Ob RVG Panda Manila

Facilitator: Dr.
Ruth Villanueva Gutierrez
Notes in OB:
BLEEDING IN THE 1ST HALF OF THE PREGNANCY
Case 1: 25 years old G3P1 (1011)
 CC: Vaginal Spotting
 + Pregnancy Test
 Delay of 15 days
2008: Same complaint

 Passage of grape like tissue
 d/c
VS: in respiratory distress
PE: tenderness on the R & hypogastric region
Uterus: slightly enlarged with mild tenderness

Adnexa: slight tenderness to the R
Cervix: slight tenderness
DDX:
1. Ectopic Pregnancy
2. Abortion
3. H – mole (gestational trophoblastic diseases)
ECTOPIC PREGNANCY
 Prevents normal migration of tube
 CAUSES vaginal bleeding:
o IF tubal rupture  more of peritoneal bleeding
o Y? No implantation in the endometrium happened (BLASTOCYST STAGE)
 No maintaining agent – endometrial lining
o Action of HCG: persistence of CL in early pregnancy

 Estrogen & Progesterone  DECIDUALIZATION (building up of uterine lining for
implantation)
o IN ECTOPIC:
 ↓↓ HCG
 No maintaining agent  total abortion
 ↓ CL  ↓↓ Estrogen & Progesterone  Shedding of deciduas (w/c is very minimal
to begin with – SPOTTING ONLY)
 Decidualization is not that complete & thick  Vaginal Spotting
o Most common cause  conditions that prevent migration of embryo  to implantation
o Intraperitoneal hemorrhage at distal 1/3 of tube
VAGINAL SPOTTING
 Uterine Enlargement: Earlier part  Possible  not beyond 2 months
o Due to hypertrophy of muscular layer due to hormones
PAIN
 Tube muscular layer – VERY THIN
o Continuous growth  Distention of the tube (serosal lining) discomfort
 Changes brought
o Fallopian tube distention of serosal covering (which is continuous with the visceral
peritoneum)
O CHADWICK’S
 If no mass in the uterine caviy – 4 x 5 complex mass on UTZ  CL or EP
O CL or EP? BHcg.
CERVICAL MOTION TENDERNESS/ WIGGLING TENDERNESS

 Causes TRACTION  disturbs SEROSAL covering
ABDOMINAL TENDERNESS & RIGIDITY

 2 to intraperitoneal hemorhage  2 to tubal rupture
1
PANDA MANILA
Facilitator: Dr.Ruth Villanueva Gutierrez
EP COMPLICATION
 TUBAL ABORTION
 TUBAL RUPTURE
SITE OF IMPLANTATION
 Isthmus: Earlier (5 – 6 weeks)
 Ampullary / Fimbrial : Later (9 – 10 weeks)
 Interstitial – even up to 4th mo AOG
O may allow growth  mimics normal pregnancy
O But RUPTURE is more catastrophic since it involves CORNUAL portion of the uterus.
 2 mo: hypertrophy of the uterus
PREGNANCY STILL INTACT

 Spotting
 Abdominal Discomfort
 (-) PREGNANCY: does not rule out EP, depends on the level of Hcg
 (+) PREGNANCY:  can help confirm EP
 Enlargement of the uterus up to 2 mo size – due to hypertrophy
 Adnexal Mass
Causes of EP (E.P.) – any that would cause narrowing of the tube: PID, Salphingitis
Ancillary:
UTZ:
 If with adnexal mass, no uterine content  request for B- HCG  if not life threatening condition
As long as the patient is STABLE
 Just wait & repeat after 2 days
 DOUBLED HCG– Pregnancy
 Not DOUBLED HCG– Ectopic
IF patient is significantly UNSTABLE

 Management: Surgical Abdomen
 Intraperitoneal hemorrhage
Scenario:
 CC: Vaginal spotting
 (+) Pregnancy Test
 Pain: 10/10
 Markedly Pale
 Surgical Abdomen: Rigidity & Tenderness
Why? Tenderness: Something irritates the peritoneum
E.P. denotes intraperitoneal hemorrhage 2 to tubal RUPTURE.
Forget: B Hcg, UTZ
BUT pay attention to the POSTERIOR FORNIX:

 Normally it is deep , deeper than anterior fornix
 BUT if SHALLOW & BULGING: CUL DE SAC filled with accumulated blood 2 to rupture
CULDOCENTESIS
 To determine what is present in the cul de sac
 Lithotomy position  Posterior cervix  Spinal needle  Aspirate
 (+) Non clotting blood: intraperitoneal hemorrhage on aspirin (2 to RUPTURE)
  May indicate IMMEDIATE LAPAROTOMY (DEFINITIVE)
+ UTZ & B Hcg, Laparoscopy: even the earliest stages of EP can already be diagnosed.
Management of EP:
 EARLY STAGES: To prevent destruction of the fallopian tube, maintaining the reproductive function
of the uterus to the tube for further menstruation and pregnancy thus to conserve tubal function
IF NOT EARLY: MEDICAL Management  MTX (INDICATIONS FOR USA)
2
PANDA MANILA
Indications:
 Pregnant <6 weeks
 Tubal Mass < 3.5 cm
 Non Viable Fetus <20 weeks
 HCG levels <15 000 ml U/ML
 If not medical  SURGICAL MANAGEMENT:

 LaparOSCOPY (Dx & Tx)
 LaparOTOMY (Open the abdominal activity)
 Depends on what you see, parity and age.
 E.g.: YOUNG BE CONSERVATIVE AS POSSIBLE

 Intact , No BOW  Conservative Management.
 Laparotomy  conservative or radical  preservation of tubal function
CONSERVATIVE
 Salphingotomy – open the tube, remove the EP, suture it back, secondary healing.
 Salphingostomy – after opening, suture it back, cauterize the bleeding, primary healing
 Resection & Anastomosis – maintain the FUNCTIONAL length of the tube
 Tube is not only for fertilization, you need it so that the fertilized egg can travel within the tube, that it
can still undergo the normal process of changes till it becomes a BLASTOCYST.
 IF it’s barely 1/2 , by the time the egg cell enters the uterine cavity it might not still be in its blastocyst
stage  NO IMPLANTATION  it will go down  it becomes a blastocyst at the time at the area of the
cervix  CERVICAL ECTOPIC PREGNANCY
 SALPHINGECTOMY: IF damage is extensive, that you cannot save the tube anymore
o Ectomy: Removal of the Tube
o Do CORNUAL resection, because a part of a tube left can be a potential site for EP.
o To make sure there is no site for another EP.
ABORTION
 One of the most common cause: CHROMOSOMAL (the product of conception)
 Early stages: vaginal bleeding, pelvic pain
 Normal fetal factors can stimulate maternal factors to maintain pregnancy
 In ABORTION:
o Retroplacental Clot  acting as foreign body 
 Uterine Contractions  ↑ intrauterine pressure  Rupture of BOW
 Vaginal Spotting
 Cervical Dilatation
 PAIN: CONTINUOUS uterine contractions

 THREATENED ABORTION
 Cervical Dilatation & Shortening
IMMINENT ABORTION
 Rupture of BOW (Watery vaginal discharge)
 INEVITABLE ABORTION
 Expulsion of portion of placenta
 INCOMPLETE ABORTION
 ↑↑ vaginal
bleeding
 Vaginal bleeding
O Detachment of placenta from implantation site
O Some sinuses become opened.
 Uterus can’t contract effectively (to constrict sinuses) since there still remain other portions
of the placenta.
COMPLETE ABORTION: Some patients: w/ passage of saclike structure: entire gestational sac (usually after
expulsion, s/sx subside and bleeding becomes minimal)
3
PANDA MANILA
Abortion is a process:
 THREATENED:
o No expulsion of products of conception
o Size = AOG (compatible uterine size)
o Continuous contraction
 IMMINENT: DILATED & SHORTER CERVIX + INTACT BOW
 INEVITABLE:
o RUPTURED membranes / BOW  removal of fluid, removes protection
o Cant save pregnancy
 INCOMPLETE:
o Sudden hypogastric pain, Heavy bleeding,
o portion of placenta are expulsed
o sinuses are left open
o uterus is smaller than expected size of AOG
o ↓↓ pain and bleeding
o MGT:
 IV fluid + 10 u oxytocin  temporarily constricts the BV  COMPLETION
CURETTAGE (DEFINITIVE MANAGEMENT)
 COMPLETE:
o smaller uterus < < expected AOG
o cervix still dilated
o pain abated
 There are instances wherein blastocyst differentiate into 2 major parts: embroblast & raphoblast
o Embyoblast gives rise to embryo.
o Trophoblast : cytotrophoblast & syncitiotrophoblast
 There are instances where trophoblast develops but embryoblast did not develop 
UNEMBRYONIC PREGNANCY / Blighted Ovum : NO FETUS
 IF early in pregnancy there is an embryo which dies: EARLY FETAL DEMISE/ EARLY EMBRYONIC
DEATH/ EARLY EMBRYONIC DEMISE
TERMS
 IF fetuses at 1st have cardiac activity, then the baby dies but there is failure of uterus to expel it out.
So the death of conception is retained inside: MISSED ABORTION
 > 3 repeated spontaneous abortion: RECURRENT/ REPEATED ABORTION
 Septic Abortion: Old Term
2 TYPES OF ABORTION
 Spontaneous
 Induced – Deliberate Action
o Considered a as ASSEPTIC ABORTION (catheterization, or other aseptic method)
o SEPTIC ABORTION: one of the most common dreaded serious infections. (Also one
condition associated to DIC...)
4
PANDA MANILA
GTD: Gestational Trophoblastic Disease

- Abnormality in development of PLACENTA
- Trophoblast  strong affinity to BLOOD VESSELS
TYPES
1. Molar – within uterine cavity/ benign
2. Non – molar – within or can go out uterine cavity, malignant
Trophoblastic Villi
 For development of placenta
 Penetrate uterine cavity, proper communication between fetal and mother
- Rapid proliferation  Hydrophic swelling
- Grapes
- Increased in the expected size
Presentation:
 EXCESSIVE NAUSEA & VOMITING: ↑↑ HCG from excessive proliferation of trophoblast
o ↑ HCG  C L  Theca Lutein (Physiologic)  Unilateral & Bilateral
 PRE-ECLAMPSIA: ↑ BP
 Bulges  Ballooning of lower uterine segment (isthmus below)
 Swelling forms vesicles – CYST
 Distention of the uterus becomes bigger than AOG
o 3 mos Normal Pregnancy = 5 mos at the level of umbilicus
CONSISTENCY of uterus from normal

o BALLOTMENT: normal with fetus (fetal head part)
o CYSTIC: H-mole
Normal Pregnancy
 With QUICKENING
 Fetal heart tones
TYPES & MGT:

 Complete – more malignant  EVACUATE
 Partial – with fetal component  depends if the fetus is viable or not
PREDISPOSITION:
 Previous pregnancy or 1st pregnancy
 Previous H-mole
DX:
 B – HCG – used also for monitoring
 CXR: Baseline, trophoblast STRONG affinity to BV  mets  malignancy CANNONBALL
 UTZ: SNOW STORM APPEARANCE
 CBC
 Liver Enzymes Test
MGT:
1. Evacuation of tissues
 Depends on: AGE, PARITY & EXISTING CONDITION
2. Follow – up
3. Chemotherapy if needed
PARTIAL H MOLE
 Conservative treatment based on symptoms
 Aside from trophoblastic swelling
 + partial fetal membrane
 If life threatening  TERMINATE pregnancy
 HYSTEROTOMY – since fetus is not viable (1st half of pregnancy)
COMPLETE H MOLE
5
PANDA MANILA
 Entire trophoblast
 No development of embryoblast
 No fetal component
MGT of COMPLETE
 SUCTION CURETTAGE – most ideal for young patients, ↓ parity
o Suction molar tissues @ shortest time
o More bleeding
o Lesser complication such as perforation
 IF D&C  longer time

 HYSTEROTOMY
 TAH – WITH MOLE IN SITU
O For advanced age, multiparous due to malignant transformation
 FOLLOW – UP (trophoblastic activity)

O B-HCG levels
 BASELINE
 ↓: Within 48 hours, 1st, 2nd , 3rd week, monthly
 IF: PLATEAUING  incomplete evacuation
1. Neoplasia (GTN) – invasion: choriocarcinoma
2. Outside the cavity
3. Choriocarcinoma distress  penetrate myometrium
PLATEAUING
 Repeat PE, US (Visualize better)
 Invasive mole  Hysterectomy
CHEMOTHERAPY
 if there’s plateau but no neoplasm
 MTX or actinomycin (substitute)
Choriocarcinoma
 guarantee 100%, responds to chemotherapy
 low or high potential malignant tumor
 good or bad prognosis
 propensity for mets: LUNGS, BRAIN, VAGINA
PERSISTENT PLACENTAL SITE TUMOR PPST

Prognosis of Neoplasms:
 Duration
 Level of HCG
 Involvement of other organs
 Antecedent pregnancy or not
6
PANDA MANILA
BLEEDING IN THE 2nd HALF OF THE PREGNANCY

Case:
 G3P2 both were delivered CS
 Pregnant, FH: 32 cm, FHT 132/ min
 36 weeks, AOG
 CC: profuse, PAINLESS vaginal bleeding
Historical review:
 IE under double set – up – No UTZ yet
o IE inside OR whom suspected to have PP with the entire instrument  CS.
o Wastes no time
o No compromise
 Rupture the BOW  pull down the fetal scab  head at tamponade  press part of placenta that is
separated to control bleeding
 Uses “high index of suspicion” to PP  1st feel around the cervix, see if there is something between
the cervix & fetus, then gently palpate inside, if soft  confirm PP.
PLACENTA PREVIA – abnormal implantation of the placenta at the LUS

DDX as to the cause of bleeding in the 2nd half of pregnancy: ABRUPTIO PLACENTA
UTERUS – where the placenta should be implanted

 UPPER ACTIVE Segment – Normal site (fetus should come out 1st followed by the placenta)
 LOWER PASSIVE Segment – Abnormal site (the part where the fetus should pass on its way to
delivery)
IF placenta 1st before the fetus
o For the placenta to come out, it should DETACH  delivered
o Placenta would detach itself from its site of implantation  Cut of blood & O2 supply
coming from the maternal contribution going to the fetus  enough to kill the fetus
o CAUSE:
 Multiparity Factor: normal site of implantation  denuded (not as fertile as
anymore), decrease vascularity  look for another vascular site
 Previous curettage: scraping of the endometrial cavity
 Malpresentation
Manifestation:
o BLEEDING: the moment the placenta detaches  BV & sinuses left open  source of
bleeding
o In Pregnancy – “bloody show”
 As pregnancy gets close to term, it is a physiologic change that the initially isthmus
(lower part of the uterus)  formation of LUS  cervical canal: mucus  by the
time it will set  expulsion of the blood  BLOODY SHOW
o In PP:
  formation of the LUS  loosening at the site of implantation (placenta covering
the side of the os)  part of placenta will lose its attachment  depending upon
the separation of placenta from its implantation site will determine the amount of
bleeding
  formation of the LUS  physiologic  NO PAIN
 Via speculum: External os

 Degree of speculum in the cervical os  TYPES, to know the management for each.
o C-Section:
 TOTALIS: if internal os is totally covered by placenta
 PARTIALIS: if os is partly covered by placenta.
 Problem is if you allow the patient to go in labor  cervix dilates  greater
SA to close the cervix as it dilates  bleeding  catastrophic 
compromise each other
o Normal Vaginal Delivery
 MARGINALIS: if ends of the placenta is at the margin
 LOW LYING: if edge of the placenta is 2 cm from the cervical os.
7
PANDA MANILA
Early month of development: common to find a product of conception located in the lower uterine
 NOT ALL CASES OF PP DELIVERED ARE CS
 Early in development, fetus is still small and can be implanted even in the lower segment
 Pregnancy  Upper segment  distends  bring about the muscles in lower segment  pull up
where uterus increase in size
 Pulling upward  brought up higher location from internal os: “Migration of placenta” (but don’t
use the word :migration)
 UTZ twice: first trimester and second: is it really case of placenta previa?
Usual:
 Multiparity , painless bleeding
 “Malpresentation”  breech & shoulder or transverse- more common (normal: cephalic)
1. due to presence of placenta in lower segment, prevent head from occupying cephalad  goes
to comfortable space
2. Laxity of abdominal wall
Confirmation of diagnosis: “CLINICAL”: Factor- character of bleeding & pain
UTZ for GOLD STANDARD

1. Confirm placenta previa
2. Type of placenta: not all cases should be CS.
3. If bleeding is not that alarming: AOG for the specific management of the placenta previa
4. Accompanying symptom of Accreta
5. Location of placenta more implanted
o Anterior: prevent low transverse CS  cut through the placenta  increase in blood
o Posterior: do low transverse CS
o 2 kinds of CS: Classical CS & LTCS (less complication)
* in abruptio placenta: UTZ has no role because AP is diagnosed based on clinical finding. If there is such use,
that is to rule out PP. (don’t do any IE)
MX:
 Factors to be considered:
1. Amount or degree of bleeding
o “high index of suspicion”
o  VS: hypovolemic shock  IE: once the examining finger has been pulled out  bleeding
will occur (open faucet)  possible DEATH.
o Painless  place your hand over the abdomen: uterus is soft, flobby, no pain with bleeding.
2. AOG
o Regardless, it can already terminate. Even for the patient to be bleeding profusely, it should
be no less than partalis, if it is just marginalis and low lying – it can’t give rise to profuse
bleeding.
3. Type of Previa
4. Maternal and Fetal conditions
 Confirm
 Enhance Lung Maturation: give steroids/ tocolytic agents  inhibit uterine contractions so steroid
works well.
CASE 1:
Patient with minimal vaginal bleeding, VS are stable. (Pulse: bounding  good)
AOG  < 32 weeks premature 
 Is it not life threatening  CONFIRM: UTZ  PP TOTALIS  keep in the hospital (Hgb & prepared
blood)
 PP: Bleeding can stop  problem: When and where?  keep hospitalized
CASE 2:
Patient with minimal vaginal bleeding, VS are stable
8
PANDA MANILA
AOG  > 36 weeks (mature lungs)  still have time to confirm UTZ  PP Totalis  TERMINATE: CS
Give steroids  maturation of the lungs of the baby, to avoid complications with prematurity.
CASE 3:
32 weeks, painless massive bleeding: pale, hypovolemic shock
NO more UTZ  time is very crucial
MGT: TERMINATE  CS
 Precaution with previous CS or scar in the uterine cavity  trophoblast to penetrate deeper in walls
 abnormally implanted placenta with penetration into the walls.
 ACCRETA  POSSIBILITY
DDX: ABRUPTIO
 Bleeding with PAIN
 Normal implantation of the site, not in the LUS.
 Cause of Bleeding:
o Premature separation of the normally implanted placenta
In normal pregnancy:
What would initiate placental separation?
 Partly contraction, after the delivery of baby  continuous contraction & relax, but the
relaxation is not for it to go back to its initial length  Diminution in the length of each
muscle fiber  retraction
 Decrease uterine content after delivery of the amniotic fluid  retraction of muscle
myometrium  disproportion with implantation site & placental site  initiate separation
 bleeding  clot  continuous contraction, retraction  complete separation
In P.Abruptio
 Fetus still inside, the patient might not still be in labor but something have triggered the separation
of the placenta
 So painless bleeding due to premature separation of a normally implanted placenta
 Premature – the placenta should come out once baby is already out, baby still inside and placenta
still going to detached
 Basic pathology:
1. Presence of retroplacental clot.
2. Abnormally short cord  free movement of fetus in the placenta
3. Smoking: BV
4. Direct trauma to abdomen
 In abruptio the same thing
9
PANDA MANILA
MECHANISM
 Break in any BV  formation of clot  bigger  clot itself would separate from the site of attachment
 clot is a foreign body reaction of the uterus: contract  aim is to expel
 Uterus contract  cannot expel the clot: edges of the placenta is still firmly attached  getting bigger
due to retraction & contraction  bigger part of the placenta that separates
 More amount of the retroplacental clot  stronger the uterine contraction “tetanic contraction”:
tenderness & rigidity  blood insinuate in different muscles  COUVELAIRE or UTERINE APOPLEXY
1. Placenta detached  rich with thromboplastin  entry to maternal circulation: cascade of
coagulation & fibrinolysis  DIC – most dreaded complication
2. Infiltration of blood in the myometrium  distention bigger uterus
KINDS OF BLEEDING
 VISIBLE  loose attachment  detachment  with external hemorrhage
 CONCEALED  membrane attached  detachment  hospital  extensive  compromise fetus
 POOR PROGNOSIS – CONCEALED, because the presence of blood will prompt the patient to the
doctor. For concealed, it would be late that the damage may be extensive that it may affect the
fetus.
 Inability to expel  increase in contraction (close to each other)  mechanically contracted 
board like, rigid UTERUS.
 Uterus inability to expel the clot  stronger contraction  close contraction to each other –
MECHANICALLY CONTRACTED: HARD UTERUS.
If PP  due to repeated pregnancy, what about Abruptio Placenta?

RISKS: what brings about the rupture of a BV?
 Usually HPN: pre-eclampsia  wide spread vasoconstriction/ vasospasm  BV: rupture behind the
placenta  no control of bleeding  bigger clot  uterine contraction
Management:
 Airway, Breathing & Circulation, IV fluids
 1st make sure its AP: Place hand in the abdomen: rigid, tender
 IE: if cervix is dilated  amniotomy: the moment high index of AP: you can’t be conservative 
TERMINATION (It can allow normal vaginal delivery.)
 Amniotomy
(1) Induce or augment labor
(2) Releases pressure within uterine cavity
Decrease in content  decrease in pressure  uterus can contract better  better contraction of
the BV  prevent extravasation of thromboplastin in maternal circulation
(3) Determine degree of cervical dilation
E.g. Above 2 – 3 cm, Faint FHT  can’t do nsd in the shortest possible time  CS
Requirement:
 Coagulation factors:
o COT (Clot observation time)
o PT & PTT
o Fibrinolytic system: dimer, fibrin degradation products.
* AP  DIC  preparation in case there is derangement in factor.
 CS: Covalier uterus (purplish/bluish)  tocolytic agent  to squeeze out blood  oxytocin/
uterotonic.
 After delivery of the baby  PG  uterus contract
* Previous CS: possibility of abnormal adherent uterus.

PREVIA ABRUPTIO
PLACENTA Placenta abnormally implanted Normal implantation
BLEEDING Bleeding is due to formation of LUS Bleeding due to premature separation
SYMPTOMS PAINLESS PAIN: Uterus contraction
Soft & Flabby Rigidity
No increase in size Increase in size: distention
Bleeding w/ or without bleeding
FACTORS Multiparous Retroplacental clot
Previous curettage Abnormally short cord
Malpresentation Smoking:
Direct trauma to abdomen
Amt of Proportionate Proportionate
10
PANDA MANILA
bleeding Not proportionate: CONCEALED TYPE

IE Do not perform Can be perform
GENERAL LECTURE: Dr. Z.N. Gamilla
HYPOVOLEMIC SHOCK & DIC

HYPOVOLEMIC SHOCK
 Redistribution of cardiac output and blood volume by selective centrally mediated arteriolar
constriction
Decreased Perfusion Maintained Blood Flow

Kidneys Heart
Splanchnic Beds Brain
Skin Adrenals
Uterus
KISSU BAH
Notes:
 Passive resistance vessels are venules controlled by the humoral and the catecholamines.
 Uterus  hypotonic  prone to uterine atony  prone to post-partum haemorrhage
 Decrease perfusion due to the redistribution of blood
Samplex: Primary defect of shock: INSUFFICIENT PERFUSION
DECOMPENSATION
 Blood volume deficits of 25%
o Inadequate compensatory mechanisms
o Instability to maintain cardiac output and blood pressure
o ↑ CR ↓ BP
ESTIMATION OF BLOOD LOSS (No accurate way to determine)

 Hct
o (Least ancillary. Most available)
o ↓3 volume % in the 1st hour: LOSS OF 1 LITER
o Initial is always the highest during an episode of acute significant haemorrhage
 Urine Output
o Reflects the adequacy of renal perfusion and perfusion of other vital organs
o Renal blood flow is especially sensitive to changes in blood volume
o Urine flow of at least 30 mL and preferable 60 mL per hour should be maintained.
* Fluctuating output (30 – 20 – 30): Compromised patient (in the loop of shock)
MANAGEMENT
 Fluid Replacement
o Crystalloid solutions
 Used for initial volume resuscitation
 20% remain in the circulation after 1 hour
o Blood replacement
 Recommended if:
 Hct < 24 volume percent
 Hgb is < 8 g/dL
* suspected placenta previa with crossmatch even at admission together
with CBC, 2 units  Blood replacement.
 Compatible Whole Blood

 Ideal for treatment of hypovolemia from catastrophic acute haemorrhage
 1 unit ↑ Hct by 3 or 4 volume %
 Replaces many coagulation factors esp. FIBRINOGEN
 Plasma expands hypovolemia from hemorrhage
DIC
 Thromboembolic disorder: activation of the coagulation & fibrinolyric pathway  fibrin clot
formation & lysis
11
PANDA MANILA
 CO-exists when intravascular activation of clotting mechanism results in excess consumption of

components of coagulation
 Almost always seem as a complication of an identifiable, underlying pathological process against
which treatment must be directed to reverse defibrination (SECONDARY)
NOTES
Work the prevention of consumption of the clotting factors 
 PP & AP: not allowed to bleed profusely
 AP: 4 though concealed hemorrhage  thromboplastin in the circulation will be enough to
consume the coagulation factors
 The underlying cause may lead to the prevention of the consumption.
 Late Stage: IRREVERSIBLE/ Cannot be corrected
 Pregnancy itself is HYPERCOAGULABLE.
PREGNANCY HYPERCOAGULABILITY
 ↑ Factor 1 (Fibrinogen). 7, 8, 9, 10.
 ↑ plasminogen levels : Activation of coagulation incite conversion of plasminogen to plasmin
NORMAL HOMEOSTASIS
Activity of Activity of anti-

COAGULATION clotting mechanism
Normal Hemostasis
Activity of anti-
clotting mechanisms
Activity of
COAGULATION
THROMBOSIS
NOTES:
 SIG: This is the mediating factors for the production of the clot factors.
 Normal: Activation of coagulation  conversion of plasminogen to plasmin  anti-clotting
mechanism = BALANCE
 Present PH: No blood flow, always clot with no circulation. Just like the infarct, only the infarct is
close to a vessel, a clot is just there. Passageway where everything is block.
 Anti-clotting mechanism  Good perfusion and circulation
 Activation of coagulation  downgraded due to ↑ activity of anti-clotting mechanism  action that
would 1st be compensatory leading to the formation of THROMBOSIS
Diagram:
 CLOT INITIATION: Platelet attraction  Activation of coagulation 
 CLOT FORMATION: Thrombin  (Fibrinogen –> FIBRIN)  Fibrin Polymers  Retraction 
 FIBRINOLYSIS: Fibrin Fragments
Notes:
 Normal Fibrinogen: Clot Formation
 HYPOFIBRINOGENEMIA: Clot does not retract but dissolves immediately
 AFIBRINOGENEMIA: No clot
FIBRIN DEGRADATION PRODUCTS:

 Plasmin-induced breakdown products of fibrin
 Inhibit platelet mediated primary phase of coagulation
 Produce profound platelet dysfunction
12
PANDA MANILA
Notes:
 IMPLICATION: If going to have platelet, have a value consistent with FDP. At some point if you get a
platelet and had a value below 50 or 30, do not expect FDP to be good.
 Give this as what may happen in cases of patients that may have an activation of this coagulation
process, no matter what the disease.
PATHOPHYSIOLOGY:
Notes:
 Activation of coagulation process no matter what the disease thru 3 cases that may have these,
either: Endothelial damage, direct tissue injury or platelet activation producing a tremendous
thrombosis making more hypercoagulable  consumption  more consumption & platelet
dysfunction 
 More imperative when looking at other disease and probably hematologic diseases you know in
medicine.
 REMEMBER: middle line, the normal course.
MECHANISMS TRIGGERING THESE EVENTS:

1. INTRINSIC PATHWAY:
 ENDOTHELIAL DAMAGE
* INFECTION
 Septic abortion
 Chorioamnionitis
2. EXTRINSIC PATHWAY:
 Massive tissue injury with entry of pro-coagulant material in the circulation
* Direct influence intrusion to the circulation.
 ABRUPTIO PLACENTA
- Thromboplastin from the separated placenta goes into the pelvic circulation 
converted  fragment: FDP greatly affected or destroyed.
 Amniotic fluid embolism
 Retained dead fetus
 Saline-induced abortion
3. INTRAVASCULAR: Abnormal platelet activation

* Normal activation but once if produce abnormal intravascular platelet coagulation.
 Thrombocytopenic purpura
 Malignant HPN: ANESTHESIA > OB
 Pregnancy – induced HPN : < OB
13
PANDA MANILA
INTRINSIC PATHWAY EXTRINSIC PATHWAY
Notes: Notes:
* Contact into the endothelium  activation thus  Ecclamptogenic toxemia – 2 to HPN
producing corollary damage to the factors cited what it  Molar Pregnancy
ends up with is formation of clot  formation of  Ruptured Uterus
fibrinogen  ↑ F1  ↓FDP  Fibrin that is clot is LYSED. * More tissue injury, more fibrin destruction
FIBRINOLYTIC PATHWAY
CLINICAL FEATURES:
 EARLY SYMPTOMS FOR HYPOVOLEMIC SHOCK
 Generalized microvascular obstruction
Insufficient tissue oxygenation
Shock
 Microcirculatory damage to various organs
MYOCARDIUM Arrythmia
Shock
LUNGS Respiratory distress
CNS Tachypnea
Fever
Convulsions
14
PANDA MANILA
KIDNEYS Renal insufficiency

SKIN Infarction
ADRENALS Shock
(Waterhouse – Friedrichsein syndrome)
 Consumption of coagulation factors and platelets: Generalized bleeding
NOTES:
 CNS: Decompensating convulsions due to neurologic system can no longer maintain the
brain blood flow.
 Skin: Petechial Hemorrhage
 LATE SYMPTOMS
 Organ dysfunction
KIDNEYS Uremia
LIVER Jaundice
Liver insufficiency
RED CELLS Jaundice
Anemia
Notes:
 Liver may manifest early on but jaundice is already a late stage.
 Anemia: compensatory, initial hematocrit in shock is highest.
CLINICAL DIAGNOSIS
 ACUTE DIC
 Laboratory tests not necessary, maybe a COT.
 Clinical manifestations
 Oozing from venipuncture sites
 Epistaxis
 Hematuria (Infarcts)
 Petechiae
 Shock out of proportion to visible blood loss
 CHRONIC DIC
 Require laboratory confirmation
LABORATORY DIAGNOSIS
 COT (CLOT OBSERVATION TEST) - BEDSIDE
 Peripheral smear
 PTT/ PT
 Factor: Fibrinogen, 5, 7, 8
 Antithrombin III
 Platelets
 Euglobin Clot Lysis Time
 Fibrin Degradation Products
 Serum Bilirubin
 Lactic Acid Dehydrogenase
* Most reliable & specific: D DIMER MONOCLONAL ASSAY
HEMOSTATIC DEFECT LABORATORY PARAMETERS

Depletion of coagulation factors ↑ PT, APTT
↓ Fibrinogen, 2,3, & 5
↓ OR ABSENT: Anti-thrombin III
Thrombocytopenia Abnormal COT
↓ platelet count
Activation of fibinolysis ↑FDP
↓ECLT
Microangiopathic haemolytic Fragmented RBC in smears
anemia ↑unconjugated bilirubin
↑ LDH
15
PANDA MANILA
MANAGEMENT OF DIC
 Primary Therapeutic Goal:
O Treatment of underlying disorder
 Septic Abortion: Evacuate
 AP: Terminate Pregnancy
 PP & Profusely Bleeding: Refer CS
O Aggressive support of BLOOD VOLUME, BP AND TISSUE OXYGENATION
MANAGEMENT OF SPECIFIC CONDITIONS

 Abruptio placenta (AP)
O Major feature: haemorrhage  hypovolemic shock & renal insufficiency
O Replace blood loss and prompt evacuation of the uterus
O Administration of CPP, PLT (can do WB)
O HEPARIN – NOT INDICATED (produce more disastrous effect, it is extrinsic pathway)
O Observe for LATE SEQUALAE:
 Renal insufficiency
 Thromboembolic complications
 Intrauterine fetal death (IUFD)

O Course of DIC is low grade
O 3rd to 5th week of retention
 ↑ FDP
 ↓platelets
 ↓fibrinogen
O HEPARIN SHOULD BE ADMINISTERED if operative intervention is necessary (evacuate by CS)
 Amniotic Fluid Embolism

O Very poor survival rates
O Correct hypoxia and shock: Replacement therapy
O USE HEPARIN AND ANTI-FIBRINOLYTIC AGENTS
 Septic Abortion
O Antibiotic coverage
O Prompt evacuation of the uterus
O Replacement therapy
 Eclampsia
O Obstruction of the microvasculature of the KIDNEYS, LIVER AND CNS
O USE OF HEPARIN – NO BENEFIT
O Important measures:
 Control of eclamptic state
 Control of HPN
 Rapid termination of pregnancy
O FFP is recommended
* REM: CAFE:
 CPP –Abruptio placenta ,
 FFP – Eclampsia
HEPARIN MGT LATE REACTION Information

AP - CPP Renal Insufficiency - Replace blood loss
(more PLT Thromboembolic complications - Prompt evacuation of the uterus
disastrous)
(WB)
IUFD + 3rd to 5th week of retention - Course of DIC is low grade
(if operated) O ↑ FDP
O ↓PLTS & FIBRINOGEN
AFE + Supportive Severe tachypnea & arrest - Very poor survival rates
& A-FA - Correct hypoxia and shock
E - FFP Control of eclamptic state - Obstruction of the microvasculatures
(no benefit) Control of HPN of the kidneys, liver & CNS
Rapid termination of
pregnancy
16
PANDA MANILA
POSTPARTUM HEMORRHAGE RVG, MD NOV 27, 2012

NOTES:
* Why would patient bleed after delivery?
1. 300 cc: Detachment of placenta leaving sinuses open
2. 200 cc: Episiotomy
 Normal amount of bleeding: < 500 cc BUT there is no ACCURATE means to quantify the loss of blood.
INCIDENCE:
 World’s leading cause of maternal mortality
 1/3 all maternal death worldwide
 60% maternal deaths in developing countries
 Death occurring within 4 hours of delivery
DEFINITION
 Loss of >500 ml of blood after the 3rd stage of labor
 Loss of >1000 ml in CS
 Any blood loss that has the potential to produce hemodynamic instability.
PRIMARY OR IMMEDIATE
 Excessive bleeding within the 1ST 24 HOURS AFTER delivery
O 70% UTERINE ATONY
O Lacerations
* peurperium – 6 weeks
SECONDARY OR LATE
 Excessive bleeding between AFTER 24 HOURS AFTER DELIVERY AND 6 WEEKS POSTPARTUM
O Retained secundines
O Infection
O Combination
BLOOD LOSS: HOW MUCH?

 MILD : <20%
o Mild tachycardia (Degree of Blood Loss: 90 – 95 bpm)
o Mottled skin, cool extremities: 2O to ↑ Systemic Vascular Resistance & prolonged capillary
refilling
o ↓ Urinary output (Kidney is the 1st organ to be sensitive)
o Dizziness, ‘though normal neurologic status’
 MODERATE: 20 - 40%
o PR > 110 bpm
o RR > 30 bpm
o Marked pallor
O POSTURAL HYPOTENSION
o Anxious
 SEVERE: >40%
o Marked tachycardia
o Oliguria or anuria
o Agitation or confusion
o Classic signs of shock
o LOSS OF CONSCIOUSNESS – OMINOUS SIGN
 ESTIMATING BLOOD LOSS

o Use of standardized absorbent materials
o Practicing estimation of blood loss, appearance of blood
17
PANDA MANILA
o Developing visual aids

o Comparing weight of blood-soaked pads to the weight of a 500 cc or 1,000 cc bag of fluid
 Remember ALWAYS!!
o blood loss is consistently underestimated
o underestimation  inadequate treatment
o ongoing trickling  significant blood loss
o blood loss tolerated by healthy patients, to a point
o anemia and other health conditions profoundly affect tolerance to any amount of blood loss
PPH (POST PARTUM HEM)
o Orthostatic hypotension
o Anemia
o Fatigue
 Poor lactation
 Depression – affecting bonding with baby
o Myocardial ischemia
o Dilutional coagulopathy
o DEATH
CAUSES OF PPH
1. TONE: Uterine atony – failure of “human ligature”
2. TRAUMA: Laceration of birth canal
3. TISSUE: Retained placental fragments
4. THROMBIN: Coagulation disorders
RISK FACTORS CAUSE CLINICAL RISK FACTORS
Over-distended uterus  Hydramnios
Abnormalities of uterine  Multiple gestation
contraction  Macrosomia
Uterine muscle exhaustion  Rapid labor
 Prolonged labor
“TONE”  Multiparity
Intraamniotic infection  Fever
 ROM
Functional or anatomical distortion of uterus  Myxomatous
 Previa or Abruptio
 Anomalies
Uterine relaxing drugs  Halogenated Anesthetics
NOTE: Halogenated Anesthetics:
 usually if you need to explore uterine cavity after delivery of baby due to
o Abnormal adherence of the uterus
Retained Products of Retained products  Incomplete placenta
conception  Previous uterine surgery
 Abnormal placenta
“Tissue” Retained blood clots  Atonic uterus
NOTES:
 Previous uterine surgery : previous CS  prone to placenta accrete
 Abnormal placenta: placenta succinata
Lacerations  Precipitous delivery
Genital Tract Trauma Ruptured varicosities  Operative delivery
 Due to episiotomy
Extensions, lacerations at CS  Malposition
“Trauma”  Deep engagement
Uterine rupture  Previous uterine surgery
Uterine inversion  Multiparity
 Fundal placenta
NOTES:
 Lacerations  rapid labor  no support  Ritgen Maneuver (Grade 4)
- Fundus: 4 cm BELOW umbilicus & well contracted.
 Operative: Vacuum
 Episiotomy: Small  Big Baby  Tearing to 4th degree
 Extension: Head is so deeply engaged  scooped head – extension of
incision
Abnormalities of Pre-existing states  History of hereditary
Coagulation  Haemophilia A coagulopathies
18
PANDA MANILA
 Von Willebrand’s disease  History of liver disease

Acquired in pregnancy  Bruising
“Thrombin”  ITP
 Thrombocytopenia
 Elevated BP
 Fetal demise
 DIC  Fever
 WBC
 Antepartum hemmorhage
 Sudden collapse
 Therapeutic anticoagulation History of thrombotic disease
Risk Factors: PPH more likely to occur:
Risk Factors DO NOT PREDICT complications.
Need to be PREPARED for the possibility of life-threatening complications in all women, with or without risk
factors.
UTERINE ATONY
In the presence of a relaxed, boggy uterus
- Fundus 2 cm above the uterus
- Twin Pregnancy, Big Baby, Multiparous
 Management:
o Medicine: Uterotonics
o Mechanism: Application
o Surgery
Give: More
 Oxytocin : Adverse effect in undiluted bolus: HYPOTENSION, Cardiac Arrythmia effective than
 Ergot alkaloids Misoprostol
 Misoprostol
 Prostaglandins
Apply:
 Uterine Massage
 Bimanual compression of the uterus
 Compression of the aorta – Control temporarily loss of blood
At the same time
 Blood transfusion
 Indwelling catheter
 Assess clotting status
If despite medical management, bleeding persists ...

Preservation of uterus is considered ....
Mild – Moderate Blood Loss

 Hydrostatic intrauterine balloon tamponade
 Arterial embolization
o Femoral vein  gelatine plug  clot part of uterine
 Laparotomy
O SYSTEMIC PELVIC DEVASCULARISATION
 UTERINE & UTERO-OVARIAN LIGATION
 INTERAL ILIAC LIGATION
 IF accidentally: External Iliac  no pulsation  no blood supply to lower extremity
O COMPRESSION NATURE
 B-Lynch technique  NSD (suspender like)
 Cho technique  Square, specific where is the location of the implantation site
But if bleeding is life-threatening: Hysterectomy should be considered!

OVERTREATMENT CAUSES LESS HARM THAN INACTION.
Manual Removal of the placenta

- If placenta does not detach after 30 mins to 1 hour
1. Explore the uterine cavity
2. Follow umbilical cord
3. Feel the line of cleavage
4. Begin to separate placenta as if slicing
5. When all sides have been separated  DETACH
- If not all are attached & a part is abnormally adherent  accreta (well invaginated)  HYSTERECTOMY/
19
PANDA MANILA
Thorough examination of the placenta

 Maternal Side: Corrugated
 Fetal Side: Smooth
Prevention of the uterine atony

Active management of the 3rd d stage of labor: ANTICIPATION
TRAUMA: O FUNDAL PLACENTA

Lacerations: O RELAXED UTERUS
 Continuous bleeding in the presence of a firm, LEVEL:
well-contracted uterus  Beyond the level of the cervix: COMPLETE
Management:  DRUGS TO REPOSITION:
 Look for bleeders o Terbutaline
 Proper hemostasis o MgSO4
o Ritodrine
RUPTURE OF THE UTERUS
 Unexplained shock following: After repositioning: give OXYTOCIN
o Use of Oxytocin for induction or augmenting THROMBIN
labor Coagulation disorders
o After delivery of big baby Obstetrical conditions
o Prolonged labor  Septic abortion
o With uterine scar  Fetal death
o Multiparous patient  Pre-eclampsia – Abruptio
 Manifestations  Uterine atony
o Abnormal heart rate
o Abdominal pain Post-partum Hemorrhage
o Rapid pulse  Leading cause of maternal mortality
o Signs of shock  Uterine atony most common cause of PPH
 Management:  Preventable complication of childbirth
o Repair  Best prevention – ANTICIPATION
o Hysterectomy
TISSUES:
 Retained Placenta
o 10 – 15 minutes – normal duration of the 3rd
stage
o 30 – 60 minutes undelivered placenta –
prolonged 3rd stage
 Management:
o Explore uterine cavity
o Manual removal of the placenta
*Bleeding while the uterus is contracted is a strong
evidence of retained placental fragment.
MARKEDLY ATTACHED PLACENTA W/O CLEAVAGE....
Suspect ACCRETA!
 With prior uterine surgery
 With placenta previa
 Grand multiparas
Management: Replacement
 “last out, first in:
 Pressure over the leading POINT
UTERINE INVERSION
 Repositional management
 Placed it back, and then detach the placenta for
uterus to contract.
 COMMON CAUSES:
O EXCESSIVE TRACTION OF THE CORD
20
PANDA MANILA
PUERPERAL INFECTION
Danice Notes – RVG
PEURPERAL INFECTION – Any bacterial infection of the genital tract after delivery
PEURPERIUM
 period that starts immediately after delivery & lasts until 6 weeks
 return to pregnancy state
PARTURIENT – in labor
LOCHIA
 vaginal discharge that originate mainly from the uterus during the postpartum period
 consists: RBC, decidua, epithelial cells and bacteria
 may persist from 4 – 8 weeks
LOCHIA RUBRA
 lasts for 3 – 4 days
 reddish brown discharfe
 no offensive smell
LOCHIA SEROSA – PALER
LOCHIA ALBA – 10 days 10 days post partum, yellowish white
PEURPERAL FEVER - see Lala
PRINCIPAL CAUSES OF MATERNAL MORTALITY

1. Postpartum hemorrhage
2. Peurperal infection
3. Hypertension
CAUSES OF PEURPERAL FEVER

 Puerperal infection (bacterial infection) 20% within 24 hours
 UTI – alternate hormonal, course of labor, freq vaginal exams
 Breast engorgement (in preparation for breastfeeding)
o 15% - <39C, <24 hours,
o >39C - Mastitis of infection of mammary gland
 70% Abdominal incisions – SSI – CS
 Intercurrent infections - respiratory
 Thrombophlebitis – BV , clots
High spiking temperature >39C within 24 hour  virulent pelvic infection (Group A & B Strep)
PUERPERAL SEPSIS
 Infection of genital tract at any time between delivery until 42 days after
 At least 2
o Pelvic pain
o T= 38.5 C / 101.3 F
o Abnormal vaginal discharge (lochia) , pus
o Foul vaginal discharge
st
o Delay in uterine involution < 2 cm within 1 8 days, seropurulent
ENTRY POINTS OF INFECTION

 Placental Site – raw wound with gaping veins occluded by thrombi (good culture medium)
 Cervix – nearly always torn even in normal parturition (Normal: 2 cm laceration of cervix)
 Vagina – often torn or involved in episiotomy
MODES OF INFECTION
 Endogenous bacteria become harmful after delivery
o Prolonged ROM
o Organism usually present in vagina becomes pathogen in the presence of tissue injury
o Introduced into the uterus by IE or during manipulation
 Iatrogenic (int. podalic version, manual removal of the placenta)
21
PANDA MANILA
 Change the postion
o Bruised tissues, lacerated or dead (after a traumatic delivery or after obstructed labor)
 Exogenous Bacteria
o unclean hands, unsterile instruments, sexual activity
o foreign substances introduced into the vagina (oils, herbs)
Bacteriology
 Anaerobic > aerobic
 Vaginal Flora (Late Pregnancy)
o Doderleins bacillus 60 – 75%  maintains vaginal pH
o Candida 25%
o Staph aureas/ albus
o Strep – anaerobic
o E coli & Bacteroides
PREDISPOSING FACTORS OF PLACENTAL SEPARATION

 ↓Resistance
 ↑ Multiplication & virulence of organism from outside
 Introduction of organism from outside
 ↑prevalence of organism Resistant to antibiotics & chemotx
RF - MATERNAL FACTORS:
 Anemia & malnutrition – low socioeconomic poor hygiene & poor aseptic techniques
 DM (food – most abused substances)
 Prolonged PROM
 Prolonged & obstructed labor
 Frequent vaginal exam
 Operative deliveries
 Unrepaired cervical & vaginal lacerations
 Postpartum hemorrhage
 Operative deliveries – forceps, vacuum, breach, vaginal
 Manipulations high in birth canal
 IUFD, retained placenta
 Preexisting STD
 Colonization of the vagina with GBS, Chlamydia, mycoplasma, Ureaplasma, Gardnerella
Community Risk Factors: Socioeconomic, cultural, etc

Health Service Risk Factors Monitoring, Prevention, Treatment
UTERINE INFECTIONS
ROUTE OF DELIVERY – SINGLE MOST SIGNIFICANT RISK FACTOR

 Vaginal – NSD
o Metritis 1.3%
o ↑risk in patients – 6%
o With chorioamnionitis – 13%
 Abdominal – CS
o Duration of labor
 FEVER – Most important criterion for diagnosis of post partum

 Temp: >38 – 39 C metritis
 Chills/ Fever: suggests Bacteremia
 Leukocytosis: 15000 – 30 000 (higher than physiologic leukocytosis of pregnancy)
CLINICAL FEATURES OF LOCAL INFECTIONS:

 slight ↑of temperature, generalized malaise, headache,
 wound – swollen red
 pus formation – tissue disruption
Metritis of Pelvic Cellulitis – Severe
ENDOMETRITIS – MILDEST FORM (spectrum)

 placental site – seat of infection
 with chorioamnionitis – close to fetus (infections continuous from intranatal to postnatal)
 Symptoms appear 3 – 6 days post delivery in some cases
22
PANDA MANILA
 Common after CS
 Prolonged lochial discharge – uterus can’t involute
MILD: fever proportional to tachycardia, soft and tender uterus, subvolution, ↑ lochia
Endometritis w/ Beta haemolytic Strep:

 Fever + Chills + rigor, (fever <<< tachycardia)
 No LOCAL SIGNS: No foul smelling discharge nor involution
 Note: smell of discharge depends on etiolofqgic organism
SUBINVOLUTION
 Delay (arrest in the process of involution)
 FH Movement <1 – 2 cm / day
 Abdominal pa rin after 2 weeks
4 CLASSICAL SIGNS
1. Pyrexia
2. Pulse 100 – 120
3. FH not falling – par involution
4. Lochia remain red
PARAMETRITIS (PELVIC CELLULITIS)

 7 – 10 day
th
 Sustained ↑ of temperature
 Constant pelvic pain
 Tenderness,
 Unilateral/ bilateral tender indurated mass felt at lateral fornix
PELVIC PERITONITIS
 Tenderness on the fornix and movement of cervix
o WIGGLING TENDERNESS - ectopic at PID
 Pus collection in the pouch of Douglas
 Fever of ↑↑ pulse rate
 Lower Abdominal pain and tenderness
GENERALIZED PERITONITIS
- high fever, vomiting, generalized abdominal pain, rebound tenderness
If untreated  saphingitis  distended pus  pyosalpinx
Management:
 Mild – oral
 Severe – IV
 Broad spec ABC – not necessary in vaginal delivery infections, 90% cases: GENTAMICIN + AMPICILLIN
 Following CS  CLINDAMYCIN + GENTAMICIN (gold standard 95% resolution)
 + Ampicillin (sepsis syndrome, enterococcal)
 Metronidazole – Anaerobes
SURGICAL TREATMENT
Perineal wound
 Stitches may be removed to facilitate drainage
 Antiseptic solution followed by anti-septic ointment
 2 suture (later)
 2 healing
Pelvic Abscess  usually in the pouch of Douglas

 Proper draining by colpotomy
 Abscess pointing above poupart’s ligament – I & D
Prevention
 Broad spec ABCs  no benefit
 Metro + Erythromycin  ↓metritis incidence (5.2  2.1)
 Erythro + Ampi  no change in incidence of infection in PROM - but still GIVE!
 Vaginal irrigation with povidone – iodine  no effect on incidence of fever, netritis, & abd incisional infection
 IDEAL prophylactics  ampicillin & 1 Gen Cephalosporin
st
 Before CS  70 – 80% decrease endometritis

 Metronidazole gel (as adjuct) - ↓rate of metritis But no effect on morbidity and abdominal incisional infections
23
PANDA MANILA
Complications
 WOUND INFECTION – most common cause of antimicrobial failure
o Obesity, DM, corticosteroid treatment, immunosuppress, anemia, poor haemostasis of hematoma formation.
 Wound dehiscence – separation of fascial laters  2 closure
o Serious complication
 Necrotizing fasciitis
o Most serious, high mortality
o Clindamycin + B Lactam
o Debridement & Surgical rash
Peritonitis
 c/s, VBAG. Ruptured abscess
 Paralytic ileus  1 symptom
st
 Treatment: Infection: antimicrobial

 Necrosis – Surgical + antimicrobial
Parametrial Phlegmon
 > 72 hours fever despite treatment
 Unilateral in most
Toxic Shock Syndrome
ANTEPARTUM SURVEILLANCE: DR. V.B. CASTRO

DYSTOCIA
RVG
Factors that Affect Labor:
1. Power - Uterus: ability of the uterus to contract effectively to expel the product of conception
2. Passenger – Fetus
3. Passage – Pelvis
3 Divisions of Labor
1. PREPARATORY DIVISION: Latent Phase + Acceleration Phase
* Head of the baby might still be above the pelvis

* When regular rhythmic contractions happen that such strength would be sufficient enough to cause dilatation and
effacement of the cervix until the cervix achieves a full cervical dilatation of 10 cm
 LATENT PHASE: Before the cervix achieves the 4 cm dilatation

o Preparatory Phase
o Effacement is usually completed
o Slow dilatation of the cervix
o No complication except when it become so prolong that patient is exhausted and might end up with dehydration
 ACTIVE PHASE:
 from latent to active hard to discern
 Practical standpoint: active phase & maximum slope have been reached when cervix >4 cm dilated.
* In practice, difficult to know when the will latent phase and active phase begins because 4 cm cervical dilatation is
SUBJECTIVE. Remember you assess the cervical dilatation of the cervix based on your digital examination, making use of 1
finger as 1 cm. (ROUGH ESTIMATION).
* As long as FHT is okay, and in the early part of Active Phase, don’t follow the 2 hours duration. Williams: extends up to 3
hours depending upon the result of palpation.
24
PANDA MANILA
* If uterine contractions are normal: strong & goo, pelvis is adequate. Fetus good presentation, position, average in size
then you can expect a 3 cm/hour change in the cervical dilatation of maximum slope in multigravid patients.
PARTS:
 Acceleration phase
 Phase of the Maximum Slope
o 3 cm/ hr in primi
o 5 cm/ hr in multi
 Deceleration Phase
2. DILATATIONAL DIVISION - FULL DILATATION

 Most dramatic dynamic remarkable cervical changes take place
 Start of the descent of the baby and reach the pelvic floor: PERINEAL MUSCLES (Station +4 +5)
 Significance of the head in the muscle floor: it will give the mother the urge to push down
 PHASE 1: PASSIVE PHASE/ PHASE OF DESCENT

- From time of full dilatation until further descent  begins to distend pelvic floor musculature
 Initiating spontaneous urge to push
 PHASE 2: ACTIVE PHASE

- Heralded by onset of active pushing:
Associated with great maternal effort & a degree of hypoxic stress is imposed on the fetus by the increase frequency
of uterine contractions.
* Pushing should be spontaneous, if pushing is done even though the head of the baby is not touching the floor 
VULVAR EDEMA (friable, prone to lasceration)
3. PELVIC DIVISION: REMARKABLE DESCENT

 Deceleration Phase + 2 Stage of Labor
nd
 Head of the baby passes the pelvis
DYSTOCIA:
Difficult Childbirth
Abnormalities of Labor & Delivery caused by:
1. Relative disproportion between the size of the fetus and the size of maternal pelvis - lessening of the power
2. Malposition of the fetus - should be normally well flex, in cephalic presentation  undergo rotation.
3. Uterine contractions that did not result in dilatation of the cervix
Dysfunctional Uterine Contractions:

 Normal progress expected when contractions 2 – 4 contractions/ 10 minutes
- IF <2: not enough power
- IF >4: every contraction  compress placenta  oxygen & BS to the uterus is impeded if at the time the cervix is not
that dilated to allow the delivery of the baby  Fetus Mortality
* Every contraction of upper segment Lower Segment is being pulled up  Contraction & Retraction  Cervix
shortens  EFFACEMENT  DILATATION
* IF contractions are q 2 min, > 8 contractions/10 mins, Cervix: little shortening  markedly thinned out and even
rupture the part of the fetus.
 Low levels of PGF2a

 Infections : Chorioamnionitis, once muscles are infected  weak contractions
 Analgesia : Too early affecting integrity of contractions.
Inefficient uterine activity
1. Hypotonic uterine dysfunction: <200 montevideo units

 Insufficient generation of action potentials from the myometrial pacemaker
 Inadequate propagation
 Only when the patient is in ACTIVE PHASE OF LABOR
 MX: OXYTOCIN
2. Hypertonic uterine dysfunctions

 r/o: ABRUPTIO PLACENTA
 Includes a group of disorders associated contraction that are generated in the lower pole of the uterus or in multiple
sites.
 MX: SEDATION
25
PANDA MANILA
Most of the fetal head will enter the pelvis in:

1. OCCIPUT TRANSVERSE POSITION
2. Deceleration Phase (8 – 9 cm) head: OCCIPUT ANTERIOR
A. Average Multipara
B. Average Primigravida
C Arrest of active phase
D. Protracted active phase
E. Prolonged latent phasE
Latent Phase:
 Prepares the cervix for a more dynamic dilatation
 Primi – often long (8 hours)
o Average 0.35 cm/hr

 Multi – shorter (4 hours)
Prolonged Latent Phase

 Primi > 20 hours
 Multi > 14 hours
Oversedation
- has considered one common cause of P.L.P.
Unless there is maternal or fetal indication for expeditions delivery, most authorities agree that the management of choice
consists of therapeutic rest.
This allows the patient a respite from the physical and emotional rigors of labor and can aid in the distinction between TRUE
and FALSE labor.
Condemned during the latent phase:

1. Amniotomy - no benefits, increase infection and prolapse of cord
2. CS – benefits neither mother nor fetus
Active Phase
1. Acceleration phase – 4 cm dilatation
2. Phase of maximum slope – 5 – 9 cm dilatation
3. Deceleration phase – 9 – 10 cm dilatation
Must remember:
Dilatation Descent
Primi 1.2 cm / hour 1 cm / hour
Multi 1.5 cm / hour 2 cm / hour
Failure of the cervix to dilate and for the presenting part to descent is a clinical observation and NOT a diagnosis.
Abnormal Labor Patterns: Active Phase

Cervical dilatation less than expected normal rate:
26
PANDA MANILA
PROTRACTED CERVICAL DILATATION
WHO definition of PROTRACTION
 With the use of management partograph
 < 1 cm dilatation for a minimum of 4 hours
Arrest in Cervical Dilatation - No change in cervical dilatation > 2 hours

ACOG: Diagnosis of Arrest is made:
 Latent phase is completed
 Cervix dilated 4 cm or more
 Uterine contraction pattern of 200 montevideo units or more in a-10 minute period for 2 hours without cervical
change
DESCENT OF THE FETAL HEAD
nd
Abnormalities in the 2 Stage of Labor
Prolonged:
 > 2 hours in primi
 > 1 hour in multi
 Additional hour if under epidural anesthesia
Failure of Descent:
 no change in the station of the head from deceleration till full cervical dilation
 non-descent of the fetal head
Arrest in Descent
 there is no further descent for more than 1 hour
Etiology:
A. Fetal-Pelvic Disproportion
 “fetus that is too large, a pelvis that is too small”
 “a fetus un a position as to interfere with the normal mechanism of labor”
Case 1:
A 24 year old primi, admitted due to hypogastric pain of 5 hours duration.
VS: BP 110/70 PR 87/min T- 37C FH 34 cm FHT 145 cephalic
IE Cervix = 2 cm dilated, 80% effaced, cephalic
At this point, assessment should include

 ? true labor
 Status of bag of waters
 Station
 Fetal status
 Maternal condition
If after 7 hours, repeat IE will reveal 3 cm dilatation. What is your assessment?
Latent Phase: LONG

 Preparatory stage
 Abnormal: if more than:
o 20 hours primi
o 14 hours multi
Management: Just observe

 If with intact BOW
 No maternal indication that will indicate immediate delivery
o Hypertension
o Infection
27
PANDA MANILA
CASE NO. 2
30 year old G3P2 admitted in labor for 4 hours. Stable VS.
FH 35 cms FHT 135/min. Cephalic presentation. Uterine contractions q 3- 4 minutes
IE – Cervix 4 cm dilated, 80% effaced intact BOW LOT, station -1
2 hours after admission, there was passage of watery vaginal discharge
Do an IE: Why?
 Confirm rupture of BOW
 r/o possible prolapsed of the cord
 reassess cervical dilatation
If on IE: Cervix 5 cms, 80% effaced, (-) BOW Station -1

Assessment?
Protraction in Cervical Dilatation:

Normally cervix should dilated 1.5 cms/hr
 there is a change in cervical dilatation, but not the expected rate of change
Management:
Refer: Augmentation of Labor
Causes: Protraction in Cervical Dilatation

 too much analgesia
 Malposition
 CPD
Case 3:
29 year old primi, 38 weeks A/G admitted because of labor pains of 5 hours duration. Stable VS.
FH - 35 cms FHT 146/min cephalic presentation IE – Cervix 4 – 5 cm dilated, 8-% effaced + BOW, LOT, Station -1
Assess condition of the mother and of the baby.

3 hours later, there is spontaneous rupture of BOW.
IE: Cervix 6 cm dilated, (-) BOW, Station -1
Patient is allowed to go on with her labor.

2 hours after, she complained of unbearable pain
Repeat IE:
Cervix = 6 cms dilated, 90% effaced, (-) BOW, Station -1 LOT
Arrest in Cervical Dilatation

 No change in cervical dilatation after 2 hours
 Diagnosed only after > 4 cm
 Good contractions q 2-3 minutes
CS is indicated!
Effects of Arrest in Cervical Dilatation:

 Hypoxia to the baby 1
 Formation of pathologic retraction ring
o Fistula formation
o Rupture of the uterus
Case 5
A.B. 23 year old primigravida, fully dilated after 10 hours of labor. Stable VS. FHT – 145/ min
What should be done on admission?
Assess:
Station and position of the fetal head!
Patient should be instructed to PUSH only if: head is already in the pelvic floor
 Bulging of the perineum
 Anal opening becomes bigger
Pushing is ineffective if the fetal head is still high in the pelvis

 It will only exhaust the patient
 It may even predispose to vulvar edema
28
PANDA MANILA
Adequate Powers:
 Contraction are regular
 Progressive leads to dilatation
 Frequent (2 – 3 minutes)
 Lasting for 60 seconds
Inadequate Powers:
 Hypotonic or uncoordinated contractions
 Weak maternal expulsive efforts
Abnormal Labor:
 Prolonged or difficult labor.
4 Ps of Labor:
1. Power – Uterus
2. Passenger – fetus
3. Passage – pelvis
4. Psychology
nd
Effects of Prolonged 2 Stage of Labor
 Formation of excessive caput succedaneum
 Formation of excessive molding of fetal head
 Fetal hypoxia or fetal death
 Development of pathologic retraction ring

 Predisposition to fistula formation
 Predisposition to uterine rupture
MALPRESENTATION
. Fetal-Pelvic Disproportion
 “fetus that is too large, a pelvis that is too small”
 “a fetus un a position as to interfere with the normal mechanism of labor”
Malposition/ Malpresentation
Malposition
 Incorrect position of the vertex.
 This includes occipito-posterior (OP) positions and deflection of the head short of brow presentation
Malpresentation
 Presence of any presenting part other than the vertex – face, browm breech, shoulder & compound presentation.
MALPRESENTATIONS
Breech Presentation:
 Occurs when there is a longitudinal lie and the fetal buttock is the most dependent fetal part.
Varieties of Breech:
 Frank Breech – both hips flexed and both knee extended placing feet near face
 Complete Breech – both hips flexed, both knees extended, both feet presenting with the breech
 Incomplete or Footling – at least one hip and knee partially extended and thus below the presenting breech.
29
PANDA MANILA
Incidence of Breech Presentation

 Indirectly related to gestational age
 Abnormalities causing reduced fetal movements andtone
 Congenital anomalies 3 x ↑ versus cephalic
 CNS malformations 10x higher
Etiology
 Prematurity – the most common cause
 Factors preventing spontaneous version

1. Extended legs
2. Twins
3. Oligohydramnios
4. Congenital malformation of the uterus
5. Short cord
 Favorable adaptation
1. Hydrocephalus
2. Abnormal placental implantation
Diagnosis:
 Clinical: Leopold’s Maneuver
 Sonography
Prognosis:
Maternal: CS
 Higher morbidity: slightly higher mortality
 Risk ↑ with ER CS than elective
Fetal: worse than cephalic

 Preterm deliveries
 Congenital anomalies
 Birth trauma
Management: Early Diagnosis

 Identification of complicating factors
 ECV, if not contraindicated
Indications for CS in Breech Presentation

 Primigravida
 Preterm
 BW = >3500 grams or < 2500 grams
 Not of frank breech variety
 Extended head
 Poor OB history
Vaginal Breech Delivery:

1. Spotaneous breech – natural forces of the mother with no assistance other than the support of baby as it is born
2. Assisted breech
 Partial breech extraction
 Total or complete breech extraction
Delivery of After – coming head

1. Mauriceau’s
2. Bracht’s
3. Prague’s
4. Piper’s Forceps
Face Presentation: - There is complete extension of the head

Etiology:
 Inlet contraction
 Congenital abnormalities
 Multiparity
Diagnosis:
 Usually at the time of delivery
 Cephalic prominence along the side of the fetal back
30
PANDA MANILA
Management: Overall Assessment

 Pelvic adequacy
 Size of the baby
 Associated complicating factors
 Congenital fetal malformations
 Position of the mentum
Brow Presentation
 Rarest variety of cephalic presentation
 Unstable & converts either to vertex or face
Transverse Lie – Shoulder Presentation

 The long aixs of fetus lies perpendicular to maternal pelvis
Etiology
1. Multiparity
2. Prematurity
3. Multiple Pregnancy
4. Hydramnios
5. Contracted Pelvis
6. Placenta Previa
7. Pelvic Tumors
8. Congenital Malformations of the Uteruss
9. IUFD
Diagnosis:
 Inspection – uterus looks broader and asymmetrical
 Palpation – fundic height is less that the age of festation
 LMI – no fetal pole
 Auscultation – FHT heard easily much below the umbilicus
 Internal Examination – feeling of the ribs & intercostals spaces – “gridiron feel”
Gridiron Feel – confirmatory of transverse lie

Cundiplicato Corpore - condition that occurs during birth if the fetus is quite small and the pelvis is large.
Complications
 Cord prolapsed
 Uterine rupture
Management:
 External cephalic version – if there is no contraindication, > 32 weeks
 CS
Dystocia Caused by Fetal Anomalies

1. Fetal Macrosomia
2. Shoulder dystocia
3. Hydrocephalus
4. Anencephaly
5. Enlargement of fetal abdomen
6. Conjoined twins
Fetal Macrosomia: with birthweight of >3500 grams
Causes:
 Hereditary
 Poorly controlled DM
 Postmaturity
 Multiparity
Diagnosis:
 Fundic height ↑
 Fetus feels big & firm
 Big fetus on x-ray
 BPD > average size
Dangers:
 Dystocia due to big baby  trauma, asphyxia, leading to perinatal mortality or morbidity
31
PANDA MANILA
Shoulder Dystocia
 The shoulders fail to deliver shortly after delivery of the fetal head
 The chin presses against the walls of the perineum
“Turtle’s Sign” – appearance & retraction of the fetal head

 “Turtle withdrawing into its shell”
 Erythematous, red puffy face indicative of facial flushing
McRobert’s Maneuver: To expand pelvic outlet
Disimpaction of the Anterior Shoulder

Abdominal disimpaction: MAZZANTI’S
 firm pressure over the posterior aspect of the anterior shoulder
Vaginal disimpaction: RUBIN’S

 2 fingers placed on the posterior aspect of the anterior shoulder pushing it in the direction of the baby’s eyes.
Mazzanti & Rubin’s Wood’s
Wood’s Maneuver or Corkscrew

 Applying pressure on the anterior aspect of the posterior shoulder, rotating it through 180
O
Jacquemier’s or Barnum’s Maneuver:

 Delivery of the posterior shoulder
 Reduce the bisacromial diameter
 Allow rotation of the shoulders by traction on the arm
Hydrocephalus
 Excessive accumulation of CSF in the __ with thinning of brain tissus & enlargement of the cranium
Anencephaly
 Deficient development of the vault of the skull & brain tissue but the facial portion is normal.
 The pituitary gland is often absent or hypoplastic.
32
PANDA MANILA
PASSAGE: PELVIS
True Pelvis: 2. Midpelvis:
1. Inlet – the brim of the pelvis  Lateral pelvic walls
 True conjugate – 11 cms  Ischial spines
 Obstetrical conjugate -10 cms  Concavity of the sacrum
 Diagonal conjugate – 12 cms
 Traverse diameter – 13cms 3. Outlet:
 Ischial tuberosities
 Pubic arch
Contracted Pelvis:
 One where the essential diameters of one or more planes are shortened by 1.5 cm
 Alteration in the size and/or shape of the pelvis of sufficient degree so as to alter the normal mechanism of labor in an
average size baby
Diagnosis of Contracted Pelvis:

1. Stature – less than 5 feet
2. In primi – non engagement of the head in term pregnancy
3. Clinical pelvimetry
Clinical Assessment of the Pelvis

 Measurement of transverse diameter of the outlet and pelvic angle
Abdomino-vaginal (Muller-Munro Kerr) Method

 Muller introduced the method by placing the vaginal finger tips at the level of the ischial spines to note the descent of
the head.
 Munro Kerr added placement of the thumb over the symphjisis to note the degree of overlapping.
 if head can be pushed down upto level of ischial spines, no overlapping of parietal bone over symphysis
 No disproportion
 Head can be pushed down a little but not upto level of ischil spines, slight overlapping of parietal bone
 Moderate disproportion
 Head cannot be pushed down * instead parietal bone overhangs at symphisis displacing thumb
 Severe disproportion
Effects of Contracted Pelvis:

 ↑ incidence of PROM
 ↑ incidence of cord prolapsed
 Slower cervical dilatation
 ↑ incidence of prolonged labor
 ↑ incidence of operative deliveries
Forceps & Vacuum Extraction, Breech Delivery, CS &

Peripartum Hysterectomy
Breech Presentation & Delivery
Breech Presentation
 When there is a longitudinal lie with fetal buttock as the most dependent fetal part
Etiology
 Prematurity
 Hydramnios - enabling the fetus to move around
 Oligohydramnios – fetus cannot change anymore
 Multiparity
 Congenital anomalies
 Uterine abnormalities
No strong correlation between breech presentation and contracted pelvis
33
PANDA MANILA
Varieties of Breech:
 Frank Breech – both hips flexed and both knee extended placing feet near face
 Complete Breech – both hips flexed and both knees flexed, both feet presenting with the breech.
 Incomplete or footling – at least one hip and knee partially extended and thus below the presenting breech.
Remember:
FRANK BREECH - Possible vaginal delivery in MULTIGRAVID patient WHEN:
 Tested Pelvis
 Term Pregnancy
 Not more than 3500 grams
 Well Flexed
Diagnosis:
 Clinical – Leopold’s Maneuver
o Examine the fundus of the uterus, instead of appreciating the (round hard mass) head. It will be the buttocks
that will occupy the fundus.
 Sonography
o Abuse of the machine (for Dra. RVG )
o Advantages:
 Accurate estimation of the fetal head
 To Rule out congenital abnormalities for mgmt. of breech presentation
 Confirmation: Clinical – Leopold’s Maneuver & IE
Prognosis:
Maternal: risk is too much
CS
 Trauma to genital tract
 Infection
 Anesthetic Complication
FETUS: Vaginal Delivery

 Head difficulty:
o Intracranial hemorrhage
o Asphyxia
o Injuries
Especially if you have to bring down the lower extremities, sometimes will even come down with:
o Fracture of the femur
o Dislocation of upper extremities
o Injury to the brachial plexus
MANAGEMENT:
Early Diagnosis
 Identification of complicating factors
 EXTERNAL CEPHALIC VERSION, if not contraindicated.
o ECV is possible IF you’ve been DX A BREECH in a patient who is IN TERM but NOT YET IN LABOR.
INDICATIONS FOR CS IN BREECH PRESENTATION

 PRIMIGRAVIDA: have not proven the ability of pelvis to deliver babies vaginally.
 Even in cephalic presentation there would still be some doubts.
 Preterm
 BW >3500 grams (LGA) or <2500 grams (SGA)
 Not of frank breech variety: FOOTLING/ INCOMPLETE & COMPLETE
 Extended head
 Poor OB history: Preterm
Vaginal Breech Delivery

1. Spontaneous Breech – natural forces of the mother with no assistance other than support of baby as it is born
 Natural forces: uterine contraction & pushing
 Not the most ideal:
o The first to go out will be the buttocks. The moment the UMBILICUS GOES OUT, remember that you already
have the umbilical cord, as the baby goes down the cord is being drawn with it.
o Then the cord is exposed to be compressed between the fetus itself and that of the maternal parts.
o The cord can be compressed only to a LIMITED period of time. Remember the head of the baby which is the
BIGGEST, will be the LAST to come out.
o And it will take TIME for the head to come out. For the head to be delivered without much compromise, the
most that you could give is about 7 – 10 minutes. Longer than that expect the baby to be HYPOXIA.
o No guarantee the head will be delivered within the period of time.
o ONLY ALLOWED: babies weighing < 1000 grams
- Very severely immature babies that even if you do CS or vaginal, the outcome will be the SAME.
34
PANDA MANILA
2. Assisted Breech –
 PARTIAL BREECH EXTRACTION – MOST IDEAL
 TOTAL OR COMPLETE breech extraction – only to deliver the 2 twin who happens to be in a breech or transverse
nd
lie that we even have to alter the presentation:

o Transverse  Total Footling Presentation
o Internal Podalic Version followed by total breech extraction.
*FACTORS: Multigravid, Term, Frank Breech Variety and between 2500 – 3500 grams.
Vaginal Delivery:
 Draws the umbilicus & cord into pelvis  cord compression
 Once breech has passed beyond introitus, abdomen, thorax, arms & head be delivered promptly
Preterm Fetus:
 Disparity between head & buttocks much greater than term
 Cervix may not be adequately dilated for head to escape.
 Preterm is NOT ideal for vaginal delivery, the more the preterm the baby is, the bigger is the disproportion between
the head size and that of the body  CS.
 Problem:
IF Pelvis is adequate & head of the preterm baby is small, can we not deliver the baby vaginally?
But the PROBLEM IS CERVIX.
The cervix might only be 7 cm, the body would come out but would ENTRAP the head.
DUHRSSEN INCISION:
 Incisions at 10 am & 2 o’ clock positions to relieve entrapped after-coming head.
 NOT 3 & 9 o’ clock? Because we have the blood supply  uncontrollable hemorrhage.
 REMEMBER: it is the CERVIX that causes the entrapment of the head.
Delivery of After-coming Head:

1. Mauriceau’s
 Fingers on either side of neck for gentle downward traction

 Fingers over maxilla to keep the head flexed
 Partial Breech Extraction: you allow spontaneous delivery up to the level of umbilicus. Once the umbilicus is already
out, then you facilitate in the delivery of the fetus. Hold in the buttocks, and then you try to move the fetus (/) so that
the bisocromial diameter will occupy the AP dm of the pelvis.
 Why? Remember: BSC dm is longer so that it will utilize the AP diameter of the pelvis. Because the transverse diameter
of the pelvis esp. at the midpelvis is NARROW.
 Once anterior aspect of the scapula is seen, apply traction downward, it will deliver the anterior shoulder and then let
it pass under the symphysis pubis.
 Then lift the baby upwards to deliver posterior shoulder, once both shoulder is open then rotate so that the sagittal
suture of the baby will be along the AP diameter of the maternal pelvis.
 Let the baby straddle on your palm and your other dominant hand over the shoulder
 Ring & Middle Finger: over the malar prominence: TO KEEP THE HEAD FLEXED while another hand keeping pressure on
the suprapubic area to keep the head more flexed
 While the force or the traction that will make the baby force way out will be coming from the right hand. Deliver it
downwards til you deliver occiput part, then lift it upwards.
2. Bracht’s
– no need to place fingers on the malar

prominence but you bring the FETAL BACK
TOWARDS THE MATERNAL ABDOMEN.
3. Prague’s
– the baby is facing UP, more of OCCIPUT IN THE POSTERIOR downwards  expose chin 
bring the FETAL ABDOMEN TOWARDS THE MATERNAL ABDOMEN.
35
PANDA MANILA
4. Piper’s forceps
Why encourage forceps?

 So the head will not extend so you
could easily extract the fetal head.
O
Do not move 180 in one turn
 Move bit by bit (45 )
O
 Observe per turn

 IF returns to initial position:
o Possible nuchal cord
o Appreciate the FHT
 If completed turn of 180
O
 Observe for 30 mins to 1 hour. Why?
Remember:
- You turn the baby externally, so you might not be aware that
the placenta is ANTERIORLY located.
- So when you turn, there might be predisposition to
ABRUPTIO PLACENTA.
- If that happens, the patient is still with you.
Helpful: http://www.youtube.com/watch?v=VKqAkjGCVOk
Breech Decomposition
- Conversion of frank breech to become double footling breech.
- Thru PINARD’S MANEUVER
Pinard’s Maneuver
- Bringing down the leg by flexion and abduction of the popliteal fossa
*Rem: Frank Breech Variety- MOST IDEAL FOR VAGINAL DELIVERY

 Real instances when there is anticipation of vaginal delivery fully dilated. Then all of a sudden there is spontaneous rupture
of BOW  prolapse of the cord  ER due to possible compression of the cord
 Instead of CS  convert frank breech to double footling breech
Version
 Alteration of fetal presentation, substituting either
 One pole of a longitudinal presentation for the other
Ex. Breech  Cephalic
 Converting an oblique or transverse lie into a longitudinal presentation
Ex. Shoulder  Breech
Types of Version
1. External Cephalic Version
2. Internal Podalic Version
External Cephalic Version

 To come up with the most ideal presentation (CEPHALIC)
 Done after 36 completed weeks, not in labor
 Markedly decreased CS for breech presentation
Note:
 First: r/o possible causes why the baby presents as breech/ shoulder presentation
 Absence of previa, no congenital abnormalities & adequate amount of AF then you do the version.
Failures of ECV due to:

 Engaged presenting part: should be FLOATING
 Difficulty identifying the fetal head: thick abdominal fat that would require UTZ for confirmation
 Uterus tense to palpation: ticklish
For Dra. RVG

 IF 36 weeks: still conservative, there might be borderline maturity
 She does it for > 37 weeks. Why?
 Natural Complication: LABOR/ predisposition to delivery
o Labor & Term: 
o Labor & Preterm: 
36
PANDA MANILA
Technique: Hazards Contraindications

 Talc the abdomen  Preterm labour Absolute Relative
 Use tocolytics  Abruption o Multiple pregnancy  Previous CS
 Administer anti-D placenta o Previous antepartum  IUGR
to Maternal Rh –  Cord accident haemorrhage  Pre-eclampsia
 Uterine o Ruptured  Rh- isoimmunization grand
rupture of membranes multiparity
previous scar o Oligohydramnios  Anterior placenta
 Obesity
Internal Podalic Version

 Rarely used due to high fetal & maternal mortality and morbidity
 Occasionally performed – as a life-saving
 DELIVERY OF NON-CEPHALIC 2 TWIN
ND
 Done during 2 STAGE OF LABOR

ND
 MEMBRANES BE INTACT
 CONTRAINDICATED in ruptured membrane with oligohydramnios
*Insert right hand in uterus, hold both feet of the fetus but you should be well acquainted where is the location of both feet. As
you extract the feet, from the transverse  double footling. While the other hand is over the abdomen of the mother, you guide
the head if the baby.
st nd
* Once delivery of the 1 baby, right away rupture the BOW of 2 twin baby so you still have the room for you to do the
manipulation. Remember as you rupture the BOW, the uterus continuously contracts so in Moriceau’s you might even cause
rupture of the uterus.
FORCEPS & VACUUM DELIVERY
4 parts:
1. Handle
2. Lock
3. Shank – differentiates forceps due to the length of the shank
4. Blades
 Cephalic Curvature
 Pelvic Curvature
Types of Forceps
 Simpson’s Forceps – commonly used
 Kjelland Forceps
 Piper’s Forceps
- After-coming head in breech presentation
Classification of Forceps & Vacuum Delivery

Procedure Criteria
MIDPELVIC o Station above +2; head is engaged
LOW o Leading point of fetal skull >+2 not on pelvic floor

O
o Rotation is 45 or less (LOA or ROA  OA or LOP or ROP  OP)
O
o Rotation is < than 45
OUTLET o Scalp visible at introitus w/o separating labia

o Fetal skull has reached pelvic floor (+4, +5)
o Sagittal suture in AP diameter
o Fetal head is at or on the perineum
O
o Rotation does not exceed 45 or occiput is under symphisis pubis
37
PANDA MANILA
*Classification depends on the:

1. STATION of the HEAD: edge of the presenting part in relation to the ischial spine
2. POSITION: cephalic presentation, point of reference for position is OCCIPUT (L or R or Ant or Post)
For you to apply forceps, it is only when the HEAD is ENGAGED, (> + 2)
The lower the head is, the more rotated is, it will be safer and easier for you to apply the forceps.
Outlet Forceps Application  usually carried out, the simplest.

There are instances wherein patients are not allowed to push or to bear down.
Remember: it is when the head is on the pelvic floor that the patient will push. If we don’t want, we apply forceps right away.
Effects of Regional Analgesia – EPIDURAL

o Associated with failure of spontaneous rotation to OA
o Slowing of second – stage labor
o Decreasing maternal expulsive efforts
Functions of the Forceps Indication for Forceps

nd
o Traction – MAIN Termination of 2 stage of labor that threat maternal/ fetal
o Rotation conditions
nd
Prolonged 2 stage
Maternal Indication
o Pregnant CARDIAC Fetal Indication
o Hypertensive who are not supposed to push/ to bear o Fetal distress
down o Prolapsed cord when cervix is already fully dilated
Prerequisites for Forceps Application

1. Engaged Head
o When biparietal dm of the head has entered the pelvic inlet
o Ideal Well-Engaged: +2
2. Vertex in presentation mentum anterior in face.
3. Known fetal position
4. Complete dilation of the cervix.
5. Membranes must ruptured
6. No suspected Cephalo-Pelvic-Disproportion (CPD).
O PRESENCE OF CPD IS A CONTRAINDICATION
Elective Forceps
o Criteria for OUTLET forceps be satisfied
o Fetal Head on the perineal floor
O
o Sagittal suture not > 45 from AP dm
Trial Forceps
o An attempt on forceps application is anticipated to be difficult
o Unsatisfactory application of the forceps
* Aware of CPD, fully dilated labor, cannot push down, still decided to apply forceps.
Failed Forceps
o Satisfactory application of forceps achieved
o Gentle downward pulls made but no descent
 Pull but no change in the station of the head
Vacuum Extraction: Ventouse

 CMI Tender Touch Extractor Cup
 Mityvac Vacuum
Advantage: does not occupy space unlike forceps
Ventouse – method of traction

Note the finger – thump position
CHIGNON – crown marking from the vacuum
Indications and prerequisites are the same in forceps as in vacuum

Contraindications for Vacuum:
Absolute Relative
 Inexperience of the operator  Face or nonvertex presentation
 Inability to assess fetal position  Fetal coagulopathy
 High station  Known macrosomia
 Suspicion of CPD  Recent fetal scalp sampling
38
PANDA MANILA
COMPLICATIONS OF VACUUM:
 Scalp lacerations and bruising  Clavicular fracture
 Subgaleal hematomas  Shoulder dystocia
 
th th
Cephalhematomas 6 & 7 CN injury
 Intracranial hemorrhage  Erb palsy
 Neonatal jaundice  Retinal Hemorrhage
 Subconjuctival hemorrhage  Fetal Death
* Vacuum Extraction reserved for > 34 weeks
Comparison of Vacuum Extraction of Forceps Delivery

Vacuum Forceps
Maternal trauma
Blood loss Lesser Higher
Marks & Bruising
Neonatal Jaundice
Shoulder dystocia Higher
Lesser
Cephalhematoma
CS & Cesarean Hysterectomy

History of CS Delivery:
 Cadere – to cut
 Caesones – children delivered by CS
 1 performed in early 1800’s
st
 Introduction of diethylesther as anesthetic – in Massachusetts in 1846

o Increase feasibility of major abdominal surgery
 Chloroform administration – for Queen Victoria of England in her 2 deliveries: 1853 & 1857
 1876, Eduardo Porro, Italian Professor – Hysterectomy combined with CS: subtotal CS hysterectomy
Porro’s Operation – Subtotal Hysterectomy FF CS
CS - birth of a fetus through incisions
2 TYPES:
o abdominal wall - laparotomy incision
o uterine wall - hysterectomy incision
Major Complications Associated:

1. Infection
2. Hemorrhage
3. Anesthesia
Maternal Mortality
o An infrequent occurrence
o Overall rate estimate to be several fold higher than vaginal delivery
Decline in Perinatal Mortality

o Major advances in prenatal care
o UTZ & Antepartum testing - can ID babies who are compromised in utero
o AF surfactant determinations
o Dramatic improvement in neonatal intensive care
o Availability of surfactant implementation
CAUSES OF INCREASED CS:
1. Medical advances diminishing maternal risks o Increasing maternal risk

4. Fetal Factors
2. Labor and delivery – related factors o Fetus as a patient
o Repeat cesarean birth o Breech presentation
o Continuous EFM (Electronic Fetal Monitoring) o VLBW fetus (Very Low Birth Weight)
o Diagnosis of dystocia liberalized o Active genital herpes
o Epidural analgesia / anesthesia o Post-term pregnancies
o Macrosomia o Multiple Gestations
o Decreased use vacuum/ forceps o Failed induction for fetal indication
3. Maternal Factors 5. Physician Factors

o More older childbearing women delay in o Fear of malpractice litigation
childbirth o Physician compensation (possible)
o More nulliparous women with attendant risk o Physician convenience (possible)
39
PANDA MANILA
Indications:
o CS is employed when labor is contraindicated (E.g. CHF, markedly HPN in the verge of convulsion)
o Vaginal delivery unlikely to be accomplished safely within a time frame necessary to prevent the development of fetal
&/or maternal morbidity in of that expected following vaginal delivery.
ABSOLUTE INDICATION:
o Primary CS: CPD
o Repeat CS: Previous Classical CS

st
Not only in the 1 but also for the following pregnancies. Because the pelvis of the mother is not capable of delivering
babies vaginally.
RELATIVE INDICATION:
o Prior CS
o Dystocia
o Fetal Distress
o Breech Presentation
o Placenta Previa/ Abruptio

st
At that particular instance: vaginal delivery will be a threat to the 1 pregnancy, but the absence of the condition in
the next pregnancy can give the woman a chance to deliver vaginally.
Maternal Mortality
o Maternal death attribute to CS is rare
Maternal Morbidity:
o Puerperal infection
o Hemorrhage
o Thromboembolism
Abdominal Incisions for CS

1. Vertical Incision – Infraumbilical midline vertical
 Quickest to make
2. Transverse Incision – Pfannenstial Incision

 Stronger & less likely to undergo dehiscence
 Exposure not optimal
 Re-entry time-consuming
 Re-entry difficult due to scarring
 Recommended for obese patients
ABDOMINAL INCISIONS
Choice of Abdominal Incisions

 Be based on relative simplicity & speed of various incisions
 Desired exposure
 Estimated fetal weight
 Anticipated cosmetic results
 Risk factors for infection & dehiscence
Vertical Incisions
 Allow more rapid access to the LUS
 Less blood loss
 Provide greater feasibility for incisional extension around the umbilicus
 Allow easier examination of the upper abdomen
Transverse Incisions:
 Maylards - involves transverse incisions of the anterior rectus sheath and rectus muscles bilaterally
 Pfannestiel – sharp separation of the muscle of the median raphe
 More time consuming

 Preferred cosmetically
 Generally less painful
 Associated with decrease risk of subsequent herniation
40
PANDA MANILA
Types of CS:
 Classical CS Incision: Body of Uterus
 Low segment Vertical Incision: Kronig
 Low Transverse CS Kerr/ Low Cervical CS: Lower Segment of the Uterus
Notes:
* More important is the incision of the uterus
* LTCS – more recommended due to less incidence of rupture.
1. There is higher incidence of rupture in the classical. Why?

Remember that the active segment of the uterus is the one that undergoes contraction. It is the upper segment of the
uterus that is being distended to accommodate the growth of the product of conception.
2. Greater blood loss due to thicker muscle.
3. Greater incidence of adhesion: on the upper part there is the intestines & the omentum while on the lower have lesser
contact with the GIT.
LTCS
 Low Transverse CS
 Operation of choice
ADVANTAGES:
 Easier to repair
 Site least likely to rupture
 Does not promote adhesion
 Less blood loss
INDICATION FOR CLASSICAL CS:

 Transverse lie
 Placenta previa with anterior placenta
 Anterior tumor previa
PERIPARTUM HYSTERECTOMY
 INTRACTABLE UTERINE ATONY
 Placenta accrete
 Symptomatic myomas
 Severe cervical dysplasia or
COMPLICATIONS OF PERIPARTUM HYSTERECTOMY:

 Increase in blood loss
 Increase in urinary tract injury
 Increase in post-op infections
Vaginal Birth After CS (VBAC)

 Primary Indication – NOT AN ABSOLUTE INDICATION, but RELATIVE
 Primary CS – LTCS (NOT CLASSICAL)
 Singleton Pregnancy, Longitudinal Lie
FAMILY PLANNING
Dr. Z. N. Gamilla Notes of Mimi: (Late)
Need for family planning in 2008

 Met need 51%
 Unmet Need 26%
 Unintended 54%
 Intended 46%
Pregnancy & Childbirth – one of the leading causes of mortality

DALY – 311 000 lost productive years
BIOLOGICAL BASIS OF NFP

 SPERM LIFESPAN: 48-72 hours (3 days)
 OVUM LIFESPAN: 2 days
 PEAK FERTILITY: 1 day
 each ejaculate releases millions of sperms but only one is needed to fertilize
 most men are continually fertile
PREOVULATORY PHASE - LH, FSH

Early
 CERVIX: closed
41
PANDA MANILA
 ENDOMETRIUM: is reforming
 CERVICAL MUCUS: unlikely of to be extruded
POSTOVULATORY PHASE
 formation of corpus luteum
 CERVIX: closed, firm, low
 ENDOMETRIUM: thickened (secretory phase)
 MUCUS: thick, cloudy, non-stretched
OVULATORY PHASE
 CERVIX: open, soft, highly accompanied by abdominal pain and bleeding due to hormonal factor and thickened
endometrium
 CERVICAL MUCUS: presence of sperm
DAY 13
 surge in LH
 slight i↑ in FSH
 ↑ in estrogen
 fertilization, conception
 hormonal interplay that may produce symptoms felt and observed by the patient
3 BASIC ELEMENTS NECESSARY FOR CONCEPTION

1. egg
2. sperm
3. fertile mucus
**fertilization takes place in the outer part of the fallopian tube
DEGENERATION
 occurs if fertilization doesn’t take place within 24 hrs
 blighted ovum; early embryonal death
 accidental pregnancy by an unhealthy ovum
Maternal & Fetal morbidity and mortality due to contraception

 No data on deaths or morbidity due to contraception in the Philippines
 On the other hand, 12% of maternal deaths were due to unsafe abortion
Forms of contraception available in the Philipppines and the rate of use

 51% - Not using
 13% Pill
Percentage of all women and of currently married women who have ever used any contraceptive method, Phil 2003
 Withdrawal & OCP
 * NOTE: Withdrawal – not considered as part of NFP nor artificial.
Conception Control: Knowledge and Use

 98% of currently married women knew of at least one modern method (e.g. pill)
 94% knew of at least one traditional method (e.g. withdrawal)
 Use of modern methods was higher among women in URBAN areas than among rural inhabitants (31% vs 25%)
 70% of married women ages 15 – 49 say they want to limit or space future births
 But only 2/3 of this implicit demand for family planning services is currently being satisfied
 The remaining 26% have an unmet need for family planning
* Conception than Contraception

 Contraception: strong indication against conception
 Conception Control: positive definition
Natural Family Planning

 Planning or controlling pregnancy by timing sexual intercourse with the fertile or infertile phase of a woman’s
menstrual cycle
 Indicated by certain symptoms and bodily changes

Advantages:
 Allow you to achieve or control conception without the aid of artificial devices
 Effective when accurately and consistently practiced
 Create an awareness of the body and its reproductive functions
 Help enhance your marriage relationship by encouraging more intimate communication and shared decision making in
matters involving sexuality and fertility regulation
 During the SAFE period, sex relations can be as spontaneous as possible
42
PANDA MANILA
Limitations
 Require commitment, cooperation and will power
 Lessen the number of days in which you can safely have sexual intercourse
 The effectiveness also depends on the accurate determination of the fertile period
 Specifically, the calendar method relies heavily on the regularity of the menstrual cycle which may be subjected to
changes in weather or health conditions.
Biological Basis of NFP

*On the ovulation that occurs within 24 hours
* Sperm Survival: 48 – 72 hours
* Ovum Survival: 48 hours
Methods used in NFP

 Calender method
 Cervical Mucus/ Billing’s Method
 Symptothermal Method
 Standard days/ Beads Method: 2 day method
 Lactation Amenorrhea Method
I. CALENDAR METHOD
 Recommended only for women with regular cycles
 With irregular cycles entail longer periods of abstinence
 For women REGULARLY MENSTRUATING, - 14 from the cycle length, then – 5 & + 4
 Fertile: DAYS 9 – 18
 INFERTILE: DAYS 1 – 8. 19 – 28
Basis for computation for calendar method
Calendar Method
 For women with IRRREGULAR CYCLE; to get the fertile days: (get at least 3 – 6 months)
 - 20 from the SHORTEST cycle
 - 10 from the LONGEST cycle
E.G. cycle 28 – 35, Fertile: 8 – 25.
II. CERVICAL MUCUS/ BILLING’S METHOD

 Observing the quality and quantity of mucus discharge on her genital area
 * afternoon & almost the end of the day
FERTILE TYPE MUCUS

 Strings of raw egg white, smooth or slippery
 Distinct wet and slippery feeling
 Feeling of fullness, softness and swelling in the tissues around the opening of the vagina
 Provides the sperm cells with protective envelope
INFERTILE TYPE MUCUS

 Opaque and flaky
 Sticky and not elastic
 Lacks the slippery, lubricative quality of the fertile-type mucus
43
PANDA MANILA
TYPES & FUNCTIONS OF THE MUCUS

 G MUCUS
o Lower crypts
o Dense, impermeable to sperm
o Mucus plug
 L MUCUS
o Loaf/ Lump
o Middle Crypts
o Lumpy type, subtype to S. Mucus
o Filtering defective sperm
 S MUCUS
o Slippery, Stretch, Stringy
o Highest Crypts
o Swimming Lanes, Lubricant
o Protective to Sperm, Nourishing
Studies on the Effectiveness of the Billing’s Method

 WHO (1997 0 1981): “A prospective multicare trial of the ovulation method of Natural Family Planning.” Fertility and
Sterility, `98`. Vol 36. P 59 (2.2. method related pregnancies per 100 women)
 Jiangsu Family Health Institute, China (97) “Evaluation of effectiveness of a natural fertility regulation program in
China.” Bulletin of the Ovulation method Research and Reference Centre. Vol 24, No 4, pp 17 – 22. No method related
pregnancies
III. SYMPTO-THERMAL METHOD

 Changes in basal body temperature in combination with other sign, symptoms and or calculations
 Rise in basal temperature that is maintained until just before the onset of the next menstrual cycle
 Rise in the BBT is referred to as thermal shift and generally occurs during the middle of the menstrual cycle
 Abstain after the thermal shift or the peak mucus symptom is observed, whichever comes later
Lactation Amenorrhea Method
IV. STANDARD DAYS/ CYCLE BEADS METHOD

 478 women from Peru, Bolivia and Phil were followed up for 13 cycle
 Applicable to women with 26 – 32 day cycle
 Effectiveness is 95% or a pregnancy rate of 4.7%
 Each bead represents a day of her cycle
 The RED bead marks the 1 days when a women can get pregnancy
st
 The WHITE beads represent the days when a woman can get pregnant
 BROWN beads are the days when a woman cannot get pregnant
 The MARKED bead and the BLACK bead determine if the woman is within the required cycle length.
st
1. On the 1 day of menstruation, move to the RED bead
2. Every morning move the band to the next bead. Always move the band in the same direction, from narrow to wide
end. Move the band even on days when you have your menstruation
3. The day your menstruation starts again, move the band to the RED bead, A new cycle has started
2 Day Method Algorithm

 Did I have any secretions today?
o YES: I can get pregnant today
o NO  Did I have intercourse yesterday?
 YES  I can get pregnant today
 NO  Pregnancy not likely today
 Rate of Effectiveness of the 2 Day Method

o Pregnancies for every 100 woman years
o Correct use (with abstinence) 3.5
o Correct + Incorrect 13.7
o SourceL Arevalo et al. Fertility & Sterility, Oct 2004.
Efficacy in Actual Use

 Billings 92 – 96%
 Pill 92
 IUD 86.7
 Condom 64 – 88
 Spermicide 73 – 79
 Diaphragm 82 – 84
44
PANDA MANILA
Mechanical Barriers: Diaphragm, Condom, Cervical Cap

Chemical Barriers: IUD, Pills, Patch, Injectables, Spermicides, Gels & Foams
Contraceptive Failure
 Methods Perfect Use Typical Use
 OCP 0.3 8
 IUD 0.1 – 0.6 0.1 – 0.8
 Injectable 0.3 – 0.5 3 – 3.1
 BTL 0.5 0.5
 Condom 2 15
 Ovulation 3
“Using NFP to control birth is (when used legitimately) non-procreative. But contraception (even when used for the good end)
is anti-procreative.” - McManaman. The moral difference between contraception and NFP.
SB 2865
AN ACT PROVIDING FOR A NATIONAL POLICT ON REPRODUCTIVE HEALTH AND POPULATION AND DEVELOPMENT
FAMILY PLANNING – refers to a program which enables couples and individuals to decide freely and responsibly the number
and spacing of their children and to have the information and means to do so, and to have access to a full range of safe,
affordable, effective and modern methods of presenting or timing the pregnancy.
45
PANDA MANILA

Ob RVG Panda Manila

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Ob RVG Panda Manila

Caricato da

Copyright:

Formati disponibili

Facilitator: Dr.

Ruth Villanueva Gutierrez

2008: Same complaint

Uterus: slightly enlarged with mild tenderness

o Action of HCG: persistence of CL in early pregnancy

CERVICAL MOTION TENDERNESS/ WIGGLING TENDERNESS

ABDOMINAL TENDERNESS & RIGIDITY

PREGNANCY STILL INTACT

IF patient is significantly UNSTABLE

BUT pay attention to the POSTERIOR FORNIX:

 If not medical  SURGICAL MANAGEMENT:

 E.g.: YOUNG BE CONSERVATIVE AS POSSIBLE

 PAIN: CONTINUOUS uterine contractions

GTD: Gestational Trophoblastic Disease

CONSISTENCY of uterus from normal

TYPES & MGT:

 IF D&C  longer time

 FOLLOW – UP (trophoblastic activity)

 propensity for mets: LUNGS, BRAIN, VAGINA

PERSISTENT PLACENTAL SITE TUMOR PPST

BLEEDING IN THE 2nd HALF OF THE PREGNANCY

PLACENTA PREVIA – abnormal implantation of the placenta at the LUS

UTERUS – where the placenta should be implanted

 Via speculum: External os

UTZ for GOLD STANDARD

 In abruptio the same thing

If PP  due to repeated pregnancy, what about Abruptio Placenta?

* Previous CS: possibility of abnormal adherent uterus.

bleeding Not proportionate: CONCEALED TYPE

GENERAL LECTURE: Dr. Z.N. Gamilla

HYPOVOLEMIC SHOCK & DIC

Decreased Perfusion Maintained Blood Flow

ESTIMATION OF BLOOD LOSS (No accurate way to determine)

 Compatible Whole Blood

 CO-exists when intravascular activation of clotting mechanism results in excess consumption of

Activity of Activity of anti-

FIBRIN DEGRADATION PRODUCTS:

MECHANISMS TRIGGERING THESE EVENTS:

3. INTRAVASCULAR: Abnormal platelet activation

INTRINSIC PATHWAY EXTRINSIC PATHWAY

KIDNEYS Renal insufficiency

* Most reliable & specific: D DIMER MONOCLONAL ASSAY

HEMOSTATIC DEFECT LABORATORY PARAMETERS

MANAGEMENT OF SPECIFIC CONDITIONS

 Intrauterine fetal death (IUFD)

 Amniotic Fluid Embolism

HEPARIN MGT LATE REACTION Information

POSTPARTUM HEMORRHAGE RVG, MD NOV 27, 2012

BLOOD LOSS: HOW MUCH?

 ESTIMATING BLOOD LOSS

o Developing visual aids

 Von Willebrand’s disease  History of liver disease

Risk Factors DO NOT PREDICT complications.

If despite medical management, bleeding persists ...

Mild – Moderate Blood Loss

But if bleeding is life-threatening: Hysterectomy should be considered!

Manual Removal of the placenta

Thorough examination of the placenta

Prevention of the uterine atony

TRAUMA: O FUNDAL PLACENTA

PEURPERAL FEVER - see Lala

PRINCIPAL CAUSES OF MATERNAL MORTALITY

CAUSES OF PEURPERAL FEVER