In-depth explanation of labor divided into two extensive parts. A thorough examination of proper procedure, care, and health for expecting mothers. Delicate consideration must be taken to insure the safety of the baby and promote the best chances for a healthy delivery. Topics such as biochemical messengers, hormonal balance, preterm conditions, fetal position, and cardinal movements.
Physiology of pregnancy, placental hormones , parturitionshallu kotwal
Pregnancy, also known as gestation, is the time during which one or more offspring develops inside a woman. A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy can occur by sexual intercourse or assisted reproductive technology.
Physiology of pregnancy, placental hormones , parturitionshallu kotwal
Pregnancy, also known as gestation, is the time during which one or more offspring develops inside a woman. A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy can occur by sexual intercourse or assisted reproductive technology.
1 The Joy of Being a Christian Jude 1:1-2Rick Peterson
The Joy of Being a Christian Jude 1:1-2 Adapted from a sermon by Steve Shepherd http://www.sermoncentral.com/sermons/the-joy-of-being-a-christian-steve-shepherd-sermon-on-joy-126414.asp
EFL Talks - Answers : Board Games in the ClassroomNives Torresi
EFL Talks - Answers hosted by http://www.efltalks.com/ via Rob Howard and https://moodle4teachers.org/ via Dr Nellie Deutsch.
Worldwide presenters - 41 - answered questions posed by the Teaching community online. The aim for each presenter was to answer 1 question in 10 minutes using no more than 10 slides. Back to back on Saturday 20 Feb and Sunday 21 Feb 2016.
The onset of parturition, commonly known as labor, is a complex physiological process that marks the culmination of pregnancy and the initiation of the birthing process. This intricate sequence of events involves a series of hormonal, mechanical, and neurological changes that ultimately lead to the expulsion of the fetus from the mother's uterus. Understanding the onset of parturition requires a comprehensive exploration of the various stages and factors involved.
The process of parturition can be broadly categorized into three main stages: pre-labor, labor, and post-labor. The pre-labor stage encompasses the preparatory changes occurring in the days and weeks leading up to labor, while the labor stage involves the actual contractions and cervical dilation facilitating delivery. The post-labor stage involves the expulsion of the placenta and the initial postpartum adjustments.
The hormonal regulation of parturition is a crucial aspect of its onset. Throughout pregnancy, the placenta produces progesterone, a hormone that maintains the uterine environment and prevents premature contractions. As term approaches, the ratio of progesterone to estrogen changes, leading to a decline in progesterone levels and a subsequent increase in estrogen. This shift triggers a cascade of events, including the activation of uterine contractions and the initiation of cervical ripening.
The role of oxytocin, often referred to as the "love hormone" or "cuddle hormone," is paramount in the onset of labor. Produced by the hypothalamus and released by the pituitary gland, oxytocin stimulates uterine contractions. Additionally, oxytocin plays a crucial role in the positive feedback loop of labor – as contractions intensify, more oxytocin is released, further promoting labor progression.
Mechanical factors also contribute to the onset of parturition. The growing fetus applies pressure on the cervix and uterine walls, leading to the release of prostaglandins. Prostaglandins are lipid compounds that promote uterine contractions and cervical ripening. The combination of hormonal changes and mechanical pressure creates a synergistic effect, fostering the progression of labor.
The intricate interplay between the maternal-fetal unit and the surrounding environment further influences the onset of parturition. Maternal stress, for instance, can impact the release of corticotropin-releasing hormone (CRH), which, in turn, influences the production of other hormones involved in labor. Moreover, the fetus itself plays an active role in signaling its readiness for delivery through various molecular signals.
The onset of labor is often heralded by a set of common signs. These may include the engagement of the fetal head into the pelvis, the "bloody show" – a discharge of mucus mixed with blood resulting from cervical changes, and the rupture of the amniotic sac, leading to the release of amniotic fluid. These signs, in conjunction with regular and increasingly intense contractions.
This topic contains detailed description about labour, its definition, date of onset of labour, calculations of date of delivery, causes of onset of labour, physiology of normal labour, and events, clinical course and management of each stages of labour.
PHYSIOLOGICAL CHANGES IN FIRST STAGE OF LABOUR.pptAURELIATEMBA
Define the terms related to first stage of labour
Differentiate the characteristics of true VS false labor.
Describe the mechanism in initiation of onset of labor.
Describe the physiological and anatomical changes during the 1st stage of labor
Explain the 1st stage of labor
Explain midwifery roles during first stage of labour
Series of events that takes place in the genital organ in an effort to expel the viable products of conception out of the womb through the vagina into the outer world is called labour.
there are four stages of labour.
Obstetrics All lecture for exam, Obstetrics and gynecology is a field thought of as traditionally serving women because of its focus on the female reproductive system, leading care providers to make assumptions about patients' gender identity and expression in "women's health clinics" when many transgender or nonbinary patients may also seek care from
The pregnant patient content: uterine physiology and preterm labor, preterm onset of labor, tocolysis, physiologic changes of pregnancy that mimic disease, imaging modalities in the pregnant patient, fetal monitoring, appendicitis in the pregnant patient, Biliary tract disease in pregnancy, intestinal obstruction during pregnancy,
With the use of fertility enhancing medications, advance maternal age pregnancies and just the natural order od twinning, this pregnancy presentation has become more common among providers. Here we explore the etiology, presentation and management of twin pregnancies.
A normal pregnancy results in a number of important reversible physiological and hormonal changes that alter thyroid structure and more importantly function.
Understanding these change are important to interpreting, identifying and managing of thyroid disease in pregnancy.
An inspirational, self-help book designed to assist women in improving their lifestyle, physically, mentally, spiritually and emotionally. Through small but successful changes, women can find untapped roadways that lead to happier lifestyles. This book will make you laugh, cry, explore, investigate and scrutinize, but ultimately understand that it only takes simple steps to get to a better you.
The book is also designed as a journal, where you can interact with the information and maintain a personal memoir of your success. After completing this unique adventure, you will have a treasured keepsake and reference to always stay on that positive road...to a better you.
Parvovirus B-19 in Pregnancy Parvovirus is a member of the family Parvoviridae. The virus contains a single-stranded DNA. It can only infect humans. 50% of all adults have been infected sometime during childhood or adolescence.
Parvovirus B-19 in Pregnancy Epidemiology Congenital infection rates vary depending on the prevalence in the community. Approximately 50 to 75% of adult women are immune. 20% to 30% of susceptible adults in school settings will become infected. Day-care workers have a 20% to 50% risk of seroconversion. The risk of infection among susceptible adults following household exposure to an infected person is approximately 50%.
Obstetrical Ultrasound• Introduced in the late 1950’s ultrasonography is a safe, non- invasive, accurate and cost-effective means to investigate the fetus• Computer generated system that uses sound waves integrated through real time scanners placed in contact with a gel medium to the maternal abdomen• The information from different reflections are reconstructed to provide a continuous picture of the moving fetus on the monitor screen
Detailed account of the various changes that occur in maternal anatomy, physiology, and metabolism of pregnant women. These physiological changes are often very precise, and deviations of physiological responses can be a prelude to possible disease/infectious states. In this second part of Labor, we will examine the various systems of the human body,its altered states during pregnancy, and how those changes affect the woman preparing for delivery. Special care is imperative in properly determining the needs of an expecting mother, so developing an intimate, trusting relationship between the mother and fully understanding her physiological output will lead to the best chances of a successful delivery.
In-depth explanation of labor divided into two extensive parts. A thorough examination of proper procedure, care, and health for expecting mothers. Delicate consideration must be taken to insure the safety of the baby and promote the best chances for a healthy delivery. Topics such as biochemical messengers, hormonal balance, preterm conditions, fetal position, and cardinal movements.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
- 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
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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
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
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...
Labor part one
1. Labor: Part 1 by La Lura White MD Maternal Fetal Medicine
2. Labor: Part 1 Labor is a remarkable natural experience. A sequence of timed events, correlate with biochemical and hormonal messengers to develop synchronized contraction patterns. These contractions become stronger, more regulated and lead to the progressive dilation and effacement of the cervix , and ultimately the delivery of a neonate. Understanding these interactions and recognizing their normal and abnormal manifestations are paramount in the appropriate management of the obstetrical patient.
3. Labor: Part 1 The onset of labor occurs around 280 days, or 40 weeks, from the first day of a patient's last menstrual period (LMP), and serves the basis for the EDC or estimated date of confinement. Actually, only 5% of births occur on the assigned due date (EDC). 50% occur within a week. Almost 90% within 2 weeks of an EDC.
4. Labor: Part 1 According to Gabbe: Labor occurs in the term patient when she is between 37 0/7 (36 completed weeks) – 42 0/7 weeks (41 completed weeks). Pre-term or premature labor: occurs prior to 37 0/7 (36 completed weeks). Post-dates: gestation that continues past the assigned EDC. Post-term (prolonged): pregnancy progresses beyond 42 0/7. Obstetrics: Normal and Problem Pregnancies, Gabbe.
5. Labor: Part 1 Adequate dating early in pregnancy is important to distinguish term from preterm conditions that may occur later in gestation, and avoid unnecessary tocolysis or labor inductions based on erroneous dating. Pregnancy dating should also use the earliest accurate information and not be changed on later less accurate data, or represent developing conditions like macrosomia or IUGR conditions. The EDC can be calculated using an appropriate pregnancy wheel. or LMP EDC
6. Labor: Part 1 Nagele’s rule = LMP-3 months + 7 days+1 year Ex: LMP = 8 May 2007 8 May 2007 (LMP) -3 months = 8 February 2007 Add 7 days = 15 February 2007 Add 1 year = 15 February 2008 EDC=15 February 2008
7. Labor: Part 1 Using these dating methods assumes the patient has a regular menstrual cycle, a 28 day interval and an anticipated ovulation at day 14. The patient should have not recently discontinued oral contraceptives, which may affect ovulation time. If the cycles are irregular, they are adjusted based onvariations in the follicular or pre-ovulatory phase (first half of the cycle). For example, if a patient has a cycle that last 34 days (34-28=6), ovulation may have occurred 6 days later, and those 6 days may need to be added to the assigned EDC.
8. Labor: Part 1 If using ultrasound data to determine a patients gestational age, use only the earliest ultrasound information, and change the EDC if and only if that early information falls outside the normal margin of error for ultrasound. The 1st trimester (conception to 13 weeks) scan should correlate within one week of EDC by LMP. The 2nd trimester(14-27 weeks) scan should correlate within two weeks of EDC by LMP. 3rd trimester (28 weeks-delivery) should correlate within three weeks of EDC by LMP, but a single femur length may be a more accurate determination of gestational age in this late ultrasounds, if no earlier data available. PATIENTS SHOULD ONLY HAVE ONE EDC
9. Labor: Part 1Uterine Changes in Pregnancy The uterus is made primarily of smooth muscle. Increase in weight 4-70g (non-pregnant) to 1100-1200g (at term). Initial myometrial hyperplasia (increase in number cells) then hypertrophy (increase in cell size). Volume increases from 10ml to 5 L. 10 times increase in uterine blood flow, with 80-90% directed to the placenta.
10. Labor: Part 1 Uterine tonicity changes from the non-pregnant muscular uterus that has a normal but significant resting tone, to a functional uterine quiescence during pregnancy, secondary to negative inhibitory factors and finally towards the end of pregnancy to an activated, stimulated responsive uterus that is able to contract. These physiological changes are divided into four phases: Phase 0: (inhibitory) Uterine maintains functional quiescence secondary to multiple agents that exert an inhibitory and includes: progesterone, prostacyclin, prostaglandin, relaxin, parathyroid hormone-related peptide, nitric oxide, calcitonin gene-related peptide, adrenomedullin and vasoactive intestinal peptide.
11. Labor: Part 1 Before term, there is a release of this negative inhibition Phase 1: (activation) Initiate by uterotopins, like estrogen and possibly progesterone, prostaglandins and corticotrophin-releasing hormone. Increased expression of contraction associated proteins, including myometrial receptors for prostaglandin and oxytocin. Activation of certain ion channels. Increase in connexin-43 (key component for gap junctions). Increase in the number of gap junctions. This primed uterus can now be stimulated to contract.
12. Labor: Part 1 Phase 2: (stimulation) Myometrium is stimulated by uterotropins like stimulatory prostaglandin (PGE2 and PGF2 alpha) and oxytocin. Previously formed Gap junctions facilitate the passage of electrical activity. Improved synchrony between myometrial contractions, leads to a progression in myometrial activity.
13. Labor: Part 1 This results in the development of initially Braxton-Hicks contractures that are irregular, low frequency, disco-ordinate and painless) to true labor contractions (regular, painful, high intensity, high frequency). Phase 3 Occurs after delivery. Involution of uterus. Mediated by oxytocin and possibly thrombin.
14. Labor: Part 1 This uterine activity is coordinated with cervical changes: The cervix, composed some smooth muscle (greatest amount found at internal os) is mainly an extracellular connective tissue matrix. It’s major component are type 1 and type 3 collagen, with a small amount of type 4 collagen at the basement membrane. In addition, this matrix includes glycosaminoglycans and proteoglycans, predominantly dermatan sulfate, hyaluronic acid, and heparin sulfate.
15. Labor: Part 1 Collagen fibers are tightly wound into a tubular configuration that maintains a tight sphincter, protected by a mucus plug, that maintains the fetus in utero during pregnancy. Fibronectin and elastin are also found among these collagen fibers, with the highest ratio of elastin to collagen at the internal os. The actual amount of elastin and smooth muscle decrease progressively from the internal to the external os of the cervix.
16. Labor: Part 1 In late pregnancy, the hyaluronic acid content in the cervix increases that leads to increased accumulation of water molecules that intersperse among the collagen fibers. Dermatan sulfate decreases, causing reduced bridging among the collagen fibers and a decrease in cervical firmness. The amount of collagen and collagen fibrils also decrease and disperse secondary to increased decorin, a proteoglycan that coats and separates collagen fibrils.
17. Labor: Part 1 Leading to a rearrangement and realignment of the collagen molecules with diminished collagen fiber and tensile strength. The cervix becomes thinner, softer, shorter and more pliable, leading to cervical ripening. Now if coordinated with regular uterine contractions, these changes allow easier progressive dilatation and effacement of the cervix, an efficient labor and a successful delivery.
18. Labor: Part 1 The “parturition cascade” thought to recruit the factors that moves uterine activity from an irregular to a more regular contraction pattern involves activation of fetal-hypothalamic-pituitary-adrenal axis. Once activated, the fetal adrenal assist the placenta in its production of steroid hormones, especially estrogens, E1 ( estrone ) E2 (estradiol ) and E3 (estriol). However, the fetal adrenals and placenta are incomplete steridogenic organs and dependent on precursors from each other in order to complete their respective steroid synthesis.
19. Labor: Part 1 The fetal adrenals are functional early in pregnancy. Fetal pituitary basophilic cells at about 7 weeks begins to produce fetal ACTH to stimulate the fetal adrenal cortex. The placenta, because of its access to these steroid precursors, can now begins to dominate steroid production, a previous function of the corpus luteum. This is also when estrogen first appears in the maternal circulation.
20. Labor: Part 1 In the first 20 weeks of gestation, placental hCG and progesterone, and possibly prolactin help maintain and regulate the fetal adrenal cortex that is later maintained by fetal ACTH. Between 32-36 weeks, there is a marked growth in the fetal adrenal cortex, in response to the increased steroid production required towards the end of gestation. So how does the placenta and the fetal adrenals interact to affect their respective steroidgenesis?
21. Labor: Part 1 The fetal adrenal cortex is deficient in 3-B hydroxysteroid dehydrogenate, the enzyme that converts pregnenolone and DHEA to progesterone and androstendione Therefore, the fetus cannot make progesterone and androstendione But the placenta is abundant in in 3-B hydroxysteroid dehydrogenate
22. Labor: Part 1 So the fetus takes LDL cholesterol from the fetal circulation and converts it to pregnenolone sulfate and DHEA-S. It then sends pregnenolone sulfate to the placenta via the umbilical artery. The placenta converts the pregnenolone to progesterone. The progesterone (that the fetus is unable to make), is sent back to the fetal adrenals where they can proceed to synthesize various mineralcorticoids and glucocorticids.
23. Labor: Part 1 The placenta can also extract LDL cholesterol from the maternal circulation to produce progesterone, so although it uses the precussors produced in the fetal adrenal cortex, it is not dependent on them to synthesize progesterone. As a preservative measure, the placenta lacks 17-alpha hydroxylase, needed to metabolize progesterone.
24. Labor: Part 1 The placenta synthesizes estrogen, but needs external supply C-19 steroid precursor (DHEA: dehydroepiandrostenedione), DHEA is supplied from the fetal adrenal intermediate zone Remember, DHEA-S, was the other byproduct, of the fetal adrenal cortex conversion of LDL cholesterol extracted from the fetal circulation, (LDL cholesterol= pregnenolone sulfate and DHEA-S) Also DHEA-S is the delivered to the fetal liver where it is converted into16-alpha hydroxydehydroepiandrosterone sulfate (16 alpha OHDHEAS) Placenta also uses 16 alpha OHDHEAS from the fetal liver , where it is first converted into 16 alpha-hydroxyandrostenedione and further aromatized to estriol )
26. Labor: Part 1 Once a contraction pattern of Labor is established, it is divided into three stages. First Stage: onset of labor until full cervical dilation. Second Stage: full dilation of cervix until delivery of neonate. Third Stage: delivery of neonate to delivery of placenta. Fourth Stage: the hour immediately following delivery of placenta. (originally described by Friedman)
27. Labor: Part 1 First Stage : is further divided into the latent and active phase: Latent phase: onset of labor to beginning of active phase Slower rate of cervical dilation, primarily softening and effacement 14 hours in multigravid patients and up to 20 hours in nulligravida Friedman EA; Labor: clinical evaluation and management, 2nd ed. Norwalk, CT, Appleton Century Crofts, 1978.
28. Labor: Part 1 Transition between the latent and active phases can vary, usually occurs at some time between 2 and 5 cm of cervical dilation in most patients. Important to distinguish between latent phase where slow progression is normal and dysfunctional labor, where labor is abnormal and interventions may be necessary. After the latent phase is the active phase, where there is a faster rate of cervical dilatation.
29. Labor: Part 1 Active phase is further divided into: Acceleration phase: abrupt change in the rate of dilatation Phase of maximum slope: the time of rapid cervical dilation and rapid fetal descent Deceleration phase: decreased rate of dilation of the cervical os Descent phase which coincides with second stage Friedman used the lower limit value of 1cm/hr dilatation in the active phase to refer to the phase of maximum slope, not the entire active phase that many clinicians interpret, but have normally slower cervical dilatation rates
30. Labor: Part 1 Friedman (1955) evaluated uncomplicated pregnancies delivering normal infants Primagravidas Multigravidas Min. rate of cervical dilatation (5th %) 1.2cm/h 1.5cm/h Mean rate cervical dilatation 3.0cm/h 5.7 cm/h Descent of fetal head in relation to ischial spines began well before second stage (fully dilated) Rate of descent increased late in first stage and continued linearly into second stage Friedman EA. Primigravid labor; a graphicostatistical analysis. Obstet Gynecol. Dec 1955;6(6):567-89
31. Labor: Part 1 Friedman EA. Primigravid labor; a graphicostatistical analysis. Obstet Gynecol. Dec 1955;6(6):567-89
32. Labor: Part 1 Recent challenges to Friedman’s data on patient’s labor patterns reflects changes over the past 50 years in the patients we see and how we practice. More aggressive medical management, higher induction rates, use of oxytocin, regional anesthesia and continuous fetal monitoring. Maternal characteristics have also changed, with greater body mass index [BMI] and an increase in fetal size.
33. Labor: Part 1 Challenges to Friedman’s Curve: Zhang used a statistical approach to demonstrate contemporary differences in women laboring today. He showed gradual instead of abrupt change from latent to active phase. A longer length of the active labor phase, 5.5 hr. instead of vs. 2.5 hours. No deceleration phase identified. Zhang J et al. Reassessing the labor curve in nulliparous women. Am J Obstet Gynecol 2002 Oct; 187:824-8.
34. Labor: Part 1 Common for two hours to lapse in active phase without cervical change and especially before the patient was 7 cm. was not uncommon 5th percentile for rate of cervical dilatation was determined less than 1 cm/hr. Head can take up to three hours to descend from +0 station to +4 or present at the perineum, and an additional 30 minutes for delivery. Zhang J et al. Reassessing the labor curve in nulliparous women. Am J Obstet Gynecol 2002 Oct; 187:824-8.
35. Labor: Part 1 Rouse developed a protocol requiring a minimum of 12 hours of oxytocin after membrane rupture before failed labor induction could be diagnosed. Found many nulliparas who remained in the latent phase at up to 9 hours still had safe vaginal deliveries Suggest extending the minimum period of oxytocin augmentation for active phase labor arrest from 2 to at least 4 hours was found to be safe and effective Rouse DJ Owen, Hauth JC: Criteria for failed labor induction: Prospective evaluation of a standardized protocol. Obstet Gynecol 96:671,2000.
36. Labor: Part 1 Despite these differences, it is important to have normal parameters to assess the progress of the laboring patient, and identify situations of dysfunctional labor patterns that require re-evaluation and minimize interventions when both mother and fetus are stable.
37. Labor: Part 1 Abnormal Labor Patterns Prolonged Latent Phase: abnormal duration of latent phase of first stage of labor Protraction disorders: ( Slower than normal progress) Primary dysfunctional labor Protraction of descent Arrest disorders (Complete cessation of progress) Arrest of dilatation Arrest of descent
38. Labor: Part 1 Prolonged Latent Phase: Greater than 20 h in nulliparas (mean 8.6 hr.) and 14 h in multiparas (mean 5.3 hr.). May be due to a delay in cervical ripening or change in the cervical tissue biochemistry. Not correlated with adverse outcome. Expectant management. Differentiate latent phase (normal slow progression) from Braxton-Hicks (irregular pre-labor contractions).
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40. 15mg with or without phenegram 25mg or vistiril
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42. Labor: Part 1 Careful assessment to fetal size and position Augmentation and/or amniotomy if appropriate especially if poor contraction strength Most common cause in nulliparas is inadequate uterine activity and in multiparas is CPD (cephaloelvic disproportion)
43. Labor: Part 1 Arrest Disorders: Secondary arrest: cessation of previously normal active phase dilatation for 2 or more hours. Suggest dystocia in presence of adequate contractions. Requires vaginal exam to verify dilatation, presentation, position and station. Evaluate with clinical pelvimetry to assess adequacy of pelvis.
44. Labor: Part 1 Oxytocin with or without amniotomy if suboptimal contractions and candidate for artificial rupture. Greater risk for further labor abnormalities and operative delivery. Arrest 2-4 hours despite adequate contractions, preferably documented with an IUPC, may need to consider cesarean section. With a recently documented 31% cesarean section rate in the U.S., this decision should be made after a thorough evaluation, however it should not be inappropriately delayed.
45. Labor: Part 1 Arrest of descent: No descent of fetal head with an epidural of >3 hours in primips and >2 hours in multips. If no epidural >2 hours in primips and >1 hour in multip.s Usually preceded by a normal pattern of dilatation and descent. Major risk factors nulliparity, fetal macrosomia, epidural analgesia, hydramnios, hypertensive disorders and gestational diabetes mellitus. Careful evaluation with the same caveat, make an appropriate, expedient and supportive decision for further management.
46. Indication Nullipara Multipara Prolonged latent phase >20 h >14 h Average second stage 50 min 20 min Prolonged second stage: without (with) epidural >2 h (>3 h) >1 h (>2 h) Protracted dilation <1.2 cm/h <1.5 cm/h Protracted descent <1 cm/h <2 cm/h Arrest of dilation* >2 h >2 h Arrest of descent* >2 h >1 h Prolonged third stage >30 min >30 min *Adequate contractions >200 Montevideo units [MVU] per 10 minutes for 2 hours.
47. Labor: Part 1 Prevent abnormalities of second stage: “ Aggressiveness may get you in trouble.” Descent and rotation often occurs before the cervix is fully dilated. No impact of duration of second stage if progressing slowly, if mother and fetus are stable. Delayed pushing after the patient is fully dilated, especially if the head is still high , “laboring down” may have better outcome
48. Labor: Part 1 Muueller-Hillis maneuver: apply pressure to uterine fundus with one hand, and with 1-2fingers in the vagina, detect if there is descent of the fetal head. If fetal head descends 1 cm or more with pressure, prognosis for vaginal delivery is good. Once the fetus is delivered……. Remember, its not over! You still need to deliver the placenta
49. Labor: Part 1 Although most placentas deliver within 5 minutes, you have up to 30 minutes Two maneuvers Brandt-Andrews: an abdominal hand is placed on the abdomen to secure the uterus while providing downward traction on the umbilical cord;pt may assist with pushing Créde maneuver: the cord is fixed with the lower hand while the hand on the abdomen secures the uterine fundus and provides upward traction
50. Labor: Part 1 The three classic signs of placental separation will be: Lengthening of the umbilical cord A gush of blood from the vagina signifying the separation of the placenta from the uterine wall A change in the shape of the uterine fundus from discoid to globular, with an elevation of fundal height Uterotonics given after delivery of the fetus (active management can hasten the delivery of the placenta, reduce blood loss and improve uterine contractility Be Patient……………
55. Remember that the management of labor is an enlightening and rewarding experience between a provider and their patient, make it a positively memorable one. This concludes Labor: Part 1 We invite you to listen to Labor Part 2, where we will further discuss: Mechanics of Labor: Power, Passage and Passenger Calculating Montevideo units Maternal clinical pelvimetry Leopold's Maneuvers Fetal lie, position, presentation Cardinal movements
56. Visit our website @secondopinion2.com Or you can contact Dr. White for teaching and conference opportunities at: Second Opinion 2 1-800-219-0713 e-mail info@secondopinion2
57. Bibliography: 1) Pritchard JA Mac Donald PC (eds): William’s Obstetrics, 16th ed. New York, Appleton-Century-Crogts, 1980. 2) Creasy R.K., Resnik, R., Maternal Fetal Medicine, 6th ed. Saunders Elsvier, 2009. 3) Gibbs, Ronald S.; Karlan, Beth Y.; Haney, Arthur F.; Nygaard, Ingrid E, Danforth's Obstetrics and Gynecology, 10th Edition, Lippincott Williams & Wilkins. 4) Google Images