1. MD Chula 2010
TUTORIAL IN
OBSTETRICS
รศ. น.พ. ศักนัน มะโนทัย
หนวยเวชศาสตรมารดาและทารกในครรภ
y
ภาควิชาสูติศาสตร-นรีเวชวิทยา คณะแพทยศาสตร
nl
จุฬาลงกรณมหาวิทยาลัย
O
email : manotaya@hotmail.com
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Obstetrics
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¨ Overview & vital statistics
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¨ ANC
¨ Early pregnancy complications
In
¨ Late pregnancy complications
¨ Intrapartum care
¨ Postpartum care

2. MD Chula 2010
Overview & vital statistics
¨ Maternal mortality rate
¤ Maternal death Per 100,000 LB
¤ Direct / Indirect / Nonmaternal
¨ Stillbirth rate (per 1,000 births)
y
¨ Neonatal death (per 1,000 LB) – early/late
nl
¨ Perinatal mortality rate
¤ Per 1,000 births
O
¨ Infant mortality rate
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Antenatal care
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¨ Objective
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¨ Routine care
¨ Common complaints
In
¨ High risk pregnancy

3. MD Chula 2010
Objective of ANC
¨ GA estimation
¤ LMP , PE , USG
¨ Identify high-risk pregnancy
¤ History , PE , Lab
y
nl
¨ Management
¨ Advice
O
¨ Appointment
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Normal findings
rn
Naegele’s rule EDC = LMP – 3 mo. + 7 days (+1year)
Weight gain total 10-12 kg
te
trimester 1/5/5 kg
weekly 0.3-0.5 kg
In
Fundal height 12/16/20 1/3 , 2/3 , Θ
24/28/32 1/4 , 2/4 , 3/4 > Θ
Jimenez (cm) 18-32 weeks ( ± 2 cm)
Quickening nulliparous 18-20 wk
multiparous 16-18 wk

4. MD Chula 2010
General advice
First trimester Avoid drugs, X-ray, infection
Food intake
How to reduce N/V
Second trimester Food supplement
Common complaints
Third trimester Fetal movement count
y
Count-to-10
modified Sardovsky
nl
Braxton-Hicks
When to go to hospital
O
Any trimester Daily activity
Sex
seRest
Drug use
U
Common complaint
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Complaints Advice & Rx
N/V Diet – small, frequent meals
Reassure, time of improvement
te
Rx : dimenhydrinate, plasil
Constipation High fiber diet
In
Rx : fiber (Mucillin, Fybogel), senokot
Cramps Activity
Calcium supplement
Bleeding per gum Soft toothbrush, vitamin C
Uterine contraction Advice Braxton-Hicks
What is abnormal?
Leukorrhea (non itching) reassure
Numbness of hands reassure
Back pain reassure

5. MD Chula 2010
High-risk pregnancy
¨ ประวัติความผิดปกติในครรภกอนๆ
¨ ประวัติปจจุบันและโรคประจําตัว
¨ การตรวจรางกาย
y
¨ การตรวจครรภและการตรวจภายใน
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¨ การตรวจทางหองปฏิบัติการ
O
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Risk Action
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Age 35 yrs at EDC Genetic counseling
Screen DM
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Beware HT
Hx preterm birth Assess cause, prevention
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Hx ectopic pregnancy R/O ectopic by USG
Obese, FHx of DM Screen GDM (50g GCT at 24-28 wk)
In
VDRL positive Confirm by TPHA or FTA-Abs
Benzathine Penicillin 2.4 MU IM weekly*3
HBsAg positive HBeAg – assess infectivity
HBIG for newborn, HBV vaccination
Rh negative Anti-D or ICT – sensitized/unsensitized
Husband - Rh
Unsensitized – RH Ig at 28-32wk, PP
Thalassemia carrier Identify high-risk couple -> PND
(MCV < 80 fl, HbA2 > 3.5%, HbE)
Rubella Ig – non-immune Postpartum vaccination (if desire more baby)

6. MD Chula 2010
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Early pregnancy complications
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¨ Abortion (miscarriage)
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¨ Molar pregnancy
¨ Ectopic pregnancy
In
¨ Hyperemesis gravidarum

7. MD Chula 2010
Abortion
• 10-15% of clinical pregnancy
• Clinical term
– Threatened , incomplete , complete , missed
– Time/symptom sequence
y
• USG term
nl
– Anembryonic preg (Blighted ovum), embryonic death
• Management
O
– Expectant / Prostaglandins / Curettage
• Septic abortion
–
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Antibiotics / Prevention of tetanus / Beware of septic shock
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Ectopic pregnancy
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• 0.5-1 % , Tubal abortion vs Tubal rupture
Diagnosis
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•
– Symptoms and signs
Pain by Hx/PE – cervical tenderness, rebound tenderness
In
•
• Bleeding – spotting
• Missed period – not always present
– Urine pregnancy test
– Ultrasound – absence of IUP, free fluid in CDS, adnexal mass
– Culdocentesis – unclotted blood
– Beta-hCG Beta-hCG vs USG / Rising level in 48 hours
– Laparoscopy

8. MD Chula 2010
Ectopic pregnancy
¨ Management
¤ Salpingectomy
¤ Conservative Sx of tubes
¤ Medical Rx (MTX)
y
¤ Laparoscopic Sx
nl
¨ Counseling
¤ Risk of recurrence
O
se
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Hydatidiform Mole
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• Symptoms and signs
Bleeding 90%
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–
– Size > Date 50%
Hyperemesis 20%
In
–
– PIH 25%
– Theca lutein cysts, Hyperthyroidism
– Passing molar vesicles
• Diagnosis
– High hCG level
– USG snow storm, vesicles

9. MD Chula 2010
Hydatidiform Mole
¨ Management
¤ Evacuation
n Suctioncurettage
n Hysterectomy
y
¤ Follow-up
nl
n Regression of hCG in 8-10 weeks
n Clinical, CXR
O
n Contraception at least 1 yr
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Hyperemesis gravidarum
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• Definition
severe vomiting with
te
– weight loss, dehydration
In
– acid-base disturbance
– hypokalemia
• Management
– Dietary modification
– Supportive Rx
– Antiemetics
– Identify cause

10. MD Chula 2010
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Late pregnancy complications
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• Preterm labor
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• PROM
• Hypertensive disorder
In
• IUGR (Intrauterine growth resttriction)
• Twins
• Placenta previa
• Hydramnios
• Postterm

11. MD Chula 2010
Preterm labor
¨ Definition
¤ GA 28-36 weeks
¤ Regular uterine contractions
¤ Cervical change , 2 cm, 80% effacement
¨ GA >= 34 weeks
y
¨ GA < 34 weeks
nl
¤ Look for contraindications for labor inhibition
¤ Dexamethasone 6 mg IM q 12 h for 4 doses
O
¤ Terbutaline/Salbutamol/Nifedipine/Indomethacin/MgSO 4
¤ Precautions for each tocolytic agent
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PROM/PPROM
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¨ ROM before onset of labor cough test/nitrazine/Nile
blue/fern
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¨ Cord compression / infection
¨ Term pregnancy
In
¤ Induction of labor / Cesarean / wait for 12 hr
¤ GBS prophylaxis in active labor if > 18 hr
¨ Preterm
¤ No PV,PR
¤ R/O infection
¤ Antibiotics to prolong latency
¤ Steroid if < 34 weeks
¤ GBS prophylaxis

12. MD Chula 2010
GBS prophylaxis
¨ Screening-based approach culture at 35-37 wk
¨ Risk-based approach
Ø preterm birth
Ø ROM > 18 hr
y
Ø intrapartum fever
nl
Ø GBS in urine culture
Ø Hx of GBS infection previous birth
O
¨ Ampicillin 2g IV then 1g IV q 4 h until delivery
(or vancomycin if allergic to penicillin)
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Hypertensive disorder
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¨ Classification
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¤ ChronicHT / PIH / PAH
¤ Gestational HT / Preeclampsia / Eclampsia
In
¨ Hypertension SP 140 mmHg or DP 90 mmHg
¨ Proteinuria 300 mg/24h or dipstick 1+

13. MD Chula 2010
สิ่งตรวจพบ Mild preeclampsia Severe preeclampsia
ความดันโลหิต นอยกวา 160/110 mmHg ตั้งแต 160/110 mmHg ขึ้นไป
โปรตีนในปสสาวะ นอยกวา 5 กรัม/วัน มากกวา 5 กรัม/วัน
(dipstick 1+ หรือ 2+) (dipstick 3+ หรือ 4+)
ปวดศีรษะ ไมมี มี
ตามัว ไมมี มี
จุกแนนลิ้นป ไมมี มี
Oliguria (<500 ml/24 h) ไมมี มี
y
ชัก ไมมี มี (eclampsia)
nl
Serum creatinine ปกติ สูงผิดปกติ
เกร็ดเลือด ปกติ ตากวา 100,000 ตอ มม.3
O
Liver enzyme ผิดปกติเล็กนอย ผิดปกติชัดเจน
ทารกโตชาในครรภ ไมมี มี
Pulmonary edema ไมมี
se มี
ACOG Recommendations based primarily on consensus and expert opinion (Level C)
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Concept of Management
Delivery is always the best treatment for mother,
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but not always for the fetus
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Severity Preterm Term
In
Mild Expectant Termination
ACOG Level C
recommendation
Severe ??? Termination
Eclampsia Termination Termination

14. MD Chula 2010
Mild preeclampsia
¨ Hospitalization, bed rest, sedation
¨ Laboratory tests to rule out severe disease,
HELLP syndrome
y
¨ Observe worsening clinical signs&symptoms
nl
¨ Monitor fetal well-being
Continue pregnancy until term, fetal distress,
O
¨
or severe preeclampsia develops.
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Severe preeclampsia
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¨ Prevention of seizure
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¨ Control of high blood pressure
In
¨ Termination of pregnancy
depending on GA
route

15. MD Chula 2010
Effects vs Serum Mg levels
4-7 mEq/L Anticonvulsant prophylaxis
(Therapeutic level)
8-10 mEq/L Loss of DTR
y
12 mEq/L Respiratory paralysis
nl
15 mEq/L Cardiac arrest
O
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Magnesium sulfate
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Dosage 5 gm IV in 5 minutes
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1-3 gm IV drip per hour until 24 h PP
Monitoring Urine output > 30 mL/h
In
DTR
Respiratory rate > 12 per minute
Antidote 10% Calcium gluconate 10 mL IV

16. MD Chula 2010
Severe hypertension in pregnancy
Definition
DP more than 110 mmHg
Why is it dangerous?
Intracranial hemorrhage / hypertensive
encephalopathy
Aim of Rx
y
DP 90-100 mmHg, SP 140-150 mmHg
nl
Treatment
First choice Hydralazine IV
O
Alternatives Nifedipine PO
Nicardipine IV
Labetalol IV
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Severe Preeclampsia Remote from Term
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¨ GA >= 34 weeks
¤ Stabilize then TOP
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¨ GA 32-34 weeks
In
¤ Stabilize
¤ Steroid to enhance fetal lung maturity
(option for lung maturity testing)
¤ Maternal & fetal evaluation
¤ TOP after 48 hours

17. MD Chula 2010
Severe Preeclampsia Remote from Term
¨ GA 24-32 weeks
¤ Stabilize
¤ Steroid toenhance fetal lung maturity
(option for lung maturity testing)
¤ Maternal & fetal evaluation
y
¤ TOP vs continuation of pregnancy under close
nl
surveillance
¨ GA <24 weeks
O
¤ Stabilize then termination
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Twins
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¨ Type dizygotic, monozygotic
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dichorion, monochorion (DA, MA)
¨ Chorionicity sex, membrane, placenta
In
¨ MC Twin-twin transfusion
¨ F/U growth by USG q 2-4 weeks discordant twin
¨ Delivery vaginal if cephalic, bigger fetus first
second twin – internal podalic version
¨ Beware PPH

18. MD Chula 2010
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IUGR
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¨ Definition EFW < 10th centile
less than growth potential
te
¨ Type symmetrical
In
asymmetrical (small AC)
¨ Cause uteroplacental insufficiency
maternal (heart, SLE,….)
fetal (structural, chromosomal)
constitutional

19. MD Chula 2010
IUGR
¨ Asymmetrical IUGR oligohydramnios
grade 3 placenta
abnormal Doppler
¨ Rx identify type, cause
y
assess fetal wellbeing NST, BPP, Doppler
nl
steroid if < 34 weeks
USG FU growth
O
deliver if no growth, distress, term
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Placenta previa
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¨ Type totalis / marginalis / lowlying
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anterior / posterior
¨ Dx USG in 3rd trimester
In
painless bleeding in 3rd trimester
¨ Rx expectant if preterm, no severe bleeding
no PV, PR
steroid if < 34 weeks
tocolytics

20. MD Chula 2010
Placenta previa
¨ Cesarean if term or severe bleeding
M/G at least 4 units
Expert consultation
Counseling
y
Option for Classical C/S in anterior previa
nl
O
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Abruptio placentae
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Symptoms & signs
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¨ Frequent, strong, tetanic uterine contractions
¨ Vaginal bleeding +
In
¨ Severity severe FDU, board-like rigidity
moderate Fetal distress
mild Preterm labor

21. MD Chula 2010
Abruptio placentae
Rx
¨ Beware coagulapathy , M/G
¨ ARM to reduce pressure
¨ If FDU Vaginal delivery
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distress Cesarean section
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O
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Vasa previa
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¨ Risk factor velamentous insertion
twins
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lowlying placenta
abnormal placenta
In
¨ Ruptured vasa previa ROM with blood-stained AF
fetal bradycardia
high fetal death rate
¨ Diagnosis suspicion
nucleated RBC/Apt/Kleihauer
¨ Prevention pulsation of vessel before ARM

22. MD Chula 2010
Postterm (GA>42+0 wk)
¨ Oligohydramnios / MAS / asphyxia
¨ Verify GA (wrong GA is the most common cause)
¨ If definite postterm -> terminate pregnancy
¨ Induction of labor vs Cesarean section
y
¤ Indicationfor CS
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¤ Bishop score
O
n FavorableCx (>=6) Induction
n Unfavorable Prostaglandin
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Hydramnios
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¨ Definition AFI > 25 cm
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DVP > 8 cm
¨ Cause idiopathic / DM / twins (TTTS)
In
fetal anomalies
¨ Rx 100g OGTT, detailed USG
amnioreduction if respiratory distress
¨ Labor beware abruption, prolapsed cord
beware PPH

23. MD Chula 2010
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O
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Medical and surgical complications
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¨ Heart disease
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¨ Acute pyelonephritis
¨ DM
In
¨ HT
¨ Acute appendicitis

24. MD Chula 2010
Heart diseases
¨ Physiologic changes CO
¨ Functional class and pathology
Eisenmenger complex, Severe AS, Severe MS
¨ Management
y
¤ Reduce cardiac load anemia, infection
nl
¤ According to FC , option for TOP
¤ Rheumatic -> AB , Congenital -> fetal echo
O
¤ Vaginal delivery, shorten 2 nd stage, IE prophylaxis
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Acute pyelonephritis
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¨ Asymptomatic bacteriuria > 105 cfu/ml
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¨ Dx fever, CVA tenderness, UA
3rd trim , right > left
In
¨ Rx
¤ Correct dehydration, beware septic shock
¤ Parenteral AB (Ampi / Genta / Cephalosporins)
¤ Beware preterm labor
¤ FU urine culture

25. MD Chula 2010
DM
¨ Pregestational DM vs Gestational DM
¨ Complications
GDM macrosomia, hydramnios,
hypoglycemia, hypocalcemia, ………
y
Overt anomaly
nl
¨ Screening (50g GCT) 140 mg/dl
O
Age/FHx/obese/macrosomia
anomaly/stillbirth/glycosuria
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DM
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¨ Diagnosis (100g OGTT)
te
105/190/165/145 mg/dl
In
¨ GDM A1 vs GDM A2 fasting 105 / 2hPP 120
¨ Rx blood glucose monitoring, diet control
insulin sc
monitor fetus, mother
intrapartum PG 80-120 mg/dl

26. MD Chula 2010
Chronic HT
¨ 15-25 % incidence of superimposed
preeclampsia
¨ Work up Identify cause of HT
y
End-organ damage
nl
¨ Appropriate control of BP
O
¨ Close monitoring and early detection of
superimposed preeclampsia is important
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Medical Rx of Chronic HT
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Aim of treatment DP 90-100 mmHg
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Alpha-methyldopa drug of choice
In
ARB, ACE inhibitor contraindicated
Beta-blockers IUGR increases

27. MD Chula 2010
Acute appendicitis
¨ Location upward, more lateral
¨ More difficult to Dx
¨ DDx red degeneration of myoma
(Alder’s sign)
y
ovarian cyst with complications
nl
¨ Early explor. lap. in questionable case
O
se
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te
In

28. MD Chula 2010
Intrapartum care
¨ Routine care
¤ Oxytocin use , analgesia
¨ Dystocia
¨ Fetal distress (non-reassuring fetal status)
y
¨ Emergency
nl
¤ Prolapsed cord
¤ Eclampsia
O
¤ Shoulder dystocia
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Initial Assessment of Parturients
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¨ GA Assessment
¤ Preterm, Term, Postterm
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¨ Stage/Phase of labor
In
¤ 1st (Latent, Active) , 2nd , 3rd , Not in labor
¨ Pelvic assessment
¨ Low risk VS. High risk cases
¤ Maternal/Fetal wellbeing

29. MD Chula 2010
Monitoring of Parturients
¨ Fetal wellbeing
¤ AF color/volume, FHS auscultation, EFM
¨ Maternal wellbeing
¤ Pain
relief, hydration, psychological
y
support
nl
¨ Progression of labor
O
¤ Friedman’s curve
¤ Partogram se
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In

30. MD Chula 2010
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Dystocia
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Nulliparous Multiparous
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Prolonged latent phase > 20 hr >14 hr
Active phase (maximum slope)
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Protracted active phase dilatation < 1.2 cm/hr < 1.5 cm/hr
Secondary arrest of dilatation no progress for 2 hr no progress for 2 hr
In
Deceleration phase (8 cm to FD)
Protracted descent < 1 cm/hr < 2 cm/hr
Arrest of descent no progress for 1 hr no progress for 1 hr
Prolonged deceleration phase > 3 hr > 1 hr
Prolonged second stage > 2 hr > 1 hr

31. MD Chula 2010
Mx. of Prolonged Latent Phase
¨ Assess maternal wellbeing
¤ No obstetric and medical complications
¨ Assess fetal wellbeing
¤ EFM
y
¤ USG : normal AFI , no IUGR
nl
¨ Bed rest or Therapeutic rest
¨ Induction of labor
O
se
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Mx. of Abnormal Active Phase
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¨ Assess Power-Passage-Passenger (3P)
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¤ If CPD -> Cesarean section
In
¤ If Hypotonic contraction -> Oxytocin
¨ Supportive care e.g. IV fluid, Pain relief
¨ Careful fetal monitoring
¨ Reassessment after 2 hours

32. MD Chula 2010
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NST
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EFM
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In
§ NST or EFM
§ Rate 1 or 3 cm/min
§ Baseline 120-160 bpm
§ Baseline variability 6-25 bpm
§ Periodic change
Acceleration 2 in 20 min,
15 bpm for 15 sec
Deceleration

33. In
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MD Chula 2010
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34. In
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MD Chula 2010
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35. MD Chula 2010
Fetal distress
(non-reassuring fetal status)
¨ Intrauterine resuscitation
¤ Off oxytocin
¤ Left lateral position
y
¤ Oxygen mask
nl
¤ Close fetal heart rate monitoring
O
¨ Immediate delivery if not improved by 15-20 min.
se
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Shoulder dystocia
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¨ Call for help
te
¨ Suction
¨ deep episiotomy, bladder catheter
In
¨ Maneuver Suprapubic pressure
McRoberts’ maneuver
Wood’s corkscrew
deliver posterior shoulder

36. MD Chula 2010
Eclampsia - Severe Preeclampsia
¨ Airway maintenance
¨ Prevention of seizure / re-seizure
n Magnesium sulfate IV loading + drip
¨ Beware abruption , fetal distress
y
¨ Termination of pregnancy
nl
O
se
U
Prolapsed cord
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¨ How to prevent ARM
te
¨ Rx
¤ Assess fetal status USG, Doptone, cord pulse
In
¤ If alive fetus reduce cord compression
Trendelenburg position
push fetal head
fill bladder, tocolytics
emergency CS
¤ If FDU vaginal delivery

37. MD Chula 2010
Operative Obstetrics
¨ Cesarean section
¨ Forceps extraction
¨ Vacuum extraction
¨ Shoulder dystocia
y
¨ Amniotomy
nl
¨ Induction of labor
O
se
U
Amniotomy (ARM)
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¨ Timing early / late
¨ Precaution vasa previa / prolapsed card
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abruption / infection
In

38. MD Chula 2010
Oxytocin
¨ Start dose 1-6 mu/min (2-12 drops/min)
¨ Half-life 3-5 min. Adjust dose q 20-30 min.
¨ Max dose 20-30 mu/min
y
¨ If tetanic contraction off, intrauterine resusc
nl
restart at half dose
O
se
U
Forceps extraction
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¨ Conditions to be fulfilled FD/MR/no CPD/2+/alive
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¨ Indications prolonged/HT/heart/distress
prophylactic/preterm
In
¨ Instruments Simpson/Kielland/Piper
¨ Levels outlet/low/mid/high
¨ Steps pudendal block/empty bladder
orientate/apply/lock/FHS/trial

39. MD Chula 2010
Vacuum extraction
¨ Conditions to be fulfilled FD/MR/no CPD/2+/alive
¨ Indications prolonged/poor expulsion/DTA
¨ C/I preterm/HIV
¨ Instruments metallic cup/silastic cup
y
¨ Steps pudendal block/empty bladder
nl
apply/reduce pressure/trial
¨ Advantage autorotation (>45 o ,Deep transverse arrest)
O
less maternal injury
¨ Disadvantage longer duration / limited power
se
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In

40. MD Chula 2010
Postpartum care
¨ Routine care
¨ Postpartum hemorrhage
¨ Puerperal infection
y
nl
O
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U
Puerperal infection
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¨ Puerperal morbidity 38 C x 2 in 10 days (excl first 24h)
te
¨ S&S
¤ Postpartum fever
In
¤ Pelvic pain, subinvolution
¤ Foul smell lochia
¤ Leucocytosis
¨ DDx UTI, atelectasis, breast engorgement

41. MD Chula 2010
Early postpartum hemorrhage (before 24 h)
¨ DDx atony / birth canal injury
ruptured uterus
¨ Rx M/G , IV fluid loading
atony uterine massage
y
oxytocin/methergin/sulprostone
nl
bimanual compression
hypogastric/uterine artery ligation
O
hysterectomy
birth canal repair with adequate exposure
se
U
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te
In