIRAL INFECTIONS
1. Influenza
2. Variola or small pox
3. Rubella
ABORTION
Abortion is the termination of pregnancy before the foetus become viable.
Aetiology
1. Foetal factors
1. Intrinsic defects of fertilized ovum
2. Cystic degenerationof chorionic villli
3. Haemorrhage into the deciduas
4. Low quality sperm
2. Maternal factors
Infectious fevers
Hypertension
c/c nephritis
Syphilis
Diabetes
Trauma
Stress
3. Uterine causes
Congenital malformation of uterus
Fibroid tumors of the uterus
Retroversion of the uterus
Ovarian tumors
4. Hormonal causes
Hormonal imbalance may cause habitual abortion
Incompatibility of the blood of husband and wife may cause abortion.
Clinical features
1.
2.
3.
4.

Pain due to uterine contractions

Haemorrhage as a result of separation of ovum
Dilatation of cervix
Expulsion of part or entire ovum

Treatment : Removal of product of consumption when abortion is confirmed and medicinal

Management
CORD PROLAPSE
It is a condition where the umbilical cord lies below the presenting part
Diagnosis:

Feeling the cord, pulsation on vaginal examination. Sometimes cord can be seen

outside the vulva

Management: No management is required when the baby is dead or foeatal survival rates are
very less. Otherwise cord compression reduction measures should be done to improve the
condition of the foetus.
MULTIPLE PREGNANCY
Presence of more than one foetus is refered to as multiple pregnancy.
Twin pregnancy is the commonest form. Twin pregnancy can be monozygotic or uniovular or
dizygotic or biovular. Diagnosis is confirmed by ultra sound examination.
ECTOPIC PREGNANCY
Implantation and development of foetus anywhere outside the uterine cavity is called ectopic
pregnancy. Tubal pregnancy is the commonest form
Clinical features:

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Short period of amenorrhoea
Severe lower abdominal pain with or without vaginal bleeding
Fainting attacks,pallor,
Palpation through the fornix and no mass is usually felt.
PLACENTA PRAEVIA
Is the condition where the placenta is located partially or wholly within the lower uterine segment.
Clinical features: Sudden painless and causeless bleeding from vagina
Uterus is relaxed and non tender
Fetal heart rate is decreases when the head is pushed down into the pelvis due to the embedded
placental circulation by the pressure of the foetal head on the low lying placenta (stallworthys
sign)
Management: After the diagnosis is confirmed by the ultrasound, the women are advised to take
complete rest, intercourse is prohibited and medicinal management is given.
ABRUPTIO PLACENTA : It is also called as accidental haemorrhage where the cause of bleeding
is premature separation of a normally situated placenta.
PROLONGED LABOR : Labor is said to be prolonged if the duration exceeds 24 hours. The main
causes are inefficient uterine contraction, contrcted pelvis, cervical dystocia. Malposition of foetus,
congenital anomalies,uterine inertia, poor bearing down efforts, pelvic tumors.
Management:

Prolonged

labor

can

be

prevented

by

the

managing

the

causes

accordingly.suppportive measures, maintenance of hydration, and medicinal management can

be done.
OBSTRUCTED LABOR : Labor is said to be obstructed when there is no advance of presenting
part in spite of strong uterine contractions. It may be due to mechanical obstruction due to some
fault in the birth passage or in the foetus or both.
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