speculum Examination
-name of picture
-name the position of
patient
-ues for what
-How to do speculum
Examination
- is it most common
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•
-name of picture •
-name the position of •
patient
-ues for what •
Name the manuver •
Use for what •
•
Described the picture •
Obstetrical maneuvers.
Fundal height
Using reference points.
Using a tape
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
Obstetrical grips (Leopold’s maneuvers).
Lateral grips (Second
maneuvers).
On which side is the 
fetal back ?
Lie. 
Position. 
Where to auscultate for 
FHS.
Obstetrical grips (Leopold’s maneuvers).
First pelvic grip Pawlik’s grip (Third
maneuver).
What fetal part lies 
over the pelvic inlet?.
Presentation. 
Obstetrical grips (Leopold’s maneuvers).
Second pelvic grip
(Fourth maneuver)
Engagement •
Attitude •
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.
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
Barr body (arrows) in the
epidermal spinous cell layer
Nuclear
appendage
("drumstick") identified by
arrow in white blood cells
Hypothalamic-pituitarygonadal axis
+/+/-
CNS
hypothalamus
neurons
gonadotropin releasing hormone
+/-
ant. pituitary
+/-
LH
+
_
FSH
thecal cells
androgens
LH R
progestins
(LH R)
granulosa cells
FSH R
estrogens
+
Reproductive tract
inhibin
activin
when secretion throughout the sexual life of the
female?
What are the
Growth in
puberty
Girls: •
1-When start growth –
acceleration ?
2-When peak growth –
velocity occurs ?)
3-When menarche –
occurs?
Growth in
puberty
Boys: •
When Peak –
growth velocity
occurs?
Define of this endometrial cycle? How
much day each cycle take ?
Skin changes
1) identefy ? What is the
cause ?
-
2) identefy ? What is the
cause ?
-
‫الصور الجاية السؤال عليهن‬
In what step of mechanism of labor ?
What is the position ?
‫الجواب بالمالحظات‬
•
•
•
•
What is the name of this technique?
And what we use it for ?
What is the name ?
What is it`s component ?
THE BONY
PELVIS
WHICH BONES COMPOSE THE
BONY PELVIS?
I ) 2 Innominate bones :
a) Illium
b) Ischium
c) Pubis
II) Sacrum
III) Coccyx
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
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
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
After
you activate
your
The
book,pelvis.
you will
getgynecoid 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
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
PELVIC SHAPE
2-ANDROID
Typical male pelvis found in
1/3 white women 1/6 nonwhite
Pelvic brim is heart shaped
Pelvis funnels from above
downwards (convergent
sidewalls)
PELVIC SHAPE
3-ANTHROPOID
25% white women &
50% nonwhite
Pelvic brim APD > TD
Long & narrow pelvic
canal with long sacrum
Straight pelvic sidewalls
PELVIC SHAPE
4-PLATYPELLOID
3% of women
Pelvic brim TD >>>APD 
kidney shape
Sacral promontory pushed
forwards
FETAL SKULL SUTURES
Frontal suture  •
between 2 frontal
bones
Sagittal suture  •
between 2 parietal
bones
Coronal suture  •
between parietal &
frontal
Lambdoid suture •
FETAL SKULL
FONTANELLES
Anterior fontanelle :
diamond shaped
space between
coronal &
sagittal suture,
ossifies at 18 - 20
month
Post font (lambda) :
triangle shaped space
between sagittal &
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)
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)
Placenta Previa
• Bleeding results from small
disruptions in the placental
attachment during normal
development and thinning of the
lower uterine segment
Placental Abruption
•
•
•
•
external hemorrhage
concealed hemorrhage
Total
Partial
Sequelae of Placental Abruption
• Maternal Shock
• Consumptive Coagulopathy (DIC)
• Renal Failure
• Fetal Death
• Couvelaire Uterus
Vasa Previa
Velamentous insertion of the umbilical cord
Vasa Previa
Succenturiate (Accessory) lobe
Nitrazine Test
Positive Fern by Microscopic Exam
HL
Shoulder Dystocia
A review of the risks, physiology, management, and
prevention of Shoulder Dystocia
Next Slide
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
Turtle Sign
More about this in a bit
Next Slide
Risk Factors for Shoulder Dystocia
Maternal •
Abnormal pelvic anatomy
Gestational diabetes
Post-dates pregnancy
Previous shoulder dystocia
Short stature
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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.
Next Slide
•
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.
•
•
•
•
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Turtle Sign Demonstration
Oh crap, Turtle Sign!
Replay Demonstration
Next Slide
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
•
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
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
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
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
McRobert’s Maneuver
Click Diagram to Dismiss it
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
Suprapubic Pressure
Click Diagram to Dismiss it
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
"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 180degree rotation in the opposite direction.
Next Slide
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
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
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
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
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
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–
Fetal
Brachial plexus palsy
Clavicle fracture
Fetal death
Fetal hypoxia, with or without permanent neurologic damage
Fracture of the humerus
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Next Slide
•
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.
Next Slide
•
•
•
•
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.
Next Slide
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