ANSWER-2 54 to 106

54. Dropsy of pregnancy: clinical signs, diagnostic, management and prevention.

 a form of the second half of pregnancy toxemia, characterized by the appearance of edema in the absence of protein in the urine and normal blood pressure.

Usually occurs after 28 to 30 weeks of pregnancy, often multiple.

Edema due to a violation of water-salt metabolism and blood circulation in the capillaries and the system as a result of the changed pre capillary  neuro endocrine regulation.

 A finding of new-onset edema of the face and hands in association with proteinuria and elevated blood pressure is consistent with preeclampsia.

Dependent pitting edema of the ankles and legs in the absence of other findings is normal in late pregnancy.

It responds well to resting, with the legs elevated, and therefore is usually absent on rising in the morning.

Sudden weight gain in the third trimester to a large extent reflects an increase in edema.

Clinical sign-

excessive weight gain per week (more than 250-400 g),

 symptoms of "rings" (the ring on the finger becomes stiffness),

"tight shoes" (raznoshennaya shoes is close).

If measures are not taken in a timely manner, there are visible swelling.

There are 4 prevalence of edema:

1) only swelling in the feet and lower legs,

2) edema of the lower extremities, lower abdomen and lumbosacral region (if the woman is lying), and 3) in addition to these, swelling of the hands, face pastosity

4 ) total edema.

The skin becomes glossy look, keeping, however, the normal color (no pallor observed in renal edema, cyanosis, as in edema associated with cardiac activity).

Even with pronounced edema cardiac abnormalities, liver, kidney was observed.

There is no accumulation of fluid in the well cavity (pleural and peritoneal).

During the rise of edema observed decrease urine output (diuresis negative), reducing its share. General state of the pregnant remains satisfactory.

Management-

Restriction of salt (not more than 2g per day)

Reduce ammount of fluid .

Analysis of blood pressure ,urine,weight regularly.

Prescribe diuretics - gipotiazid (25 mg 2 times in the morning at four-hour intervals) 3 consecutive days,

for the night sedatives: motherwort tincture at the rate of 10 g to 200 g of water on 1 table, HP, papaverine 0.02 g, better in candles (for 1 suppository 2 times a day).

 The woman should stay in bed (better defined the diuretic effect).

Once a week, spend a day of fasting (fluid restriction to 800 ml and salt to 2 g per day) and after poluraspredelenia (without the first liquid dish).

Prescribe vitamins (vitamin C, vitamins of group b). If within 3-4 days of improvement does not occur, then treated as if nephropathy pregnant.

Diagnostic-

To check for edema that is not obvious, you can gently press your thumb over the foot, ankle or leg with slow, steady pressure.

 If edema is present, an indentation will show on the skin.  A professional evaluation to determine the cause of leg swelling is needed.

 If both legs are swollen, your doctor will inquire about other symptoms and perform a physical examination. 

A urine test will show whether you are losing protein from the kidneys.  Blood tests, a chest X-ray and an electrocardiogram (ECG) may be ordered.

Prevention-

Careful monitoring and active patronage of pregnant women, monitor their observance of hygiene, especially diet. Cm. also Pregnancy.

CHECK NUMBER 127

55. Face presentation.

With this presentation, the head is hyperextended so that the occiput is in contact with the fetal back, and the chin (mentum) is presenting .

 The fetal face may present with the chin (mentum) anteriorly or posteriorly, relative to the maternal symphysis pubis.

This position precludes flexion of the fetal head necessary to negotiate the birth canal. Thus, a mentum posterior presentation is undeliverable except with a very preterm fetus. Face presentations rarely deliver as such vaginally.

.

 Causes of face presentations are numerous and include -

conditions that favor extension or prevent head flexion.

Preterm infants, with their smaller head dimensions, can engage before conversion to vertex position .

In exceptional instances, marked enlargement of the neck or coils of cord around the neck may cause extension.

Diagnosis Face presentation-

 diagnosed by vaginal examination and palpation of facial features.

  The radiographic demonstration of the hyperextended head with the facial bones at or below the pelvic inlet is characteristic.

Mechanism of Labor Face presentations -

The mechanism of labor in these cases consists of the cardinal movements of descent, internal rotation, and flexion, and the accessory movements of extension and external rotation .

Descent is brought about by the same

factors as in cephalic presentations.

Extension results from the relation of the fetal body to the deflected head, which is converted into a two-armed lever, the longer arm of which extends from the occipital condyles to the occiput.

When resistance is encountered, the occiput must be pushed toward the back of the fetus while the chin descends. The objective of internal rotation of the face is to bring the chin under the symphysis pubis. Only in this way can the neck traverse the posterior surface of the symphysis pubis.

If the chin rotates directly posteriorly, the relatively short neck cannot span the anterior surface of the sacrum, which measures about 12 cm in length. Moreover, the fetal brow (bregma) is pressed against the maternal symphysis pubis.

This position precludes flexion necessary to negotiate the birth canal. Hence, birth of the head from a mentum posterior position is impossible unless the shoulders enter the pelvis at the same time, an event that is impossible except when the fetus is extremely small or macerated. Internal rotation results from the same factors as in vertex presentations.

After anterior rotation and descent, the chin and mouth appear at the vulva, the undersurface of t he chin presses against the symphysis, and the head is delivered by flexion. The nose, eyes, brow (bregma), and occiput then appear in succession over the anterior margin of the perineum.

After birth of the head, the occiput sags backward toward the anus

Next, the chin rotates externally to the side toward which it was originally directed, and the shoulders are born as in cephalic presentations.

Edema may sometimes significantly distort the face. At the same time, the skull undergoes considerable molding, manifested by an increase in length of the occipitomental diameter of the head.

Management

 -In the absence of a contracted pelvis, and with effective labor, successful vaginal delivery usually will follow.

-Fetal heart rate monitoring

(is probably better done with external devices to avoid damage to the face and eyes.)

-cesarean delivery frequently is indicated.

(Because face presentations among term-size fetuses are more common when there is some degree of pelvic inlet contraction.)

56. Preterm infants. Care and feeding of preterm infants.

what is preterm infants?-

Preterm infants  is defined as  infants bron when  labour occurring before 37 completed weeks. It affects 5-10% of all pregnancies but it accounts for approximately 75% of perinatal mortality.

Care and feeding of preterm infants-

The NICU is your newborn’s protective environment and home for a limited period. Therefore, it is wise to become as familiar with it as possible.  The NICU is equipped with caring staff, monitoring and alarm systems, respiratory and resuscitation equipment, access to physicians in every pediatric specialty, 24 hour laboratory service.

 monitors are similar in that they all record heart rate, respiratory rate,blood pressure, and temperature. A pulse oximeter may be used to measure the amount of oxygen in the blood.

Gavage or tube feeding is used when infants are too smalll to coordinate suck swallow and breathe.gavage may also be used to supplement during or after breast feeding.

Cup feeding is also used to supplement breastfeeding in infants with suck-swallow-breathe and gag reflex.

Breast feeding may be initiated when the infants is stable and can gag.offer opportunities for non nutritive suckling before actual feeding.

57. Cesarean section: indications and modifications of cesarean section.

indications-

The four primary indications for cesarean

delivery include dystocia,

elective repeat cesarean delivery,

fetal distress,

abnormal fetal presentation.

The modification of cesarean section-

 The delivery method of choice is cesarean section, with the choice of uterine incision being dependent on the placental location. A low transverse incision is selected if the lower uterine segment is well developed. In many cases, however, the lower uterine segment is poorly developed and a vertical incision is required.

All efforts should be made to avoid cutting through the placenta during delivery, because this can be associated with massive maternal hemorrhage and fetal blood loss. Blood loss can also be significant after delivery of the placenta as a result of lower uterine segment atony. A blood loss of 1500 mL or more at cesarean section for placenta previa is not uncommon.

Transverse Incisions

With the Pfannenstiel incision, t he skin and subcutaneous tissue are incised using a low, transverse, slightly curvilinear incision.

This is made at the level of the pubic hairline, which is typically 3 cm above the superior border of the symphysis pubis.

The incision is extended somewhat beyond the lateral borders of the rectus abdominis muscles. It should be of adequate width to accommodate delivery—12 to 15 cm is typical.

Vertical Incision

An infraumbilical midline vertical incision begins 2 to 3 cm above the superior margin of the symphysis and should be of sufficient length to allow fetal delivery without difficulty. Therefore, its length should correspond with t he estimated fetal size, and 12 to 15 cm is typical.

Low Transverse Cesarean Incision

Before any hysterotomy, the surgeon should palpate the fundus and adnexa to identify degrees of uterine rotation. The uterus may be dextrorotated so that the left round ligament is more anterior and closer to the midline.

In such cases, hysterotomy placement is modified to keep the incision centered within the lower segment. This avoids extension into and laceration of the left uterine artery.

58. Craniotomy. Indications. Conditions. Techique.

What is craniotomy-

In case of obstructed labour with fetal death ,Reduction of the size of the fetal head.

Indications and conditions

 All the following conditions must hold:

(1) The baby must be dead.

(2) 2/5 or less of his head must be above the brim (if it is higher than this, Caesarean section is usually safer, although if you are expert you may be able to do it at 3/5).

(3) His head must be impacted.

(4) His mother's cervix must be at least 7 cm dilated, and preferably fully dilated. One contributor gives 5 cm as the minimum.

(5) Her uterus must be unruptured, and not in imminent danger of rupturing. If she is multigravid and has been in labour for a long time, her lower segment will be very thin. If it is tender and distended, it is certainly very thin. She can only be saved by Caesarean section; any destructive operation, except pushing a needle into a hydrocephalic head, will rupture it.

Techniques

Make a cruciate (cross-shaped) incision on the scalp .

Cruciate incision on scalp

Open the cranial vault at the lowest and most central bony point with a craniotome (or large pointed scissors or a heavy scalpel). In face presentation, perforate the orbits.

Insert the craniotome into the fetal cranium and fragment the intracranial contents.

Grasp the edges of the skull with several heavy-toothed forceps (e.g. Kocher’s) and apply traction in the axis of the birth canal.

As the head descends, pressure from the bony pelvis will cause the skull to collapse, decreasing the cranial diameter.

If the head is not delivered easily, perform caesarean section.

After delivery, examine the woman carefully and repair any tears to the cervix  or vagina, or repair episiotomy.

Leave a self-retaining catheter in place until it is confirmed that there is no bladder injury.

Ensure adequate fluid intake and urinary output.

59. Transverse fetal positions (management of labor).

In this position, the long axis of the fetus is approximately perpendicular to that of the mother. When the long axis forms an acute angle, an oblique lie results.

 In a transverse lie, the shoulder is usually positioned over the pelvic inlet. The head occupies one iliac fossa, and the breech the other.

This creates a shoulder presentation in which the side of the mother on which the acromion rests determines the designation of the lie as right or left acromial.

And because in either position the back may be directed anteriorly or posteriorly, superiorly or inferiorly, it is customary to distinguish varieties as dorsoanterior and dorsoposterior (Fig. 23-9)

management During transverse fetal position

Active labor in a woman with a transverse lie is usually an indication for cesarean delivery.

Before labor or early in labor, with the membranes intact, attempts at external version are worthwhile in the absence of other complications.

If the fetal head can be maneuvered by abdominal manipulation into the pelvis, it should be held there during the next several contractions in an attempt to fix the head in the pelvis.

With cesarean delivery, because neither the feet nor the head of the fetus occupies the lower uterine segment, a low transverse incision into the uterus may lead to difficult fetal extraction.

This is especially true of dorsoanterior presentations. Therefore, a vertical incision is typically indicated.

60. Obstetrical assessment of the labor in vertex presentation.

61. Mechanism and purpose of obstetrical forceps.

Advantages to forceps use include avoidance of C-section, reduction of delivery time, general applicability with cephalic presentation. Complications include the possibility of bruising, deformation, rectovaginal fistula, nerve damage, Descemet's membrane rupture (extraordinarily rare),skull fractures, and cervical cord injury.

·         Maternal factors

1         Maternal exhaustion

2         Prolonged second stage

3         Maternal illness; such as heart disease, hypertension, glaucoma, aneurysm, or other things which make pushing difficult or dangerous

4         Haemorrhage

5         Analgesic drug-related inhibition of maternal effort (especially with epidural/spinal anaesthesia)

·         Fetal Factors

6         Non-reassuring fetal heart tracing

7         After-coming head in breech delivery.

Mechanism

The way the forceps are applied depends on the position and station of the baby's head, the specific type of forceps to be used, and the experience and training of the provider.

In occiput anterior positions (baby facing down) the forceps blades should slide easily into place along the doctor's hand that is in the vagina.

Usually the left blade is inserted first (the left blade is defined as the blade that goes between the baby's head and the left side of the mother's pelvis).

The right blade is then inserted in the same fashion and the lock of the two blades should come together easily.

 Each blade should be about a finger's width below the posterior fontanelle (the "soft spot" in the back of the baby's head between the unfused cranial bones).

When properly applied to a baby in occiput anterior position, the blades will extend in front of the baby's ears and on to the cheeks.

When the baby is in occiput posterior presentation (facing up), the blades can be applied in the same fashion as for an occiput anterior (facing down) presentation.

The tips of the blades still rest on the baby's cheeks, but in this position the blades meet just below the anterior fontanelle.

When the baby's head is in a transverse position (facing the side of the pelvis), the back blade is inserted first to help stabilize the position of the baby's head.

Once the forceps have been applied, it is important for the doctor to make sure they are properly positioned on the baby's head.

 If the forceps application is not easy or requires force, then something isn't right. Commonly, this means that the station is not as low as expected or that the position of the head has been incorrectly assessed.

 It may also mean that the wrong type of forceps is being used. If the forceps don't go on easily, they shouldn't be forced.

Rotation and Traction

Once properly applied, obstetric forceps can be used for rotation of the baby's head and for traction for delivery of the head.

Rotation

An outlet forceps delivery may be performed when the baby's head is visible at the vaginal opening and is within 45 degrees of an occiput anterior or an occiput posterior presentation. As the baby's head is rotated, traction is usually simultaneously performed.

Rotations greater than 45 degrees can safely be performed with forceps, but are associated with a greater potential for complications.

Larger rotations often require that the baby's station be shifted further up or further down the birth canal. It is important that a very skilled and experienced provider perform any of these more complicated maneuvers. A doctor that has experience in manipulation of the forceps can utilize the pelvic curve in the safest and most successful way possible.

Traction (Pulling)

Forceps are most often used to apply traction to guide the baby down and out through the birth canal. Traction should be directed along the axis of the birth canal-that is, behind and under the pubic bone. With occiput anterior presentations, this will often result in the handles of the forceps being directed downward and then upward as the back of the baby's head comes under the pubic bone. When a baby is being delivered in the occiput posterior position, the traction will need to be directed downward.

Traction should be applied in association with contractions and pushing efforts, with rest periods in between. It is important to avoid undue pressure on the baby's head; the doctor does this by loosening the handles in between contractions.

After Delivery

Some providers will remove the forceps before the baby is delivered and allow the head to deliver spontaneously; others will remove the forceps after the baby's head is delivered. There is no evidence proving that one approach is better than the other. The decision, therefore, often depends on the potential urgency of delivery. As with all deliveries, the condition of the baby should be assessed immediately after delivery.

62. Classification of contracted pelvis according to the form and degree of contraction.

To anomalies of bone pelvis belong such anatomic changes where all or one of external pelvic sizes is different from normal size for 2cm. and more.

Classification-

63. Spontaneous abortions. Causes. Management. Prevention.

termination of pregnancy by any means before the fetus is sufficiently developed to survive (before 22 weeks).

Abortion is the most common complication of pregnancy. 10–15% of all clinically recognised pregnancies end in a miscarriage. More than 80% of abortions occur in 12weeks of gestation.

Causes-

Defective embryological development resulting from abnormal chromosome division.

Faulty implantation of the fertilized ovum.

Failure of the endometrium to accept the fertilized ovum.

Premature separation of the normally implanted placenta

Abnormal placental implantation

Infection,severe malnutrition and abnormalities of the reproductive organs.

Endocrine problems,such as thyroid dysfunction or a luteal phase defect.

Trauma,including any surgery that requires manipulation of the pelvic organs.

Phospholipid antibody disorder

Blood group incompatibility

Drug ingestion

Management-

Because of the risk of DIC (  disseminated intravascular coagulation)

with retained IUFD (Intrauterine fetal demise ), the best treatment is delivery.

Early gestations can be evacuated from the uterus by dilation and evacuation or with mifepristone and misoprostol in some cases.

 After 20 weeks, the pregnancy is usually terminated by induction of labor with prostaglandins or high-dose oxytocin.

Helping patients understand what may have caused the fetal death is imperative to helping them cope with the situation.

Tests for causes of fetal death include screening for collagen vascular disease or hypercoagulable state, fetal karyotype, and often TORCH titers (i.e., toxoplasmosis, RPR, CMV, and HSV). Because the cells of an IUFD will often not grow to obtain karyotype, recent studies have examined performing microarray studies of the fetal or placental genome to both look for aneuploidy, in addition to, other genetic abnormalities such as copy number variants.

It is also extremely important to get an autopsy on the fetus, which can contribute valuable information. Despite this extensive battery of tests, the etiology of fetal demise will likely remain unknown in the majority of cases.

Prevention-

·         Encourage reduction of alcohol consumption.

·         Smoking cessation and stopping illicit drug use.

·         Intake of nutritional natural food

·         Avoid of getting pregnant before proper development of organs.

·         Avoid trauma risk.

·         Keep weight in limit

·         Regular exercise.

64. Postpartum hemorrhages due to defective coagulaton (clinic, diagnostic, management).

Postpartum hemorrhage is defined as blood loss in excess of 500 mL at the time of vaginal delivery. There is normally a greater blood loss following delivery by cesarean section; therefore, blood loss in excess of 1000 mL is considered a postpartum hemorrhage in such patients.

Most of the blood loss occurs from the myometrial spiral arterioles and decidual veins that previously supplied and drained the intervillous spaces of the placenta.

As the contractions of the partially empty uterus cause placental separation, bleeding occurs and continues until the uterine musculature contracts around the blood vessels and acts as a physiologic-anatomic ligature.

Failure of the uterus to contract after placental separation (uterine atony) leads to excessive placental site bleeding.

Clinic-

Blood loss more than 1000ml

Blood pressure fall

Palpitation

Dizziness

Tachycardia

Presents of anemia

Diagnosis-

estimate how much blood lost.

Measuring pulse and the blood pressure

Red blood cells count

Count for clotting factors in blood

Management-

·         Medicine or uterine massage to stimulate uterine contractions.

·         Removing pieces of the placenta that remain in the uterus.

·         Exam of the uterus and other pelvic tissues, the vagina, and the vulva to look for areas that may need repair.

·         Bakri balloon or a Foley catheter to put pressure on the bleeding inside the uterus.  healthcare provider may pack the uterus with sponges and sterile materials. This may be done if a Bakri balloon or Foley catheter is not available.

·         Laparotomy. This is surgery to open the abdomen to find the cause of bleeding.

·         Tying off or sealing bleeding blood vessels. This is done using uterine compression sutures, special gel, glue, or coils. The surgery is done during a laparotomy.

·         Hysterectomy. This is surgery to remove the uterus. In most cases, this is a last resort.

Replacing lost blood and fluids is important in treating postpartum hemorrhage.  may quickly be given IV (intravenous) fluids, blood, and blood products to prevent shock. Oxygen may also help.

65. Threatened rupture of perineum (clinic

and prevention).

 All except the most superficial perineal lacerations are accompanied by varying degrees of injury to the lower portion of the vagina.

Such tears may reach sufficient depth to involve the rectal sphincter and may extend to varying depths through the walls of the vagina.

Bilateral lacerations into the vagina are usually unequal in length and separated by a tongue-shaped portion of vaginal mucosa.

Clinic-

·         Failure of foal to pass through vaginovestibular sphincter.

·         First-degree laceration involving mucosa of vestibule and skin of dorsal commissure of vulva.

·         Second-degree laceration involving vestibular mucosa and submucosa, skin of dorsal commissure of vulva and perineal muscles including constrictor vulva.

·         Rectovestibular fistula involving ceiling of vestibule, floor of rectum, and variable amount of perineal septum and musculature.

·         Third-degree laceration involving ceiling of vestibule, rectal floor, perineal septum and musculature, and anal sphincter.

Prevention-

66. Generalized septic infection in puerperium.

Puerperal infections, also known as postpartum infections, puerperal fever or childbed fever, is any bacterial infection of thefemale reproductive tract following childbirth or miscarriage.

Signs and symptoms usually include a fever greater than 38.0 °C (100.4 °F), chills, lower abdominal pain, and possibly bad-smelling vaginal discharge.^[1] It usually occurs after the first 24 hours and within the first ten days following delivery.

The most common infection is that of the uterus and surrounding tissues known as puerperal sepsis or postpartum metritis.

Causes and Risk factors include-

woman's genital tract has a large bare surface

septicaemia (blood poisoning) or other illnesses

Generalized peritonitis

Cellulitis

Other virulence infections

Cesarean section,

the presence of certain bacteria such as group B streptococcus in the vagina,

premature rupture of membranes,

multiple vaginal exams,

manual removal of the placenta,

prolonged labour among others.

Diagnosis- is rarely helped by culturing of the vagina or blood. In those who do not improve medical imaging may be required. Other causes of fever following delivery include: breast engorgement, urinary tract infections, infections of the abdominal incision or episiotomy, and atelectasis.

Treatment-

C-section it is recommended that all women receive a preventive dose of antibiotics such as ampicillinaround the time of surgery.

Treatment of established infections is with antibiotics, with most people improving in two to three days. In those with mild disease oral antibiotics may be used otherwise intravenous antibiotics are recommended.

Common antibiotics include a combination of ampicillin and gentamicin following vaginal delivery or clindamycin and gentamicin in those who have had a C-section.

In those who are not improving with appropriate treatment other complications such an abscess should be considered.

67. Course and management of the 3rd stage of labor.

3rd stage of labor lasts from the birth of the baby until the placenta is expelled.

Physiological process of placental seperation

Placental separation

Descend of the placenta

Expulsion of placenta

Delivery of the Placenta Separation of the placenta generally occurs within 2 to 10 minutes of the end of the second stage of labor.

Squeezing of the fundus to hasten placental separation is not recommended because it may increase the likelihood of passage of fetal cells into the maternal circulation.

Mechanisms of Placental Extrusion-

 The retroplacental hematoma either follows the placenta or is found within the inverted sac.

In this process, known as the Schultze mechanism of placental expulsion, blood from the placental  site pours into the inverted sac, not escaping externally until after extrusion of the placenta.

The other method of placental extrusion is known as the Duncan mechanism.

 in which separation of the placenta occurs first at the periphery, with the result that blood collects between the membranes and the uterine wall and escapes from the vagina.

In this circumstance, the placenta descends to the vagina sideways, and the maternal surface is the first to appear at the vulva.

Signs of placental separation are as follows:

(1) a fresh show of blood from the vagina,

(2) the umbilical cord lengthens outside the vagina,

(3) the fundus of the uterus rises up, and

(4) the uterus becomes firm and globular. 

Traction on the umbilical cord must not be used to pull the placenta out of the uterus. Only when these signs have appeared should the assistant attempt traction on the cord.

With gentle traction and counterpressure between the symphysis and fundus to prevent descent of the uterus into the pelvis, the placenta is delivered.

Following delivery of the placenta, attention should be paid to any uterine bleeding that may originate from the placental implantation site.

Uterine contractions, which reduce this bleeding, may be hastened by uterine massage and the use of oxytocin.

It is routine to add 20 units of oxytocin to the intravenous infusion after the baby has been delivered.

The placenta should be examined to ensure its

complete removal and to detect placental abnormalities.

If the patient is at risk of postpartum hemorrhage (e.g., because of anemia, prolonged oxytocic augmentation of labor, multiple gestation, or hydramnios), manual removal of the placenta, manual exploration of the uterus, or both may be necessary.

68. Mechanism of placental separation.

 2 type of mechanism

1- Schultze mechanism of placental expulsion

2-duncan mechanism

In schultze mechanism

The retroplacental hematoma either follows the placenta or is found within the inverted sac.

 blood from the placental  site pours into the inverted sac, not escaping externally until after extrusion of the placenta.

Duncan mechanism-

in which separation of the placenta occurs first at the periphery, with the result that blood collects between the membranes and the uterine wall and escapes from the vagina.

 In this circumstance, the placenta descends to the vagina sideways, and the maternal surface is the first to appear at the vulva.

 Signs of placental separation are as follows:

(1) a fresh show of blood from the vagina,

(2) the umbilical cord lengthens outside the vagina,

(3) the fundus of the uterus rises up, and

(4) the uterus becomes firm and globular.

69. Management of perineal incisions.

Laceration should be repaired immediately if possible,and certain within 24 hours of delivery.

First step is to define the limits of the lacerations,which includes vagina as well as perineum.

Best suture material is catgut for the vagina and buried sutures and fine mono-filament nlon for skin.

As accurate an approximation as possible of all the tissues should be secured and no dead spaces are left.

The after-care of the repaired perineal injures is similar to that following episiotomy. Special care following repair of complete tear.

1. A low residual diet consisting of milk, bread, egg, fish is given from 2nd day onwards.

2. Lactulose 8 ml twice daily beginning on the second day and increasing the dose to 15 ml on the third day is a satisfactory regime to soften the stool.

 3. Any one of the broad spectrum antibiotics is used during the intraoperative and the post-operative period

70. Nephropathy of pregnancy. Clinic and management.

71. Course and management in puerperium.

 Check question no 117

72. Ruptures of vagina and perineum.Etiology, prevention, management.

  Etiology-

Vaginal-

During vaginal delivery, lacerations of the cervix and vagina may occur spontaneously (fetal mal presentation,insufficient distensibility of vaginal wall,large featl head), but they are more common following the use of forceps or a vacuum extractor.

The vascular beds in the genital tract are engorged during pregnancy, and bleeding can be profuse.

Lacerations are particularly prone to occur over the perineal body, in the periurethral area, and over the ischial spines along the posterolateral aspects of the vagina.

Vaginal laceration usually longitudinal

The cervix may lacerate at the two lateral angles while rapidly dilating in the first stage of labor.

Management of vaginal laceration-

Tears associated with brisk haemorrage, require exploration under general anaesthesia with good light.

The tears are repaired by interrupted or continuous sutures using catgut.

In case of extensive lacerations, in additions to sutures, haemostasis may be achieved by intravaginal plugging by roller gauze, soaked with glycerine.

The plug should be removed after 24 hours.

Prevention-

exercise by contacting, holding and then releasing the pelvic muscles. It can be easily performed in a manner as trying to consciously hold the urine.

Regular kegel exercises and other pelvic training activities help in strengthening the pelvic muscles.

Maintaining healthy consumption of fibrous fruits and vegetables along with adequate amounts of water helps in improving the skin elasticity.

An elastic skin is more resistant to tearing and rupture under pressure and stress.

After 34th week of pregnancy, perineal massage should be regularly performed by applying a lubricating gel on the perineum and then gentle rubbing.

Perineum-

 Over stretching of the perineum due to large baby, face-to-pubis or face delivery, outlet contraction with narrow pubic arch, shoulder delivery (posterior one) and forceps delivery.  

Rapid stretching of the perineum due to rapid delivery of the head during uterine contraction, precipitate labour and delivery of the after-coming head in breech. 

Inelastic perineum as in rigid perineum in elderly primigravidae, scar in the perineum following previous operations such as episiotomy or perineorrhaphy and vulval oedema.

 DEGREES. 

First degree : Involves lacerations of the remnants of the hymen, the fourchette, lower part of the vagina and the perineal skin but the perineal body remains intact.

 Second degree : Involves lacerations of the posterior vaginal wall and varying degrees of tear of the perineal body excluding the anal sphincter. 

Third degree : Injury of the perineum involving posterior vaginal wall and tear of the perineal body including the anal sphincter complex with or without involvement of the anal canal or even the rectum. 

MANAGEMENT. Repair of complete perineal tear.

Look question no 69 for perineal management.

Prevention-

Perineal massage is reduce the risk of trauma.

Water birth and laboring in water will make the perineum soft and reduce tearing.

Avoid pushing when baby crowning.

Take nutritional food

Use lubricants

73. Causes of uterine bleedings after child delivery.

After the baby is delivered, excessive bleeding from the uterus is a major concern. Ordinarily, the woman loses about 1 pint of blood after vaginal delivery.

Blood is lost because some blood vessels are opened when the placenta detaches from the uterus. The contractions of the uterus help close these vessels until the vessels can heal.

Typically, cesarean delivery results in about twice the blood loss as vaginal delivery, partly because delivery requires an incision in the uterus, and a lot of blood is pumped to the uterus during labor.

Excessive bleeding may result when the contractions of the uterus after delivery are impaired.

Then, the blood vessels that were opened when the placenta detached continue to bleed. Contractions may be impaired in the following situations.

Overdistention of the uterus 

Mulliple gestation 

Polyhydramnios 

Fetal microsomia 

Prolonged labor 

Oxytocin augmentation of labor 

Grand multi parity (a parity of 5 or more) 

Precipitous labor (one lasting -<3 hr) 

Magnesium sulfate treatment of pre-eclampsia  Chonoamnionilis 

Halogenated anesthetics 

Uterine leiomyomata.

 74.Multiple pregnancy. Clinic and diagnostic. Management of labor.

clinical science-

Increased nausea and vomiting in early months.

Cardio respiratory embarrassment

Tendency and swelling in legs,varicose vein and hemorrhoids is greater

Unusual rate uterine enlargement and excessive fetal movements.

Diagnostic-

Family history for multiple pregnancy.

Increased fetal movement.

More enlargement of abdomen.

Fundal level higher than normal

Fetal heart sound heard with maximum intensity in 2 separate points by 2 observers with a minimum different of 10 beats per minutes.

Occasionally the superimposition of two fetal heart sound produces a galloping rhythm.

Ultrasonography - separate gastation sacs can be identified.in 7^th week

 Separated fetal bodies can be detected in 8^th week.

Separated heads can be detected in 12^th week

X-ray -

It can detect fetal heads and fetal columns.

Management during labor-

Delivery should be in hospital

A team of experienced obstetrician,assistant,anaesthetist and neonatologist is necessary for safety.

Delivery of the first fetal, if it is cephalic proceed as normal,if it is breech cesarean section is safe,although vaginal delivery may pass without complication.

Immediate clamping of the cord is essential after delivery of the first fetal to avoid bleeding from a second fetal.

Delivery of th esecond fetus, it depends upon its presentation,longitudinal lie, transverse or oblique lie.

75. Urogenital and intestinal fistulas. Etiology and prevention.

Etiology-

Prevention-

    Rupture uterus /emergency obstetrical

    Hysterectomy.

       Post operative period.

76. Abnormal uterine action.

ETIOLOGY.

As the physiology of normal uterine contraction is not fully understood, the cause of its disordered action remain obscure. However, the following clinical conditions are often associated:

1. prevalent in first birth specially with advancing age of the mother;

2. prolong pregnancy;

3. over distension of the uterus due to twins and/or hydramnios;

4. psychologic factor;

5. contracted pelvis, malpresentation and deflexed head, full bladder are often associated too; all this lead to ill fitting of the presenting part into the lower uterine segment; this probably result in inhibition of the local reflex which is needed to produce effective contraction of the upper segment;

6. injudicious administration of sedatives, analgesics and oxytocics;

7. premature attempt at vaginal delivery. 

The uterine pace maker is situated at the cornua of the uterus and this generates uterine contractions Effective uterine contraction, starts at the cornua and gradually sweep downwards over the uterus.

In a primary dysfunctional labour, uterine activity instead of being governed by a single dominant space maker, is shifted to less efficient contractions due to emergence of other pacemaker foci.

2). Oxytocin therapy may be effective in restoring the global and effective uterine contractions.  

 Primary dysfunctional labour is defined when the cervix dilates < 1 cm/hr. It is a commonest abnormality and mostly corrected by amniotomy and/or oxytocin augmentation.

Secondary arrest is defined when the cervical dilatation stops or slows after the active phase of labour has started normally.

Uterine activity (contraction) is measured by noting basal tone, active (peak) pressure and frequency. Assessment is usually done by:

1. clinical palpation (inaccurate);

2.tocodynamometer with external transducer;

3. using intrauterine pressure catheter (accurate). Normal baseline tonus is between 5 and 20 mm of Hg and peak pressure is around 60 mm of Hg (8 Kpa).

Uterine inertia (hypotonic activity) Uterine inertia is the common type of disordered uterine contraction but is comparatively less serious. It may complicate any stage of labour. It may be present from the beginning of labour or may develop subsequently after a variable period of effective contractions.

The intensity of uterine contractions is diminished, duration is shortened, good relaxation in between contractions and the intervals are increased. General pattern of uterine contractions of labour is maintained but intrauterine pressure during contraction hardly rises above 25 mm of Hg.

Diagnosis:

 patient feels less pain during uterine contraction; hand placed over the uterus during uterine contraction reveals less hardening of the uterus; uterine wall is easily indentable at the acme of

the pain; uterus becomes relaxed after the contraction; fetal parts are well palpable and fetal heart rate remains good.

 Internal examination reveals poor dilatations of the cervix (normal rate of dilatation in primigravida should be at the rate of 1 cm per hour beyond 3 cm dilatation), associated presence of contracted pelvis, malposition, deflexed head or malpresentation may be evident; membranes usually remains intact. It’s necessary to exclude cephalopelvic disproportion or malpresentation. In a case of contracted pelvis, malpresentation or fetal distress cesarean section is indicated.

In other cases we should propose active measures – acceleration of uterine contraction can be brought about by low rupture of the membranes followed by oxytocin or prostaglandins drip.

The drip rate is gradually increased until effective contraction are set up. The drip is to be continued till one hour after delivery. If the cervical dilatation remains unsatisfactory and/or fetal distress appears, caesarean section is the best alternative.

77. Face presentation. Mechanism of labor and management.

check question no -55

78. Uterine atony and postpartum hemorrhage.

The majority of postpartum hemorrhages (75% to 80%) are due to uterine atony.  

Factors Predisposing to Postpartum Uterine Atony  Overdistention of the uterus 

 Mulliple gestation 

Polyhydramnios 

Fetal microsomia 

Prolonged labor 

Oxytocin augmentation of labor 

Grand multi parity (a parity of 5 or more) 

Precipitous labor (one lasting -<3 hr) 

Magnesium sulfate treatment of pre-eclampsia  Chonoamnionilis 

Halogenated anesthetics 

Uterine leiomyomata.

If uterine atony is determined to be the cause of the postpartum hemorrhage, a rapid continuous intravenous infusion of dilute oxytocin (40 to 80 U in 1 L of normal saline) should be given to increase uterine tone.

If the uterus remains atonic and the placental site bleeding continues during the oxytocin infusion, ergonovine maleate or methylergonovine, methylergometrine.

Analogues of prostaglandin F2α given intramuscularly are quite effective in controlling postpartum hemorrhage caused by uterine atony.

Failing these pharmacologic treatments, a bimanual compression and massage of the uterine corpus may control the bleeding and cause the uterus to contract.

Although packing the uterine cavity is not widely practiced, it may occasionally control postpartum hemorrhage and obviate the need for surgical intervention

The vital signs, hematocrit, and fundal height should be monitored frequently while the packing is in place, because continued bleeding will not be initially evident through the packing.

The packing may be removed in 1 to 4 hours. Usually, the bleeding will be controlled.

 Another approach that may be tried if bleeding persists is placement of the patient into an antigravity suit (G suit), which will, when inflated, compress the lower extremities and the abdominal cavity.

Experience with this device in trauma patients has demonstrated good control of intra-abdominal bleeding. This approach may occasionally be used temporarily while the blood volume is being expanded and preparations are made for more definitive surgery. Operative intervention is a last resort. If the patient has completed her childbearing, a supracervical abdominal hysterectomy is definitive therapv for intractable postpartum hemorrhage caused by uterine atony.

If reproductive potential is important to the patient, ligation of the uterine arteries adjacent to the uterus will lower the pulse pressure distal to the ligatures.

This procedure is more successful in controlling uterine placental site hemorrhage and is easier to perform than bilateral hypogastric arterv ligation.

79. Prenatal care in maternity hospital.

Read the lecture topic prenatal.

80. Extraction of fetus on breech delivery.

81. Obstetric forceps. Conditions, indications, technique of operations.

Indications-

-Delay to uterine inertia

-Failure of orogress of labor-if no progress occur more than 20 -30 min,with  the head on the perineum.

-Fetal distress in second stage when prospect of vaginal delivery is safe-abnormal heart rate pattern

Passage of meconium

Abnormal scalp blood ph

-cord prolapse in second stage

-low birth wt.baby

-post maturity

Maternal indications

-pre eclampsia

-post cesarean pregnancy

-heart disease

- intra partum infection

-neurological disorder where voluntary efforts are contraindicated or impossible

 

condition-

Cervix must be fully ruptured

Membranes must be ruptured

Baby should be living

Uterus should be contracting and relaxing

Bladder must be empty

Technique -

82. Technique of manual removal of afterbirth.

Separation of the placenta generally occurs within 2 to 10 minutes  of the end of the second stage of labor. Squeezing of the fundus to hasten placental separation is not recommended because it may increase the likelihood of passage of fetal cells into the maternal circulation.

Two types of techniques are there-

1- Schultze mechanism of placental expulsion.

The retroplacental hematoma either follows the placenta or is found within the inverted sac. In this process,blood from the placental  site pours into the inverted sac, not escaping externally until after extrusion of the placenta.

2- Duncan mechanism

 in which separation of the placenta occurs first at the periphery, with the result that blood collects between the membranes and the uterine wall and escapes from the vagina. In this circumstance, the placenta descends to the vagina sideways, and the maternal surface is the first to appear at the vulva.

83. Puerperal parametritis and thrombophlebitis.

puerperal parametritis-

 Causes-

Compared with cesarean delivery, metritis following vaginal delivery is relatively infrequent.

Vaginal delivery-because of membrane rupture, prolonged labor, and multiple cervical examinations

removal of the placenta.

Cesarean delivery-

surgery included prolonged labor, membrane rupture, multiple cervical examinations, and internal fetal monitoring.

Abortion through placental site or from laceration of cervix.

Diagnostic and clinical signs-

Fever is the most important criterion for the diagnosis of postpartum metritis. Intuitively, the degree of fever is believed proportional to the extent of infection and sepsis syndrome. Temperatures commonly are 38 to 39°C. Chills that accompany fever suggest bacteremia or endotoxemia.

Women usually complain of abdominal pain, and parametrial tenderness is elicited on abdominal and bimanual examination.

 Leukocytosis may range from 15,000 to 30,000 cells/μL, but recall that cesarean delivery itself increases the leukocyte count (Hartmann, 2000). Although an offensive odor may develop, many women have foul-smelling lochia without evidence for infection, and vice versa.

Some other infections, notably those caused by group A β-hemolytic streptococci, may be associated with scant, odorless lochia.

Treatment-

treatment with an oral antimicrobial agent is usually sufficient

For moderate to severe infections, however, intravenous therapy with a broad-spectrum antimicrobial regimen is indicated.

Thrombophlebitis -

It is a venous inflammation with thrombus formation in association with fevers unresponsive to antibiotic therapy.

Bacterial infection of the endometrium seeds organisms into the venous circulation,which damages the vascular endothelium and in turn result in thrombus formation.

The thrombus acts as a suitable medium for proliferation of anaerobic bacteria.

Diagnostic-

History, it is usually accompanies endometritis. Lower abdominal pain with or without radiation to the flank,groin or upper abdomen.

Physical examination,fever,tachycardia, on abdominal examination tender,palpable ropelike mass.

Use CT and MRI scan.

84. Premature rupture of amniotic fluid sac (causes, complications for women and fetus).

This term defines spontaneous rupture of the fetal membranes before 37 completed weeks and before labor onset.

Cervical incompetence,polyhydraminos,multiple pregnancy,malpresentations as the presenting part is not fitting against the lower uterine segment.

Chorioamnionitis

Low tensile strength of the membranes.

Causes-

Such rupture likely has various causes, but intrauterine infection is believed by many to be a major predisposing event .

 There are associated risk factors that include low socioeconomic status, body mass index ≤ 19.8, nutritional deficiencies, and cigarette smoking.

Complications-

For women-

Sepsis,placental abruption.

For fetus-

Chorioamnionitis,cord prolapse,PTL,pulmonary hypoplasia,limb contractures,death.

85. Diagnostic and management of missed miscarriage.

diagnostic-

Urine pregnancy test

FBC-full blood count

Blood group and GSH - to check rhesus ststus,and to prepare for tranfusion

Ultrasound-locate the fetus,to assess viability and to look for POC.

Histology-any tissues expelled should be investigated to exclude molar or ectopic pregnancy.

Management-

Bed rest-

HCG  injection-

Progestagen-

86. Assessment of fetal well-being

electronic fetal monitoring was used in 84% of all births, regardless of whether the primary caregiver was a physician or a midwife. With the advent of these technologies, fetal monitoring is implemented in nearly all pregnancies, either in the antepartum or intrapartum period.

 The goal is to prevent fetal and neonatal morbidity and especially mortality.

Interpretation of the Fetal Monitor Tracing-

 Analysis of the fetal monitor strip requires a systematic approach. First, the FHR is analyzed with respect to the baseline, variability, and periodic patterns, including FHR accelerations and decelerations.

Baseline Fetal Heart Rate-The normal FHR baseline ranges from 120 to 160 beats per minute. Early in pregnancy, it is closer to 160 beats per minute, declining as gestational age advances.

Likewise, the FHR may decrease gradually toward 120 beats per minute during the course of labor. An FHR baseline below 120 beats per minute is termed bradycardia, and a rate in excess of 160 beats per minute is termed tachycardia.

Abnormalities in the FHR baseline may have very different causes and consequences. It is important, therefore, to characterize the underlying etiology as accurately as possible.

Bradycardia-

Bradycardia is defined as an abnormally low baseline FHR (<120 beats per minute). Although FHR decelerations are very common, true fetal bradycardia is not. Rarely, fetal bradycardia may be seen in association with maternal hypothermiahypoglycemia, hypothyroidism, or fetal cardiac conduction defects (congenital atrioventricular block).

Documentation of fetal heart block should prompt a search for structural fetal cardiac abnormalities, which may be present in 20% of cases. Other causes of heart block include viral infections (e.g., cytomegalovirus) and damage to the cardiac conduction system by transplacental passage of maternal antiRo (anti-SS-A) antibodies. Most congenital causes of fetal bradycardia do not present as abrupt changes in the FHR and rarely require emergency intervention.

Any abrupt decline in the FHR below 120 beats per minute more likely represents a deceleration than a change in the baseline.

Tachycardia-

 Fetal tachycardia has many possible etiologies. Most often, it is the result of decreased vagal or increased sympathetic outflow, associated with fever, infection, fetal anemia, or fetal hypoxia. Other causes include maternal hyperthyroidism, fetal tachyarrhythmias (e.g., paroxysmal supraventricular tachycardia, atrial fibrillation, atrial flutter, and ventricular tachyarrhythmias), and medications ritodrine and atropine.

Sinusoidal Pattern-

The sinusoidal FHR pattern is an uncommon FHR baseline abnormality. It has the appearance of a smooth sine wave with an amplitude of 5 to 15 beats per minute and a frequency of 2 to 5 cycles per minute. There is little beat-to-beat variability, and accelerations are absent. Although the pathophysiologic mechanism is unclear, this pattern classically is associated with hypoxia and severe fetal anemia. Additionally, it has been reported in association with chorioamnionitis, fetal sepsis, and administration of narcotic analgesics.

Accelerations-

 Accelerations in the FHR occur with 90% of fetal movements as early as the second trimester, probably as a result of increased catecholamine release and decreased vagal stimulation of the heart. By 32 weeks gestation, nearly all normal fetuses will have 15 to 40 spontaneous accelerations per hour, reflecting normal oxygenation of the CNS cardiac axis. The frequency and amplitude of accelerations may be diminished by fetal sleep states, medications (narcotics, magnesium sulfate, atropine), prematurity, or fetal acidosis. Often, fetal scalp stimulation or vibroacoustic stimulation will provoke fetal movement and FHR accelerations. If these measures fail to induce FHR accelerations, hypoxia should be suspected.

Decelerations-

 Decelerations in the FHR are most commonly

encountered during the intrapartum period. They are divided into three categories: early, variable, and late decelerations. Classification is based on the characteristic appearance of the deceleration and its temporal relationship to the onset of a uterine contraction.

 Early decelerations are typically uniform, shallow dips in the FHR (rarely below 100 beats per minute) that mirror uterine contractions, beginning at the onset of the contraction and ending when the contraction ends. They are thought to result from fetal head compression, transient elevation of intracranial pressure, and reflex augmentation of vagal tone.

Early decelerations classically appear during labor when the cervix is dilated 4 to 6 cm. Perinatal outcome is not adversely affected by these decelerations, and they are considered clinically benign. Variable decelerations result from umbilical cord compression.

They are abrupt and angular in appearance and have a variable temporal relationship to uterine contractions. Variable decelerations are classified as mild, moderate and severe. Isolated, infrequent variable decelerations have little clinical significance. Repetitive severe variables, however, may not allow sufficient fetal recovery between decelerations, resulting in persistent hypoxemia, hypercapnia, and respiratory acidosis.

Prolonged tissue hypoperfusion may lead to metabolic acidosis and, ultimately, fetal death. When repetitive, severe variable decelerations are present, prolapse of the umbilical cord must be excluded. Other causes include nuchal cord, true knot in the cord, uterine rupture, placental abruption, uterine hypertonus, and tachysystole. Occasionally, variable decelerations fail to return promptly to the baseline and may more accurately be called prolonged decelerations.

 Late decelerations reflect inadequate uteroplacental transfer of oxygen during contractions. Typically, they are smooth, uniform decelerations that begin after the onset of a contraction and end after the contraction stops. Late decelerations may be caused by any factor that reduces the normal placental transfer of oxygen or increases the fetal oxygen demand beyond the available supply.

Such factors include uterine hypertonus or tachysystole (oxytocin, prostaglandins, uterine rupture, placental abruption), maternal hypertension (chronic hypertension, preeclampsia, collagen vascular disease, renal disease, diabetes), suboptimal maternal cardiac output (cardiac disease, hypovolemia, supine hypotension, sympathetic blockade from regional anesthesia, sepsis), maternal hypoxia (apnea, cardiac disease, pulmonary disease), reduced oxygen-carrying capacity of maternal blood (anemia, hemoglobinopathy), and fever (increased fetal metabolism and increased oxygen consumption).

Biophysical Profile-

 The BPP assesses five variables: FHR reactivity, fetal movement, tone, and breathing (reflecting acute CNS function), and amniotic fluid volume.

The volume of amniotic fluid is a measure of fetal well-being. By the second trimester, the predominant source of amniotic fluid is fetal urine. The level of amniotic fluid is thought to represent long-term fetal well-being.

A compromised fetus will preferentially shunt blood to the major organs, such as the central nervous system (CNS) and adrenals, and away from others, such as the kidney. Decreased fetal renal perfusion results in a decrease in fetal renal function and subsequent oligohydramnios.

The amniotic fluid can be assessed ultrasonographically. Two points are assigned for each normal variable and 0 for each abnormal variable for a maximum score of 10. A BPP score of 8 to 10, with normal amniotic fluid volume, is considered normal.

A score of 6 is considered suspicious, and testing usually is repeated the following day. Scores of less than 6 are associated with increased perinatal morbidity and mortality; they usually warrant hospitalization for further evaluation or delivery. The BPP is a reliable predictor of fetal well-being. Advantages of the BPP include excellent sensitivity, a weekly testing interval, and a low false-negative rate. The primary limitation is the requirement for personnel trained in sonography.

Additionally, although the duration of ultrasound observation is typically less than 10 minutes, the complete BPP is more timeconsuming than other noninvasive tests.

Doppler Velocimetry-

 Doppler velocimetry of fetal, umbilical, and uterine vessels has been the focus of intensive study in recent years. This technology uses systolic-to-diastolic flow ratios and resistance indices to estimate blood flow in various arteries.

Studies have shown significant improvement in perinatal outcome with the use of Doppler ultrasonography in pregnancies complicated by growth restriction.

Although severe restriction of umbilical artery blood flow, as evidenced by absent or reversed flow during diastole, has been correlated with fetal growth restriction, acidosis, and adverse perinatal outcome, the predictive values of less extreme deviations from normal remain undefined.

 In conditions other than fetal growth restriction,

Doppler velocimetry does not appear to be a useful screening test for the detection of fetal compromise and is not recommended for use as a screening test in the general obstetric population.

 Doppler velocimetry is used in some settings as an adjunct to standard methods of fetal assessment but should not be considered a replacement for traditional fetal monitoring.

Fetal Scalp Blood Sampling -

allows for the determination of the fetal acid-base status during labor. The technique requires dilation of the cervix, rupture of the membranes, and access to the fetal presenting part.

Since respiratory acidemia is generated in the blood and metabolic acidemia is generated in the tissues, a scalp sample may not reflect the state of the fetus.

In light of the technical difficulty of the procedure and the uncertainty regarding interpretation of results, many centers have reduced their reliance on fetal scalp blood sampling.

Percutaneous Umbilical Blood Sampling-

 Electronic FHR monitoring, ultrasound, and fetal scalp blood sampling can provide useful information regarding the acid-base status of the fetus.

Occasionally, however, direct access to circulating fetal blood is necessary. A classic example is the fetus with severe anemia secondary to Rh isoimmunization.

63 Doppler studies of the middle cerebral artery are a noninvasive method for the assessment of fetal anemia. In some cases, direct sampling of the fetal blood and intrauterine blood transfusion may be required.

Percutaneous umbilical blood sampling (PUBS) is a procedure that affords direct access to fetal venous blood.

Medications or blood may be infused through the needle once fetal blood samples have been obtained. Other indications for PUBS include suspected antibody-mediated fetal thrombocytopenia and fetal cardiac arrhythmias requiring assessment of fetal drug levels or direct fetal administration of antiarrhythmic agents.  

87. Pelvis justo minor. Mechanism of labor. Management of labor.

mechanism of labor-

88. Third-trimester bleeding.

Vaginal bleeding in the third trimester complicates 4% of all pregnancies.

It is considered an obstetric emergency because hemorrhage remains the most frequent cause of maternal death.

It is critical for the well-being of both the mother and fetus that the patient who presents with third-trimester bleeding be managed expediently.

Causes of Antepartum Bleeding

Common

Placenta previa  Abruptio placentae

Uncommon

Uterine rupture

Fetal (chorionic) vessel rupture

Cervical or vaginal lacerations

Cervical or vaginal lesions including cancer Congenital bleeding disorder

Unknown of the bleeding

Physical Examination -

The vital signs and amount of bleeding should be checked immediately as should the patient's mental status. Whether the skin is moist or dry and pale or mottled should be noted, as should the presence of petechial hemorrhages or bleeding from any site other than the vagina, such as the nose or rectum.

 The abdominal examination must include fundal height measurement and assessment of uterine tenderness. A pelvic examination should not be performed until placenta previa has been excluded by ultrasonography.

 

Investigations -

1-Laboratory Tests A complete blood count

should be obtained and compared with previous evaluations to help assess the amount of blood loss. An assessment of the patient's coagulation profile should be done by obtaining a platelet count, serum fibrinogen level, prothrombin time, and partial thromboplastin time- it is often helpful to do a "wall clot" test, whereby a red-topped tube of blood is drawn, taped to the wall, and timed for clot formation. If no clot develops within 6 minutes, coagulopathy is most likely present. The patient should be typed and crossmatched for at least 4 units of blood (packed cells).

 2-Ultrasonography

The ultrasonographic evaluation should include not only the location and character of the placenta, but also an assessment of gestational age, an estimate of fetal weight, determination of the fetal presentation, and a screening for fetal anomalies.

3-Monitoring

Uterine activity and the fetal heart rate should be assessed with a monitored strip to rule out labor and establish fetal well-being. 

Management-

89. Signs of clinically contracted pelvis. Management of labor.

Clinical signs-

During pregnancy-

incarcerationof gravid uterus into pelvis

Pendulous abdomen

Malpresentation

Labor-

PROM chances increase

Cord prolapse

Slow cervical dilation

Prolonged/obstructed labour

Maternal and fetal injuries-

Injury at female genital tract

Asphyxia ,caput ect...

Management-

90. Immunologic disorders in pregnancy.

91. Placenta accreta (causes, diagnostic, management).

The diagnosis of placenta accreta is made on a pathologic specimen, obtained after hysterectomy. This definitive diagnosis is dependent on the visualization of chorionic villi embedded in the myometrium with absence of the decidual layer between them. The diagnosis of accreta can also be suggested by the use of sonography and MRI

The other parts in number 141

92. Clinic signs of eclampsia. Management and prevention. Findings at autopsy in

eclampsia patients.

Clinic signs of eclampsia

Many of the clinical manifestations of preeclampsia and

eclampsia can be explained on the basis of vasospasm.

Angiotensin Sensitivity

One of the earliest signs of developing preeclampsia is a

lowering of the effective pressor dose of infused angiotensin II. In

normal pregnancy, the amount of angiotensin necessary to increase the

diastolic pressure 20 mm Hg is increased, whereas in patients destined

to develop pre-eclampsia the effective pressor dose is lower.

Weight Gain and Edema

Abnormal weight gain and edema occur early and reflect an

expansion of the extra vascular fluid compartment. This expansion is

related to the increased capillary permeability that allows fluid to

diffuse from the intravascular space with resultant expansion of the

extracellular space.

Excessive weight gain and edema, especially if confined to the

lower extremities, do not establish a diagnosis of pre-eclampsia.

Edema that includes the face and hands is of more concern but is still

not diagnostic.

Elevation of Blood Pressure

The next sign usually detected is an elevation of blood pressure,

particularly the diastolic pressure, which more closely mirrors changes

in peripheral vascular resistance than does the systolic blood pressure.

In the antepartum period, the blood pressure changes may occur days

to weeks after the onset of pathologic fluid retention.

Proteinuria

Proteinuria completes the classic clinical triad of pre-eclampsia.

In the antepartum period, this sign may occur days or weeks after the

onset of hypertension. If the disease first manifests during labor or in

the immediate postpartum period, this progression of events is

compressed into hours and sometimes minutes. The proteinuria of preeclampsia/

eclampsia can be explained on the basis of afferent

arteriolar constriction with increased glomerular permeability to

proteins.

Renal Function

It is usually only during the Stage of renal involvement,

clinically denoted by proteinuria, that detectable changes in renal

function appear. The earliest change may be an increase in serum uric

acid concentration. Creatinine clearance may decrease, and serum creatinine and blood urea nitrogen levels may increase. The

hematocrit may also increase, reflecting a relative hypovolemia. Renal

involvement may progress to significant oliguria and frank Tenal

failure.

Liver and Placental Function

In the liver, vasospasm may produce focal hemorrhages and

infarctions. Therefore, elevated serum enzyme levels are usually

present. Thrombocytopenia and disseminated intravascular

coagulopathy may occur, reflecting an increased platelet destruction

consistent with the HELLP syndrome. Spasm in the uteroplacental

vascular bed results in placental infarctions, which may become extensive

and lead to a retroplacental hemorrhage. The indirect evidence for

reduced uteroplacental blood flow is the increased incidence of

placental infarctions and intrauterine fetal growth restriction.

Central Nervous System Effects

Visual disturbances, such as blurred vision, spots, and

scotomata, represent degrees of retinal vasospasm. Increased reflex

irritability or hyperreflexia aTe extremely worrisome signs of central

nervous system (CNS) involvement and may connote imminent seizures

related to cerebral vasospasm and hypoxia.

Management and prevention

The management of pre-eclampsia should begin at the first sign

of abnormality, well before the diagnosis is confirmed. When excessive weight gain or fluid retention is documented in the absence of other pathognomonic changes, a brief dietary history should be

obtained to look for indiscretions and excesses. Appropriate

counseling should follow. The patient should be advised of any concerns

and be requested to increase periods of bed rest, preferably in

the left lateral position. For the following 48 hours, activity out of bed

should be limited to eating meals (not preparing them) and using the

bathroom. A no-added-salt diet may be prescribed. More Severe

sodium restriction is contraindicated for all but those in frank renal

failure. Follow-up is requested 48 hours or less later to ton-firm

continued normal blood pressure and to determine the efficacy of

treatment for the weight gain and fluid retention. Successful treatment

dictates no further intervention, other than perhaps the continuation of

the no-added-salt diet. If there has been no weight loss, continued

reduction of activity with increased periods of bed rest and more

frequent prenatal visits are indicated.

The treatment of hypertension depends to a great extent on the

duration of the pregnancy and the elevation of blood pressure. At the

lowest end of the hypertensive spectrum, 140/90 mm Hg, and in

the absence of proteinuria, outpatient management is possible.

Mild salt reduction (no added salt) and bed rest in the left lateral

position are again advised. The patient and her family should be

counseled regarding warning symptoms of deterioration. Follow-up

should occur no later than 48 hours. Many patients in this category

respond to bed rest with a normalization of blood pressure. These

women merely require more frequent follow-up than usual.

For the nonresponders, the next step should be a trial of bed rest

and a no-added-salt diet in the more controlled environment of the

hospital. If blood pressure normalizes, observation should be

continued for an additional 24 to 48 hours and the patient should

follow a regimen of continued bed rest and diet with frequent followup.

Nonresponders who are 37 weeks' gestation or greater should be

evaluated for induction of labor. Those at less than 37 weeks' gestation

should continue bed rest and diet in the hospital for several days while

undergoing the work-up detailed in Table. Patients with continued

mild hypertension (not greater than 150/100 mm Hg) without

proteinuria and with normal laboratory values may be considered for discharge and close follow-up.

93. Mechanism of labor in occipito-posterior position.

94. Signs and management of anterpartum asphyxia.

95. Ruptures of uterus. Etiology and prevention.

96. Postdate pregnancy and delayed labor.

Prolonged pregnancy is defined as pregnancy which progresses beyond 42 weeks.^[1]Prolonged pregnancy is associated with fetal, neonatal and maternal complications. Risks increase after term and significantly so after 41 weeks of pregnancy. A policy of induction of labour appears to improve outcomes and reduce perinatal mortality.^[2] Where possible, first trimester ultrasound rather than last menstrual period (LMP) dating should be relied on to assess pregnancy duration. This should be determined using crown-rump measurement or head circumference if crown-rump length is above 84 mm.^[3]

Risks associated with post-term pregnancy^[4] 

Fetal and neonatal risks

Prolonged pregnancy is associated with an increase in perinatal morbidity and mortality. There is an increased risk of stillbirth and neonatal death, as well as an increase in risk of death in the first year of life. The increased mortality is thought to be due to factors such as utero-placental insufficiency, meconium aspiration and intrauterine infection.

Fetal morbidity is also increased, with higher risks of:

·         Meconium aspiration.

·         Macrosomia and larger babies resulting in:

·         Prolonged labour.

·         Cephalo-pelvic disproportion.

·         Shoulder dystocia.

·         Birth injury resulting in, for example, brachial plexus damage or cerebral palsy.

·         Neonatal acidaemia.

·         Low five-minute Apgar scores.

·         Neonatal encephalopathy.

·         Neonatal seizures.

·         Features of intrauterine growth restriction (IUGR) due to placental insufficiency

Maternal risks

Prolonged pregnancy is also associated with increased risk for the mother, including:

·         Obstructed labour

·         Perineal damage

·         Instrumental vaginal delivery

·         Caesarean section

·         Postpartum haemorrhage

·         Infection

Where labour is induced before the uterus or cervix are in a favourable state, obstetric problems may follow which can have an adverse effect on either mother or baby, including:

·         Need for caesarean section.

·         Prolonged labour.

·         Postpartum haemorrhage.

·         Traumatic delivery.

Epidemiology

·         The use of ultrasound in early pregnancy for precise dating is thought to reduce the number of post-term pregnancies compared to dating based on the LMP.^[5] 

·         5-10% of pregnancies are prolonged beyond 42 weeks.^[1] 

·         Around 20% of pregnant women will need induction of labour - the majority for post-term pregnancy.^[6] 

Risk factors^[4] 

·         Previous post-term pregnancy increases the risk of recurrence in subsequent pregnancies.

·         Primigravidity.

·         High maternal BMI is associated with longer gestation and increased rate of induction of labour.^[7]Elevated pre-pregnancy weight and maternal weight gain both increase the risk of a post-term delivery.^[8]

·         Genetic factors. There is an increased risk of post-term pregnancy for mothers who were themselves born post-term and twin studies also suggest a genetic role.

·         Advanced maternal age.^[9]

Presentation

Symptoms

·         When post-term, the neonate has lower than normal amounts of subcutaneous fat and reduced mass of soft tissue.

·         The skin may be loose, flaky and dry.

·         Fingernails and toenails may be longer than usual and stained yellow from meconium.

97. Pathologies of afterbirth stage. Causes of placental separation.

98. Dyscoordinated labor activity. Diagnostic, management.

Check question 151

99. Placenta previa. Clinic, management.

Number 155

100. Prevention of uterus’ ruptures.

Number 95

101. Primary powerless labor. Diagnostic and management.

Primary uterine inertia occurs from the early onset of labor and lasts during the its second stage until the end of labor.

  Primary uterine inertia is characterized by such signs as:

            Inadequate uterine activity;

            Lack of the progressive cervical effacement and dilation;

                   Station of presenting part in the pelvic inlet (- 3 station) for a long period of time and slowly descent of the fetus in the case of “cephalopelvic disproportion” absence;

            Increased duration of labor;

            Maternal exhaustion and impairment of fetal well-being .  

Diagnosis of primary uterine inertia is made during dynamic monitoring for woman during 2-3 hours. Important clinical evaluation of labor duration is the rate of cervical dilation. If, the cervical dilation to 6 cm is absent if from the onset of labor in nulliparous women have been passed 12 hours and in multiparous women have been passed 6 hours, the diagnosis of primary uterine inertia has been made.

Management of abnormal labor in the case of uterine inertia

Uterine inertia, as a rule,  accompanies by female sickness and tiredness. That’s why for successful induction or augmentation of labor therapeutic rest should be prescribed obligatory.

In the case of maternal exhaustion therapeutic rest should be indicated. Obstetrics anesthesia is prescribed by combination of such drugs as: Sol. Promedoli 1% - 1,0, Sol. Dimedroli – 2% -2, 0,  Sol. Atropini Sulfatis 0,1 % - 1,0. For this purpose Droperidoli 0,25 % - 1 ml or Natrii Oxybuturatis 20 % should be prescribed also.

Induction of labor is the stimulation of uterine contractions before the spontaneous onset of labor, with the goal of achieving delivery.

Augmentation of labor is the stimulation of uterine contractions that began spontaneously but are either too infrequent or too weak, or both. 

Stimulation of labor is usually carried out with several ways:

                 intravenous administrated 5 units (1 ml) oxytocin in 500 ml 0,9 % isotonic solution NaCl (dilute intravenous solution) with the initiated dose 6-8 drops per minute to 40 drops per minute;

                 intravenous administrated 5 mg (1 ml) prostaglandin F2a in 500 ml        0,9 % isotonic solution NaCl with the initiated dose 6-8 drops per minute to 25-30 drops per minute;

                 combine intravenous administration of 2,5 units of oxytocin and 2,5 mg of prostaglandin F2a in 500 ml 0,9 % isotonic solution NaCl with the initiated dose 6-8 drops per minute to 40 drops per minute.

102. Tsovianov maneuver at breech delivery.

103. Appendicitis and pregnancy.

Diagnosis

The most common presenting symptoms include anorexia, nausea, vomiting, and right lower quadrant pain.^[2,8,15] Fever and tachycardia may not be present during pregnancy.^[8,15] Right upper quadrant pain, uterine contractions, dysuria, and diarrhea can also be present.^[1,3,6] It is believed that the appendix changes its location during pregnancy with an upward displacement toward the costal margin in the later stages of pregnancy (Figure 1).^[16,17] Patients may then present with right upper quadrant pain or entire right-sided pain, although the relocation of the appendix during the later stages of pregnancy and right upper quadrant pain was not reproduced in some patients.^[1] A presentation with right upper quadrant pain can be highly variable with an incidence as high as 55%.^[3]

Management and Treatment

Early surgical intervention, with less than a 24-hour delay, has shown to be vital in minimizing both maternal and fetal morbidity and mortality. Surgical delays of more than 24 hours from the time of presentation have been associated with appendiceal perforation and significant fetal loss and cases of maternal mortality.^[8,14] Various tocolytic agents are used prophylactically for uterine irritability; however their efficacy has not been demonstrated.^[2,6]

Antibiotic use during or after surgery may expose the developing fetus to potentially teratogenic substances.^[10] Pregnancy related pharmacodynamic changes result in reduced maternal plasma levels of antibiotics.^[23] Gentamycin and related aminoglycosides have been associated with nephrotoxicity and ototoxicity, while tetracyclines may cause permanent tooth discoloration and long bone malformation. Fluoroquinolones may cause dysplasia of cartilage and arthropathies in children so are not currently recommended in pregnancy. If perforation, peritonitis, or gangrenous appendix has occurred, broad-spectrum antibiotics with anaerobic coverage such as the second-generation cephalosporins would be appropriate.^[12] Perioperative (prophylactic) antibiotics were administered to 94% of the patients undergoing appendectomies of which 60% were second-generation cephalosporins.^[9] Ampicillin or cephalosporins are used in combination with metronidazole in cases with perforated or gangrenous appendix.^[6]

104. Complications after cesarean section.

·       After cesarean section, the most common complications for the mother are:

·       Infection.

·       Heavy blood loss.

·       A blood clot in the legs or lungs.

·       Nausea, vomiting, and severeheadache after the delivery (related to anesthesia and the abdominal procedure).

·       Bowel problems, such asconstipation or when theintestines stop moving waste material normally (ileus).

·       Injury to another organ (such as the bladder). This can occur during surgery.

·       Maternal death (very rare). About 2 in 100,000 cesareans result in maternal death.¹

·       Cesarean risks for the infant include:

·       Injury during the delivery.

·       Need for special care in the neonatal intensive care unit (NICU).³

·       Immature lungs and breathing problems, if the due date has been miscalculated or the infant is delivered before 39 weeks of gestation.^3, 4

Long-term risks of cesarean section

Women who have a uterine cesarean scar have slightly higher long-term risks. These risks, which increase with each additional cesarean delivery, include:⁵

·         Breaking open of the incision scar during a later pregnancy or labor (uterine rupture). For more information, see the topic Vaginal Birth After Cesarean (VBAC).

·         Placenta previa, the growth of the placenta low in the uterus, blocking the cervix.

·         Placenta accreta, placenta increta, placenta percreta (least to most severe). These problems occur when the placenta grows deeper into the uterine wall than normal, which can lead to severe bleeding after childbirth, and sometimes may require a hysterectomy.

105. Clinically contracted pelvis.

106. Contemporary principles of management of gestosis.