Intrapartum sonography can be used to more accurately assess fetal head position, station, descent, and rotation during labor compared to digital examination alone. It also helps predict success of induction of labor and instrumental delivery. The document outlines the basic technique, objectives, and various clinical applications of intrapartum sonography during different stages of labor.
Role of Stem Cells in Obstetrics and Gynecology PracticeAsha Jain
Role of Stem Cells in Obstetrics and Gynecology Practice
Talk delivered at 4th Biennial International ISCSGCON 2021
on Febuary 13,2021 by Dr. Asha Jain
interest in stem cells is raising in different field of medicine. The question is : is it successful in Gynecology or it is still too early to say that. The present talk may help to explore this .
Role of Stem Cells in Obstetrics and Gynecology PracticeAsha Jain
Role of Stem Cells in Obstetrics and Gynecology Practice
Talk delivered at 4th Biennial International ISCSGCON 2021
on Febuary 13,2021 by Dr. Asha Jain
interest in stem cells is raising in different field of medicine. The question is : is it successful in Gynecology or it is still too early to say that. The present talk may help to explore this .
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
Embryo implantation in the region of a previous caesarean section scar is a rare but potentially catastrophic complication of a previous cesarean birth.
Selection of an embryo from a large number of embryos and then placing it to the uterus is known as selective embryo transfer. This fertility preservation process is usually done after the process of IVF cycle and cancels the risks of spontaneous transfer of multiple embryos. Have a look at the detailed description of elective single embryo transfer in the following ppt.
THIS WAS PRESENTED AT SAFOG MOGS "SMART CONFERENCE "IN MUMBAI
PREPARED WITH HELP OF DR SUCHITRA PANDIT,DR CN PURANDARE AND DR ALPESH GANDHI.....VIDEOS CAN BE SEEN AT U TUBE
LSCS is the most common obstetric procedure but it can be very difficult to manage in cases of previous LSCS, low lying placenta, and PPH. please check out the youtube links to the videos embedded in this PPT.
ADHESIOLYSIS DURING LSCS https://youtu.be/2Hv80v3yu20
BLADDER DISSECTION https://youtu.be/6qsaTJ1yRUY
RECTUS SHEATH ADHESIOLYSIS https://youtu.be/SryJHjuGsME
VECTIS IN FLOATING HEAD DURING LSCS https://youtu.be/3PECperU8Cw
BREECH DELIVERY https://youtu.be/i-LcmTNNVvU
TRANSVERSE LIE WITH IUFD https://youtu.be/hG28uqpkdpU
CONJOINT TWINS https://youtu.be/KLR7D6wkf38
LSCS IN PLACENTA PREVIA https://youtu.be/dNKQwt4KhVY
SYSTEMATIC PELVIC DEVASCULARISATION https://youtu.be/UwSH6V6GBVw
OVERVIEW
Aim
Definition
Prerequisites
Individualisation of patient.
Ohss free IUI. Clinic
{Strict cancellation of cycle if OHSS is suspected}
Newer trends
Sucess Rates in IUI with COH
PROGNOTIC FACTORS to increase Pregnancy Rates..& discussion
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
Embryo implantation in the region of a previous caesarean section scar is a rare but potentially catastrophic complication of a previous cesarean birth.
Selection of an embryo from a large number of embryos and then placing it to the uterus is known as selective embryo transfer. This fertility preservation process is usually done after the process of IVF cycle and cancels the risks of spontaneous transfer of multiple embryos. Have a look at the detailed description of elective single embryo transfer in the following ppt.
THIS WAS PRESENTED AT SAFOG MOGS "SMART CONFERENCE "IN MUMBAI
PREPARED WITH HELP OF DR SUCHITRA PANDIT,DR CN PURANDARE AND DR ALPESH GANDHI.....VIDEOS CAN BE SEEN AT U TUBE
LSCS is the most common obstetric procedure but it can be very difficult to manage in cases of previous LSCS, low lying placenta, and PPH. please check out the youtube links to the videos embedded in this PPT.
ADHESIOLYSIS DURING LSCS https://youtu.be/2Hv80v3yu20
BLADDER DISSECTION https://youtu.be/6qsaTJ1yRUY
RECTUS SHEATH ADHESIOLYSIS https://youtu.be/SryJHjuGsME
VECTIS IN FLOATING HEAD DURING LSCS https://youtu.be/3PECperU8Cw
BREECH DELIVERY https://youtu.be/i-LcmTNNVvU
TRANSVERSE LIE WITH IUFD https://youtu.be/hG28uqpkdpU
CONJOINT TWINS https://youtu.be/KLR7D6wkf38
LSCS IN PLACENTA PREVIA https://youtu.be/dNKQwt4KhVY
SYSTEMATIC PELVIC DEVASCULARISATION https://youtu.be/UwSH6V6GBVw
OVERVIEW
Aim
Definition
Prerequisites
Individualisation of patient.
Ohss free IUI. Clinic
{Strict cancellation of cycle if OHSS is suspected}
Newer trends
Sucess Rates in IUI with COH
PROGNOTIC FACTORS to increase Pregnancy Rates..& discussion
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
presentation on ultrasound elastography-introduction ,techniques,physics,application, interpretation and future prospects.sourced from multiple articles.
Malpresentations are all presentations of
fetus other than vertex. Face presentation, brow presentation, shoulder presentation and breech presentation are common malpresentations.
Ultrasonography plays a important role in intrapartum period,
It predicts the success rate induction of labour,
Detects favorable factors for vaginal delivery
Assists in instrumental delivery
Prediction of delivery mode by ultrasound-assessed fetal position in nulliparous women with prolonged first stage of labor
T. M. Eggebø, W. A. Hassan, K. Å. Salvesen, E. A. Torkildsen, T. B. Østborg and C. C. Lees
Volume 46, Issue 5, pages 606–610
View the free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.14773/full
Influence of ultrasound determination of fetal head position on mode of delivery: a pragmatic randomized trial
T. Popowski, R. Porcher, J. Fort, S. Javoise and P. Rozenberg
Volume 46, Issue 5, 520–525
View the free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.14785/full
Ultrasonographic Cervical Length Measurement at 10-14- and 20-24-weeks’ Gesta...AI Publications
Preterm labor is a regular occurrence in pregnancy; an estimated 15 million babies are born prematurely each year, with the number increasing. This was a prospective study of pregnant women who came to the Maternity Teaching Hospital in Erbil, Kurdistan Province, Iraq, for an outpatient clinic. On a manageable sample of 150 singleton pregnancies. In this study, one hundred fifty singleton asymptomatic pregnancies encountered the inclusion criteria during the study period, 69 primi gravid, 81 multi gravid. The correlation between the cervical length at 20–24 weeks and preterm delivery was moderately poor (r =0.715), and this correlation was highly significant (P < 0.001). In another word, a better correlation was found between preterm delivery and cervical length at 20–24 weeks than at 10–14 weeks in the prediction of preterm delivery. This study also points towards the importance of serial ultrasound scans to detect those who are at higher risk. There was no statistically significant effect of age, parity. Finally, the findings revealed that trans vaginal ultrasound is more accurate at 20-24weeks than 10-14weeks gestation for prediction of preterm labor, it can be used routinely to prevent preterm birth.
Placental Elastography in Intrauterine Growth Restriction: A Case–control Studyasclepiuspdfs
Background: Intrauterine growth restriction (IUGR) is related to poor fetal outcome. Though, various tools are available for evaluation of IUGR they are notreliable inearly diagnosis of IUGR. Shear wave elastography (SWE) can be used to study the change in mechanical properties of various disease which can be a potential technique for early diagnosis of IUGR. Objective: The objective of the study was to compare the differences in SWE values of placentas between IUGR and normal pregnancies. Methodology: Normal second- and third-trimester pregnancies and IUGR pregnancies between 24 and 42 weeks period of gestation (POG), meeting the inclusion criteria were matched for age group and POG. SWE of placenta was performed in supine position during quiet respiration. The SWE of placenta was measured by placing the region of interest in relatively homogeneous area. The placental elasticity values obtained in pregnancies complicated by IUGR were compared with that of normal controls. Umbilical artery (UA) and fetal middle cerebral artery (MCA) Doppler findings were correlated with placental elasticity value of IUGR pregnancies.
Background: Doppler ultrasound velocimetry of uteroplacental umbilical and fetal vessels has become an established method of antenatal monitoring, Cerebroplacental and Cerebrouterine ratios have been studied to predict neonatal outcomes.
Aim of the Work: To assess if Cerebrouterine Ratio would be complementary to cerebroplacental Ratio in predicting adverse
neonatal outcome in preeclamptic pregnant women.
Large randomized trial comparing transabdominal ultrasound-guided embryo transfer with a technique based on uterine length measurement before embryo transfer
A. Revelli, V. Rovei, P. Dalmasso, G. Gennarelli, C. Racca, F. Evangelista, C. Benedetto
Volume 48, Issue 3, Pages 289–295
Read the free-access article:http://onlinelibrary.wiley.com/doi/10.1002/uog.15899/full
Vaginal progesterone decreases preterm birth ≤ 34 weeks of gestation in women with a singleton pregnancy and a short cervix: an updated meta-analysis including data from the OPPTIMUM study
R. Romero, K. H. Nicolaides, A. Conde‐Agudelo, J. M. O'Brien, E. Cetingoz, E. Da Fonseca, G. W. Creasy, S. S. Hassan
Volume 48, Issue 3, Pages 308–317
Read the free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.15899/full
This presentation discusses the basics and updates about the assessment and management of chronic pelvic female in women. It highlights the recent thoughts about the biopsychosocial model of chronic pelvic pain. It provides an algorithm that joins the management between primary and tertiary care in the management of CPP.
It describes the Progesterone physiology. It describes the latest evidence as regards progesterone formulations, use of progesterone as Luteal phase support. It scrutinizes the value of serum progesterone in monitoring luteal phase
this presentation highlights the principles of uterine and ovarian transplantation. It explores the past and examines the current status for uterine and ovarian factor infertility.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
4. • Extensive evidence over the last 30 years has
demonstrated the value of ultrasound in the
prenatal fetal assessment (anatomy, physiology
and pathology): Antepartum Sonography
• Over the last 10 years, recent studies suggest that
ultrasound may play an important role in the
prediction of the time of onset and the progress
of labor: Intrapartum Sonography (IPS)
5. What do we need to learn?
• Is it the emergency obstetric care unit ?
• Is it the labour ward?
• Is it the delivery room?
7. • Machine: simple 2-D machine can be used
satisfactorily
• Probe: abdominal probe with a frequency 3.5-
5.5 MHz
• Route:
– Abdominal.
– Trans-perineal (translabial).
11. Technique
• Maternal position: supine
• Transducer position: transverse on the
suprapubic region of the maternal abdomen
• Landmarks:
– The foetal orbits.
– Midline cerebral echo.
– Cerebellum.
13. Technique
• Position: supine
• Transducer: place a covered transabdominal transducer
on the perineum in a mid-sagittal position between the
labia below the pubic symphysis.
• Manipulate the probe by small lateral movements until
an image is obtained that visualizes clearly symphysis
pubis and fetal skull with no shadows from pubic rami.
• Landmarks:
– The foetal orbits: occipto-posterior
– Midline cerebral echo: occipto-transverse.
– Cerebellum: occipto-anterior
15. Three Practical measures that are
measurable and reproducible !!
1. Progression distance:.
2. Fetal head direction:
3. Angle of progression:
16. I. Progression Distance
Distance from the lowest part of the fetal skull related to a line
perpendicular to the inferior border of the symphysis pubis
17. II. Fetal Head Direction
Assesses the direction of the fetal head related to same
line
30. WHEN TO USE IPS ?
INDUCTION OF
LABOUR
PRELABOUR
LABOUR:
FIRST STAGE
PROGRESS
LABOUR:
SECOND STAGE
NORMAL
INSTRUMENTAL
LABOUR:
THIRD STAGE
31. I- IPS before Induction of Labour
• Four sonographic parameters predicts success
of induction:
– Pre-induction cervical length. <20 mm
– Position of the fetal occiput.
– Posterior cervical angle. < 90
– Perineum-head distance. <40 mm
The odds of CS increases by about 10% with each
increase of 1 mm in cervical length above 20 mm
34. • Adopting a policy of “delayed induction” in
prolonged pregnancy: Rao et al, 2008
– 80% spontaneous onset of labour and delivery.
– 50% reduction in fetal distress.
– 50% reduction in failure to progress.
– 50% reduction in the need for prostaglandin (Park et al.,
2011)
Ultrasound-based Prolonged
Pregnancy clinic
35. WHEN TO USE IPS ?
INDUCTION OF
LABOUR
PRELABOUR
LABOUR:
FIRST STAGE
PROGRESS
LABOUR:
SECOND STAGE
NORMAL
INSTRUMENTAL
LABOUR:
THIRD STAGE
36. II- Pre-labour
• To differentiate false from true labour pains.
• They evaluated 100 with a diagnosis of labor.
• To determine if the presence or absence of fetal breathing
movements was helpful in diagnosing false from true labor.
• Results:
– 30/31 (96.8%): of patients with absent FBM delivered within 48 hours.
– 61/69 (88.5%): of patients with preserved FBM continued pregnancy
for at least 48 hours.
– There is no difference in its use between term and preterm babies.
Boylan P, O'Donovan P, Owens OJ. Obstet Gynecol. 1985
Oct;66(4):517-20
37. An EBM!
• A SR (8 studies, 328 patients), evaluating the
accuracy of absence of FBM in predicting
spontaneous preterm birth in women with
threatened preterm labor.
• Absence of fetal breathing movements is a
useful test in predicting preterm birth both
within 7 days and within 48 h of testing.
H. HONEST*, L. M. BACHMANN*†, R. SENGUPTA*, J. K. GUPTA*, J. KLEIJNEN‡ and K. S. KHAN*.
Accuracy of absence of fetal breathing movements in predicting preterm birth: a systematic
review. Ultrasound Obstet Gynecol 2004; 24: 94–100
38. WHEN TO USE IPS ?
INDUCTION OF
LABOUR
PRELABOUR
LABOUR:
FIRST STAGE
PROGRESS
LABOUR:
SECOND STAGE
NORMAL
INSTRUMENTAL
LABOUR:
THIRD STAGE
39. III. First stage
Question I: Why did obstetrician think of using
US to follow the progress of labour during first
stage of labour ??
Question II: How shall we use IPS?
To assess head position.
To assess head station.
To assess head rotation.
40. The story of digital pelvic examination
• HEAD POSITION:
– It is not accurate for the determination of fetal
head position during labor. Discrepancy reaches
53 and 39% of patients in the first and second
stage of labor Sherer et al., 2002.
– Failed to diagnose fetal head position in 34% of
cases, and incorrectly determined head position in
51% of patients. Akmal et al., 2002.
41. Another trial !!
• HEAD POSITION:
– Was not possible in 61% of cases in the first stage and
in 31% in the second stage of labor.
– Was inaccurate in 69% of the cases in the first stage
and in 34% of cases in the second stage of labor.
– Difficulty was more likely if the occiput was posterior
in comparison to anterior and in the maternal right in
comparison to the left side.
Souka et al., 2003
42. A Third Trial !!!
• HEAD STATION: Dupuis et al, 2005
– Incorrect assessment: 50-88% of cases for residents
and in 36–80% of cases for obstetricians.
– The commonest mistake: misdiagnosis of a station
as representing a mid-pelvic station rather than a
true high-pelvic station accounted for 88 and 67%
of the errors made by residents and obstetricians,
respectively.
43. A recent trial; April 2013
• Aim: to analyze the relationship between IPS parameters
and to compare them with digital palpation.
• Methods: university hospital in Norway, comparing 3-D
transperineal IPS to digitally palpated head station and
cervical dilatation.
• Conclusion: IPS shows high degree of correlation with
each other, but only moderate correlation to vaginally
palpated fetal head station.
Tutschek, B., Torkildsen, E.A., Eggebø, T.M. 2013. Comparison
between ultrasound parameters and clinical examination to
assess fetal head station in labor. Ultrasound in Obstetrics and
Gynecology 41 (4) , pp. 425-429.
45. There is a good correlation between gold standard (MRI) and perineal US with
subsequent proposed clinical benefit, Bamberg 2012
46. Assessing Head descent
• The angle of head descent measured by
transperineal sonography is an objective,
accurate and reproducible means for assessing
descent of the fetal head during labor.
A. F. BARBERA, X. POMBAR, G. PERUGINO, D. C. LEZOTTE§ and J. C.
HOBBINS 2009. A new method to assess fetal head descent in labor with
transperineal ultrasound Ultrasound Obstet Gynecol 2009; 33: 313–319
47. Assessing Head Position
• Aim to determine whether US is more accurate than vaginal
examination in the determination of fetal occiput position in
the second stage of labor.
• Study design: 88 patients were evaluated by vaginal
examination and by combined transabdominal and
transperineal ultrasound examination to determine occiput
position.
• Results: Vaginal examination was correct in 71.6% of the time;
ultrasound was correct in 92.0% of the time (P=.018).
Margaret R. Chou, Doron Kreiser, M. Mark Taslimi, Maurice L. Druzin, Yasser
Y. El-Sayed,. Vaginal versus ultrasound examination of fetal occiput position
during the second stage of labor American Journal of Obstetrics and
Gynecology (2004) 191, 521e4
48. Assessing head engagement
• There is high rate of agreement (85.6%)
between IPS and digital assessment of fetal
head engagement.
• These data support the use of intrapartum
trans abdominal assessment of fetal head
engagement.
D. M. SHERER and O. ABULAFIA. Intrapartum assessment of fetal head
engagement: comparison between transvaginal digital and transabdominal
ultrasound determinations. Ultrasound Obstet Gynecol 2003; 21: 430–436
51. WHEN TO USE IPS ?
INDUCTION OF
LABOUR
PRELABOUR
LABOUR:
FIRST STAGE
PROGRESS
LABOUR:
SECOND STAGE
NORMAL
INSTRUMENTAL
LABOUR:
THIRD STAGE
52. IPS before ventouse application
Transabdominal IPS assessment of the fetal head
position during the 2nd stage of labor improves
the accuracy of vacuum cup placement.
G.Y. Wong a, Y.M. Mok a, S.F. Wong. Trans-abdominal ultrasound
assessment of the fetal head and the accuracy of vacuum cup
application International Journal of Gynecology and Obstetrics (2007)
98, 120–123
53. Prediction of success of ventouse
delivery
• Good prognostic signs:
– Head-up sign (head pointing ventrally)
– Objective descent of the fetal head below infrapubic
line, both noted at the height of pushing.
• The ‘infrapubic line’: perpendicular to the long axis of the pubic joint
and extending dorsally from its inferior margin in a mid-sagittal plane
• The widest fetal head diameter and its movement with regard to the
infrapubic line during pushing.
• The ‘head direction’.
Henrich W, Dudenhausen J, Fuchs I, Kamena A, Tutschek B: Intrapartum
translabial ultrasound (ITU): sonographic landmarks and correlation with
successful vacuum extraction. Ultrasound Obstet Gynecol 2006; 28: 753–760.
54. WHEN TO USE IPS ?
INDUCTION OF
LABOUR
PRELABOUR
LABOUR:
FIRST STAGE
PROGRESS
LABOUR:
SECOND STAGE
NORMAL
INSTRUMENTAL
LABOUR:
THIRD STAGE
Retained
Placenta
57. Placenta not delivered 30 minutes
1- Edge of the placenta is palpable through tight cervical os
2- Fundus small and contracted.
US: the myometrium is seen to be thickened all around the
uterus and a clear demarcation is often seen between the
placenta and the myometrium
Trapped
placenta
Tocolytics
“Nitrolgycerin”
Succeeded Failed
MROP
With no bleeding
US. Myometrium will be thickened in all
areas except where the placenta is
attached where it will be very thin or
even invisible
Adherent
placenta
Systemic
oxytocics
FailedSucceeded
Intraumbilical
oxytocics
Succeeded
60. Is it important to learn IPS?
Ultrasound in Obstetrics & Gynecology
Volume 41, Issue 4, pages 361–363, April
2013
ACOG releases a DVD in 2004 for standards
in performing IPS
There are ongoing multicetre RCTs to evaluate
its role in intrapartum care
LAST 2 ISOUG conference had much
discussion about IPS
61. Is it easy to learn IP sonography?
• Learning and accuracy of the determination of
fetal head position in labor is easier and
higher, respectively, with trans-abdominal
sonography than with digital examination.
• This should encourage physicians to introduce
clinical ultrasound examination into their
practice.
P. ROZENBERG, R. PORCHER, L. J. SALOMON, F. BOIROT, C. MORIN and Y. VILLE. Comparison of the
learning curves of digital examination and transabdominal sonography for the determination of
fetal head position during labor. Ultrasound Obstet Gynecol 2008; 31: 332–337
62. Does IPS needs special experience?
• No:: Measurement of the angle of progression
on transperineal ultrasound imaging is reliable
regardless of fetal head station or the
clinician’s level of ultrasound experience.
A. M. DU¨ CKELMANN, C. BAMBERG, S. A. M. MICHAELIS, J. LANGE, A. NONNENMACHER, J. W.
DUDENHAUSEN and K. D. KALACHE. 2010. Measurement of fetal head descent using the ‘angle of
progression’ on transperineal ultrasound imaging is reliable regardless of fetal head station or
ultrasound expertise. Ultrasound Obstet Gynecol; 35: 216–222
63. Is it convenient to the patient?
• Yes: it takes < 5minutes to perform.
• Yes: it is even more tolerable than digital
examination
64. Is 3D superior to 2 D in IPS?
• NO
– For single ultrasound operator the intraobserver
repeatability and agreement between 2D and 3D
ultrasound methods in prolonged first stage of labor
were good.
– Because 2D methods are simpler to learn and can be
analyzed quickly, 2D equipment are therefore preferred
in the labor room.
E. A. TORKILDSEN, K. A° . SALVESEN and T. M. EGGEBØ. Agreement between two- and
three-dimensional transperineal ultrasound methods in assessing fetal head descent in
the first stage of labor. Ultrasound Obstet Gynecol 2012; 39: 310–315
65. Does IP US have predictive clinical
value?
Yes
• Favorable for vaginal delivery:
– Fetal head–perineum distance: < 40mm
– Angle of progression: > 110 ͦ
• 2D or 3D ultrasound have similar predictive
values.
E. A. TORKILDSEN, K. A° . SALVESEN and T. M. EGGEB. Prediction of delivery mode with
transperineal ultrasound in women with prolonged first stage of labor. Ultrasound
Obstet Gynecol 2011; 37: 702–708
66. Does IP US have predictive clinical
value?
• When the angle of
progression was 120◦,
the probability of
either spontaneous
vaginal delivery or an
easy and successful
vacuum extraction
was 90%.
K. D. KALACHE, A. M. DU¨ CKELMANN, S. A. M. MICHAELIS, J. LANGE, G. CICHON and J. W. DUDENHAUSEN.
Transperineal ultrasound imaging in prolonged second stage of labor with occipitoanterior presenting fetuses:
how well does the ‘angle of progression’ predict the mode of delivery?. Ultrasound Obstet Gynecol 2009; 33:
326–330
67. Does IP US have predictive clinical
value?
• The shorter the head-
to-perineum distance,
the shorter the time to
deliver.
68. Can it lower CS rate?
• Yes by more objective use of intsrumental
delivery.
• Yes by better assessment of progress of labour
• Yes by lowering the need for induction of labour
69. Does it replace clinical examination?
No
• It just tunes finely the clinical examination
(improves its value).
• It is superior in difficult cases.
71. We have the patients, man power, US
machines !!!!
• RCT addressing the value of “ultrasound-
based prolonged pregnancy clinic”
• RCT addressing the issue of lower CS rate
through more liberal use of IPS.
• RCT addressing its value before ventouse
application.
73. 1. IPS adds significant importance to the conduct of normal
labour and instrumental delivery.
2. IPS is essential but not substitute to clinical skills.
3. The best predictor for success of induction is cervical length
measured by US.
4. The best predictor for vaginal delivery is angle of progression.
5. Our emergency unit is a rich source for applying useful
research beneficial to science and to our patients.
6. IPS may decrease the need for CS; it may represent a trial to
overlook the sarcastic dictum “Once a pregnancy, always a
cesarean !!”