Labour induction
Induction of labour
Guidelines on induction of labour
Guidelines on labour induction
induction of labour is not risk free
prostaglandins for induction of labour
Bishop score
Cervical ripening techniques
mechanical and pharmacological induction of labour
Post dates induction
options for cervical ripening
oral vs. vaginal misoprostol
advantages diadvantages and techniques for induction of labour
gynecology & obstetrics
Labour induction methods
review of guidelines for labour induction
For difficult vaginal delivery,forceps delivery,vacuum application are done to assist the vaginal delivery.Many types of forceps are there divided in 3 categories.
Cervical ripening is the preparation of the cervix for labour and delivery. The Bishop score is the commonest used methodology to assess it. For more like this visit my page on YouTube https://www.youtube.com/@mudiagaakpoghene2243
Labour induction
Induction of labour
Guidelines on induction of labour
Guidelines on labour induction
induction of labour is not risk free
prostaglandins for induction of labour
Bishop score
Cervical ripening techniques
mechanical and pharmacological induction of labour
Post dates induction
options for cervical ripening
oral vs. vaginal misoprostol
advantages diadvantages and techniques for induction of labour
gynecology & obstetrics
Labour induction methods
review of guidelines for labour induction
For difficult vaginal delivery,forceps delivery,vacuum application are done to assist the vaginal delivery.Many types of forceps are there divided in 3 categories.
Cervical ripening is the preparation of the cervix for labour and delivery. The Bishop score is the commonest used methodology to assess it. For more like this visit my page on YouTube https://www.youtube.com/@mudiagaakpoghene2243
complcations of third stage of labour, includes PPH, Inversion of uterus, retained placenta, placenta accreta, increta, percreta, amniotic fluid embolism
It is the expulsion or extraction from its mother of an embryo or fetus weighing 500 gm or less when it is not capable of independent survival (WHO).
The 500gm of fetal development is attained approximately at 22 weeks of gestation.
Expelled fetus- Abortus
INTRODUCTION
DEFINITION
TYPES
CAUSES
MANAGEMENT-Management of 3rd stage bleeding
Actual management
MANAGEMENT OF 3RD STAGE BLEEDING
Steps of management
1. Placental site bleeding-
To palpate the fundus and massage the uterus to make it hard. The massage is to be done by placing four fingers behind the uterus and thumb in front.
To start crystalloid solution (NS or RL) with oxytocin (1L with 20 units) at 60 drops per minute and to arrange for blood transfusion if necessary.
Oxytocin 10 unit IM or methergine 0.2 mg is given intravenously.
To catheterize the bladder.
To give antibiotics (Ampicillin 2gm and Metronidazole 500mg IV)
2. Management of traumatic bleed
The uterovaginal canal is to be explored under general anesthesia after the placenta is expelled and haemostatic sutures are placed on the offending sites.
STEPS OF MANUAL REMOVAL OF PLACENTA
The patient is placed in lithotomy position. With all aseptic measures, the bladder is catheterized.
One hand is introduced into the uterus in cone shaped manner following the cord. While introducing the hand, the labia are separated by the fingers at the other hand.
Counter pressure on the uterine fundus is applied by the hand placed over the abdomens. The abdominal hand should steady the fundus and guide the movement of the fingers inside the uterine cavity till the placenta is completely separated.
Emergencies that occur in pregnancy or during or after labor and delivery.
main emergencies are
Ectopic Pregnancy
Uterine Inversion
Obstetrical Shock
Cord Prolepses
Amniotic Fluid Embolism
Postpartum Hemorrhage
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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
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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
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
MANAGEMENT OF ACUTE UTERINE INVERSION BY DR SHASHWAT JANI
1. Acute Uterine Inversion
What to do & What not to do ?
Dr. Shashwat Jani.
M.S. ( Gynec ).
Diploma in Advance Endoscopy ( France ) .
Assistant Prof., Smt. N.H.L. Mun. Medical College,
Ahmedabad, Gujarat.
Mobile : +91 99099 44160.
E- mail : drshashwatjani@gmail.com
2. Definition
When Uterus Turns Inside Out, It Is Called
Uterine Inversion.
Uterine inversion is the folding of the fundus
into the uterine cavity in varying degrees.
2Dr Shashwat Jani. 9909944160
4. Incidence
Rarely , it Can occur
even in the non-pregnant
uterus in relation to the
expulsion of an
intrauterine tumor…!!!
4Dr Shashwat Jani. 9909944160
5. CLASSIFICATION
A. TYPES :
1) Incomplete Inversion :
When fundus of uterus has turned inside out,
like toe of socks, but inverted fundus has not
descended through cx…
2) Complete Inversion :
When the inverted fundus has passed
completely through cx to lie within the vagina or lie
often outside the introitus.
5Dr Shashwat Jani. 9909944160
6. B. Degrees
First degree: The uterus is partially turned out
Second degree: The fundus has passed
through the cervix but not outside the vagina
Third degree: The fundus is prolapsed
outside the vagina
Fourth degree: The uterus, cervix and vagina
are completely turned inside out and are
visible
6Dr Shashwat Jani. 9909944160
7. Universally…
First Degree : Incomplete Inversion
Second Degree : Complete inversion in the
vagina
Third Degree : Complete inversion outside the
introitus
7Dr Shashwat Jani. 9909944160
8. C. In relation to time interval between its
diagnosis & time of delivery :
Acute : It occurs within 24 hrs of delivery.
Sub-acute : It presents between 24 hrs & 4 wks of
delivery.
Chronic : It presents beyond 4 wks of delivery or in
non pregnant stage.
8Dr Shashwat Jani. 9909944160
9. Causes…
For the uterus to be inverted, must be
relaxed or local atony of uterus at the site of
placental insertion especially fundal.
There should be fundal insertion of placenta.
Either of above two along with :
Spontaneous OR Iatrogenic causes.
9Dr Shashwat Jani. 9909944160
10. Spontaneous (40%):
Abnormal short umbilical cord or functionally
shortened by being wrapped around the fetal body.
Sudden rise in intra abdominal pressure due to
maternal coughing or vomiting.
Morbid adherence of fundally implanted
placenta
Connective tissue disorder such as Marphan’s
syndrome.
Dr Shashwat Jani. 9909944160 10
11. B. Iatrogenic
Due to mismanagement of third stage of labor…
Pulling the cord when the uterus is atonic while
combined with fundal pressure
Crede’s Expression while the uterus is relaxed
Faulty technique in manual removal of placenta
While separating retained placenta from the wall,
a portion may remain attached and as the placenta is
withdrawn, the fundus is also withdrawn.
11Dr Shashwat Jani. 9909944160
12. Patho physiology
In complete inversions, once the
fundus passes through the cervix, the
cervical tissues function as a
constricting band and edema rapidly
forms.
The prolapsed mass then
progressively enlarges and
increasingly obstructs venous and
finally arterial flow, contributing to
the edema.
12Dr Shashwat Jani. 9909944160
13. Clinical Presentation
Large boggy mass appears at introitus with or without
placenta attached
Other signs and symptoms are as follows –
Severe and sustained hypogastric pain in 3rd stage of labor
Shock
Shock is initially out of proportion with the amount of
blood loss.
Woman becomes sweaty with bradycardia, profound
hypotension and rarely cardiac arrest.
In short time there is marked hemorrhage and hypovolumic
shock.
13Dr Shashwat Jani. 9909944160
14. • P/A :
In incomplete uterine inversion: fundus of uterus may appear
to be normal. Only in thin woman it is possible to feel fundal
dimple of incomplete inversion.
In complete inversion : uterus is not palpable per abdomen.
At Vulva,
a pear shaped mass is seen protruding outside vulva with
broad end pointing downwards, looking reddish purple in
color
• Bimanual Examination -
Confirm the diagnosis by detecting inverted body of the
uterus and above encircling it, the ring of cervix.
14Dr Shashwat Jani. 9909944160
15. DIFFERENTIAL DIAGNOSIS
Inversion of uterus
Uterine rupture.
Prolapse of uterine tumor (submucous fibroid).
Large endometrial polyp.
Passage of succenturiate lobe of placenta.
15Dr Shashwat Jani. 9909944160
17. Prevention
Do not employ any method to expel the
placenta when the uterus is relaxed
Patient should not be instructed to change
her position.
Pulling the cord simultaneously with fundal
pressure should be avoided
Manual removal of placenta should be done
in proper manner.
17Dr Shashwat Jani. 9909944160
18. 1) Starting from the edge of placenta ,
2) The placenta is separated by
a) keeping the back of the hand in contact with the
uterine wall.
b) with slicing movement of the hand.
18Dr Shashwat Jani. 9909944160
19. Mx of Acute Inversion of Uterus
• Delay in treatment increases the mortality, So number
of steps are taken immediately and simultaneously.
Before shock develops :
• When one is on the spot when the inversion happens
TRY IMMEDIATE MANUAL REPLACEMENT, even without
anesthesia if not easily available.
Principle :
“ The part of the uterus which has come
down last , should go back first. “
19Dr Shashwat Jani. 9909944160
20. Procedure
• If the diagnosis is made immediately after the
inversion has occurred, then that same degree of
relaxation of myometrium and cervix (which is
required for the inversion to occur) will allow
uterine replacement easily…
1. The gloved hand is lubricated with suitable
antiseptic cream and placed inside the vagina.
2. The uterine fundus with or without the attached
placenta, is cupped in the palm of the hand. The
fingers and thumb of the hand are extended to
identify margins of the cervix.
20
21. 3. The whole uterus is
lifted upwards towards
and beyond umbilicus
4. Additional pressure is
exerted with the
fingertips systematically
and sequentially to push
and squeeze the uterine
wall back through the
cervix.
21Dr Shashwat Jani. 9909944160
22. 5. Sustained pressure for 3-5 mins to
achieve complete replacement
6. Apply counter support by the other hand
placed on the abdomen
7. Once the fundus has been replaced keep the
hand in the uterus while rapid infusion of
oxytocin is given to contract the uterus.
Initially, bimanual compression aids in
control of further hemorrhage until uterine
tone is recovered.
Dr Shashwat Jani. 9909944160 22
23. 8. When the uterus is felt contracting, the hand
is slowly withdrawn.
If placenta is attached, it is to be removed only
after the uterus becomes contracted.
If the placenta is partially attached , it should
be peeled out before replacement of uterus.
Dr Shashwat Jani. 9909944160 23
24. If the patient comes late :
Within 1 -2 minutes, from the occurrence of inversion, the cervix
and lower segment clamps down inverted part of the uterus.
increasing congestion, Edema of the inverted fundus.
makes manual replacement without anesthesia difficult.
If first attempt at immediate manual replacement of
uterus fails, move to the following sequence …
1. Call assistance
Anesthesiologist (assistance of nurse and obstetricians SOS)
2. Elevation of the foot of the delivery table may relieve the
tension on the viscera and reduce the pain and shock
24Dr Shashwat Jani. 9909944160
25. 3. Establish two wide bore i.v. cannulae.
Send blood for for grouping and cross match.
Rapidly run in 1-2 L of crystalloid.
Because though initially shock is neurogenic
type, hypovolumia will follow due to hemorrhage.
4. Catheterize.
5. Prophylactic antibiotics are given
6. If pain is a dominant symptom, small doses of i.v.
Morphine or Pentazocine with Atropine is given.
7. If the inverted uterus is prolapsed beyond the vagina,
it is replaced within the vagina
8. Patient is shifted to OT.
9. Anaesthesia
25Dr Shashwat Jani. 9909944160
26. General Anesthesia :
• Shock and with cardiovascular instability. G.A. is preferred.
• For this one of the fluorinated hydrocarbons are preferred
(Halothne, Sevofurane, Isoflurane) to aid uterine relaxation.
• Halothane is associated with rare myocardial
irritability/arrythmia and hepatotoxicity. Therefore other two
are preferred .
Epidural/ Spinal Anaesthesia :
• With normal vital signs, spinal anaesthesia can be given or if
the patient is already in epidural anaesthesia, then it maybe
continued.
• When anesthetic facilities are not available, replacement
will have to be undertaken and combination of i.v. narcotics,
combined paracervical and pudendal block and inhalation
anesthesia as available and feasible.
26Dr Shashwat Jani. 9909944160
27. 10. If G.A. does not produce adequate uterine
relaxation or if patient is in regional anaesthesia,
tocolysis is necessary.
• If the patient is hypotensive, MgSO4 2 gm i.v. bolus is
given to relax cervical contraction ring.
• If the patient is stable NTG is given…
1 Ampoule of NTG ( 5mg in 1ml solution) is diluted in 100ml
NS. This gives concentration of 50 μg/ml.
Draw 20ml in syringe
4ml given i.v. (i.e. 200μgm) and repeat it at 2 mins interval SOS
in normotensive patient
2ml given i.v. (100μgm) and repeat it at 2 mins interval in
hypotensive patient after correcting hypovolumia
In all the cases where oxytocin or prostaglandin has been
given previously higher doses of NTG is required.
Onset of action – 90sec and lasts for 1-2 mins
27Dr Shashwat Jani. 9909944160
28. Maternal side effect :
- Peripheral vasodilatation and reduced venous tone
- so Rapid infusion with crystalloid is needed in pts who are
hypovolemic
• Peripheral vasodilatation responds to adrenaline.
• Uterine relaxation responds to oxytocin.
• TERBUTALINE CAN BE USED AS TOCOLYTICS AGENT.
11. Manual replacement of uterus.
As described before
12. As soon as the uterus is restored to its normal
configuration
-- The agent used for uterine relaxation is stopped
-- Simultaneously oxytocin is started to contract the uterus.
28Dr Shashwat Jani. 9909944160
29. 13. If there is delay in presentation of the patient i.e. more than
2 hrs or if manual replacement fails then…
O’Sullivan’s hydrostatic replacement technique
is used:
Pre-requisites:
• Make sure that the uterus and vagina have no lacerations.
• If there are found, should be sutured.
Principle:
• Install large volume of saline at body temperature (3-5lt) into upper
vagina
• This distends the upper fornices, which serves to pull open the
cervical ring
• This allows replacement of uterine fundus
Procedure :
• Until replacement is effected, a towel soaked with warm hypertonic
saline is draped over the inverted uterus to reduce the oedema.
29Dr Shashwat Jani. 9909944160
30. • Use douche and rubber
tubing with warm sterile fluid at
3 feet height or 1 litre bags of
warm saline with a pressure
infuser.
• Rubber tubing is placed in
posterior fornix by one hand
which also cups the fundus.
• The other hand seals the
introitus around the wrist so that
there is no leakage of fluid.
30Dr Shashwat Jani. 9909944160
31. • Alternatively the tubing can be attached to
sialistic vacuum extracter cup which is placed
inside introitus and may provide better seal.
• As the vaginal wall distends, there is increase in
intravaginal pressure, the fundus of uterus rises
and inversion is corrected
• Once this is achieved, fluid is allowed to
escape slowly from vagina.
Dr Shashwat Jani. 9909944160 31
32. 14. In rare delayed cases, manual
replacement with or without hydrostatic
technique may be unsuccessful.
In such cases, Surgical replacement will
have to be done…
Procedure:
• Patient is cleaned and draped in Lloyd Davis
position
( frog legged ) with head down (Trendelenberg)
32Dr Shashwat Jani. 9909944160
33. Catheterisation
Midline laparotomy done
Bowels packed upwards and away from uterus
The obstetric surgeon places his/her hands in
front and back of the lower segment with the
fingertips below the level of inverted fundus.
33Dr Shashwat Jani. 9909944160
34. With progressive pressure on the finger tips of
both hands which flip up simultaneously.
The internal dimple is replaced with rising
fundus.
Uterine perfusion returns.
• If this technique fails, Huntington’s Operation :
In this following steps are taken:
• Exteriorize the uterus
• Cervical ring may be stretched
34Dr Shashwat Jani. 9909944160
35. • Locate the cup of the uterus
formed by the inversion
• Dilate the constricting cervical
ring digitally
• Stepwise traction on the funnel
of the inverted uterus or the
round ligament is given with
Allis forceps .
• Reapplied progressively as
fundus emerges.
36. (A) Obstetric ventouse
applied on the inverted
uterine fundus.
(B) Reduction of the
inverted uterus after
traction with the
ventouse.
Instead of allies forceps
alternatively vaccum cup can
be used in HUNTINGTON
PROCEDURE 36
37. HAULTAIN’S PROCEDURE :
Incision is made posteriorly
through the cervix,
relieving cervical constriction
to increase the size of the
ring and allowing traction on
the round ligament for the
replacement of uterus with
subsequent repair of incision
from inside the abdomen.
37
42. Post Operative :
Whatever method for uterine replacement is used ,
It should be followed by…
1. Oxytocics to keep uterus is well contracted for 8 – 12hrs.
Oxytocin drip
15-methyl PGF2α
Ιnitially, after correction of inversion, inj. 15-methyl PGF2α
(carboprost) given in dose of 0.25mg i.m. or
intramyometrially (0.25mg diluted in 5 ml and given at two
sites is uterine fundus).
Duration of action: 6 hrs
2. Broad Spectrum Antibiotics given, if it is not given before.
42Dr Shashwat Jani. 9909944160
43. COMPLICATIONS OF
INVERSION OF UTERUS.
Postpartum hemorrhage due to uterine atony.
Hypovolaemic shock and all its consequence.
Vasovagal shock (due to severe pain).
Endometritis (sepsis).
43Dr Shashwat Jani. 9909944160
44. Infection of adnexa.
Necrosis of adnexa (ovaries) due to
compression of ovaries as they drawn inside.
Damage to intestine / septic paralytic ileus.
Chronic inversion.
44
44Dr Shashwat Jani. 9909944160
45. • Recurrence of inversion.
• Increased risk of rupture of uterus in next
pregnancy (when surgical procedure done for
inversion).
• Increased risk of C-section in subsequent
delivery.
• Chronic pelvic pain -> if chronic inversion is not
treated.
45Dr Shashwat Jani. 9909944160
46. PREVENTION
• Many cases of acute uterine
inversion result mainly from
mismanagement of the third
stage of labour in women who
are already at risk.
46Dr Shashwat Jani. 9909944160
47. MANEUVERS : TO BE AVOIDED
• Excessive traction on the umbilical cord
• Excessive fundal pressure
• Excessive intra-abdominal pressure
• Excessively vigorous manual removal of placenta.
47Dr Shashwat Jani. 9909944160
48. Recently...
• Vijayaraghvan et al. 26 reported a case where
acute inversion of the uterus was managed
under laparoscopic guidance, citing the
advantages of laparoscopic surgery as the
reason for the procedure.
• Consideration, however, needs to be given to
the woman’s hemodynamic status and the
possible effects of pneumoperitoneum.
48Dr Shashwat Jani. 9909944160
49. 49
(A) Laparoscopic appearance of the inverted uterus.
(B) A 5-mm forceps being used to press down on the top of the inverted uterus.
(C) Partial reduction achieved; further reduction was completed using a 10-mm blunt-tipped
Teflon rod to press down on the top of the inverted uterus.
(D) Complete reduction achieved.