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Obstetrics & Gynecology Exam 1. Maternity and childhood protection system. Levels of maternal and perinatal care in the Republic of Belarus. Basics of legislation on maternal and child welfare in the republic of belarus ●The law on demographic security of the republic of belarus ●Decree on strengthening maternal support to families at the birth of children ○At the birth of third and subsequent children, lump-sum beneﬁt is paid in the amount of three minimum subsistence incomes ●The law on state social beneﬁts, rights and guarantees for certain categories of citizens ○Allowances for families raising a disabled child or a child infected with HIV or an AIDS patient aged up to 18 are granted regardless of total income per family member ●The national program of demographic security ○Measures aimed at improving the health of women and children ●The law on assisted reproductive technologies ○Provides new approach to legal regulation in order to apply assisted reproductive technologies based on modern trends Levels of maternal and perinatal care in the Republic of Belarus ●First level of perinatal care ○District level ○Medical care is provided to pregnant women and newborns without risk or with a minimal risk of prenatal loss ○Ensures the identiﬁcation of perinatal and maternal risk factors ○Early diagnosis of diseases and complications of pregnancy ○Referral to higher level of perinatal care if necessary ○First level of perinatal care includes; ■Women's clinic ■Maternity and children's department of the central district hospital ■Outpatient clinic ●Second level of perinatal care ○Inter-district level ○Pregnant women and women in labor with a physiological and pathological course of pregnancy and childbirth and some extragenital pathology are provided with full medical care ○Second level of perinatal care includes; ■Maternity hospitals or obstetric departments of a multidisciplinary hospital ■Intensive care or newborn ICU within the anesthesiology and ICU ■Mobile ICU teams ■Second stage neonatal care units in children's hospitals ■Pediatric departments Ban \| Ham / Aro 1
●Third level of perinatal care ○Is in the regional city ○Medical care of any degree of difﬁculty is provided to pregnant women and their newborn children ○Regional level of perinatal care includes; ■Regional maternity hospital ■Obstetric departments of a multidisciplinary regional hospital ■Regional perinatal center ■Regional children's hospital ■Genetics center ■ICU for newborns ■Mobile ICU teams ■Second stage neonatal care units in children's hospitals ●Fourth level of perinatal care ○National level ■Represented by state institution “Mother and Child Republican Research and Practical Center”-RRPC ○Provides medical care to the most difﬁcult contingent of pregnant women, women in labor, newborn babies and women with reproductive disabilities ■Through the use of modern up-to-date treatment and diagnostic technologies ○Allows minimally invasive surgery ○Laser and cryosurgery ○In vitro fertilization ●Belarus currently has; ○1 perinatal center-level 4 ○16 perinatal centers-level 3 ○28 perinatal centers-level 2 ○66 health care organizations-level 1 2. Concepts of demography. Demographic (population) policy in the Republic of Belarus. Current demographic trends in the world and in the Republic of Belarus. Ban \| Ham / Aro 2
3. Specialized obstetrics and gynecological services. Medico-genetic counseling. ●Prenatal genetic counselors work with individuals, couples, or families who have increased chances of having a child with a birth defect or genetic condition. ●Those who are already pregnant or are considering having a child in the future can meet with a prenatal genetic counselor to ○Learn more about the condition in question ○Understand their risks more clearly, ○Discuss options for prenatal screening, testing, and/or assisted reproduction techniques such as sperm and egg donation. ●During pregnancy, if a baby is found to have a birth defect or genetic condition you may be referred to a prenatal genetic counselor. ●The counselor will help the expecting couple understand the medical information, what to expect, and how to prepare for the birth of a child with special needs, as well as discuss options such as pregnancy termination or adoption. ●Prenatal counselors also help many families who do not have an increased chance of having a child with a birth defect or genetic condition understand prenatal screening and testing options. ●Procedures such as blood tests and ultrasounds may be able to give a better idea if a developing baby has a chance of having birth defects or a genetic condition. 4. Maternal mortality rate and ways of its reduction. ●Maternal mortality rate is the death of a women while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes ●Maternal mortality is calculated by; x100 000𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑑 𝑝𝑟𝑒𝑔𝑛𝑎𝑛𝑡 𝑤𝑜𝑚𝑒𝑛, 𝑤𝑜𝑚𝑒𝑛 𝑖𝑛 𝑙𝑎𝑏𝑜𝑟𝑠, 𝑛𝑒𝑤 𝑚𝑜𝑡ℎ𝑒𝑟𝑠 𝑖𝑛 42 𝑑𝑎𝑦𝑠 𝑎𝑓𝑡𝑒𝑟 𝑡ℎ𝑒 𝑑𝑒𝑙𝑖𝑣𝑒𝑟𝑦 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛 𝑏𝑜𝑟𝑛 𝑎𝑙𝑖𝑣𝑒 ●Maternal mortality is classiﬁed as ○Death caused directly by obstetric reasons ■Obstetric complication of pregnancy ■Childbirth ■Postnatal period ■Inappropriate treatment tactics ○Death indirectly due to obstetric reasons ■Pre-existing disease, directly related to pregnancy or other obstetric causes, but exacerbated by the physiological effects of pregnancy ○Accidental death not related to pregnancy, childbirth, postnatal period or their complications and treatment ●Maternal mortality rate makes it possible to asses all losses of pregnant women from abortion, ectopic pregnancy, obstretic and extra-uterine pathology during the entire period of gestation and postnatal period Ban \| Ham / Aro 3
●“Near Miss” ○A women who nearly died but survived a complication that occured during pregnancy, childbirth or within 42 days of termination of pregnancy ○3 types of near miss ■Class 1 ●Almost dead with a favorable outcome for the newborn ■Class 2 ●Nearly dead mothers and nearly dead fetus/newborn ■Class 3 ●Nearly dead women who have also suffered perinatal loss Factors contributing to the reduction in maternal mortality ●Economic factors ●Social factors ●Hygienic factors ●Progress made in prevention and treatment of infectious diseases ●Establishment of perinatal centers ●Identiﬁcation of women at risk of complications during pregnancy and childbirth ●Improvement in prenatal and antenatal care of pregnant women ●Availability of well equipped maternity departments ○To provide qualiﬁed medical care for severe extragenital pathologies, anesthesiological and obstetric complications Ways to reduce maternal mortality rate ●Basic antenatal, intranatal and postnatal care ●A skilled attendant should be present at every birth. ●Emergency obstetric care (EMOC) is to be provided at the ﬁrst referral unit (FRU). ●Good quality obstetric services at the referral centers are to be ensured. ●Facilities for blood transfusion, laparotomy and cesarean section must be available at the FRU level. ●Prevention of unwanted pregnancy and unsafe abortion. ●All couples and individuals should have access to effective, client oriented and conﬁdential family planning services. ●Frequent joint consultation among specialists in the management of medical disorders in pregnancy particularly anemia, diabetes, cardiac disease, viral hepatitis,and hypertension. ●Maternal mortality conferences to evaluate the cause of death and the avoidable factors. ●Periodic refresher courses for continuing education of obstetricians, general practitioners, midwives and ancillary staff and to highlight the preventable factors. Ban \| Ham / Aro 4
5. Perinatal mortality rate and ways of its reduction. ●Perinatal mortality is deﬁned as death among fetuses weighing 1000 g or more at birth (28 weeks of gestation) who died before or during delivery or within the ﬁrst 7 days of delivery. ●Perinatal mortality rate is calculated per 1000 live and dead birth x1000𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑠𝑡𝑖𝑙𝑙 𝑏𝑜𝑟𝑛 𝑎𝑛𝑑 𝑑𝑒𝑎𝑑 𝑑𝑢𝑟𝑖𝑛𝑔 7 𝑑𝑎𝑦 𝑖𝑛𝑓𝑎𝑛𝑡𝑠 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑖𝑛𝑓𝑎𝑛𝑡𝑠 𝑏𝑜𝑟𝑛 𝑎𝑙𝑖𝑣𝑒 𝑜𝑟 𝑑𝑒𝑎𝑑 Ways to reduce perinatal mortality rate ●Pre Pregnancy health care and genetic counseling. ●Regular antenatal care, with advice regarding health, diet and rest. ●Detection and management of medical disorders in pregnancy. ○Anemia ○Diabetes ○Infections ○Preeclampsia/Eclampsia ●Immunization against tetanus ●Careful monitoring in labor to detect hypoxia early ●Skilled birth attendant. 6. Antenatal, intranatal and early neonatal mortality-deﬁnitions, risk factors and causes. ●Antenatal death ○From 22 weeks of pregnancy ●Intranatal death ○During childbirth ●Early neonatal death ○During ﬁrst 168 hours of life (7 days) Causes ●Antenatal Causes: ○Maternal diseases ■Hypertension ■Cardiovascular diseases ■Diabetes ■Infections ■Anemia ■Pelvic diseases ■Anatomical defects. ●Intranatal Causes: ○Birth injuries ○Asphyxia ○Prolonged effort time ○Obstetric complications ●Postnatal Causes: ○Prematurity ○Respiratory distress syndrome ○Respiratory and alimentary infections ○Congenital anomalies Ban \| Ham / Aro 5
Risk factors ●Unfavorable obstetric history ○>2 previous miscarriages or cervical incompetence ●Preeclampsia ●Gestational diabetes ●Antepartum hemorrhage ●Premature birth ●Low birth weight and birth defects ●Delivery complication ●Puerperal complication 7. Diagnostic methods in obstetrics. Prenatal screening. Diagnostic Methods ●Alpha-fetoprotein (AFP) test or multiple marker test. ●Amniocentesis. ●Chorionic villus sampling. ●Cell-free fetal DNA testing. ●Percutaneous umbilical blood sampling (withdrawing a small sample of the fetal blood from the umbilical cord) ●Ultrasound scan. Ban \| Ham / Aro 6
8. Critical periods of fetal development. Inﬂuence of harmful factors during pregnancy. ●3 periods are distinguished in the prenatal development of the fetus. ○Ovular period or germinal period ■Lasts for the ﬁrst 2 weeks following ovulation. ■In spite of the fact that the ovum is fertilized, it is still designated as ovum. ○Embryonic period ■Begins at 3rd week following ovulation and extends up to 10 weeks of gestation (8 weeks post conception). ■The crown-rump length (CRL) of the embryo is 4 mm. ○Fetal period ■Begins after 8th week following conception and ends in delivery. ■The chronology in the fetal period is henceforth expressed in terms of menstrual age and not in embryonic age Inﬂuence of Harmful Factors ●Alcohol use ○Drinking alcohol during pregnancy can increase the baby's risk for fetal alcohol spectrum disorders (FASDs), sudden infant death syndrome, and other problems. ○The effects range from mild to severe, and they include ■Intellectual and developmental disabilities ■Behavior problems ■Abnormal facial features ■Disorders of the heart, kidneys, bones, and hearing. ●Tobacco use. ○Smoking during pregnancy puts the fetus at risk for preterm birth, certain birth defects, and sudden infant death syndrome (SIDS). ○One study showed that smoking doubled or even tripled the risk of stillbirth, or fetal death after 20 weeks of pregnancy. ○Smoking during pregnancy leads to changes in an infant's immune system. ○Secondhand smoke also puts a woman and her developing fetus at increased risk for health problems. ●Drug use. ○Smoking marijuana and using illegal drugs doubled the risk of stillbirth. ○Research also shows that smoking marijuana during pregnancy can interfere with normal brain development in the fetus, possibly causing long-term problems. Ban \| Ham / Aro 7
9. Congenital abnormalities of the fetus. Screening for congenital malformations during pregnancy. Common congenital abnormalities ●Anencephaly ●Meningoencephalocele ●Spina biﬁda occulta ●Meningocele, Meningomyelocele ●Hydrocephalus ●Microcephaly ●Congenital heart diseases ●Tracheoesophageal ﬁstula ●Esophageal atresia ●Congenital megacolon ●Exomphalos Identiﬁcation of fetal abnormality ●The identiﬁcation of fetal abnormality is an important component of antenatal care. ●It is now possible to identify a large number of abnormalities. ●Many of these are sufﬁciently severe to be detectable at early gestations allowing the woman to elect for termination of the pregnancy if she wishes. ●In other cases, termination may not be indicated but knowledge of the presence of the condition permits preparation of the woman, her partner and the pediatric and obstetric teams for treatment following delivery. ●A number of conditions may be amenable to fetal surgery but this expertise remains largely within a small number of highly specialized centers. ●The term 'prenatal diagnosis' has become established to describe these diagnostic techniques. Screening tests and diagnostic tests ●Screening tests are offered to a population in which there are no speciﬁc risk factors which would indicate the need for diagnostic testing. ●Thus, a woman who had previously had a pregnancy complicated by fetal trisomy may elect to opt for diagnostic testing from the outset. Screening at 11 to 14 weeks ●Screening for congenital abnormality may be undertaken using biochemical assays, ultrasound. ●Ultrasound can be used at this stage to identify structural abnormalities. ●Anencephaly and anterior abdominal wall defects may be seen but more subtle signs are now used, the foremost of which is measurement of nuchal translucency. ●In normal ﬁrst trimester pregnancy a ﬂuid ﬁlled area on the posterior surface of the neck may be seen and measured. ●An association between increased size of nuchal translucency (NT) and chromosomal and heart abnormalities is now well recognized. ●At any given maternal age, the measurement of NT can be used to modify the underlying age-related risk of a fetal trisomy. ●Measurement of NT can be analyzed in combination with biochemical markers such as Pregnancy Associated Proteins and oestriol and HCG to give a speciﬁc risk of the fetus being affected. ●In many centers a risk of 1250 would be used to identify women at sufﬁciently high risk to merit diagnostic testing such as chorionic villus sampling or amniocentesis. Ban \| Ham / Aro 8
Screening at 15 to 21 weeks ●Detailed ultrasound assessment of fetal anatomy is commonly undertaken around 18 to 20 week's gestation ●But at this stage ultrasound is not of value in identifying Down's syndrome since nuchal translucency has disappeared at this stage (in the absence of associated abnormalities such as anterior abdominal wall defects such as exomphalos). ●Biochemical measurement of maternal serum α-fetoprotein (AFP), HCG and oestriol can be used in conjunction with maternal age, to calculate a risk for Down's syndrome, so-called triple testing. ●Again, a high risk indicates the need for amniocentesis to obtain a fetal karyotype. ●Measurement of AFP alone can be used as a screening test for a number of defects if detailed anatomy screening by ultrasound is not available. ●AFP is elevated in a number of conditions and, if elevated, indicates the need for further ultrasound assessment. ●AFP is elevated in conditions such as: ○Anencephaly (AFP screening detects all cases) ○Open neural tube defect (AFP screening detects 85-90% of cases) ○Exomphalos ○Gastroschisis ○Placental hemangioma ○Certain fetal renal dysplasia ○AFP is also elevated in multiple pregnancies ○In cases of fetomaternal bleeding as may occur with threatened miscarriage. ○Some structural anomalies are best identiﬁed by detailed ultrasound examination later in pregnancy and fetal echocardiography may be undertaken between 20 and 24 weeks. Diagnostic testing ●Ultrasound examination may be used to diagnose structural abnormality as the consequence of the results of a screening test, for example, an elevated MS AFP level. ●When there is a question of chromosomal abnormality, invasive testing is required to obtain fetal tissue from which chromosomes can be identiﬁed for karyotyping. ●In the 1sttrimester Chorionic Villus Sampling (CVS)may be done, using ultrasound guidance. ●Tissue can be obtained either transvaginally or transabdominally. ●The pregnancy loss rate after CVS is 4% but this reﬂects the high spontaneous miscarriage rate between eight and twelve weeks. ●This procedure is now usually performed around eleven weeks gestation. ●Fetal blood sampling offers a rapid result for karyotyping but requires considerable expertise in removing blood from the fetal umbilical vessels. ●This technique may also be used ○Diagnostically in cases of rhesus disease, when blood grouping of fetus can be performed, ○Therapeutically when blood transfusion into the fetal circulation is highly effective. Ban \| Ham / Aro 9
10. The development and functions of the placenta. Functions of the amniotic ﬂuid. THE PLACENTA ●Human placenta is ○Discoid一 because of its shape; ○Hemochorial一 because of direct contact of the chorionwith the maternal blood ○Deciduate一 because some maternal tissue is shed atparturition. ●The placenta is attached to the uterine wall and establishes connection between the mother and fetus through the umbilical cord. ●The fact that maternal and fetal tissues come in direct contact without rejection suggests immunological acceptance of the fetal graft by the mother. DEVELOPMENT ●The placenta is developed from 2 sources. ○The fetal component which develops from the chorion frondosum ○The maternal component consists of decidua basalis. ●When the interstitial implantation is completed on the 11th day, the blastocyst is surrounded on all sides by lacunar spaces around cords of syncytial cells, called trabeculae. ●From the trabeculae develops the stem villi on the 13th day, which connects chorionic plate with basal plate. ●Primary, secondary and tertiary villi are successively developed from the stem villi. ●Arterio-capillary-venous system in the mesenchymal core of each villus is completed on 21st day. ●This makes connection with the intraembryonic vascular system through the body stalk ●Simultaneously, lacunar spaces become conﬂuent with one another and by 3rd-4th week, form a multilocular receptacle lined by syncytium and ﬁlled with maternal blood. ●This space becomes the future intervillous space. ●As the growth of the embryo proceeds, ○Decidua capsularis becomes thinner beginning at 6th week and both the villi ○Lacunar spaces in the abembryonic area get obliterated, converting the chorion into chorion laeve ●This is, however, compensated by ○Exuberant growth and proliferation of the decidua basalis ○Enormous and exuberant division and subdivision of the chorionic villi in the chorion frondosum. ●These two, i. e., chorion frondosum and the decidua basalis form the discrete placenta. ●It begins in the 6th week and is completed by the 12th week. ●Until the end of the 16th week, the placenta grows both in thickness and circumference due to growth of the chorionic villi with accompanying expansion of the intervillous space. ●Subsequently, there is little increase in thickness but it increases circumferentially till term. ●The human hemochorial placenta derived its name from hemo (blood) that is in contact with the syncytiotrophoblasts of chorionic tissue. Ban \| Ham / Aro 10
Functions of Placenta ●Function of the placenta is not merely the transport of nutrients and respiratory gasses. ●Respiratory Function. ○The anatomy of the fetal and maternal blood supply to the placenta ensures efﬁcient transport of oxygen and carbon dioxide, chieﬂy by diffusion. ○The difference in oxygen dissociation characteristics of fetal blood from maternal blood further enhances fetal oxygen uptake. ●Excretory Function. ○Waste products form the fetus such as urea, uric acid, and creatinine are excreted in the maternal blood by simple diffusion. ●Nutritional. ○Permeability of the placenta to glucose is much greater than would be expected from its lipid solubility ○There is a speciﬁc transport mechanism for glucose, lipids, fatty acids. ●Endocrine Function. ○A large number of hormones are produced by the placenta. ○These include hormones analogous to adult hypothalamic and pituitary hormones and steroid hormones. ○A variety of other products are produced by the placenta. ○Many of these are glycoproteins such as Pregnancy Associated Proteins A to D, Pregnancy Speciﬁc Glycoprotein (SP1) and Placental Protein 5 (PP5). Functions of Amniotic Fluid ●Its main function is to protect the fetus. ●During pregnancy: ○It acts as a shock absorber, protecting the fetus from possible extraneous injury; ○Maintains an even temperature; ○The ﬂuid distends the amniotic sac and thereby allows for growth and free movement of the fetus and prevents adhesion between the fetal parts and amniotic sac; ○Its nutritive value is negligible because of the small amount of protein and salt content; however, water supply to the fetus is quite adequate. ●During labor: ○Amnion & chorion are combined to form a hydrostatic wedge which helps in dilatation of cervix; ○During uterine contraction, it prevents marked interference with the placental circulation so long as the membranes remain intact; ○It guards against umbilical cord compression; ○It ﬂushes the birth canal at the end of the ﬁrst stage of labor and by its aseptic and bactericidal action protects the fetus and prevents ascending infection to the uterine cavity. Ban \| Ham / Aro 11
11. The structure and functions of the umbilical cord and placenta. PLACENTA ●The placenta consists of two plates. ●The chorionic plate lies internally. ●It is lined by the amniotic membrane. ●The umbilical cord is attached to this plate. ●The basal plate lies in the maternal aspect. ●Between the two plates lies the intervillous space containing the stem villi with their branches, the space being ﬁlled with maternal blood. FUNCTIONS OF THE PLACENTA ●Transfer of nutrients and waste products between the mother and fetus. ●In this respect, it attributes to the following functions: ○Respiratory; ○Excretory; ○Nutritive ○Endocrine function: ■Placenta is an endocrine gland. ■It produces both steroid and peptide hormones to maintain pregnancy. ○Barrier function. ○Immunological function. ○Enzymatic Function THE UMBILICAL CORD ●The umbilical cord or funis forms the connecting link between the fetus and the placenta through which the fetal blood ﬂows to and from the placenta. ●It extends from the fetal umbilicus to the fetal surface of the placenta. ●DEVELOPMENT: ○The umbilical cord is developed from the connective stalk or body stalk, which is a band of mesoblastic tissue stretching between the embryonic disk and the chorion. ○Initially, it is attached to the caudal end of the embryonic disk, but as a result of cephalocaudal folding of the embryo and simultaneous enlargement of the amniotic cavity the amnio ectodermal junction converges on the ventral aspect of the fetus. ○As the amniotic cavity enlarges out of proportion to the embryo and becomes distended with ﬂuid, the embryo is carried more and more into the amniotic cavity with simultaneous elongation of the connective stalk, the future umbilical cord. Ban \| Ham / Aro 12
●STRUCTURES: ○The constituents of the umbilical cord when fully formed are as follows ○Covering epithelium: ■It is lined by a single layer of amniotic epithelium but shows stratiﬁcation like that of fetal epidermis at term. ○Wharton's jelly: ■It consists of elongated cells in a gelatinous ﬂuid formed by mucoid degeneration of the extraembryonic mesodermal cells. ■It is rich in mucopolysaccharides and has got protective function to the umbilical vessels. ○Blood vessels: ■Initially, there are 4 vessels — 2 arteries and 2 veins. ■The arteries are derived from the internal iliac arteries of the fetus and carry the venous blood from the fetus to the placenta. ■Of the two umbilical veins, the right one disappears by the 4th month, leaving behind one vein which carries oxygenated blood from the placenta to the fetus. ○Remnant of the umbilical vesicle (yolk sac) and its vitelline duct: ■Remnant of the yolk sac may be found as a small yellow body near the attachment of the cord to the placenta ■On rare occasions, the proximal part of the duct persists as Meckel's diverticulum. ○Allantois: ■A blind tubular structure may be occasionally present near the fetal end which is continuous inside the fetus with its urachus and bladder. ○Obliterated extraembryonic coelom: ■In the early period, intraembryonic coelom is continuous with extraembryonic coelom along with herniation of coils of intestine (midgut). ■The condition may persist as congenital umbilical hernia or exomphalos. ●ATTACHMENT: ○In the early period, the cord is attached to the ventral surface of the embryo close to the caudal extremity, but as the coelom closes and the yolk sac atrophies the point of attachment is moved permanently to the center of the abdomen at 4th month. ○Unlike the fetal attachment, the placental attachment is inconsistent. ○It usually attaches to the fetal surface of the placenta somewhere between the center and the edge of the placenta, called eccentric insertion. ○The attachment may be central, marginal or even on the chorion leave at a varying distance away from the margin of the placenta, called velamentous insertion. Ban \| Ham / Aro 13
FUNCTIONS OF UMBILICAL CORD ●The umbilical cord plays a vital role in the transport of maternal nutrients for the development of the fetus during gestation. ●Within the fetus, the umbilical vein goes towards the transverse ﬁssure of the liver and happens to split into two. ○One of these branches joins with the hepatic portal vein which carries blood into the liver. ○The second branch bypasses the liver ﬂowing into the inferior vena cava, which carries blood towards the heart. ●The two umbilical arteries are formed by the hypogastric arteries which branch from the internal iliac arteries and pass on either side of the urinary bladder into the cord, completing the route back to the placenta. 12. The size of the fetus head, sutures, fontanelles. Sutures ●Sutures are joints between the bones of the skull. ●In the fetus they can give a little under the pressure on the baby's head as it passes down the birth canal. ●During early childhood, these sutures harden, and the skull bones can no longer move relative to one another, as they can to a small extent in the fetus and newborn. ○The lambdoid sutureforms the junction between theoccipital and the parietal bone. ○The sagittal suturejoins the two parietal bones together. ○The coronal suturejoins the frontal bone to the twoparietal bones. ○The frontal suturejoins the two frontal bones together. Ban \| Ham / Aro 14
13. Diagnostics of pregnancy. SIGNS AND SYMPTOMS ●AMENORRHOEA ○An overdue menstrual period remains, for most women with a regular menstrual cycle, the ﬁrst suggestion of pregnancy. ○Pregnancy is the commonest cause of amenorrhoea ○Occasionally a women may continue to bleed in early pregnancy around the time of suppressed menstruation. ○This is usually called decidual bleeding and may, in theory, continue until about 12 weeks when the decidua capsularis fuses with the decidua vera ●NAUSEA OR SICKNESS ○Many women suffer some gastric upset in the early months of pregnancy, from nausea and anorexia to repeated vomiting, especially in the morning. ○The cause is unknown and raised levels of both estrogen and human chorionic gonadotropin (HCG) in the circulation have been blamed. ○Gastric motility is reduced, and in early pregnancy, the lower esophageal sphincter is relaxed. ●BLADDER SYMPTOMS ○Increased frequency of micturition in the second and third months is due to a combination of increased vascularity and pressure from the enlarging uterus. ○Near term, frequency may again appear due mainly to pressure of the fetal head on the bladder. ●BREAST CHANGES ○The earliest symptoms and signs — increased vascularity and a sensation of heaviness, almost of pain — appear at 6 weeks. By 8 weeks the nipple and surrounding area — the primary areola — have become more pigmented. ○Montgomery's tubercles — sebaceous glands which become more prominent as raised pink-red nodules on the areola. ○By 16 weeks a clear ﬂuid (colostrum) is secreted and may be expressed. ○By 20 weeks the secondary areola — a mottled effect due to further pigmentation — has become prominent. ●Uterine changes ○Although no longer commonly undertaken, uterine enlargement may be detected on bimanual examination at seven to eight weeks. ●PALPABLE UTERINE ENLARGEMENT ○At 7 weeks the uterus is the size of a large hen's egg. ○At 10 weeks it is the size of an orange. ○At 12 weeks it is the size of a grapefruit. ○Cervical and uterine softening and a bluish discoloration of the cervix, due to increased vascularity, may be apparent but these signs are not invariable. ○The uterus is palpable abdominally by 12 weeks and the mother may be aware of an increase in abdominal size by 16 weeks. ○The fundal height increases progressively until near term. ○It is an uncertain guide to gestational age of the fetus, however, because of factors such as liquor volume, obesity and muscle tone. Ban \| Ham / Aro 15
○A reduction in fundal height ('lightening') may occur at the end of pregnancy when the presenting part of the fetus descends as the lower segment and cervix prepare for labour. ●AWARENESS OF FETAL MOVEMENT ('QUICKENING') ○Felt by the mother at 16-18 weeks in parous women and two to three weeks later in a primigravida. ●PALPABLE UTERINE CONTRACTIONS ○The uterus undergoes irregular, painless contractions from the 9th to 10th week onward. ○These may become palpable by the 20th week on abdominal examination. ○Braxton Hicks' contractionsand they become more frequentas pregnancy advances. ●AUSCULTATION OF THE FETAL HEART ○The fetal heart may be heard with a fetal stethoscope (Pinard) pressed on the abdomen, over the back of the fetus, from about 24-26 weeks. ○Using small, highly portable fetal heart detectors, which rely on Doppler ultrasound, fetal heart activity may be identiﬁed from 12-14 weeks. ○As Doppler methods detect movements within a beam of transmitted ultrasound, the sounds obtained have to be distinguished from ■The maternal pulse, transmitted by the aorta, ■The uterine soufﬂe, a blowing sound caused by pulsation of blood through the enlarged uterine arteries. Ban \| Ham / Aro 16
●PALPABLE FETAL PARTS ○Fetal parts, such as the head and limbs, begin to be felt from around 26 weeks. ●SKIN CHANGES ○As pregnancy proceeds, areas which are already pigmented become more so — the nipples, external genitalia and anal region. ○Some fresh pigmentation appears on the face (chloasma) and on the abdomen (linea nigra). ○These changes are thought to be due to the deposition of melanin. ○Melanocyte-stimulating hormone is elevated from early pregnancy. ○Striae gravidarum are depressed streaks on the skin of the fat areas — abdomen, breasts, thighs. ○After delivery they regress and persist as striae albicantes. ○They are due to stretching, but may also be associated with increased secretion of ACTH affecting connective tissues. PREGNANCY TESTS ●DETECTION OF HCG ○By 14 days after fertilization the chorion of the blastocyst is secreting HCG and this can be detected in either the mother's blood or urine by the time of the ﬁrst missed period. ○Modern pregnancy tests identify speciﬁcally the beta subunit of HCG and can detect as little as 25 IU/l HCG. ○They are available commercially as simple slide tests. ●ULTRASOUND ○An ultrasound scan can detect an intrauterine gestation sac after 5 to 6 weeks of amenorrhoea. ○Scanning by the vaginal route will identify a fetus as early as 5 weeks gestation. ○Trans-abdominal scanning from 7 weeks will permit measurement of the crown-rump length of the fetus. ○This can be measured to determine gestational age. ○Ultrasound is the only technique which can conﬁrm fetal viability in early pregnancy. Ban \| Ham / Aro 17
14. Initial routine examination of obstetric patient: medical history, physical exam. Method for estimating due date (EDD) and gestational age. Sick leave beneﬁts during pregnancy. GENERAL RECOMMENDATIONS AT FIRST VISIT ●PRENATAL DIAGNOSIS ○Facilities available for prenatal screening and diagnosis of fetal anomalies should be explained. ○It should be emphasized that the mother 'opts in' to these services rather than the reverse. ●DIET, SMOKING AND ALCOHOL ○Routine iron supplementation for non anemic women is unnecessary and may be harmful. ○Help with discontinuing smoking should be offered and nicotine replacement therapy may be used with some beneﬁt. ○There is an increasing body of evidence suggesting harm to the fetus from alcohol consumption during pregnancy. ○Binge drinking in early pregnancy may be particularly harmful. ○However, it remains the case that there is no evidence of harm from low levels of alcohol consumption, deﬁned as no more than one or two units of alcohol once or twice a week. ○In antenatal clinics, effort should be made to improve objective history taken about alcohol and other substance abuse, in order to identify the high-risk group of women with problem drinking. ●EXERCISE AND WORK ○Most mothers should be encouraged to see pregnancy as a healthy state and, within reason, normal activity both domestic and recreational, may be continued. ○Outside employment usually continues at least until the end of the second trimester. ○Increasingly women, especially in the professional groups, work until term. ○They should make efforts to ensure adequate rest. ●COITUS ○Normal behaviour in pregnancy encompasses continued sexual intercourse. ○Uncommonly, in complicated pregnancies, this may not be appropriate. ●DRUGS ○The mother should be advised to avoid any form of medication unless authorized by her doctor. ●TEETH ○A full dental check in early pregnancy should be recommended ○There is no objection to the use of local anesthesia for dental treatment. ●BOWEL ACTION ○Constipation is common in pregnancy and should not be a cause for concern. ○A diet high in ﬁber and fruit helps and mild laxatives may be taken if required. MEDICAL HISTORY ●Gravida and parity: ○Gravida denotes a pregnant state both present and past, irrespective of the period of gestation. ○Parity denotes a state of previous pregnancy beyond the period of viability. ○Gravida and para refer to pregnancies and not to babies. ●Complaints Ban \| Ham / Aro 18
●History of present illness ●History of present pregnancy ○These are hyperemesis and threatened abortion in ﬁrst trimester, features of pyelitis in second trimester and anemia, preeclampsia and antepartum hemorrhage in the last trimester. ○Number of previous antenatal visits (booking status), immunization status, has to be noted. ○Any medication or radiation exposure in early pregnancy or medical-surgical events during pregnancy should be enquired. ●Menstrual history: ○Cycle, duration, amount of blood ﬂow and ﬁrst day of the last normal menstrual period (LNMP) are to be noted (spontaneous). ○From the LNMP, the expected date of delivery (EDD) has to be calculated. ○The ﬁrst day of the menstruation being the important event can be remembered precisely while the last day of the period is often tailed off and hence may be forgotten. SUBSEQUENT ANTENATAL EXAMINATIONS ●The traditional pattern, monthly examination until 28 weeks, then fortnightly until 38 weeks and weekly thereafter has much to commend it since antenatal care remains a screening test for impaired fetal growth, malpresentation, anemia, pre-eclampsia and other disorders. ●Special investigations are only used when indicated by a possible abnormality by the routine examinations. ●In parous, healthy women, a less intensive pattern of antenatal care is appropriate. ●BLOOD PRESSURE ○Should be measured at each visit ○Should be 130/80 mm Hg or less and not above 140/90 mm Hg. ○Elevation above these levels demands further investigation. ●URINE ○The urine should be tested at each visit for protein and sugar. ○When protein is detected, contamination and infection should be excluded before the observation is signiﬁcant. ○Glycosuria is common but if persistent or recurrent a glucose tolerance test is indicated. ●HAEMOGLOBIN ○Dietary anemia is now less common. ○Haemoglobin levels should be estimated early in pregnancy and at about 30 and 36 weeks. ○Levels below 100 g/l are indicative of anemia regardless of gestation. ●RHESUS TESTING ○Rhesus negative women are identiﬁed at the booking visit. ○A screening test for other red cell antibodies is also carried out. ○This should be repeated regularly throughout the pregnancy ABDOMINAL EXAMINATION ●Regular abdominal palpation remains an important part of antenatal care. ●It is the easiest and cheapest method of fetal monitoring and repeated examinations by the same observer may give a ﬁrst indication of restricted fetal growth, or excessive increase in uterine size due to polyhydramnios or multiple pregnancy. ●Continuity of care is clearly important in this context. ●Need to check Ban \| Ham / Aro 19
○Presentation ○Attitude ○Lie ○Position ○Pelvis ○Denominator CALCULATION OF THE EXPECTED DATE OF DELIVERY (EDD): ●This is done according to Naegele's formula (1812) by adding 9 calendar months and 7 days to the ﬁrst day of the last normal (28 days cycle) period. ●Alternatively, one can count back 3 calendar months from the ﬁrst day of the last period and then add 7 days to get the expected date of delivery; the former method is commonly employed. ○Example: The patient had her ﬁrst day of last menstrual period on 1st January. By adding 9 calendar months it comes to 1st October and then adds 7 days, i. e. 8th October, which becomes the expected date of delivery. ●For IVF pregnancy date of LMP is 14 days prior to date of embryo transfers (266 days). Ban \| Ham / Aro 20
15. Anatomy of the female pelvis. Planes and diameters of the pelvis. ●The pelvic girdle, a basin shaped cavity, and consist of two innominate bone (hip bones), ○Sacrum ○Coccyx ●It is also a bony ring between the movable vertebrae of the vertebral column which it supports, the lower limbs that it rests on. ●It contains and protects the bladder, rectum and internal reproductive organs. ●Some women experience pelvic girdle pain in pregnancy and need referral to a physiotherapist. Innominate bone ●Each innominate bone (hip bone) is made up of 3 bones that have fused together: ○Ilium, ○Ischium ○Pubis. ○It is a ﬁxed bone. The sacrum ●A wedge-shaped bone consisting of ﬁve fused vertebrae. ●Upper border of the ﬁrst sacral vertebra, which juts forward, is known as the sacral promontory ●Coccyx is a vestigial tail. ○Consists of four fused vertebrae, forming a small triangular bone, which articulates with the 5thsacral segment. Pelvic joints ●There are 4 pelvic joints: ○Symphysis pubis ○Two sacroiliac joints ○Sacrococcygeal joint. ●The symphysis pubis is the midline cartilaginous joint uniting the rami of the left and right pubic bones. ●Sacroiliac joints are strong, weight-bearing synovial joints. ●They join the sacrum to the ilium and as a result connect the spine to the pelvis. ●The joints allow a limited backward and forward movement of the tip and promontory of the sacrum, sometimes known as 'nodding' of the sacrum. ●The sacrococcygeal joint is formed where the base of the coccyx articulates with the tip of the sacrum. It permits the coccyx to be deﬂected backwards during the birth of the fetal head. Pelvic Ligaments ●Ligaments connecting the bones of the pelvis with each other can be divided into four groups: ○Sacroiliac ligament-those connecting the sacrum and ilium, ○Sacrospinous ligament-those passing between the sacrum and ischium. ○Sacrococcygeal ligaments-those uniting the sacrum and coccyx. ○Interpubic ligaments-those between the two pubic bones Ban \| Ham / Aro 21
●The ligaments that are important to midwifery practice are the sacrotuberous and the sacrospinous ligaments as they form the posterior wall of the pelvic outlet. Pelvis False pelvis (pelvis major) True pelvis (pelvis minor) ●True pelvis is located below the iliopectineal line, bounded anteriorly by the pubic bones, posteriorly by the sacrum and coccyx, laterally by the ischium and a small segment of the ilium. ●Bony canal through which the fetus must pass during labor. ●It is divided into a brim, a cavity, and outlet. Pelvic Brim ●The pelvic brim called pelvic inlet :Pelvic inlet ( = pelvic brim) ●The brim is rounded except where the sacral promontory projects into it. ●The Plane of the Brim is bounded ○Anteriorly by the Pubis, ○Laterally by the Iliopectineal lines, ○Posteriorly by the Alae and Promontory of the Sacrum. Ban \| Ham / Aro 22
Pelvic Cavity & Outlet ●Pelvic cavity extended from the brim superior to the outlet inferiorly. ●The pelvic outlet is formed by the lower borders of each of the bones together with the sacrotuberous ligament. ○It includes the narrow pelvic strait which the fetus must pass. ●The Plane of the Outlet is bounded Anteriorly by Pubic Arch, Laterally by Great Sacrosciatic Ligaments and Ischial Tuberosities, Posteriorly by Tip of Coccyx if fused or to End of Sacrum. Diameters of Pelvis Ban \| Ham / Aro 23
16. Female pelvic ﬂoor anatomy and function. PELVIC FLOOR STRUCTURE ●The pelvic ﬂoor is a funnel-shaped structure. ●It attaches to the walls of the lesser pelvis, separating the pelvic cavity from the perineum inferiorly (region which includes the genitalia and anus). ●In order to allow for urination and defecation, there are a few gaps in the pelvic ﬂoor. ●There are two 'holes' that have signiﬁcance: ○Urogenital hiatus ■An anteriorly situated gap, which allows passage of the urethra (and vagina in females). ○Rectal hiatus ■Centrally positioned gap, which allows passage of the anal canal. ○Between the urogenital hiatus and the anal canal lies a ﬁbrous node known as the perineal body, which joins the pelvic ﬂoor to the perineum (described further here). Ban \| Ham / Aro 24
FUNCTIONS ●As the ﬂoor of the pelvic cavity, these muscles have important roles to play in the correct functioning of the pelvic and abdominal viscera. ●The roles of the pelvic ﬂoor muscles are: ○Support of abdominopelvic viscera (bladder, intestines, uterus etc. ) through their tonic contraction. ○Resistance to increases in intra-pelvic/abdominal pressure during activities such as coughing or lifting heavy objects. ○Urinary and fecal continence. ○The muscle ﬁbers have a sphincter action on the rectum and urethra. ○They relax to allow urination and defecation. MUSCLES ●There are three main components of the pelvic ﬂoor: ○Levator ani muscles (largest component). ○Coccygeus muscle. ○Fascia coverings of the muscles. ●Levator Ani Muscles ○Innervated by anterior ramus of S4 and branches of the pudendal nerve (roots S2, S3, S4). ○The levator ani is a broad sheet of muscle. ○It is composed of three separate paired muscles; ■Pubococcygeus, ■Puborectalis ■Iliococcygeus. ○These muscles have attachments to the pelvis as follows: ■Anterior-pubic bodies of the pelvic bones. ■Laterally-thickened fascia of obturator internusmuscle, known as tendinous arch. ■Posteriorly-ischial spines of the pelvic bones. ○Puborectalis ■The puborectalis muscle is a U-shaped sling, extending from the bodies of the pubic bones, past the urogenital hiatus, around the anal canal. ■Its tonic contraction bends the canal anteriorly, creating the anorectal angle (90 degrees) at the anorectal junction (where the rectum meets the anus). ■The main function of this thick muscle is to maintain fecal continence-during defecation this muscle relaxes. ■Some ﬁbers of the puborectalis muscle (pre-rectal ﬁbers) form another U-shaped sling that ﬂank the urethra in the male and the urethra and vagina in the female (in some textbooks they appear as pubovaginalis or sphincter urethrae / vaginae). ■These ﬁbers are very important in preserving urinary continence, especially during abrupt increase of the intra-abdominal pressure i. e. during sneezing. ○Pubococcygeus ■The muscle ﬁbers of the pubococcygeus are the main constituent of the levator ani. ■Arise from the body of the pubic bone and anterior aspect of the tendinous arch. ■The ﬁbers travel around the margin of the urogenital hiatus and run posteromedially, attaching at the coccyx and anococcygeal ligament. Ban \| Ham / Aro 25
○Iliococcygeus ■The iliococcygeus has thin muscle ﬁbers, which start anteriorly at the ischial spines and posterior aspect of the tendinous arch. ■They attach posteriorly to the coccyx and the anococcygeal ligament. ■This part of the levator ani is the actual “levator” of the three: its action elevates the pelvic ﬂoor and the anorectal canal. ●Coccygeus ○Innervated by the anterior rami of S4 and S5. ○The coccygeus (or ischiococcygeus) is the smaller, and most posterior pelvic ﬂoor component-as the levator ani muscles are situated anteriorly. ○It originates from the ischial spines and travels to the lateral aspect of the sacrum and coccyx, along the sacrospinous ligament. 17. Fetal heart rate (FHR). Interpreting fetal heart rate tracings during pregnancy. Criteria of normal and pathological FHR. ●Fetal heart rate monitoring measures the heart rate and rhythm of the fetus. ●Baseline FHR is the mean level of FHR excluding accelerations and decelerations. ●It is expressed in beats per minute (bpm). ●Normal baseline FHR is 110-160 bpm. ●Two methods are applied: ○External ■Continuous tracing of FHR can be obtained using ultrasound Doppler effect. ■The transducers are placed on the maternal abdomen, one over the fundus and other at a site where the fetal heart sound is best audible. ■Frequency of uterine contractions and uterine pressure are recorded simultaneously by tocodynamometer. ○Internal: ■Fetal ECG tracing is made by applying a spiral pointed scalp electrode to the fetal scalp after rupturing the membranes. ■Intrauterine pressure could be simultaneously measured by passing a catheter inside the uterine cavity Interpretation of intrapartum FHR Tracings ●The average baseline rate should be between 120 and 160 beats per minute. ●Sustained tachycardia may be a warning of fetal distress and prolonged or severe bradycardia is ominous. Ban \| Ham / Aro 26
●Baseline variability. ○The normal FHR ﬂuctuates by 10 beats/min every 5 seconds or so, evidence of fetal ability to react normally to the stress of labor. ○Loss of this variability, especially in association with tachycardia, indicates severe hypoxia. (This is sometimes referred to as 'beat to-beat variation'. ) ○Acceleration: ■Transient increase in FHR by 15 bpm or more lasting for at least 15 seconds. ■Prolonged acceleration lasts > 2 min but < 10 min and when it is > 10 min it is a baseline change. ■Acceleration denotes an intact neurohormonal and cardiovascular activity and therefore a healthy fetus. ○Deceleration: ■Transient decrease in FHR below baseline by 15 bpm or more and lasting ≥ 15 secs. ■Three basic types of deceleration are observed and are called early, late and variable ■Early deceleration (Type I Dips), ●Uniform, repetitive periodic slowing of FHR and in most cases the onset, nadir and recovery of deceleration coincides with the beginning, peak and ending of uterine contraction respectively. ●It is due to head compression (vagal nerve activation) ■Late deceleration (Type II Dips), ●Uniform, repetitive periodic slowing of FHR. It begins after the onset of the uterine contraction. ●Usually, the onset, nadir and recovery of the deceleration occur after the start, peak and end of the uterine contraction respectively. ●Nadir occurs 20 seconds after the peak of the contraction and FHR returns to normal after the contraction is over. ●It suggests uteroplacental insufﬁciency and fetal hypoxia (50%). ● Causes of late deceleration: ○Placental pathology (postmaturity, hypertension, diabetes, placental abruption) ○Excessive uterine contractions ○Injudicious use of oxytocin ○Regional anesthesia (spinal of epidural). ■Variable deceleration: ●Intermittent periodic slowing (variable) of FHR with rapid onset and recovery ●Decelerations are variable in all respect of size, shape, depth, duration and timing to the uterine contractions. ●It is thought to indicate cord compression and may disappear with the change in position of the patient. ●It is the most common type. ●Accelerations often precede and follow the deceleration. ■Prolonged deceleration ●Abrupt decrease in FHR to levels below the baseline and it lasts > 2 min but < 10 min. ●If it lasts > 10 min. it is a baseline change. Ban \| Ham / Aro 27
■Lag period: ●It is the time taken for the FHR to reach the nadir (the lowest point of the FHR dip) from the apex of the preceding uterine contraction. ●In deceleration lag period is > 30 seconds. ■Sinusoidal pattern: ●It resembles a sine wave. It has a stable baseline FHR with ﬁxed or absent baseline variability lasting > 20 min. ●Accelerations are absent. ●It is often associated with fetal anemia, fetomaternal hemorrhage, fetal hypoxia (acidosis). ●It may occur when narcotics are given to the mother. ●Such FHR patterns are called pseudo sinusoidal as the fetus is well-oxygenated ●Response of FHR to uterine contractions. ○The uterine contraction acts as a stress to the fetus, producing a transient reduction in oxygenated blood supply. ○The normal FHR should be maintained with the contraction or show only a slight deceleration of less than 40 beats/min. ○If it is greater than this and especially if there is a 'lag phase' or late deceleration occurring after the period of uterine contraction, a pathological degree of hypoxia may be present. ●National Institute of Child and Human Development (2008), ACOG (2009); Three tier FHR interpretation system ○Category I: ■Normal (baseline rate 110-160 bpm; ■FHR variability-moderate; ■No late or variable deceleration; ■Early deceleration ±; acceleration ± ○Category II ■Indeterminate—all tracings not categorized as category I or III. ○Category III: ■Abnormal either absent baseline FHR variability and any of the following: ●Recurrent late/variable decelerations, ●Bradycardia ●Sinusoidal pattern Ban \| Ham / Aro 28
18. Normal pregnancy events in the ﬁrst, second and third trimester. FIRST TRIMESTER ●Amenorrhea ○Amenorrhea during the reproductive period in an otherwise healthy individual having previous normal periods, is likely due to pregnancy unless proved otherwise. ○However, cyclic bleeding may occur up to 12 weeks of pregnancy, until the decidual space is obliterated by the fusion of decidua vera with decidua capsularis. ○Such bleeding is usually scanty, lasting for a shorter duration than her usual and roughly corresponds with the date of the expected period. ■This is termed as placental sign. ○This type of bleeding should not be confused with the commonly met pathological bleeding, i. e. threatened abortion. ○Pregnancy, however, may occur in women who are previously amenorrhoeic — during lactation and puberty. ●Morning sickness (Nausea and vomiting) ○Inconsistently present in most cases, more often in 1stpregnancy than in subsequent one. ○It usually appears soon following the missed period and rarely lasts beyond 16 weeks. ○Its intensity varies from nausea on rising from the bed to loss of appetite or even vomiting. ○But it usually does not affect the health status of the mother ●Frequency of micturition ○It is quite a troublesome symptom during 8-12th weeks of pregnancy. ○It is due to resting of the bulky uterus on the fundus of the bladder because of exaggerated anteverted position of the uterus, congestion of the bladder mucosa change in maternal osmoregulation causing increased thirst and polyuria ●Breast discomfort in the form of feeling of fullness and 'pricking sensation' is evident as early as 6-8th week especially in primigravidae. ●Fatigue is a frequent symptom which may occur early in pregnancy. ●Breast changes ○Are valuable only in primigravidae, as in multiparous, the breasts are enlarged and often contain milk for years. ○The breast changes are evident between 6 and 8 weeks. ○Enlargement with vascular engorgement evidenced by delicate veins visible under the skin ○The nipple and the areola (primary) become more pigmented specially in dark women. ○Montgomery's tubercles are prominent. ○Thick yellowish secretion (colostrum) can be expressed as early as 12th week. SECOND TRIMESTER ●The subjective symptoms — such as nausea, vomiting and frequency of micturition usually subside, while amenorrhea continues. ●The new features that appear are: ○“Quickening” (feeling of life) ■Denotes the perception of active fetal movements by the women. ■It is usually felt about the 18th week, about 2 weeks earlier in multiparous. ■Its appearance is a useful guide to calculate the expected date of delivery with reasonable accuracy. ○Progressive enlargement of the lower abdomen by the growing uterus. Ban \| Ham / Aro 29
●Chloasma: ○Pigmentation over the forehead and cheek may appear at about the 24th week. ●Breast changes: ○Breasts are more enlarged with prominent veins under the skin ○Secondary areola specially demarcated in primigravidae, usually appears at about 20th week ○Montgomery's tubercles are prominent and extend to the secondary areola ○Colostrum becomes thick and yellowish by 16th week ○Variable degree of striae may be visible with advancing weeks. THIRD TRIMESTER ●Amenorrhea persists ●Enlargement of the abdomen is progressive which produces some mechanical discomfort to the patient such as palpitation or dyspnea following exertion ●Lightening — At about 38th week, especially in primigravidae, a sense of relief of the pressure symptoms is obtained due to engagement of the presenting part ●Frequency of micturition reappears ●Fetal movements are more pronounced. ●Cutaneous changes are more prominent with increased pigmentation and striae. ●Uterine shape is changed from cylindrical to spherical beyond 36th week. ●Fundal height: ○Distance between the umbilicus and the ensiform cartilage is divided into 3 equal parts. ○Fundal height corresponds to ■The junction of the upper and middle third at 32 weeks, ■Up to the level of ensiform cartilage at 36th week and ■It comes down to 32-week level at 40th week because of engagement of the presenting part. ○To determine whether the height of the uterus corresponds to 32 weeks or 40 weeks, engagement of the head should be tested. ○If the head is ﬂoating, it is of 32 weeks pregnancy and if the head is engaged, it is of 40 weeks pregnancy. ●Symphysis fundal height (SFH). ○Upper border of the fundus is located by the ulnar border of the left hand & this point is marked. ○The distance between the upper border of the symphysis pubis up to the marked point is measured by a tape in centimeters. ○After 24 weeks, the SFH measured in cm corresponds to the number of weeks up to 36 weeks. ○Braxton-Hicks contractions are more evident ○Fetal movements are easily felt ○Palpation of the fetal parts and their identiﬁcation become much easier. ○Lie, presentation and position of the fetus are determined. Ban \| Ham / Aro 30
19. Management of physiological pregnancy. Examination and supervision of pregnant women in the woman consultation. ●First trimester ○Amenorrhea ■Cyclic bleeding may occur up to 12 weeks of pregnancy, until the decidual space is obliterated by the fusion of decidua vera with decidua capsularis. ■Such bleeding is usually scanty, lasting for a shorter duration than usual and roughly corresponds with the date of the expected period. This is termed as placental sign. ■This type of bleeding should not be confused with the commonly met pathological bleeding, i. e. threatened abortion. ■Pregnancy, however, may occur in women who are previously amenorrhoeic — during lactation and puberty. ○Morning sickness (Nausea and vomiting) ■It is inconsistently present in about 70% cases, more often in the ﬁrst pregnancy than in the subsequent one. ■It usually appears soon following the missed period and rarely lasts beyond 16 weeks. ■Intensity varies from nausea on rising from bed to loss of appetite or vomiting ■But it usually does not affect the health status of the mother ○Frequency of micturition ■A troublesome symptom during 8—12th week of pregnancy. ■It is due to ●Resting of the bulky uterus on the fundus of the bladder because of exaggerated anteverted position of the uterus, ●Congestion of the bladder mucosa ●Change in maternal osmoregulation causing increased thirst and polyuria ○Fatigue is a frequent symptom which may occur early in pregnancy. ○Breast discomfort in the form of feeling of fullness and 'pricking sensation' is evident as early as 6—8th week especially in primigravidae. ○Breast changes ■Are valuable only in primigravidae, as in multiparae, the breasts are enlarged and often contain milk for years. ■The breast changes are evident between 6 and 8 weeks. ■There is enlargement with vascular engorgement evidenced by the delicate veins visible under the skin ■The nipple and the areola (primary) become more pigmented specially in dark ■women. ■Montgomery's tubercles are prominent. ■Thick yellowish secretion (colostrum) can be expressed as early as 12th week. ●Second trimester ○The subjective symptoms — such as nausea, vomiting and frequency of micturition usually subside, while amenorrhea continues. The new features that appear are: Ban \| Ham / Aro 31
○“Quickening” (feeling of life) ■Denotes the perception of active fetal movements by the women. ■It is usually felt about the 18th week, about 2 weeks earlier in multiparae. ■Its appearance is a useful guide to calculate the expected date of delivery with reasonable accuracy ○Progressive enlargement of the lower abdomen by the growing uterus. ○Chloasma: ■Pigmentation over the forehead and cheek may appear at about the 24th week. ○Breast changes: ■Breasts are more enlarged with prominent veins under the skin ■Secondary areola specially demarcated in primigravidae, usually appears at about 20th week ■Montgomery's tubercles are prominent and extend to the secondary areola ■Colostrum becomes thick and yellowish by 16th week ■Variable degree of striae may be visible with advancing weeks. ●Third trimester ○Amenorrhea persists ○Enlargement of the abdomen is progressive which produces some mechanical discomfort to the patient such as palpitation or dyspnea following exertion ○Lightening — At about 38th week, especially in primigravidae, a sense of relief of the pressure symptoms is obtained due to engagement of the presenting part ○Frequency of micturition reappears ○Fetal movements are more pronounced. ○Cutaneous changes are more prominent with increased pigmentation and striae. ○Uterine shape is changed from cylindrical to spherical beyond 36th week. ○Fundal height: ■Distance between the umbilicus and ensiform cartilage is divided into 3 equal parts. ■The fundal height corresponds to the junction of the upper and middle third at 32 weeks, up to the level of ensiform cartilage at 36th week and it comes down to 32-week level at 40th week because of engagement of the presenting part. ■To determine whether the height of the uterus corresponds to 32 weeks or 40 weeks, engagement of the head should be tested. ■lf the head is ﬂoating, it is of 32 weeks pregnancy and if the head is engaged, it is of 40 weeks pregnancy. ○Symphysis fundal height (SFH). ■The upper border of the fundus is located by the ulnar border of the left hand and this point is marked. ■The distance between the upper border of the symphysis pubis up to the marked point is measured by a tape in centimeters. ■After 24 weeks, the SFH measured in cm corresponds to the number of weeks up to 36 weeks. ○Braxton-Hicks contractions are more evident ○Fetal movements are easily felt ○Palpation of the fetal parts and their identiﬁcation become much easier. ○Lie, presentation and position of the fetus are determined Ban \| Ham / Aro 32
20. The methods of external obstetric examination. Obstetrics terminology: fetal lie, fetal position, vision of fetal position, fetal presentation. External Obstetric Examination ●Abdominal examination: inspection ○Apparent size of the abdominal distension. ○Any asymmetry. ○Fetal movements. ●Cutaneous signs of pregnancy: ○linea nigra (dark pigmented line stretching from the xiphi sternum through the umbilicus to the suprapubic area) ○Striae gravidarum (recent stretch marks are purplish in color) ○Striae albicans (old stretch marks are silvery-white) ○Flattening/eversion of umbilicus (due to intra-abdominal pressure). ●Abdominal examination: palpation ○Symphysis fundal height (SFH): ○Estimation of number of fetuses: multiple fetal poles. ○Fetal lie (relationship of longitudinal axis of fetus to that of the uterus ○Presentation (part of the fetus overlying the pelvic brim): ●Amniotic ﬂuid volume: ○Increased tense abdomen with fetal parts not easily palpated ○Decreased compact abdomen with fetal parts easily palpable. ●Auscultation of the fetal heart rate ●Normal uterine size ●Symphysis fundal height ○The uterine size is objectively measured with a tape measure from the highest point of the fundus to the upper margin of the symphysis pubis. ○Appropriate growth is usually estimated to be the number of weeks gestation in centimeters. OBSTETRIC TERMINOLOGIES ●The fetus lies inside the uterus in a closed sac ﬁlled with liquor amnii. ●Has enough freedom of movement until the later months of pregnancy, when it becomes relatively ﬁxed. ●Till then, periodic examination is essential to note its lie, presentation, position and attitude. ●Incidental ideas can be gained about the size of the fetus or amount of liquor amnii. Ban \| Ham / Aro 33
LIE: ●The lie refers to the relationship of the long axis of the fetus to the long axis of the centralized uterus or maternal spine, ●Most common lie is longitudinal (99. 5%). ●The lie may be transverse or oblique; sometimes the lie is unstable until labor sets in, when it becomes either longitudinal or transverse. PRESENTATION: ●The part of the fetus which occupies the lower pole of the uterus (pelvic brim) is called the presentation of the fetus. ●Accordingly, the presentation may be ○Cephalic (96. 5%), ○Podalic (3%) or ○Shoulder ○Other (0. 5%). ●When more than one part of the fetus presents, it is called compound presentation. PRESENTING PART: ●The presenting part is deﬁned as the part of the presentation which overlies the internal os and is felt by the examining ﬁnger through the cervical opening. ●Thus, in cephalic presentation, the presenting part may be vertex (most common), brow or face, depending upon the degree of ﬂexion of the head. ●Similarly, the fetal legs in a breech presentation may be ○Flexed (complete breech), ○Extended (frank breech) ○Foot may be present (footling). Ban \| Ham / Aro 34
●However, the term presentation and presenting part are often used synonymously and expressed more commonly in clinical practice according to the latter deﬁnition. ATTITUDE: ●The relation of the different parts of the fetus to one another is called the attitude of the fetus. ●The universal attitude is that of ﬂexion. ●During the later months, the head, trunk and limbs of the fetus maintain the attitude of ﬂexion on all joints and form an ovoid mass that corresponds approximately to the shape of uterine ovoid. ●The characteristic ﬂexed attitude may be modiﬁed by the amount of liquor amnii. ●There may be exceptions to this universal attitude ○Extension of the head may occur (deﬂexed vertex, brow or face presentation, according to the degree of extension), ○The legs may become extended in breech. ●The course of labor in such circumstances may be modiﬁed accordingly. DENOMINATOR: ●It is an arbitrary bony ﬁxed point on the presenting part which comes in relation with the various quadrants of the maternal pelvis. ●The following are the denominators of the different presentations—occiput in vertex, mentum (chin) in face, frontal eminence in brow, sacrum in breech and acromion in shoulder. POSITION: ●It is the relation of the denominator to the different quadrants of the pelvis. ●For descriptive purposes, the pelvis is divided into equal segments of 45° to place the denominator in each segment. ●Thus, theoretically, there are 8 positions with each presenting part. ●Anterior, posterior, right or left position is referred to in relation to the maternal pelvis, with the mother in erect position. ●However, some have retained the conventional description of four vertex positions. ○Vertex occupying the left anterior quadrant of the pelvis is the most common one and is called left occiput anterior (LOA). ○This is the ﬁrst vertex position. ○Similarly, right occiput anterior (ROA) is the second vertex; right occiput posterior (ROP) third vertex and left occiput posterior (LOP) is the fourth vertex position. Ban \| Ham / Aro 35
21. Labor precursors. Physiological preliminary period: characteristics, diagnosis, management. Labour precursors FALSE PAIN: (Synonym: false labor, spurious labor): ●It is found more in primigravidae than in parous women. ●Usually appears prior to the onset of true labor pain by 1 or 2 weeks in primigravidae and by a few days in multiparae. ●Such pains are probably due to stretching of the cervix and lower uterine segment with consequent irritation of the neighboring ganglia. PRELABOR: (Synonym: premonitory stage): ●The premonitory stage may begin 2-3 weeks before the onset of true labor in primigravidae and a few days before in multiparae. ●The features are inconsistent and may consist of the following: “LIGHTENING”: ●A few weeks prior to the onset of labor, especially in primigravidae, the presenting part sinks into the true pelvis. ●Due to active pulling up of the lower pole of the uterus around the presenting part. ●Signiﬁes incorporation of the lower uterine segment into the wall of the uterus. ●This diminishes the fundal height and hence minimizes the pressure on the diaphragm. ●Mother experiences a sense of relief from the mechanical cardiorespiratory embarrassment. ●There may be frequency of micturition or constipation due to mechanical factor—pressure by the engaged presenting part. ●It is a welcome sign as it rules out cephalopelvic disproportion and other conditions preventing the head from entering the pelvic inlet. CERVICAL CHANGES: ●A few days prior to the onset of labor, the cervix becomes ripe. ●A ripe cervix is ○Soft, ○80% effaced (<1. 5 cm in length), ○Admits one ﬁnger easily, ○Cervical canal is dilatable. APPEARANCE OF FALSE PAIN ●Dull in nature, ●Conﬁned to lower abdomen and groin, ●Not associated with hardening of the uterus, ●They have no other features of true labor pain as discussed above ●Usually relieved by enema or sedative. Ban \| Ham / Aro 36
Physiological preliminary period TRUE LABOR PAIN IS CHARACTERIZED BY: ●Painful uterine contractions at regular intervals, ●Frequency of contractions increase gradually, ●Intensity and duration of contractions increase progressively, ●Associated with “show”, ●Progressive effacement and dilatation of the cervix, ●Descent of the presenting part, ●Formation of the “bag of forewaters” ●Not relieved by enema or sedatives. FALSE LABOR PAIN IS: ●Dull in nature, ●Conﬁned to lower abdomen and groin, ●Not associated with hardening of the uterus, ●They have no other features of true labor pain as discussed above ●Usually relieved by enema or sedative. LABOR PAIN: ●Throughout pregnancy, Braxton Hicks contractions with simultaneous hardening of the uterus occur. ●These contractions change character, become more powerful, intermittent & are associated with pain. ●Pain more often felt in front of the abdomen or radiating toward the thighs. SHOW: ●With the onset of labor, there is profuse cervical secretion. ●Simultaneously, there is slight oozing of blood from rupture of capillary vessels of the cervix & from the raw decidual surface caused by separation of the membranes due to stretching of the lower uterine segment. ●Expulsion of cervical mucus plug mixed with blood is called “show”. DILATATION OF INTERNAL OS: ●With the onset of labor pain, the cervical canal begins to dilate more in the upper part than in the lower, the former being accompanied by corresponding stretching of the lower uterine segment. FORMATION OF “BAG OF WATERS”: ●Due to stretching of the lower uterine segment, the membranes are detached easily because of its loose attachment to the poorly formed decidua. ●With the dilatation of the cervical canal, the lower pole of the fetal membranes becomes unsupported and tends to bulge into the cervical canal. ●As it contains liquor, which has passed below the presenting part, it is called “bag of waters”. ●During uterine contraction with consequent rise of intra-amniotic pressure, this bag becomes tense and convex. After the contractions pass off, the bulging may disappear completely. ●This is almost a certain sign of onset of labor. ●In some cases the membranes are so well applied to the head that the ﬁnding may not be detected Ban \| Ham / Aro 37
22. Clinical course of labor: signs of the labor onset, stages of the labor, their characteristics. Duration of labor. ●Labor consists of a series of rhythmic, involuntary or medically induced contractions of the uterus that result in effacement (thinning and shortening) and dilation of the uterine cervix. ●The stimulus for labor is unknown, but digitally manipulating or mechanically stretching the cervix during examination enhances uterine contractile activity, most likely by stimulating release of oxytocin by the posterior pituitary gland. ●Normal labor usually begins within 2 weeks (before or after) the estimated delivery date. ●In a ﬁrst pregnancy, labor usually lasts 12 to 18 hours on average; subsequent labors are often shorter, averaging 6 to 8 hours. ●Rupture of the chorioamniotic membranes or bloody show is diagnostic for onset of labor. ●Occasionally, the membranes (amniotic and chorionic sac) rupture before labor begins, and amniotic ﬂuid leaks through the cervix and vagina. ●Labor begins with irregular uterine contractions of varying intensity; they apparently soften (ripen) the cervix, which begins to efface and dilate. As labor progresses, contractions increase in duration, intensity, and frequency. Stages of Labor ●There are 3 stages of labor. ●1st stage ○From onset of labor to full dilation of the cervix (about 10 cm)—has 2 phases, latent and active. ○During thelatent phase,irregular contractions becomeprogressively coordinated, discomfort is minimal, and the cervix effaces and dilates to 4 cm. ○Thelatent phaseis difﬁcult to time precisely, andduration varies, averaging 8 hours in nulliparas and 5 hours in multiparas; duration is considered abnormal if it lasts > 20 hours in nulliparas or > 12 hours in multiparas. ○During theactive phase, the cervix becomes fullydilated, and the presenting part descends well into the midpelvis. ○On average, theactive phaselasts 5 to 7 hours innulliparous and 2 to 4 hours in multiparas. ○Standing and walking shorten the ﬁrst stage of labor by > 1 hour and reduce the rate of cesarean delivery. ○If the membranes have not spontaneously ruptured, amniotomy (artiﬁcial rupture of membranes) to be done routinely during the active phase. ○During the 1st stage of labor, maternal heart rate and blood pressure and fetal heart rate should be checked continuously by electronic monitoring or intermittently by auscultation. ●2nd stage ○The time from full cervical dilation to delivery of the fetus. ○On average, it lasts 2 hours in nulliparas (median 50 minutes) and 1 hour in multiparas (median 20 minutes). ○It may last another hour or more if conduction (epidural) analgesia or intense opioid sedation is used. ○To make it through the passage, the fetus makes several positional changes which are calledcardinal movementsor mechanisms of labor. ○Initially there isdescent, which is the downwardmovement of the fetus to the pelvic inlet. Ban \| Ham / Aro 38
○The fetus moves from the pelvic inlet down to the ischial spines, this position's called engagement. ○Then there'sﬂexion, where the fetal chin pressesagainst its chest as its head meets resistance from the pelvic ﬂoor. ○Next there'sinternal rotation, where the fetal shouldersinternally rotate by 45 degrees so the widest part of the shoulders are in line with the widest part of the pelvic inlet. ○After the fetal head passes under the symphysis pubis there'sextension, which is where the fetal head will change from ﬂexion to extension, and then they move and emerge from the vagina. ○After the delivery of the head, there'srestitution,where the head externally rotates so that the shoulders can pass through the pelvic outlet and under the symphysis pubis. ○Finally there'sexpulsion,where the anterior shoulderslips under the symphysis pubis, followed by the posterior shoulder, and followed by the rest of the body. ○For spontaneous delivery, women must supplement uterine contractions by expulsively bearing down. ○Women should be attended constantly, and fetal heart sounds should be checked continuously or after every contraction. ○Contractions may be monitored by palpation or electronically. ○Perineal massage with lubricants and warm compresses may soften and stretch the perineum and thus reduce the rate of 3rd-and 4th-degree perineal tears. ●3rd stage ○Begins after delivery of the infant and ends with delivery of the placenta. ○This stage usually lasts only a few minutes but may last up to 30 minutes. ●4th stage: ○It is the stage of observation for at least 1 hour after the expulsion of the afterbirths. ○During this period maternal vitals, uterine retraction and any vaginal bleeding are monitored. ○Baby is examined. ○These are done to ensure that both the mother and baby are well. 23. Management of the ﬁrst stage of labor. PRINCIPLES: ●Noninterference with watchful expectancy so as to prepare the patient for natural birth. ●To monitor carefully the progress of labor, maternal conditions and fetal behavior so as to detect any intrapartum complication early. PRELIMINARIES: ●This consists of basic evaluation of the current clinical condition. ●Enquiry is to be made about the onset of labor pains or leakage of liquor, if any. ●Thorough general and obstetrical examinations including vaginal examination are to be carried out and recorded. ●Records of antenatal visits, investigation reports and any speciﬁc treatment given, if available, are to be reviewed. Ban \| Ham / Aro 39
ACTUAL MANAGEMENT: ●General ○Antiseptic dressing ○Encouragement, emotional support and assurance are given to keep up the morale. ○Constant supervision is ensured. ○Generally, a woman in early normal labor may not be conﬁned to bed. ○While in bed she may take the position most comfortable to her. ○She should avoid dorsal supine position to avoid aortocaval compression. ●Bowel ○An enema with soap and water or glycerin suppository is traditionally given in the early stage. ○This may be given if the rectum feels loaded on vaginal examination. ○But enema neither shortens the duration of labor nor reduces the infection rate. ●Rest and ambulation ○If the membranes are intact, the patient is allowed to walk about. ○This attitude prevents vena cava compression and encourages descent of the head. ○Ambulation can reduce the duration of labor, need of analgesia and improve maternal comfort. ○If, however, labor is monitored electronically or analgesic drug (epidural analgesia) is given, she should be in bed. ●Diet ○There is delayed emptying of the stomach in labor. ○Low p H of the gastric contents is a real danger if aspirated following general anesthesia when needed unexpectedly ○So, food is withheld during active labor. ○Fluids in the form of plain water, ice chips or fruit juice may be given in early labor. ○Intravenous ﬂuid with ringer solution is started where any intervention is anticipated or the patient is under regional anesthesia. ●Bladder care ○Patient is encouraged to pass urine by herself as full bladder often inhibits uterine contraction and may lead to infection. ○If the woman cannot go to the toilet, she is given a bed pan. ○Privacy must be maintained and comfort must be ensured. ○If the patient fails to pass urine especially in late ﬁrst stage, catheterization is to be done with strict aseptic precautions. ●Relief of pain ○For practical purposes, the common analgesic drug used is pethidine 50-100 mg intramuscularly when the pain is well established in the active phase of labor. ○If necessary, it is repeated after 4 hours. ○Pethidine is an effective analgesic as well as a sedative. ○Metoclopramide 10 mg IM is commonly given to combat vomiting due to pethidine. ○Pethidine crosses the placenta and is a respiratory depressant to the neonate. ○The drug should not be given if delivery is anticipated within 2 hours. Ban \| Ham / Aro 40
●Assessment of progress of labor and partograph recording. ○Pulse is recorded every 30 minutes and is marked with a dot (. ) in the partograph. ○Blood pressure is recorded at every 1 hours and is marked with arrows ( ↔ ) ○Temperature is recorded every 2 hours. ○Urine output is recorded for volume, protein or acetone. ○Any drug (oxytocin or other) when given is recorded in the partograph. GENERAL EXAMINATIONS DONE: ●Abdominal palpation ○Uterine contractions as regard the frequency, intensity and duration are assessed. ○The number of contractions in 10 minutes and duration of each contraction in seconds are recorded in the partograph ○Partograph is charted every half an hour as: ■Contraction duration less than 20 seconds (mild); ■Between 20 and 40 seconds (moderate) ■More than 40 seconds (strong) ●Pelvic grip: ○Gradual disappearance of poles of the head (sinciput and occiput) which were felt previously, (usually occur in labor). ○Abdominal palpation for descent of fetal head in terms of ﬁfths felt above brim is used ○Shifting of the maximal intensity of the fetal heartbeat downward and medially. VAGINAL EXAMINATION ●Dilatation of the cervix in centimeters in relation to hours of labor is a reliable index to note the progress of labor. ●To note the position of the head and degree of ﬂexion. ●To note the station of the head (degree of descent) in relation to the ischial spines. ●Color of the liquor (clear or meconium stained) if the membranes are ruptured ●Degree of molding of the head— molding occurs ﬁrst at the junction of occipito parietal bones and then between the parietal bones (Caput formation—progressive increase is more important than its mere presence TO NOTE THE FETAL WELL-BEING: ●Fetal heart rate (FHR) along with its rhythm and intensity should be noted every half hour in the ﬁrst stage and every 15 minutes in second stage or following rupture of the membranes. ●To be of value, the observation should be made immediately following uterine contraction. ●The count should be made for 60 seconds. ●For routine clinical observation, an ordinary stethoscope is quite suitable. ●Doppler ultrasonic cardiography (Dopplex) is helpful in the case of obesity & polyhydramnios. ●To avoid confusion of maternal and fetal heart rates, maternal pulse should be counted. ●Otherwise maternal tachycardia may be wrongly treated as fetal heart rate. ●Normal fetal heart rate ranges from 110 to 150 per minute. WATCH THE MATERNAL CONDITION: ●Routine checkup includes: ○To record 2 hourly pulse, blood pressure and temperature; ○To observe the tongue periodically for hydration ○To note the urine output, urine for acetone, glucose Ban \| Ham / Aro 41
○IV ﬂuids, drugs. EVIDENCE OF MATERNAL DISTRESS ARE: ●Anxious look with sunken eyes ●Rising pulse rate of 100 per minute or more ●Dehydration, dry tongue ●Hot, dry vagina often with offensive discharge ●Acetone smell in breath ●Scanty high colored urine with presence of acetone. 24. Management of the second stage of labor. The transition from the ﬁrst stage to the second stage is evidenced by the following features: ●Increasing intensity of uterine contractions to Bearing-down efforts ●Urge to push or defecate with descent of the presenting part ●Complete dilatation of the cervix as evidenced on vaginal examination PRINCIPLES: ●To assist in the natural expulsion of the fetus slowly and steadily ●To prevent perineal injuries. GENERAL MEASURES: ●Constant supervision is mandatory and the FHR is recorded every 5 minutes. ●To administer inhalation analgesics, if available, in the form of gas N2O and O2 to relieve pain during contractions. ●Vaginal examination is done at the beginning of the second stage not only to conﬁrm its onset but to detect any accidental cord prolapse. ●The position and the station of the head are once more to be reviewed and the progressive descent of the head is ensured. PREPARATION FOR DELIVERY ●Position: ○Positions of the woman during delivery may be lateral, squatting or partial sitting (45°). ○Dorsal position with 15° left lateral tilt is commonly favored as it avoids aortocaval compression and facilitates pushing effort. ○The accoucheur scrubs up and puts on sterile gown, mask and gloves and stands on the right side of the table. ○Toileting the external genitalia and inner side of the thighs is done with cotton swabs soaked in Savlon or Dettol solution. ○One sterile sheet is placed beneath the buttocks of the patient and one over the abdomen. ○Sterilized leggings are to be used. ○Essential aseptic procedures are remembered as three Cs: ■Clean hands, ■Clean surface ■Clean cutting and ligaturing of the cord. ○To catheterize the bladder, if it is full. CONDUCTION OF DELIVERY: ●The assistance required in spontaneous delivery is divided into three phases : ○Delivery of the head ○Delivery of the shoulders Ban \| Ham / Aro 42
○Delivery of the trunk IMMEDIATE CARE OF NEWBORN ●Soon after the delivery of the baby, it should be placed on a tray covered with clean dry linen with the head slightly downward (15°). ○It facilitates drainage of the mucus accumulated in the tracheobronchial tree by gravity. ○The tray is placed between the legs of the mother and should be at a lower level than the uterus to facilitate gravitation of blood from the placenta to the infant ○Air passage (oropharynx) should be cleared of mucus and liquor by gentle suction. ○Apgar rating at 1 minute and at 5 minutes is to be recorded. CLAMPING AND LIGATURE OF THE CORD: ●Cord is clamped by two Kocher's forceps, the near one is placed 5 cm away from the umbilicus and is cut in between. ●Two separate cord ligatures are applied with sterile cotton threads 1 cm apart using reef-knot, the proximal one being placed 2. 5 cm away from the navel. ●Squeezing the cord with ﬁngers prior to applying ligatures or plastic cord clamps prevents accidental inclusion of embryonic remnants ●Leaving behind a length of the cord attached to the navel not only prevents inclusion of the embryonic structure, if present, but also facilitates control of primary hemorrhage due to a slipped ligature. ●The cord is divided with scissors about 1 cm beyond the ligatures taking aseptic precautions so as to prevent cord sepsis. ●Presence of any abnormality in cord vessels (single umbilical artery) is to be noted. ●The cut end is then covered with sterile gauze pieces after making sure that there is no bleeding. ●The purpose of clamping the cord on the maternal end is to prevent soiling of the bed with blood and to prevent fetal blood loss of the second baby in an undiagnosed monozygotic twin. ●Delay in clamping for 2-3 minutes or till cessation of the cord pulsation facilitates transfer of 80-100 m L blood from the compressed placenta to a baby when placed below the level of the uterus. ●This is beneﬁcial to a mature baby but may be deleterious to a preterm or a low birthweight baby due to hypervolemia and hyperbilirubinemia. ●But early clamping should be done in cases of Rh-incompatibility (to prevent antibody transfer from the mother to the baby) or babies born asphyxiated or one of a diabetic mother. ●Cord is usually clamped after cleaning the airway after about 1-2 minutes of birth. ●Early clamping reduces the need of phototherapy due to hyperbilirubinemia. ●Quick check is made to detect any gross abnormality and the baby is wrapped with a dry warm towel. ●The identiﬁcation tape is tied both on the wrist of the baby and the mother. Ban \| Ham / Aro 43
25. Management of the third stage of labor. ●Third stage is the most crucial stage of labor. ●Previously uneventful ﬁrst and second stages can become abnormal within a minute with disastrous consequences. ●The principles underlying the management of the third stage are to ensure strict vigilance and to follow the management guidelines strictly in practice so as to prevent the complications, the important one being postpartum hemorrhage. STEPS OF MANAGEMENT: ●Two methods of management are currently in practice. ○Expectant management ○Active management (preferred) EXPECTANT MANAGEMENT (TRADITIONAL): ●The placental separation and its descent into the vagina are allowed to occur spontaneously. ●Minimal assistance may be given for the placental expulsion if it is needed. ●Constant watch is mandatory and the patient should not be left alone. ●If the mother is delivered in the lateral position, she should be changed to dorsal position to note features of placental separation and to assess the amount of blood loss. ●A hand is placed over the fundus ○To recognize the signs of separation of placenta, ○To note the state of uterine activity—contraction and relaxation ○To detect, though rare, cupping of the fundus which is an early evidence of inversion of the uterus. ●Desire to ﬁddle with the fundus or massage the uterus is to be strongly condemned. ●Placenta is separated within minutes following the birth of the baby. ●A watchful expectancy can be extended up to 15-20 minutes. ●In some institutions, “no touch” or “hands off ” policy is employed. ●The patient is expected to expel the placenta within 20 minutes with the aid of gravity. ●Expulsion of the placenta: ○Only when the features of placental separation and its descent into the lower segment are conﬁrmed, the patient is asked to bear down simultaneously with the hardening of the uterus. ○The raised intra-abdominal pressure is often adequate to expel the placenta. ○If the patient fails to expel, one can wait safely up to 10 minutes if there is no bleeding. ○As soon as the placenta passes through the introitus, it is grasped by the hands and twisted round and round with gentle traction so that the membranes are stripped intact. ○If the membranes threaten to tear, they are caught hold of by sponge-holding forceps and in similar twisting movements the rest of the membranes are delivered. ○Gentleness, patience and care are prerequisites for complete delivery of the membranes. ○If the spontaneous expulsion fails or is not practicable, because of delivery under anesthesia, any one of the following methods can be used to expedite expulsion. Ban \| Ham / Aro 44
○Assisted expulsion: ■Controlled cord traction (modiﬁed Brandt-Andrews method) ●Palmar surface of the ﬁngers of the left hand is placed (above the symphysis pubis) approximately at the junction of upper and lower uterine segments. ●Body of the uterus is pushed upward and backward, toward the umbilicus while by the right hand steady tension is given in downward and backward direction holding the clamp until the placenta comes outside the introitus. ●It is thus more an uterine elevation which facilitates expulsion of the placenta. ●The procedure is to be adopted only when the uterus is hard and contracted. ■Fundal pressure ●Fundus is pushed downward and backward after placing 4 ﬁngers behind the fundus and the thumb in front using the uterus as a sort of piston. ●Pressure must be given only when the uterus becomes hard. ●If it is not, then make it hard by gentle rubbing. ●Pressure is to be withdrawn as soon as placenta passes through introitus. ●If the baby is macerated or premature, this method is preferable to cord traction as the tensile strength of the cord is much reduced in both the instances. ●Cord may be accidentally torn which is not likely to cause any problem. ■Sterile gloved hand should be introduced, & placenta is to be grasped and extracted. ■Uterus is massaged to make it hard, which facilitates expulsion of retained any clots ■Injection of oxytocin (5-10 units) IV slowly/IM or methergine 0. 2 mg is given IM. ■Oxytocin is more stable and has lesser side effects compared to ergometrine (nausea, vomiting, rise of BP). ●Examination of the placenta membranes and cord: ○Placenta is placed on a tray and is washed out in running tap water to remove blood & clots. ○The maternal surface is ﬁrst inspected for its completeness and anomalies. ○The maternal surface is covered with grayish decidua (spongy layer of the decidua basalis). ○Normally cotyledons are placed in close approximation & any gap indicates a missing cotyledon. ○The membranes—chorion and amnion are to be examined carefully for completeness and presence of abnormal vessels indicative of succenturiate lobe. ○The amnion is shiny but the chorion is shaggy. ○The cut end of the cord is inspected for the number of blood vessels. ○Normally, there are two umbilical arteries and one umbilical vein. ○An oval gap in the chorion with torn ends of blood vessels running up to the margin of the gap indicates a missing succenturiate lobe. ○The absence of a cotyledon or evidence of a missing succenturiate lobe or evidence of signiﬁcant missing membranes demands exploration of the uterus urgently. ●Vulva, vagina and perineum are inspected carefully for injuries and to be repaired, if any. ●The episiotomy wound is now sutured. ●The vulva and adjoining part are cleaned with cotton swabs soaked in antiseptic solution. Ban \| Ham / Aro 45
●A sterile pad is placed over the vulva. Ban \| Ham / Aro 46
26. Biomechanism of the labor in case of the occipito-anterior presentation. ●The mechanism of labor is the series of passive movements of the baby, particularly its presenting part, as it descends through the birth canal. ●Illustrated is the mechanism of labor where the vertex presents in the left occipito-lateral (LOL) position. Ban \| Ham / Aro 47
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27. Biomechanism of the labor in case of the occipito-posterior presentation. Ban \| Ham / Aro 51
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28. Primary sanitation and cleansing of a newborn. ●Once the head is delivered, the airway is cleared of blood and amniotic ﬂuid using a bulb suction device. ●The oral cavity is cleared initially and then the nares are cleared. ●Suction of the nares is not performed if fetal distress or meconium-stained liquor is present because it may result in gasping and aspiration of pharyngeal contents. ●A second towel is used to wipe secretions from the face and head. ●After the airway has been cleared, an index ﬁnger is used to check whether the umbilical cord encircles the neck. ●If so, the cord can usually be slipped over the infant's head. ●If the cord is too tight, it can be cut between two clamps. ●Following delivery of the head, the shoulders descend and rotate into the anteroposterior diameter of the pelvis and are delivered. ●After delivery, blood will be infused from the placenta into the newborn if the baby is held below the mother's introitus. ●Usually, the cord is clamped and cut within 15 to 20 seconds. ●Delayed cord clamping can result in neonatal hyperbilirubinemia as additional blood is transferred to the newborn infant. ●The newborn is then placed under an infant warmer. IMMEDIATE CARE OF THE NEWBORN ●Soon after the delivery of the baby, it should be placed on a tray covered with clean dry linen with the head slightly downward (15°). ●It facilitates drainage of the mucus accumulated in the tracheobronchial tree by gravity. ●The tray is placed between the legs of the mother and should be at a lower level than the uterus to facilitate gravitation of blood from the placenta to the infant. ●Air passage (oropharynx) should be cleared of mucus and liquor by gentle suction. ●Apgar rating at 1 minute and at 5 minutes is to be recorded. ●Clamping and ligature of the cord: APGAR SCORE ●The Apgar scoring system is universally accepted, and evaluation is made at 1 minute after birth and again at 5 minutes. A score above 7 indicates good condition. ●A score of three or less at one minute indicates the need for active full resuscitation which may include external cardiac massage, intubation and ventilation. ●A score of 6 or less at 5 minutes suggests perinatal asphyxia but is a poor prognostic indicator. ●Most infants will establish respiration within three minutes of birth. Ban \| Ham / Aro 54
29. Anatomical and physiological features of the newborn baby. Signs of a term fetus. SIGNS OF A TERM FETUS ●Healthy infant born at term (between 38 weeks and 42 weeks) ○Should have an average birth weight for the country (usually exceeds 2,500 g), ○Cries immediately following birth, ○Establishes independent rhythmic respiration ○Quickly adapts to the changed environment. ○The weight is variable from country to country but usually exceeds 2,500 g. ●The length (crown to foot) is 50-52 cm. ●The length is a more reliable criterion of gestational age than the weight. ●Occipitofrontal circumference measures about 32-37 cm ●Biparietal diameter measures about 9. 5 cm. ANATOMICAL PHYSIOLOGICAL FEATURES ●The newborn must be examined thoroughly within 24 hours of birth. ●Before the actual examination, the important maternal and perinatal history should be reviewed. ○Maternal history (age, parity, medical disorders, etc. ), ○Pregnancy problems—present and past (drugs, IUFD, preeclampsia, IUGR, prematurity), ○Labor and Delivery history (duration, anesthesia, duration of PROM, Apgar score) ●Assessment of gestational age is done. ●Examination of vital signs: ○Temperature ■Recorded and the site (e. g. rectal, oral or axillary) is mentioned. ○Respiration: ■Normal, 30-60 breaths/min. ■May need screening with pulse oximetry (>95% and ≤3% difference between right hand and foot). ○Pulse: ■Normal, 100-160 beats per min (bpm) ■When asleep it is around 70-80 bpm. ○Blood pressure: ■Normal range 45-60/25-40 mm Hg. ■BP is directly related to gestational age and birth weight of the infant. ●General examination: ○Skin color: ■It is the single most important parameter of cardiorespiratory function. ■Pallor may be due to anemia, birth asphyxia, or shock. ■Cyanosis: ●Central cyanosis (bluish skin, including the tongue and lips) ○Caused by low oxygen saturation. ○It may be due to congenital heart or lung disease. ○Desaturation of hemoglobin should be >3-5 g/d L. ●Peripheral cyanosis (bluish skin with pink lips and tongue) ○May be due to drugs (nitrates or nitrites) or hereditary. ○It is often associated with methemoglobinemia (hemoglobin oxidizes from ferrous to ferric form) Ban \| Ham / Aro 55
●Acrocyanosis (bluish hands and feet only) ○May be normal immediately following birth. ○It may be due to cold stress ■Plethora ●Commonly seen in infants with polycythemia. ●It may be seen in an overheated or over oxygenated infant. ●Hematocrit value may be done. ■Jaundice: ●Bilirubin level > 5 mg/d L. ■Extensive bruising ●May be due to difﬁcult or traumatic delivery. ■Skin rashes: ●Milia ○Seen on the nose, cheeks and forehead are due to plugged sweat glands. ●Mongolian spots ○Bluish, often large, commonly seen on the back, buttocks or thighs. ○Usually present in Blacks and Asians (90%). ○They disappear by 4 years of age. ●Erythema toxicum: ○These are papular lesions with an erythematous base. ○Commonly seen after 48 hours of birth. ○They resolve spontaneously. ●Diaper rash ○Usually the skinfolds are involved. ○Appears as erythematous plaques and the edges are well demarcated. ○It is a form of irritant contact dermatitis. ○It may be infected with Candida albicans. ○Head: ■Large fontanels ●Associated with hypothyroidism, osteogenesis imperfecta or chromosomal anomalies (Down syndrome). ●Bulging fontanel may be due to increased intracranial pressure, meningitis or hydrocephalus. ●Depressed fontanels are seen with dehydration. ●A small fontanel may be due to hyperthyroidism, microcephaly or craniosynostosis. ■Caput succedaneum ●Should be differentiated from cephalhematoma. ■Molding ●Seen with prolonged labor. ●Usually molding subsides within 5 days. ■Cephalhematoma ●Due to subperiosteal hemorrhage resulting from a traumatic delivery ●It never extends beyond the suture line. Ban \| Ham / Aro 56
■X-ray and CT scans should be taken to exclude skull fracture. ■Hematocrit and bilirubin levels should be estimated. ■Aspiration of hematoma is rarely needed as they often resolve in 4-6 weeks' time ●Craniosynostosis ○Premature closure of one or more sutures of the skull. ○On palpation, a bony ridge is felt over the suture line and the cranial bones cannot be moved. ○X-ray studies of the skull should be done. ○Neck: ■It is checked for ●Movements, ●Goiter, ●Thyroglossal cysts, ●Sternomastoid hematoma (sternomastoid tumor) ●Short neck, webbed neck (Turner's syndrome). ○Face and Mouth: ■Face is looked for ●Hypertelorism (eyes widely separated) ●Low-set ears (trisomy 9, 18, triploidy) ●Facial nerve injury. ■Mouth is checked for ●Clefts (palate, lips), ●Natal teeth, ●Lingual frenulum (tongue tie), ●Macroglossia (Beckwith syndrome) ●Oral thrush. ○Eyes ■Examined ●Congenital cataract, ●Brushﬁeld's spots in the iris (Down's syndrome) ●Subconjunctival hemorrhage (traumatic delivery) ●Conjunctivitis. ○Chest ■Examined for ●Any asymmetry (tension pneumothorax), ●Tachypnea, ●Grunting, ●Intercostal retractions (respiratory distress), ●Pectus excavatum ●Breath sounds. ■Newborn's breasts may be enlarged (normally 1 cm in diameter) due to maternal estrogen. ■The white discharge from the nipple is commonly known as “Witch's milk”. Ban \| Ham / Aro 57
○Heart ■Examined for ●Rate (normal 120-160 bpm), ●Rhythm, ●Quality of heart sounds ●Presence of any murmur. ■Murmurs may be associated with VSD, PDA, ASD, transposition of great vessels, tetralogy of Fallot, coarctation of aorta and others. ■Fetal echocardiography at 18-20 weeks gestation can make the antenatal diagnosis in utero. ■Fetal cardiac intervention in utero is a new and promising method of treatment. ○Abdomen ■Examined for ●Any defect, e. g. omphalocele, ●Hepatomegaly (sepsis), ●Splenomegaly (CMV, rubella infection) ●Any other mass. ■A scaphoid abdomen may be due to diaphragmatic hernia. ○Umbilicus ■Examined for any discharge, redness or infection. ■A greenish-yellow colored cord suggests meconium staining (fetal distress). ■Single umbilical artery (more in twin births) indicates genetic (trisomy 18) and congenital anomalies (40%), and IUGR. ○Genitalia ■Should be examined carefully before gender assignment. ■Male ●Examined for penis (normal > 2 cm), testes within the scrotum, any hydrocele or hypospadias. ●Prepuce is normally long and phimosis is present. ■Female ●Examined for any clitorial enlargement (maternal drug), fused labia with clitorial enlargement (adrenal hyperplasia). ●Blood stained vaginal discharge may be due to maternal estrogen withdrawal. ●Normally labia majora covers the labia minora and clitoris. ○Anus and Rectum ■Checked to rule out imperforation and their position. ■Meconium should be passed within 48 hours of birth. ○Extremities, spine and joints ■Examined for ●Syndactyly (fusion of digits), ●Polydactyly, ●Simian crease (Down's syndrome), ●Talipes equinovarus, ●Hip dislocation (Ortolani and Barlow maneuvers). Ban \| Ham / Aro 58
○Nervous system ■Examined for ●Any irritability, ●Abnormal muscle tone, ●Reﬂexes, ●Cranial and peripheral nerves. ■Neurological development is dependent on gestational age. ■The reﬂexes including Moro reﬂex are present at birth. ■Reﬂexes: ●Rooting reﬂex: ○Stroke the corner of the cheek with a ﬁnger ○Infant will turn in that direction and open her mouth; ●Glabellar reﬂex: ○To tap gently over the forehead and the eyes will blink; ●Grasp reﬂex (Palmar grasp): ○Place a ﬁnger in the open palm of the infant's hand ○The infant will grasp the ﬁnger; ●Moro reﬂex: ○Infant is supported from behind the upper back with one hand and then the baby is allowed to drop back ≥1 cm but not on the mattress. ○The baby will symmetrically abduct, extend the arms and ﬁngers. ○This is followed by ﬂexion and adduction of the arms. ○Asymmetry may signify ➢Fractured clavicle, ➢Hemiparesis ➢Brachial plexus injury. ○An absent Moro reﬂex may signify CNS pathology; ●Sucking and swallowing reﬂexes: ○Normal infant starts sucking when something (nipple and the areola) touches the palate. ○Baby swallows when the mouth is ﬁlled with milk. ●Hematological ﬁndings: ○Blood volume soon after birth is about 80 m L/kg body weight if immediate cord clamping is carried out. ○RBC—6-8 million/cu mm, Hb%—18-20 g%, ○WBC—10,000-17,000/cu mm, ○Platelets —3,50,000/cu mm, ○Nucleated red cells 500/ cu mm, ○ESR rate is elevated. ○Clotting power may be poor because of deﬁcient vitamin K which is necessary for the production of prothrombin from the liver. ○Reticulocyte count ranges from 3% to 7%. ○In a healthy term infant, hemoglobin values reach a nadir of 11 g/d L at 8-12 weeks of birth. ■This is known as physiological anemia of infancy. ○In preterm infants, the decline (7-9 g/d L) is more at 4-8 weeks. Ban \| Ham / Aro 59
30. Pain management in labor. Methods of analgesia. OBSTETRIC ANALGESIA AND ANESTHESIA ●During labor and vaginal delivery, analgesia can be achieved with nonpharmacologic techniques, systemic medication, inhalation agents, or regional analgesia. ●For cesarean section, regional or general anesthesia may be used. ●The obvious goal of obstetric anesthesia is to optimize maternal and neonatal outcome. ●Thus, the anesthesiologist must be aware of the maternal risks and beneﬁts of the analgesic and anesthetic options that are available, the effects of analgesic tech-niques on the progress of labor, and the potential direct (due to placental drug transfer) and indirect (due to reduced uterine blood ﬂow) adverse effects of the drugs and techniques on the fetus and neonate.   ANALGESIC AND ANESTHETIC TECHNIQUES FOR OBSTETRICS  ●Nonpharmacologic ○Lamaze ○Leboyer ○Acupuncture ○Hypnosis ●Regional Analgesia/Anesthesia ○Local inﬁltration for episiotomy (lidocaine) Epidural (bupivacaine) ○Spinal (tetracaine, bupivacaine, or lidocaine) ○Caudal ○Paracervical ○Pudendal (lidocaine) ●Systemic Medication ○Narcotics (fentanyl) ○Sedative-tranquilizers (Phenergan) ●Inhalation Analgesia ○Nitrous oxide Penthran ○Ethran CESAREAN SECTION ●Regional Anesthesia ○Epidural (lidocaine, chloroprocaine, or bupivacaine) ○Spinal (tetracaine, bupivacaine, or lidocaine) ●General Anesthesia ○Although all drugs cross the placenta to some extent, the degree of transfer is determined by maternal and fetal blood ﬂow to the placenta as well as by factors that determine drug passage across the placental barrier itself. ○These inhalation anesthetics produce a dose-dependent decrease in uterine resting tone, uterine contractility, and uterine responsiveness to oxytocin. ○During the active phase of the ﬁrst stage of labor, epidural analgesia has either no signiﬁcant effect or causes enhanced uterine activity. ○Excessive anesthesia during the ﬁrst stage of labor relaxes the pelvic ﬂoor musculature and may cause malrotation by interfering with internal rotation of the fetal head. ○In the patient who is motivated to bear down and is properly instructed, the appropriate use of regional anesthesia without excessive motor blockade should not prolong the second stage of labor. Ban \| Ham / Aro 60
31. Programmed, induced delivery. Indication. Management. Methods of induction of labor. ●Induction of labor (IOL) means initiation of uterine contractions (after the period of viability) by any method (medical, surgical or combined) for the purpose of vaginal delivery. ●The patient and the family members are informed about the beneﬁts, potential complications and the possibility of cesarean delivery. ●Augmentation of labor is the process of stimulation of uterine contractions (both in frequency and intensity) that are already present but found to be inadequate ARTIFICIAL RUPTURE OF MEMBRANES ●LOW RUPTURE OF THE MEMBRANES (LRM) ○It is widely practiced nowadays with a high degree of success. ○The membranes below the presenting part overlying the internal os are ruptured to drain some amount of amniotic ﬂuid. ○Contraindication: ■Preferably avoided in chronic hydramnios, due to risk of sudden massive liquor drainage. ■Sudden uterine decompression may precipitate early placental separation (abruption). ■In such a case controlled ARM is done. Ban \| Ham / Aro 61
○Procedures: ■Preliminaries: ●It is an indoor procedure. ●The patient is asked to empty her bladder. ●The procedure may be conducted in the labor ward or in the operation theater if the risk of cord prolapse is high. ■Actual steps: ●FHR status is monitored before and after the procedure. ●The patient is in a lithotomy position. ●Full surgical asepsis is to be taken. ●Two ﬁngers are introduced into the vagina smeared with antiseptic ointment. ●The index ﬁnger is passed through the cervical canal beyond the internal os. ●Membranes are swept free from the lower segment as far as reached by the ﬁnger. ●With one or two ﬁngers still in the cervical canal with the palmar surface upwards, a long Kocher's forceps with the blades closed or an amnion hook is introduced along the palmar aspect of the ﬁngers up to the membranes. ●Blades are opened to seize the membranes and are torn by twisting movements. ●Amnihook is used to scratch over the membranes. ●This is followed by visible escape of amniotic ﬂuid. ●If the head is not engaged, an assistant should push the head to ﬁx it to the brim of the pelvis to prevent cord prolapse. ●If the head is deeply engaged and the drainage of liquor is insigniﬁcant, gentle pushing of the head up, facilitates escape of desired amount of amniotic ﬂuid. ○After the membranes rupture, the following are to be assessed: ■Color of the amniotic ﬂuid; ■Status of the cervix; ■Station of the head; ■Detection of cord prolapse if any; ■The FHR pattern is again checked. ■In high-risk cases scalp electrode for fetal monitoring is applied. ●STRIPPING THE MEMBRANES ○Stripping (sweeping) of the membranes means digital separation of the chorioamniotic membranes from the wall of the cervix and lower uterine segment. ○It is thought to work by release of endogenous prostaglandins from the membranes and decidua. ○Manual exploration of the cervix triggers Ferguson reﬂex which promotes oxytocin release from maternal pituitary. ○Sweeping of the membranes is done prior to ARM. ○It is simple, safe and beneﬁcial for induction of labor. ○As an isolated procedure, stripping the membranes off from its attachment from the lower segment is an effective procedure for induction provided cervical score is favorable. Ban \| Ham / Aro 62
○It is used as a preliminary step prior to rupture of the membranes. ○It is also used to make the cervix ripe. ○Criteria to be fulﬁlled for membrane stripping are: ■The fetal head must be well applied to the cervix; ■The cervix should be dilated so as to allow the introduction of the examiner's ﬁnger. OXYTOCIN INDUCTION ●Oxytocin is an endogenous uterotonic that stimulates uterine contractions. ●Oxytocin receptors present in the myometrium are more in the fundus than in the cervix. ●Receptor concentrations increase during pregnancy and in labor (cf. prostaglandins). ●Oxytocin acts by ○Receptor mediation; ○Voltage-mediated calcium channels ○Prostaglandin production. ●Because of short half life (3-4 minutes) plasma levels fall rapidly when intravenous infusion is stopped ●Oxytocin is effective for induction of labor when the cervix is ripe. ●It is less effective as a cervical ripening agent. PROSTAGLANDINS: ●Act locally (autocrine and paracrine hormones) on the contiguous cells. ●PGE2 and PGF2α both cause myometrial contraction. ●But PGE2 is primarily important for cervical ripening whereas PGF2α for myometrial contraction. ●PGE2 has greater collagenolytic properties and also sensitizes the myometrium to oxytocin. ●Intracervical application of dinoprostone (PGE2-0. 5 mg) gel is the gold standard for cervical ripening ●It may be repeated after 6 hours for 3 or 4 doses if required. ●The woman should be in bed for 30 minutes following application and is monitored for uterine activity and fetal heart rate. ●Side effects are few Ban \| Ham / Aro 63
MECHANICAL: ●Dilators ○Act by release of endogenous prostaglandins from the membranes and maternal decidua to induce labor and cervical ripening. ○Hygroscopic dilators, e. g. laminaria (desiccated seaweed), lamicel (magnesium sulfate in polyvinyl alcohol) act by absorption of water. ○They swell and forcibly dilate the cervix. ○Mechanical dilators are as safe and effective as PGE2 in cervical ripening. ●TRANSCERVICAL BALLOON CATHETER (FOLEY CATHETER)and EXTRA-AMNIOTIC SALINE INFUSIONis effective for cervical ripening. 32. Preterm premature rupture of membranes (causes, maternal and fetal consequences). ●Means rupture of membranes, in the absence of any uterine activity, prior to 37 completed weeks. ●Spontaneous rupture of the membranes any timebeyond28th week of pregnancy but before the onset of laboris called prelabor rupture of the membranes(PROM). ●When rupture of membranes occurs beyond the 37th week but before the onset of labor, it is called term PROM. ●When it occurs before 37 completed weeks, it is called preterm PROM. ●Rupture of membranes for > 24 hours before delivery is called prolonged rupture of membranes. ●CAUSES: ○Increased friability of membranes ○Decreased tensile strength of membranes ○Polyhydramnios ○Cervical incompetence ○Multiple pregnancy ○Infection—Chorioamnionitis, urinary tract infection and lower genital tract infection ○Cervical length < 2. 5 cm ○Prior preterm labor ○Low BMI (< 19 kg/m2). ●Fetal Consequences ○Preterm labor and prematurity; ○Chance of ascending infection is more if labor fails to start within 24 hours. Liquor gets infected (chorioamnionitis) and fetal infection supervenes; ○Cord prolapse, especially when associated with malpresentation; ○Continuous escape of liquor for long duration may lead to dry labor; ○Placental abruption; ○Fetal pulmonary hypoplasia, especially when associated with oligohydramnios ○Neonatal sepsis, RDS, IVH and NEC in preterm PROM ○Perinatal morbidities (cerebral palsy) are high. ●Maternal complications ○Chorioamnionitis, ○Placental abruption ○Retained placenta, ○Endometritis, ○Maternal sepsis and even death. Ban \| Ham / Aro 64
33. Episiotomy and perineotomy. Indications. Postpartum perineal care. ●Making an incision in the perineal body at the time of delivery. ●Surgically planned incision on the perineum and posterior vaginal wall during 2ndstage of labor. ●Objectives: ○To enlarge the vaginal introitus so as to facilitate easy and safe delivery of the fetus: ■Spontaneous or manipulative. ○To prevent a perineal tear or excessive stretching of the muscles. ○To protect the fetus if it is premature or is being forced repeatedly against an unyielding perineum which is obstructing delivery. ○To reduce the stress and strain on the fetal head. ○To prevent damage from an abnormal presenting part — occipito-posterior positions, face presentations, after-coming head in breech deliveries, all instrumental deliveries. ●Indications: ○In elastic(rigid) perineum: ■Causing arrest or delay in descent of the presenting part as in elderly primigravidae. ○Anticipating perineal tear: ■Big baby ■Face to pubis delivery ■Breech delivery ■Shoulder dystocia. ○Operative delivery: Forceps delivery, ventouse delivery. ○Previous perineal surgery: Pelvic ﬂoor repair, perineal reconstructive surgery. ●Postpartum care ○Use sitz baths (sit in water that covers the vulvar area) a few times a day. ○Wait until 24 hours after birth to take a sitz bath as well.. ○Change pads every 2 to 4 hours. ○Keep the area around the stitches clean and dry. ○Pat the area dry with a clean towel after bath. ○After urinating or having a bowel movement, spray warm water over the area and pat dry with a clean towel or baby wipe. Do not use toilet paper. ○Painkillers for pain relief 34. Asphyxia of newborns (clinic, Apgar score). ASPHYXIA OF NEWBORNS ●In common clinical parlance, asphyxia neonatorum means non establishment of satisfactory pulmonary respiration at birth. Its literal meaning is “stopping of the pulse”. ●Perinatal asphyxia is a condition of impaired blood gas exchange that, if persisted, leads to progressive hypoxemia, hypercapnia and metabolic acidosis. ●The essential characteristics for the diagnosis of perinatal asphyxia are: ○Profound acidemia (p H < 7. 0) on umbilical cord arterial blood sample; ○Persistence of an Apgar score 0-3 for > 5 minutes; ○Neurological manifestations (hypotonia, coma, seizures) in the immediate neonatal period; ○Evidence of multiorgan system dysfunction. ●Often it is the continuation of antepartum or intrapartum event. ●Perinatal asphyxia is a signiﬁcant cause of perinatal death (50%). Ban \| Ham / Aro 65
●FETAL RESPIRATION ○Human fetal breathing activity is observed at 11 weeks of intrauterine life. ○Initially these are rapid and small amplitude movements (60-90 per minute). ○Fetal breathing occurs during the periods of low-voltage electrocortical activity, e. g. rapid eye movement (REM) sleep. ○During high voltage electrocortical activity (non-REM sleep) occasional breaths are observed. ○Increased fetal breathing movements are seen with increased fetal oxygen tension and hyperglycemia and it is decreased in hypoxia. ○Following birth the ﬂuid ﬁlled lung becomes the organ of gas exchange. ○The essential requirements are: ■Aeration of the lungs; ■Establishment of pulmonary circulation; ■Establishment of ventilation ■Diffusion of O2and CO2through the alveolar—capillarymembranes ●ETIOPATHOLOGY OF PERINATAL ASPHYXIA: ○Asphyxia can be classiﬁed broadly into the following groups: ■Continuation of intrauterine hypoxia (placental insufﬁciency) ●Placenta fails functionally ●Maternal hypoxic states: ■Prenatal and intranatal medication to the mother ●Morphine, pethidine and anesthetic agents depress the respiratory centers directly and the chance of development of asphyxia is increased. ■Birth trauma to the neonate ●Malpresentation such as breech, oblique lie, occipitoposterior often requires manipulative and operative vaginal delivery (forceps or ventouse). ●Prolonged second stage of labor in contracted pelvis often causes asphyxia. ●Increased intracranial tension cerebral edema and congestion increased intracranial pressure asphyxia. ■Postnatal factors ●Postnatal asphyxia is secondary to pulmonary, cardiovascular and neurological abnormalities of the neonate. ●These often overlap, making isolation of a single causative factor difﬁcult ●CLINICAL FEATURES ○The clinical features depend upon the etiology, intensity and duration of oxygen lack, plasma carbon dioxide excess and subsequent acidosis. ○The fetus and neonate are more resistant to asphyxia than the adults. ○In response to asphyxia, a mature fetus redistributes the blood ﬂow to the heart, brain and adrenals to ensure adequate oxygen and substrate delivery to these vital organs. Ban \| Ham / Aro 66
APGAR SCORING ●This scoring is done in a newborn baby at 1 minute, 5 minutes and 15 minutes ●Long-term neurological correlation is obtained at the 5-minute score which is of more value. ●In cases where the score remains signiﬁcantly depressed at 5 minutes, it should be evaluated again after 15 minutes. ●Majority of infants born with an Apgar score ≥4 by 10 minutes, >99% do not develop cerebral palsy ●75% of children who develop CP have a normal Apgar score at birth. ●Apgar score alone should not be taken as evidence of neurological damage. ●Cord blood p H can assess fetal oxygenation status better. MANAGEMENT ●Management of perinatal asphyxia can be divided into two: ○Prophylactic ○Deﬁnitive ●PROPHYLACTIC: ○Antenatal detection of high-risk patients; ○Scrupulous fetal monitoring to ensure early detection of fetal distress and timely delivery; ○Intrapartum use of electronic fetal monitoring and scalp blood p H assessment when indicated. ■Scalp blood p H < 7. 0 is a substantial evidence of prolonged intrauterine asphyxia; ○Judicious administration of anesthetic agents and sedatives during labor; ○Cooperation between obstetric and pediatric staff since delivery and ○Avoidance of difﬁcult or traumatic delivery. Ban \| Ham / Aro 67
●DEFINITIVE: ○Apgar rating—classically, the evaluation of the cardiopulmonary status in the newborn has been assessed by Apgar rating at 1 minute and 5 minutes after birth. ○Most infants born with Apgar scores of 7-10 are essentially normal. ○Apgar score 8-10 (Pink, breathing spontaneously, HR > 100 bpm). ■The oropharynx and the nasopharynx are to be cleared off any mucus by suction. ■Dry the infant and place it under a radiant heat source. ■Oxygen is administered only when required. ■The condition is reassessed at 5 minutes and if found normal, the infant should be given to the mother. ○Apgar score 5-7 Peripheral cyanosis, breathing spontaneously, HR > 100 bpm. ■Babies may follow primary apnea. ■Place under a radiant heater, dry the baby. ■A pulse oximeter placed on the right hand. ■The baby is put ﬂat, head in midline with slight extension position. ■Immediate suction of the oropharynx and nasopharynx is done. ■Stimulus to back and sole (gentle rubbing). ■Oxygen (100%) is administered at a rate of 5 L/min by bag and mask at a pressure range of 30-40 cm H2O ■CPAP may be given if necessary. ■Support should be continued until respirations are spontaneous, color improves and the heart rate is > 100 bpm. ■Such an infant may be acidotic but it is corrected spontaneously after respiration is established. ■In the majority of cases, the baby takes independent respiration with these simple measures. ■Apgar rating is done at 5 minutes and if found satisfactory, the baby is returned to the mother. ■Almost all newborns respond to ventilation with 100% O2. ■Failure to respond to intubation and ventilation can result from mechanical causes, pulmonary hypoplasia or severe asphyxia. ○Baby is apneic despite tactile stimulation: Central cyanosis or HR < 100 bpm (Apgar score 3-4) ■Babies may develop secondary apnea : call for assistance. ■A bag (750 m L volume) and a mask ventilation is started. ■O2 is administered at the rate of 5-8 L/ min. ■Positive pressure of 25-30 cm H2O may be needed for appropriate chest rise ■If not effective intratracheal intubation and IPPV is started. ■A rate of 40-60 breaths/minute should be used. ■Baby is reassessed in the next 15-30 seconds. ■Support is continued until respirations are spontaneous, HR is >100 bpm. ■These infants will be acidotic but are able to correct themselves once spontaneous respiration is established. ● Ban \| Ham / Aro 68
○Baby is apneic, HR < 100 bpm despite 30 seconds of assisted ventilation (Apgar Score 0-2) ■HR > 60 bpm, to continue positive pressure ventilation. ■The heart rate is rechecked in 30 seconds of ventilation. ■Increase the oxygen concentration to 100% if resuscitation was started using an air-oxygen blend. ■Failure to increase HR, poor status of oxygen saturation, persistent cyanosis, intubation is done rapidly by a skilled person. ■Cardiac massage is given to maintain circulation if HR < 60 bpm. ●Drugs used for resuscitation: ○Drugs are needed for a persistent HR < 60 bpm even after ventilation + chest compression. ○Drug of choice is epinephrine. ○Other drugs are given as needed RESUSCITATION OF NEWBORN IN DELIVERY ROOM ●Ventilatory resuscitation: ○Dry the infant to place under the radiant heater. ○Place the infant with head in midline position, neck with slight extension. ○Suction of mouth, oropharynx with a suction bulb. ○Assess the infant's condition: ■Respiratory effort, (apnea or regular breathing) and heart rate. ○Infants with regular breathing and heart rate > 100 bpm need no further intervention; ■If cyanotic, provide O2 supplementation. ○Infants HR < 100 bpm, apnea or irregular respiration: ■Bag and mask ventilation (100% O2) to be given. ■A soft mask that seals around the mouth and nose is to be used. ○Most neonates can be effectively managed with a bag and face mask. ○If no improvement by another 30-40 seconds-intubation is proceeded. ●Chest compression: ○Regular rate of 90 compressions/min while ventilating (PPV) infant at 30 breaths/min (31). ○HR is checked periodically and chest compression is discontinued when HR > 60 bpm. ○The thumbs are placed together over the lower third of the sternum. ○The palms encircle the torso and support the back. ●Medications: ○Epinephrine: ■0. 1-0. 3 m L/kg in 110,000 dilution is given IV or endotracheal, when there is persistent bradycardia. ■It may be repeated every 5 minutes. ○Sodium bicarbonate to treat metabolic acidosis (p H < 7. 2) IV (1-2 m Eq/kg of 0. 5 m Eq/m L, 4. 2% solution) is given. ○Reversal of narcotic drugs is needed when the mother has been given pethidine or morphine within 3 hours of delivery. ○Naloxone 0. 1-0. 2 mg/kg is given to the baby by IV, IM or endotracheal. ○Volume expansion is needed when blood pressure is low and tissue perfusion is poor. ○Normal saline, 5% albumin or whole blood (10 m L/kg) IV is given. ○Dopamine infusion may be given for hypotension Ban \| Ham / Aro 69
35. Placental insuﬃciency and fetal growth restriction: symptoms, diagnosis, treatment. ●Placental insufﬁciency is failure of the placenta to deliver sufﬁcient nutrients to the fetus during pregnancy, and is often a result of insufﬁcient blood ﬂow to the placenta. ●The term is also sometimes used to designate late decelerations of fetal heart rate as measured by electronic monitoring, ●Fetal Growth Restriction (FGR) is said to be present in those babies whose birth weight is below the 10th percentile of the average for the gestational age. ●Growth restriction can occur in preterm, term or post-term babies. Ban \| Ham / Aro 70
Diagnosis ●Clinical: ○Clinical palpation of the uterus for the fundal height, liquor volume and fetal mass may be used for screening. But it is less sensitive. ○Symphysis Fundal Height (SFH) measurement in centimeters closely correlates with gestational age after 24 weeks. A lag of 3 cm or more suggests growth restriction ○Maternal weight gain remains stationary or at times falling during the second half of pregnancy. ○Measurement of the abdominal girth showing stationary or falling value. ●Ultrasound doppler parameters ○Doppler Velocimetry:Elevated systolic/diastolic (S/D)ratio, the resistance index and the pulsatility index indicate increased blood ﬂow resistance and decrease in end-diastolic velocity. These are associated with FGR and intrauterine fetal hypoxia ○Uterine artery: The presence of diastolic notch suggestsincomplete invasion of placental trophoblasts to the uterine spiral arteries. This also predicts the possible development of preeclampsia. ○Umbilical artery (UA)decreased end diastolic velocityindicates increased placental vascular resistance. ○Umbilical artery Doppler studycan predict moderateacidosis and recommends delivery when there is presence of AREDV. ○Reduced or absent or reversed end diastolic velocity (AREDV) in the umbilical artery indicates fetal jeopardy and poor perinatal outcome. ○Umbilical venous pulsationsindicate insufﬁcientcardiac output with rise in central venous pressure impending cardiac failure. ○Ductus venosus Doppler study can predict fetal acidemia and adverse perinatal outcome. It is used when ○UA Doppler study is abnormal and also to decide the time of delivery. ●Biochemical markers: ○A low level of PAPP-A in maternal serum in the ﬁrst trimester of pregnancy is considered a marker of major risk factor for FGR. Treatment & Management ●Unfortunately, there is no treatment that can effectively ﬁx placental insufﬁciency. ●Careful management can successfully minimize potential consequences and adverse effects of the condition. ●When placental insufﬁciency ﬁrst presents in the latter stages of pregnancy (after week 35) a C-section will often be the best course of action. Ban \| Ham / Aro 71
●Once placental insufﬁciency is diagnosed management plans will usually include the following measures: ○Preeclampsia monitoring ○Referral to a high-risk fetal specialist ○Bed rest ●In addition to these management measures, doctors will usually prescribe a course of steroids. ○Steroids help to accelerate the ﬁnal development of the baby's lungs, one of the last things to develop before birth. Ban \| Ham / Aro 72
36. Course and management of pregnancy in women with acquired and congenital heart defects. Indications for the abortion. ●These patients pose little problem in obstetrics. But when pregnancy occurs in uncorrected congenital lesions, problems are very much there especially in a cyanotic group. ●Major maternal risks in pregnancy are: ○Cyanosis ○Left ventricular dysfunction ○Pulmonary hypertension. ●The common maternal complications are: ○Congestive cardiac failure ○Pulmonary edema ○Arrhythmia and ○Hypertension. ●All women should have a fetal echocardiography examination at mid pregnancy. Acyanotic (l to R shunt) ●Atrial Septal Defect (ASD): ○ASD (ostium secundum type) is the most common CHD during pregnancy. ○Even uncorrected ASD tolerates pregnancy and labor well. ○Congestive cardiac failure unresponsive to medical therapy requires surgical correction. ○Shunt reversal is the major risk which may develop in hypovolemia. ○Such cases may occur in hemorrhagic conditions and following injudicious administration of epidural anesthesia. ○In the absence of arrhythmias, and pulmonary hypertension, ASD does not usually complicate pregnancy. ●Patent Ductus Arteriosus (PDA): ○Presence of continuous murmur at the upper left sternal border is suggestive of diagnosis. ○Most patients with PDA tolerate pregnancy well. ○Pulmonary hypertension may cause maternal death. ○Surgical correction during pregnancy can be performed if there is no pulmonary hypertension. ○Epidural analgesia is better avoided to minimize shunt reversal due to systemic hypotension. ○Fetal loss may be up to 7% and there is a 4% chance that the child of this parent will suffer from the same abnormality. ○Endocarditis prophylaxis should be given. ●Ventricular Septal Defect (VSD): ○In general, if the defect is <1. 25 cm2, pulmonaryhypertension and heart failure do not develop. ○Pregnancy is well tolerated with small to moderate left to right shunt or with moderate pulmonary hypertension. ○The major risk is shunt reversal leading to circulatory collapse and cyanosis. ○Hypotension is to be avoided. ○Fetal loss may be up to 20%. Ban \| Ham / Aro 73
●Mitral Valve Prolapse (MVP): ○Is the commonest congenital valvular lesion. ○Most of them are asymptomatic. ○Women tolerate pregnancy and labor well. ○Endocarditis prophylaxis is given. Cyanotic (R to l shunt) ●Fallot's tetralogy: ○It is the most common form of cyanotic heart lesion. ○It is a combination of ■Ventricular septal defect, ■Pulmonary valve stenosis, ■Right ventricular hypertrophy ■An overriding aorta. ○After surgical correction, patients tolerate pregnancy well. ○Surgically uncorrected patients are at increased risk. ○Bacterial endocarditis, brain abscess and cerebral embolism are more common. ○Maternal mortality is 5-10% and the perinatal mortality is 30-40%. ○IUGR is common. ○hypotension is dangerous which may lead even to death. ○Epidural or spinal anesthesia is avoided. ○Pregnancy is discouraged in women with uncorrected tetralogy. ●Eisenmenger's syndrome: ○Patients with Eisenmenger's syndrome have pulmonary hypertension with shunt (right to left) through an open ductus, an atrial or ventricular septal defect. ○Termination of pregnancy should be seriously considered. ○Heparin should be used throughout pregnancy as there is risk of thromboembolism. ○Epidural anesthesia is contraindicated. ○Inhaled nitric oxide or I. V. prostacyclin is used as a pulmonary vasodilator. ○To maintain hemodynamic stability, pulmonary artery catheters and a peripheral artery catheter are used. ○Complications are: ■CCF, ■Hemoptysis, ■Arrhythmia, ■Cerebrovascular accident and hypoxemia; ■Hyperviscosity syndrome and sudden death. Other congenital heart lesions ●Coarctation of aorta: ○The maternal risks are hypertension, aortic dissection, bacterial endocarditis and cerebral hemorrhage due to ruptured intracranial aneurysms. ○Maternal mortality is high 3-9%. ○Fetal loss is also increased to 25%. ○Surgical correction should be done prior to pregnancy. ○Termination of pregnancy should be seriously considered. ○Elective cesarean section is preferred to minimize dissection associated with labor. Ban \| Ham / Aro 74
●Marfan's syndrome: ○Marfan's syndrome is an autosomal dominant condition. ○There is a 50% chance of transmission to the offspring. ○Dilatation of aorta more than 40 mm as evidenced from echocardiography is a contraindication of pregnancy. ○Beta blocking drugs should be used to maintain resting heart rate around 70 bpm. ○Hypertension should be avoided to prevent aortic dissection. Vaginal delivery is desirable with shortening of the second stage. ○When the aortic root diameter measures more than 4 cm, mortality increases to 25%. ○Women with aortic diameter more than 5. 5 cm should have graft and valve replacement before pregnancy. 37. Course of pregnancy, its supervising and management in women with chronic hypertension. Contra-indications to a child-bearing. Tactics at childbirth. ●Hypertension during pregnancy is deﬁned as a systolic pressure of 140 mm Hg or higher, a diastolic pressure of 90 mm Hg or higher, or both. ●Hypertension during pregnancy can be classiﬁed into three main categories ○Chronic hypertension, ○Gestational hypertension, ○Preeclampsia, with or without preexisting hypertension. ●In general, hypertensive disorders can complicate 12% to 22% of pregnancies and are a major cause of maternal morbidity and mortality. ●Chronic hypertension is deﬁned as ○Blood pressure of 140/90 mm Hg or higher that was present ■Before pregnancy, ■Before the 20th week of gestation, ■Persisting beyond the 42ndpostpartum day. ●Frequently, women with chronic hypertension must change their medical regimens when they anticipate pregnancy to maximize the safety of the growing fetus. ●Women of childbearing age who take chronic antihypertensive medications should be counseled about the safety of these medications in the event of pregnancy well in advance of a potential pregnancy. Management ●Detection ○There is no established, practical screening procedure other than good antenatal care. ○Regular supervision, especially of recognised high-risk groups, may be shared between the general practitioner, midwife and obstetrician. ●Observations ○Serial blood pressure recordings. ○Quantitation of proteinuria. ○Plasma urate levels. ○Platelet counts. ○Liver enzymes if b, c or d are abnormal. ○Assessment of fetal growth and wellbeing by kick charts, cardiotocography and ultrasound estimates of fetal weight and liquor volume Ban \| Ham / Aro 75
●Treatment ○Admission to hospital ■Indicated if the diastolic blood pressure remains at 100mm Hg or more. ■The presence of proteinuria and evidence of fetal compromise are also indications for admission. ■Many patients with hypertension arising late in pregnancy require no other treatment before delivery. ■It must always be remembered, however, that the disease can run an unpredictable course and its severity may change very quickly. ○Hypotensive agents — these may be used in three situations ■Chronic hypertension, ■Severe pregnancy-induced hypertension ■In the treatment of a hypertensive crisis or imminent eclampsia ○Methyldopa ■Usual dosage is 250 mg twice or three times daily. ○Labetalol, ■Combined alpha and beta blocker ■Reduces peripheral resistance. ■Protects the heart from the reﬂex sympathetic drive normally induced by peripheral vasodilatation. ■The dosage by mouth is 100-400 mg twice daily. ○Nifedipine ■Calcium channel blocker and may be used as an alternative to labetalol. ■Given orally in a dose of 10 mg three times daily and appears to be safe in late pregnancy. ●Delivery ○The ultimate treatment of hypertensive pregnancy, and its timing depends on the observations of fetal and maternal wellbeing noted above. ○Prolongation of the pregnancy by drug therapy may reduce the risks of prematurity and improve the chances of vaginal delivery. ○Epidural block for both analgesia in labor and delivery by cesarean section is excellent providing the platelet count is satisfactory. Tactics at labor ●If you're taking medicine throughout pregnancy to control your blood pressure, keep taking it during labor. ●If you have mild or moderate hypertension, your blood pressure should be monitored hourly during labor. ●As long as your blood pressure remains within target levels, you should be able to have a natural vaginal birth. ●If you have severe hypertension, your BP will be monitored every 15 to 30 minutes in labor. ●Your doctors may also recommend your baby be delivered using forceps or ventouse, or by cesarean section. ●After the birth, your blood pressure will be monitored. ●If you had hypertension before you got pregnant, your treatment should be checked 2 weeks after your baby is born. Ban \| Ham / Aro 76
38. The course of pregnancy and its management in women with diabetes mellitus. Indications for the abortion. Diabetic fetopathy. ●Pregnancy aggravates pre existing type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes but does not appear to exacerbate diabetic retinopathy, nephropathy, or neuropathy. ●Gestational diabetes (diabetes that begins during pregnancy can develop in overweight, hyperinsulinemic, insulin-resistant women or in thin, relatively insulin-deﬁcient women. ●Women with gestational diabetes are at increased risk of type 2 diabetes in the future. MATERNAL ●During pregnancy: ○Abortion: Recurrent spontaneous abortion may be associated with uncontrolled diabetes. ○Preterm labor (26%) may be due to infection or polyhydramnios. ○Infection: Urinary tract infection and vulvovaginitis. ○Increased incidence of preeclampsia (25%). ○Polyhydramnios is a common association. ■Large baby, large placenta, fetal hyperglycemia leading to polyuria, increased glucose concentration of liquor irritating the amniotic epithelium or increased osmosis, are some of the probabilities. ○Maternal distress may be due to the combined effects of an oversized fetus and polyhydramnios. ○Diabetic retinopathy (Class R) ■Characterized by the proliferative retinopathy having neovascularization and microaneurysms. ■These vessels may rupture and may cause vitreous hemorrhage, scarring, retinal detachment and loss of vision. ■Severity of retinal pathology depends on ●Age (time) of onset, ●Duration of the disease, ●Degree of rise in blood Hb AIC ●Association of hypertension. ■Laser photocoagulation is the preferred treatment. ○Diabetic nephropathy (Class F) ■Diagnosed when creatinine clearance is reduced or there is persistent proteinuria (≥300 mg/24 hours) during the ﬁrst 20 weeks of gestation. ■Predictive factors for perinatal outcome (e. g., low birth weight, preterm delivery or preeclampsia) are: ●Proteinuria > 3 g/24 hours, ●Serum creatinine > 1. 5 mg/dl ■Most women (90%) develop preeclampsia. ■Control of hypertension is important to prevent further deterioration of kidney function. Calcium channel blocker is commonly used. ■These women have signiﬁcantly reduced life expectancy. ■The disease progression is characterized by hypertension, falling glomerular ﬁltration rate and creatinine clearance. ■The end stage disease needs dialysis or renal transplantation. ■Renal transplantation improves survival of women with diabetic nephropathy. Ban \| Ham / Aro 77
○Coronary artery disease (Class H): ■These women run a high risk for ischemic heart disease especially when the disease is long standing. ○Ketoacidosis ●During labor: ○There is increased incidence of: ■Prolongation of labor due to big baby. ■Shoulder dystocia ●Shoulder dystocia is due to disproportionate growth with increased shoulder/head ratio. ■Perineal injuries. ■Postpartum hemorrhage. ■Operative interference. ○Puerperium: ■Puerperal sepsis. ■Lactation failure. FETAL AND NEONATAL HAZARDS: ●Fetal macrosomia (40-50%) with birth weight > 4 kg (>90th percentile) probably results from: ○Maternal hyperglycemia hypertrophy and hyperplasia of the fetal islets of langerhans increased secretion of fetal insulin stimulates carbohydrate utilization and accumulation of fat. ■Insulin-like growth factors (IGF-I and II) are also involved in fetal growth and adiposity. ■With good diabetic control, incidence of macrosomia is markedly reduced. ○Elevation of maternal free fatty acid (FFA) in diabetes leads to its increased transfer to the fetus acceleration of triglyceride synthesis adiposity. ●Congenital malformation (6-10%) ○Related to the severity of diabetes affecting organogenesis, in the ﬁrst trimester (both in type 1 and type 2 diabetes). ○The factors associated with teratogenesis are multifactorial: ■Genetic susceptibility ■Hyperglycemia ■Arachidonic acid deﬁciency ■Ketone body excess ■Somatomedin inhibition ■Free oxygen radical excess (superoxide dismutase, an oxygen radical scavenging enzyme can protect excess malformation). ○Risks of fetal chromosomal abnormalities are not increased. ●Early detection of fetal anomalies: ○Estimation of glycosylated hemoglobin A (Hb A1c) before 14 weeks reﬂects the quality of diabetic control over the previous 3 months. ○Overall risk of fetal malformations are increased when level of Hb A1c is high (normal < 6%). ○Maternal serum α-fetoprotein level at 16 weeks and a detailed high resolution ultrasonography of the fetus including fetal echocardiography at 20-22 weeks are advocated. Ban \| Ham / Aro 78
○A comprehensive ultrasound examination—including fetal echocardiography is done at 20-22 weeks to detect any cardiac anomaly along with other structural malformation. ■Birth injuries (brachial plexus) ●Associated with prolonged labor and shoulder dystocia due to macrosomic baby. ■Growth restriction ●Less commonly observed and is associated with maternal vasculopathy. ●Placental amino acid transporters are involved in fetal macrosomia or IUGR in women with diabetes. ■Fetal death ●Multifactorial pathogenesis but the ﬁnal event being hypoxia and lactic acidemia. ●It is observed more in patients with poor glycemic control, vasculopathy, preeclampsia, ketoacidosis and fetal macrosomia. ●Fetal hyperglycemia and hyperinsulinemia increase fetal oxygen demand. ●Glycosylated hemoglobin carries less oxygen molecules. ●It binds O2 more avidly and releases O2 less. ●Other factors involved are fetal polycythemia, and hyperviscosity. ■Neonatal complications include ●Hypoglycemia (< 35 mg/dl) ○Due to hyperinsulinemia. ○It is common in macrosomic infants. ●Respiratory distress syndrome ○Due to excess levels of fetal insulin that blocks the action of cortisol. ○Cortisol activates type II pneumocytes for the synthesis of phospholipids (surfactant). ○Risk of RDS is reduced when diabetes is well controlled and delivery is done after 38 weeks of gestation. ●Hyperbilirubinemia ○Due to increased red cell production (polycythemia) and breakdown of red cells. ●Polycythemia ●Hypocalcemia (≤7 mg/dl) ●Hypomagnesemia (<7 mg/dl) ●Cardiomyopathy ○More common when diabetes is poorly controlled. ○Septal hypertrophy and cardiac hypertrophy are also observed. ●Long-term effects—childhood obesity, neuropsychological effects and diabete Ban \| Ham / Aro 79
MANAGEMENT ●Antenatal care ○Diet ○Frequent blood sugar estimation is needed ○Hb A1c level of <6% is desirable ○Ultrasound ○Assessment of fetal wellbeing made from 28 weeks onwards ○Umbilical artery velocimetry ○Insulin therapy ■When ﬁrst detected during pregnancy and cannot be controlled with diet alone ■Postprandial (2 hrs) plasma glucose of >140 mg% even on diet is an indication ■Glycemic goals should be around 90 mg/dl before meals and not to exceed 120 mg/dl, 2 hours after meals ●Admission: ○In uncomplicated cases, the patient is admitted at 34-36 weeks. ○Early hospitalization facilities: ■Stabilization of diabetes ■Minimizes the incidence of preeclampsia, polyhydramnios and preterm labor ■To select out the appropriate time and method of delivery. ●Induction of labor: ○The indications are — ■Diabetic women controlled on insulin (GDM or class B diabetes) are considered for induction of labor after 38 completed weeks ■Women with vascular complications (preeclampsia, IUGR) often require induction after 37 weeks. ●Cesarean section: ○The indications are— ■Fetal macrosomia (>4 kg) ■Diabetes with complications or difﬁcult to control ■Fetal compromise as observed in antepartum fetal monitoring ■Elderly primigravidae ■Multigravidae with a bad obstetric history ■Obstetric complications like preeclampsia, polyhydramnios, malpresentation. ○As such 50% of diabetic mothers are delivered by cesarean section ● Puerperium: ○Antibiotics should be given prophylactically to minimize infection. ○Insulin requirement falls dramatically following delivery. ○She is to revert to the insulin regime as was prior to pregnancy. ○A fresh blood glucose level after 24 hours will help to adjust the dose of insulin. ○Breastfeeding is encouraged. ○Women who breastfeed should have an additional 500 Kcal daily in their diet. ○In lactating women insulin dose is lower. Ban \| Ham / Aro 80
●Care Of The Baby: ○A neonatologist should be present at the time of delivery. ○The baby should preferably be kept in an NICU and to remain vigilant for at least 48 hours, to detect and to treat effectively any complication likely to arise. ■Asphyxia is anticipated and be treated effectively ■To look for any congenital malformation. ■All babies should have blood glucose to be checked within 2 hours of birth to avoid problems of hypoglycemia (blood glucose < 35 mg/dl). ■All babies should receive 1 mg vitamin K intramuscularly. ■Early breastfeeding within half to 1 hour is advocated and to be repeated at three to four hourly intervals thereafter to minimize hypoglycemia and hyperbilirubinemia 39. The course of pregnancy and its management in women hypothyroidism. Maternal, fetal and neonatal consequences Indications for the abortion. ●May be subclinical (elevated TSH and normal FT4) or overt (elevated TSH and low FT4). ●The clinical association of hypothyroidism in pregnancy may be due to First time diagnosis in pregnancy ○Hypothyroid women who either discontinue thyroid therapy or who need larger doses of pregnancy. ○Hyperthyroid women on excessive amounts of antithyroid drugs. ○Women with lithium or amiodarone therapy. ●Primary hypothyroidism met in pregnancy is mostly related to thyroid autoimmunity (Hashimoto thyroiditis). ●Myxedema rarely presents in pregnancy because they tend to be infertile. ●Untreated hypothyroidism in early pregnancy has a high fetal wastage in the form of abortion, stillbirth and prematurity and deﬁcient intellectual development of the child. ●Pregnancy complications like preeclampsia and anemia are high. ●Serum thyroid peroxidase antibodies (TPO-Ab) or antimicrosomal antibodies are elevated in autoimmune thyroiditis. ●Serum TSH should be repeated at an interval of 6-8 weeks as there is increased demand for thyroid hormone in the second half of pregnancy. ●If the patient is having substitution therapy in a pre-pregnant state, the dose of levothyroxine needs to be increased in pregnancy. ●Generally, therapy is started 2 to 2. 4 mcg/kg/day. ●The maintenance dose for most patients is between 75 and 150 mcg of l-thyroxin per day. ●The serum TSH should be repeated every 2 to 6 weeks. ●In order to keep serum TSH, serum FT4 or FT41 values within the normal range, the dose needs to be increased in the second trimester of pregnancy. After delivery, dose is reduced. Ban \| Ham / Aro 81
40. The course of pregnancy and its management in women with thyrotoxicosis. Maternal, fetal and neonatal consequences Indications for the abortion. ●Causes of thyrotoxicosis ○Graves' disease. ○Toxic multinodular goiter. ○Toxic adenoma. ○Carcinoma. ○Subacute thyroiditis. ○Amiodarone. ○Lithium. ●Women with hyperemesis or a molar pregnancy may mimic biochemical hyperthyroidism as h CG, at high levels, can stimulate TSH receptors. ●They usually have no clinical signs of thyrotoxicosis and should not be treated. ●Management ○Graves' disease often improves in pregnancy, but relapses post-partum. ○With treatment the outlook is good for mother and baby. ○Untreated thyrotoxicosis is dangerous for mother and baby. ○PTU and carbimazole may be used as treatment; both cross the placenta. ○Avoid radioactive iodine. ○Check for TSH receptor stimulating antibodies. ○Monitor thyroid function every 4-6wks in new cases, less frequently in stable cases. ○Monitor fetus by fetal heart rate and serial USS for growth and presence of goiter. ○Breast-feeding is safe with doses of PTU <150mg/day and carbimazole <15mg/day. ○Monitor TFTs in babies at higher doses. ????????????? 41. Features of a clinical course and diagnosis of pyelonephritis during pregnancy. Treatment. Management of pregnancy, labor and postpartum period. ●The onset is acute and usually appears beyond the 16th week. ●The involvement is bilateral but if unilateral, it is more frequent on the right side. ●Clinical features are mainly due to endotoxemia. ●The chemical mediators (cytokines) released are: Il-1, TNF and endogenous pyrogen. ●Important features are: ○Acute aching pain over the loins, often radiating to the groin ○Costovertebral angle tenderness, ○Urgency, frequency, dysuria, hematuria. ○Fever (spiky 40°C) with chills and rigor followed by hypothermia (34°C); ○Anorexia, nausea, vomiting and myalgias; ○Respiratory distress and pulmonary edema (ARDS) due to endotoxin induced alveolar injury. ●Investigations: ○Apart from the routine ones, serum level of creatinine, electrolytes and culture studies of urine and blood should be done. Ban \| Ham / Aro 82
●Differential Diagnosis: ○Acute appendicitis ○Abruptio placentae ○Red degeneration of ﬁbroid ○Acute cholecystitis ○labor ○Chorioamnionitis. ●Fetal Complications ○There may be increased fetal loss due to abortion, preterm labor, ○intrauterine fetal death caused by hyperpyrexia ○low birth weight babies (prematurity and dysmaturity). ●Maternal Complications: ○Anemia, Septicemia, septic shock, renal dysfunction and pulmonary insufﬁciency. ○ARDS may develop due to endotoxin induced alveolar capillary membrane damage following septicemia. ●Management ○Intravenous ﬂuid (crystalloid) for adequate hydration. ○Evaluate hemogram, serum electrolytes, creatinine. ○Acetaminophen is given for the fever. ○Monitor urine output (> 60 ml/hr), temperature and BP. ○IV antibiotics—Cephalosporins, aminoglycosides (gentamicin), Cefazolin or Ceftriaxone, for 48 hours till culture report is available and then changed to oral therapy for another 10-14 days. ○Repeat urine culture after 2 weeks of antimicrobial therapy and is repeated at each trimester of pregnancy. ○If the symptoms recur or the dipstick test for nitrate and leukocyte esterase is positive, urine culture is repeated. ○The woman needs retreatment if the culture is positive. ○Patients not responding with this therapy need to be evaluated (sonography) for urinary tract obstruction. ○Antimicrobial suppression therapy is continued till the end of pregnancy to prevent recurrence. ○Nitrofurantoin 100 mg daily at bedtime is effective. Ban \| Ham / Aro 83
42. Anemia during pregnancy. Features of clinical course. Treatment. Management of pregnancy, labor and postpartum period. ●Anemia is deﬁned as reduction in circulating hemoglobin mass below the critical level. ●The normal hemoglobin (Hb) is 12-14 gm%. ●WHO has accepted up to 11 gm% as the normal hemoglobin level in pregnancy. ●Therefore, any hemoglobin level below 11gm in pregnancy should be considered as anemia Physiological adaptation in pregnancy ●Plasma volume expansion (50%) greater than red cell mass (25%). ●This leads to physiological dilution with d Hb and hematocrit. ●Anemia is diagnosed if Hb <10. 5 g/d L in pregnancy. ●There should be no change in mean corpuscular volume (MCV) or mean corpuscular hemoglobin concentration (MCHC) in normal pregnancies. ●Normally pregnancy has: ○2-3-fold increase in iron requirements ○10-20-fold increase in folate requirements in pregnancy Causes Of Anemia ●Physiological ●Nutritional ○Iron deﬁciency ○Folate &Vit B12 deﬁciency ●Dimorphic ●Hemorrhagic: Acute or Chronic ●Hemoglobinopathies ●Hemolytic: Congenital or acquired ●Aplastic anemia Maternal Risk Factors ●Antenatal Period ○Poor weight gain ○Preterm labor ○PIH ○Placenta previa ○PROM ●Intranatal Period ○Dysfunctional labor ○Hemorrhage ○Shock ○Cardiac failure ○Anesthesia risk ●Postnatal ○Postnatal sepsis ○Subinvolution ○Embolism Ban \| Ham / Aro 84
Fetal & Neonatal Risk Factors ●Prematurity ●Low birth weight ●Poor APGAR score ●Fetal distress ●Neonatal Anemia. Complications ●During Pregnancy ○Preeclampsia: may be related to malnutrition and hypoproteinemia. ○Intercurrent infection—Not only does anemia diminish resistance to infection, but also any pre-existing lesion, will ﬂare up. It should be noted that the infection itself impairs erythropoiesis by bone marrow depression. ○Heart failure at 30-32 weeks of pregnancy. ○Preterm labor. ●During Labor ○Uterine inertia is not a common associate, on the contrary the labor is short because of a small baby and multiparity. ○Postpartum hemorrhage-Patient tolerates even a minimal amount of blood loss. ○Cardiac failure-may be due to accelerated cardiac output which occurs during labor or immediately following delivery. As the blood in the uterine circulation is squeezed in the general circulation, it puts undue strain on the weak heart already compromised by hypoxia. ○Shock—Even a minor traumatic delivery without bleeding may produce shock or a minor hypoxia during anesthesia which may be lethal ●Puerperium ○There is increased chance of: ○Puerperal sepsis ○Subinvolution ○Poor lactation ○Puerperal venous thrombosis ○Pulmonary embolism. ●Fetus & Neonates ○Amount of iron transferred to the fetus is unaffected even if the mother suffers from iron deﬁciency anemia. So, the neonate does not suffer from anemia at birth. ○There is increased incidence of low-birth-weight babies with its incidental hazards ○Intrauterine death—due to severe maternal anoxemia. ○The sum effect is increased perinatal loss. Management ●During Labor ○First stage: The following are the special precautions that are to be taken when an anemic patient goes into labor. ■The patient should be in bed and should lie in a position comfortable to her. ■Arrangements for oxygen inhalation are to be kept ready to increase the oxygenation of the maternal blood and thus diminish the risk of fetal hypoxia. ■Strict asepsis is to be maintained to minimize puerperal infection. Ban \| Ham / Aro 85
○Second stage: ■Asepsis is maintained. ■Prophylactic low forceps or vacuum delivery may be done to shorten the duration of the second stage. ■Intravenous methergine 0. 2 mg should be given soon following the delivery of the baby. ○Third stage: ■Signiﬁcant amounts of blood loss should be replenished by fresh packed cell transfusion after taking the usual precautions mentioned earlier. ■The danger of postpartum overloading of the heart should be avoided. ○Puerperium ■Adequate rest ■Prophylactic antibiotics are given to prevent infection. ■Predelivery anti anemia therapy should be continued till the patient restores her normal clinical and hematological states. ■Patients should be warned of the danger of recurrence in subsequent pregnancies. ■Careful watch for puerperal sepsis, failing lactation; subinvolution of uterus and thromboembolism. ●Avoidance of frequent child-births—a minimum interval between pregnancies, should be at least 2 years, if not three, to replenish the lost iron during childbirth process and lactation. ●This can be achieved by proper family planning guidance. ●Supplementary iron therapy-Daily administration of 200 mg of ferrous sulfate (containing 60 mg of elemental iron) along with 1 mg folic acid is a quite effective prophylactic procedure. ●Dietary prescription: A realistic balanced diet, rich in iron and protein, should be prescribed which should be within the reach of the patient and should be easily digestible. ●Adequate treatment should be instituted to eradicate hookworm infestation, dysentery, malaria, bleeding piles, and urinary tract infection ●Early detection of falling hemoglobin level is to be made. Hemoglobin level should be estimated at the ﬁrst antenatal visit, at the 30th week and ﬁnally at 36th week. 43. Characteristic features, diagnosis and treatment of appendicitis in diﬀerent terms of pregnancy. ●Incidence is about 1 in 1,000 pregnancies. ●It is the commonest non gynecological cause of acute abdomen requiring surgery. ●Diagnosis is difﬁcult in pregnancy due to ○Nausea and vomiting common in normal pregnancy are also the common symptoms of appendicitis ○Leukocytosis is common in normal pregnancy ○Appendix moves upwards and outwards as the uterus enlarges. ■So pain and tenderness may not be located in right iliac fossa (Mc Burney's point) ○Diagnosis is often confused with disturbed ectopic pregnancy, pyelonephritis, twisted ovarian cyst, abruptio placenta and red degeneration of a ﬁbroid, preterm labor. Ban \| Ham / Aro 86
●Effect of appendicitis on pregnancy ○May lead to ■Miscarriage, ■Preterm delivery, ■Increased perinatal mortality and maternal mortality. ○Effect of pregnancy on appendicitis is adverse because of ■Late diagnosis ■Failure of localization due to displacement of the position ■Peritonitis is more common, especially in the last trimester. ●The risks of maternal and fetal mortality from appendicitis in pregnancy is high especially when associated with perforations. ●Ultrasonography is commonly done. ●MRI may be used when ultrasound is inconclusive. ●Treatment consists of laparotomy at the earliest opportunity. ○Once the diagnosis is suspected, it is essential to operate rather than to wait until generalized peritonitis has developed. ○Muscle splitting incision should be made at the point of maximum tenderness. ○Uterine manipulation is avoided to minimize the risk of preterm labor. ○Laparoscopic appendicectomy can be done before 28 weeks of gestation. ○Intraoperative fetal monitoring should be considered. 44. Cholecystitis during pregnancy. Features of a course, diagnostics and treatment. ●Incidence is about 1 in 2,000 pregnancies. ●It is the second most common non gynecological condition that needs surgery during pregnancy. ●Initial management is conservative. ●Elective endo cystectomy is done in the second trimester or puerperium. ●Deterioration of clinical condition despite medical therapy or recurrent biliary colic needs cholecystectomy regardless of trimester. ●Laparoscopic cholecystectomy can be done in the second trimester of pregnancy safely. ●Research has indicated that there are physiologic changes during pregnancy that lead to an increased incidence of gallstone formation. ○During early pregnancy there is increased synthesis of bile acids leading to an increase in both the cholate and chenodeoxycholate bile acid pools. ○During the 2ndand 3rdtrimesters of pregnancy, however,there is a progressive decrease in the chenodeoxycholate pool secondary to a decrease in the rate of its synthesis, but there is no decrease in the cholic acid pool. ○Total rate of cholesterol secretion remains constant; ○But relative to the now altered chenodeoxycholate/cholate ratio its concentration in bile increases, resulting in the creation of lithogenic bile. ○In addition, during pregnancy there are signiﬁcant changes in gallbladder function. ○During the 2ndand 3rdtrimesters, the volume of thegallbladder increases almost twofold. ○Moreover, after stimulation the rate and percentage of bile discharged are reduced. ○The combination of increased residual volume and lithogenic bile leads to an increased opportunity for cholesterol crystals to form, allowing gallstone formation to begin. Ban \| Ham / Aro 87
●Symptoms and signs during pregnancy are similar to those in the nonpregnant individual. ○Major diagnostic difﬁculty that pregnancy imposes is differentiating between cholecystitis and appendicitis, as in the pregnant woman the appendix may also occupy the RUQ ○Pain, usually localized to the RUQ, is constant and accompanied by nausea and fever. ○Physical examination often reveals RUQ tenderness and severe pain under the costal margin with deep inspiration (Murphy's sign). ○Laboratory examination usually reveals an increased white blood cell count with an increase in immature forms. ●Diagnostic of choice is Ultrasound ○Ultrasonography conﬁrms the presence of stones in the gallbladder ○Sometimes reveals a thickened gallbladder wall suggestive of acute inﬂammation. ●MRI can be used as an alternative method of diagnosis if ultrasound is inconclusive ●Late 2ndtrimester is the most favorable time fora cholecystectomy usually done laparoscopically. 45. Obstructive disorders of the bowel. Management. Indications for termination of pregnancy. SMALL BOWEL OBSTRUCTION ●Obstruction of the small intestines may be partial or complete and can result from adhesions following intra abdominal surgery, infection, or malignancy. ●Surgical adhesions are the most common cause. ●Small bowel obstruction (SBO) develops following 1-2% of total abdominal hysterectomies, and nearly 75% of obstructions are complete. ●Initial SBO management is similar to that or POI, but distinguishing between the two is important to prevent serious SBO sequelae. ●During SBO, the bowel lumen dilates proximal to the obstruction, and decompression may develop distally. ●Bacterial overgrowth in the proximal small bowel can promote bacterial fermentation and worsening dilation. ●The bowel wall also becomes edematous and dysfunctional. ●Progressive increases in bowel pressure compromise perfusion to the intestinal segment and can ultimately lead to ischemia or rupture ●Clinical signs that may help distinguish ○SBO from POI include tachycardia, oliguria, and fever. ○Physical examination may reveal abdominal distention, high-pitched bowel sounds, and an empty rectal vault during digital examination. ○Last, leukocytosis with a neutrophil dominance should alert to possible coexistent bowel ischemia. ●MRI can be used for imaging studies ●Treatment of SBO varies with the degree of obstruction. ●For partial obstruction, feedings are withheld, IV ﬂuids and antiemetics are initiated, and an NG is placed for signiﬁcant nausea and vomiting. ●Continued surveillance monitors or signs of bowel ischemia. ●Symptoms in most cases of partial SBO improve within 48 hours. ●In contrast, or most of those with complete bowel obstruction, surgery to relieve the obstruction is indicated. Ban \| Ham / Aro 88
LARGE BOWEL OBSTRUCTION ●Colonic obstruction is rare following gynecologic surgery but carries a high mortality rate ●The colon can be obstructed by ○Intrinsic lesions such as colon cancer or diverticulitis-related strictures or can be compressed by a pelvic mass or oreign body, such as a retained surgical sponge. ●An enlarged cecum found on an abdominal radiograph requires further evaluation by either a barium enema or colonoscopy. ●Immediate intervention is necessary when the cecal diameter exceeds 10 to 12 cm to minimize perforation risk ●Treatment is surgical 46. Pancreatitis during pregnancy. Features of a course, diagnostics and treatment. ●It is difﬁcult to diagnose during pregnancy because of the physiological increase of amylase value during the second and last trimester. ●Serum amylase is elevated to 1000 IU/l or more, serum calcium is usually low. ●Ultrasound is of diagnostic value. ●Preterm labor is more common. ●Once the diagnosis is made, the treatment should be conservative rather than surgical. ●Medical management includes ○IV ﬂuids, ○Gastric acid suppression, ○Analgesia ○Nasogastric suction. ●The incidence of pancreatitis during pregnancy is unknown, but probably acute pancreatitis is uncommon with over 40% of cases during the third trimester. ●It may be due in part to the known tendency of serum triglyceride levels to rise sharply during this period or to the increased chance that cholesterol microcrystals have formed by the end of the pregnancy in atonic gallbladders with increased lithogenic bile. ●Most cases occur in multigravidas. ●Cholelithiasis is the most commonly identiﬁed cause, occurring in one-third to over one-half of cases of pancreatitis during pregnancy. ●Other causes of acute pancreatitis include hyperlipidemia (types I, V, and occasionally IV), hyperparathyroidism, and drug and alcohol intake. ●The incidence of tetracycline-and thiazide-induced pancreatitis is decreasing because of the decreased use of these drugs during pregnancy. ●Regardless of the etiology of the pancreatitis, the clinical presentation is the same. SIGNS AND SYMPTOMS ●The patient presents with steady epigastric pain, at times severe, often radiating to the back. ●Physical examination may reveal a tachycardic and sometimes hypotensive patient with epigastric tenderness and a silent abdomen. ●In severe cases of hemorrhagic pancreatitis there may be ○Bloody discoloration of the umbilicus (Cullen sign) ○Retroperitoneal dissection of the hemorrhage to the ﬂank (Grey Turner sign). ●Chest examination might show evidence of a pleural effusion or signs of respiratory distress syndrome. Ban \| Ham / Aro 89
DIAGNOSTICS ●The clinical diagnosis of acute pancreatitis is conﬁrmed by determination of the serum amylase level, which is above normal in 95% of cases ●The amylase level does not reﬂect the severity of the disease process. ●In cases where serum amylase level is normal but the clinical suspicion of pancreatitis is strong, a 24-hour urine collection with determination of urinary amylase may be helpful for conﬁrming the clinical diagnosis. ●Ultrasound examination of the pancreas and the pelvis is safe and may be helpful for demonstrating an ectopic pregnancy or an enlarged head of the pancreas. MANAGEMENT ●Medical management of acute pancreatitis is basically supportive. ●Intravascular volume must be restored vigorously and monitored. ●The use of parenteral analgesics for pain relief is often necessary; ○Meperidine is the drug of choice because it has the least effect on the sphincter of Oddi. ●The patient is kept fasting initially until all pain has resolved. ●Despite numerous control trials, no speciﬁc therapy has been shown to be of beneﬁt for acute pancreatitis. ●In gallstone pancreatitis symptoms and signs usually subside with supportive management. ●To protect the fetus from protracted fasting, total parenteral nutrition must be considered in the pregnant patient with pancreatitis of any cause when the illness is severe or protracted or whenever feeding causes an exacerbation of symptoms. 47. Chlamydiosis, mycoplasmosis in diﬀerent terms of pregnancy, characteristic features, diagnosis and treatment during pregnancy. Chlamydiosis ●Chlamydial infection is becoming the common sexually transmitted pathogen. ●The organisms are found in urethra, endocervix and rectum. ●C. trachomatis is an obligate intracellular bacteria. ●The adverse effects in pregnancy are: Preterm labor, PROM, Chorioamnionitis, stillbirth, perihepatitis (Fitz-Hugh-Curtis syndrome). ●Puerperal endometritis or acute salpingo-oophoritis may develop. ●Neonates may develop conjunctivitis or pneumonia. ●Conﬁrmation is only done by tissue culture methods which are expensive and time consuming. ●The culture materials should be taken from both the cervix and urethra. ●Culture is replaced by antigen detection methods. ●Serological detection of chlamydial antigen (lipopolysaccharide) by El ISA is done using a kit. ●DNA ampliﬁcation by PCR is more reliable. ●Treatment is highly effective with erythromycin in doses 0. 5 g 4 times a day for 7-10 days. ●Azithromycin 1 gm in a single dose could also be prescribed. ●Therapy should be instituted to the husband simultaneously. ●As a prophylaxis to ophthalmia neonatorum, tetracycline or erythromycin ointment 1% is to be applied to the infant's eyes soon following birth. ●Neonatal infection is treated with erythromycin 50 mg/kg/day 4 times a day for 14-21 days. Ban \| Ham / Aro 90
Mycoplasmosis ●Mycoplasma hominis and Ureaplasma spp. may colonize the human genital tract and have been associated with adverse pregnancy outcomes such as preterm labor and preterm premature rupture of membranes. ●Inﬂammatory reactions that arise in the genital tissues of pregnant women are a common pathway that results in labor and delivery-not only in instances of prematurely initiated labor, but also in spontaneous, term labors as well. 48. Syphilis and pregnancy: diagnosis, treatment. ●Syphilis is a sexually transmitted disease caused by Treponema pallidum. ●Incidence is rising due to upsurge of HIV infection and IV drug abuse. ●The symptoms may be suppressed during pregnancy EFFECTS ON PREGNANCY ●Mother ○Syphilis accelerates the course of HIV infection in pregnant women. ●Baby ○Congenital infection results from transplacental migration of spirochete to the fetus. ○Congenital disease occurs with all stages of maternal infection and at any gestational age. ○The basic pathology is obliterative endarteritis. ○There is perivascular inﬁltration of lymphocytes and plasma cells within the developing fetus. ○The placenta becomes bulky from increased connective tissue. ○The villi become bulky due to increased cellularity, the vascularity being diminished. ○Spirochete can hardly be found in the placenta. However, the baby may be affected without speciﬁc changes in the placenta. ●Depending upon the intensity and time of occurrence of the inﬁltration, the fate of the fetus will be as follows: ○Abortion ○Preterm birth ○Intrauterine deaths leading to either a macerated or a fresh stillbirth ○Non-immune fetal hydrops (ascites, hepatomegaly) ○Delivery of a highly infected baby with early neonatal death ○Survival with congenital syphilis. DIAGNOSIS: Mother ●Obstetric history in multigravidae ○With serial pregnancies, there have been gradually improved obstetric performances. ○A classic history shows—late abortion macerated stillbirth fresh stillbirth congenital syphilitic baby healthy baby. ●Clinical ﬁndings of various stages of syphilis ○usually suppressed during pregnancy. ●Investigations: ○Serological test ■This should be done as a routine in the ﬁrst antenatal visit. ■VDRL (positive within 4 weeks of infection) is commonly done Ban \| Ham / Aro 91
○A positive VDRL test ■Has to be conﬁrmed by ﬂuorescent treponemal antibody absorption test (FTA-ABS) and Treponema pallidum microhemagglutination (MHA-TP) test which are speciﬁc. ■Husband's blood should also be tested for VDRL ○Detection of spirochetes from the cutaneous lesion if any, ■By dark ﬁeld examination ○Fetal infection ■Diagnosed by polymerase chain reaction (PCR) of T. pallidum in amniotic ﬂuid, fetal serum or spinal ﬂuid. ■Spirochetes may be detected from the fetal liver or spleen. TREATMENT: Mother: ●Treatment should be started as soon as the diagnosis is established. ●The baby may have the chance of protection even if the treatment is begun late in pregnancy. ●For primary or secondary or latent syphilis (< 1 year duration): ○Benzathine penicillin 2. 4 million units intramuscularly single dose. ●When the duration is more than a year ○Benzathine penicillin 2. 4 million units IM weekly for 3 doses is given. ●If the patient is allergic to penicillin ○Oral azithromycin 2 gm as a single dose is given. ●Tertiary disease: Neurosyphilis ○Aqueous crystalline penicillin G 18-24 million units IV daily for 10-14 days is given. ●If the treatment is given in early pregnancy, the treatment should be repeated in late pregnancy. ●Irrespective of the serological report, treatment should be repeated in subsequent pregnancies. Baby: ●Positive serological reaction without clinical evidences of the disease ○The baby is treated with a single intramuscular dose of penicillin G 50,000 units per kg body weight. ●Infected baby with positive serological reaction: ○Isolation with the mother ○Intramuscular administration of aqueous procaine penicillin G 50,000 units per kg body weight each day for 10 days. ●An apparently healthy child of a known syphilitic mother: ○Serological reactions should be tested weekly for the ﬁrst month and then, monthly for 6 months. 49. Characteristic features and diagnosis of gonorrhea in diﬀerent terms of pregnancy. ●The manifestations of the disease are the same as in the non-pregnant state. ●If the infection takes place during pregnancy, it tends to be more acute. ●Postnatal salpingitis may occur with considerable tubal damage. ●The diagnosis is to be conﬁrmed by bacteriological identiﬁcation of intracellular Gram-negative diplococci from urethral or cervical smear. ●Serological test is to be done to exclude concurrent syphilitic infection. ●Infection increases the risk of preterm labor, PROM, intrapartum and postpartum infection. ●Disseminated infection includes : arthritis, meningitis, endocarditis and perihepatitis (Fitz-Hugh-Curtis syndrome). Ban \| Ham / Aro 92
●The baby may be affected during labor while passing through the infected birth canal resulting in ophthalmia neonatorum. ●Treatment: ○Single dose injection of Ceftriaxone 125 mg IM or Ceﬁxime 400 mg PO single dose or a single 2 gm IM dose of spectinomycin is effective. ○Both the parents are treated. ○Ophthalmia neonatorum is treated with either silver nitrate or tetracycline preparation. ○Infected neonates are treated with a single dose of ceftriaxone 50 mg/kg IM. 50. HIV-infection and pregnancy. Prevention of perinatal HIV transmission from mother to child. ●HIV causes an incurable infection that leads ultimately to a terminal disease called AIDS. ●The main modes of transmission of HIV are ○Sexual contact (homosexual or heterosexual) ○Transplacental ○Exposure to infected blood or tissue ﬂuids and ○Through breast milk Perinatal transmission of HIV: ●Vertical transmission to the neonates is about 14-25%. ●Transmission of HIV 2 is less frequent (1-4%) than for HIV 1 (15-40%). ●Transplacental transmission occurs: ○20% before 36 weeks, over 80% of transmissions occur around the time of labor and delivery. ●Vertical transmission is more in cases with preterm birth and with prolonged membrane rupture. ●Risks of vertical transmission is directly related to maternal viral load (measured by HIV RNA) and inversely to maternal immune status (CD4+ count). ●Maternal antiretroviral therapy reduces the risk of vertical transmission by 70%. ●Breastfeeding doubles the risk of MTCT transmission (14% to 28%). ●Male to female transmission is about double compared to female to male transmission. ●Rectal intercourse is more dangerous than vaginal. ●Parenteral transmission is the most potent route. Effects: ●Pregnancy per se has no effect on the disease progression in HIV positive women. ●Increased incidence of abortion, prematurity, preeclampsia, IUGR and perinatal mortality in HIV seropositive mothers still remains inconclusive. ●Maternal mortality and morbidity are not increased by pregnancy. Clinical presentation: ●Initial presentation of an infected patient may be fever, malaise, headache, sore throat, lymphadenopathy and maculopapular rash. ●Primary illness may be followed by an asymptomatic period. ●Progression of the disease may lead to multiple opportunistic infections (OI) with candida, tuberculosis, pneumocystis and others. ●Patients may present with neoplasms such as cervical carcinoma, lymphomas (Hodgkin's and non-Hodgkin's) and Kaposi's sarcoma. Ban \| Ham / Aro 93
●There may be associated constitutional symptoms like weight loss, lymphadenopathy or protracted diarrhea. ●CD4+ count < 200 cells/mm3 is diagnostic of AIDS. ●The median time from infection to AIDS is about 10 years. Diagnosis: ●HIV diagnosis is made by detecting HIV viral RNA in blood by PCR testing (HIV RNA PCR) or by detecting antibodies to HIV. ●The enzyme immunoassay (EIA) is used as a screening test for HIV antibodies. ●It is extremely sensitive (99. 5%), inexpensive but less speciﬁc. ●EIA kits are commercially available. ●An initial positive EIA test must be conﬁrmed with a second, more speciﬁc test Western blot or HIV RNA PCR. ●This is then conﬁrmed by Western blot, immunoﬂuorescence assay (IFA) or HIV RNA PCR. ●Western blot detects speciﬁc viral antigens P24 (Capsid), GP41 (envelope) and GP 120/160 (envelope). ●False positive rate of Western blot is less than 1 in 10,000. MANAGEMENT ●Prenatal care ○Integrated counseling and testing (ICT) in the antenatal clinic (ANC) to all pregnant women with an 'Opt Out' approach is offered. ○In seropositive cases the following additional tests should be done. ■Test for other STDs— hep B and C viruses, syphilis, chlamydia, herpes rubella, ■Serological testing for cytomegalovirus and toxoplasmosis, ■Tuberculosis, ■Fungal opportunistic infections, ■Partner should be offered serological testing for HIV. ○Counseling with education to the patient is done about the impact of HIV infection on pregnancy; ○Perinatal transmissions, side effects of medications and mode of delivery. ○Pregnancy does not affect the progression of HIV disease. ○Progression of the disease is assessed by— ■CD4+ T lymphocyte counts ■HIV RNA (viral load). ■Assessment is done at every 3-4 months interval. ○The patient should have T lymphocyte count in each trimester. ■If the count falls to less than 200 cells/mm3, the patient should receive prophylaxis against Pneumocystis carinii and other opportunistic infections. ○Highly active antiretroviral therapy (HAART) to HIV 1 positive women is effective in reducing the viral (HIV RNA) load. ○Triple chemotherapy is preferred as a ﬁrst line defense and to be started anytime between 14-28 weeks and then continued throughout pregnancy, labor and postpartum period. ○Women taking HAART should be screened for gestational diabetes. Ban \| Ham / Aro 94
●Antenatal care ○Women need screening against opportunistic infections especially when CD4+ cell count is <200 cells/mm3. ○Women on HAART should be screened for GDM. ○Screening for aneuploidy anomaly scan. ○Monitoring of plasma viral load and drug toxicities, vaccination against HBV and pneumococcal infection should be done. ●Intrapartum care ○Women presenting in labor; ■Need to check her recent viral load to plan the mode of delivery. ■Women with viral load < 400 copies/ml, neonatal infection was 1%, whereas infection rate was >30% when maternal viral load was >100,000 copies/ml. ○Zidovudine (ZDV) is given IV infusion starting at the onset of labor (vaginal delivery) or 4 hours before cesarean section. ■Loading dose 2 mg/kg/hr, maintenance dose 1 mg/kg/hr until cord clamping is done. ■Women taking HAART can have planned vaginal delivery when plasma viral load is < 50 copies/ml (RCOG 2010). ○Elective cesarean delivery is recommended (RCOG-2010) at 38 weeks for women taking HAART who have plasma viral load > 50 copies/ml. ■Elective cesarean delivery reduces the risk of vertical transmission by about 50%. ■Avoidance of breastfeeding, HAART therapy and appropriate mode of delivery has reduced MTCT rates from 25-30% to < 1%. ■Baby should be bathed immediately. ○Perioprative or peripartum broad spectrum antibiotics should be given as per hospital protocol. ○Invasive procedures that might result in break in the skin or mucous membrane of the infants (procedures like attachment of scalp electrode and determination of scalp blood p H) are contraindicated. ■Instrumentation (ventouse) is avoided. ○Amniotomy and oxytocin augmentation for vaginal delivery should be avoided whenever possible. ○Place of cesarean delivery to reduce MTCT: ■Elective CS should be done at 38 weeks gestation. ■CS to be done prior to onset of labor and prior to rupture of membranes if viral load is >1000 copies/ml or when viral load is unknown. ■ZDV IV to be started 4 hours prior to the procedure. ■Pediatrician should be involved. ■Caps, masks, gowns and double gloves should be worn. ■Protective eyewear (goggles) should be used. ■Mechanical suctioning devices should be used to remove secretions from the neonates airways. ■Blunt tipped needles should be used to avoid needle stick injury and washing on any blood contamination from the skin immediately. ■Appropriate sterilization of instruments and linens should be done. Ban \| Ham / Aro 95
○Health-care workers should be protected from contact with potentially infected body ﬂuids. ○Estimated risk of infection after parenteral or mucous membrane exposure is 0. 36%. ○Post exposure prophylaxis with triple therapy for 4 weeks, reduces the risk of seroconversion by more than 80%. ■ZDV 200 mg tid + Lamivudine 150 mg bid + Indinavir 800 mg tid. ○Disposable syringes and needles are used and they are deposited in the puncture proof containers. ●Postpartum care ○Women should continue HAART with CD4 count. ○Formula feeding or breast-feeding to be started with counseling and informed consent. ○Neonatal care: ■Antiretroviral therapy (ARV) should be given to all neonates within 4 hours of birth. ■Usually ZDV monotherapy is started. ■When all these tests are negative and the baby is not breastfed a conﬁrmatory HIV antibody test is done at 18 months. ■Once this test is negative, the child is declared to be free of HIV. ○Breastfeeding ■Doubles the risk of MTCT (from 14% to 28%) but where alternative forms of infant nutrition are not safe, the risks associated with breastfeeding may be accepted. ○Zidovudine syrup-2 mg/kg, ■Given to the neonate 4 times daily for the ﬁrst 6 weeks of life. ■High risk neonates should be treated with HAART. ■The infant is tested at weeks 6, 12 and at 18 months of age. HAART THERAPY ●Principles of HAART are to: ○Suppress viral multiplication maximally ○Reduce perinatal transmission ○Reduce the risk of drug resistance. ●Prophylactic antibiotics should be started when there is opportunistic infection ●Anti-HIV 1 drugs are grouped into— A. Nucleoside reverse transcriptase inhibitors (NRTIs): ■Zidovudine, ■Didanosine, ■Lamivudine, ■Abacavir. B. Non-nucleoside reverse transcriptase inhibitors (NNRTIs): ■Nevirapine, ■Efavirenz. C. Protease inhibitors (PI): ■Indinavir, ■Saquinavir, ■Ritonavir. D. Entry inhibitors: ■Enfuvirtide. Ban \| Ham / Aro 96
●Treatment regimens change frequently. ●However, recommended regimens (USDHHS-2011) are: ○Two from: ■Group A plus one from either Gr. B or Gr. C. ■In resource poor settings Zidovudine 100 mg given ﬁve times daily PO can reduce perinatal transmission from 25% to 7%. ●WHO recommends ﬁrst line ART regimen to include: ○Zidovudine (ZDV), + lamivudine (3 TC), + Nevirapine (NVP) or ZDV + 3 TC + EFV (Efavirenz). 51. Course and management of pregnancy and delivery at women with uterus myoma. EFFECTS ON PREGNANCY: ●It depends on their location. ○May be none; ○Pressure symptoms due to impaction ■Bladder—retention of urine ■Rectum—constipation ■Abortion; ■Malpresentation; ■Non-engagement of the presenting part; ■Preterm labor and prematurity; ■Placental abruption. EFFECTS ON LABOR: ●May be unaffected; ●Uterine inertia; ●Dystocia due to: ○cervical or broad ligament ﬁbroid ○ﬁbroid not pulled up above the presenting part during labor; ●Obstructed labor; ●Postpartum hemorrhage is due to atonicity or due to morbid adherent placenta ●Difﬁcult cesarean section. EFFECTS ON PUERPERIUM: ●Subinvolution; ●Sepsis is common when placenta is implanted over the myoma site which is a submucous or intramural type; ●Secondary PPH; ●Inversion of uterus; ●Lochiometra and pyometra. EFFECTS OF PREGNANCY ON FIBROID: ●Increases in size due to increased vascularity, edema and hypertrophy and hyperplasia of the ﬁbromuscular tissues. The tumor feels soft ●Changes in position, ●Changes in shape — becomes ﬂattened, ●Degenerative changes, especially red degeneration, ●Torsion of pedunculated subserous ﬁbroid, ●Infection and polypoidal changes are more in puerperium. Ban \| Ham / Aro 97

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