MBBS pratical ppt

1. Gynaecology & Obstetrics
Practical
Prepared by:
Dipendra Jung Shahi

2. Special thanks to
• Jyoti shah, 5th batch PAHS
• Anish Dhakal, 5th batch PAHS
• Dr. Bibek Ghimire , 3rd batch PAHS
• PAHS , 5TH batch friends
• PAHS , 3rd batch
• Raj Krishna Shrestha KU ,7th Batch
• Sarensa Palikhey KU ,7th Batch

3. Vacuum Delivery

4. Vacuum Extraction
In Europe, also called ventouse (means soft cup)
In 1953, the Swedish obstetrician, Tage
Malmstrom, introduced a hollow disc-shaped
stainless steel metal cup for vacuum assisted
delivery.
Instrumental device designed to assist delivery
by applying traction to a suction cup attached to
the fetal scalp.

5. Instrumentation
Components :
A Suction cup
Metal cup
Soft cup
Silastic cup
Rigid plastic cup
Vacuum pump
Traction tubing
Silastic vacuum cup
Mityvac pump with tube and soft cup

6. Indication
Used as an alternative to the obstetric
forceps.
Reserved for fetuses who have attained a
gestational age of at least 34 weeks.
Maternal indication
Fetal indication

7. Maternal Indication
Maternal distress, exhaustion after a long
and painful labor due to insufficient uterine
contractions.
Prolonged second-stage labor
Maternal medical disorder such as heart
disease, hypertensive disorders and anemia.
Previous cesarean section or genital prolapse
repair.
Intrapartum infection.

8. Fetal Indication
Fetal distress
Prolapse of umbilical cord
Premature separation of placenta
Non rotated heads or occipitotransverse
position
Occipitoposterior position

9. Contraindication
Premature babies (<36 weeks of gestation -
risk of fetal interventricular hemorrhage)
Soft tissue obstruction in the pelvis
Macrosomia
Inability to access fetal position or high
station
Major degrees of cephalopelvic disproportion
Face and non vertex presentation
Fetal coagulopathy

10. Criteria
Presenting part should be cephalic and
preferably well flexed
No evidence of cephalopelvic disproportion
Head well engaged
Cervix is fully dilated or almost so
Well trained obstetrician
[Note – Preparations are made for the
caesarean section delivery]

11. Determine the flexion point

12. Note
The total time from the application until
delivery should not exceed 20 minutes.
If >20 minutes, the risk of fetal scalp trauma
and intracranial damage increased thereafter
For the same reason, many pulls to achieve
progress should not be done
The operator should be wiling to abandon the
procedure if it does not proceed easily or if
the cup dislodges >3 times.

13. Summary of the technique
Ask for help, Address the patient (inform her
about what you are going to do and get
informed consent) Anesthesia needs
Bladder empty
Cervix fully dilated
Determine fetal position and think shoulder
dystocia

14. Extractor and resuscitation equipment ready
Flexion point – apply cup
Gentle traction in the proper axis
Halt traction when the contraction is over,
halt the procedure if it is not progressing
normally
 Incision
 Remove the vacuum ,when jaw is reachable
Summary of the technique

15. Advantage of ventouse over forceps
• less space occupying device
• Low maternal trauma and laceration
• Used for unrotated and malrotated head
• Less postpartum discomfort
• Easy to learn
• Less analgesic needed

16. Advantage of forceps
• High successful rate
• Can use less than 36 weeks of gestation
• Less chance of neonatal scalp trauma
• Used in anterior face where ventouse is
containdicated

17. Episiotomy
By definition,
A surgically planned incision on the perineum
and the posterior vaginal wall during the
second stage of labor is called episiotomy

18. Indications
• Shoulder dystocia
• Breech delivery
• Macrosomic fetuses
• Operative vaginal deliveries
• Persistent occiput posterior positions and
• Other instances in which failure to perform an
episiotomy will result in significant perineal
rupture.

19. Timing
• Ideal time is during crowning
• Significant bleeding during the interval
between incision and delivery if performed
unnecessarily early.
• If it is performed too late, lacerations will not
be prevented.

20. Types
• Midline
• Mediolateral
• J shaped
• Lateral

21. Characteristics Type of Episiotomy
Midline Mediolateral
Surgical repair Easy More difficult
Faulty healing common Rare More common
Postoperative pain Minimal Common
Anatomical results Excellent Occasionally faulty
Blood loss Less More
Dyspareunia Rare Occasional
Extensions Common Uncommon

22. Incision
• Two fingers are placed in the vagina between the
presenting part and the posterior vaginal wall.
• The incision is made by a curved or straight blunt
pointed sharp scissors (scalpel may also be used)
• One blade of which is placed inside, in between
the fingers and the posterior vaginal wall and the
other on the skin.
• The incision should be made at the height of an
uterine contraction

23. • In midline incision, the scissors are positioned
at 6 o’clock on the vaginal opening and
incision is extended 2 to 3 cm directed
posteriorly .
• In mediolateral incision, scissors are
positioned at 7 o’clock or at 5 o’clock, and the
incision is extended 3 to 4 cm toward the
ipsilateral ischial tuberosity.

24. Layers cut
• Posterior vaginal wall
•
• Superficialand deep transverse perineal muscles
• Bulbospongiosus and part of levator ani muscles and
fascia covering them
• Transverse perineal branches of pudendal vessels and
nerves
• Subcutaneous tissue and skin.

25. Repair
The repair is to be done in the following order:
– Vaginal mucosa and submucosal tissues
– Perineal muscles
– Skin and subcutaneous tissues.

26. Foetal skull and Pelvis

27. Foetal skull
• Head → most common presenting part
• The firm skull is composed of two frontal, two parietal, and
two temporal bones, along with the upper portion of the
occipital bone and the wings of the sphenoid

29. Areas of skull
• Vertex
– It is a quadrangular area bounded anteriorly by the bregma and
coronal sutures behind by the lambda and lambdoid sutures and
laterally by lines passing through the parietal eminences.
• Brow
– It is an area bounded on one side by the anterior fontanelle and
coronal sutures and on the other side by the root of the nose and
supraorbital ridges of either side.
• Face
– It is an area bounded on one side by root of the nose and
supraorbital ridges and on the other, by the junction of the floor of
the mouth with neck.
• Sinciput
– It is the area lying in front of the anterior fontanelle and
corresponds to the area of brow and the occiput is limited to the
occipital bone.

31. Contd..
• Sutures :
– Frontal, between the two frontal bones
– Sagittal, between the two parietal bones
– Two coronal, between the frontal and parietal bones
– Two lambdoid, between the posterior margins of the parietal bones and
upper margin of the occipital bone
• Fontanel :
– The greater, or anterior, fontanel is a lozenge-shaped space situated at the
junction of the sagittal and the coronal sutures.
– The lesser, or posterior, fontanel is a small triangular area at the intersection
of the sagittal and lambdoid sutures.

32. Diameters of the skull
Diameter and extent Measurement
(cm)
Obstetric significance
Biparietal diameter 9.5 Greatest transverse diameter of the head, which
extends from one parietal eminence to the other.
Bitemporal diameter 8.0 Greatest distance between the two temporal
sutures.
Suboccipitobregmati
c diameter
9.5 Extends from the nape of the neck to the center of
the bregma (anterrior fonanel).
Suboccipito-frontal 10 Extends from the nape of the neck to the anterior
end of the anterior fontanel.
Occipitofrontal
diameter
11.5 Extends from the occipital eminence to the root of
the nose.
Occipitomental 12.5 Extends from the chin to the most prominent
portion of the occiput.

35. Contd..
Molding
• It is the alteration of the shape of the forecoming head while passing through the resistant
birth passage during labor
• In addition to soft tissue changes, the bony fetal head shape is also altered by external
compressive forces and is referred to as molding.
• During normal delivery, an alteration of 4 mm in skull diameter commonly occurs.
• Grading : There are three gradings. Grade-1 — the bones touching but not overlapping,
Grade-2 — overlapping but easily separated and Grade-3 — fixed overlapping.
• Importance:
– Slight moulding is inevitable and beneficial. It enables the head to pass more easily, through the birth
canal.
– Extreme moulding as met in disproportion may produce severe intracranial disturbance in the form of
tearing of tentorium cerebelli or subdural hemorrhage.
– Shape of the moulding can be an useful information about the position of the head occupied in the pelvis

36. Maternal pelvis
• Above the pelvic brim is the False pelvis (Greater pelvis) and below is
the True pelvis (Lesser Pelvis)
• True pelvis
– Important in obstetrics (bony canal, fetus must negotiate during labor).
– Further divided to → Inlet, cavity and outlet.
• False Pelvis
– Considered as part of abdominal cavity
– Supports the gravid uterus (after 3rd month of pregnancy)
– Guides the fetus into the true pelvis (during the early stages of labor)

37. Pelvic brim (Pelvic Inlet)
1. Pelvic brim is the edge of pelvic inlet.
Sacral promontory
2. Ileopectineal lines (Arcuate line of Ilium;
Pectineal line of Pubis)
3. Symphysis pubis
Sacral
Promontory
Arcuate
Line
Pectineal
Line
Pubic
Symphysis
Ileopectineal
Line
Pelvic
Brim

40. Anteroposterior Oblique Transverse
Inlet 11 cm 12 cm 13 cm
Cavity 12 cm 12 cm 12 cm
Outlet 13 cm - 11 cm
fig. Pelvic outlet fig. J-shaped axis of birth canal

42. Pelvic organ prolapse

43. • The uterus is normally
anteverted, anteflexed
• Version
– Is the angle between the
longitudinal axis of cervix, and
that of the vagina
• Flexion
– Is the angle between the
longitudinal axis of the uterus,
and that of the cervix

44. Uterus
• True Ligament
1. Round ligament of the
uterus
2. Transverse ligament of
the uterus (Cardinal,
Mackendrots ligament)
3. Utero-sacral ligament
4. Pubocervical ligament
• False ligament
1. Utero vesical fold
2. Rectovaginal fold
3. Recto uterine fold and
4. Broad ligament

45. Pelvic organ prolapse
• Pelvic organ prolapse is divided into
1. Vaginal prolapse
2. Uterine prolapse
• Vaginal prolapse are independent
• Uterine prolapse are involved with variable
degree of vaginal descent

48. Vaginal prolapse
• Anterior wall
1. Cystocele:
• Formed by laxity and descent of upper two thirds of the
anterior vaginal wall
• Herniation of bladder base through the lax anterior wall
2. Urethrocele:
• Laxity in the lower-third of the vaginal wall
• Urethra herniates through it

49. • Posterior wall
1. Relaxed perineum
• Torn perineal body produces gaping introitus with bulge
of lower part of posterior vaginal wall
2. Rectocele
• Laxity of middle-third of posterior vaginal wall
• As a result, herniation of rectum

50. 3. Vault prolapse
– Enterocele
• Laxity of upper-third of posterior vaginal wall
• Results in herniation of Pouch of Douglas
– Secondary vault prolapse
• Occurs following vaginal or abdominal hysterectomy
• Undetected enterocele during initial operation or
inadequate primary repair usually results in secondary
vault prolapse

51. Uterine Prolapse Clinical Grading
• 1st Degree
– Uterus descends down from its normal anatomical position but the external os still remains inside the
vagina
• 2nd Degree
– External os protrudes outside the vaginal introitus but the uterine body still remains inside the vagina
• 3rd Degree
– Uterine cervix and body descends to lie outside the introitus
• Complete prolapse or procidentia
– Prolapse of the uterus with eversion of the entire vagina
• Complex prolapse
– When prolapse is associated with some other specific defects such as

52. Uterine Prolapse Clinical Grading

53. Pelvic Organ Prolapse quantitative scoring

55. Morbid changes
• Vaginal mucosa
– The mucosa becomes stretched and thickened and dry
with surface keratinization when exposed to air
• Decubitus ulcer
– Tropic ulcer at the dependent site of the prolapsed mass
lying outside the introitus
– Keratinization -> cracks -> infection -> slouging
->ulceration

56. Symptoms
1. Feeling of something coming down per vaginum
2. Backache or dragging pain in pelvis
3. Dyspareunia
4. Urinary symptoms in presence of cystocele
– Difficulty in passing urine, urgency and frequency of micturition may also be due
to cystitis, Painful micturition is due to infection, Stress incontinence is usually due
to associated urethrocele
5. Bowel symptoms in presence of rectocele
– Difficulty in passing stool, fecal incontinence
6. Excessive white or blood-stained discharge per vaginum is due to associated
vaginitis or decubitus ulcer

57. Clinical examination and diagnosis of POP
• General examination
• Inspection and palpation – vaginal, rectal, rectovaginal (even
under anasthesia)
• Pelvic examination in both dorsal and standing positions is done
– Patient is asked to strain as to perform Valsalva maneuver
– Negative finding on inspection in dorsal position- asked to strain in
squatting position
• Prolapse of one organ is usually associated with prolapse of
another organ
• Etiological aspect of prolapse should be elicited

58. • Cystocele
– Bulge on anterior vaginal wall which increases when patient is
asked to strain
• Cystourethrocele
– The bulging of anterior vaginal wall involves lower third too
– Presence of stress incontinence
• Rectocele and enterocele
– There is bulging of posterior vaginal wall with transverse sulcus
between two
– Enterocele has bulging close to the cervix and cannot be
reached by the finger inside the rectum

59. • Differential diagnosis of cystocele
– The cystocele is often confused with cyst in the
anterior vaginal wall, commonest being Gartner’s
cyst

60. Management
1. Preventive
2. Conservative
– Pessary treatment
3. Surgical treatment

61. 1. Preventive
• Adequate antenatal and intranatal care
– To avoid injury to the surrounding structures during delivery
• Adequate post natal care
– To encourage early ambulance
– To encourage pelvic floor exercise by squeezing pelvic floor
muscles in the puerperium
• General measures
– To avoid strenous exercise, chronic cough, constipation and
heavy weight lifting
– To avoid too soon and too many future pregnancies by
contraceptive practise

62. 2. Conservative
• Indications
– Asymptomatic women
– Mild degree prolapse
– POP in early pregnancy
• Meanwhile following measures can be taken
– Improvement of general measures (see above)
– Estrogen replacement therapy in post-menopausal women
– Pelvic floor exercises in an attempt to strengthen the muscles (Kegel
exercises)
– Pessary treatment

63. Pessary
• A pessary is a device which is inserted into the upper part of the
vagina to provide support to the pelvic structures
• Can’t cure the prolapse but relieve the symptoms by stretching
urogenital hiatus thus preventing vaginal and uterine descent
• The majority of pessaries are made of silicone and come in a
number of shapes and sizes
• A pessary needs to be inserted by a medical professional and can
be kept in place for 3-4 months, after which it will require
changing
• Pessary provides temporary solution for prolapse symptoms

64. Types
• Ring pessaries
– A pessary of suitable size is introduced in the vagina above the
level of the levator ani muscles
– It prevents descent of the uterus
• The "cup and stem" pessary
– Is used if the patient's pelvic floor are so weak or lacerated
that a ring pessary cannot be retained in the vagina
• Pessaries broadly classified into
– 1) Support
– 2) Space occupying type

65. Pessaries

66. Indications
1. Early pregnancy: for upto 18 wks when the uterus becomes
sufficiently enlarged to sit on the brim of the pelvis
2. Puerperium : To facilitate involution
3. Patient unsuitable for surgery
4. Patient unwanting the operation
5. While waiting for operation
6. Additional benefits: Urinary symptoms (voiding problems,
urgency)

67. Limitations
• It is never curative and can only be palliative
• It can cause vaginitis
• Pessary needs to be changed every 3 months
• The wearing of a pessary is not comfortable to some women and
may cause dyspareunia
• If the vaginal orifice is very patulous, the pessary is often not
retained
• A forgotten pessary can be the cause of ulcer, rarely carcinoma of
vagina and a vesicovaginal fistula
• A pessary does not cure urinary stress incontinence

68. 3. Surgery
• Indicated when conservative management fails or
not indicated
• Types:
A. Restorative
• Correcting her own support tissues
• Compensatory : using permanent graft material
B. Extirpative
• Removing the uterus and correcting support tissues
C. Obliterative
• Closing the vagina (colpocleisis)

70. Cervical Intraepithelial
Neoplasia

71. Introduction
• Cervical dysplasia
– Cytological term to describe cells resembling cancer
cells
• Cervical intraepithelial neoplasia (CIN)
– A part or the full thickness of the stratified
squamous epithelium is replaced by cells showing
varying degrees of dysplasia; however, the
basement membrane is intact

72. SCJ
• Squamocolumnar junction
– The meeting point of the columnar epithelium lining endocervical
canal and squamous epithelium ectocervix
– This SCJ is a dynamic point
• It moves up and down in relation to different phases of life, e.g. puberty,
pregnancy and menopause
• Transformation zone
– The metaplasia extends from the original SCJ (now squamosquamous)
outside to the newly developed (physiologically active) SCJ (now
squamocolumnar) inside
– This area is defined as transformation zone (TZ)

74. Correlation of Dysplasia, CIN(WHO)
and Bethesda system

75. Epidemiology
• Usually is the disease of younger women
• Mean age of carcinoma-in-situ is 30 years
– 15 years less than malignant carcinoma

76. Infectious agent
• Most common infectious agent is Human Papilloma Virus (HPV)
• HPV infected cells (koilocytes) are characterized by enlarged cells with
perinuclear halos
– The nucleus is large, irregular and hyperchromatic
• More than 130 HPV types have been identified
– High oncogenic risk- Types 16, 18
– Moderate oncogenic risk- Types 31, 33, 35, 45, 56
– Low oncogenic risk- types 6, 11, 42, 43
• 99.7% of patients with CIN and invasive cancer are found positive with
HPV DNA

77. Pathogenesis of HPV
1. Infection of cervical epithelium
2. Upregulation of viral oncogens
3. Expression of E6 and E7 oncoproteins
4. Interference to tumor supressor gene (p53 and
Rb respectively)
5. Neoplastic transformation

78. Triage screening for HPV
1. Liquid based thin layer cytology evaluation for
atypical squamous cells
2. Hybrid capture 2 for HPV DNA
3. HPV DNA test positive Colposcopy biopsy
4. HPV DNA test negative Repeat smear after
one year

79. Diagnosis
• Routine cytological screening or Pap smear
• DNA study
• Speculoscopy
• Spectroscopy
• Colposcopy
• Cone biopsy Gold standard

80. Routine Cytological screening
• For all women >21 years and sexually active
• Women at risk of cervical cancer
• Mild Dysplasia seen
• DNA Study to identify aneuploidy

81. Pap Smear
• Identifies abnormalities in the cells
• Latent period from CIN to Cancer, allows
prevention of invasive cancer
• Screening has been proven successfully to reduce
incidence by 80% in developed countries

82. Intervals
• All sexually active women should be screened starting
from the age aged 21 years or having sex for last 3 years
of vaginal sex with no upper age limits
1. Screening should be yearly till the age of 30
2. Thereafter, every 2–3 years after age 30 with 3
consecutive yearly negative smears
• The high risk group should be screened with HPV DNA
testing combined with cytology

83. Instructions to the patient
1. To avoid intercourse for about 48 hours
2. Not to use vaginal douche for 24 hours
3. To withhold use of hormonal drugs
NOTE: Pap smear shouldn’t bet done in
menstruation

85. Biopsy
• Under direct colposcopic visualization suspicious
lesions on ectocervix are taken
• Usually no anesthesia required
• Thickened Monsel Solution can be used to create
hemostatsis
• Usually Tischler’s Biopsy Forcep is used
• Sent for histopathology

86. Colposcope
• Colposcope and colpomicroscope
– Are the low-power binocular microscope, mounted on a
stand
• It is designed to magnify the surface epithelium of the
vaginal part of the cervix including entire transformation
zone
• The magnification is to the extent of 15–40 times in
colposcopy and about 100–300 times in colpomicroscopy

87. Colposcope
• Consists of a stereoscopic lens (magnification
range 3- 40*, attached to a movable stand)
• Best known : Reid Colposcope
• Locates the abnormal lesions and corrects the
false +ves of pap smear
• Done to differentiate normal and abnormal for
biopsy and to decide app. treatment options

88. Patient Preparation
• Woman’s medical records, history of dysplasia should be
reviewed and indications confirmed
• Optimally timed to avoid menses
• If severe cervicitis +nt, its should be tested and treated first
• Solutions used :
– Normal Saline
– Acetic Acid
– Lugol’s Solution

89. • Normal Saline removes cervical mucus and allows to see
surface contour and initial vascular asessment
• 3-5 % acetic acid is applied that causes clumping of
nuclear chromatin -> neoplastic lesions appear white
being more dense and abnormal vessels prominent
• Lugol’s iodine solution stains normal epithelium as
brown due to high glycogen content while dysplastic cells
fail to stain due o low glycogen content (*allergy )

90. Management

92. Treatment
• Mild dysplasia (CIN I/LSIL
– Pap smear follow-up done every 6 months or HPV DNA test
at 12 months
– If both the tests are negative routine recall (screening) is
done
• Indication for colposcopy and treatment of LSIL are:
– Persistent LSIL (CIN-I) over 1 year
– Patient shows poor compliance
– LSIL showing HSIL on colposcopy

93. • Moderately severe to severe dysplasias (CIN-II and CIN-III)
– Local destructive methods
• Cryosurgery
• Cold coagulation
• Electrodiathermy
• Carbondioxide laser
• Fulguration/electrocoagulation
• Laser ablation
– Excision of abnormal tissue
• Conization
– Surgery
• Therapeutic conization, Hysterectomy

94. Excision
• Large loop excision of the transformation zone
(LLETZ)
• Loop electrosurgical excision procedure (LEEP)
• Needle excision of transformation zone (NETZ)
• Excisional procedures should be done in the
immediate postmenstrual phase, most of them
under colposcopic view and under local
anaesthesia; this reduces incomplete excision to
only 2-3%

95. Conization (Cone biopsy)
• Removal of cone of the cervix which includes entire
squamocolumnar junction, stroma with glands and
endocervical mucous membrane
• Complications
– Bleeding
– Sepsis
– Cervical stenosis
– Abortion
– Preterm labour

96. Hysterectomy
• Indicated to:
– CIN lesion associated with other gynecologic problems such as prolapse,
fibroid, pelvic inflammatory disease or endometriosis
– CIN extends into the vagina
– Persistent dyskaryotic smear even with treatment
– High grade CGIN in elderly women
– Patients with CIN 3
– Patients with poor compliance for follow up
– Cancer phobia
• Removal of vaginal cuff is done, if the lesion extends to the vaginal
fornices

97. Prophylaxis
• Vaccines :
– Bivalent Vaccines against HPV 16 and 18
– Quadrivalent Vaccine against HPV 6,11,16,18
• Dosing :
– 1st dose at elected time before exposure to sexual
activity ( 0.ml)
– 2nd dose 2 months after 1st dose
– 3rd dose 6 months after the 1st injection

98. Prophylaxis
• Vaccines
– Bivalent vaccine against HPV 16, 18 (Cervarix)
– Quadrivalent vaccine (Gardsil) against HPV 6,11,16,18
• Dosing
– 1st dose at elected time before exposure to sexual
activity (0.5 ml)
– 2nd dose 2 months after 1st injection
– 3rd dose 6 months after the 1st injection
• Contraindicated during pregnancy

99. Oral Contraceptive Pills

100. • It contains an estrogen and a progestin
1. Estrogen (Ethinyl estridiol )
2. Progestin (Levonogesterol)
• Both estrogens and progestins synergise to
inhibit ovulation
Combined Pill

102. • Endometriosis, uterine fibroid,
ovarian/endometrial cancer
• Dysmenorrhea, DUB
• PID
• Epilepsy, TB
• Thyroid disease
• Varicose veins
• Benign breast disease
• Age: Menarche to 40 years
• Post-abortion
• Anemia (iron deficiency,
malaria)
• HIV or AIDS (additional to
condom use)
• GTN following normal hCG
level
• History of ectopic pregnancy
Indications of COCs

103. Contraindications

104. 1. Unexplained vaginal
bleeding
2. Hyperlipidemia
3. Liver tumors (benign)
4. Breast feeding (postpartum
6 weeks to 6 months)
5. Heavy smoker (>20
cig./day)
6. Past breast cancer
WHO cat-3 (Adv.<Risk)
1. Age> 40 years
2. Smoker <35
3. History of jaundice
4. Mild Hypertension
5. Gall bladder disease
6. Diabetes
7. Sickle cell disease
8. Headache
9. Cancer cervix or CIN
WHO cat-2(Adv>Risk)
Relative Contraindications

105. Absolute Contraindications (Cat-4)
Circulatory diseases Diseases of
liver
Others
 Arterial or venous
thrombosis
 Severe HTN, stroke
 Valvular heart disease
 Ischemic heart disease
 Angina
 Diabetes with vascular
complications
 Migraine with Focal
neurological symptoms
• Active liver
diseases
• Liver
adenoma,
carcinoma
 Pregnancy
 Undiagnosed genital tract
bleeding
 Estrogen dependent neoplasm
eg: Breast cancer
 Breast feeding (within 6 weeks
postpartum)
 Major surgery or prolonged
immobilization (4 to 6 weeks
prior to planned surgery)

106. • Oestrogen
• Nausea, vomiting, headache
• Mastalgia
• Weight gain
• Chloasma and acne
• Menstrual abnormalities
– Breakthrough bleeding
– Menorrhagia
• Libido
• Leucorrhea
• Monilial vaginitis, carcinoma of endocervix (>5 yrs)
• Carbohydrate tolerance may be reduced
Minor complications

107. • Progesterone
– Headache, migraine, Irritability
• Leg cramps
• Mastalgia
• Weight gain
• Acne
• Menstrual abnormalities
• Hypomenorrhea
• Amenorrhea
– Suppressed Lactation
Contd..

108. • Depression
• Hypertension
• Vascular complications
– Venous thromboembolism
• Cholestatic jaundice
• Adenoma, chronic liver disease
• Neoplasia
Major complications

109. • Nausea, vomiting, headache and leg cramps
• Mastalgia — transient heaviness or even tenderness in the
breast
• No weight gain
• Chloasma and acne
• Libido- diminished (dryness of vagina)
• Leucorrhea- due to increased preponderance of monilial
infection
Minor complication

110. • Menstrual abnormalities
– Breakthrough bleeding (Exogenous estrogen)
– Hypomenorrhea- due to local endometrial changes
– Menorrhagia
– Amenorrhea- > 6 month in 1%
• A refractory case (> 12 months) should be
investigated as a case of secondary amenorrhea
Contd..

111. • Depression- low dose oestrogen not associated
• Hypertension- change in systolic BP
• Vascular complications
– Venous thromboembolism- 3 to 4 times
– Arterial thrombosis
• Cholestatic jaundice
• Neoplasia- reduce risk of epithelial ovarian and
endometrial carcinoma
Major complications

112. • Any women of reproductive age group
without any systemic disease and
contraindications are suitable
Selection of patient

113. • New users On day 1 of cycle
– One tablet taken daily at bedtime for 21 days
– Seven days break or dummy tablet
– Next pack started right after finishing dummy pills
(irrespective of bleeding)
• In 28 pillsSeven pills are dummies and contain iron
or vitamin
• Can also start on day 5 of bleeding, but should use
condom for next 7 days
How to prescribe pill

114. • After abortion
– Pill should be started on the day after abortion
• After childbirth
– In non lactating mother→Start after 3 weeks
– In lactating mother→Start after 6 months
Contd..

115. • One pill missed (late 24 hrs)
– Take as soon as remembered or take 2 at usual time
– Continue the rest as usual
• If missed two pills in the 1st week
– Take 2 pills on each of the next two days
– Continue the rest as usual
– Extra precaution
• Back up contraception for next 7 days (condom or avoid
intercourse)
• Warn about occurrence of spotting
Missed Dose

116. • If two pills missed on the 3rd week (day 15-21) or missed
more than two pills anytime
– Stop the pill on current use
– Use another contraception method for next 7 days
– Then start fresh pack
– Vaginal bleeding and spotting expected
• If any of the 7 inactive pills missed (in a 28 day pack only)
– Throw away the missed pills
– Take the remaining pills once a day
– Start the new pack as usual
Contd..

117. • OCP has significant interaction with other drugs-
do not take any medicine without prescription
• Usually women will have normal menstrual
cycles within 6 months of stopping OCP
– But return of fertility may be slightly delayed on
account of delayed return of ovulation
Contd..

118. 1. First follow up after 3 months
2. Second 6 months
3. Then after yearly
• Patient > 35 should be checked more frequently
• Any adverse symptoms should be noted
• Examination of
– Breast, weight, BP recording and pelvic examination like
cervical cytology are to be done and compare with
previous records
Follow up

119. • Treatment should generally begin with preparations
containing the minimum dose of steroids that provides
effective contraceptive coverage
• Breakthrough bleeding may occur if the estrogen-to-
progestin ratio is too low to produce a stable
endometrium, and this may be prevented by switching to
a pill with a higher ratio
• In women for whom estrogens are contraindicated or
undesirable, progestin-only contraceptives may be an
option
Choice of Contraceptives

120. 1. Lower probability of developing endometrial
and ovarian carcinoma; probably colorectal
cancer as well
2. Reduced menstrual blood loss and associated
anemia; cycles if irregular become regular;
premenstrual tension and dysmenorrhea are
ameliorated.
3. Endometriosis and PID are improved
4. Reduced incidence of fibrocystic breast disease
Noncontraceptive Health Benefits

122. • Discontinuation of OCP may result in return of fertility
within 1-2 months with increased chance of multiple
pregnancy or may not return at all
• Pregnancy occuring during OCP use should be terminated
• If breakthrough bleeding occurs
– Switch to high estrogen containing pills
• If androgenic side effects (acne, weight gain and raised
LDL)
– Switch to 19-nortestosterone
Practical consideration

123. Intrauterine Contraceptive
Devices (IUCD)

125. First generation: Inert IUDs
Second generation: Copper IUDs
Third generation: Hormonal IUDs
Intra-‐uterine devices

126. Commonly Used IUCDs
• Cu T 200
• Multiload 250
• Multiload 375
• Cu T 380 A
• LNG-IUS
• Gynefix

127. Cu T 380A
• Carries 380 mm2 surface area of copper wire
wound
– Around the vertical stem314 mm2
– Each copper sleeve of horizontal arms 33mm2
• Frame contain barium sulphate and is radiopaque
• Replaced in every 10 years

128. Cu T 380A

129. LNG-IUS
• Levonorgestrel Intrauterine System
• Total amount of levonorgestrel is 52 mg and is
released at the rate of 20 microgram per day
• Replaced in every 7 years

130. Mode of Action

131. Contraindications
1. Presence of pelvic infection current or within 3 months
2. Undiagnosed genital tract bleeding (DUB)
3. Suspected pregnancy
4. Distortion of the shape of uterine cavity as in fibroid or
congenital uterine-malformation
5. Past history of ectopic pregnancy
6. Within 6 weeks following Cesarean section

132. Timing for Insertion
• Beyond 6 weeks following childbirth or abortion is over
• Can be inserted any time during the cycle even during menstrual
phase (have advantages like open cervical canal, distended uterine
cavity, less cramp)
• During lactation amenorrhea, it can be inserted at any time
• It can be kept just after termination of pregnancy

133. No Touch Insertion Technique
• Loading the IUD in the inserter without opening the sterile
package
• The loaded inserter is now taken out of package without
touching distal end
• Not to touch the vaginal wall and the speculum while
introducing the loaded IUD inserter through the cervical
canal

134. Instruction to Client
• Possible symptoms of pain and slight vaginal
bleeding should be explained
• The patient are advised to feel the thread
periodically by the finger
• Patient are advised to follow up in 1 month for
the first time then annually

135. Complication
• Immediate
– Cramp like pain
– Syncopal attack
– Partial or complete perforation
• Late
– Pain due to myometrial distention
– Abnormal menstrual bleeding
– Pelvic Infection (PID) – risk develop 2 to 10 % among
IUCD user

136. Advantages
• Inexpensive: Cu T distributed free of cost through Governmental
channel
• Simplicity in techniques of insertion and most cost effective of all
methods
• Prolonged contraceptive protection after insertion (5-10 years) and
suitable for the rural population of developing countries
• Systemic side effects are nil. Suitable for hypertensive, breastfeeding
women and epileptics
• Reversibility to fertility is prompt after removal

137. Disadvantages
• Requires motivation, experts for insertion
• Limitation in its use
• Adverse local reactions manifested by menstrual
abnormalities, PID, Pelvic pain and heavy periods
– Beside effects are less with third generation of IUDs
• Risk of ectopic pregnancy

138. 1. Significantly reduction in menstrual blood loss,
menorrhagia, dysmenorrhea and pre-menstrual tension
syndrome
2. Treatment of:
– Endometrial hyperplasia
– Adenomyosis
– Endometriosis
– Uterine leiomyoma
– Endometrial cancer
3. Can be used as an alternative to hysterectomy for
menorrhagia, DUB
Non-Contraceptive Benefits

139. 1. Persistent excessive regular or irregular uterine bleeding
2. Flaring of salpingitis
3. Perforation of uterus
4. Partial IUD expulsion
5. Pregnancy occurring with the device insitu
6. Woman desirous of a baby
7. Missing thread
8. One year after menopause
9. When effective life span of device is over
Indications For Removal

140. Removal
• IUD removal is simple and can be done at any
time by pulling the strings gently and slowly
with a forceps

141. Thread May Not Visible
• Due to
– Thread coil inside
– Thread torn through
– Device expelled outside unnoticed by the client
– Device perforated the uterine wall and is lying in
the peritoneal cavity
– Device pulled up the growing uterus in pregnancy

142. Thread May Not Visible
• Pregnancy should be excluded first
• Methods of Identification of missing thread
1. Ultrasonography
• Can be detected either in uterine cavity of peritoneal
cavity
2. Hysteroscopy
• Can be used for direct visualization of the uterine
cavity and can be removed spontaneously
3. Sounding
4. Straight X-ray

143. Progesterone Contraceptives
Oral pills (mini pills)
Intramuscular injections
Implants
Mirena IUCD

144. Mechanism of Action
 It makes cervical mucus thick and viscous 
prevention of sperm penetration
 Atrophy of endometrial hinders blastocyst
implantation
 Inhibition of ovulation
 Increased tubal motility
 Premature luteolysis Minipill

145. Common Advantages
• Can be used during lactation Estrogen is not
good for lactation because it dries the milk
and reduces production
• Can be prescribed to patient having
hypertension, fibroid, diabetes, epilepsy,
smoking, and history of
thrombo-embolism
• Reduces risk of Pelvic Inflammatory
Disease

146. Common Advantages
 Side effects attributed to estrogen in
combined pill are totally eliminated
 Decrease total menstrual blood loss
 Decreases dysmenorrhoea
 Reduces risk of endometrial cancer
 Reduces risk of ovarian cancer
 Reduces risk of ectopic pregnancy

147. Common Disadvantages
• Irregular bleeding
• Weight gain
• Headache most in Norplant
• Nausea
• Dizziness
• Breast tenderness
• Loss of libido

148. Common Disadvantages
 Depression
 Fatigue
 Nervousness
 Acne
 Hirsutism
 Loss of scalp hair
 Low protection from STDs

149. Injectable Progestins

150. Types
1. Depomedroxyprogesterone Acetate (DMPA)
2. Norethisterone Enanthate (NET-EN)

151. How to Use
• Both are given Intramuscularly (deltoid and
gluteus muscle) within 5 days of the cycle
• Make sure you counsel patient about
mechanism of action, advantage,
disadvantages
DMPA
•Dose : 150mg given every 3
months
•Dose : 300mg given every 6
months
NET-EN
•Dose: 200mg given 2
months interval

152. Advantages
 Easy to administer and there is no worry
over ‘missing pill’
 Long-acting, reversible
 Good compliance
 DMPA is least androgenic
Incidence of PID, ectopic pregnancy and
functional
ovarian cysts is low

153. Disadvantages
 Once administered, side effect if any tolerated
until the progestogenic effect of the injection
is over
 Weight gain, depression, bloated feeling
and mastalgia
 Women are clinic-dependent
 Delayed return to fertility
In 80 % by end of one year

154. Norplant

155. Norplant
 It is an implant
 Used subdermally
 2 rods of 4cm long with diameter 2.4mm used
 Each rod contains 75mg of levonogesterel
 Releases 50 microgram of levonogesterel/day
 Effective for 5 years

156. Norplant
• Efficacy similar to Combined Oral Contraceptive Pills
• Failure rate = 0.1/100 women years
• Easier to insert and remove
• It is ideally inserted within Day 5 of a menstrual
cycle, immediately after abortion and 3 weeks after
post-partum

157. Norplant
• Norplant I  Used to contain 6 capsules but now
it is replaced by 1 capsule. These 6 capsules were
inserted in fan-like fashion
• Norplant II (Jadelle)  2 capsules as described in
later slides

158. How to Insert
• Inserted subdermally
• Inner aspect of non-dominant arm, 6-8 cm above
elbow fold
• Between biceps and triceps muscles
• Area is cleaned and small cut is made
• Implants are placed under the skin
• Bandage is put to protect the spot for a few days

159. How to Insert
• Procedure takes 5-10 minutes
• You can feel it in your arms but it won’t
bother, hurt or disturb

160. Advantages
• Long-acting with sustained effect—compliance
is good
• Coital-independent with no ‘nuisance’ of daily oral or frequent
injections
• Pregnancy rate—varies between 0.2 and 1.3 per 100 woman years
• Systemic side effects are few and first pass effect on the liver avoided
• Can be used by lactating mothers and over the age 40
• Decreases incidence of anemia
• Effective within 24 hours

161. Disadvantages
• High cost
• Requires minor surgical procedure for insertion and removal
• Inadvertent deep insertion or inadequate insertion of capsule
• Local infections
• Infertility seen in few cases

162. Contraindications
• Previous ectopic pregnancy
• Ovarian cyst (Mini pills)
• Breast and genital cancers
• Abnormal vaginal bleeding
• Active liver and arterial disease; porphyria, liver
tumour
• Osteopenia

163. Sim’s Double Bladed Posterior Vaginal Speculum
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164. Sim’s Double bladed Posterior Vaginal Wall
Speculum
• The instrument has double blades on each side with handle in the
middle.
• The double bladed sim’s can be used in both parous and
nulliparous vagina and has better holding system.
• Along the whole length there is a groove for the purpose of
drainage of collected fluid and materials.
• It can be used in both gynecological and obstetric cases.
• Sterilization: Autoclaving or boiling
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165. Gynecological uses:
Diagnostic uses:
• To visualize the cervix for detection of any pathological conditions like:
cervical erosion, cervical polyp, carcinoma cervix, chronic cervicitis,
cervical tear.
• To visualize anterior vaginal wall for detection of any pathological
conditions like: cystocele, VVF.
• To collect samples for exfoliative cytology and gram’s staining.
Therapeutic uses:
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• Dilatation and curettage.
• Evacuation and curettage.
• Anterior colporrhaphy
• Vaginal hysterectomy
• Local repair of VVF.
• Polypectomy.
• It can also be used for insertion and removal of IUCD.

166. Obstetrical uses:
• To visualize any injured site on the cervix and the vagina during
post partum hemorrhage.
• To inspect cervix for exclusion of any local lesion causing bleeding
either in threatened abortion or ante partum hemorrhage.
• During repair of cervical tear.
• For diagnosis of pre-mature rupture of membrane.
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167. Drawbacks:
• Use of this instrument need assistance.
• During examination by this instrument the patient must be at the
edge of the bed.
Method of introduction:
• It is introduce into the vagina with the patient in lithotomy
position-dorsal position with buttocks at the edge of the bed or in
Sim’s left lateral position. The blade is introduced into the vagina
from lateral side then rotated at right angle to depress the
posterior vaginal wall.
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168. Cusco’s Self Retaining Bi-valve Vaginal Speculum
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169. Cusco’s Self Retaining Bi-valve Vaginal Speculum
 The instrument has two valves with adjustable screw.
 Used only in gynecological cases to retract anterior and posterior
vaginal wall.
 It has diagnostic and therapeutic uses.
 Diagnostic use:
1. To visualize cervix for detection of:
- Cervical erosion
- Chronic cervicitis
- Cervical polyp
- Cervical malignancy
2. To collect samples (cervical smear or high vaginal swab)for
exfoliative cytology and gram’s staining.
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170. Therapeutic uses:
1. TO remove IUCD (Cu T).
2. To perform minor operations like cervical biopsy,
polypectomy, electro cauterization of cervix in
cervical erosion.
Sterilization: Autoclaving
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171. Method of introduction.
• The blades of the speculum are closed and lubricated.
• After separating the labia minora the speculum is introduced into
the vagina vertically and once inside the vagina it is rotated in right
angle. The hinges are pressed to open the blades.
• The blades are fixed with the adjustable screw.
• After inspection, close the blade and withdraw the speculum.
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172. Advantage of Cusco’s over Sim’s Speculum
• Self retaining so, it doesn’t require assistant.
• Patient may be examined in the middle of the bed.
• Size can be changed according to need of by the screw.
• Both walls of the cervix can be seen.
Disadvantage:
• Anterior and posterior walls of vagina cannot be seen.
• It gives less exposure. A light source from behind is essential.
• Operation is difficult due to limited space.
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173. Doyen’s Retractor
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174. Doyen’s Retractor
• It is an instrument to retract the abdominal wall in the abdominal and
pelvic surgery to expose the field of operation.
Uses:
• To retract the abdominal wall along with the bladder in pelvic surgery.
e.g. caesarian section, abdominal hysterectomy.
• To protect the bladder during pelvic surgery (It is a bladder loving
retractor because of its curved end)
• It may also be used along with self-retaining abdominal retractor.
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Sterilization:
• Autoclaving

175. Deaver’s Retractor
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176. Deaver’s Retractor
• It is used to retract the abdominal wall during abdominal and
pelvic surgery.
Uses:
• During intestinal surgeries and liver surgeries.
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Its disadvantage over Doyen’s retractor is that it causes injury to the
bladder.

177. Hegar’s Dilator
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178. Hegar’s Dilator
• It is a long cylindrical dilator
• There are two sizes present in each end of the instrument.
• The difference of the diameter between the tip and the main stalk is
3mm.
• The diameter is least at the tip and maximum at the stalk.
Uses:
• To dilate the cervix prior to D&C, D&E.
• Prior to evacuation of molar pregnancy.
• Removal of uterine polyp or any foreign body.
• Prior to vaginal hysterectomy.
• Treatment of cervical stenosis post surgery or post radiation.
• To drain pyometra or haematometra or lochiometra.
• As a treatment of primary dysmenorrhoea.
• To diagnose cervical incompetence.
• To confirm the patency of cervical canal after amputation of cervix.
• To dilate the urethra in urethral stricture.
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179. Complications:
• Cervical tear
• Uterine perforation
• Haemorrhage due to injury to the descending cervical artery.
• Repeated dilatation of the cervix can result in cervical incompetence.
Contraindications:
• Presence of active uterine infection.
• Pregnancy or suspected pregnancy.
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Which case we do only dilation of cervix?
• Treatment of Dysmenorrhoea
• Drainage of pyometra, haematometra
• Insertion of radium prior to radiotherapy

180. Uterine Sound
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181. Uterine Sound
• It has a handle and a graduated shaft bent at an angle of 150° at the
blunt end.
• The bent end corresponds to the utero-cervical junction.
Uses:
• To measure the length of the uterine cavity. (Normal length: 7.5 cms)
• To confirm whether the uterus is anteverted or retroverted.
• Used as a first dilator while doing D&C.
• To sound the uterine cavity in a case of IUCD with missing thread.
• Used to diagnose and differentiate a uterine polyp from chronic
inversion.
• Used to differentiate uterine mass from an ovarian mass.(on moving
the mass if the uterine sound moves as well, the mass is uterine)
• To diagnose congenital anomalies of uterus such as bicornuate
uterus.
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182. Conditions in which length of the uterus is increased:
• Pregnancy
• Fibroid
• Adenomyosis
• Pyometra, Haematometra
• Endometrial Carcinoma
• H. Mole
Contraindications:
• Pregnancy
• Infection
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Complications:
• Perforation
• Creation of false passage

183. Uterine Curette with Sharp
and Blunt End
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184. Uterine Curettage
• It has a sharp and blunt end with a handle.
Uses:
• Infertility (Call the patient after 14th day of cycle)
• DUB
• TB Endometritis
• Incomplete abortion or missed abortion
• Suspected Choriocarcinoma
• Suspected Endometrial carcinoma
• Curettage of endometrium before starting hormonal therapy.
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185. Towel Clip
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186. Towel Clip
• It has a sharp end.
Uses:
• To fix the draping sheets after antiseptic cleaning of the operation area.
• To fix the diathermy wire, sucker tube with draping sheet.
• It can also be used during operation like vasectomy (Non scalpel method
of vasectomy)
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187. Needle Holder
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188. Needle holder
• It looks like artery forceps but has shorter blade and has criss-cross
serrations in the blade.
Uses:
• To catch hold the needle for suturing the tissues.
• Whenever holding the needle, hold in two third forward and one third
backward.
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189. Kocher’s Haemostatic Forceps
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190. Kocher’s Haemostatic Forceps
• It has a single toothed end.
Obstetrical Uses:
• To clamp the umbilical cord for better grip and effective crushing effect
to occlude the vessels.
• In low rupture of membranes as surgical induction of labour or
augmentation of labour.
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Gynaecological Uses:
• To use as clamp in hysterectomy operation.

191. Multiple Toothed Vulsellum
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192. Multiple Toothed Vulsellum
• It has multiple tooth in each blade.
Uses:
• To hold the anterior lip of the cervix during D&C, biopsy taking, Cu-T
insertion, polypectomy, vaginal hysterectomy.
• To hold the posterior lip of the cervix during colpotomy, colposcopy and
colpopuncture.
• To hold the fundus of the uterus in hysterectomy operation and find out
exact degree of uterine prolapse.
• It can also be used during drainage the hydrocephalus of fetus.
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193. Allis Tissue Forceps
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194. Allis Tissue Forceps
• It is a long forceps with multiple tooth at the end.
Uses:
• To hold the rectus sheath during opening and closure of the abdomen.
• To hold the vaginal wall during abdominal hysterectomy.
• To oppose skin margin during its closure.
• To hold the vaginal flap in anterior colporrhaphy and posterior
colpoperineorrhaphy.
• To hold the torn end of the sphincter ani externus prior to suture in
repair of complete perineal tear.
• To remove small polyp from the cervix.
• To hold the tissue in cervical biopsy.
• To hold the loop of fallopian tubes during tubectomy in place of
Babcock’s forceps.
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195. Green Armytage Haemostatic Forceps
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196. Green Armytage Haemostatic Forceps
• It has a rectangular end horizontal serrations.
• It is non-toothed and can be used safely in
pregnant uterus.
Uses:
• For holding the cut surface of uterus to make the
area avascular during caesarean section.
• Four pairs of forceps are required for holding the
cut surface of the uterus.
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197. Sponge Holding Forceps
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198. Sponge Holding Forceps
• It has a hole at the tip with serrations.
Uses:
• For antiseptic painting of the abdominal wall prior to caesarean
section and other abdominal operations.
• For toileting the vulva, vagina and the perineum prior to and
following any vaginal operations.
• In case of PPH, to catch hold the cervix for inspection for any
trauma following child birth (two pairs are needed)
• To hold the cut margin of the uterus during caesarean section.
(Disadvantage over Green Armytage: suture can get entangled
inside the hole)
• To remove the product of conception after its separation partially
or completely instead of ovum forceps.
• To hold the lower uterine segment as an haemostat.
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199. Babcock’s Forceps
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200. Babcock’s Forceps
• The blades are fenestrated and bent at the edges.
• It is s non-traumatic instrument.
Uses:
• To hold fallopian tube in operations like tuboplasty, tubectomy.
• To hold appendix in appedicectomy.
• To hold lymph glands during dissection in radical hysterectomy.
• To hold the ureter while separating it from ovarian or broad ligament
tumor.
• To hold the bladder during repair of vesico-vaginal fistula repair.
• To hold the ovaries during surgeries on polycystic ovaries and
removal of chocolate cysts.
• To hold the small bowel during repair of recto-vaginal fistula, repair
of third degree perineal tear, repair of bowel injury.
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201. Curved Haemostatic Artery Forceps
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202. Curved Haemostatic Artery Forceps
• It is a curved forceps.
• It comes in three different sizes: Long,
medium and short.
Uses:
• As a clamp in hysterectomy,
salphingectomy, salphingo-oopherecomy
operations.
• To catch a bleeding vessel for haemostasis.
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203. Scissor
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204. Plain Dissecting Forceps
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205. Plain Dissecting Forceps
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206. Toothed Dissecting Forceps
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207. Rubber Catheter
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208. Rubber Catheter
• It is a long hollow rubber tube with one end closed and other open.
• There is a small hole in the closed end.
Uses:
• To empty the bladder in case of retention of urine.
• Evacuation of bladder during labour, prior to application of forceps
during forceps delivery, during PPH and destructive operation such as
craniotomy and decapitation.
• During operation for continuation of bladder such as caesarean section,
abdominal hysterectomy, ectopic pregnancy.
• As a torniquet during myomectomy.
• As a torniquet before giving intravenous cannula.
• To administer oxygen as nasal catheter.
• Can be attached to a mechanical mucous sucker.
• It can also be used for ripening of cervix. (It works as a mechanical
stimulator for production of prostaglandin)
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209. Bard Parker Handle
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210. Bard Parker Handle
• It is composed of handle and a blade that can be
detachable.
Uses:
• In any surgery to cut skin, subcutaneous tissue,
peritoneum etc.
• Handle can be used as blunt dissector.
• Note: Its use is contraindicated in obstetric operations
(Symphysiotomy)
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211. Obstetric Forceps
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212. Fibroid Uterus
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213. Hydatidiform Mole
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214. Hydatidiform Mole
• It is a formalin preserved specimen showing grape like vesicles so
it is a Hydatidiform mole.
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215. Oxytocics

216. ACTION ON THE UTERUS:
It increases the force and frequency of uterine
contractions.
The uterine contractions are physiological i.e
causing fundal contraction with relaxation of
the cervix.
It stimulates amniotic and decidual
prostaglandin production.

217. MECHANISM OF ACTION:
Myometrial oxytocin receptor concentration
increases maximum(100-200 fold) during
labour.
Acts through specific G-protein coupled
oxytocin receptors which mediate the
response mainly by depolarization of muscle
fibres and influx of calcium ions as well as
through IP3 generation and intracellular
release of calcium.

218. •OXYTOCIN HAS A HALF LIFE OF 3-4 MINUTES
AND A DURATION OF ACTION OF
APPROXIMATELY 20 MINUTES.
• RAPIDLY METABOLISED BY LIVER AND KIDNEY
AND DEGRADED BY OXYTOCINASE.

219. EFFECTIVENESS:
• In the first trimester,the uterus is almost
refractory to oxytocin.
• In the second trimester,relative refractoriness
persists and as such,it can only supplement other
abortifacient agents in induction of abortion.
• In later months of pregnancy and during labour
in particular,it is highly sensitive to oxytocin even
in small doses.
• oxytocin loses its effectiveness unless preserved
at the correct temperature(2-8 °C).

220. INDICATIONS
THERAPEUTIC:
PREGNANCY
 EARLY:-
• To accelerate abortion
• To stop bleeding following evacuation of the uterus.
• As an adjunct to induction of abortion along with
other abortifacient agents(PGE1 or PGE2)
 LATE:-
• To induce labour
• To facilitate cervical ripening for effective induction

221. LABOUR:-
• Augmentation of labour
• Uterine inertia
• In active management of third stage of labour(IM 10
Units)
• Following expulsion of placenta as an alternative to
ergometrine.
PUERPERIUM:-
• To minimise blood loss and to control postpartum
haemorrhage.
DIAGNOSTIC
• Contraction stress test(CST)
• Oxytocin sensitivity test(OST)

222. CONTRAINDICATIONS
During pregnancy:
• Grand multipara ( hyperresponsive danger of rupture)
• Contracted pelvis
• History of caesarean section or hysterotomy
• Malpresentation
During labour:
• All contraindications in pregnancy
• Obstructed labour
• Incoordinate uterine contraction
• Fetal distress
During any state:
• Hypovolaemic state
• Cardiac disease

223. DANGERS OF OXYTOCIN
MATERNAL
Uterine hyperstimulation
Uterine rupture
Water intoxication
Hypotension
Antidiuresis
FETAL
Fetal distress,fetal hypoxia or even fetal death

224. ROUTES OF ADMINISTRATION
Controlled intravenous infusion is widely used
Bolus IV or IM
Intramuscular
Buccal tablets or nasal spray(trial basis)

225. HOW TO GIVE OXYTOCIN?
FOR INDUCTION AND AUGMENTATION OF
LABOUR:-
• 2.5 units in 500 ml of dextrose(normal saline)
at 10 drops per minute.(2.5 mIU per minute)
• the infusion rate by 10 drops per minute every
30 minutes until a good contraction
pattern(optimal response) is
established(contractions lasting more than 40
sec and occuring 3 times in 10 minutes).
• Maintain this rate until delivery is completed.

226. • If hyperstimulation occurs use tocolytics.
-terbutaline 250 mcg IV slowly over 5
minutes
-OR salbutamol 10 mg in 1 L IV fluids (normal
saline or ringer’s lactate)at 10 drops per
minute.
• If not satisfactory contractions
-double the dose i.e 5 units in 500 ml and
adjust the infusion rate to 30 drops per
minute(15mIU per minute);

227. • If labour still has not been established :
-In multigravidae and in women with
previous caesarean scars,induction has
failed;delivery by caesarean section.
-In primigravidae,10 units in 500 ml dextrose
(or normal saline)at 30 drops per minute;
-if good contractions are not established at 60
drops per minute(60 mIU per minute),deliver
by caesarean section.

228. ERGOT DERIVATIVES
TWO MOST COMMONLY USED:
ERGOMETRINE(alkaloid-fungus Claviceps
Purpurea)
METHERGIN(semisynthetic product derived
from lysergic acid)

229. MODE OF ACTION
Acts directly on the myometrium.It excites
uterine contractions which come so frequently
one after the other with increasing intensity
that the uterus passes into a state of spasm
without any relaxation in between.

230. EFFECTIVENESS
• Keeping physiological functions in mind,it
should not be used in the induction of the
abortion or labour.
• It is highly effective in haemostasis-to stop
bleeding from the uterine sinuses,either
following delivery or abortion.

231. Modes of administration:
• Used parenterally or orally.
• Should be used either in late second stage of
labour(after the delivery of the anterior
shoulder)or following delivery of the baby.

232. INDICATIONS
THERAPEUTIC:
• To stop the atonic uterine bleeding , following
delivery , abortion or expulsion of
hydatidiform mole.
PROPHYLACTIC:
• As a prophylactic against excessive
haemorrhage following delivery,it may be
used after the delivery of anterior shoulder.

233. CONTRAINDICATIONS
PROPHYLACTIC:
Suspected plural pregnancy
Organic cardiac disease
Severe pre-eclampsia and eclampsia
Rh-negative mother
THERAPEUTIC:
Heart disease or severe hypertensive disorders

234. HAZARDS
Nausea and vomiting
May precipitate rise of blood
pressure,myocardial infarction,stroke and
bronchospasm due to its vasoconstrictive
action.
Gangrene of the toes
Interfers with lactation(decreases the
prolactin)

235. CAUTIONS
Should not be used during pregnancy,first stage
of labour,second stage prior to crowning of
the head and in breech delivery prior to
crowning.

236. PROSTAGLANDINS

237. Mechanism of Action:
 PGE₂ and PGF₂ α have got oxytocic effect on the pregnant
uterus.
Probable mechanism is by:
 Change in myometrial cell membrane permeability and/
or alteration of membrane bound calcium channel.
 Sensitises the myometrium to oxytocin.
 PGF₂ α acts mainly on myometrium while PGE₂ acts on
cervix,due to its collagenolytic property.

238. Uses in Obstetrics:
• Induction of abortion
• Induction of labour.
• Cervical ripening prior to induction of abortion or labour.
• Acceleration of labour.
•Management of atonic PPH.
• Termination of molar pregnancy.
• Medical management of tubal pregnancy.

239. MISOPROSTOL
To ripen the cervix in highly selected situation such as :
1. severe pre-eclampsia or eclampsia when the cervix is
unfavourable and safe caesarean is not available or baby is too
premature to survive.
2. fetal death in utero if woman has not gone into spontaneous
labour after four weeks and platelets are decreasing.

240. Advantages:
1.Powerful oxytocic effect irrespective of period of gestation.
2. In later months, when the pre-induction score is low or IUD is effective than oxytocin.
3. No diuretic effect.
Disadvantages:
1. Costly
2. side effects: nausea, vomiting, diarrhea, pyrexia, bronchospasm.
3. when used as abortifacient drug extensive cervical laceration may occur.
4. tachysystole of uterus during induction and may continue for variable period.

241. Contraindication
 Hypersensitivity to the
compound
 Uterine scar
 Bronchial asthma

242. TOCOLYTIC AGENTS

243. Rationale for tocolysis
• Improve survival
– < 27-28 weeks
• Allow time for steroids
– < 34 weeks
• Allow time for in-utero transfer

244. TYPES OF AGENTS:-
Betamimetics: Terbutaline, Ritodrine, Isoxsuprine, Fenoterol, Salbutamol
NSAIDs: Indomethacin, Sulindac
Calcium channel blockers: Nifedipine, Nicadipine
Magnesium Sulphate
Oxtocin Antagonists: Atosiban
Nitric oxide(NO) donors: Glyceryl Trinitrate(GTN)
Ethyl Alcohol (????)

245. 1.Betamimetics:-
Mechanism of Action:-
- Activation of the intracellular enzymes (Adenylate
cyclase, cAMP, Protein kinase), reduces
intracellular free calcium and inhibits activation
of MLCK →reduced interaction of actin and
myosin→ smooth muscle relaxation
β (β2) receptor stimulation causes smooth
muscle relaxation.

246. A.Ritodrine:-
- The only FDA approved tocolytic.
- High cost
Dose:
 150 mg in 500 ml DS
 Start 100 mcg /min, go up to 350 mcg, in increments
of 50 mcg every 10 mins, until 12 hours of cessation
of contractions, then switch to 10mg tab 2 hourly &
maintain at 10-20 mg 2-6 hourly
Contraindication:
 Poorly controlled Thyroid disease and Diabetes

247. Side Effects:-
• Maternal:-
 Metabolic hyperglycemia
 Hyperinsulinemia
 Hypokalemia
 Antidiuresis
 Altered thyroid function
 Physiologic tremor
 Palpitations
 Nervousness
 Nausea or vomiting
 Fever
 Hallucinations
• Fetal and
Neonatal:-
 Neonatal tachycardia
 Hypoglycemia
 Hypocalcemia
 Hyperbilirubinemia
 Hypotension
 Intraventricular hemorrhage

248. B. Tebutaline:-
 Is often the drug given first, especially if there is only
low risk of preterm birth
 Low cost, widely used
Dose:
250 mcg IV / SC every 3 to 4 hrs until 12 hours of
cessation of contractions followed by oral 5 mg 2/4/6
hours
Contraindication:
Cardiac arrhthymias

249. Side Effects:-
• Maternal:-
 Cardiac or
cardiopulmonary
arrhythmias
 Pulmonary edema
 Myocardial ischemia
 Hypotension
 Tachycardia
• Fetal and Neonal :-
 Fetal tachycardia
 Hyperinsulinemia
 Hyperglycemia
 Myocardial and septal
hypertrophy
 Myocardial ischemia

250. C. Isoxsuprine:-
-Low cost, Moderate side effects,widely used in India since long
-Dose:
*60mg in 500ml 0.2-1mg / minute IV drip for 12 hours of cessation
of contractions – 10mg IM/6hourly for 48 hours – then switch to
oral 20mg X 3-4 / 40mg x 2 times
D. Salbutamol:-
-Low cost, Moderate side effects, mostly used in Australia
-Dose:
*4-32 mcg/min IV until 12 hours of cessation of contractions
followed by 2/4mg 2/4/6/8 hours– Oral

251. 2. NSAIDs:-
Mechanism of Action:-
Reduces synthesis of PGs, thereby
reduces intracellular free calcium
ions→ reduces activation of MLCK and
uterine contraction

252. A.Indomethacin:-
 Cyclo-oxygenase inhibitor
 Compared with ritodrine there is insufficient evidence for any
differential effect on delay in delivery, but indomethacin does seem
to have fewer maternal adverse effects than the beta-
agonists
 Indomethacin therapy for
•< 48 hours
•< 30-32 weeks' gestation
•Not > 200mg/day.
appears to be a relatively safe and effective tocolytic agent
 Can be given for short periods of <72 hours
 Indomethacin can be used as a second-line tocolytic agent in
early gestational age preterm labors.
 Indomethacin may be a first-line tocolytic in Associated
Polyhydramnios ( to have renal effects of indomethacin)

253. Dose:-
Initial loading dose of 50 mg then 25-50 mg oral every 4
hours until contractions cease and maintenance
therapy at 25 mg oral every 4 - 6 hours up to 35 weeks
Contraindication:-
Late pregnancy (ductus arteriosus), significant renal or
hepatic impairment

254. Side Effects:-
Maternal:-
 Nausea
 Heart burn
 G.I bleeding
 Asthma
 Thombocytopenia
 Renal injury
Fetal and Neonatal:-
 Constriction of ductus
arteriosus
 Pulmonary hypertension
 Reversible decrease in
renal function with
oligohydramnios
 Intraventricular
hemorrhage
 Hyperbilirubinemia
 Necrotizing enterocolitis

255. 3. Calcium Channel Blockers (Nifedipine)
Mechanism of Action:
Nifedipine blocks the entry of calcium inside the cell
Is one of the most commonly used tocolytic agents
Nifedipine- compared with ritodrine has:
*Higher delaying of delivery for >48 H.
*Lower risk of RDS and Neonatal jundice.
*Lower admission to NICU
*Fewer maternal adverse effects

256. -When tocolysis is indicated for women in preterm
labor, calcium channel blockers are preferable to
other tocolytic agents compared, mainly
betamimetics.
Contraindication:-
*Cardiac disease. It should not be used
concomitantly with magnesium sulfate
Move to ban sublingual getting wider
acceptance.
Dose:
*Oral (not sublingual) 10-20 mg every 6-8
hours

257. Side Effects:-
• Maternal:-
Flushing, headache, dizziness, nausea, transient
hypotension.
 Administration of calcium channel blockers
should be used with care in patients with renal
disease and hypotension.
 Concomitant use of calcium channel blockers and
magnesium sulfate may result in cardiovascular
collapse

258. 4. Magnesium Sulphate:-
Mechanism of Action:
It acts by competitive inhibition to calcium ion
either at the motor end plate or at the cell
membrane reducing calcium influx.
Decreases acetylcholine release and its
sensitivity at the motor end plate.
Direct depressant action on the uterine muscle.
Shown to be ineffective.
Has been recommended for women at high risk.
However, meta-analyses have failed to support it as a
tocolytic agent.

259. Dose:
4-6 Gm IV/IM loading dose over 20 minutes,
followed by 2-4 Gm IV/IM every hour for 12 hours
after contractions stop to be followed by beta
agonists orally
For IV 40 gms in one Lit of 5%DS or 0.45% Normal
saline
 Watch for hypermagnesemia
 Monitor Mg level

260. Side Effects:-
Maternal:-
 Flushing
 Perspiration
 Lethargy
 Headache
 Muscle weakness
 Diplopia
 Dry mouth
 Pulmonary edema
 Cardiac arrest.
Fetal and Neonatal:-
 Lethargy
 Hypotonia
 Respiratory depression
 Demineralization with
prolonged use.

261. 5. Oxytocin Antagonists (Atosiban):-
A nona peptide oxytocin analouge and acts as oxytocin/ADH antagonists
Mechanism of Action:-
Atosiban is a competitive oxytocin(OT) receptor
antagonist that binds to membrane bound myometrial cell OT
receptors resulting in:
(a) Dose dependent inhibition of OT stimulated IP3
production with release of stored intracellular
Ca2+ in sarcoplasmic reticulum.
(b) Closure of voltage gated channels in myometrial
cell membrane to prevent influx of Ca2+ into the
myometrial cell
(c) Prevents OT mediated release of PG from
decidua and fetal membranes which potentiate
(a) and (b)

262. Atosiban: Pharmacokinetics
• Plasma half-life suitable for treating preterm
labour (t½ = 13 minutes)
• Well tolerated at all dose levels, including
proposed clinical dose up to 48 hours
• Pharmacokinetic profile similar in pregnant and
non-pregnant women
• Maternal/fetal transfer relatively low with no
accumulation in fetal circulation
(fetal/maternal ratio of 12%)

263. Dose:-
• Bolus dose of 6.75 mg in 0.9ml (7.5
mg/ml)
• Then 300 g/min for
3 hours
• Then 100 g/min for upto 45 hours

264. Indications for Atosiban Administration:-
Atosiban is indicated to delay imminent preterm birth
in pregnant women with:
•Regular uterine contractions of at least 30 seconds
duration at a rate of 4 per 30 minutes
•Cervical dilation of 1–3 cm (0–3 cm for nulliparas) and
effacement of 50%
•Age 18 years
•Gestational age from 24 until 33 completed weeks
•Normal fetal heart rate

265. Contraindications for Atosiban
Administration
• Gestational age <24 or >33
completed weeks
• Premature rupture of the
membranes >30 weeks
gestation
• Antepartum uterine
haemorrhage requiring
immediate delivery
• Eclampsia and severe pre-
eclampsia requiring delivery
• Intrauterine fetal death
• Suspected intrauterine
infection
• Placenta praevia
• Abruptio placenta
• Intrauterine growth
retardation and abnormal fetal
heart rate
• Any other condition of the
mother or fetus in which
continuation of pregnancy is
hazardous
• Hypersensitivity to the active
substance or any of the
excipients

266. Side Effects:-
• Nausea
• Vomitting
• Chest Pain (rarely)

267. Contraindications to tocolysis:-
Fetus is older than 34 weeks gestation
Fetus weighs less than 2500 grams or has intrauterine growth
restriction (IUGR) or placental insufficiency
Lethal congenital or chromosomal abnormalities
Cervical dilation is greater than 4 centimeters
Chorioamnionitis or intrauterine infection is present
Mother has severe pregnancy-induced hypertension,
eclampsia/preeclampsia, active vaginal bleeding, placental
abruption, a cardiac disease, or another condition like DM,
Hyperthyroidism which indicates that the pregnancy should not
continue..

268. ANTICONVULSANTS IN
OBSTETRICS

269. Overview
A. Magnesium sulphate
B. Diazepam
C. Phenytoin
D. Epilepsy in Pregnancy

270. A. Magnesium Sulphate

271. Mechanism of Action
• Decreases release of acetylcholine from nerve
endings
• Reduces motor end plate sensitivity to
acetylcholine
• Blocks calcium channels
• Causes
– Vasodilatation
– Increased cerebral, renal and uterine blood flow
– Decrease in intracranial oedema

272. Pharmacokinetics
• Intravenous administration
– Onset: immediate
– Duration: 30 min
• Intramuscular administration
– Onset: 1 hour
– Duration: 3-4 hours
• Effective anticonvulsant serum levels 2.5 – 7.5
meq/L

273. Regimens
• Prichard Regimen
• Others
– Zuspan
– Sibai

274. Loading Dose
• 4g IV over 5
min
• 10g deep IM
(5gm in each
buttock)
Maintenance Dose
• 5 g IM 4 hourly
in alternate
buttock
Dose (Prichard Regimen)

275. Method of administration
Loading Dose
• Prepare 20ml syringe
• Take 4g/8ml MgSO4 (50%; 4amp)
• Add 12 ml water (makes the solution 20%)
• Administer slow IV over 5 min
• Take 2 10 ml syringes
• Take 5g/10ml MgSO4 (50%; 5amp) in each syringe
• Add 1ml 2% lignocaine in each syringe
• Give 5g MgSO4 deep IM in each buttock
• For recurrence: 2g/4ml MgSO4 (50%; 2amp) slow IV over 5 min

276. Maintenance dose
• Take 10 ml syringe
• Take 5g/10ml MgSO4 (50%; 5amp)
• Add 1ml 2% lignocaine
• Give 5g MgSO4 deep IM in alternately in each
buttock 4 hourly
• Continued same treatment for 24 hours after
last convulsion or last delivery which ever
occur last.

277. Adverse Drug Reactions
Common
– Flushing
– Nausea
– Vomiting
– Palpitations
– Headache
– General muscle weakness
– Lethargy
– Constipation
Rare (overdose)
– Cardiac arrest
– Pulmonary edema (lungs fill
with fluid; can be fatal)
– Chest pain
– Cardiac conduction defects
– Low blood pressure
– Low calcium
– Increased urinary calcium
– Visual disturbances
– Decreased bone density
– Respiratory depression
(difficulty breathing)
– Muscular hyperexcitability

278. Drug Interactions
– CNS Depressants → Marked depression
– Neuromuscular blocking agents → Paralysis
– Digitalized patients → Heart block
– Nifedipine → Paralysis
– Terbutaline → Pulmonary edema &
cardiovascular complications

279. Contraindications
– Heart block
– Serious renal impairment
– Myocardial damage
– Hepatitis
– Addison’s disease
– Myasthenia gravis

280. Monitoring & Management of Toxicity
• Monitored by observing
– Respiratory rate
– Patellar reflex
– Urine output
– Other parameters:
• Blood pressure
• Serum magnesium
• Diarrhea
• Respiratory & CNS depression
• Management
• 10ml 10% calcium gluconate IV slowly
• Respiratory support
• Extreme Cases → haemodialysis/peritoneal dialysis

281. IV Regimens
• Loading: 4-6gm over 15 to 20 min
• Maintenance: 1-2g/hr infusion

282. Other Uses
• Tocolysis
• Hypomagnesaemia
• Pediatric acute nephritis
• Hyperalimentation
• Torsades de pointes

283. Thank you