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  1. 1. HYPERLINK "" Home » Health Policies and Laws<br />Executive Order<br />Executive Order No. 288 Providing for the Implementing Details for Reorganization Plans Nos. 12-A, 13-A and 14-A relative to Health<br />Executive Order No. 663Implementing the the National Commitment for " Bakuna ang Una Sa Sanggol At Ina" , Attaining World Health Organization's goals to Eliminate Measles and Neonatal Tetanus, Eradicate Polio, Control Hepatitis B and Other Vaccine-Preventable Diseases<br />Executive Order No. 637Providing the Basis for the Computation of the Incentive Benefits of Personnel who may be Affected by the Implementation of the Rationalization Program under Executive Order No. 366s. 2004<br />Executive Order No. 611Authorizing Compensation Adjustments to Government Personnel<br />Executive Order No. 567Devolving the Taguig-Pateros District Hospital from the Department of Health to the City of Taguig<br />Executive Order No. 452Directing the Enrollment of 2.5 Million Indigent Families Pursuant to Executive Order No. 276s. 2004 also known as the Enhanced PCSO Greater Medicare Access Program and for other Purposes<br />Executive Order No. 441Delegating to the Secretary of Department Health (DOH) the Power to Exercise Oversight Function over the Philippine Sports Commission (PSC)<br />Executive Order No. 442 Designating the Philippine International Trading Corporation as the Lead Coordinating Agency to Make Quality Medicines Available, Affordable and Accessible to the greater masses of Filipinos<br />Executive Order No. 437Encouraging the implementation of Community-Based Rehabilitation (CBR) for persons with disabilities in the Philippines<br />Executive Order No. 417Directing the implementation of the Economic Independence Program for Person with Disabilities<br />Executive Order No. 392Amending Executive Order No. 182 dated February 14, 2003, Entitled " Transferring the Medicare Functions of the Overseas Workers Welfare Administration to the Philippine Health Insurance Corporation<br />Executive Order No. 102Redirecting the Functions and Operations of the Department of Health.<br />Executive Order No. 51Adopting a National Code of Marketing of Breastmilk Supplements and related products, penalizing violations thereof, and for other purposes.<br />Executive Order No. 247Prescribing Guidelines and Establishing a Regulatory Framework for the Prospecting of Biological ang Genetic Resources, their By-Products and Derivatives, for Scientific and Commercial Purposes; and for other Purposes<br />Executive Order No. 455Transferring the Supervision and Control of the Philippine Charity Sweepstakes from the Department of Social Welfare and Development to the Department of Health, and for other Purposes<br />Executive Order No. 472Transferring the National Nutrition Council from the Department of Agriculture to the Department of Health<br />DILATION AND CURETTAGE OVERVIEW<br /><ul><li>Dilation and curettage (D and C) is a procedure in which material from the inside of the uterus is removed. The "dilation" refers to dilation of the cervix, the lower part of the uterus that opens into the vagina (picture 1). "Curettage" refers to the scraping or removal of tissue lining the uterine cavity (endometrium) with a surgical instrument called a curette.
  2. 2. D&C may be done to diagnose a problem, such as abnormal uterine bleeding, or as a treatment for miscarriage or excessive bleeding. This topic discusses the reasons for D&C, how to prepare for the procedure, and what to expect afterwards.</li></ul>REASONS FOR D AND C<br /><ul><li>There are a number of reasons a D and C might be performed. In some cases, the procedure is used to gain information about the uterus to diagnose a medical condition (called diagnostic D and C). In other cases, the procedure is used to treat a medical problem or condition (called therapeutic D and C).
  3. 3. Diagnostic D and C — The primary reason for a diagnostic D and C is to obtain samples of the endometrium to evaluate abnormal uterine bleeding or abnormal cells found during routine screening for cervical cancer. (See "Patient information: Cervical cancer screening".)
  4. 4. In most cases, a healthcare provider will try to obtain a tissue sample with an office procedure called endometrial biopsy. In some cases, endometrial biopsy is not possible or insufficient tissue is obtained. When this occurs, D and C must be done to obtain an adequate tissue sample.
  5. 5. Diagnostic D and C is usually done with hysteroscopy; this involves dilating the cervix and inserting a small instrument to examine and photograph the inside of the uterus. The images are displayed on a monitor, allowing the physician to visualize the endometrium. This helps the physician to avoid missing small polyps and ensures that the most visibly abnormal areas are sampled. (See "Patient information: Abnormal uterine bleeding".)
  6. 6. A pathologist then examines the tissue with a microscope to establish certain diagnoses, including endometrial (uterine) cancer, endometrial polyps, or precancerous conditions of the lining of the uterus (endometrial hyperplasia). (See "Patient information: Endometrial cancer diagnosis and staging".)</li></ul>Therapeutic D and C — Therapeutic D and C is done to remove the contents of the uterus in the following circumstances:<br /><ul><li>Miscarriage — In some miscarriages, the tissues from a pregnancy are passed completely. In other cases, a D and C is needed to remove this tissue or to ensure that all of it has been passed. (See "Patient information: Miscarriage".)
  7. 7. Abortion — A D and C can be done to remove the contents of the uterus when a woman chooses to end a pregnancy. (See "Overview of pregnancy termination".)
  8. 8. Treatment of molar pregnancy — A molar pregnancy occurs when a tumor forms in place of normal pregnancy placenta. It is often treated with a D and C. (See "Gestational trophoblastic disease: Management of hydatidiform mole".)
  9. 9. Prolonged or excessive vaginal bleeding — D and C may be done as a treatment in some cases of prolonged or excessive bleeding that do not respond to medical treatment. (See "Patient information: Abnormal uterine bleeding".)
  10. 10. Postpartum hemorrhage — Curettage may be done to manage excessive bleeding after delivery of an infant (postpartum hemorrhage). (
  12. 12. Some patients will need to have blood testing before D and C (such as a blood count), although this is not always necessary. You should not eat or drink anything before the procedure. You will need someone to accompany you home because it will not be safe to drive after receiving anesthesia, which causes sedation.
  13. 13. You may need to have a device or medication placed in the cervix the day before your procedure. The purpose is to safely and gradually enlarge the cervical opening, reducing the risk of cervical injury. Devices are used when the cervix must be dilated to a larger size than is typically needed for D and C, such as with pregnancy terminations and some types of hysteroscopy. You may be instructed to insert a medicine in your vagina to soften your cervix prior to the procedure.
  14. 14. After arriving for the procedure, a nurse may place an intravenous (IV) line, which can be used to give fluids and medicine before, during, and after the procedure. The nurse or doctor will review your medical history, list of medications used, and any drug allergies.</li></ul>D AND C PROCEDURE<br /><ul><li>D and C can be performed in an operating room in a hospital or clinic. Your blood pressure, pulse, and blood oxygen levels are monitored during the procedure. The procedure takes 15 to 30 minutes to complete.
  15. 15. Anesthesia — The procedure can be done using general, regional, or local block anesthesia. The type of anesthesia chosen depends upon the reason for the procedure as well as your medical history.</li></ul>CARE AFTER D AND C<br /><ul><li>After the procedure, you will rest in a recovery or post-anesthesia care unit for a few hours. This is necessary to monitor for excessive vaginal bleeding or other complications, and allows time for you to recover from the anesthesia. If you were given general anesthesia, you may have nausea and vomiting, which can be treated with medications.
  16. 16. Recovery at home — You should be able to resume your regular activities within a day or two. Mild cramping and spotting may occur for a few hours or days; cramping can be treated with nonsteroidal antiinflammatory medications such as ibuprofen (Advil®, Motrin®). You should not put anything into the vagina (tampons, douches) during this time and should ask when you can safely have sexual intercourse. Your next menstrual period usually occurs within four to six weeks of the procedure.
  17. 17. When to call for help — You should call your physician if you develop fever (temperature greater than 100.4º F), cramps lasting longer than 48 hours, increasing rather than decreasing pain, prolonged or heavy bleeding, or foul-smelling vaginal discharge.
  18. 18. D AND C COMPLICATIONS</li></ul>D and C is a commonly performed procedure that is usually very safe. Yet as with any operation, complications occur. Complications of D and C can include:<br /><ul><li>Uterine perforation — Uterine perforation occurs when one of the surgical instruments makes a hole in the uterus. It is more common when the procedure is done during pregnancy due to softening of the uterine wall.
  19. 19. Fortunately, most uterine perforations heal on their own and do not require any treatment. Two potential problems caused by perforation are bleeding from injury to a blood vessel and injury to other internal organs. A second procedure may be needed to repair these types of injury.
  20. 20. Cervical injury — Injuries to the cervix can occur during dilation or from trauma related to the curettage. Lacerations (cuts) to the cervix are managed with pressure to the area, application of medications that help stop bleeding, or in some cases, stitches in the cervix.
  21. 21. Infection — Infection from D and C is rare.
  22. 22. Intrauterine adhesions — Adhesions (areas of scar tissue) can sometimes form in the uterus following D and C. Adhesion is most common when D and C is performed during or after pregnancy. In some cases, this can lead to abnormalities in the menstrual cycle, painful menstrual cycles, infertility, or miscarriage. If adhesions are extensive, you can be treated with hormones to encourage growth of healthy uterine tissue and the scar tissue can be removed with a surgical procedure.
  23. 23. </li></ul>Cesarean Section<br />Definition<br />A cesarean section is a surgical procedure in which incisions are made through a woman's abdomen and uterus to deliver her baby.<br />Purpose<br />Cesarean sections, also called c-sections, are performed whenever abnormal conditions complicate labor and vaginal delivery, threatening the life or health of the mother or the baby. In 2003, about 27% of U.S. deliveries were cesarean, up 6% from 2002. The procedure is often used in cases where the mother has had a previous c-section. Dystocia, or difficult labor, is the other common cause of c-sections.<br />Difficult labor is commonly caused by one of the three following conditions: abnormalities in the mother's birth canal; abnormalities in the position of the fetus; or abnormalities in the labor, including weak or infrequent contractions.<br />Another major factor is fetal distress, a condition where the fetus is not getting enough oxygen. Fetal brain damage can result from oxygen deprivation. Fetal distress is often related to abnormalities in the position of the fetus or abnormalities in the birth canal, causing reduced blood flow through the placenta. Other conditions also can make c-section advisable, such as vaginal herpes, hypertension, and diabetes in the mother.<br />Precautions<br />There are several ways that obstetricians and other doctors diagnose conditions that may make a c-section necessary. Ultrasound testing reveals the positions of the baby and the placenta and may be used to estimate the baby's size and gestational age. Fetal heart monitors, in use since the 1970s, transmit any signals of fetal distress. Oxygen deprivation may be determined by checking the amniotic fluid for meconium (feces)—a lack of oxygen causes an unborn baby to defecate. Oxygen deprivation may also be determined by testing the pH of a blood sample taken from the baby's scalp; a pH of 7.25 or higher is normal, between 7.2 and 7.25 is suspicious, and below 7.2 is a sign of trouble.<br />When a c-section is being considered because labor is not progressing, the mother should first be encouraged to walk around to stimulate labor. Labor may also be stimulated with the drug oxytocin.<br />When a c-section is being considered because the baby is in a breech position, the doctor may first attempt to reposition the baby; this is called external cephalic version. The doctor may also try a vaginal breech delivery, depending on the size of the mother's pelvis, the size of the baby, and the type of breech position the baby is in. However, a c-section is safer than a vaginal delivery when the baby is 8 lbs (3.6 kg) or larger, in a breech position with the feet crossed, or in a breech position with the head hyperextended.<br />A woman should receive regular prenatal care and be able to alert her doctor to the first signs of trouble. Once labor begins, she should be encouraged to move around and to urinate. The doctor should be conservative in diagnosing dystocia (nonprogressive labor) and fetal distress, taking a position of " watchful waiting" before deciding to operate.<br />Description<br />The most common reason that a cesarean section is performed (in 35% of all cases, according to the United States Public Health Service) is that the woman has had a previous c-section. The " once a cesarean, always a cesarean" rule originated when the classical uterine incision was made vertically; the resulting scar was weak and had a risk of rupturing in subsequent deliveries. Today, the incision is almost always made horizontally across the lower end of the uterus (this is called a " low transverse incision" ), resulting in reduced blood loss and a decreased chance of rupture. This kind of incision allows many women to have a vaginal birth after a cesarean (VBAC).<br />The second most common reason that a c-section is performed (in 30% of all cases) is difficult childbirth due to nonprogressive labor (dystocia). Uterine contractions may be weak or irregular, the cervix may not be dilating, or the mother's pelvic structure may not allow adequate passage for birth. When the baby's head is too large to fit through the pelvis, the condition is called cephalopelvic disproportion (CPD).<br />Another 12% of c-sections are performed to deliver a baby in a breech presentation: buttocks or feet first. Breech presentation is found in about 3% of all births.<br />In 9% of all cases, c-sections are performed in response to fetal distress. Fetal distress refers to any situation that threatens the baby, such as the umbilical cord getting wrapped around the baby's neck. This may appear on the fetal heart monitor as an abnormal heart rate or rhythm.<br />The remaining 14% of c-sections are indicated by other serious factors. One is prolapse of the umbilical cord: the cord is pushed into the vagina ahead of the baby and becomes compressed, cutting off blood flow to the baby. Another is placental abruption: the placenta separates from the uterine wall before the baby is born, cutting off blood flow to the baby. The risk of this is especially high in multiple births (twins, triplets, or more). A third factor is placenta previa: the placenta covers the cervix partially or completely, making vaginal delivery impossible. In some cases requiring c-section, the baby is in a transverse position, lying horizontally across the pelvis, perhaps with a shoulder in the birth canal.<br />The mother's health may make delivery by c-section the safer choice, especially in cases of maternal diabetes, hypertension, genital herpes, Rh blood incompatibility, and preeclampsia (high blood pressure related to pregnancy).<br />Preparation <br />There is no perfect anesthesia for a c-section because every choice has its advantages and disadvantages. When a c-section becomes necessary and if it is not an emergency, the mother and her significant other should take part in the choice of anesthetic by being informed of risks and side effects. The anesthesia is usually a regional anesthetic (epidural or spinal), which makes her numb from below her breasts to her toes. In some cases, a general anesthetic will be administered if the regional does not work or if it is an emergency c-section. Every effort should be made to include the significant other in the preparations and recovery as well as the surgery if at all possible. An informed consent needs to be signed, and the physician should explain the surgery at that time. The mother may already have an intravenous (IV) line of fluid running into a vein in her arm. A catheter is inserted into her bladder to keep it drained and out of the way during surgery and the upper pubic area is usually shaved. Antacids are frequently administered to reduce the likelihood of damage to the lungs should aspiration of gastric contents occur. The abdominal area is then scrubbed and painted with betadine or another antiseptic solution. Drapes are placed over the surgical area to block a direct view of the procedure. <br />The type of skin incision, transverse or vertical, is determined by time factor, preference of mother, or physician preference. Two major locations of uterine incisions are the lower uterine segment and the upper segment of the body of the uterus (classical incision). The most common lower uterine segment incision is a transverse incision because the lower segment is the <br />To remove a baby by cesarean section, an incision is made into the abdomen, usually just above the pubic hairline (A). The uterus is located and divided (B), allowing for delivery of the baby (C). After all the contents of the uterus are removed, the uterus is repaired and the rest of the layers of the abdominal wall are closed (D). <br />(Illustration by GGS Information Services.) <br />thinnest part of the pregnant uterus and involves less blood loss. It is also easier to repair, heals well, is less likely to rupture during subsequent pregnancies and makes it possible for a woman to attempt a vaginal delivery in the future. The classical incision provides a larger opening than a low transverse incision and is used in emergency situations, such as placenta previa, preterm and macrosomic fetuses, abnormal presentation, and multiple births. With the classical incision, there is more bleeding and a greater risk of abdominal infection. This incision also creates a weaker scar, which places the woman at risk for uterine rupture in subsequent pregnancies. <br />Once the uterus is opened, the amniotic sac is ruptured and the baby is delivered. The time from the initial incision to birth is typically five to ten minutes. The umbilical cord is clamped and cut, and the newborn is given to the nursery personnel for evaluation. Cord blood is normally obtained for analysis of the infant's blood type and pH. The placenta is removed from the mother and her uterus is closed with suture. The abdominal area may be closed with suture or surgical staple. The time from birth through suturing may take 30 to 40 minutes. The entire surgical procedure may be performed in less than one hour. Physical contact or <br />holding of the newborn may take place briefly while the mother is on the operating table if the baby is stable. The significant other can go with the baby to the nursery for the remainder of the operation. <br />Aftercare<br />A woman who undergoes a c-section requires both the care given to any new mother and the care given to any patient recovering from major surgery. She should be offered pain medication that does not interfere with breastfeeding. She should be encouraged to get out of bed and walk around eight to 24 hours after surgery to stimulate circulation (thus avoiding the formation of blood clots) and bowel movement. She should limit climbing stairs to once a day, and avoid lifting anything heavier than the baby. She should nap as often as the baby sleeps, and arrange for help with the housework, meals, and care of other children. She may resume driving after two weeks, although some doctors recommend waiting for six weeks, the typical recovery period from major surgery.<br />Risks<br />Because a c-section is a surgical procedure, it carries more risk to both the mother and the baby. The maternal death rate is less than 0.02%, but that is four times the maternal death rate associated with vaginal delivery. However, many women have a c-section for serious medical problems. The mother is at risk for increased bleeding (because a c-section may result in twice the blood loss of a vaginal delivery) from the two incisions, the placental attachment site, and possible damage to a uterine artery. Complications occur in less than 10% of cases. The mother may develop infection of either incision, the urinary tract, or the tissue lining the uterus (endometritis). Less commonly, she may receive injury to the surrounding organs, like the bladder and bowel. When a general anesthesia is used, she may experience complications from the anesthesia. A 2004 report said that spinal anesthesia and obesity impair a mother's respiratory function during cesarean section procedures. Obese women were particularly susceptible to breathing problems. Very rarely, a woman may develop a wound hematoma at the site of either incision or other blood clots leading to pelvic thrombophlebitis (inflammation of the major vein running from the pelvis into the leg) or a pulmonary embolus (a blood clot lodging in the lung).<br />Normal results<br />The after-effects of a c-section vary, depending on the woman's age, physical fitness, and overall health. Following this procedure, a woman commonly experiences gas pains, incision pain, and uterine contractions—which are also common in vaginal delivery. Her hospital stay may be two to four days. Breastfeeding the baby is encouraged, taking care that it is in a position that keeps the baby from resting on the mother's incision. As the woman heals, she may gradually increase appropriate exercises to regain abdominal tone. Full recovery may be seen in four to six weeks.<br />Key terms<br />Breech presentation — The condition in which the baby enters the birth canal with its buttocks or feet first.<br />Cephalopelvic disproportion (CPD) — The condition in which the baby's head is too large to fit through the mother's pelvis.<br />Classical incision — In a cesarean section, an incision made vertically along the uterus; this kind of incision makes a larger opening but also creates more bleeding, a greater chance of infection, and a weaker scar.<br />Dystocia — Failure to progress in labor, either because the cervix will not dilate (expand) further or (after full dilation) the head does not descend through the mother's pelvis.<br />Low transverse incision — Incision made horizontally across the lower end of the uterus; this kind of incision is preferred for less bleeding and stronger healing.<br />Placenta previa — The placenta totally or partially covers the cervix, preventing vaginal delivery.<br />Placental abruption — Separation of the placenta from the uterine wall before the baby is born, cutting off blood flow to the baby.<br />Prolapsed cord — The umbilical cord is pushed into the vagina ahead of the baby and becomes compressed, cutting off blood flow to the baby.<br />Respiratory distress syndrome (RDS) — Difficulty breathing, found in infants with immature lungs.<br />Transverse presentation — The baby is laying side-ways across the cervix instead of head first.<br />VBAC — Vaginal birth after cesarean.<br />The prognosis for a successful vaginal birth after a cesarean (VBAC) may be at least 75%, especially when the c-section involved a low transverse incision in the uterus and there were no complications during or after delivery.<br />Abnormal results<br />Of the hundreds of thousands of women in the United States who undergo a c-section each year, about 500 die from serious infections, hemorrhaging, or other complications. These deaths may be related to the health conditions that made the operation necessary, and not simply to the operation itself. New research in 2004 reported that c-section delivery affects the amount of breast milk an infant may receive from its mother for the first five days following birth. This can result in lower post-birth weighs as well. But the study found that by the sixth day, mother who had delivered by c-section began to produce milk at the same rate as those who delivered vaginally.<br />Undergoing a c-section may also inflict psychological distress on the mother, beyond hormonal mood swings and postpartum depression (" baby blues" ). The woman may feel disappointment and a sense of failure for not experiencing a vaginal delivery. She may feel isolated if the father or birthing coach is not with her in the operating room, or if she is treated by an unfamiliar doctor rather than by her own doctor or midwife. She may feel helpless from a loss of control over labor and delivery with no opportunity to actively participate. To overcome these feelings, the woman must understand why the c-section was necessary. She must accept that she couldn't control the unforeseen events that made the c-section the optimum means of delivery, and recognize that preserving the health and safety of both her and her child was more important than her delivering vaginally. Women who undergo a c-section should be encouraged to share their feelings with others. Hospitals can often recommend support groups for such mothers. Women should also be encouraged to seek professional help if negative emotions persist.<br />Cesarean section. (A), Classic; (B), low vertical; (C), transverse incisions.<br />abdominal section  laparotomy.<br />cesarean section  delivery of a fetus by incision through the abdominal wall and uterus. <br />Cesarean section. (A), Classic; (B), low vertical; (C), transverse incisions.<br />frozen section  a specimen cut by microtome from tissue that has been frozen.<br />perineal section  external urethrotomy.<br />Saemisch's section  see under operation. <br />serial section  histologic sections made in consecutive order and so arranged for the purpose of microscopic examination.<br />instruments in cesarean section surgery?<br />Hemostats (used for bleeders, blunt dissection) Kelley's Kocher's (used for faschia, and sometimes to clamp the umbilical cord. Long Kelley's (also used for umbilical cords) Allis Allis Adairs (some MD's use these to clamp uterine " bleeders" ) Babcocks (used for tubal ligations) Sponge sticks (also used on the uterus) Penningtons (uterus) Needle drivers Bandage scissors (to cut cord) Straight mayos (suture scissors) Curved Mayos (anatomy scissors) Metzenbaum scissors (used for the bladder flap and fine tissues) Pickups: Russians (uterus) Bonnies Adsons (skin) Smooth pick ups (bladder flap) Pick ups with teeth Retractors: Bladder blade Small and large richardson balfor blade extra: bulb syringe a couple of cord clamps cord blood collection kit needle counter towels rayotec and laps ioban drape vacuum<br />Types<br /> Cesarean section instruments can be grouped by type: retractors, clamps, forceps, scalpels, scissors and staplers. Of the retractors, a Richardson retractor and bladder blade are needed. Clamps such as the needle drive, kocher clamps and hemostat are used. Adson, Russian and pick-up forceps with teeth are the forceps used. The general scalpel, scissors and staplers are used for the cesarean section. <br />Function<br /> Retractors hold organs and tissues out of the surgical field. They also open up incisions. Clamps grasp tissue or hold an incised blood vessel closed. They also hold the umbilical cord closed after it is cut. Forceps grasp and hold tissues and materials. Scalpels and scissors are for cutting and staplers are used to close the cesarean incision after the birth. <br />Identification<br /> Forceps look like scissors with long arms and a small cutting tip. They have a grooved outcropping between the finger holds that locks the forceps in place. Some look like tweezers with teeth at the tips. Clamps can look like the scissor forceps, but with an extra locking mechanism in the place where the scissor-like instrument opens and closes. Retractors are a one-piece steel instrument with a hooked end, a finger ring (loop at the other end) and dimpled place called a finger rest. A scalpel is a sharp blade with a slim, straight handle. <br />Significance<br /> These instruments are used in the delicate procedure of removing a baby from the womb. Cesarean-section instruments must cut through the layers of skin and the womb. Retractors open the area while protecting organs that are not a part of the surgery. Forceps are also used to help remove the child if necessary. Clamps and scissors are used to separate mother and child. Staplers close the incision. <br />Numbers<br /> According to the study " A Cost-effective Approach to Cesarean Sections," 80 instruments of the types previously mentioned are prepared for a cesarean section. However, only 55 are used. Thus, many of the extra instruments are unnecessary. Read more: Surgical Instruments Used for a Cesarean Section |<br />Resources<br />Childbirth Org. of Dimes Birth Defects Foundation. 1275 Mamaroneck Ave., White Plains, NY 10605. (914) 428-7100.<br />National Institute of Child Health and Human Development. Bldg 31, Room 2A32, MSC 2425, 31 Center Drive, Bethesda, MD 20892-2425. (800) 505-2742.<br />United States Department of Health and Human Services. 200 Independence Avenue SW, Washington DC 20201. (202) 619-0257. Section." MedlinePlus. Available online at (accessed <br />Spontaneous Vaginal Delivery<br />Spontaneous vaginal delivery at term has long been considered the preferred outcome for pregnancy. Because of the perceived health, economic, and societal benefits derived from vaginal deliveries, lowering the cesarean delivery rate has been a goal in the United States for more than 25 years.1 Although some experts now support elective primary cesarean delivery, and although the percentage of operative deliveries has increased from 21 percent in 1996 to 30 percent in 2005, most women still deliver vaginally.2  There are relatively few absolute contraindications to vaginal delivery (Table 1).3–5 In 2003, nearly 3 million vaginal deliveries occurred in the United States.2 Despite a decreasing trend in the number of family physicians providing maternity services, about 25 percent continue to perform vaginal deliveries, whereas less than 5 percent perform cesarean deliveries.6 Management guided by current knowledge of the relevant screening tests and normal labor process can greatly increase the probability of an uncomplicated delivery and postpartum course<br />Absolute Contraindications to Vaginal Delivery<br />Complete placenta previaHerpes simplex virus with active genital lesions or prodromal symptomsPrevious classic uterine incision or extensive transfundal uterine surgeryUntreated human immunodeficiency virus infectionNormal Spontaneous Vaginal Delivery<br />Normal Spontaneous Vaginal Delivery a.k.a. Vaginal Birth, Spontaneous Vaginal Delivery, Normal Vaginal Delivery, is the term used to describe any delivery of the baby through the vagina (versus a c-section delivery). The baby typically comes through head first. If the baby is not head first, (e.g., breech) it may need to be delivered by c-section.VariationsWhen the amniotic sac has not ruptured during labor or pushing, the infant can be born with the membranes intact. This is referred to as " being born in the caul." The caul is harmless and easily wiped away by the doctor or person assisting with the childbirth. In medieval times, a caul was seen as a sign of good fortune for the baby, in some cultures was seen as protection against drowning, and the caul was often impressed onto paper and stored away as an heirloom for the child. With the advent of modern interventive obstetrics, premature artificial rupture of the membranes has become common and it is rare for infants to be born in the caul in Western births.Pain controlDue to the relatively-large size of the human skull and the shape of the human pelvis forced by the erect posture, childbirth is more difficult and painful for human mothers than other mammals. Many methods are available to reduce the pain of labor, including psychological preparation, emotional support, epidural analgesia, spinal anesthesia, nitrous oxide and opioids, the Lamaze Technique. Each method has its own advantages and disadvantages.ComplicationsComplications occasionally arise during childbirth; these generally require management by an obstetrician.Non-progression of labor (longterm contractions without adequate cervical dilation) is generally treated with cervical prostaglandin gel or intravenous synthetic oxytocin preparations. If this is ineffective, Caesarean section may be necessary.Fetal distress is the development of signs of distress by the child. These may include rising or decreasing heartbeat (monitored on cardiotocography/CTG), shedding of meconium in the amniotic fluid, and other signs.Non-progression of expulsion (the head or presenting parts are not delivered despite adequate contractions): this can require interventions such as vacuum extraction, forceps extraction and Caesarian section.In the past, a great many women died during or shortly after childbirth but modern medical techniques available in industrialized countries have greatly reduced this total.Baby In Normal Position <br />left0Not every woman experiences a text book pattern of delivery. You may have variations in the course of labour. Inspite of these variations you may have safe delivery and a healthy baby. The variations are: <br />Variations in the time of labour. <br />Variations in the positions of the baby. <br />Variations in conducting the vaginal delivery (operative vaginal delivery). <br />Prolonged Labour <br />The word ‘difficult labour’ or ‘dystocia’ suggests that labour has failed to progress normally and is causing difficulties for you and your baby. Delayed progress of labour can be due to various causes. If the labour doesn’t complete within-18 hours in case of the first time pregnant woman and 12 hours in case of those who have had a prior delivery,it is considered prolongued.<br />Causes of prolonged labour: <br />Factors causing delayed progress of labour are:<br />Inadequate intensity and frequency of uterine contractions.<br />Overdistention of the uterus (in cases like twins or large baby). <br />The position of the baby in your uterus is not favorable.   <br />Pelvis is not adequate for the passage of the baby’s head. Then Caesarean section is a best option   .<br />Some medications have been given to you for pain relief or to decrease the perception of contractions (epidural anaesthesia) These sometimes have an effect of prolonging labour, particularly the second stage. <br />If you have not completely evacuated your urinary bladder / bowels, they may rarely cause failure of progress of labour. In most hospital enema is given during the 1st stage of labour.   <br />Effects of prolonged labour:<br /> This difficulty in progress of labour may lead to: <br /> Exhaustion of the mother. <br />Increased post partum bleeding. <br />Increased chances of trauma to the genital tract. <br />Increased chances of operative deliveries – like, forceps, vacuum.        <br />Decreased supply of oxygen to your baby. <br />Increased chances of infection in the uterus. <br />On admission in the hospital <br /> Your doctor will do the following things. <br />Try and rule out the different causes of prolonged labour.<br />Assess your condition by checking your pulse, blood pressure, uterine activity and cervical dilatation.<br />Assess your baby’s condition. <br />To hasten the process of labour your doctor might adopt various measures. <br />Rupture the membrane.<br />To augment the labour. <br />To see the colour of the amniotic fluid. <br />Start intravenous drip of oxytocin if needed after ruling out inadequacy of pelvis. <br />Give antibiotics to prevent infections. <br />Mode of delivery: <br />Your doctor may consider operative vaginal delivery by the forceps or vacuum .OR <br />May consider caesarean section, if no satisfactory progress in cervical dilatation / descent of the head of the baby/ any irregularities in your baby’s heart rate suggestive of foetal condition being compromised. <br />