{"id":37100,"date":"2026-06-25T13:52:07","date_gmt":"2026-06-25T08:22:07","guid":{"rendered":"https:\/\/atsixty.com\/?p=37100"},"modified":"2026-06-25T13:52:58","modified_gmt":"2026-06-25T08:22:58","slug":"obstetrics-summative-revision-notes","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/obg\/obstetrics-summative-revision-notes\/","title":{"rendered":"Obstetrics: Summative Revision Notes"},"content":{"rendered":"\n\n\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n#orev01 *,#orev01 *::before,#orev01 *::after{box-sizing:border-box;margin:0;padding:0}\n#orev01{\n  --ob:#4B3A6E;--ob-dark:#362952;--ob-pale:#EFE9F5;--ob-mid:#5F4D85;\n  --acc:#A23B5C;--acc-pale:#FBEFF2;\n  --ink:#241B36;--ink-mid:#4A3D63;--ink-soft:#8A7FA0;\n  --line:#E0D8EC;--cream:#F8F6FB;--warm:#FCFBFD;\n  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.rv-quiz-link:hover{background:var(--ob);color:#fff}\n#orev01 .rv-footer{margin-top:32px;text-align:center;font-size:0.80rem;color:var(--ink-soft);font-style:italic;line-height:1.6}\n#orev01 .rv-footer a{color:var(--ob);font-style:normal;font-weight:600;text-decoration:none;border-bottom:1px solid var(--ob)}\n#orev01 .rv-footer a:hover{opacity:0.75}\n@media print{\n  #orev01 .rv-header{background:#4B3A6E !important;-webkit-print-color-adjust:exact}\n  #orev01{padding-bottom:20px}\n  #orev01 .rv-section{break-inside:avoid;box-shadow:none}\n}\n@media(max-width:480px){\n  #orev01 .rv-title{font-size:1.45rem}\n  #orev01 .rv-sec-title{font-size:1rem}\n  #orev01 table{font-size:0.76rem}\n  #orev01 td,#orev01 th{padding:6px 8px}\n}\n<\/style>\n\n<div id=\"orev01\">\n\n  <div class=\"rv-header\">\n    <div class=\"rv-eyebrow\">Morning Rounds &middot; Obstetrics Series<\/div>\n    <div class=\"rv-title\">Obstetrics<br><em>Summative Revision Notes<\/em><\/div>\n    <div class=\"rv-subtitle\">Seven topics &middot; NEET-PG \/ INI-CET \/ UPSC CMS &middot; Key facts, thresholds, classifications and the law<\/div>\n    <div class=\"rv-chips\">\n      <span class=\"rv-chip\">Antenatal &amp; Consent<\/span>\n      <span class=\"rv-chip\">Hypertensive Disorders<\/span>\n      <span class=\"rv-chip\">Antepartum Hemorrhage<\/span>\n      <span class=\"rv-chip\">Labor &amp; Partograph<\/span>\n      <span class=\"rv-chip\">PPH &amp; Maternal Death<\/span>\n      <span class=\"rv-chip\">Medical Disorders<\/span>\n      <span class=\"rv-chip\">High-Risk &amp; Obstetric Law<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"rv-body\">\n\n    <div class=\"rv-intro\">\n      <p>These notes consolidate the seven Obstetrics Morning Rounds. They are written for rapid pre-exam revision &mdash; not first-time learning. Each section heading links to its quiz. Summative pill-badges at the end of each section capture the single-line facts most likely to appear as isolated IBQs.<\/p>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 1 \u2014 ANTENATAL CARE, SCREENING & CONSENT\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-01\">\n          <div class=\"rv-sec-num\">Topic 01 &middot; Obstetrics<\/div>\n          <div class=\"rv-sec-title\">Antenatal Care, Screening &amp; Informed Consent <span class=\"rv-arrow\">&#x2197;<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">Screening vs Diagnostic Testing<\/div>\n        <p>A <strong>screening<\/strong> test (NT scan, biochemistry, NIPT) gives a probability, never a yes\/no answer &mdash; a \"high risk\" or \"positive\" result always requires a <strong>diagnostic<\/strong> test (CVS, amniocentesis) for confirmation before any irreversible decision. No screening test, however high its reported accuracy, substitutes for diagnostic confirmation.<\/p>\n\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Test<\/th><th>Window<\/th><th>What it screens<\/th><\/tr>\n            <tr><td>First-trimester combined<\/td><td>11&ndash;13+6 wks<\/td><td>NT + free &beta;-hCG + PAPP-A &mdash; aneuploidy risk<\/td><\/tr>\n            <tr><td>Quadruple screen<\/td><td>15&ndash;20 wks<\/td><td>Second-trimester serum aneuploidy risk<\/td><\/tr>\n            <tr><td>NIPT (cfDNA)<\/td><td>&ge;10 wks<\/td><td>Common trisomies &mdash; high sensitivity, still a screen<\/td><\/tr>\n            <tr><td>Anomaly scan<\/td><td>18&ndash;20 wks<\/td><td>Structural anomalies &mdash; not replaced by NIPT<\/td><\/tr>\n          <\/table>\n        <\/div>\n\n        <div class=\"rv-sub\">Normal Physiology &mdash; Don't Over-Call These<\/div>\n        <p><strong>Dependent ankle oedema<\/strong> (resolves overnight, no HTN\/proteinuria) &mdash; normal. <strong>Dilutional anaemia<\/strong> (plasma volume rises faster than RBC mass) &mdash; expect Hb to dip, not pathological alone. <strong>Supine hypotensive syndrome<\/strong> (IVC compression by gravid uterus, relieved by lateral position) &mdash; textbook benign, no cardiology workup needed for the classic picture.<\/p>\n\n        <div class=\"rv-sub\">First Antenatal Visit &mdash; Baseline Panel<\/div>\n        <p>CBC &middot; blood group\/Rh + antibody screen &middot; urine R\/M &middot; <strong>universal<\/strong> HIV\/syphilis\/HBsAg screening (not risk-factor-gated) &middot; TFT &middot; blood glucose &middot; folic acid\/iron counselling. Done <em>early<\/em> &mdash; not deferred to 20 weeks.<\/p>\n\n        <div class=\"rv-sub\">Informed Consent for Prenatal Testing<\/div>\n        <p>Must cover: purpose\/accuracy, procedure-specific risks (miscarriage risk for invasive tests), voluntary nature with no coercion, the range of possible results, and that the decision to continue or end the pregnancy remains the patient's alone &mdash; never framed as an obligation. A strong medical indication never substitutes for the consent process itself.<\/p>\n\n        <p><span class=\"rv-pill\">Screening = probability, never diagnosis<\/span> <span class=\"rv-pill\">NIPT positive still needs CVS\/amniocentesis<\/span> <span class=\"rv-pill-blue\">Universal infection screening, not risk-gated<\/span> <span class=\"rv-pill-green\">Decision after diagnosis stays the patient's own<\/span><\/p>\n\n        <a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-01\">&#x25B6; Open Quiz 01<\/a>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 2 \u2014 HYPERTENSIVE DISORDERS\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-02\">\n          <div class=\"rv-sec-num\">Topic 02 &middot; Obstetrics<\/div>\n          <div class=\"rv-sec-title\">Hypertensive Disorders of Pregnancy <span class=\"rv-arrow\">&#x2197;<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Entity<\/th><th>Defining feature<\/th><\/tr>\n            <tr><td>Gestational HTN<\/td><td>New HTN &ge;20 wks, <strong>no<\/strong> proteinuria\/organ dysfunction<\/td><\/tr>\n            <tr><td>Preeclampsia<\/td><td>New HTN &ge;20 wks <strong>+<\/strong> proteinuria (or other organ involvement)<\/td><\/tr>\n            <tr><td>Chronic HTN + superimposed PE<\/td><td>HTN predates 20 wks \/ pre-pregnancy, new proteinuria\/severity added<\/td><\/tr>\n            <tr><td>Eclampsia<\/td><td>Preeclampsia + generalised tonic-clonic seizure<\/td><\/tr>\n          <\/table>\n        <\/div>\n\n        <div class=\"rv-sub\">Severe Features (any ONE changes management)<\/div>\n        <p>BP &ge;160\/110 &middot; platelets &lt;100,000 &middot; impaired LFTs\/RUQ pain &middot; rising creatinine &middot; pulmonary oedema &middot; severe headache\/visual symptoms. Severe features &rarr; <strong>MgSO&#8324; + BP control + deliver after brief stabilisation<\/strong>, not prolonged expectant care, regardless of gestational age. Proteinuria amount alone does not define \"severe.\"<\/p>\n\n        <div class=\"rv-sub\">Magnesium Sulfate &mdash; Eclampsia First-Line<\/div>\n        <p>First-line for both treatment and prevention of seizures &mdash; superior to phenytoin\/diazepam, which are not first-line. Started <strong>empirically<\/strong> once severe features\/seizure occur &mdash; never delayed for neuroimaging. <strong>Toxicity monitoring:<\/strong> deep tendon reflexes, respiratory rate, urine output; antidote is IV calcium gluconate. Delivery, not seizure control alone, is the definitive treatment for eclampsia &mdash; stabilise first, then proceed.<\/p>\n\n        <div class=\"rv-sub\">HELLP Syndrome<\/div>\n        <p><strong>H<\/strong>aemolysis (schistocytes, &uarr;LDH) + <strong>EL<\/strong>evated liver enzymes + <strong>L<\/strong>ow <strong>P<\/strong>latelets &mdash; a severe preeclampsia variant. No safe platelet threshold to justify watchful waiting; risk of hepatic rupture\/DIC drives prompt delivery after stabilisation. Platelet transfusion is not mandatory in every case &mdash; reserved for bleeding risk or specific low counts before cesarean.<\/p>\n\n        <div class=\"rv-sub\">Escalation &amp; ICU Referral<\/div>\n        <p>Once a unit's documented protocol criteria for ICU referral are met, failure to escalate is a deviation from that unit's own standard of care &mdash; carries independent medico-legal weight regardless of eventual outcome.<\/p>\n\n        <p><span class=\"rv-pill\">Severe features = deliver after stabilising, not \"wait it out\"<\/span> <span class=\"rv-pill-blue\">MgSO&#8324; first-line, started empirically<\/span> <span class=\"rv-pill-green\">HELLP: no safe platelet \"wait\" number<\/span><\/p>\n\n        <a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-02\">&#x25B6; Open Quiz 02<\/a>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 3 \u2014 ANTEPARTUM HEMORRHAGE & CONSENT\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-03\">\n          <div class=\"rv-sec-num\">Topic 03 &middot; Obstetrics<\/div>\n          <div class=\"rv-sec-title\">Antepartum Hemorrhage &amp; Emergency Consent <span class=\"rv-arrow\">&#x2197;<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Feature<\/th><th>Placenta Previa<\/th><th>Abruptio Placentae<\/th><\/tr>\n            <tr><td>Pain<\/td><td>Painless<\/td><td>Severe; tense\/tender uterus<\/td><\/tr>\n            <tr><td>Bleeding<\/td><td>Visible &asymp; true loss<\/td><td>May be concealed &mdash; underestimated<\/td><\/tr>\n            <tr><td>Uterus<\/td><td>Soft, non-tender<\/td><td>Tense, &plusmn; woody-hard<\/td><\/tr>\n            <tr><td>Key risk<\/td><td>Recurrent\/massive bleed<\/td><td>DIC, fetal hypoxia, hidden loss<\/td><\/tr>\n          <\/table>\n        <\/div>\n        <p>Vaginal examination avoided in suspected previa until placental location is confirmed sonographically. <strong>Complete (type IV) previa = absolute contraindication to vaginal delivery<\/strong>, bleeding status notwithstanding. A settled bleed in known previa still means <strong>admission<\/strong>, not discharge.<\/p>\n\n        <div class=\"rv-sub\">Abruption &mdash; Dangerous Errors<\/div>\n        <p><strong>Never tocolyse<\/strong> in abruption. Visible loss underestimates true loss when concealed &mdash; resuscitate beyond the visible volume. Fetal bradycardia with abruption needs urgent action, not an hour of observation.<\/p>\n\n        <div class=\"rv-sub\">Vasa Previa<\/div>\n        <p>Antenatal diagnosis (colour Doppler) changes management even when <strong>asymptomatic<\/strong>: third-trimester hospitalisation, elective cesarean before labor\/membrane rupture (~34&ndash;36 wks). <strong>Amniotomy is contraindicated<\/strong> &mdash; it is the dangerous act, not a diagnostic step. Vaginal delivery is never the plan, regardless of FHR reassurance.<\/p>\n\n        <div class=\"rv-sub\">Emergency Consent &amp; Refusal<\/div>\n        <p><strong>Doctrine of necessity:<\/strong> incapacitated patient + necessary life-saving intervention + no time for consent &rarr; proceed with the <em>full<\/em> necessary treatment, document reasoning; no waiting for next-of-kin or an ethics committee. <strong>Competent refusal<\/strong> (e.g. transfusion refusal on religious grounds) must be respected even if fatal &mdash; pursue non-blood alternatives, document thoroughly; distress alone &ne; incapacity; family cannot override a competent patient's own refusal.<\/p>\n\n        <p><span class=\"rv-pill\">Previa: never vaginal exam without imaging confirmation<\/span> <span class=\"rv-pill-blue\">Abruption: visible loss &ne; true loss<\/span> <span class=\"rv-pill-blue\">Vasa previa: amniotomy is the danger, not the test<\/span> <span class=\"rv-pill-green\">Necessity doctrine: full treatment, no delay for consent-seeking<\/span><\/p>\n\n        <a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-03\">&#x25B6; Open Quiz 03<\/a>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 4 \u2014 LABOR, PARTOGRAPH & MALPRESENTATION\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-04\">\n          <div class=\"rv-sec-num\">Topic 04 &middot; Obstetrics<\/div>\n          <div class=\"rv-sec-title\">Labor, Partograph &amp; Malpresentation <span class=\"rv-arrow\">&#x2197;<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">Partograph &mdash; Alert vs Action Line<\/div>\n        <p><strong>Alert line crossed<\/strong> = heightened surveillance + consider transfer to a centre capable of operative delivery; <strong>not<\/strong> itself an indication for cesarean. <strong>Action line crossed<\/strong> (alert + 4 hrs) = the actual threshold for reassessment and intervention. Never augment blindly before assessing the cause of delay (power vs mechanical obstruction).<\/p>\n\n        <div class=\"rv-sub\">Malposition &amp; Instrumental Delivery<\/div>\n        <p>Safe instrumental delivery needs full dilatation <strong>and<\/strong> adequately low station &mdash; \"fully dilated\" alone is not sufficient. Many OP positions rotate spontaneously in a well-conducted second stage; persistent OP at full dilatation is not, by itself, an absolute indication for either instrumental delivery or cesarean.<\/p>\n\n        <div class=\"rv-sub\">Breech<\/div>\n        <p><strong>Offer ECV<\/strong> around 36&ndash;37 wks before defaulting to either vaginal breech trial or elective cesarean &mdash; skipping ECV is a recognised standard-of-care omission. Spontaneous cephalic conversion becomes progressively less likely closer to term.<\/p>\n\n        <div class=\"rv-sub\">Obstructed Labor<\/div>\n        <p>Plateaued dilatation <strong>despite adequate contractions<\/strong> + worsening caput\/moulding + FHR changes = obstruction (often CPD) &rarr; <strong>cesarean<\/strong>. Augmenting with oxytocin here is dangerous, not just unhelpful &mdash; risks uterine rupture. Instrumental delivery is not an option before full dilatation.<\/p>\n\n        <div class=\"rv-sub\">Partograph as Medico-Legal Record<\/div>\n        <p>Late starts, missing dilatation entries, and unmonitored FHR stretches are treated as <strong>significant adverse markers<\/strong> in litigation &mdash; independent of the actual care given, because the contemporaneous record is the primary evidence that monitoring was adequate. \"Not statutorily mandated\" &ne; legally inconsequential.<\/p>\n\n        <p><span class=\"rv-pill\">Alert line = watch; action line = act<\/span> <span class=\"rv-pill-blue\">Station, not just dilatation, decides instrumental safety<\/span> <span class=\"rv-pill-blue\">Breech: offer ECV before either delivery route<\/span> <span class=\"rv-pill-green\">Augmenting adequate contractions in CPD = rupture risk<\/span><\/p>\n\n        <a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-04\">&#x25B6; Open Quiz 04<\/a>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 5 \u2014 PPH, SEPSIS & MATERNAL DEATH AUDIT\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-05\">\n          <div class=\"rv-sec-num\">Topic 05 &middot; Obstetrics<\/div>\n          <div class=\"rv-sec-title\">PPH, Puerperal Sepsis &amp; Maternal Death Audit <span class=\"rv-arrow\">&#x2197;<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">Atonic PPH &mdash; Escalation Ladder<\/div>\n        <p>Call for help + IV access + first uterotonic + bimanual massage &rarr; add second uterotonic (ergometrine\/carboprost) &rarr; balloon tamponade + crossmatch &rarr; B-Lynch\/uterine artery ligation &rarr; hysterectomy (last resort). Each rung moves <strong>fast, in parallel<\/strong> with resuscitation &mdash; no single rung gets a prolonged \"wait and watch.\"<\/p>\n\n        <div class=\"rv-sub\">Causes of PPH &mdash; the 4 Ts<\/div>\n        <p><span class=\"rv-pill-blue\">Tone<\/span> (atony, commonest) <span class=\"rv-pill-blue\">Tissue<\/span> (retained placenta\/products) <span class=\"rv-pill-blue\">Trauma<\/span> (lacerations, rupture) <span class=\"rv-pill-blue\">Thrombin<\/span> (coagulopathy)<\/p>\n\n        <div class=\"rv-sub\">Placenta Accreta Spectrum<\/div>\n        <p>Risk markers: prior cesarean(s) + anterior low-lying placenta over scar + loss of retroplacental clear space + lacunae. Plan: confirm (USS\/MRI), deliver at a tertiary centre with multidisciplinary team, consent covering possible hysterectomy. <strong>Never attempt manual removal<\/strong> when accreta is suspected &mdash; that is the dangerous act, not the fallback.<\/p>\n\n        <div class=\"rv-sub\">Puerperal Sepsis<\/div>\n        <p>Genital tract infection any time from labor\/ROM up to <strong>42 days<\/strong> postpartum (not a 24-hour window) &mdash; fever + pelvic pain\/foul discharge\/delayed involution. Clinical diagnosis; positive blood culture not required.<\/p>\n\n        <div class=\"rv-sub\">Maternal Death Classification<\/div>\n        <p><strong>Maternal death:<\/strong> during pregnancy or within 42 days of termination. <strong>Late maternal death:<\/strong> 42 days&ndash;1 year (captures cases like peripartum cardiomyopathy deaths). <strong>Direct<\/strong> cause = obstetric complication itself; <strong>indirect<\/strong> = pre-existing\/pregnancy-aggravated disease (e.g. peripartum cardiomyopathy is indirect, a frequent misclassification).<\/p>\n\n        <div class=\"rv-sub\">Documentation as Legal Exposure<\/div>\n        <p>Missing timestamps\/vitals create independent medico-legal exposure regardless of whether care was actually appropriate &mdash; the record, not testimony after the fact, is what defends care.<\/p>\n\n        <p><span class=\"rv-pill\">4 Ts: Tone, Tissue, Trauma, Thrombin<\/span> <span class=\"rv-pill-blue\">Accreta: never manual removal if suspected antenatally<\/span> <span class=\"rv-pill-blue\">Puerperal sepsis: 42-day window, clinical diagnosis<\/span> <span class=\"rv-pill-green\">Late maternal death: 42 days&ndash;1 year<\/span><\/p>\n\n        <a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-05\">&#x25B6; Open Quiz 05<\/a>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 6 \u2014 MEDICAL DISORDERS IN PREGNANCY\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-06\">\n          <div class=\"rv-sec-num\">Topic 06 &middot; Obstetrics<\/div>\n          <div class=\"rv-sec-title\">Medical Disorders in Pregnancy <span class=\"rv-arrow\">&#x2197;<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">GDM Screening<\/div>\n        <p><strong>DIPSI<\/strong> (India): 75 g glucose, non-fasting, single 2-hr value &ge;140 mg\/dL = diagnostic, no confirmatory test needed &mdash; this is the entire design of the test. <strong>IADPSG<\/strong> (international): fasting OGTT, any one of fasting &ge;92 \/ 1-hr &ge;180 \/ 2-hr &ge;153. Management: MNT first; <strong>insulin<\/strong>, not oral agents, is the standard Indian step-up.<\/p>\n\n        <div class=\"rv-sub\">Anemia in Pregnancy<\/div>\n        <p>Hb 7.8 with exertional-only symptoms at 32 wks &rarr; <strong>IV iron<\/strong>, not oral (too slow) and not transfusion (threshold not yet met). Parenteral iron is safe in 2nd\/3rd trimester, not teratogenic.<\/p>\n\n        <div class=\"rv-sub\">Cardiac Disease &amp; Anticoagulation<\/div>\n        <p>Mechanical valve + warfarin + pregnancy: switch to <strong>therapeutic LMWH for weeks 6&ndash;12<\/strong> (peak warfarin embryopathy window), with documented discussion of the LMWH-vs-warfarin trade-off. Never stop anticoagulation outright regardless of prior exposure.<\/p>\n\n        <div class=\"rv-sub\">Thyroid<\/div>\n        <p>Pregnancy <strong>increases<\/strong> levothyroxine requirement (&uarr;TBG, &uarr;clearance, fetal demand) &mdash; increase dose ~25&ndash;30%, target <strong>TSH &lt;2.5<\/strong> in 1st trimester (trimester-specific, tighter than non-pregnant range). Maternal T4 crosses the placenta and matters for early fetal neurodevelopment; no role for T3 supplementation.<\/p>\n\n        <div class=\"rv-sub\">Epilepsy &amp; AED Teratogenicity<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Drug<\/th><th>Relative risk<\/th><\/tr>\n            <tr><td><strong>Valproate<\/strong><\/td><td>Highest (~9&ndash;10%, dose-dependent) &mdash; NTDs + cognitive impairment<\/td><\/tr>\n            <tr><td>Carbamazepine<\/td><td>Intermediate (~3&ndash;4%)<\/td><\/tr>\n            <tr><td>Lamotrigine \/ Levetiracetam<\/td><td>Lower (~2&ndash;3%) &mdash; preferred where seizure type allows<\/td><\/tr>\n          <\/table>\n        <\/div>\n        <p>Never stop valproate abruptly (seizure\/status risk); refer urgently for a <strong>supervised<\/strong> switch. No dose of valproate is established \"safe\" &mdash; disclosure obligation applies regardless of dose.<\/p>\n\n        <p><span class=\"rv-pill\">DIPSI: single non-fasting 2-hr value &ge;140<\/span> <span class=\"rv-pill-blue\">Pregnancy increases, never decreases, levothyroxine need<\/span> <span class=\"rv-pill-blue\">Valproate: no safe dose, no abrupt stop<\/span> <span class=\"rv-pill-green\">Mechanical valve: LMWH in weeks 6&ndash;12<\/span><\/p>\n\n        <a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-06\">&#x25B6; Open Quiz 06<\/a>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 7 \u2014 HIGH-RISK PREGNANCY & OBSTETRIC LAW\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-07\">\n          <div class=\"rv-sec-num\">Topic 07 &middot; Obstetrics<\/div>\n          <div class=\"rv-sec-title\">High-Risk Pregnancy &amp; Obstetric Law <span class=\"rv-arrow\">&#x2197;<\/span><\/div>\n        <\/a>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">MTP Act 2021 (Amendment) &mdash; Gestational Bands<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Gestation<\/th><th>Decision-maker<\/th><th>Notes<\/th><\/tr>\n            <tr><td>&le;20 weeks<\/td><td>1 RMP<\/td><td>Available to any woman<\/td><\/tr>\n            <tr><td>20&ndash;24 weeks<\/td><td>2 RMPs<\/td><td>Special categories: rape\/incest survivors, minors, change in marital status, disability, fetal abnormality<\/td><\/tr>\n            <tr><td>&gt;24 weeks<\/td><td>State-level Medical Board<\/td><td>Substantial fetal abnormality only; no fixed upper limit<\/td><\/tr>\n          <\/table>\n        <\/div>\n        <p><strong>\"Married woman\" &rarr; \"any woman or her partner\"<\/strong> &mdash; marital status is not a bar to any ground, including contraceptive failure (confirmed in <em>X v. Union of India<\/em>, 2022). Guardian consent applies only to minors\/unsound mind, not to competent unmarried adults.<\/p>\n\n        <div class=\"rv-sub\">PCPNDT Act, 1994<\/div>\n        <p>Liability extends to <strong>both<\/strong> the discloser (sonologist) <strong>and<\/strong> the seeker of sex-determination information (e.g. a relative) &mdash; not the doctor alone. <strong>Section 24<\/strong> presumes the pregnant woman <em>not guilty<\/em> unless proven she compelled the disclosure.<\/p>\n\n        <div class=\"rv-sub\">Rh Isoimmunization<\/div>\n        <p>Anti-D 300 mcg IM at <strong>28 weeks<\/strong> regardless of a negative ICT (negative ICT means prophylaxis will still work, not that it's unnecessary), repeated within <strong>72 hrs postpartum<\/strong> if baby is Rh-positive. Additional doses after any sensitising event (APH, amniocentesis, ECV, trauma).<\/p>\n\n        <div class=\"rv-sub\">Multifetal Pregnancy Reduction (MFPR)<\/div>\n        <p>Falls within the MTP Act's \"termination of pregnancy\" definition when done by a registered RMP with consent &mdash; follows ordinary gestational-band rules. PCPNDT Act applies on top only if the reduction is sex-selective; a Medical Board is not required for routine early MFPR.<\/p>\n\n        <p><span class=\"rv-pill\">MTP bands: 1 RMP \/ 2 RMPs \/ Medical Board<\/span> <span class=\"rv-pill-blue\">PCPNDT: discloser + seeker both liable<\/span> <span class=\"rv-pill-blue\">Anti-D at 28 wks regardless of ICT<\/span> <span class=\"rv-pill-green\">MFPR &ne; PCPNDT unless sex-selective<\/span><\/p>\n\n        <a class=\"rv-quiz-link\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obs-07\">&#x25B6; Open Quiz 07<\/a>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         EXAMINER'S FAVOURITES \u2014 CROSS-SERIES RAPID RECALL\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <div class=\"rv-sec-num\">Cross-Series &middot; Obstetrics<\/div>\n        <div class=\"rv-sec-title\">Examiner's Favourites \u2014 Rapid Recall<\/div>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">Classifications to know cold<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Classification<\/th><th>What it grades<\/th><th>Key anchor<\/th><\/tr>\n            <tr><td>Placenta previa (I&ndash;IV)<\/td><td>Degree of os coverage<\/td><td>IV = complete; absolute contraindication to vaginal delivery<\/td><\/tr>\n            <tr><td>MTP gestational bands<\/td><td>RMP-opinion requirement<\/td><td>&le;20: 1 RMP; 20&ndash;24: 2 RMPs; &gt;24: Medical Board<\/td><\/tr>\n            <tr><td>Severe features (preeclampsia)<\/td><td>When disease becomes \"severe\"<\/td><td>Any ONE of BP\/platelets\/LFT\/creatinine\/oedema\/symptoms<\/td><\/tr>\n            <tr><td>4 Ts of PPH<\/td><td>Cause of postpartum bleeding<\/td><td>Tone (commonest), Tissue, Trauma, Thrombin<\/td><\/tr>\n            <tr><td>Partograph lines<\/td><td>Labor progress<\/td><td>Alert = watch; Action (alert+4h) = intervene<\/td><\/tr>\n          <\/table>\n        <\/div>\n\n        <div class=\"rv-sub\">Eponymous \/ named signs &amp; doctrines &mdash; one-liners<\/div>\n        <p>\n          <span class=\"rv-pill\">Doctrine of necessity: emergency treatment without consent when incapacitated + life-threatening + no time<\/span>\n          <span class=\"rv-pill\">Section 24 (PCPNDT): pregnant woman presumed not guilty unless proven she compelled disclosure<\/span>\n          <span class=\"rv-pill-blue\">Supine hypotensive syndrome: relieved by lateral position, not a cardiology workup<\/span>\n          <span class=\"rv-pill-blue\">DIPSI: single-step, non-fasting, no confirmatory test needed<\/span>\n          <span class=\"rv-pill-green\">Late maternal death: 42 days&ndash;1 year, recorded separately for audit<\/span>\n        <\/p>\n\n        <div class=\"rv-sub\">Number anchors<\/div>\n        <p>\n          <span class=\"rv-pill\">Combined screening: 11&ndash;13+6 wks<\/span>\n          <span class=\"rv-pill\">Anomaly scan: 18&ndash;20 wks<\/span>\n          <span class=\"rv-pill\">Anti-D: 28 wks antenatal + within 72 hrs postpartum<\/span>\n          <span class=\"rv-pill-blue\">Severe preeclampsia BP: &ge;160\/110<\/span>\n          <span class=\"rv-pill-blue\">Warfarin embryopathy window: 6&ndash;12 wks<\/span>\n          <span class=\"rv-pill-blue\">Puerperal sepsis window: up to 42 days postpartum<\/span>\n          <span class=\"rv-pill-green\">Elective delivery, complete previa: ~36&ndash;37 wks<\/span>\n          <span class=\"rv-pill-green\">DIPSI cut-off: 2-hr value &ge;140 mg\/dL<\/span>\n        <\/p>\n\n        <div class=\"rv-sub\">Sequence rules \u2014 act in order<\/div>\n        <p>\n          <span class=\"rv-pill\">Eclampsia: stabilise (MgSO&#8324; + BP) before delivery, never the reverse<\/span>\n          <span class=\"rv-pill\">Breech: offer ECV before defaulting to vaginal trial or cesarean<\/span>\n          <span class=\"rv-pill-blue\">Screening before diagnostic invasive testing, never the reverse<\/span>\n          <span class=\"rv-pill-blue\">Abruption: resuscitate, never tocolyse<\/span>\n          <span class=\"rv-pill-green\">Suspected accreta: planned multidisciplinary delivery, never manual removal<\/span>\n          <span class=\"rv-pill-green\">Valproate in pregnancy: supervised switch, never an abrupt stop<\/span>\n        <\/p>\n\n      <\/div>\n    <\/div>\n\n    <!-- Footer -->\n    <div class=\"rv-footer\">\n      Obstetrics Summative Revision &middot; atsixty.com &middot; Morning Rounds Series<br>\n      <a href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/obstetrics-morning-rounds-index\">&#x2190; Return to Obstetrics Series Index<\/a>\n    <\/div>\n\n  <\/div>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"<p>Morning Rounds &middot; Obstetrics Series ObstetricsSummative Revision Notes Seven topics &middot; NEET-PG \/ INI-CET \/ UPSC CMS &middot; Key facts, thresholds, classifications and the law Antenatal &amp; Consent Hypertensive Disorders Antepartum Hemorrhage Labor &amp; Partograph PPH &amp; Maternal Death Medical Disorders High-Risk &amp; Obstetric Law These notes consolidate the seven Obstetrics Morning Rounds. 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