Direct causes:

• Hemorrhage (25 %)
• Hypertensive disorders (20 %)
• Sepsis (10 %)
• Unsafe abortion (8 %)
• Obstructed labour (5 %)

Indirect: Anemia, heart disease.

📘 Tip: Mnemonic – “5 H’s → Hemorrhage > HTN > Sepsis > Hazardous Abortion > Heart Disease.”
(Ref – Park 26/e Ch. 12)

• Current MMR (2022 SRS): 97 per 1 lakh live births.
• Target (SDG 2030): < 70 per 1 lakh.

• Government initiatives:
  • Janani Suraksha Yojana (JSY) – incentive for institutional delivery.
  • LaQshya – labour-room quality improvement.
  • PMSMA – monthly antenatal check-ups by specialists.
  • Maternal Death Surveillance & Response (MDSR).

📘 Tip: MMR < 100 = India’s milestone success in 2022

What is hypertension = sustain rise of BP more than 140/90 on two occasion 4 or more hour apart ^{upsc cms 2022}

PIH (pregnancy induced HTN) = gestational HTN ^{upsc cms 2022}

Normotensive female before pregnancy  →   Develop HTN AFTER ^{upsc cms} 20 weeks of pregnancy resolve BP within 12 weeks of delivery  ^{Q Q}

Make it easy –ok

^{****upsc cms****} Diagnose HTN after 20 wk but resolve before 12 wk after delivery ^{****upsc cms****}

Gestational HTN = PIH + without proteinuria or END organ damage ^Q

Preeclampsia = PIH + either proteinuria or END organ damage ^Q

Eclampsia = severe Pre eclampsia + GTCS / coma ^Q

Reference = Target CMS 2025 RR

HELLP syndrome  ^{UPSC CMS 2024 & 2014}

Symptoms:- Nausea + vomiting + Headaches. + Visual disturbances.

HELLP syndrome is a severe form of pregnancy complications characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count.^{UPSC CMS 2024 & 2014}

Mc in 3^rd trimester

H – Hemolysis (Low haptoglobin, elevated LDH, increased indirect bilirubin.)

EL – Elevated liver enzymes > 2 times of normal

LP – Low platelets < 1 lakh

 Treatment :- immediate termination of Pregnancy

Reference = Target CMS 2025 RR

1. Stabilize: Airway → Left lateral position → O₂.
   2. Control convulsions: Magnesium sulphate (Pritchard regimen).
   3. Control BP: Labetalol / Hydralazine IV.
   4. Monitor: Urine output > 30 mL/h.
   5. Plan delivery after stabilization.

📘 Tip: MgSO₄ = drug of choice for seizure control in eclampsia — not phenytoin.

• Dose:
  • IM loading: 4 g IV (20% solution) over 3–4 min + 10 g IM (5 g each buttock).
  • IM maintenance: 5 g IM alternate buttock q4h.

Or

• • IV loading: 4–6 g IV over 15–20 min.
  • IV maintenance: 1–2 g/hr infusion.
• Therapeutic level: 4–7 mEq/L. ^Q
• Monitoring before repeat dose: ^{Q CMS}
  ✅ Knee jerks present
  ✅ Urine output > 30 mL/hr
  ✅ Respiration > 12/min
• Side effects (signs of toxicity): ^{Q CMS 2025}
  • Muscular paresis → loss of knee jerk reflex (earliest sign)
  • Respiratory failure (with higher levels) ^{Q CMS}
  • Cardiac conduction abnormalities (heart block) → cardiac arrest (late, fatal)
• Antidote: 10 mL of 10% calcium gluconate IV. ^{Q CMS}
• Contraindication: Myasthenia gravis.

The main goals are:

1. To reduce fertility and stabilize population growth.
2. To ensure spacing of births and improve maternal–child health.
3. To provide access to safe, voluntary contraception for all eligible couples.
4. To promote informed choice through counseling and education.

📘 Tip: “From population control → to reproductive rights & choice.”
(Ref – Park 26/e Ch. 14)

📘 Tip: Always classify as temporary vs permanent + male vs female.

Generations of Intrauterine Devices (IUDs)

Mechanism of Action

 Copper IUCD: Copper ions create a toxic environment for sperm, inhibiting fertilization.
• Levonorgestrel IUCD: The hormone thickens cervical mucus, prevents sperm penetration, and alters the endometrial lining to prevent implantation.

Levonorgestrel induces endometrial thinning, reducing the thickness of the uterine lining — decreased blood loss during menstruation.

1. • Studies show that women using LNG-20 report a significant reduction in menstrual blood loss (up to 80–90% decrease over 12 months).

Indications:

1. Contraception: Primary use for preventing pregnancy in women seeking long-term, reversible contraception.
2. IUD insertion can be performed immediately after a cesarean section, as the uterus is already open, making insertion easier and reducing the risk of insertion complications. ^{Cms 2020}
3. Postpartum:  after 6 weeks postpartum.
4. Heavy Menstrual Bleeding: Levonorgestrel-releasing IUCD helps reduce heavy menstrual bleeding. (extra advantage of LNG- IUCD) ^{Cms 2020 & 2024}
5. Post-abortal: immediately after a miscarriage or abortion.
6. Medical Conditions: Suitable for women with medical conditions like diabetes, hypertension, or those breastfeeding. (OCP cant use) ✶✶ ^{most imp line}

Side Effects:

1. Menstrual Changes: ✶²⁰²⁰
   • Copper IUCD: May cause heavier✶ periods and cramping.
   • Levonorgestrel IUCD: May cause lighter periods or amenorrhea.
2. Pelvic Pain:✶ Some cramping or discomfort, especially in the first few months.
3. Increased Risk of PID: ✶2024 P2 Q 65 Higher risk of pelvic infections
4. Ectopic Pregnancy: ✶Increased risk if pregnancy occurs while using IUCD.
5. Expulsion: Risk of the IUCD being expelled, especially in the first year.
6. Uterine Perforation: Rare, but can occur during insertion.

Contraindications: ^{*✶2002 & 2014 & 2009 & 2016 & 2013 & 2019 & 2017 & 2020 & 2021 & 2022 & 2023 & 2024 EVERY}  YEAR U GET Q from here

1. Pregnancy: ✶²⁰²⁰
2. Active PID: ✶²⁰²⁰
3. Unexplained Vaginal Bleeding: ✶²⁰²⁰
4. Uterine Anomalies: e.g., fibroids.
5. History of Ectopic Pregnancy✶^{2020 & 2022 & 2000 & 2024}:
6. Cervical or Endometrial Cancer:
7. severe dysmenorrhea✶²⁰²⁰ can be a contraindication for IUD insertion if it worsens the pain.
8. Trophoblastic disease✶²⁰²⁰: IUDs should not be inserted in cases of trophoblastic disease

Indication of removal (same as contraindication mostly)

• Pregnancy (intrauterine or ectopic). ✶^{2021 & 2023 & 2024}
• PID or severe infection. ✶²⁰²⁴
• Persistent irregular uterine bleeding ✶²⁰²⁴
• Uterine perforation. ✶^{2020  & 2023 & 2024}
• Device expiration.
• Desire for pregnancy. ✶

• Condoms: Dual protection against STIs + pregnancy; cheap and available under NACP.
• Vasectomy: Simple OPD procedure, no hormonal side effects, permanent reliable method.

📘 Tip: Non-scalpel vasectomy (NSV) is preferred — faster healing, less pain.

📘 Tip: Tubectomy failure rate ≈ 0.4 %; Vasectomy ≈ 0.15 %.

• Mission Parivar Vikas (2016): Focus on high-fertility districts (TFR > 3).
• Antara & Chhaya schemes: Promote injectable DMPA & Centchroman pill.
• Enhanced Post-Partum FP (PPFP): IUCD within 48 h of delivery.
• Adolescent health services (RMNCH + A): Counseling and contraceptive education.

📘 Tip: “Parivar Vikas → spacing and choice expansion, not sterilization targets.”

Define → diagnostic criteria → management outline.

Model Answer:
PCOS is a multifactorial endocrine disorder characterized by chronic anovulation, hyperandrogenism, and polycystic ovaries on ultrasound.

Diagnosis (Rotterdam criteria – need 2 of 3):

1. Oligo/anovulation
2. Clinical/biochemical hyperandrogenism
3. Polycystic ovaries (>12 follicles, 2–9 mm, or ovarian volume >10 mL)

Management:

• Lifestyle modification (weight reduction, exercise).
• For cycles: Combined OCPs.
• For infertility: Clomiphene / Letrozole.
• For metabolic: Metformin if insulin resistance.

📘 Tip: Always mention Rotterdam criteria – it’s the examiner’s keyword.
(Ref – Shaw’s Gynaecology 18/e)

📘 Tip: Fibroid = nodular; Adenomyosis = diffuse.

1. Evaluation:

• USG pelvis → number, site, size of fibroids.
• CBC for anemia; Pap smear.

1. Management:

• Asymptomatic/small: Observe.
• Symptomatic:
  • Medical: Tranexamic acid, OCPs, GnRH analogues.
  • Surgical: Myomectomy (for fertility preservation), Hysterectomy (definitive).
  • Uterine artery embolization (select cases).

📘 Tip: Treatment depends on size, symptoms, and desire for fertility

Mc site Fallopian Tube

(Ampulla) ^{***UPSC CMS***2012} > Isthmus > Infundi > interstitial

Mnemonic = Ampulla is in inter

• Amenorrhea (6-10 weeks)
• Pain lower abdomen

• Bleeding P/V
• Max risk Previous H/O ECTOPIC TUBAL ^{cms 2007 & 2014 & 2019 & 2025}

Diagnosis :-

NOTE – hCG doubling time is 48 hours in normal pregnancy.

Treatment of ruptured Ectopic

Symptoms- pt came with above

triad

+

 sign of shock (HR ↑ + BP ↓)

 +

tender cervical movement

 +

fullness of pouch of Douglas ) ^{UPSC CMS **** 2020 & 2019 & cms 2011 & 2007 & 2000 & 2014 & 2019}

Mx – Always Surgical

Tt of unruptured Ectopic  (EXPECTANT MANAGEMENT)

Initially medical if ^{CMS 2017}

Many time asked in cms

 VITAL STABLE

 BETA HCG < 5000 I/U

GESTATIONAL SAC SIZE ON USG < 4 CM

 FAMILY NOT COMPLETED

NO FETAL CARDIAC ACTIVITY

EXPECTANT MANAGEMENT

Single dose therapy

GIVE ^{****UPSC CMS 2016****}

 Methotrexate (MTx) Dose 50 mg Intramuscular route single dose same day ^Q

multidose regime ^{imp point for upsc cms 2024}

Mtx 1 mg/kg

On

Day 0,1,3,5,7

 Sx

 If medical Mx failed

Beta hCG > 5000 I/U

Sac size on USG > 4 cm

 Family completed

Route of Sx

 Sx of choice

• Ovulatory: PCOS, thyroid disorders, hyperprolactinemia.
• Tubal: PID, post-surgery adhesions.
• Uterine: Fibroids, endometrial synechiae.
• Cervical: Infection, hostile mucus.
• Male factor: Low sperm count, motility defects.

📘 Tip: Always mention “male factor” — accounts for ~40% of cases

Screening methods:

1. Pap smear (cytology): every 3 years, age 21–65.
2. Visual inspection with acetic acid (VIA): used at primary level.
3. HPV DNA testing: every 5 years in higher centers.

Follow-up:

• Abnormal results → Colposcopy → Biopsy → Treatment.

📘 Tip: India recommends VIA-based screening in resource-limited setups.

• Route: IM (deltoid).

📘 Tip: Now part of India’s National Immunization Program (Budget 2024–25).

Menopause is cessation of menstruation for 12 months due to ovarian follicular depletion, usually between 45–55 years.

Symptoms:
Hot flashes, mood swings, vaginal dryness, sleep disturbance.

Long-term effects:

• Osteoporosis
• Cardiovascular risk
• Urogenital atrophy

Management:
Lifestyle modification, calcium-vitamin D, HRT in selected cases.

📘 Tip: Always mention “12 months of amenorrhea” as diagnostic criterion

Define quantitatively → classify → outline immediate management.

Model Answer:
PPH is blood loss > 500 mL after vaginal delivery or > 1000 mL after LSCS, within 24 hours (primary) or up to 6 weeks (post-partum).

Types:

• Primary PPH: within 24 h.
• Secondary PPH: after 24 h to 6 weeks.

📘 Tip: “Any bleeding causing hemodynamic instability = PPH clinically.”
(Ref – DC Dutta 9/e Ch. 37)

📘 Tip: Always massage uterus first — most common cause = atony.

• A – Airway & O₂ support.
• B – Breathing/Circulation: 2 large IV lines, blood grouping & cross-match, start fluids (2 L crystalloids).
• C – Cause search & Control:
  • Uterine massage.
  • Uterotonics: Oxytocin (10 IU IV slow + infusion), Methylergometrine (avoid in HTN), Carboprost (IM), Misoprostol (PR).
  • Inspect for tears → repair.
  • Remove retained tissue (manual exploration).
• D – Drugs/Blood: Transfuse PRBC/Fresh frozen plasma if needed.
• E – Escalate: If persistent → Balloon tamponade (B-Lynch, Bakri), arterial ligation / hysterectomy as last resort.

📘 Tip: “Massage → Medications → Measure loss → Move to OT if refractory.”

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Definition: Inability to deliver shoulders after head has delivered due to impaction of anterior shoulder behind maternal pubic symphysis.

Steps:

1. Call for help & announce emergency.
2. McRoberts maneuver (hips hyperflexed on abdomen).
3. Suprapubic pressure (not fundal!).
4. Episiotomy if needed.
5. Internal manoeuvres: Rubin / Woods corkscrew / delivery of posterior arm.
6. Last resort: Zavanelli (replacement of head → CS).

📘 Tip: “McRoberts + Suprapubic = first two life-saving steps.”

📘 Tip: Suspect rupture in labour with sudden pain relief, fetal parts palpable, shock with no bleeding.

• Call for help immediately.
• Avoid handling cord.
• Elevate presenting part (manually or with knee-chest position / Trendelenburg).
• Cover cord with warm saline-soaked gauze.
• O₂ to mother; continuous FHR monitoring.
• Definitive step: Immediate cesarean section.

📘 Tip: If cord pulsations absent → urgent delivery = only chance to save baby.

Labor is called normal if it fulfills the following criteria

• Spontaneous ^Q in onset and at term

• Painful ^Q uterine contraction at Regular interval^{** UPSC CMS 2024 **}

• Intensity & duration of contraction increasing progressively ^{cms 2023 & 2024}
• Formation of bag of FORE WATER ^Q (descent of presenting part)
• Without undue prolongation
• With vertex presentation
• Natural termination with minimal aids.
• Without having any complications affecting the health of the mother and/or the baby.

📘 Tip: Always mention “regular + progressive contractions.”
(Ref – DC Dutta 9/e, Ch. 32)

Engagement → Flexion → Internal Rotation → Crowning → Restitution → External Rotation. ^{Q CMS 2020}

Enjoy Fresh Ice Cream Regularly Everyday

• E → Engagement
• F → Flexion
• I → Internal rotation
• C → Crowning
• R → Restitution
• E → External rotation

lateral flexion (body of baby delivered)

station at ischial spine = zero station

mc position of fetus during labor – LOT

Active Mx for 3^rd stage of labor  (AMTSL) = Considered the best method to prevent PPH.

Steps in AMTSL (ADDI) ^{cms 2023}

1. Administration of uterotonic (Oxytocin 10 Unit im )
   • Within 1 minute of delivery of the baby.
   • ⚠️ In twins → given only after delivery of last twin ^{Q CMS 2023}
2. Delayed cord clamping:
   • Clamp the umbilical cord 1–3 minutes after delivery.
3. Delivery of placenta:
   • Using controlled cord traction (e.g., Brandt-Andrews technique).
4. Intermittent uterine tone assessment:
   • Earlier practices involved uterine massage.

Note

• Early cord clamping is not a part of AMTSL. ✶✶

Model Answer:

• Cervical dilatation – 1 cm/h in primigravida, 1.5 cm/h in multipara.
• Descent of head – station progress.
• Contraction pattern – frequency 3 / 10 min, duration 30–40 s.
• Fetal heart rate – 120–160 bpm.
• Partograph – to objectively chart progress.

📘 Tip: The alert and action lines on partograph help detect obstructed labour early.

A partograph is a graphical record of key events during labour — cervical dilatation, fetal heart rate, uterine contractions, maternal vitals, and descent of head.

Importance:

• Early detection of abnormal labour progress.
• Guides timely intervention → reduces maternal and perinatal morbidity.
• WHO recommends use for all labours.

📘 Tip: “Alert line = expected progress; Action line = need to intervene.”

indication

F-favorable position and station (+2) ^{cms 2012}

O– os should be fully dilated (2^nd stage of labor) ^{cms 2012}

R– Ruptured membrane ^{upsc cms}

       Rotated head

C– Contracting uterus

E– episiotomy should be given

     Empty bladder ^{upsc cms 2022}

P– pelvis should be adequate (No CPD)

Benefit – PAC MAD (PAC करा लो पागलों की)

(Dear friends max problem preterm ko hi hoti hai – general statement like RDS, jaundice IVH hypothermia )

 P– preterm delivery

AC– after coming head

MA– face mento anterior

D– fetal distress, face presentation, after coming head in breech ^{****UPSC CMS 2015****}

📘 Tip: Remember “Forceps for Fetal distress & Fatigued mother.”

fetal distress

Mal-rotated head (OPP– occipito posterior position of head & DTA ) ^{****UPSC CMS 2015 **** & 2012 & 2020}

Cervix > 6 cm dilated. (incomplete dilated first stage also) ^{Q Q}

position- 6 cm posterior to anterior fontanelle & 3 cm ant to post fontanelle

contraindication of  Ventouse

• preterm (never forget)  ^{** 2023}
• face presentation
• fetal coagulopathy

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• Severe abdominal pain with no progress of labour.
• Contractions become strong and frequent → uterine tetany.
• Bandl’s ring, full bladder, edematous cervix, moulding of head.
• Fetal distress / absent FHR.

📘 Tip: Uterine rupture = final catastrophe of obstruction.

• Immediate stabilization: IV fluids, catheterize bladder.
• Avoid oxytocin / fundal pressure.
• Antibiotics + pain relief.
• Refer urgently to CEmOC centre for operative delivery (usually LSCS).

📘 Tip: Never attempt instrumental delivery in obstructed labour at PHC.

• Absolute: Cephalopelvic disproportion, major placenta previa, transverse lie, previous classical scar.
• Relative: Fetal distress, non-progress, malpresentation, eclampsia, multiple pregnancy with malpresentation.

📘 Tip: “CPD + Placenta previa = must go for LSCS.”

1. Preparation: Explain, empty bladder, asepsis, monitor FHR.
2. Second stage: Encourage pushing with contractions.
3. Delivery of head: Support perineum (Ritgen’s maneuver).
4. Check for cord around neck → slip over head if loose.
5. Deliver shoulders (by gentle traction).
6. Deliver baby → clamp & cut cord (after 1 min if stable).
7. Deliver placenta by controlled cord traction + uterine massage.
8. Inspect perineum and placenta, ensure uterine contraction.

📘 Tip: Remember “head → shoulders → body → placenta → bleeding check.”