2. speculum Examination

4. -name the position of patient -ues for what
-name of picture
-name the position of patient
-ues for what
-How to do speculum Examination
- is it most common
1- Cusco’s or bivalve speculum
2-women in the dorsal position
3-examine the cervix
4-Use a warm and well lubricated speculum.
The labia minora must be adequately parted with the left hand.
Insert the speculum upwards and backwards (direction of vagina)
Advance into vagina fully.
Directly visualize as you open the plates to expose the cervix.
If cervix not seen: close plates, withdraw slightly, change direction and open again.
5- Cusco’s bivalve is more frequently used

6. -name the position of patient -ues for what
-name of picture
-name the position of patient
-ues for what
1-a sims speculum
2-left lateral position
3-used in pelvic organ prolapse.
For examine posterior vaginal wall

8. Name the manuver Use for what 1-Bimanual Vaginal Examination
2- to palpat the the uterus and adenexia

9. Described the picture Adnexae:to assess
Mal ovaries are usually not palpable
Any masses systic/solid and described approximate size
Tenderness is assessed by direct digital pressure into the fornices and cervical

10. Obstetrical maneuvers. Fundal height
Using reference points.
Using a tape

11. Obstetrical grips (Leopold’s maneuvers).
Fundal grip (First maneuver) What fetal part occupies the fundus if soft consistency/ indefinite outline broad & irregular  breech
If hard, smooth, well defined, rounded, bullottable  head

12. Obstetrical grips (Leopold’s maneuvers).
Lateral grips (Second maneuvers).
On which side is the fetal back ?
Lie.
Position.
Where to auscultate for FHS.

13. Obstetrical grips (Leopold’s maneuvers).
First pelvic grip - Pawlik’s grip (Third maneuver).
What fetal part lies over the pelvic inlet?.
Presentation.

14. Obstetrical grips (Leopold’s maneuvers).
Second pelvic grip (Fourth maneuver)
Engagement
Attitude

15. A and B. Children with Down syndrome, which is characterized by a flat,
broad face, oblique palpebral fissures, epicanthus, and furrowed lower lip.
C. Another characteristic of Down syndrome is a broad hand with single transverse or simian crease.

16. Structural chromosome abnormalities
Patient with Prader-Willi syndrome resulting from a microdeletion on paternalchromosome 15.
If the defect is inherited on the maternal chromosome, Angelmansyndrome occurs

17. Barr body (arrows) in the epidermal spinous cell layer
Nuclear appendage ("drumstick") identified by arrow in white blood cells

18. Hypothalamic-pituitary- gonadal axis
CNS
+/-
hypothalamus
+/-
neurons
gonadotropin releasing hormone
+/- + _
ant. pituitary
+/- LH
FSH
(LH R)
thecal cells
androgens
inhibin
granulosa cells
LH R
هذي الصوره متكرره مرتين بالمحاضره يمكن يحط فراغات باماكن الهرمونات واحنا نعبيها أو يتنيذل ويقول اشرحي عمل الهرمونات
The Hypothalamus Secretes GnRH, Which Causes the Anterior Pituitary Gland to Secrete LH and FSH: the pulsatile nature of GnRH release (lasting 5 to 25 minutes that occur every 1 to 2 hours) is essential to its function
Estrogen in small amounts has a strong effect to inhibit the production of both LH and FSH. Also, when progesterone is available, the inhibitory effect of estrogen is multiplied, even though progesterone by itself has little effect.
These feedback effects seem to operate mainly on the anterior pituitary gland directly, but they also operate to a lesser extent on the hypothalamus to decrease secretion of GnRH
Hormone inhibin from the corpus luteum inhibits FSH and LH Secretion
Hormone activin from the stimulates FSH Secretion
FSH R
progestins
activin
estrogens +
Reproductive tract

19. when secretion throughout the sexual life of the female?
The increasing levels of estrogen secretion at puberty,
the cyclical variation during the monthly sexual cycle,
the further increase in estrogen secretion during the first few years of reproductive life,
the progressive decrease in estrogen secretion toward the end of reproductive life, and, finally,
almost no estrogen or progesterone secretion beyond menopause.

20. What are the

21. Growth in puberty Girls: 1-When start growth acceleration ?
2-When peak growth velocity occurs ?)
3-When menarche occurs?
1-Growth acceleration begins at the onset of puberty
2-Peak growth velocity occurs earlier (6-9 months after thelarche)
3-Menarche occurs after peak growth velocity

22. Growth in puberty Boys: When Peak growth velocity occurs? Boys:
Peak growth velocity occurs relatively late in puberty

23. Define of this endometrial cycle? How much day each cycle take ?
proliferative phase: proliferation of the uterine endometrium;
secretory phase: development of secretory changes in the endometrium; and
desquamation of the endometrium, which is known as menstruation..
Define of this endometrial cycle? How much day each cycle take ?

24. Skin changes 1) identefy ? What is the cause ? -
1)Skin changes in pregnancy Pigmentation: chloasma gravidarum: Butterfly pigmentation of the face (mask of pregnancy)
due to increased melanocyte stimulating hormone
2) Striae gravidarum :
- stretch of the abdominal wall rupture of the subcutaneous elastic fibers
pink lines in flanks
- become white after labor

25. ماادري وش ممكن يكون عليه سؤال بس حطيته للذمة عشان يشمل كل الصور

26. للذمة

27. الصور الجاية السؤال عليهن
In what step of mechanism of labor ?
What is the position ?
الجواب بالملاحظات

28. Descent step - occiputo transverse position

29. Flextion step - occiputo transverse position

30. Internal rotation
occipito- anterior position.

31. Delivery by Extension: As the fetal head reaches the maternal symphysis pubis it hitches under the bone.
The pressure by the uterine contractions causes the neck of the baby to get extended

32. External Rotation:
The shoulders rotate into an oblique or frankly anterio-posterior orientation with further descent. This encourages the fetal head to return to its transverse position. This is also known as Restitution .

33. External Rotation:نفس اللي قبل
The shoulders rotate into an oblique or frankly anterio-posterior orientation with further descent. This encourages the fetal head to return to its transverse position. This is also known as Restitution

34. Transverse – vertex – breech lie

35. What is the name of this technique? And what we use it for ?
Leopold’s Maneuvers
It uses to palpate the fetus part , to estimate it position ,lie engagement

36. للذمة

37. What is the name ? What is it`s component ?
Partogram
- It include :
fetal heart rate
Uterine contraction
pulse, blood pressure, temp
fluid intake, oxyotcin
dilation of the cervix
station of the presenting part, status of membranes, meconium, blood

38. للذمة

39. للذمة

41. WHICH BONES COMPOSE THE BONY PELVIS?
Iliopectineal line
Left sacro-iliac joint
Sacrospinous ligament
Sacrotuberous ligament
Symphysis pubis
Sacral promontory 48 L4
Ischial spine
Ischial tuberosity
THE BONY PELVIS
WHICH BONES COMPOSE THE BONY PELVIS?
I ) 2 Innominate bones :
a) Illium
b) Ischium
c) Pubis
II) Sacrum
III) Coccyx

42. False pelvis
The false pelvis is bounded posteriorly by the lumbar vertebra and laterally by the iliac fossa. In front, the boundary is formed by the lower portion of the anterior abdominal wall.

43. 43

44. After you activate your book, you will get
Pelvic inlet and its diameters.
Printed from: Hacker & Moore's Essentials of Obstetrics and Gynecology 5e (on 05 January 2013) © 2013 Elsevier
After you activate your book, you will get
اتوقع يسأل عن اسماء conjugate and its length in cm
WHAT IS THE OBSTETRIC CONJUGATE?
The shortest APD between sacral promontory & symphysis pubis
Can only be measured radiologically
N ≥ 10 cm
WHAT IS THE TRUE CONJUGATE?
APD between promontory of the sacrum & superior margin of the symphysis pubis 11cm
or diagonal conjugate – 1.5cm
WHAT IS THE DIAGONAL CONJUGATE?
Distance between sacral promontory & inferior margin of the symphysis pubis cm?
Measured clinically

45. After you activate your book, you will get
The four basic pelvic types. The dotted line indicates the transverse diameter of the inlet. Note that the widest diameter of the inlet is posteriorly situated in an android or anthropoid pelvis. The gynecoid pelvis illustrates the location of the sacrosciatic notch, present in all pelvic types.
Printed from: Hacker & Moore's Essentials of Obstetrics and Gynecology 5e (on 05 January 2013) © 2013 Elsevier
After you activate your book, you will get

46. PELVIC SHAPE 1-GYNECOID Typical female pelvis found in 50% of women
Rounded—slightly oval inlet
Straight pelvic sidewalls with roomy pelvic cavity
Good sacral curve
Ischial spines are not prominent
Pubic arch is wide 46

47. PELVIC SHAPE
2-ANDROID
Typical male pelvis found in 1/3 white women 1/6 non-white
Pelvic brim is heart shaped
Pelvis funnels from above downwards (convergent sidewalls)
Narrow pubic arch
Prominent spines 47

48. PELVIC SHAPE 3-ANTHROPOID 25% white women & 50% nonwhite
Pelvic brim APD > TD
Long & narrow pelvic canal with long sacrum
Straight pelvic sidewalls 48

49. PELVIC SHAPE 4-PLATYPELLOID 3% of women
Pelvic brim TD >>>APD  kidney shape
Sacral promontory pushed forwards 49

50. FETAL SKULL SUTURES Frontal suture  between 2 frontal bones
Sagittal suture 
between 2 parietal bones
Coronal suture 
between parietal & frontal
Lambdoid suture 
between parietal & occipital
Temporal suture 
between inferior margin
of the parietal & temporal

51. FETAL SKULL FONTANELLES
Anterior fontanelle :
diamond shaped
space between coronal &
sagittal suture,
ossifies at month
Post font (lambda) :
triangle shaped space
between sagittal & lambdoid suture

52. Diameteres of the fetal skull
Biparietal diameter = 9.5cm
Suboccto-bregmatic diameter = 9.5cm
Occipito-frontal diameter = 11.5cm
(occipito-posterior position)
The suboccipito-frontal diameter= 10 cm
(1st diameter passes through vulval orifice)

53. Diameteres of the fetal skull
Mento-vertical diameter =13cm
(Brow presentation)
Submento-bregmatic diameter = 9.5cm
(face presentation)
Bis-acromial diameter =12cm
(diameter of the shoulder)
Bitrochanteric diameter =10cm
(Diameter of the breech)

64. Placenta Previa
Bleeding results from small disruptions in the placental attachment during normal development and thinning of the lower uterine segment

66. Placental Abruption external hemorrhage concealed hemorrhage Total
Partial

67. Sequelae of Placental Abruption
Maternal Shock
Consumptive Coagulopathy (DIC)
Renal Failure
Fetal Death
Couvelaire Uterus

68. Vasa Previa Velamentous insertion of the umbilical cord

69. Vasa Previa Succenturiate (Accessory) lobe

70. Nitrazine Test

71. Positive Fern by Microscopic Exam

72. HL
Shoulder Dystocia
A review of the risks, physiology, management, and prevention of Shoulder Dystocia
Next Slide

73. PATHOPHYSIOLOGY
The anterior shoulder can then slide under the symphysis pubis for delivery.
If the fetal shoulders remain in an anterior-posterior position during descent or descend simultaneously rather than sequentially into the pelvic inlet, then the anterior shoulder can become impacted behind the symphysis pubis and/or the posterior shoulder may be obstructed by the sacral promontory.
Then you get the dreaded “Turtle Sign” of doom.
Next Slide

74. Turtle Sign
More about this in a bit
Next Slide

75. Risk Factors for Shoulder Dystocia
Maternal
Abnormal pelvic anatomy
Gestational diabetes
Post-dates pregnancy
Previous shoulder dystocia
Short stature
Fetal
Suspected macrosomia
Male sex
Labor related
Assisted vaginal delivery (forceps or vacuum)
Protracted active phase of first-stage labor
Protracted second-stage labor
Put mouse over chart to review pt’s information.
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76. Vignette
Since she is post-term and nothing good happens after 41 weeks…you decide to induce Jaquita.
Labor has been fine, she has progressed like she should, and is now complete and ready to push.
You gown up and are ready to catch this baby.
The head begins to come out and…Oh crap…..Turtle Sign.
Click HERE for a purely representative and graphical demonstration.

77. Turtle Sign Demonstration
Oh crap, Turtle Sign!
Replay Demonstration
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78. HELPERR Mnemonic
The HELPERR mnemonic is a clinical tool that offers a structured framework for coping with shoulder dystocia.
These maneuvers are designed to do one of three things:
Increase the functional size of the bony pelvis through flattening of the lumbar lordosis and cephalad rotation of the symphysis (i.e., the McRoberts maneuver)
Decrease the bisacromial diameter, the breadth of the shoulders, of the fetus through application of suprapubic pressure.
Change the relationship of the bisacromial diameter within the bony pelvis through internal rotation maneuvers.
Next Slide

79. HELPERR Mnemonic H Call for Help:
This refers to activating the pre-arranged protocol or requesting the appropriate personnel to respond with necessary equipment to the labor and delivery unit.
Click HERE for Diagram.
Next Slide

80. HELPERR Mnemonic H Call for Help:
This refers to activating the pre-arranged protocol or requesting the appropriate personnel to respond with necessary equipment to the labor and delivery unit.
Click HERE for Diagram.
Click Diagram to Dismiss it

81. HELPERR Mnemonic E Evaluate for episiotomy:
Episiotomy should be considered throughout the management of shoulder dystocia but is necessary only to make more room if rotation maneuvers are required. Shoulder dystocia is a bony impaction, so episiotomy alone will not release the shoulder.
Because most cases of shoulder dystocia can be relieved with the McRoberts maneuver and suprapubic pressure, many women can be spared a surgical incision.
Next Slide

82. HELPERR Mnemonic L Legs (the McRoberts maneuver):
This procedure involves flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. This position flattens the sacral promontory and results in cephalad rotation of the pubic symphysis. Nurses and family members present at the delivery can provide assistance for this maneuver.
Click HERE for McRobert’s Diagram.
Next Slide

83. McRobert’s Maneuver
Click Diagram to Dismiss it

84. HELPERR Mnemonic P Pressure (Suprapubic):
The hand of an assistant should be placed suprapubically over the fetal anterior shoulder, applying pressure in a cardiopulmonary resuscitation style with a downward and lateral motion on the posterior aspect of the fetal shoulder. This maneuver should be attempted while continuing downward traction.
Click HERE for Diagram.
Next Slide

85. Suprapubic Pressure
Click Diagram to Dismiss it

86. HELPERR Mnemonic E Enter maneuvers (internal rotation):
These maneuvers attempt to manipulate the fetus to rotate the anterior shoulder into an oblique plane and under the maternal symphysis.
Next Slide

87. "Enter" Maneuvers 1. 2. 3.
1. Rubin II At vaginal examination apply pressure as indicated. If shoulders move into the oblique diameter, attempt delivery.
2. Rubin II + Woods corkscrew maneuver If unsuccessful, add the Woods corkscrew maneuver and continue rotation in the same direction. Use both hands and apply pressure as indicated. If shoulders now move into the oblique, attempt delivery. If this is unsuccessful, continue rotation 180 degrees and deliver.
3. Reverse Woods corkscrew maneuver If the last maneuver is unsuccessful, change to reverse Woods corkscrew maneuver. Slide fingers down to back of posterior shoulder and attempt 180-degree rotation in the opposite direction.
Next Slide

88. HELPERR Mnemonic R Remove the posterior arm:
Removing the posterior arm from the birth canal also shortens the bisacromial diameter, allowing the fetus to drop into the sacral hollow, freeing the impaction.
The elbow then should be flexed and the forearm delivered in a sweeping motion over the fetal anterior chest wall.
Grasping and pulling directly on the fetal arm may fracture the humerus.
Click HERE for Diagram.
Next Slide

89. Removing Posterior Arm
R Remove the posterior arm:
Removing the posterior arm from the birth canal also shortens the bisacromial diameter, allowing the fetus to drop into the sacral hollow, freeing the impaction.
The elbow then should be flexed and the forearm delivered in a sweeping motion over the fetal anterior chest wall.
Grasping and pulling directly on the fetal arm may fracture the humerus.
Click HERE for Diagram.
Click Diagram to Dismiss it

90. HELPERR Mnemonic R Roll the patient:
The patient rolls from her existing position to the all-fours position.
Often, the shoulder will dislodge during the act of turning, so that this movement alone may be sufficient to dislodge the impaction.
In addition, once the position change is completed, gravitational forces may aid in the disimpaction of the fetal shoulders.
Click HERE for Diagram.
Next Slide

91. HELPERR Mnemonic R Roll the patient:
The patient rolls from her existing position to the all-fours position.
Often, the shoulder will dislodge during the act of turning, so that this movement alone may be sufficient to dislodge the impaction.
In addition, once the position change is completed, gravitational forces may aid in the disimpaction of the fetal shoulders.
Click Diagram to Dismiss it

92. Complications of Shoulder Dystocia
Maternal
Postpartum hemorrhage
Rectovaginal fistula
Symphyseal separation or diathesis, with or without transient femoral neuropathy
Third- or fourth-degree episiotomy or tear
Uterine rupture
Fetal
Brachial plexus palsy
Clavicle fracture
Fetal death
Fetal hypoxia, with or without permanent neurologic damage
Fracture of the humerus
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93. Prevention
Evidence is lacking to support labor induction or elective cesarean delivery in women without diabetes who are at term when a fetus is suspected of having macrosomia.
In two studies of 313 women without diabetes, induction for suspected fetal macrosomia did not lower the rates of shoulder dystocia or cesarean delivery, nor did it improve the rates of maternal or neonatal morbidity.
While labor induction in women with gestational diabetes who require insulin may reduce the risk of macrosomia and shoulder dystocia, the risk of maternal or neonatal injury is not modified.
Not enough evidence is available to routinely support elective delivery in this population.
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94. Prevention
So, prophylactic cesarean delivery is not recommended as a means of preventing morbidity in pregnancies in which fetal macrosomia is suspected.
Analytic decision models have estimated that 2,345 cesarean deliveries, at a cost of nearly $5 million annually, would be needed to prevent one permanent brachial plexus injury in a patient without diabetes who had a fetus suspected of weighing more than 4,000 g.
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95. Prevention
One method of preliminary intervention for shoulder dystocia in a patient with risk factors involves implementing the "head and shoulder maneuver" to "deliver through" until the anterior shoulder is visible.
This step is accomplished by continuing the momentum of the fetal head delivery until the shoulder is visible.
After controlled delivery of the head, the physician proceeds with immediate delivery of the anterior shoulder without stopping to suction the oropharynx.
Next Slide