1
Q
What is antepartum hemorrhage?
A
🔹Any vaginal bleeding after 20 weeks of pregnancy and before delivery of the baby
2
Q
What percentage of pregnancies does antepartum hemorrhage complicate?
A
🚩3-5% of the pregnancies
Antepartum hemorrhage is a significant concern in prenatal care.
3
Q
When does antepartum hemorrhage occur?
A
🔹After 20 weeks of pregnancy and before delivery
It is important to assess any vaginal bleeding during this time.
4
Q
What is the first step in the management of a patient with suspected APH ?
A
🔹Start with clinical evaluation to assess the amount of bleeding and signs of clinical shock
▪️ Do not trust your eyes 👀, it could be concealed abruptio
⚠️ Q:Why should we not rely only on visible bleeding to assess placental abruption?
A: Because in concealed abruption, ➡️there may be severe internal bleeding with little or no external blood loss, ➡️leading to shock and fetal distress despite minimal vaginal bleeding.
5
Q
What is the primary goal in the management of APH patient?
A
🚩Save the mother’s life
This prioritization is critical in emergency situations involving significant maternal bleeding.
6
Q
Management steps of APH case ?
A
🚩First : Save the mother life
📍 withdraw blood samples to test for CBC, Blood group , cross matching ,coagulation profile
📍 Apply IV access ( large bore canula)
📍 start resuscitation with IV fluid
📍 Check fetal heart activity and do CTG if applicable
➢⚠️ Identify and Manage the Cause
💡 Placenta previa? → painless bleeding so Avoid digital vaginal examination until placenta previa is ruled out by ultrasound.
💡 Placental abruption? → Look for painful bleeding, uterine tenderness, and fetal distress.
💡 Vasa previa? → Consider if there is painless bleeding with fetal distress.
7
Q
Why is it important of taking history in case of APH ?
A
To looking for :
▪️Previous C-section,
▪️myomectomy,
▪️D&C,
▪️known uterine abnormalities
💡which increase the risk of placenta previa or accreta
8
Q
Why is it important to check the placental site?
A
🚩To rule out placenta previa, which is a common cause of painless vaginal bleeding in pregnancy.
9
Q
What is the next step if placenta previa and vasa previa are ruled out?
A
▪️ Perform a vaginal examination to assess the cervix and identify other possible causes
💡 Assess for placental abruption — the most common cause of APH after previa/vasa previa are excluded.
💡 Always consider other less common causes: uterine rupture, local lesions (e.g., cervical polyp, cancer), or trauma.
10
Q
What are some possible cervical causes of APH?
A
🔹 Labor with a heavy bloody show – Could the patient be in labor?
🔹 Cervical ectropion
– Is there friable cervical tissue that bleeds easily?
🔹 Cervical carcinoma
– Could the bleeding be due to a malignant lesion?
🔹 Cervicitis
– Is there an infection causing cervical inflammation and bleeding?
11
Q
What does the presence of blood vessels crossing the internal os suggest?
A
🔹 It suggests vasa previa, a dangerous condition where fetal blood vessels are exposed and at risk of rupture ➡️leading to fetal distress or death
12
Q
What is placenta previa?
A
🔹 Placenta previa is a condition where the placenta implants in the lower uterine segment, partially or completely covering the internal cervical os.
13
Q
How is placenta previa classified based on placental location?
A
▪️ Complete previa: The placenta completely covers the internal os.
▪️ Partial previa: The placenta partially covers the internal os.
▪️ Marginal previa: The placenta reaches the edge of the os but does not cover it
▪️Low-lying placenta — placenta is near but not touching the os
14
Q
What is a common symptom of placenta previa?
A
🚩 Painless bright red vaginal bleeding in the 2nd or 3rd trimester spontaneously or after sexual intercourse
▪️ Soft, non-tender uterus
▪️ Fetal heart rate usually normal (unless bleeding is severe)
🚫 Digital vaginal exam is contraindicated if previa is suspected (risk of hemorrhage)
15
Q
How is a definitive diagnosis of placenta previa made?
A
on ➡️ Transabdominal or transvaginal ultrasound
It is often detected on routine ultrasound 📍at 18–20 weeks, but a definitive diagnosis is made in the third trimester if the placenta remains low.
16
Q
What is expected to happen to a low-lying placenta as gestational age increases?
A
🚩It is supposed to migrate higher with increasing gestational age
## Footnote
💡. At 32 weeks, 📍90% of low-lying placentas will be found to be high.
17
Q
What should be done if a placenta is still low at 36 weeks?
A
🔸Repeat a transvaginal ultrasound to re-evaluate the exact placental position
📍 To determine whether the placenta is still covering or near the cervical os.
📍Management based on results:
✅ If placenta is ≥2 cm away from the os
➡️ Trial of vaginal delivery is possible
⛔ If placenta is covering or <2 cm from the os (i.e., placenta previa persists)
➡️ Schedule cesarean delivery, usually at 36–37 weeks
18
Q
At what weeks should all low-lying placenta and placenta previa deliver?
A
🚩By cesarean section at 36-37 weeks
This timing is crucial for the safety of both the mother and the baby.
19
Q
What should be administered if there is recurrent bleeding with placenta previa?⁉️
A
🚩Give steroids before 34 weeks and plan cesarean section 📍at 34 to 36 weeks
Steroids help in fetal lung maturity in anticipation of early delivery.
20
Q
At what gestational age will 90% of low lying placentas be found to be high?
A
🚩32 weeks
21
Q
Complications of Placenta previa ?⁉️
A
🔸 Preterm birth in 40%
🔹 Massive hemorrhage before and during CS
🔸 DIC
🔹 multi-organ failure
🔸 death
🔹 Hystrectomy
22
Q
What is the percentage of preterm birth associated with placenta previa case ?
A
🚩40%
23
Q
What is the main characteristic of placenta accreta?
A
🔹The chorionic villi attach to the myometrium (without invasion).
▪️the most common type.75%
This condition represents the least severe form of abnormal placentation.
24
Q
What defines placenta increta?
A
🚩The chorionic villi penetrate invade into the myometrium (the muscular layer of the uterus), but do not penetrate through it
🚩17% of Placenta accrete spectrum
Increta indicates a deeper level of invasion compared to accreta.
25
**What is the most severe form of abnormal placentation?**
**Percreta** 5%
## Footnote
💡placenta percreta ➡️the chorionic villi penetrate through the entire thickness of the myometrium and may invade adjacent organs, most commonly the bladder.
⚠️ Clinical risks:
▪️ Severe hemorrhage at delivery
▪️ Bladder injury
▪️ High likelihood of requiring cesarean hysterectomy
💡 Commonly associated with placenta previa + prior cesarean delivery ➡️ always suspect PAS in this setting.
26
**List the three types of abnormal placentation based on the degree of penetration⁉️**
▪️ **Accreta 75%
▪️ Increta 17%
▪️ Percreta 5%**
## Footnote
These types are categorized by how deeply the chorionic villi invade the uterine tissue.
27
True or False: Placenta percreta involves the chorionic villi only attaching to the myometrium.
False
## Footnote
Percreta involves penetrates through the myometrium and serosa, possibly reaching nearby organs.
, indicating a more severe condition.
28
**Risk factors of placental accreta spectrum ?**
▪️ **Previous placenta accreta
▪️ Previous CS { the risk of placents previa
and accreta increased with increase number of previous CS}
▪️ Placenta previa
▪️ Previous uterine operation
▪️ Caesarian scar pregnancy
▪️ Advanced maternal age > 40
▪️ IVF**
29
**What is the risk of placenta accreta after a first cesarean delivery?**
🚩3%
30
**What is the risk of PAS after the 3rd cesarean section?**
🚩40%
31
**What is the risk of placenta accreta after a
4th CS delivery ?**
🚩**61%**
32
**What is the risk of placenta accreta after cesarean delivery in the 5th pregnancy?**
🚩**67%**
33
**What is the relationship between placenta previa and the risk of accreta?**
🚩**Risk of accreta increases dramatically with each subsequent cesarean**
34
**What is Vasa Previa?**
**🔹Fetal vessels crossing through the membranes unprotected by the placenta or cord over the internal os and below the fetal presenting part.**
🚨 risk of rupture and fetal hemorrhage
## Footnote
Vasa Previa is a serious condition that can lead to vessel rupture and fetal hemorrhage during labor.
35
**What symptom may indicate vasa previa?**
**Minimal painless vaginal bleeding**
## Footnote
This bleeding comes from the umbilical cord.
36
**What is the mortality rate associated with vasa previa if it occurs?**
🚩**60%**
## Footnote
This is hazardous and can kill the baby in few minutes , mortality rate ( death )60%
37
True or False: Vasa previa is protected by placental tissue.
False
## Footnote
Vasa previa is unprotected by placental tissue or wharton’s gelly of the umbilical cord and poses significant risks during labor.
38
**When is vasa previa likely to rupture?**
**Vasa previa is likely to rupture in
▪️active labor
▪️ when artificial amniotomy (ARM) is done**
## Footnote
Rupture of vasa previa can lead to significant fetal hemorrhage.
39
**What are Types of vasa previa?**
🔹**Type 1: The vessels are connected to a velamentous umbilical cord**
🔹**Type 2: the vessels connect the placenta with a succenturiate or accessory lobe**
## Footnote
💡Velamentous cord insertion occurs when the umbilical vessels separate from the placenta and travel through the membranes.
💡A succenturiate lobe is an additional lobe of placental tissue that is separate from the main body of the placenta.
40
**What are the risk factors of vasa previa?**
🔹 **Bilobed placenta or succenturiate lobes
🔸Velamentous cord insertion
🔹 Low lying placenta or placenta previa ➡️ Increases likelihood of vessels crossing cervical os
🔸 Multiple pregnancy ➡️ Higher risk of abnormal placentation
🔹 IVF➡️ Strongly associated with abnormal cord insertion and lobed placentas**
## Footnote
IVF refers to in vitro fertilization, which can increase the chances of multiple pregnancies.
📍These conditions increase the chance that fetal vessels lie in membranes covering the internal os, leading to life-threatening fetal hemorrhage if ruptured during labor or membrane rupture.
41
**How is vasa previa diagnosed?**
📍**By transvaginal ultrasound and 📍color Doppler, repeat imaging at 32 weeks**
## Footnote
Transvaginal ultrasound is a common imaging technique used in obstetrics to assess placental position.
42
**What is the management protocol for vasa previa if there is a risk for preterm labor?**
📍 **Admit and do cesarean section at 34-36 weeks**
📍Key goal: Deliver before labor or membrane rupture to prevent fetal death
## Footnote
🧠 Vasa previa = C-section only — no vaginal delivery allowed
✅ Mnemonic: “VASA = Vaginal Avoided, Section Always”
🚩Details
1️⃣ Hospitalization at 28–32 weeks
▪️ For close monitoring of signs of labor or bleeding
2️⃣ Antenatal corticosteroids
▪️ Administered between 24–34 weeks to enhance fetal lung maturity
3️⃣ Avoid vaginal exams and minimize uterine manipulation
▪️ To prevent premature rupture of membranes
4️⃣ Plan elective C-section at 34–36 weeks
▪️ Before labor or spontaneous rupture occurs
5️⃣ Immediate C-section if:
▪️ Vaginal bleeding
▪️ Rupture of membranes
▪️ Signs of labor
43
**What imaging technique is recommended to confirm vasa previa diagnosis at 32 weeks?**
**Color Doppler ultrasound**
## Footnote
Color Doppler is used to visualize blood flow and can help identify abnormal placental positions.
44
**What is abruptio placenta?**
**🚩premature separation of a normally implanted placenta from the uterine wall before delivery of the fetus.**
💡 Key features:
• Occurs 📍after 20 weeks gestation
• Can be partial or complete
• Blood collects between placenta and uterine wall
💡 Important types:
• Revealed abruption ➡️ with vaginal bleeding
• Concealed abruption ➡️ no bleeding visible; blood trapped behind placenta
## Footnote
Abruptio placenta is a serious condition that can lead to complications for both the mother and the fetus.
45
**What are the symptoms associated with abruptio placenta?**
**🔺 Classic triad:**
1. Painful vaginal bleeding ‼️
2. Uterine tenderness or hypertonicity
3. Fetal distress or death 💔
## Footnote
These symptoms can indicate a medical emergency and require immediate attention.
46
**What is concealed abruptio?**
**🚩A type of abruptio placenta where there is no visible vaginal bleeding**
## Footnote
It is important to recognize concealed abruptio as it can lead to serious complications.
47
**What are the risks associated with abruptio placenta?**
🚩**High risks for fetal and maternal morbidity and mortality**
💡 Fetal: hypoxia, IUGR, death
💡 Maternal: hemorrhage, DIC, shock, renal failure
## Footnote
These risks necessitate close monitoring and management.
48
**What serious condition can abruptio placenta cause rapidly?**
🔹**🚩DIC (Disseminated Intravascular Coagulation)**
## Footnote
DIC is a critical condition that can lead to severe bleeding and organ failure.
49
True or False: In all cases of abruptio placenta, there is visible bleeding.
False
## Footnote
Concealed abruptio is a situation where bleeding may not be apparent.
50
**What is a risk factor for abruptio placenta?**
▪ **Abdominal trauma
▪ Previous abruptio
▪ Chronic HTN , pre-eclampsia
▪ Thrombophilia
▪ PROM
▪️ polyhydromnios
▪ Advanced maternal age
▪ IVF
▪ Smoking**
## Footnote
📍 Most common maternal risk factor for abruption ➡️chronic HTN
How⁉️
💡damages uterine arteries ➡️ causes poor placental blood flow ➡️ leads to ischemia and infarcts ➡️ weakens attachment between placenta and uterus ➡️ increases risk of abruption
51
**What is the major cause of maternal death worldwide?**
🚩**Post partum hemorrhage (PPH)**
## Footnote
PPH is a significant concern in maternal health.
52
According to WHO, what percentage of maternal deaths in developing countries are due to PPH?
🚩**60%**
## Footnote
This accounts for more than 100,000 maternal deaths per year.
53
**What is the definition of PPH?**
🔹**excessive bleeding after childbirth, defined as blood loss >500 mL after vaginal delivery or >1000 mL after cesarean section.**
## Footnote
This definition highlights the severity of the condition.
54
**How common is PPH**?
▪️ **1–5% of all deliveries**
## Footnote
🔹 a leading cause of maternal mortality worldwide.
55
**How frequently does PPH cause maternal death?**
🚩**PPH kills one woman every 4 minutes globally**
## Footnote
This statistic underscores the urgency of addressing PPH.
56
**How much blood does the uterus receive per minute at term?**
🚩**400-600 ml**
## Footnote
This blood flow rate is significant during and after delivery.
57
**Why is PPH dangerous?**
🔹 **The uterus receives 400–600 mL of blood per minute at term, so excessive bleeding can lead to
▪️hypovolemic shock
▪️organ failure
▪️death if not managed quickly.**
58
**What are the two types of PPH?**
🔹**Primary : within first 24 hrs of delivery
🔹Secondary : after 24 hrs till 6 weeks post partum**
59
**When does Secondary PPH occur?**
**▪️After 24 hours till 6 weeks postpartum**
60
**What is considered Minor PPH in terms of blood loss?**
▪️**Blood loss from 500-1000 m**
61
**What is considered Major PPH in terms of blood loss?**z
🚩**> 1000 ml**
62
**What is classified as Moderate PPH?**
**▪️1000-2000 ml**
63
**What is classified as Severe PPH?**
**▪️>= 2000 ml**
64
What defines Massive PPH?
**🚩A blood loss >40% ➡️is life-threatening and needs aggressive resuscitation**
65
**Causes of Postpartum Hemorrhage (PPH) ?**
**The 4 Ts
🔹Tone ( atonic PPH )➡️ the most common of primary PPH 70%
🔹 Tissue “ retained products of conception”
🔹Trauma
🔹Thrombin
66
**What is uterine atony?**
▪️**Uterine atony is the failure of the uterus to contract after delivery, ➡️leading to continuous bleeding from open blood vessels**
67
**What are the risk factors for uterine atony?**
🔸 **Overdistended uterus:**
Macrosomia (big baby), multiple pregnancy, polyhydramnios.
🔹 **Infection:**
Fever, prolonged rupture of membranes.
🔸 **Exhausted uterus:**
Prolonged labor, rapid labor, failure to progress.
🔹 **Anatomic distortion:**
Fibroids, placenta previa, uterine anomalies**
68
**How do retained products cause PPH?**
**▪️If placental fragments or membranes remain inside the uterus, ➡️ prevent proper contraction, ➡️leading to continuous bleeding**
69
**What types of trauma can lead to PPH?**⁉️
🚩 **Vaginal/cervical tears from
forceps, vacuum delivery, or macrosomia**
🚩 **Uterine rupture**,
especially in VBAC (vaginal birth after cesarean)
🚩 **Uterine inversion**
where the uterus turns inside out.
70
**How does a coagulation disorder cause PPH?**
Conditions like :
🔹 **DIC (disseminated intravascular coagulation),
🔹thrombocytopenia,
🔹hemophilia ➡️impair blood clotting, making bleeding harder to stop.**
71
**What are common causes of coagulopathy in pregnancy?**
🔹 **HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets).
🔹 Sepsis-related DIC.
🔹 Anti-coagulant use (e.g., heparin, warfarin)**
72
**How much blood loss defines postpartum hemorrhage (PPH) after vaginal delivery?**
A) >250 mL
B) >500 mL
C) >750 mL
D) >1000 mL
✅ B) >500 mL
💡CS ➡️“”>1000 ml
73
Which of the following conditions is associated with a high risk of coagulopathy-related PPH?
A) HELLP syndrome
B) Gestational diabetes
C) Preeclampsia without complications
D) Placenta accreta
✅ A) HELLP syndrome
(Hemolysis, Elevated Liver enzymes, and Low Platelets )
lead to impaired clotting and increased bleeding risk.)
74
**What is the active management of the third stage of labor (AMTSL)?**
AMTSL includes three key interventions:
🚩 **Use of uterotonics
▪️ Administer oxytocin 10 IU IM after delivery of the fetal shoulder.
🚩 Controlled cord traction (CCT) –
▪️Helps deliver the placenta efficiently and ⬇️⬇️the risk of retained placenta and excessive bleeding**
🚩 Uterine fundal massage –
▪️Performed after the placenta is expelled to stimulate uterine contraction**
75
**How effective is active management of the third stage of labor in preventing postpartum hemorrhage (PPH)?**
🔹**It prevents up to 60% of PPH cases**
76
**Why is oxytocin the preferred uterotonic?**⁉️
🚩**Oxytocin is fast-acting, effective, and has minimal side effects compared to other uterotonics like misoprostol or ergometrine**
77
**What is the recommended uterotonic for the active management of the 3rd stage of labor according to WHO?**
🚩**Oxytocin 10 ml IM after delivery of fetal shoulder**
## Footnote
Uterotonics are medications used to induce contractions of the uterus.
78
**Management of Postpartum Hemorrhage (PPH) ?**⁉️
* Basic Measures
**🚩Vital signs ( HR, BP, O2 sat) , if in shock ! :
o Start with ABC ( Airway, breathing , circulation )
🚩 IV access ( large bore canula)
🚩 Blood sample for CBC, cross match , coagulation profile
🚩 Start running ✨1500 cc IV fluid with crystalloid ( normal
saline or ringer lactate)
▪️ Continuous uterine massage ( for atonic PPH)
▪️uterotonics :
1. oxytocin
2. Methergine (vasoconstriction): ⚠️ contraindicated with HTN, Pre-eclampsia
3. misoprostol
4. Carboprost: ⚠️ contraindicated with asthma**
79
**Why is IV fluid resuscitation important?**⁉️
🚩**Rapid IV fluid administration helps maintain circulatory volume, preventing hypovolemic shock while preparing for further management**
80
**Mention the uterotonics used in PPH ?**
🔹**. oxytocin
🔹 Methergine = methylergonovine ➡️ ⚠️ (v.c )contraindicated with HTN, Pre-eclampsia
🔹. misoprostol
🔹. Carboprost: (p.GF2alfa)** ➡️ ⚠️ contraindicated with asthma
81
**What is the first uterotonic used in PPH?**
oxytocin
## Footnote
Oxytocin is commonly administered to stimulate uterine contractions.
82
**Which uterotonic is contraindicated in patients with asthma?**
**Carboprost = p.G F2alfa = hemabate**
## Footnote
Carboprost can cause 📍bronchospasm, making it unsuitable for asthmatic patients.
83
**What should be considered if there is no response to medical management in PPH?**
**🚩Apply Bakri Balloon**
## Footnote
This indicates the need for further intervention, possibly surgical.
84
**Which uterotonic is contraindicated in patients with preeclampsia ?**
**Methargine (v.c)**
85
**What should be done if bleeding continues after applying the Bakri Balloon in PPH ?**
**Go to surgical approach**
86
**List three surgical approaches for ongoing bleeding in PPH**
🔹 **B lynch suture
🔹 Internal iliac artery ligation
🔹 Hysterectomy**
***
💡In short
Management of PPH :
1) basic measures
2) medical management
3) Bakari Ballon
4) surgical management
1. B-Lynch Suture – A compression suture applied to the uterus to control bleeding in cases of uterine atony.
2. Internal Iliac Artery Ligation – Reduces blood flow to the uterus, helping to decrease bleeding while preserving fertility.
3. Hysterectomy – A last resort when all other measures fail, involving removal of the uterus to stop life-threatening bleeding.
***
87
**What is secondary PPH?**
🔹**Secondary PPH is significant vaginal bleeding that occurs after 24 hours of delivery and up to 6 weeks postpartum.**
88
**What is the time frame for Secondary PPH?**
**🚩Occurs after 24 hours of delivery ➡️ up to 6 weeks postpartum**
89
**What is the most common cause of secondary PPH?**
**🚩Endometritis**
(infection of the uterine lining) is the main cause.
90
**What factors increase the risk of infection leading to secondary PPH?**
✔ **Retained products of conception (e.g., placental tissue left in the uterus)
✔ Infection after C-section
✔ Manual removal of placenta after vaginal delivery
✔ Prolonged rupture of membranes (increases infection risk)**
91
**less common causes of secondary PPH?**
🚩 **Fibroids (can cause abnormal bleeding)
🚩 Uterine vascular malformations (abnormal blood vessel growth in the uterus)
🚩 Choriocarcinoma (a rare but aggressive pregnancy-related cancer)
🚩 Undiagnosed cervical carcinoma (cervical cancer causing heavy bleeding)
🚩 Inherited bleeding disorders (e.g., von Willebrand disease)
🚩 Infected polyps or submucosal infections**
92
**What are the symptoms of secondary PPH?**
The key symptoms include:
✔ **Fever (suggesting infection)
✔ Heavy vaginal bleeding
✔ Abdominal pain (due to uterine infection or retained tissue)
✔ Offensive vaginal discharge (indicating endometritis)**
93
**What is the first step in managing secondary PPH?**
🔹**Resuscitation if the patient is in shock by:
▪️ IV fluid administration (to maintain blood pressure and circulation)
▪️ Oxygen therapy (if needed)**
94
**MANAGEMNET OF SECONDARY PPH؟**
🔹 **Resuscitation if in shock ( IV fluid , O2 )
🔹 Remove the retained placenta ( source of infection ) >> D&C
🔹 Give antibiotics
🔹 Uterotonics
oxytocin, misoprostol ,
methergine, carboprost**
95
**What is the role of Dilation & Curettage (D&C) in secondary PPH?**
🔹**D&C is performed to remove retained placental tissue, which is the main source of infection and bleeding**
96
**When is surgery considered in secondary PPH?**
🔹**If bleeding persists despite medical management, surgical options like
▪️uterine artery embolization
▪️ hysterectomy may be necessary**
97
**What is uterine inversion?**
**🚩A rare but serious obstetric emergency where the uterine fundus collapses inward and protrudes through the cervix or vagina after delivery**
98
**What are the risk factors for uterine inversion?**
🔹 **Myometrial weakness( uterine atony) (📍most common)
🔹 Previous uterine inversion
🔹 Excessive traction on the umbilical cord (esp. with fundal placenta)
🔹 Fundal pressure before placental separation
🔹 Placenta accreta**
99
**What are the clinical findings of uterine inversion?**
▪️ **A beefy, bleeding mass seen in the ✨vagina**
▪️ ** Uterus not palpable abdominally (because it has prolapsed through the vagina)**
▪️Sudden hemorrhage due to 🚫 Loss of uterine tone
• 🚫 Exposure and tearing of uterine vessels
▪️ lower abdominal pain
🧠 Clinical tip:
💡If a patient collapses with severe shock and heavy bleeding shortly after delivery, and the uterus is not palpable abdominally ➡️ always suspect uterine inversion.
100
**How is uterine inversion managed**?
**📍. Call for help
📍. Administer ✨Nitroglycerin (to relax the cervix and pelvic muscles) to allow repositioning
📍. Perform manual uterine replacement (Johnson maneuver) by:
▪️Elevating the vaginal fornices
▪️Gently lifting the uterus back to its anatomical position**
101
A 32-year-old woman has just delivered a baby vaginally. Soon after, she develops heavy vaginal bleeding. On examination, a red, fleshy mass is seen protruding from the vagina, and the uterine fundus is not palpable abdominally.
What is the most appropriate initial step in management?
A. Administer oxytocin infusion
B. Manual removal of placenta
C. Administer uterine relaxant and attempt uterine replacement
D. Perform laparotomy immediately
E. Administer ergometrine
⸻
Answer:
✅ **C. Administer uterine relaxant and attempt uterine replacement**
*****
▪️This is a classic case of uterine inversion. The key findings are a fleshy vaginal mass and absent uterine fundus on palpation. The first priority is to relax the uterus (using nitroglycerin or other tocolytics) and manually replace it (Johnson’s maneuver). Uterotonics like oxytocin or ergometrine are contraindicated initially because they can worsen the inversion.
102
**يا رب اشرح لي صدري ويسر لي أمري واحلل عقدة من لساني يفقه قولي, افتح علي فتوح العارفين بفضلك,اللهم لا سهل إلا ما جعلته سهلا وأنت تجعل الحزن إن شئت سهلا, اللهم أني استودعتك ما علمتني إياه فرده إلي حين حاجتي إليه ولا تنسيني إياه بفضلك وكرمك يا أرحم الراحمين يا بديع السماوات والأرض, يا معلم سيدنا إبراهيم علمني**🧠✨ 👨⚕️
103
**What is shoulder dystocia?**
🚩**A delivery complication where the anterior fetal shoulder becomes impacted behind the maternal pubic symphysis after delivery of the head, preventing the rest of the body from being delivered**
104
105
**Shoulder dystocia is a clinical diagnosis made when:**
📍 **There is difficulty delivering the face and chin after the head emerges.
📍 The “Turtle sign” is seen: the fetal head retracts against the perineum (as if tucking in like a turtle), instead of progressing forward.
📍 There is failure of restitution (no rotation of the fetal head).
📍 Delivery of the shoulders does not occur with normal gentle traction**
## Footnote
106
**What does the turtle-neck sign indicate in cases of shoulder dystocia?**
📍**The head tightly applied to the vulva or even retracting**
## Footnote
This sign suggests that the fetal head is not progressing through the birth canal as expected.
107
**What are the risk factors for shoulder dystocia?**
▪️ **Macrosomia
▪️ Maternal diabetes
▪️ Obese mother
▪️ Prolonged first or second stage of labor
▪️ Previous shoulder dystocia
▪️ Instrumental delivery (vacuum
forceps
▪ Oxytocin augmentation
▪️Induction of labor**
108
**COMPLICATIONS of shoulder dystocia **?
**▪ Brachial plexus injury ➡️ the most common
<10% resulting in permanent neurological dysfunction
Two types:
🔹Erb’s palsy ( C5, C6 )
🔹Klumpke’s palsy ( C8, T1)
▪ Fetal bones fractures ( clavicle, humerus)
▪ Asphyxia ( hypoxic brain damage )
▪ Fetal Death !
▪ Atonic PPH
▪ 3rd and 4th degree perineal tears
▪️ Traumatic PPH**
109
**What is the most common complication of shoulder dystocia?**
🔹**Brachial plexus injury**
## Footnote
Brachial plexus injury occurs in 📍less than 10% of cases, resulting in permanent neurological dysfunction in some instances.
110
**What are the two types of brachial plexus injuries?**
🔹 **Erb’s palsy (C5, C6)
🔹 Klumpke’s palsy (C8, T1)**
## Footnote
These types are classified based on the affected nerve roots.
111
**Which of the following is a type of brachial plexus injury involving C5–C6?**
A. Klumpke’s palsy
B. Erb’s palsy
C. Bell’s palsy
D. Horner syndrome
E. Radial nerve palsy
Answer: ✅**B) Erb’s palsy**
💡Remember that
✅Klumpke’s palsy (C8–T1) – less common
112
**What is the most specific clinical sign of shoulder dystocia?**
A. Fetal bradycardia
B. Failure of descent
C. Turtle sign
D. Umbilical cord prolapse
E. Prolonged second stage
Answer: **✅C). Turtle sign**
113
**What is the first priority in managing shoulder dystocia?**
🚩**Deliver the baby as quickly as possible to prevent hypoxic brain injury or fetal death**
114
**What are the first steps in shoulder dystocia management?**
1. **Call for help
2. McRoberts maneuver
• Flex and abduct maternal hips (knees to chest)
• Widen pelvic outlet
• Success rate: ~90%
3. Suprapubic pressure
• Apply firm pressure above the pubic bone
• Aim: Dislodge anterior fetal shoulder
• Never apply fundal pressure**
115
**What is McRobert’s maneuver?**
🚩**Flexion and abduction of the maternal hips (put her thighs on her abdomen) to widen the pelvis**
116
**What is the success rate of McRobert’s maneuver?**
✅90%
117
What is suprapubic pressure?
🔹**Putting hands on the abdomen of the mother to push the anterior shoulder of the fetus from beneath the pubic bone**
118
**What are the internal maneuvers for shoulder dystocia?**
🔹 Woods and Rubin maneuver
🔹 Delivering the posterior arm
🔹 All fours technique
119
**What is the Woods and Rubin maneuver?**
🚩**Through vagina put your fingers behind the fetal shoulder and push it forward**
120
**How do you deliver the posterior arm during childbirth?**
📍**Insert your hand to the vagina till reach the posterior hand and pull it out**
121
**What percentage of deliveries is associated with humeral fracture when delivering the posterior arm?**
🔹**2-12%**
122
What are the maneuvers rarely needed in shoulder dystocia ?
▪ Cleidotomy
▪ Symphysiotomy
▪ Zavanelli
123
**What is cleidotomy?**
📍**Surgical division of the fetal clavicle**
124
**What does symphysiotomy involve?**
📍**Dividing the symphysis pubis to open the pelvis**
125
**What is the Zavanelli maneuver?**
🚩**Try to re-insert the head back to the uterus, and do CS**
126
**Which of the following is the first-line maneuver with the highest initial success rate in managing shoulder dystocia?**
A. Zavanelli maneuver
B. Fundal pressure
C. Rubin maneuver
D. McRoberts maneuver
E. Cleidotomy
**Answer: ✅D. McRoberts maneuver**
127
**What is the purpose of suprapubic pressure during shoulder dystocia?**
A. Stimulate contractions
B. Dislodge the anterior shoulder from under the pubic symphysis
C. Assist delivery of the head
D. Increase uterine tone
E. Push the fetus back into the uterus
**Answer: ✅B. Dislodge the anterior shoulder from under the pubic symphysis**
128
**Which of the following maneuvers is associated with a 2–12% risk of humerus fracture?**
A. McRoberts
B. Rubin
C. Delivery of the posterior arm
D. Zavanelli
E. Symphysiotomy
**Answer: ✅C. Delivery of the posterior arm**
129
**Which of the following is a last-resort maneuver involving re-inserting the fetal head for cesarean delivery?**
A. Cleidotomy
B. Woods screw maneuver
C. Zavanelli maneuver
D. Rubin maneuver
E. Symphysiotomy
**Answer: ✅C. Zavanelli maneuver**
130
**What is cord prolapse?**
🔹**The descent of the umbilical cord through the cervix before delivery of the baby after rupture of membranes**
## Footnote
Cord prolapse can lead to serious complications if not managed promptly.
131
**What is cord presentation?**
🔹**The presence of the umbilical cord between the fetal presenting part and the cervix**
## Footnote
Cord presentation can complicate labor and delivery.
132
**How can you elevate the fetal head in cases of cord prolapse?**
**By your fingers or by filling the bladder with fluid to elevate the fetal head**
## Footnote
Elevating the fetal head can relieve pressure on the cord.
133
**Why is cord prolapse dangerous?**
🚩**Because the fetal head compresses the umbilical cord, causing:
▪️ Occlusion of blood flow
▪️ Fetal hypoxia
▪️ Risk of fetal death if not managed quickly**
134
**How is cord prolapse managed initially?**
🔹The goal is to relieve pressure on the cord and preserve fetal oxygenation until delivery:
▪️ Do NOT handle or manipulate the cord
▪️ Elevate the presenting fetal part using:
▪️ Fingers in the vagina
▪️ Bladder filling (with 500–750 mL saline via catheter)
▪️ Position mother:
▪️ Knee-chest or Trendelenburg to reduce gravity pressure
▪️ Immediate delivery (usually emergency cesarean section)
135
A 30-year-old woman at 38 weeks presents in labor. After spontaneous rupture of membranes, you note the umbilical cord prolapsing through the cervix. What is the most appropriate immediate step?
A. Attempt vaginal delivery
B. Push the cord back into the uterus
C. Elevate the fetal head and prepare for emergency C-section
D. Start oxytocin infusion
E. Perform amniotomy
Answer: ✅C. Elevate the fetal head and prepare for emergency C-section
🔹Explanation: Relieve pressure on the cord to preserve fetal oxygenation while arranging delivery. Never attempt to replace the cord.
136
What is the difference between cord prolapse and cord presentation?
A. Cord prolapse occurs before membrane rupture
B. Cord presentation is only seen in second stage of labor
C. Cord prolapse occurs after rupture of membranes; cord presentation occurs with intact membranes
D. Cord presentation causes fetal death more commonly
E. Cord prolapse is not visible on examination
Answer: C. Cord prolapse occurs after rupture of membranes; cord presentation occurs with intact membranes
137
Which maternal position is helpful in relieving pressure from a prolapsed cord while awaiting emergency delivery?
A. Lithotomy position
B. McRoberts position
C. Trendelenburg position
D. Prone position
E. Left lateral position
Answer: ✅C. Trendelenburg position
🔹Explanation: Trendelenburg or knee-chest position reduces cord compression by gravity.
138
When is cord prolapse more likely to occur?
Cord prolapse is more common when the fetal presenting part is not engaged with the cervix, allowing space for the cord to slip through, especially after rupture of membranes.
139
What maneuvers help relieve pressure on the prolapsed cord?
▪️ Place the mother in knee-chest or Trendelenburg position
▪️ The examiner should insert fingers into the vagina to apply continuous upward pressure on the presenting part to lift it off the cord
▪️ Fill the maternal bladder with saline (via Foley catheter) to further elevate the presenting part and relieve cord compression
140
What are the risk factors for PPH
🔹General anesthesia,
🔹oxytocin induction ,, augmentation of labor
🔹 uterine infection,
🔹 prolonged labor,
🔹 operative delivery,
🔹 uterine leiomyomas,
🔹 precipitous labor,
🔹 placenta accreta,
🔹 abruptio placenta
## Footnote
PPH stands for postpartum hemorrhagey.
141
What type of anesthesia is considered a risk factor for PPH?
General anesthesia
142
Q: What are the key laboratory findings in DIC?
1. Prolonged PT (Prothrombin Time)
2. Prolonged aPTT (Activated Partial Thromboplastin Time)
3. Low platelet count(thrombocytopenia)
4. Low fibrinogen levels
5. Elevated D-dimer (marker of fibrin degradation)
6. Elevated fibrin
****
Key features of DIC:
• Widespread activation of the coagulation cascade → leads to microthrombi in small vessels.
• Consumption of clotting factors and platelets → causes a bleeding tendency.
• Can be acute (e.g. in sepsis, trauma, obstetric complications) or chronic (e.g. in cancers).
Obs & Gyn
flashcards
Decks in class (11)
# Cards
-
Pregnancy A - Z175
-
pregnancy part 299
-
Normal and Abnormal Labor204
-
Obs Emergencies142
-
Medical disorder in pregnancy191
-
Normal menstrual cycle and its disorder140
-
Contraception Types and Infections189
-
Benign and malignant Lesions (Uterus, Ovaries)139
-
Benign and malignant lesions (vulva, cervix)163
-
Infertility and PCOs110
-
Urogynecology and Menopause84
