The presentation can be used for training of Doctors and Staff nurses on Emergency Obstetric care and MMR reduction strategies in Low Resource settings.

1. Maternal Mortality Reduction
strategies
with special focus on
POST PARTUM HAEMORRHAGE & PREGNANCY
INDUCED HYPERTENSION -in low
resource settings
Dr. N.S. Iyer
CONSULTANT - Maternal health,Coimbatore
Mobile 09444993777

2. •Dr N S Iyer is from Thiruvananthapuram Kerala
•He was in Kerala Govt Health services as
Gynaecologist for nearly 3 decades 1971 to 2000.
•As a laparoscopic surgeon in Govt Service he had
done more than 75000 Lap sterilisation
•He had also done nearly 4000 C section all under local infiltration
anaesthsia without any complication.
•As Health officer in UNICEF he was managing Safe Motherhood
programme in Tamil nadu and Kerala
•While working with Pathfinder International he was instrumental in
introducing Non Pneumatic Anti Shock Garment in India for the
prevention of maternal deaths from Shock following PPH.
•He had also trained more than 2000 Newly recruited Doctors and
Staff nurses in Tamil nadu on the reduction of maternal Mortality in
Low resource settings.
•He is the recipient of Best Doctor Award in Kerala Govt Health
services in 2000.
•He is settled in Coimbatore with his wife Rajalakshmy

4. metamorphosis
40 wks
10 wks
20 wks
6 wks

5. TheGrowth of a Foetus

28. Hormonal Changes in Pregnanacy and
Menstruation
• GNRH from Hypothlamus Stimlulates production of
LH and FSH by gonadotrope cells located in the
anterior pituitary gland .
• LH and FSH Stimulates the gonads to produce
estradiol, progesterone, and androgens in a cyclic
manner and serves as the signal for ovulation
• LH primarily stimulates theca cells to produce
androgens.
• These androgens are aromatized to estradiol in the
granulosa cells of the maturing ovarian follicle under
the influence of FSH.

29. Menstrual problems
• Not yet started after 3 years of thelarchie
• Not yet started by 14years but with signs of
Hirsuitism
• Not yet started by 14years with excessive
eating disorder
• Not started by 15 year
• Freequency <21 or >45
• Lasts more than 7 days
• Frequent pad changes every 1-2 hrs

30. • Week 1
• Oestrogen and
progesterone levels are at
their lowest now, which
could translate into two
things: tiredness, though
many women don't notice
energy level dips; and low
libido.
.
• Week Two: Pending Ovulation
• Oestrogen levels begin to build
again. feel more energy, pending
ovulation mean you may have a
heightened sense of smell, along
with clearer thinking and better
coordination. Many women, in fact,
report feeling their best at this time
of the month—physically and
mentally

31. Week Three: Post-Ovulation.
The luteal phase, women
feel hot. “may look and feel
more bloated. anxiety,
depression, irritability and mood
swings, Have strange and vivid
dreams. May crave for carbs
and sugary foods in response to
depleting serotonin levels.
Week Four: Your Period
•A drop in estrogen and
progesterone collapses the
lining of the uterus. “
•"Many women, especially
those who have experienced
PMS, feel much better during
the early part of the follicular
phase as their hormone levels
have dropped back to baseline."

33. Polycystic ovary syndrome (PCOS) is a set of symptoms due to
elevated male hormone in women.[3]
Signs and symptoms of PCOS include irregular or no
menstrual periods, heavy periods, excess body and facial hair,
acne, pelvic pain, difficulty getting pregnant, and
patches of thick, darker, velvety skin.[4]
Associated conditions include type 2 diabetes, obesity,
obstructive sleep apnea, heart disease, mood disorders,
and endometrial cancer.[3]

34. Diagnosis is based on two of the following three findings: no
ovulation, high androgen levels, and ovarian cysts.[3]
Cysts may be
detectable by ultrasound.
Other conditions that produce similar symptoms include adrenal
hyperplasia, hypothyroidism, and hyperprolactinemia.[7]
PCOS has no cure.[8]
Treatment may involve lifestyle changes such as weight loss and
exercise.
Birth control pills may help with improving the regularity of
periods, excess hair growth, and acne.
Metformin and anti-androgens may also help. Other typical acne
treatments and hair removal techniques may be used.[9]
Efforts to
improve fertility include weight loss,clomiphene, or metformin.
of the leading causes of poor fertility.[3]

35. Polycystic ovary syndrome (PCOS) should be considered in any adolescent girl
with a chief complaint of hirsutism, menstrual irregularity, or obesity.
Acanthosis nigricans, treatment-resistant acne, scalp hair loss, or
hyperhidrosis may alternatively be the chief complaint, although these features
are not always present.
PCOS is primarily characterized by ovulatory dysfunction and
hyperandrogenism
The diagnosis of PCOS has life-long implications with increased risk for
infertility, metabolic syndrome, type 2 diabetes mellitus, and possibly
cardiovascular disease and endometrial carcinoma
Treatment for PCOS in adolescents is primarily directed at the major clinical
manifestations, which are:
●Abnormal uterine bleeding – menstrual irregularity or excessive bleeding
●Cutaneous hyperandrogenism – primarily hirsutism and persistent acne
●Obesity and insulin resistance

36. Endometriosis in Adolescents
• Ectopic Decidual cells-
– Adolescent patients typically present with progressive and severe
dysmenorrhea, but also may present with acyclic pelvic pain
– Standard therapy (combination hormone therapy and NSAIDs)
for dysmenorrhea should be initiated, if symptoms do not resolve
after 3 months further evaluation for endometriosis is indicated
– A bimanual pelvic examination may be difficult
: cotton-tipped swab to evaluate for the presence of transverse
vaginal septum, or agenesis of the lower vagina
: ultrasound exam in evaluation the pelvis of adolescents
– Endometriosis in adolescents typically presents as early disease
& clear, red, and white lesions are the most common

37. Endometriosis in Adolescents
• Summary
– Treatment should focus on conservative measures with surgical
& medical interventions
– Only procedures that preserve fertility options be applied
– Because there is no cure for endometriosis, long-term treatment should
continue until desired family size is reached or fertility no longer needs to be
preserved

38. Now We are on to Real Pregnancy

39. Prevention of Cong Anomalies
•Improving the diet of women throughout their reproductive years, ensuring
an adequate dietary intake of vitamins and minerals, and particularly
folic acid,through daily oral supplements or fortification of staple
foods such as wheat or maize flours;
•Ensuring mothers abstain from, or restrict, their intake of harmful
•substances, particularly alcohol;
•Controlling preconceptional and gestational diabetes,through counseling,
weight management, diet and administration of insulin when needed;
•Avoiding environmental exposure to hazardous substances
•(e.g. heavy metals, pesticides) during pregnancy;
•Ensuring that any exposure of pregnant women to medications or
medical radiation (e.g. imaging rays) is justified, based on
careful health risk–benefit analysis;
•Improving vaccination coverage, especially against the rubella virus,
for children and women.Rubella can be prevented through childhood vaccination.
The rubella vaccine can also be given at least 1 month prior to pregnancy
to women who have not been vaccinated and do not have a history of rubella
in childhood;
•Increasing and strengthening education of health staff and others involved in
promoting prevention of congenital anomalies.

40. Fill up the gap
• Most of the pregnancies are normal but all
• are at
•
RISK
When a woman is in labour you should always
Expect THE UNEXPECTED

41. What I Hear I forget
What I see I remember
What I Do I Understand

42. By the time

43. • Sheela was pregnant by 3 months and had had bleeding
PV all on a sudden
• By the time she realised that she had to go to hospital
• By the time she informed her husband
• By the time the family decided to go to the hospital
• By the time the husband got the required finance
• By the time they reached a motorable Road
• By the time they got a vehicle
• By the time they reached the hospital
• By the time the entry was cleared
• By the time dots and crosses were filled up

44. • By the time the nurses came and examined her
• By the time the doctor was summoned
• By the time the Doctor examined her and referred her to Major
hospital
• By the time the Doctor in referral hospital examined her and asked
for blood
• By the time the husband fetched the cross matched blood
• By the time the next duty nurse prepared her for evacuation
• By the time the husband`s signature was sought in various consent
forms
• By the time sheela was taken to theatre for evacuation
• Sheela Died
• Her husband started searching for a buyer to sell the unused
medicine so that he can return to his village with her dead body.
• What are the issues that lead her to death

45. Eclampsia
12%
severe bleeding
24%
Indirect causes
20%
Other direct
causes
8%
Obstructed labour
8%
Infection
15%
Unsafe abortion
13%
Maternal Mortality is preventable-
Evidence based interventions are available
Iron supplements
Malaria Mgt.ARV
(HIV)
Iron Sucrose
P
Partogram
Antibiotics,TT
Family planning
Emergency Contraception
Post abortion care-MVA
Magsulph
LD-4 amp (50%)+12ml DW IV
5amp each IM on BB .Watch
RR,reflex and urinary output
Calcium Gluconate as antidote
AMTSL
Manual removal of
placenta
Bimanual Ut
compression
Abdominal aorta
compression
Misoprestol
0.5%Chlorine
solution
CC of PFI -NASG
100 mgm in 100 ml N S in 20-30 m -80-90 drops per
minute. 2 infusions at an interval of 2-4 days

46. The prostaglandins are a group of lipids made at
sites of tissue damage or infection that are involved
in dealing with injury and illness. They control
processes such as inflammation, blood flow, the
formation of blood clots and the induction of labour.
Unlike most hormones, the prostaglandins are not
secreted from a gland to be carried in the
bloodstream and work on specific areas around the
body. Instead, they are made by a chemical reaction
at the site where they are needed and can be made
in nearly all the organs in the body. Prostaglandins
are part of the body’s way of dealing with injury and
illness.

47. 06/09/05 50
The Modified WHO Partograph
Fetal heart rate: Record every half hour
Amniotic fluid: Record the color at every
vaginal examination:
I: membranes intact,C: membranes ruptured, clear flui
M: meconium-stained fluid,B: blood-stained fluid
Molding:1: sutures apposed 2: sutures overlapped
but reducible 3: sutures overlapped and not reducible
Cervical dilatation: Assess at every vaginal examination,mark with
cross (X).Alert line: Line starts at 4 cm of cervical dilatation to the
point of expected full dilatation at the rate of 1 cm per hour.Action
line: Parallel and 4 hours to the right of the alert line .
Descent assessed by abdominal palpation: Part of head
(divided into 5 parts) palpable above the symphysis pubis; recorded
as a circle (O) at every vaginal examination.
At 0/5, the sinciput (S) is at the level of the symphysis pubis
Hours: Time elapsed since onset of active phase of labor
(observed or extrapolated)
Time: Record actual time
Contractions: Chart every half hour;
palpate the number of contractions in 10 minutes and their
duration in seconds.Less than 20 seconds:
Between 20 and 40 seconds:
More than 40 seconds:
.......
Oxytocin: Record amount per volume IV fluids in drops/min.
every 30 min. when used
Drugs given: Record any additional drugs given
Temperature: Record every 2 hours
Pulse: Record every 30 minutes and mark with a dot (•)
Blood pressure: Record every 4 hours and mark with arrows
Protein, acetone and volume: Record every time urine is passed

48. 15/02/18 Dr N S iyer 51

52. Brow Presentation Face Presentation

53. Compound
Presentation
Breech Presentation
Flexed Extended Footling

54. Baby rests with Head downwards in the Pelvis.|
Delivery process started. Labour pain yet to begin

55. Labor has begun. Cervix is dilating. Baby`s head is
pressing downwards through the opening.

56. Cx has dilated and he3ad rests on the pelvic
floor.Membranes intact

57. The tail bone of mother Coccyx is bent back. Baby`s
body stream lined to make the exit easier

58. The Head emerges and turn upward accentuating and
lengthening the baby`s head

59. Occipito Posterior –The dilemma
of the Maternity Staff.
• Occipito posterior positions are the most common type of
malposition of the occiput and occur in approximately 10% of
labours.
• A persistent occipito posterior position results from a failure
of internal rotation prior to delivery. This occurs in 5% of
deliveries.
• The vertex is presenting, but the occiput lies in the posterior
rather than the anterior part of the pelvis.
• As a consequence, the foetal head is deflexed and larger
diameters of the foetal skull is present

60. Definition
• It is a vertex presentation where the occiput is placed
posteriorly over the sacro-iliac joint or directly over the
sacrum is called an occipito-posterior position.
INCIDENCE
• -10% at onset of labour.
• -Right occipito-posterior (ROP) is more common than left
occipito-posterior (LOP) because:
• · The left oblique diameter is reduced by the presence of
sigmoid colon.
• · The right oblique diameter is slightly longer than the left
one.
• · Dextro-rotation of the uterus favours occipito-posterior
in right occipito-anterior position

61. Aetiology
• 1. The shape of the pelvis: anthropoid and android pelvis are
the most common cause of occipito-posterior due to narrow
fore-pelvis.
• 2. Maternal kyphosis: The convexity of the foetal back fits
with the concavity of the lumbar kyphosis.(Normally there is
mild Scoliosis in the lumbar region and lordosis in Thoracic
region.But when there is mild Kyphois below Curvature may
accomodate the foetal back)
• 3. Anterior insertion of the placenta: the foetus usually faces
the placenta (doubtful).
• 4. Other causes of malpresentations: as
• a - placenta praevia, b- pelvic tumours,
• c- multiple pregnancy, d- polyhydramnios, e- pendulous
abdomen

62. • DIAGNOSIS
• (A) During pregnancy:
• Inspection:
– The abdomen looks flattened below the umbilicus
due to absence of round contour of the foetal
back.
– A groove may be seen below the umbilicus
corresponding to the neck.
– Foetal movement may be detected near the
middle line.

63. • Palpation:
– Fundal grip:
• The breech is felt as a soft, bulky, irregular non-
ballotable mass.
– Umbilical grip:
• The back felt with difficulty in the flank away from the
middle line.
• The anterior shoulder is at least 3 inches from the
middle line.
• The limbs are easily felt near, or on both sides, of the
middle line.

64. First pelvic grip:
The head is usually not engaged due to deflexion.
The head is felt smaller and escapes easily from the
palpating fingers as they catch the bitemporal diameter
instead of the biparietal diameter in occipito-anterior.
Second pelvic grip:
The head is usually deflexed.
Auscultation:
FHS are heard in the flank away from the middle line.
In major degree of deflexion, the FHS may be heard in
middle line.
Ultrasonography or lateral view x-ray.

65. • B) During labour:
• In addition to the previous findings vaginal
examination reveals:
• The direction of the occiput.
• The degree of deflexion.
•

66. • MECHANISM OF RIGHT OCCIPITOPOSTERIOR
POSITION (LONG ROTATION)
• · The lie is longitudinal.
• · The attitude of the head is deflexed.
• · The presentation is vertex.
• · The position is right occipitoposterior.
• · The denominator is the occiput.
• · The presenting part is the middle or anterior
area of the left parietal bone.
• · The occiputo frontal diameter, 11.5cm, lies in
the right oblique diameter of the pelvic brim. The
occiput points to the right sacroiliac joint and the
sinciput to the left iliopectineal eminence.

67. • Flexion: Descent takes place with increasing flexion.
The occiput becomes the leading part.
• Internal rotation of the head: The occiput reaches
the pelvic floor first and rotates forwards 3/8 of the
circle along the right side of the pelvis to lie undre
the symphosis pubis. The shoulders follow, turning
2/8 of a circle from the left to the right oblique
diameter.
• Crowning: The occiput escapes under the
symphysis pubis and the head is crowned.

68. Extension: The sinciput, face and chin sweep the perineum and
the head is born by a movement of extension.
Restitution: In restitution the occiput turns 1/8 of a circle to the
right and the head realigns itself with the shoulders.
Internal rotation of the shoulders: The shoulders enter the
pelvis in the right oblique diameter; the anterior shoulder
reaches the pelvic floor first and rotates forwards 1/8 of a circle
to lie under the symphysis pubis.
External rotation of the head: At the same time the occiput
turns a futher 1/8 of a circle to the right.
Lateral flexion: The anterior shoulder escapes under the
symphysis pubis, the posterior shoulder sweeps the perineum
and the body is born by a moovement of lateral flexion.

69. • (A) Normal mechanism(90%):
• Deflexion is corrected and complete flexion
occurs. The occiput meets the pelvic floor
first, long anterior rotation 3/8 circle occurs
bringing the occiput anteriorly and the foetus
is delivered normally.
• Factors favouring long anterior rotation:
• (1) Well flexed head.
• (2) Good uterine contractions.
• (3) Roomy pelvis.
• (4) Good pelvic floor.
• (5) No premature rupture of membranes.

70. Causes of failure of long anterior rotation:
(1)Deflexed head.
(2) Uterine inertia.
(3) Contracted pelvis: rotation of the head cannot easily
occur in android pelvis due to projection of the ischial
spines and convergence of the side walls.
(4) Lax or rigid pelvic floor.
(5) Premature rupture of membranes or its rupture early in
labour.

71. • (B) Abnormal mechanism (10%):
• (1) Deep transverse arrest (1%):
• The head descends with some increase in
flexion. The occiput reaches the pelvic floor
and begins to rotate forwards. In mild
deflexion, the occiput rotates 1/8 circle
anteriorly and the head is arrested in the
transverse diameter. Flexion is not maintained
and the occipito-frontal diameter becomes
caught at the narrow bispinous diameter of
the outlet. Arrest may be due to weak
contractions, a straight sacrum or a narrowed
outlet.

72. 2) Short internal rotation -Persistent occipito-posterior
(3%):
The term ‘persistent occipitoposterior position’ indicates
that the occiput fails to rotate forwards. In moderate
deflexion, the occiput and sinciput meet the pelvic floor
simultaneously, no internal rotation and the head persists
in the oblique diameter.

73. (3) Direct occipito-posterior (face to pubis) (6%):
In marked deflexion, the sinciput meets the pelvic floor first,
rotates 1/8 circle anteriorly and the occiput goes into the hallow
of the sacrum. The baby is born facing the pubic bone.
*- In deep transverse arrest and persistent occipito-posterior no
further progress occurs and labour is obstructed as the head
cannot be delivered spontaneously.
*- In direct occipito-posterior, the head can be delivered by
flexion supposing that the uterine contractions are strong and
there is no contracted pelvis. However, perineal lacerations are
more liable to occur as:
· the vulva is distended by the large occipito-frontal diameter
11.5 cm,
· the perineum is overstretched by the large occiput.

74. • MANAGEMENT OF LABOUR:
• A- First Stage:
• Exclude contracted pelvis.
• Exclude presentation or prolapse of the cord.
• Inertia and prolonged labour are expected so oxytocin may be
indicated unless there is contraindication.
• Contractions are sustained, irregular and accompanied by
marked backache which needs analgesia as pethidine or
epidural analgesia.
• Avoid premature rupture of membranes by:-
– rest in bed,
– no straining,
– avoid high enema,
– minimise vaginal examinations.
• The other management and observations as in normal labour.

75. • B- Second Stage:
• Wait for 60-90 minutes.
• During this period:
– Observe the mother and foetus carefully.
– Combat inertia by oxytocin unless it is
contraindicated.
• Contraindications of oxytocins:
– Disproportion.
– Incoordinate uterine action.
– Uterine scar e.g. previous C.S, hysterotomy,
myomectomy, metroplasty or previous perforation.
– Grand multipara.

76. One of the following will occur:
Long internal rotation 3/8 circle:
occurs in about 90% of cases and delivery is completed
as in normal labour.
Direct occipito-posterior (face to pubis):
occurs in about 6% of cases.
the head can be delivered spontaneously or by aid of
outlet forceps.
Episiotomy is done to avoid perineal laceration.
Deep transverse arrest (1%) and
Persistent occipito-posterior (3%

77. 1 .Gynaecoid Pelvis
• .
• This is the most suitable female pelvic shape.
This allow normal child birth with ease. It has
round pelvic inlet and shallow pelvic cavity
with short ischial spines. All these feature
allow rapid birth of the baby. So Gynaecoid
Pelvis is the most suitable pelvic shape for
childbirth.

78. 2. Anthropoid Pelvis.
• Anthropoid pelvis has oval shaped inlet with
large anterio-posterior diameter and
comparatively smaller transverse diameter. It
has larger outlet. The problem in this pelvis is
the inlet. The diameters of inlet favors the
engagement of fetal head in occiput-posterior
position that may slow down the progress of
labor. If head engages in anterior position then
labor progress normally in most of the cases.

79. 3. Android Pelvis.
• Android shaped pelvis has triangular or heart-shaped
inlet and is narrower from the front.
• It has prominent ishcial spines and also has narrower
transverse outlet diameter. Such pelvis is more likely
to be present in tall women.
• African-Caribbean women are more at risk of having
an android shaped pelvis.
• Child birth is difficult and more complicated in
android shaped pelvis than gynaecoid pelvis.
• Women have to push harder, walk more often and
chances of instrumental vaginal delivery are high. It
may prolong the labor.

80. 4. Platypelloid Pelvis
• Platypelloid pelvis is has narrow anterio-
posterior diameter of pelvic inlet.
• The pelvic inlet is specifically kidney shaped.
The pelvic cavity is usually shallow and
diameters of outlet are favourable for the
process of labor.
• But platypelloid pelvis don’t allow the head to
engage with ease. But if the head manage to
engage then rest of the process of labor may
occur normally but in most of the cases it is
longer as compared to progress of labor

81. The Pelvises

82. • The female pelvis is larger and broader than the male pelvis which is taller
(owing to a higher iliac crest), narrower, and more compact.The distance
between the ischium bones is small in males. This causes the sides of the
male pelvis to converge from the inlet to the outlet,
• whereas the sides of the female pelvis are wider apart. This results in the
female inlet being large and oval in shape, while the male inlet is more
heart-shaped.
• The angle between the inferior pubic rami is acute (70 degrees) in men, but
obtuse (90-100 degrees) in women. Accordingly, the angle is called the
subpubic angle in men and pubic arch in women.
• The ischial spines and tuberosities are heavier and project farther into
the pelvic cavity in males.The male sacrum is long, narrow, straighter, and
has a pronounced sacral promontory. The female sacrum is shorter, wider,
more curved posteriorly, and has a less pronounced promontory.
• The acetabula are wider apart and face more medially in females than in
males. This change in the angle of the femoral head gives the female gait its
characteristic (i.e. swinging of hips)

83. Diameter of skull
The engaging diameter of the fetal
skull depends on the degree of the
flexion of the presenting part.
A. The antero-posterior diameter
which may be engaged are:-
1.Sub-occipito bregmatic:-
It extends from the nape of the
neck to the centre of anterior
fontanelle.
Length:-9.5cm
Attitude:-complete flexion
Presentation:-Vertex.
Clinical importance:-
Smallest diameter.

84. 2.Suboccipit
o frontal:-
It extends
from the
nape of the
neck to root
of nose.
Length:-
10cm
Attitude:-
Incomplete
flexion.
Presentatio
n:-Vertex.

85. 3.Occipito-frontal:-
Extends from the occipital
eminence to the root of
the nose (Glabella).
Length:-11.5cm
Attitude:-Marked
deflexion
Presentation:-vertex
Clinical importance:-
This engaging diameter
may give rise to prolonged
labour.

86. 4.Mento-vertical:-
It extends from the mid-point
of the chin to the center of
the sagittal suture.
Length:-14cm
Attitude :- Partial extension.
Presentation:- Brow
Clinical importance:-
In this engaging diameter,
baby has to be delivered by
caesarean section.

87. 5.Sub-mento vertical:-
It extends from the junction of
the floor of the mouth and
neck to the center of the
sagittal suture,
Length:-11.5cm
Attitude: -Incomplete
extension.
Presentation:-Face
Clinical importance:-
In this engaging diameter,
baby has to be delivered by
caesarean section.

88. 6.Sub-mento bregmatic:-
It extends from the junction of
the floor of the mouth and Neck
to the centre of bregma.
Length:-9.5cm
Attitude:-Complete extension
Presentation:-Face
Clinical importance:-
In this engaging diameter,
baby has to be delivered by
caesarean section.

89. B. The transverse diameter are:-
1. Bi parietal diameter:-
It extend between 2 parietal
eminences.
Length:-9.5cm
Attitude:-irrespective of position
of head this diameter always
engages.
2. Bi temporal diameter:-
Distance between the anterior-
inferior ends of the coronal
suture.
Length:- 8.5 cm

90. CAPUT SUCCEDANEUM
It is localized area of edema on fetal scalp on vertex
presentation due to pressure effect of dilating
cervical ring and vaginal introitus.
Characteristics:-
1.It is physiological, present at birth and disappears within 24 hours.
2.It is soft, diffuse and pits on pressure.
3.No underlying skull bone fracture.

91. CAPUT SUCCEDANEUM CEPHAL HAEMATOMA
1. Present at birth on normal
vaginal delivery.
1. Appears within a few days after
birth on normal or forceps
delivery.
2. May lie on sutures, not well
defined.
2. Well defined by suture,
gradually developing hard edge.
3. Soft, pits on pressure. 3. soft, elastic but does not pits on
pressure.
4. Skin ecchymotic. 4. No skin change.
5. Size largest at birth , gradually
subsides within a day.
5. Become largest after birth and
then disappears within 6-8 weeks
to few months.
6. No underlying skull bone
fracture.
6. May underlying skull bone
fracture.
DIFFERENCES

92. Pelvic outlet:-
A-P diameter:-it is the distance between tip of sacrum to the mid
point of inferior border of pubic symphysis.
Transverse or bispinous diameter:- distance between the tip of two
ischial spine.
Brim Cavity Outlet
Transverse
(cm)
13 12 10.5
Oblique (cm) 12 12 ----
Antero
posterior(cm)
11 12 11

93. Normal labour—Engagament –ROA-
Suboccipito Bregmatic-9.5 Cm.
Pelvic Diameters –Brim -13 T,12 O ,11AP
Out let Diameters-10.5 T ,11 AP –
Labour Process –Occiput Anterior-Descend-Complete Flexion
–
Internal Rotation 45 degree -Occiput under SympysisPubis-
Head hinges out-Restitution-External rotation
Internal Rotation assisted by Pelvic floor muscles which are
directed downwards forward and medial

94. Occiput Posterior
Increased flexion with engagement –Internal Roatation
Head turns 135degree-Turns into
Occiput becomes anterior – Normal Delivery
Complete extension-
Annthropoid Pelvis --Normal Delivery as
face to Pubis .
Plattypelloid/Contracted Gynaecoid Pelvis
Occipito Sacral arrest
Mild Extension –Android Pelvis -Deep transverse arrest
Moderate Extension-Contracted Gynaecoid Pelvis
Persistant occipito posterior -Oblique Posterior arrest

95. Assistant pushing flexed knees firmly towards ches

96. Caput Succedaneum and Cephal haematoma

97. Universal Precautions in Infection
Prevention
Managing Complications in
Pregnancy and Childbirth

104. Abortion Care
• Prevention of Unwanted pregnancy
• Family planning counselling
• Advise on various methods of contraception
• Menstrual regulation Syringe
• Manual Vacuum aspiration Syringe
• Emergency Contraception
• Medical Termination of Pregnancy
• a

105. Oral Contraceptive pills
• Drospirenone and ethinyl estradiol (Yasmin) 3 mg DRSP and 0.03
mg EE
• Levonorgestrel and ethinyl estradiol (Levora)
• Norethindrone and ethinyl estradiol (Estrostep or Ortho-Novum)
• Norgestimate and ethinyl estradiol (Ortho-Tri-Cyclen Lo)
• Norgestrel and ethinyl estradiol (Lo/Ovral-28)
MINI Dose
• Desogestrel/ethinyl estradiol and ethinyl estradiol (Mircette)
• Drospirenone and ethinyl estradiol (Yaz)
• Levonorgestrel and ethinyl estradiol (Alesse)
• Norethindrone and ethinyl estradiol (Lo Loestrin Fe)

106. Contraindications for OCP
• : uncontrolled high blood pressure, heart
disease, a blood-clotting disorder, circulation
problems, diabetic problems with eyes or
kidneys, unusual vaginal bleeding, liver
disease or liver cancer, severe migraine
headaches, smoking, had breast or uterine
cancer, jaundice caused by birth control pills,a
heart attack, strokeblood clot.

107. How OCP Acts
• drospirenone and ethinyl estradiol prevents
ovulation (the release of an egg from an
ovary) and also cause changes in your cervical
and uterine lining, making it harder for sperm
to reach the uterus and harder for a fertilized
egg to attach to the uterus.

108. IUDs
• Hormonal IUD. The hormonal IUD, such as Mirena or
Skyla, releases levonorgestrel, which is a form of the
hormone progestin. The hormonal IUD appears to be
slightly more effective at preventing pregnancy than
the copper IUD. There are two hormonal IUDs—one
works for 5 years, and the other works for 3 years.
• Copper IUD. The most commonly used IUD is the
copper IUD (such as Paragard). Copper wire is wound
around the stem of the T-shaped IUD. The copper IUD
can stay in place for up to 10 years and is a highly
effective form of contraception

109. Mechanism of action
• Hormonal IUD. This IUD prevents fertilization by damaging
or killing sperm and making the mucus in the cervix thick
and sticky, so sperm can't get through to the uterus. It also
keeps the lining of the uterus (endometrium) from growing
very thick.1
• This makes the lining a poor place for a fertilized egg to
implant and grow. The hormones in this IUD also reduce
menstrual bleeding and cramping.
• Copper IUD. Copper is toxic to sperm. It makes the uterus
and fallopian tubes produce fluid that kills sperm.
• This fluid containswhite blood cells, copper ions, enzymes,
and prostaglandins.1

110. Advnatages
• Reduces heavy menstrual bleeding by an average of
90% after the first few months of use.1
• Reduces menstrual bleeding and cramps and, in many
women, eventually causes menstrual periods to stop
altogether. In this case, not menstruating is not
harmful.
• May prevent endometrial hyperplasia or endometrial
cancer.
• May effectively relieve endometriosis and is less likely
to cause side effects than high-dose progestin.4
• Reduces the risk of ectopic pregnancy.
• Does not cause weight gain.

111. Side effects
• The copper IUD may increase menstrual
bleeding or cramps. Women may also
experience spotting between periods.
• The hormonal IUD may reduce menstrual
cramps and bleeding.1

112. Pre Eclampsia
BP≥140/90 mm Hg on 2 occasions, 4 hours apart
Urine proteinuria ≥ traces or ≥ 300 mg/24 hrs
sample
Period of gestation>20 weeks

113. Newer generation intrauterine devices
(IUDs)
.
IUDs are devices that are inserted into the uterus. Their presence
renders the environment within the uterus unfavourable for pregnancy,
making them effective contraceptive agents. For most Indian women,
Copper-T is the most popularly used IUD.
The newer generation IUDs contain hormones that are slowly released
into the uterus. Mirena is one such and contains the hormone
levonorgestrel.
Unlike some of the other newer birth control methods, Mirena does not
affect one’s periods and instead actually reduces heavy bleeding.
In India, it is often used in the treatment of dysfunctional uterine
bleeding, a condition that causes women to have very heavy flow during
their periods

114. Birth control ring
• This is a soft, flexible ring that has to be inserted into the
vagina and works by releasing hormones similar to those in
the pill. But unlike the pill, the ring is effective for 3 weeks,
so it does not have to be changed every day. Also, you can
insert it yourself – since it does not work as a barrier
method, its position is not critical to its effectiveness.
• A new ring is inserted every 3 weeks and the fourth week
left ring-free so periods can occur. But if you choose not to
have your cycle, then the next ring can be inserted
immediately instead of waiting the week out. One of the
problems reported with this device is that it sometimes
slips out. But that is easily resolved by reinserting it after a
wash or using a new one instead

115. Depot contraceptive injections
• Instead of taking a pill every day,
contraceptive hormones are given as
intramuscular injections. Depot Provera, an
injection containing medroxyprogesterone for
instance, is effective for about 150 days.
Periods do not occur while on this birth
control method.

116. Other contraceptive methods for
Indian women
• Birth control Patch
• It’s a small, skin-coloured patch that you can wear on the skin
of your arms or back and releases the same hormones as the
pill that are absorbed through the skin. A patch worn once
works for a week, so you don’t have to remember to change
it every day.
• Although associated with the same risks as those with using
the pill because of their oestrogen content, no increased risk
of heart attack or stroke has actually been reported with their
use.
• Birth control patches are generally worn over three weeks
with a break over the fourth week so periods can occur. But
if you don’t want your periods then you just continue
wearing a patch.

117. The birth control implant
• A small piece of metal containing progesterone is surgically
inserted into the arm from where it slowly releases the
hormone so it can exert its contraceptive effect.
• The implant works for three years after which it has to be
replaced.
• Although it may cause some spotting or minor bleeding,
some women using it have no period at all.
• Also, the device helps avoid all the health risks associated
with oestrogen as it only contains progesterone.

118. What about male contraceptives?
• The male pill still seems to be a myth.
Although this concept has been doing the
rounds for years now, the solution to reduce
sperm production without affecting libido
seems to keep evading researchers, so
vasectomy seems to be the only viable answer
so far (apart from condoms, of course).

119. Choosing the birth control method
to postpone pregnancy/, spacing between children/ have you already
‘completed’ family?
• For a young woman having no intentions of starting a family in the
near future, the pill is usually considered the best option.
• Unfortunately, not all the newer alternatives to the pill are freely
available in India and may be on the expensive side even if they are
accessible.
• The pill is not a good for a nursing mother. Breast feeding itself is
supposed to exert a contraceptive effect but is not completely
reliable as a method of birth control.
• Depot Provera injections are a good solution at this stage and can
also be used effectively to space children
• Intrauterine devices, with or without hormones, are also safe and
effective in this phase.

120. Pre Eclampsia
•Mild Pre eclampsia
•l BP 140/90 mm Hg
•l Protienuria traces to 2 + or 300 mg/24 hrs
•l Hospitalize to evaluate and investigate
•l Reassure, no restriction on routine salt intake
•l Rest with limited activity
•l Start anti hypertensive when DBP ≥ 100 mm Hg
•l Tab Alpha Methyl Dopa 250–500 mg 6-8 hourly
•(max 2 gm/day) OR
•l Tab Labetalol 100 mg BD (max 2.4 gm/day)
•l Investigate — Hgm, LFT, KFT, S Uric acid,
•S LDH and fundus exam
•l BP and urine output monitoring

121. Severe Pre eclampsia
l BP 160/110 mm Hg
l Proteinuria 3 + by dipstick or 5 gm/24 hrs
Headache, Epigastric pain,blurring of vision,oliguria,
pulmonary odema, thrombocytopenia, IUGR.
Creatinine >1.2 mg/dl, serumtransaminase levels,
Serum Aspartate Amino transferase AST(SGOT)
>70 IU/L(10—40)- Found RBC Liver cell etc
SLactate Dehydrogenase SLDH >600 IU/L (180-
280IU/L

122. Urgent hospitalization
l Start anti hypertensive
l Oral Nifedepine 10 mg stat, repeat after 30 minutes if needed
OR
l Inj Labetalol 20 mg IV bolus, repeat 40 mg after 10 minutes if
BP not controlled again repeat 80 mg every 10 minutes (max
220 mg) with
cardiac monitoring
Continue Tab Nifedepine 10 mg TDS (max 80 mg/day) OR Tab
Labetalol 100 mg BD (max 2.4 gm/day)
l Investigate — Hgm, LFT, KFT, S Uric acid, S LDH and fundus
exam
l Urine output charting
l BP Monitoring

123. Management
<24 wks-Difficult Foetal salvage –Termination
Inj. Betamethasone l 12 mg IM l Repeat 12 mg after 24 hours
Or Dexamethazone 6 mg 12 hrly.4 doses
BP controlled- Explain maternal and foetal
adverse effect to relatives Regular maternal + foetal
Surveillance
BP uncontrolled- Worsening of clinical /biochemical
parameters,Signs of foetal compromise
lTerminate at 37 weeks .l Terminate pregnancy
l Induction of labor give Magsulf as in Eclampsia
24 to 37 weeks
No Role for Diuretics

124. Eclampsia
Pregnancy with Convulsion;
BP≥140/90 mmHg; Proteinuria
Keep her in quiet room in bed
with padded rails on sides
2 Position her on left side, Oropharyngeal
airway to be kept patent.
3 Ensure preparedness to manage
maternal and foetal complications
Oxygen by mask at 6-8 l/min, Start IV fluids-
RL/ NS at 60 ml/hr, Catheterize with indwelling
catheter

125. Anti Hypertensive
l If Diastolic BP 100 mmHg ,l Strict BP monitoring
l Oral Nifedepine 10 mg stat, repeat after 30 minutes if
needed (if pt unconscious ,through ryles tube) OR
l Inj Labetalol 20 mg IV bolus,repeat 40 mg after 10 minutes
again repeat 80 mg every.10 minutes if needed
(maximum 220 mg) with,cardiac monitoring
Gluconate 1 gm IV 10 ml of 10% solution in 10 minutes

126. Anti Convulsants
l Magnesium Sulfate is drug of choice,l
¢ 50% of 4 gm diluted to 20% (8 ml drug with 12 ml NS) to be
given slowly IV in 5 minutes ¢ 5 gm IM (50%) each buttock
with 1 ml of 2% Xylocaine (Total 10 gm) ¢
If recurrent fits after 30 minutes of loading dose – repeat 2
gm 20% (4 ml drug with 6 ml NS) slow IV in 5 minutes.
4 gm IM (50%) alternate buttocks after monitoring every 4
hourly, Presence of patellar jerks Resp. rate (RR) 16/min u
Urine output 30 ml/hr in last 4 hours l 24 hours after last
fit/delivery which ever is later,
If Patellar jerk absent or urine output<30 ml/hr withhold
Magsulf and monitor hourly– restart maintenance dose if
criteria fulfilled l If RR<16/min, withhold Magsulf, give
antidote – Calcium

127. Deliver the baby irrespective of gestational age
l Admission-delivery interval should not be more than 12
hours
Favourable Cervix
l Induction with ARM and Oxytocin
l 2nd stage to be cut short by Forceps/Ventouse
Unfavourable Cervix
Ripening with Dinoprostone gel/ intracervical
Indwelling catheter and after 6 hrs

128. Active seizures should be treated with
intravenous magnesium sulfate as a first-line
agent. A loading dose of 4 g should be given
by an infusion pump over 5-10 minutes,
followed by an infusion of 1 g/h maintained for
24 hours after the last seizure.” Latest Update

129. If fits not controlled/ status
eclampticus • Foetal distress
• Failed Induction •
Any other obstetric indication
LSCS:
Deteriorating maternal
condition

130. HELLP SYNDROME-Another Life Threatenig disorder
from PIH- Eclampsia affects Brain-HELLP is from Liver
disorder.
• Haemolysis-MAHA-Micro
Angiopathic Haemolytic
Anaemia
• Elevated Liver Enzymes-
Serum Aspartate Amino
glutamate (AST/SGOT)
• Low Platelet count.
• Liver-Abnormal vascular tone
-Vasospasm-Hepatic endothelial
disruption-Platelet activation-
Consumption-Ischaemia –Death of
Hepatocytes
• Haemolysis- RBC Fragmentation due
to fibrin aggregation-In terminal
vessals-MAHA
• AST (SGOT) level 70 IU /l (10—40IU//L)
• S Lactate dehydrogenase->600
IU/L(180-280 IU/L)
• Platelet count -<100000/cc
• Peripheral smear show different
fragmented forms odf RBCs-
Sherocytes—Shizocytes-Bur Celles-
(Spiculated Rbcs)

131. Signs and symptoms
• Right sided upper abdominal pain
• Nausea
• Head ache,malaise
• Rt Quadrant tenderness
• Increased BP
• Proteinuria
• Oedema
Any pregnant woman in the third trimester coming with a
viral like illness should be evaluated to rule out
HELLP Syndrome-Management-If detected early termination
of pregnancy at 34 weeks with Beta/DexaMethazone for
lung maturity.

133. Post partum Haemorrhage
All pregnancies are at risk of PPH
even if no predisposing factors
are present

134. PPH
Just 120 minutes
Can we prevent this situation

135. Continuum of Care for PPH
• Prevent PPH-AMTSL
• Early identification
• Management of Hypoxia-ABC
• Management of Hypovolemia
• Referral for comprehensive care maintaining
vital functions.

137. Causes of continued PP bleedingCauses of continued PP bleeding
TONETONE
Ut Atony: Uterine fatigue,Precipitous labour
distension of uterus,Retained placental
fragments/clots,High parity- many children.
Chorioamnionitis- infection of gestational
sac and membrane.
Retained placenta/products of conceptionTISSUETISSUE
TRAUMATRAUMA Ruptured uterus
Genital tract or perineal lacerations
THROMBINTHROMBIN Bleeding disorders

138. Risk factors for PPH
o Previous PPH
o Multiple gestation
o Pre-eclampsia
o Obesity
2/3 rd
of PPH cases occur in women with no
identifiable risk
But as we all are aware

139. Methods of Estimating Blood Loss
• Visual Estimation-
• Blood Collection Drape
• Kidney tray/ calibrated container under a
cholera bed
Any method that you can devise- what is
important is that we need a good method!
Notoriously incorrect

140. Soiled Sanitary Towel
30 ML
Saturated Sanitary Towel
100 ml
Saturated Small Swab
10 X 10 cm
60 ml
Incontinence Pad
250 ML
Saturated Swab 45 c
X 45 cm
350 ML
100 cm Diameter
Floor Spill
1500 ML
PPH on Bed
1000 ML
PPH Spilling to Floor
2000 ML

141. Management of PPH

143. Management of Atonic PPH
Placenta expelled, uterus soft and flabby-No Trauma
Shout for help, Rapid Initial Assessment to evaluate vital
signs: PR, BP, RR and Temperature
l Establish two I.V. lines with wide bore cannulae (16-18
gauge) l Draw blood for grouping and cross
Matching l
If heavy bleeding, infuse NS/RL 1L
in 15-20 minutes l Give O @ 6-8 L /min by mask, 2
Catheterize l Check vitals & blood loss every 15 minutes,
Monitor input & output
Perform continuous uterine massage l Give Inj. Oxytocin 20
IU in 500 ml RL/ NS @ 40 drops/minute l Do not give Inj.
Oxytocin as IV bolus

144. Uterus still not contracted If bleeding P/V not controlled
Inj Ergometrine* 0.2 mg IM or IV slowly (contraindicated in
high BP, severe anemia, heart disease)
If bleeding P/V not controlled Inj Carboprost* (PGF2) 250 μg
IM (contraindicated in Asthma)
Tab Misoprostol (PGE1) 800 μg Per rectal
Bleeding not controlled by drugs-Explore uterine cavity for
retained placental bits.l Perform bimanual compression
l If fails perform compression of abdominal
Check for coagulation defects,l If present give blood products
Uterine Tamponade (Indwelling atheters/Condom/Sangstaken
tube/Ribbon gauze packing) as life saving measure
Surgical intervention l Uterine compression suture (B-Lynch)
l Uterine/Ovarian A ligation l Hysterectomy

145. l Repeat uterine massage every 15 minutes for first 2 hours
l Monitor vitals closely every 10 minutes for 30 minutes,
every 15 minutes for next 30 minutes and every 30 minutes
for next 3-6 hours or until stable
l Continue Oxytocin infusion (Total Oxytocin not to exceed
100 IU in 24 hours)
l Check for coagulation defects
l If present give blood products

146. Continue vital monitoring
Transfuse blood if indicated
Monitor Input/ Output
Inj. Ergometrine can be repeated every
15 minutes (max 5 doses =1 mg)
Inj Carboprost can be repeated every 15
minutes (max 8 doses= 2 mg)

147. Bimanual uterine compression
Abdominal aorta
compression
Uterine temponade with condom

150. Non-Inflatable Anti-Shock Garment

151. How the NASG works

152. Non-Pneumatic Anti Shock Garment
(NASG)
An Innovation for addressing PPH related
morbidity and mortality in resource
constrained settings
Introduced in India and Nigeria by

153. Coneptualisation
• Research done in University of California since
1970 –on low cost interventions for
addressing PPH.
• NASG originally designed by NASA in 1970
• Ms Suellen Miller proposed NASG as the first
aid device to curb blood loss.as

154. What is NASG?
• The NASG is a lightweight (1.5 kg) compression suit
made of neoprene.
• Efficient, simple and safe means to apply external
counter pressure to the lower body.
• Is washable and reusable (at least 30 times) and can
easily be packed into a bag for storage
• Has received a United States FDA 510K medical device
regulation number. (K904267/A, Regulatory Class II, Jan 1991)
169

155. Indications for Using NASG
• The NASG could be used to manage any condition where there is
severe bleeding below the diaphragm.
• Can be used with all forms of obstetric hemorrhage (in excess of 750
ml)
(as long as the fetus is not viable in utero)
170
Before delivery: ectopic pregnancy, abruption, acute or chronic,
placenta previa ruptured uterus, h. mole, spontaneous abortion
After delivery: uterine atony, retained products of conception,
obstetrical trauma

156. How Does NASG Work?
Dual Mode of Action
1) Resucitation of central circulating volume
 Provides mild pressure, pushing blood from the lower
extremities into central circulation, making sure there is
sufficient blood reaching vital organs, including the
brain
 Results in translocation of 1.5-2.0 liters of blood from
the lower body to the head and chest.
2) Reduces haemorrhage in lower body
 The foam ball over the abdomen applies pressure to
the blood vessels of the uterus, decreasing blood flow
171

157. How Does NASG Work?
172

158. Mean R.I. values
0.860.86
1.001.00
1.011.01
0.800.80
0.820.82

159. Doppler Images of Internal Iliac
Artery: No NASG, Forward Flow

160. Doppler Image with Absent or
Reverse Flow when NASG Fully Applied

161. Mean Pressure Measure
(mmHg)
1.1
67.5
61.0
5.3

162. ISCHEMIA
OF VITAL
ORGANS
BLOO
D
LOSS

163. NASG – Applying &
Removing
• NASG can be applied by any trained person
• The NASG should only be removed:
– Under medical supervision
– When the woman is stable
– According to proper time line
• Rapid removal of the NASG or removal of the segments
in the wrong order can result in death
Benefits –
• Faster resuscitation and lesser blood loss.
• Fewer mortalities and severe morbidities from obstetric
shock ,Safe, easy to use, clean and store.
• Surgical procedures can be performed with NASG
applied
178

164. Avoiding adverse events when using NASG
•One person alone should apply the body segments of
NASG
•Urine output should be monitored
•Ensure airway protection and prevent aspiration as
required
•Ensure one-on-one nursing care
•Ensure presence of a relative/support person with
unconscious patient, ready to explain the garment when
patient returns to consciousness

165. PUNITHAVATHY IN KILPAK MEDICAL COLLEGE
4th
November 2008

166. Punithavathy on 8th
November 2008

167. Some of the research findings
Pilot Study published in BJOG –
158 had Standard treatment for Obst Haemorrhagee
208 had Standard treatment with NASG
50% reduction in blood loss in those treated with NASG
Post NASG study of 854 women in 4 tertiary centers in
Egypt and 2 in Nigeria conducted from 2004-2008
50% reduction in measured blood volume
Adverse outcome from PPH reduced from 12.1% to 4.1%

168. Normal Newborn Care
Advances in Maternal and Neonatal
Health

170. • Warm delivery room (25° C) with no draughts
• Dry the baby immediately;remove the wet cloth
• Wrap the baby with clean drycloth
• Keep the baby close to the mother (ideally skin-to-skin) to
stimulate early breastfeeding • Postpone bathing/sponging
for 24 hours
At delivery

171. After Delivery
• • Keep the baby clothed and wrapped with the
head covered
• • Minimize bathing especially in cool weather or for
small babies
• • Keep the baby close to the mother
• • Use kangaroo care for stable LBW babies and for
re-warming stable bigger babies
• • Show the mother how to avoid hypothermia, how
to recognize it, and how to re-warm a cold

172. Summary
The essential components of normal newborn
care include:
• Clean childbirth and cord care
• Thermal protection
• Early and exclusive breastfeeding
• Monitoring
• Eye care
• Immunization
Normal
Newborn
Care
205

173. Change the PIED
PIPER CULTURE OF
OUR PROFESSION
Endoscopy
USG
ART
Mushrooming of Life
giving centres ,
No life saving centres
Young Doctors lured by
Endoscopists and sonologists
OBGYNS first duty is maternal care

174. Questions?
You can contact me any time in my mobile
9444993777
Thank you for your patient attention
Dr N S Iyer

175. Thank you for your attention