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Questions and Answers
What is the structure involved in a 1st degree perineal tear?
What is the structure involved in a 1st degree perineal tear?
Routine episiotomy is recommended by WHO.
Routine episiotomy is recommended by WHO.
False
What is the recommended immediate repair time frame for tears after delivery?
What is the recommended immediate repair time frame for tears after delivery?
less than 24 hours
Which of the following positions is the most common for occipito-posterior malposition?
Which of the following positions is the most common for occipito-posterior malposition?
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The surgical planned incision of perineum to facilitate delivery is called an __________.
The surgical planned incision of perineum to facilitate delivery is called an __________.
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Malpresentation is more common in nulliparous women than in multiparous women.
Malpresentation is more common in nulliparous women than in multiparous women.
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Match the degree of perineal tear with the structure involved:
Match the degree of perineal tear with the structure involved:
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What is the most common cause of occipito-posterior malposition?
What is the most common cause of occipito-posterior malposition?
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The incidence of occipito-posterior malposition at term and onset of labor is _____ %.
The incidence of occipito-posterior malposition at term and onset of labor is _____ %.
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Match the following positions with their definitions:
Match the following positions with their definitions:
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What is the first step in managing suspected uterine inversion during the third stage of labour?
What is the first step in managing suspected uterine inversion during the third stage of labour?
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The Johnson's method involves separating the placenta during manual replacement.
The Johnson's method involves separating the placenta during manual replacement.
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What is used as a uterine relaxant during the repeat manual replacement of the uterus if initial attempts fail?
What is used as a uterine relaxant during the repeat manual replacement of the uterus if initial attempts fail?
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The ______ structure can be felt in the vagina during a vaginal examination when uterine inversion is suspected.
The ______ structure can be felt in the vagina during a vaginal examination when uterine inversion is suspected.
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Match the surgical methods for uterine replacement with their appropriate conditions:
Match the surgical methods for uterine replacement with their appropriate conditions:
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What is a major clinical intervention immediately after the occurrence of Amniotic Fluid Embolism?
What is a major clinical intervention immediately after the occurrence of Amniotic Fluid Embolism?
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Amniotic Fluid Embolism occurs in 1 in every 1,000 deliveries.
Amniotic Fluid Embolism occurs in 1 in every 1,000 deliveries.
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What is the definition of Amniotic Fluid Embolism?
What is the definition of Amniotic Fluid Embolism?
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The incidence of Amniotic Fluid Embolism is about 1 in _____ deliveries.
The incidence of Amniotic Fluid Embolism is about 1 in _____ deliveries.
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Match the clinical features of Amniotic Fluid Embolism with their descriptions:
Match the clinical features of Amniotic Fluid Embolism with their descriptions:
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Which type of episiotomy involves cutting more muscle fibers?
Which type of episiotomy involves cutting more muscle fibers?
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A median episiotomy is associated with a longer healing time compared to a mediolateral episiotomy.
A median episiotomy is associated with a longer healing time compared to a mediolateral episiotomy.
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What is the angle of a mediolateral episiotomy in relation to the introitus?
What is the angle of a mediolateral episiotomy in relation to the introitus?
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An episiotomy performed after crowning is known as a __________ episiotomy.
An episiotomy performed after crowning is known as a __________ episiotomy.
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Match the following characteristics with the type of episiotomy:
Match the following characteristics with the type of episiotomy:
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What is the most common cause of vulval hematoma?
What is the most common cause of vulval hematoma?
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A vulval hematoma is characterized by hypovolemia after vaginal delivery.
A vulval hematoma is characterized by hypovolemia after vaginal delivery.
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What are two conservative management techniques for vulval hematoma?
What are two conservative management techniques for vulval hematoma?
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The artery involved in vulval hematoma is the __________.
The artery involved in vulval hematoma is the __________.
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Match the following management types with their indications:
Match the following management types with their indications:
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Which type of placenta involves chorionic villi that invade into the myometrium?
Which type of placenta involves chorionic villi that invade into the myometrium?
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Placenta previa is a risk factor for placenta accreta spectrum.
Placenta previa is a risk factor for placenta accreta spectrum.
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What is the management option for placenta accreta spectrum?
What is the management option for placenta accreta spectrum?
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In uterine inversion, the _____ of the uterus prolapses into the uterine cavity.
In uterine inversion, the _____ of the uterus prolapses into the uterine cavity.
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Match the risk factors with their descriptions:
Match the risk factors with their descriptions:
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Which classification describes the time period after delivery?
Which classification describes the time period after delivery?
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Acute labor complications can occur anytime before delivery.
Acute labor complications can occur anytime before delivery.
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What is the term used for complications that arise during the time after delivery?
What is the term used for complications that arise during the time after delivery?
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Complications identified in the acute phase after delivery typically require __________ intervention.
Complications identified in the acute phase after delivery typically require __________ intervention.
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Match the following terms related to the classification of labor and puerperium:
Match the following terms related to the classification of labor and puerperium:
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Which symptom indicates the clinical onset of shock within 30 minutes of labor?
Which symptom indicates the clinical onset of shock within 30 minutes of labor?
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In cases of uterine inversion, immediate shock is experienced with excessive bleeding.
In cases of uterine inversion, immediate shock is experienced with excessive bleeding.
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What is the m/c cause of post-partum collapse?
What is the m/c cause of post-partum collapse?
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The onset of symptoms of amniotic fluid embolism occurs within _____ minutes of delivery.
The onset of symptoms of amniotic fluid embolism occurs within _____ minutes of delivery.
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Match the conditions with their corresponding clinical presentations:
Match the conditions with their corresponding clinical presentations:
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What is the most favorable outcome of the occipito-posterior position during childbirth?
What is the most favorable outcome of the occipito-posterior position during childbirth?
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In occipito-anterior positions, fetal heart sounds are typically heard towards the flank.
In occipito-anterior positions, fetal heart sounds are typically heard towards the flank.
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What engaging diameter is used in occipito-anterior presentation?
What engaging diameter is used in occipito-anterior presentation?
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In occipito-posterior presentations, the fetal abdomen is felt near the ______.
In occipito-posterior presentations, the fetal abdomen is felt near the ______.
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Match the following features to their respective presentations:
Match the following features to their respective presentations:
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Study Notes
Occipito-Posterior Malposition (OP)
- Longitudinal lie, cephalic presentation, vertex presenting part.
- 6 (ROP) > 7 (DOP) > 8 (LOP) are the most common positions.
- Android pelvis and deflexed head are the main causes.
- Occurs in 10% of pregnancies at term and onset of labor.
- Decreases to 2% later in labor as the baby rotates to occipito-anterior.
- More common in multiparous women.
- Most frequent in nulliparous women.
Perineal Tear Classification
- Divided into 4 degrees based on structures involved.
- Degree 1: Vaginal mucosa
- Degree 2: Vaginal mucosa and muscles
- Degree 3A: < 50% external anal sphincter
- Degree 3B: ≥ 50% external anal sphincter
- Degree 3C: Internal and external anal sphincters
- Degree 4: Internal and external anal sphincters, and rectal mucosa.
### Repair of Perineal Tears
- 1st and 2nd degree tears repaired in the labor room under local anesthesia.
- 3rd and 4th degree tears repaired in the operating theater under general or spinal anesthesia.
- Repair sequence: vaginal mucosa (continuous sutures), muscles (interrupted sutures), vaginal skin (mattress suture), rectal mucosa, internal anal sphincter, external anal sphincter (end-to-end anastomosis).
- Immediate repair within 24 hours of delivery, delayed repair after minimum 3 weeks for tears older than 24 hours.
### WHO Recommendations to Prevent Perineal Tears
- Perineal massage
- Warm compression of perineum
- Controlled delivery of the fetal head
- Guarding the perineum
- Ritgen maneuver
### Not Recommended by WHO
- Fundal massage
- Routine episiotomy
### Episiotomy
- Surgical incision of the perineum to facilitate delivery of the fetal head
- Indications include shoulder dystocia, instrumental delivery, after-coming head of breech.
- Other factors: face to pubis delivery, macrosomia, rigid perineum; all increase the chance of tearing.
### Types of Episiotomy
- Median episiotomy cuts fewer muscle fibers, with easier bleeding management and quicker repair and healing. Less chance of gaping and dyspareunia. It involves the anal sphincter.
- Mediolateral episiotomy cuts more muscle fibers with more difficult bleeding management, longer repair and healing times. It has a greater chance of gaping and dyspareunia. It does not involve the anal sphincter.
Structures Cut in Episiotomy
- Vaginal mucosa
- Skin subcutaneous tissue
- Branches of the pudendal artery and nerve
- Muscles
Muscled Cut in Episiotomy
- Pubococcygeus
- Deep transverse perinei
- Superficial transverse perinei
- Bulbospongiosus
Muscles Not Cut in Episiotomy
- Ischiocavernosus
- Ischiococcygeus
- Obturator
- Anal sphincter
Timing of Episiotomy
- Performed after crowning, during perineal climbing in breech births, before or after forceps application, or before traction.
Vulval Hematoma
- Laceration of underlying blood vessels.
- Most commonly caused by instrumental delivery.
- Other causes include precipitate labor and rarely, spontaneous labor.
- Presents as localized excruciating pain after delivery, inability to urinate, and hypovolemia.
- Involves the internal pudendal artery for vulval hematomas and the vaginal artery for vaginal hematomas.
- On examination, a tense, tender, fluctuant swelling with bluish discoloration can be seen.
- Conservative managed with ice packs, analgesics and vital signs monitoring.
- Surgical management indicated for hematomas greater than 5cm or increasing in size.
Placenta Accreta Spectrum
- Normal placenta, placenta accreta, placenta increta, placenta percreta.
- Placenta accreta is the most common and occurs when the chorionic villi are superficially attached to the myometrium.
- Placenta increta happens when the chorionic villi invade the myometrium.
- Placenta percreta occurs when the chorionic villi attach to the serosa.
- Risk factors: placenta previa, previous c-section, dilatation & curettage, and myomectomy.
- Etiology includes absent Nitabuch's layer and defective decidua basalis.
- Investigated with ultrasound and Doppler: heterogeneous placenta, moth-eaten placenta, placental lakes, absence of the hypoechoic area below the placenta (decidua basalis), white line of bladder serosa interface interruption.
- Management involves hysterectomy.
Uterine Inversion
- Prolapse of the fundus of the uterus into the uterine cavity.
- Differentiated from uterine prolapse by a visible os.
- Managed with resuscitation, stopping uterotonics (Oxytocin).
- Manual replacement using Johnson's method, where the first prolapsed part is the last to be reposited, avoiding separation of the placenta to decrease the risk of hemorrhage.
- If manual replacement fails, repeat under general anesthesia or with uterine relaxant.
- Huntington's or Haltane's methods in cases of further failure.
- Haultain's method for constricted rings.
- Outdated methods: hydrostatic Osullivan method, vaginal surgeries like Spinelli and Cascardics.
Amniotic Fluid Embolism (AFE)
- Entry of amniotic fluid into the maternal circulation
- Also called anaphylactoid syndrome of pregnancy
- A catastrophic obstetric emergency
- Incidence of 1 in 100,000 deliveries
- Pathophysiology: Erratic uterine contractions, breach in the maternal-fetal interface, opening of venous sinuses allowing amniotic fluid (including fetal skin cells, debris, and antigens) to enter the maternal and then pulmonary circulation.
Post-Replacement Management
- Stop uterine relaxant
- Remove placenta
- Start oxytocin
- Start antibiotics
Amniotic Fluid Embolism (AFE) Clinical Features
- Phase 1 (during labor/immediately after delivery): Respiratory difficulty, shock, minimal bleeding.
### Post-partum Collapse Diagnosis
- PPH - Postpartum Hemorrhage, DIC -Disseminated Intravascular Coagulation
| PPH | Uterine inversion | Amniotic fluid embolism | |
|---|---|---|---|
| Appearance of symptoms | Within 24hrs of delivery | Within 30 mins of delivery | |
| Symptoms | Excessive bleeding, m/c cause of post-partum collapse. | Immediate shock after delivery + minimal bleeding initially. | 1st phase: Respiratory difficulty + Shock + minimal bleeding. 2nd phase: DIC (↑Bleeding). |
| P/A examination | ↓ Tone of uterus | Cup-like depression below umbilicus. | Normal |
| P/v examination | ↑ Blood loss | Globular structure inside vagina. | Normal |
Occipito-posterior vs.Occipito-anterior
| Feature | Occipito-posterior (OP) | Occipito-anterior (OA) |
|---|---|---|
| Abdomen below umbilicus | Felt near umbilicus, away from midline | Felt towards back, towards the midline |
| Fetal limbs | ||
| Anterior shoulder | ||
| Fetal back & fetal heart sounds | Towards the flank | Towards the midline |
| Engaging diameter | Occipitofrontal: 11.5cm Suboccipitofrontal: 10cm Delayed engagement | Suboccipitobregmatic: 9.5cm Well flexed head |
### Outcomes in OP Position
| Outcome | Description |
|---|---|
| Complete forward rotation | Most common and favorable outcome (90% cases) |
| Incomplete forward rotation | |
| Posterior rotation |
### Labor and Puerperium
- Classified based on the time of occurrence into acute and chronic types.
- Acute postpartum hemorrhage occurs within 24 hours post-delivery.
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Description
This quiz covers key concepts related to occipito-posterior malposition and the classification and repair of perineal tears. Understanding the implications of these topics is crucial for obstetrics and maternal care. Test your knowledge on these important aspects of childbirth.
