Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care
Uterine inversion occurs when the uterus turns inside out, most commonly during delivery from excessive cord traction or fundal pressure. It can range from the fundus inverting into the cervix to the entire uterus prolapsing outside the body. Prompt diagnosis and management is needed to prevent shock. The uterus must be manually or surgically replaced before detaching the placenta to avoid hemorrhage. Prevention involves controlled cord traction and avoiding fundal pressure until the placenta separates naturally.
Vaginal fistula is an abnormal connection between the vagina and bladder (vesicovaginal), rectum (rectovaginal), colon (colovaginal), or bowel (enterovaginal). It is usually caused by tissue damage during childbirth but can also result from other causes like Crohn's disease or surgery. Symptoms include incontinence, discharge, and pain. Diagnosis involves physical exams, scans, and tests. Treatment options include antibiotics, anti-inflammatory drugs, and surgery to close the fistula.
Hyperemesis gravidarum is a severe form of vomiting during pregnancy that negatively impacts a mother's health and daily activities. It most commonly occurs during the first trimester of a woman's first pregnancy. Symptoms include persistent and forceful vomiting, weight loss, and dehydration. Treatment focuses on rehydration through intravenous fluids, antiemetic drugs to reduce nausea and vomiting, vitamins to prevent nutritional deficiencies, and hospitalization for severe cases. With proper treatment, the condition typically improves and the mother can resume oral intake.
Umbilical cord prolapse is a serious obstetric emergency where the umbilical cord precedes the fetus through the birth canal. It can be diagnosed by feeling the cord or detecting fetal heart abnormalities. Management involves manually lifting the presenting part off the cord, placing the mother in a position to relieve pressure on the cord, considering tocolysis to stop contractions, and delivering via the fastest route, typically an emergency c-section.
This document discusses multiple pregnancy and the management of twin pregnancies. It defines multiple pregnancy as when more than one fetus develops simultaneously in the uterus. The most common type is twins, but higher order multiples like triplets can also occur. It describes the diagnosis of twin pregnancies including ultrasound findings and complications specific to monozygotic and monochorionic twins. The document outlines the increased risks of twin pregnancies and recommendations for antenatal care, delivery management, and indications for c-section.
This document discusses intrauterine growth restriction (IUGR), defined as birth weight below the 10th percentile for gestational age. IUGR can be symmetrical, affecting all organs early in fetal development, or asymmetrical, affecting growth later. Causes include maternal factors like nutrition, disease, and toxins; fetal issues like anomalies and infections; placental problems; and unknown causes. Diagnosis involves monitoring fetal growth by fundal height, ultrasound, and Doppler. Complications for the growth-restricted infant include asphyxia, hypoglycemia, and long term developmental delays. Management focuses on monitoring during pregnancy, careful delivery, and addressing medical issues in the newborn period like temperature, glucose, feeding, and infection risk
1) Malpresentations occur when the fetus is positioned abnormally during delivery, with the most common normal positions being left or right occiput anterior. Malpositions involve a normal presentation (vertex) but abnormal positioning of the occiput.
2) Causes of malpresentations can include faults in the powers (weak uterine contractions), faults in the passages (abnormal pelvis), or faults in the passenger (fetal anomalies). Specific causes mentioned include contracted pelvis, uterine anomalies, large fetus size, and placenta previa.
3) Diagnosis involves history of abnormal fetal movements, abdominal exam findings like non-engaged head, and vaginal exam finding anything other than vertex. Comp
Uterine inversion occurs when the uterus turns inside out, most commonly during delivery from excessive cord traction or fundal pressure. It can range from the fundus inverting into the cervix to the entire uterus prolapsing outside the body. Prompt diagnosis and management is needed to prevent shock. The uterus must be manually or surgically replaced before detaching the placenta to avoid hemorrhage. Prevention involves controlled cord traction and avoiding fundal pressure until the placenta separates naturally.
Vaginal fistula is an abnormal connection between the vagina and bladder (vesicovaginal), rectum (rectovaginal), colon (colovaginal), or bowel (enterovaginal). It is usually caused by tissue damage during childbirth but can also result from other causes like Crohn's disease or surgery. Symptoms include incontinence, discharge, and pain. Diagnosis involves physical exams, scans, and tests. Treatment options include antibiotics, anti-inflammatory drugs, and surgery to close the fistula.
Hyperemesis gravidarum is a severe form of vomiting during pregnancy that negatively impacts a mother's health and daily activities. It most commonly occurs during the first trimester of a woman's first pregnancy. Symptoms include persistent and forceful vomiting, weight loss, and dehydration. Treatment focuses on rehydration through intravenous fluids, antiemetic drugs to reduce nausea and vomiting, vitamins to prevent nutritional deficiencies, and hospitalization for severe cases. With proper treatment, the condition typically improves and the mother can resume oral intake.
Umbilical cord prolapse is a serious obstetric emergency where the umbilical cord precedes the fetus through the birth canal. It can be diagnosed by feeling the cord or detecting fetal heart abnormalities. Management involves manually lifting the presenting part off the cord, placing the mother in a position to relieve pressure on the cord, considering tocolysis to stop contractions, and delivering via the fastest route, typically an emergency c-section.
This document discusses multiple pregnancy and the management of twin pregnancies. It defines multiple pregnancy as when more than one fetus develops simultaneously in the uterus. The most common type is twins, but higher order multiples like triplets can also occur. It describes the diagnosis of twin pregnancies including ultrasound findings and complications specific to monozygotic and monochorionic twins. The document outlines the increased risks of twin pregnancies and recommendations for antenatal care, delivery management, and indications for c-section.
This document discusses intrauterine growth restriction (IUGR), defined as birth weight below the 10th percentile for gestational age. IUGR can be symmetrical, affecting all organs early in fetal development, or asymmetrical, affecting growth later. Causes include maternal factors like nutrition, disease, and toxins; fetal issues like anomalies and infections; placental problems; and unknown causes. Diagnosis involves monitoring fetal growth by fundal height, ultrasound, and Doppler. Complications for the growth-restricted infant include asphyxia, hypoglycemia, and long term developmental delays. Management focuses on monitoring during pregnancy, careful delivery, and addressing medical issues in the newborn period like temperature, glucose, feeding, and infection risk
1) Malpresentations occur when the fetus is positioned abnormally during delivery, with the most common normal positions being left or right occiput anterior. Malpositions involve a normal presentation (vertex) but abnormal positioning of the occiput.
2) Causes of malpresentations can include faults in the powers (weak uterine contractions), faults in the passages (abnormal pelvis), or faults in the passenger (fetal anomalies). Specific causes mentioned include contracted pelvis, uterine anomalies, large fetus size, and placenta previa.
3) Diagnosis involves history of abnormal fetal movements, abdominal exam findings like non-engaged head, and vaginal exam finding anything other than vertex. Comp
Diabetes is a common medical complication of pregnancy that can be detrimental if not properly managed. It includes pre-existing diabetes, gestational diabetes, and pre-diabetes. Strict control of blood sugar levels is important to prevent complications in both the mother and baby such as preeclampsia, macrosomia, and birth injuries. Management involves medical nutrition therapy, insulin when needed, exercise, tight glucose monitoring, and obstetric care. Close cooperation is needed between the doctor, patient, and family to help achieve successful outcomes.
Multiple pregnancies are pregnancies carrying more than one fetus. The incidence of twins is 1 in 80 births according to Hellin's formula, with the incidence increasing with maternal age and use of ovulation-inducing drugs. There are two types of twins: monozygotic (identical) twins that develop from one egg and dizygotic (fraternal) twins that develop from two separate eggs. Risks of multiple pregnancies include anemia, pregnancy-induced hypertension, preterm labor, and delivery complications related to malpresentations. Management involves frequent checkups, proper diet, rest, and delivery in a hospital equipped to handle potential complications.
Diabetes is a common complication of pregnancy, affecting 4-6% of pregnancies in the US. It can lead to both maternal and fetal morbidity. The main types of diabetes in pregnancy are gestational diabetes (88% of cases), type 2 diabetes (8% of cases), and type 1 diabetes (4% of cases). Diabetes in pregnancy is associated with increased risks of miscarriage, preterm delivery, birth defects, macrosomia, growth restriction, hypoglycemia, jaundice, and respiratory distress in the baby. It also increases the mother's risk of preeclampsia, diabetic ketoacidosis, and complications from existing diabetes or related conditions. Diagnosis and treatment focus on managing blood glucose
1. Miscarriage, or spontaneous abortion, is defined as the loss of a pregnancy without outside intervention between the beginning of pregnancy and 37 weeks of gestation.
2. Causes of miscarriage include uterine abnormalities, chromosomal anomalies, immunological issues, endocrine disorders, infections, and somatic or psychological factors.
3. Treatment for threatened miscarriage may include bed rest, medications to relax the uterus, and hormonal therapy with progesterone. Monitoring includes checking symptoms, hormone levels, and ultrasound imaging.
Premature Rupture of Membranes (PROM) refers to rupture of membranes before the onset of labor. It occurs in 10% of term pregnancies and more commonly in preterm labor. PROM can be diagnosed through various tests including a nitrazine paper test, fern test, sterile speculum exam, or ultrasound. Complications of PROM include preterm labor, infection, and fetal deformities or distress. Management depends on gestational age - expectant management is common above 34 weeks while induction or C-section may be recommended below 36 weeks to prevent complications.
“Difficulty encountered in the delivery of the fetal shoulders after delivery of the head.”
Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%.
An increase in the incidence of shoulder dystocia has been recorded over the last 20 years. Incidence appears to be increasing as birth weights increase.
Gestosis is a multiorgan systemic complication of pregnancy characterized by various symptoms. It is caused by imbalances in prostaglandins that impact vascular resistance and platelet activation. Risk factors include age over 40, primigravida under 17 or over 30, family history, chronic conditions like hypertension and diabetes, and multiple gestation. Preeclampsia is defined as new hypertension and proteinuria developing after 20 weeks of pregnancy. Eclampsia involves preeclampsia with seizures. HELLP syndrome is a variant associated with hemolysis, elevated liver enzymes and low platelets, more common in multiparous women over 25. Early identification and treatment of pregestosis, a preclinical form, can help prevent severe
Hyperemesis gravidarum is severe nausea and vomiting during pregnancy that requires hospitalization. It is diagnosed after ruling out other causes and is characterized by dehydration, weight loss, and an inability to keep food or fluids down. Treatment involves hospitalization, IV rehydration, electrolyte and nutritional supplementation, antiemetic medications, and monitoring for complications of dehydration and malnutrition. The goals are to rehydrate the mother and prevent risks to her and fetal health.
Uterine Rupture
Deepa Mishra
Assistant Professor (OBG)
Introduction
Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth
Symptoms while classically including increased pain, vaginal bleeding, or a change in contractions are not always present.
Disability or death of the mother or baby may result.
Definition
Uterine rupture is giving way of gravid uterus or dissolution in the continuity of uterine wall anytime after 28 weeks of gestation with or without expulsion of the fetus.
Incidence
Rates of uterine rupture during vaginal birth following one previous C-section, done by the typical technique, are estimated at 0.9%
Rates are greater among those who have had multiple prior C-sections or an atypical type of C-section.
In those who do have uterine scarring, the risk during a vaginal birth is about 1 per 12,000
Risk of death of the baby is about 6%
Etiology
Risk Factors
Previous cesarean section
Myomectomy
Dysfunctional labor
Labor augmentation by oxytocin or prostaglandins
High parity
First pregnancy- very rare
Types of uterine rupture
Complete Rupture
All the layers including peritoneum are torn and the uterine contents escape into the peritoneal cavity.
Usually results in death
Incomplete Rupture
Visceral peritoneum is intact and usually the fetus remains in the uterine cavity
Sign & Symptoms
Uterine dehiscence and abdominal pain and vaginal bleeding
Deterioration of fetal heart rate
Loss of fetal station on manual vaginal exam
Hypovolemic shock due to intrabdominal bleeding
Chest pain between the scapulae, pain during inspiration due to irritation of blood below the perineum
Cessation of uterine contractions
Palpation of fetus outside the uterus
Signs of abdominal pregnancy
Post term pregnancy
Diagnosis
Signs of obstructed labor with dehydration, exhaustion, tachycardia raised temperature tonic contraction , pathological retraction ring
Absent fetal heart sound
On PV hot, dry vagina with a large caput over the presenting part
Prevention
Early diagnosis and management of CPD mal presentation and obstructed labor
Proper selection of cases for vaginal delivery
Carefull monitoring of oxytocin infusion specially in multipara
Avoid intra uterine manipulation no version in single fetus
Instrumental delivery after cervical dilatation
Immediate CS in obstructed labor
Hospital delivery for high risk cases
ECV should be avoided during general anaesthesia
Careful manual removal of placenta
Treatment
Resuscitation with adequate hydration and blood transfusion
Laprotomy
Hysterectomy
Repair
Complication
Rupture uterus with haemorrhage, shock and sepsis
Fetal loss is high in spontaneous and traumatic rupture
Mortality is low in LSCS scar rupture
This document discusses vesicovaginal fistula (VVF), including:
1. VVF is an abnormal opening between the bladder and vagina, causing continuous urinary incontinence.
2. VVF has various classifications based on location, size, and complexity.
3. Treatment involves conservative management or surgical repair, with the surgical approach depending on the fistula characteristics.
Chorioamnionitis and PROM - Nahrain UniversityAli Al-Shimmary
Chorioamnionitis is an inflammation of the fetal membranes caused by bacterial infection, usually ascending from the vagina during prolonged labor. It complicates 1-4% of births in the US and 40-70% of preterm births following premature rupture of membranes or spontaneous labor. Risk factors include prolonged rupture of membranes, prolonged labor, nulliparity, smoking, and bacterial vaginosis. Diagnosis is based on maternal fever, uterine tenderness, and fetal tachycardia. Treatment involves intravenous antibiotics until delivery. Complications for both mother and fetus include sepsis, pneumonia, and cerebral palsy. Premature rupture of membranes can occur preterm or at term and increases risks of infection, cord prolapse
Vaginal bleeding in late pregnancy can be caused by placenta previa, placental abruption, ruptured vasa previa, or uterine scar disruption. It is important to determine the diagnosis as treatment depends on the underlying cause. A history, physical exam, ultrasound, and labs can help identify conditions like placenta previa or abruption. Placenta previa is treated expectantly if no active bleeding, while abruption may require delivery depending on grade. Ruptured vasa previa and uterine rupture require emergent delivery.
Preterm Labour and Premature Rupture of Membranes Mob: 7289915430, www.drprad...Pradeep Garg
The document summarizes information on preterm labor and premature rupture of membranes. It defines preterm labor as regular contractions before 37 weeks of gestation that are associated with cervical changes. It notes the incidence of preterm labor is 8-10% and discusses definitions, magnitude, causes, risk factors, signs and symptoms, biological markers, cervical length screening, infections associated with preterm labor, and treatments including tocolytics and antenatal corticosteroids.
Conservative surgeries for genital prolapseNikhil Bansal
The document discusses various conservative surgical procedures for genital prolapse that preserve menstrual and childbearing functions. It describes procedures like anterior and posterior colporrhaphy, Fothergill's repair, Shirodkar's procedure, and abdominal sling operations. Each procedure is explained detailing its principles, indications, steps, and potential complications. Conservative surgeries presented aim to correct prolapse of the uterus, bladder, rectum or vagina without removing organs or abolishing functions.
Uterine rupture is a life-threatening condition where the wall of the uterus tears, potentially exposing the fetus and placenta to the mother's abdominal cavity. It most commonly occurs in women with a previous cesarean section scar. Signs include acute abdominal pain, fetal distress, and hemorrhage. Diagnosis is often made using ultrasound or MRI to detect tears in the uterine wall. Immediate exploratory laparotomy and cesarean delivery is usually required for treatment. Conservative uterine repair may be attempted for some cases but hysterectomy is often necessary due to severe hemorrhage. Prevention focuses on careful management of trial of labor for women with previous scars.
Caesarean section is the removal of a child through an incision in the abdominal wall of an intact uterus. The incidence of caesarean sections has increased worldwide in the last 25 years, mainly due to repeat caesareans, dystocia, and fetal distress. Indications for caesarean section include maternal factors like previous c-sections, fetal distress, and fetal-maternal factors. The most common type is a lower segment caesarean section (LSCS) which involves a transverse incision in the lower uterine segment. While caesarean section can be life-saving, it carries more risks than a planned vaginal delivery.
ECTOPIC PREGNANCY. An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes. Risk factors include previous pelvic inflammatory disease or use of an intrauterine device. Clinical presentation includes amenorrhea, abdominal pain, and vaginal bleeding. Diagnosis is made through pregnancy tests, ultrasound, and clinical examination. Treatment options include surgery such as salpingectomy or salpingotomy. Conservative treatment with methotrexate may also be used. Complications can include hemorrhage and shock.
Early bleeding in pregnancy can be caused by ectopic pregnancy, abortion, or hydatidiform mole. Abortion, also called miscarriage, is the spontaneous loss of a fetus before 24 weeks gestation and can be caused by fetal chromosome abnormalities in 50% of cases, uterine abnormalities like fibroids, endocrine issues like diabetes, infections, or environmental factors. The types of abortion include threatened, inevitable, incomplete, complete, and missed. Missed abortion features the gradual disappearance of pregnancy signs and symptoms despite an empty uterus seen on ultrasound. Management depends on the type but may include medication, dilation and evacuation, or expectant management.
This document discusses vaginal birth after cesarean (VBAC) and elective repeat cesarean delivery (ERCD). It begins by outlining the history of the "once a cesarean, always a cesarean" dictum and subsequent research challenging this view. It then compares the risks and benefits of VBAC versus ERCD. Key points include a VBAC success rate of 60-80% and increased risks of uterine rupture and emergency cesarean with VBAC. Factors affecting VBAC likelihood of success and failure are also reviewed. The document provides guidance on candidate selection and counseling for VBAC.
The document discusses how various natural processes like birth, sunset, fruit ripening, song composition, films, rain, rainbows, rose growth and finding a lifelong partner all take time. It notes that while some things take hours, days or even a lifetime, falling in love does not take too long. All events are part of God's plan and will, with everything happening at the right time according to His design.
The document discusses tackling internal security threats in India through enhanced technologies for intelligence and operations management. It describes Orkash Services, a consulting firm focused on risk management, intelligence, and homeland security technologies. The document outlines challenges facing security forces in India, such as information availability and asymmetry. It proposes automating intelligence creation through techniques like information extraction, semantic analysis, geospatial analysis, and data mining to help address these challenges.
Diabetes is a common medical complication of pregnancy that can be detrimental if not properly managed. It includes pre-existing diabetes, gestational diabetes, and pre-diabetes. Strict control of blood sugar levels is important to prevent complications in both the mother and baby such as preeclampsia, macrosomia, and birth injuries. Management involves medical nutrition therapy, insulin when needed, exercise, tight glucose monitoring, and obstetric care. Close cooperation is needed between the doctor, patient, and family to help achieve successful outcomes.
Multiple pregnancies are pregnancies carrying more than one fetus. The incidence of twins is 1 in 80 births according to Hellin's formula, with the incidence increasing with maternal age and use of ovulation-inducing drugs. There are two types of twins: monozygotic (identical) twins that develop from one egg and dizygotic (fraternal) twins that develop from two separate eggs. Risks of multiple pregnancies include anemia, pregnancy-induced hypertension, preterm labor, and delivery complications related to malpresentations. Management involves frequent checkups, proper diet, rest, and delivery in a hospital equipped to handle potential complications.
Diabetes is a common complication of pregnancy, affecting 4-6% of pregnancies in the US. It can lead to both maternal and fetal morbidity. The main types of diabetes in pregnancy are gestational diabetes (88% of cases), type 2 diabetes (8% of cases), and type 1 diabetes (4% of cases). Diabetes in pregnancy is associated with increased risks of miscarriage, preterm delivery, birth defects, macrosomia, growth restriction, hypoglycemia, jaundice, and respiratory distress in the baby. It also increases the mother's risk of preeclampsia, diabetic ketoacidosis, and complications from existing diabetes or related conditions. Diagnosis and treatment focus on managing blood glucose
1. Miscarriage, or spontaneous abortion, is defined as the loss of a pregnancy without outside intervention between the beginning of pregnancy and 37 weeks of gestation.
2. Causes of miscarriage include uterine abnormalities, chromosomal anomalies, immunological issues, endocrine disorders, infections, and somatic or psychological factors.
3. Treatment for threatened miscarriage may include bed rest, medications to relax the uterus, and hormonal therapy with progesterone. Monitoring includes checking symptoms, hormone levels, and ultrasound imaging.
Premature Rupture of Membranes (PROM) refers to rupture of membranes before the onset of labor. It occurs in 10% of term pregnancies and more commonly in preterm labor. PROM can be diagnosed through various tests including a nitrazine paper test, fern test, sterile speculum exam, or ultrasound. Complications of PROM include preterm labor, infection, and fetal deformities or distress. Management depends on gestational age - expectant management is common above 34 weeks while induction or C-section may be recommended below 36 weeks to prevent complications.
“Difficulty encountered in the delivery of the fetal shoulders after delivery of the head.”
Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%.
An increase in the incidence of shoulder dystocia has been recorded over the last 20 years. Incidence appears to be increasing as birth weights increase.
Gestosis is a multiorgan systemic complication of pregnancy characterized by various symptoms. It is caused by imbalances in prostaglandins that impact vascular resistance and platelet activation. Risk factors include age over 40, primigravida under 17 or over 30, family history, chronic conditions like hypertension and diabetes, and multiple gestation. Preeclampsia is defined as new hypertension and proteinuria developing after 20 weeks of pregnancy. Eclampsia involves preeclampsia with seizures. HELLP syndrome is a variant associated with hemolysis, elevated liver enzymes and low platelets, more common in multiparous women over 25. Early identification and treatment of pregestosis, a preclinical form, can help prevent severe
Hyperemesis gravidarum is severe nausea and vomiting during pregnancy that requires hospitalization. It is diagnosed after ruling out other causes and is characterized by dehydration, weight loss, and an inability to keep food or fluids down. Treatment involves hospitalization, IV rehydration, electrolyte and nutritional supplementation, antiemetic medications, and monitoring for complications of dehydration and malnutrition. The goals are to rehydrate the mother and prevent risks to her and fetal health.
Uterine Rupture
Deepa Mishra
Assistant Professor (OBG)
Introduction
Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth
Symptoms while classically including increased pain, vaginal bleeding, or a change in contractions are not always present.
Disability or death of the mother or baby may result.
Definition
Uterine rupture is giving way of gravid uterus or dissolution in the continuity of uterine wall anytime after 28 weeks of gestation with or without expulsion of the fetus.
Incidence
Rates of uterine rupture during vaginal birth following one previous C-section, done by the typical technique, are estimated at 0.9%
Rates are greater among those who have had multiple prior C-sections or an atypical type of C-section.
In those who do have uterine scarring, the risk during a vaginal birth is about 1 per 12,000
Risk of death of the baby is about 6%
Etiology
Risk Factors
Previous cesarean section
Myomectomy
Dysfunctional labor
Labor augmentation by oxytocin or prostaglandins
High parity
First pregnancy- very rare
Types of uterine rupture
Complete Rupture
All the layers including peritoneum are torn and the uterine contents escape into the peritoneal cavity.
Usually results in death
Incomplete Rupture
Visceral peritoneum is intact and usually the fetus remains in the uterine cavity
Sign & Symptoms
Uterine dehiscence and abdominal pain and vaginal bleeding
Deterioration of fetal heart rate
Loss of fetal station on manual vaginal exam
Hypovolemic shock due to intrabdominal bleeding
Chest pain between the scapulae, pain during inspiration due to irritation of blood below the perineum
Cessation of uterine contractions
Palpation of fetus outside the uterus
Signs of abdominal pregnancy
Post term pregnancy
Diagnosis
Signs of obstructed labor with dehydration, exhaustion, tachycardia raised temperature tonic contraction , pathological retraction ring
Absent fetal heart sound
On PV hot, dry vagina with a large caput over the presenting part
Prevention
Early diagnosis and management of CPD mal presentation and obstructed labor
Proper selection of cases for vaginal delivery
Carefull monitoring of oxytocin infusion specially in multipara
Avoid intra uterine manipulation no version in single fetus
Instrumental delivery after cervical dilatation
Immediate CS in obstructed labor
Hospital delivery for high risk cases
ECV should be avoided during general anaesthesia
Careful manual removal of placenta
Treatment
Resuscitation with adequate hydration and blood transfusion
Laprotomy
Hysterectomy
Repair
Complication
Rupture uterus with haemorrhage, shock and sepsis
Fetal loss is high in spontaneous and traumatic rupture
Mortality is low in LSCS scar rupture
This document discusses vesicovaginal fistula (VVF), including:
1. VVF is an abnormal opening between the bladder and vagina, causing continuous urinary incontinence.
2. VVF has various classifications based on location, size, and complexity.
3. Treatment involves conservative management or surgical repair, with the surgical approach depending on the fistula characteristics.
Chorioamnionitis and PROM - Nahrain UniversityAli Al-Shimmary
Chorioamnionitis is an inflammation of the fetal membranes caused by bacterial infection, usually ascending from the vagina during prolonged labor. It complicates 1-4% of births in the US and 40-70% of preterm births following premature rupture of membranes or spontaneous labor. Risk factors include prolonged rupture of membranes, prolonged labor, nulliparity, smoking, and bacterial vaginosis. Diagnosis is based on maternal fever, uterine tenderness, and fetal tachycardia. Treatment involves intravenous antibiotics until delivery. Complications for both mother and fetus include sepsis, pneumonia, and cerebral palsy. Premature rupture of membranes can occur preterm or at term and increases risks of infection, cord prolapse
Vaginal bleeding in late pregnancy can be caused by placenta previa, placental abruption, ruptured vasa previa, or uterine scar disruption. It is important to determine the diagnosis as treatment depends on the underlying cause. A history, physical exam, ultrasound, and labs can help identify conditions like placenta previa or abruption. Placenta previa is treated expectantly if no active bleeding, while abruption may require delivery depending on grade. Ruptured vasa previa and uterine rupture require emergent delivery.
Preterm Labour and Premature Rupture of Membranes Mob: 7289915430, www.drprad...Pradeep Garg
The document summarizes information on preterm labor and premature rupture of membranes. It defines preterm labor as regular contractions before 37 weeks of gestation that are associated with cervical changes. It notes the incidence of preterm labor is 8-10% and discusses definitions, magnitude, causes, risk factors, signs and symptoms, biological markers, cervical length screening, infections associated with preterm labor, and treatments including tocolytics and antenatal corticosteroids.
Conservative surgeries for genital prolapseNikhil Bansal
The document discusses various conservative surgical procedures for genital prolapse that preserve menstrual and childbearing functions. It describes procedures like anterior and posterior colporrhaphy, Fothergill's repair, Shirodkar's procedure, and abdominal sling operations. Each procedure is explained detailing its principles, indications, steps, and potential complications. Conservative surgeries presented aim to correct prolapse of the uterus, bladder, rectum or vagina without removing organs or abolishing functions.
Uterine rupture is a life-threatening condition where the wall of the uterus tears, potentially exposing the fetus and placenta to the mother's abdominal cavity. It most commonly occurs in women with a previous cesarean section scar. Signs include acute abdominal pain, fetal distress, and hemorrhage. Diagnosis is often made using ultrasound or MRI to detect tears in the uterine wall. Immediate exploratory laparotomy and cesarean delivery is usually required for treatment. Conservative uterine repair may be attempted for some cases but hysterectomy is often necessary due to severe hemorrhage. Prevention focuses on careful management of trial of labor for women with previous scars.
Caesarean section is the removal of a child through an incision in the abdominal wall of an intact uterus. The incidence of caesarean sections has increased worldwide in the last 25 years, mainly due to repeat caesareans, dystocia, and fetal distress. Indications for caesarean section include maternal factors like previous c-sections, fetal distress, and fetal-maternal factors. The most common type is a lower segment caesarean section (LSCS) which involves a transverse incision in the lower uterine segment. While caesarean section can be life-saving, it carries more risks than a planned vaginal delivery.
ECTOPIC PREGNANCY. An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes. Risk factors include previous pelvic inflammatory disease or use of an intrauterine device. Clinical presentation includes amenorrhea, abdominal pain, and vaginal bleeding. Diagnosis is made through pregnancy tests, ultrasound, and clinical examination. Treatment options include surgery such as salpingectomy or salpingotomy. Conservative treatment with methotrexate may also be used. Complications can include hemorrhage and shock.
Early bleeding in pregnancy can be caused by ectopic pregnancy, abortion, or hydatidiform mole. Abortion, also called miscarriage, is the spontaneous loss of a fetus before 24 weeks gestation and can be caused by fetal chromosome abnormalities in 50% of cases, uterine abnormalities like fibroids, endocrine issues like diabetes, infections, or environmental factors. The types of abortion include threatened, inevitable, incomplete, complete, and missed. Missed abortion features the gradual disappearance of pregnancy signs and symptoms despite an empty uterus seen on ultrasound. Management depends on the type but may include medication, dilation and evacuation, or expectant management.
This document discusses vaginal birth after cesarean (VBAC) and elective repeat cesarean delivery (ERCD). It begins by outlining the history of the "once a cesarean, always a cesarean" dictum and subsequent research challenging this view. It then compares the risks and benefits of VBAC versus ERCD. Key points include a VBAC success rate of 60-80% and increased risks of uterine rupture and emergency cesarean with VBAC. Factors affecting VBAC likelihood of success and failure are also reviewed. The document provides guidance on candidate selection and counseling for VBAC.
The document discusses how various natural processes like birth, sunset, fruit ripening, song composition, films, rain, rainbows, rose growth and finding a lifelong partner all take time. It notes that while some things take hours, days or even a lifetime, falling in love does not take too long. All events are part of God's plan and will, with everything happening at the right time according to His design.
The document discusses tackling internal security threats in India through enhanced technologies for intelligence and operations management. It describes Orkash Services, a consulting firm focused on risk management, intelligence, and homeland security technologies. The document outlines challenges facing security forces in India, such as information availability and asymmetry. It proposes automating intelligence creation through techniques like information extraction, semantic analysis, geospatial analysis, and data mining to help address these challenges.
An obstetric examination involves inspecting, palpating, and auscultating a pregnant patient's abdomen. The examiner should ensure patient privacy and comfort, explain the exam, and obtain consent. By palpating the abdomen, the examiner can determine the fundal height, fetal lie, presentation, position, and engagement as well as the fetal heart rate. An accurate exam requires practice and experience, and abnormal findings may require ultrasound confirmation.
Leopold's maneuver is a systematic method to determine the position of a fetus in the uterus. It involves gently palpating the abdomen with both hands to feel the different fetal parts. The head feels hard and round while the buttocks feel softer. By assessing where the back, limbs, and head are located, the presentation and position of the fetus can be determined. Nursing considerations include ensuring privacy, a comfortable position, and explaining the procedure to the patient.
The document discusses the assessment of maternal and fetal well-being during pregnancy. Maternal assessment includes taking history, general and obstetrical examination, and radiological tests. Fetal assessment includes clinical maneuvers, biophysical tests like fetal movement count and non-stress test, biophysical profile, cardiotocography, and ultrasound. Both maternal and fetal assessments are important to monitor the health and development of the mother and fetus during pregnancy.
This document provides information on examining a pregnant patient and summarizing the stages of labor. It begins with guidelines for conducting the abdominal examination, including obtaining consent and maintaining privacy. It then describes assessing the abdomen through inspection, palpation, and auscultation to determine fetal position, presentation, and other details. Finally, it divides labor into three stages - the first stage from onset to full dilation, the second from full dilation to delivery, and the third being delivery of the placenta. Key points on assessing cervical dilation and the definition and typical durations of each stage are also provided.
This document outlines antenatal care (ANC), including its objectives to reduce maternal and infant morbidity and mortality through early detection of complications, health education, and preventive interventions. It describes traditional and focused ANC models, with the focused model recommending 4 routine visits and evidence-based activities. The initial ANC visit includes a detailed history, exam, and diagnostic workup to identify risks and plan care. Subsequent visits monitor progress and new issues. Strategies to assure fetal well-being include assessing growth, movements, and tests after 28 weeks. Health interventions emphasize education, nutrition, and psychological support.
Primary Maternal Care: Skills workshop examination of the abdomen in pregnancySaide OER Africa
This document provides guidance on examining the abdomen in pregnancy. It outlines how to determine gestational age by measuring the fundal height and assessing fetal presentation and position. The exam involves general inspection of the abdomen and specific palpation of the uterus and fetus to evaluate size, lie, presentation, head engagement, fetal heart rate and movements. Close monitoring of the amount of amniotic fluid and signs of uterine irritability are also described. The goal is to accurately assess fetal growth, position and well-being during routine prenatal exams.
The document outlines the steps for performing a pregnant abdomen examination, including gathering equipment, introducing oneself to the patient, inspecting and palpating the abdomen, assessing fetal position and presentation, measuring fundal height, listening for the fetal heartbeat, and summarizing findings. The examination provides information on the pregnancy and well-being of the mother and fetus. Further assessments like blood pressure, urinalysis, and ultrasound may also be performed.
Primary Maternal Care: Assessment of fetal growth and condition during pregnancySaide OER Africa
Primary Maternal Care addresses the needs of healthcare workers in level 1 district hospitals and clinics who provide antenatal and postnatal care, but do not conduct deliveries. It is adapted from theory chapters and skills workshops from Maternal Care. This book complements the national protocol of antenatal care in South Africa. It covers: booking for antenatal care, assesing fetal growth and wellbeing, hypertensive disorders of pregnancy, antepartum haemorrhage, preterm labour, important medical conditions
Intrapartum Care: Skills workshop Examination in labourSaide OER Africa
Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning
Maternal Care: Assessment of fetal growth and condition during pregnancySaide OER Africa
Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care
An obstetric physical examination involves a full examination of the pregnant woman, including abdominal and pelvic examinations. The abdominal examination assesses the size, shape, and position of the uterus to determine information like fetal presentation, position, and lie. The pelvic examination allows assessment of cervical dilation, effacement, and fetal station and engagement. Together these examinations provide important information about the fetus and progress of the pregnancy or labor.
The document summarizes the management of the three stages of labour. The first stage involves assessing the patient's history and examining cervical dilation and fetal descent using a partogram. The second stage focuses on monitoring the mother and baby, maintaining an optimal birthing position, and gently guiding the baby's head and shoulders out. Immediate newborn care is also described. The third stage centers on delivering the placenta through controlled cord traction and examining for completeness or anomalies. Perineal tears are repaired to prevent bleeding and infection.
Identify the onset of the second stage of labour.
Decide when the patient should start to bear down.
Communicate effectively with the patient during labour.
Use the maternal effort to the best advantage when the patient bears down.
Make careful observations during the second stage of labour.
Assess the fetal condition during the time the patient bears down.
Accurately evaluate progress in the second stage of labour.
Manage a patient with a prolonged second stage of labour.
Diagnose and manage impacted shoulders.
The first stage of labor involves the dilation of the cervix from 0-10cm as contractions become stronger and more frequent. It is divided into three phases: latent, active, and transitional. Several factors influence the progress of labor including uterine contractions, cervical effacement and dilation, fetal descent, and pressure from amniotic fluid. Monitoring includes regular assessment of maternal and fetal vital signs, uterine contractions, cervical dilation, and fetal heart rate. Natural pain management methods include breathing exercises, hydrotherapy, and doula support.
The document describes the normal mechanism of labor, including the three stages of labor and the fetus' seven passive movements that enable it to navigate the birth canal. The first stage involves cervical dilation. The second stage is when the fetus is delivered. The third stage involves delivery of the placenta. Key movements include engagement, descent, flexion, internal rotation, extension, restitution/external rotation, and expulsion. Close monitoring of the fetus and mother is important throughout labor.
BREECH DELIVERY By Odokoyero Abdalah Fadhil and Nanfuka MariamOdokonyerofadhil
This document provides an overview of breech delivery, including:
1. Definitions of breech presentation and breech birth, as well as the epidemiology and types/classifications of breech presentations.
2. Risk factors for breech presentation, the diagnosis process, and management options including external cephalic version and vaginal breech delivery.
3. Details on the procedure for a vaginal breech delivery, including positioning, maneuvers to assist delivery of the legs, shoulders, and head, as well as potential complications.
Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning
The document discusses the physiology of labor, including theories of labor initiation and signs that labor is impending or has begun. It describes five theories for what triggers the start of labor: the uterine stretch theory; oxytocin theory; progesterone deprivation theory; prostaglandin theory; and aging placenta theory. It also outlines seven common premonitory or warning signs that labor may start soon: lightening; Braxton Hicks contractions; maternal energy; weight loss; cervical changes; rupture of membranes; and bloody show. Finally, it provides diagnostic criteria for differentiating true labor contractions from false labor contractions based on regularity, location, changes over time, and impact of activity, as well as comparing cervical changes.
This document outlines the key components of an obstetric physical examination. It defines presentation, attitude, position, station, and engagement of the fetus. It describes inspecting the uterus size and shape and palpating the fundus, back, and head using Leopold's maneuver and lateral palpation. Auscultation is used to assess fetal well-being. During labor, contractions, cervical dilation, effacement, consistency, and position are examined along with status of membranes. The goals are to determine fetal lie, attitude, presentation, position, and engagement as well as assess fetal and maternal health.
This document provides an overview of obstetrical emergencies including uterine rupture and shoulder dystocia. For uterine rupture, it defines the condition, describes the causes, clinical features, and management approach. Management involves supportive care like IV fluids and antibiotics followed by definitive surgery like repair or hysterectomy. For future pregnancies, cesarean delivery is recommended. For shoulder dystocia, it defines the condition, discusses prediction and clinical presentation. Management involves initial maneuvers applied sequentially like McRoberts, Woods screw, and extraction of the posterior arm. More invasive options like clavicular fracture or Zavanelli maneuver may be considered if initial attempts fail. Complications for both mother and baby are described.
Sara was admitted to the labor unit with possible rupture of membranes. Upon admission, her cervix was 4 cm dilated, -3 station, and 80% effaced. She was experiencing regular contractions.
The document provides information on the stages of labor, including the three stages of the first stage (latent, active, transition), signs of each stage, and nursing care required. It also discusses factors that can influence the duration of labor like fetal position and size, as well as maternal health factors.
Nursing diagnoses for Sara's admission include risks for injury, pain, fear, and infection due to her status on admission and the labor process. Proper monitoring, fluid management, and communication are important for
This document summarizes the normal labor process and its stages. It describes the first stage of labor as dilation of the cervix, usually taking 12 hours for first-time mothers and 6 hours for mothers who have given birth before. The second stage is described as beginning with full cervical dilation and ending with delivery of the fetus, typically taking 2 hours for first-time mothers and 30 minutes for others. The third stage involves delivery of the placenta, usually within 15 minutes. Key parameters like fetal position and presentation are also defined. The document provides details on managing each stage of labor.
This document discusses the process of labor and outlines the female pelvis and fetal skull anatomy. It describes the stages of normal labor and the mechanism of labor. Abnormal labor patterns including protraction disorders and arrest disorders are defined. Risk factors for abnormal labor include older age, diabetes, and prior complications. Dystocia can cause issues for both the mother and neonate. Causes of dystocia are classified as abnormal power, abnormal passage, or abnormal passenger. Management may include supportive care, augmentation, and operative delivery depending on the type of dystocia. The role of the partograph in monitoring labor is also summarized.
Leopold's Maneuver is used to determine the position and orientation of the fetus through abdominal palpation. It involves 4 specific palpation techniques performed by a healthcare provider: 1) palpating the fundus to determine if the fetal head or breech is present, 2) locating the fetal back by palpating opposite sides of the uterus, 3) determining if the presenting part is engaged by pressing on the lower abdomen, and 4) assessing fetal attitude and position by placing fingers along the uterine wall. The results of Leopold's Maneuver can indicate whether the fetus is positioned correctly for birth.
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Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
Chapter wise All Notes of First year Basic Civil Engineering.pptx
Maternal Care: Skills workshop Examination of the abdomen in pregnancy
1. 1B
Skills workshop:
Examination of
the abdomen
in pregnancy
A. Preparation of the patient
Objectives for examination
1. The patient should have an empty bladder.
When you have completed this skills 2. She should lie comfortably on her back with
a pillow under her head. She should not
workshop you should be able to:
lie slightly turned to the side, as is needed
• Determine the gestational age from the when the blood pressure is being taken.
size of the uterus.
• Measure the symphysis-fundus height. B. General appearance of the abdomen
• Assess the lie and the presentation
The following should be specifically looked for
of the fetus. and noted:
• Assess the amount of liquor present.
1. The presence of obesity.
• Listen to the fetal heart.
2. The presence or absence of scars. When
• Assess fetal movements. a scar is seen, the reason for it should be
• Assess the state of fetal wellbeing. specifically asked for (e.g. what operation
did you have?), if this has not already
become clear from the history.
GENERAL EXAMINATION 3. The apparent size and shape of the uterus.
4. Any abnormalities.
OF THE ABDOMEN
C. Palpation of the abdomen
There are two main parts to the examination
of the abdomen: 1. The liver, spleen, and kidneys must be
specifically palpated.
1. General examination of the abdomen. 2. Any other abdominal mass should be
2. Examination of the uterus and the fetus. noted.
3. The presence of an enlarged organ, or a
mass, should be reported to the responsible
2. SK ILLS WORKSHOP : EXAMINATION OF THE ABDOMEN IN PREGNANC Y 45
Lower edge of sternum
Left hand
Uterus
Pelvic inlet
Figure 1B-1: Determining the fundal height
doctor, and the patient should then be • If the fundus is palpable just above the
assessed by the doctor. symphysis pubis, the gestational age is
probably 12 weeks.
• If the fundus reaches halfway between
EXAMINATION OF THE the symphysis and the umbilicus, the
gestational age is probably 16 weeks.
UTERUS AND THE FETUS • If the fundus is at the same height as
the umbilicus, the gestational age is
probably 22 weeks (one finger under
D. Palpation of the uterus
the umbilicus = 20 weeks and one
1. Check whether the uterus is lying in the finger above the umbilicus = 24 weeks).
midline of the abdomen. Sometimes it is
rotated either to the right or the left. F. Determining the height of the
2. Feel the wall of the uterus for irregularities. fundus from 18 weeks gestation
An irregular uterine wall suggests either:
• The presence of myomas (fibroids) The symphysis-fundus height should be
which usually enlarge during measured as follows:
pregnancy and may become painful. 1. Feel for the fundus of the uterus. This is
• A congenital abnormality such as a done by starting to gently palpate from
bicornuate uterus. the lower end of the sternum. Continue to
palpate down the abdomen until the fundus
E. Determining the size of the uterus is reached. When the highest part of the
before 18 weeks gestation fundus has been identified, mark the skin at
this point with a pen. If the uterus is rotated
1. Anatomical landmarks, i.e. the symphysis
away from the midline, the highest point
pubis and the umbilicus, are used.
of the uterus will not be in the midline but
2. Gently palpate the abdomen with the left
will be to the left or right of the midline.
hand to determine the height of the fundus
Therefore, also palpate away from the
of the uterus:
3. 46 MATERNAL CARE
24 weeks
Umbilicus 22 weeks
20 weeks
16 weeks
12 weeks
Figure 1B-2: Determining the uterine size before 24 weeks
Incorrect
Correct
Figure 1B-3: Measuring the symphysis-fundus height
midline to make sure that you mark the doing the measurement. Measure this
highest point at which the fundus can be distance in centimetres from the symphysis
palpated. Do not move the fundus into the pubis to the top of the fundus. This is the
midline before marking the highest point. symphysis-fundus height.
2. Measure the symphysis-fundus (s-f) height. 3. If the uterus does not lie in the midline
Having marked the fundal height, hold but, for example, lies to the right, then the
the end of the tape measure at the top of distance to the highest point of the uterus
the symphysis pubis. Lay the tape measure must still be measured without moving the
over the curve of the uterus to the point uterus into the midline.
marking the top of the uterus. The tape
measure must not be stretched while
4. SK ILLS WORKSHOP : EXAMINATION OF THE ABDOMEN IN PREGNANC Y 47
Having determined the height of the fundus, ballotable. The breech feels soft, triangular
you need to assess whether the height of the and continuous with the body.
fundus corresponds to the patient’s dates, and 2. Second step. The hands are now placed
to the size of the fetus. From 18 weeks, the s-f on the sides of the abdomen. On one side
height must be plotted on the SF growth curve there is the smooth, firm curve of the back
to determine the gestational age. This method of the fetus, and on the other side, the
is, therefore, only used once the fundal height rather knobbly feel of the fetal limbs. It is
has reached 18 weeks. In other words, when often difficult to feel the fetus well when
the s-f height has reached two fingers width the patient is obese, when there is a lot of
under the umbilicus. liquor, or when the uterus is tight, as in
some primigravidas.
G. Palpation of the fetus 3. Third step. The examiner grasps the lower
portion of the abdomen, just above the
The lie and presenting part of the fetus only symphysis pubis, between the thumb and
becomes important when the gestational age fingers of one hand. The objective is to feel
reaches 34 weeks. for the presenting part of the fetus and to
The following must be determined: decide whether the presenting part is loose
above the pelvis or fixed in the pelvis. If
1. The lie of the fetus. This is the relationship the head is loose above the pelvis, it can be
of the long axis of the fetus to that of easily moved and balloted. The head and
the mother. The lie may be longitudinal, breech are differentiated in the same way as
transverse, or oblique. in the first step.
2. The presentation of the fetus. This is 4. Fourth step. The objective of this step is to
determined by the presenting part: determine the amount of head palpable
• If there is a breech, it is a breech above the pelvic brim, if there is a cephalic
presentation. presentation. The examiner faces the
• If there is a head, it is a cephalic patient’s feet, and with the tips of the
presentation. middle three fingers palpates deeply in
• If no presenting part can be felt, it is a the pelvic inlet. In this way the head can
transverse or oblique lie. usually be readily palpated, unless it is
3. The position of the back of the fetus. This already deeply in the pelvis. The amount
refers to whether the back of the fetus is on of the head palpable above the pelvic brim
the left or right side of the uterus, and will can also be determined.
assist in determining the position of the
presenting part.
I. Special points about the palpation
of the fetus
H. Methods of palpation
1. When you are palpating the fetus, always
There are four specific steps for palpating the try to assess the size of the fetus itself.
fetus. These are performed systematically. With Does the fetus fill the whole uterus, or
the mother lying comfortably on her back, the does it seem to be smaller than you would
examiner faces the patient for the first three expect for the size of the uterus and the
steps, and faces towards her feet for the fourth. duration of pregnancy? A fetus which
1. First step. Having established the height feels smaller than you would expect for
of the fundus, the fundus itself is gently the duration of pregnancy, suggests intra-
palpated with the fingers of both hands, in uterine growth restriction, while a fetus
order to discover which pole of the fetus which feels smaller than expected for the
(breech or head) is present. The head feels size of the uterus, suggests the presence of
hard and round, and is easily movable and a multiple pregnancy.
5. 48 MATERNAL CARE
Figure 1B-4: The four steps in palpating the fetus
2. If you find an abnormal lie when you 2. Does the head feel too hard for the size of
palpate the fetus, you should always the fetus? The fetal head feels harder as the
consider the possibility of a multiple pregnancy gets closer to term. A relatively
pregnancy. When you suspect that a patient small fetus with a hard head suggests the
might have a multiple pregnancy, she presence of intra-uterine growth restriction.
should have an ultrasound examination.
K. Assessment of the amount
J. Special points about the palpation of liquor present
of the fetal head
This is not always easy to feel. The amount of
1. Does the head feel too small for the size of the liquor decreases as the pregnancy nears term.
uterus? You should always try to relate the The amount of liquor is assessed clinically by
size of the head to the size of the uterus and feeling the way that the fetus can be moved
the duration of pregnancy. If it feels smaller (balloted) while being palpated.
than you would have expected, consider the
1. If the liquor volume is reduced
possibility of a multiple pregnancy.
(oligohydramnios), it suggests that:
6. SK ILLS WORKSHOP : EXAMINATION OF THE ABDOMEN IN PREGNANC Y 49
Figure 1B-5: An accurate method of determining the amount of head palpable above the brim of the pelvis
• There may be intra-uterine growth L. Assessment of uterine irritability
restriction.
This means that the uterus feels tight, or has
• There may be a urinary tract obstruction
a contraction, while being palpated. Uterine
or some other urinary tract abnormality
irritability normally only occurs after 36
in the fetus. This is uncommon.
weeks of pregnancy, i.e. near term. If there is
2. If the liquor volume is increased
an irritable uterus before this time, it suggests
(polyhydramnios), it suggests that one of
either that there is intra-uterine growth
the following conditions may be present:
restriction or that the patient may be in, or is
• Multiple pregnancy.
likely to go into, preterm labour.
• Maternal diabetes.
• A fetal abnormality such as spina bifida,
anencephaly or oesophageal atresia. M. Listening to the fetal heart
In many cases, however, the cause of 1. Where should you listen? The fetal heart is
polyhydramnios is unknown. However, most easily heard by listening over the back
serious problems can be present and the of the fetus. This means that the lie and
patient should be referred to a hospital where position of the fetus must be established by
the fetus can be carefully assessed. The patient palpation before listening for the fetal heart.
needs an ultrasound examination by a trained 2. When should you listen to the fetal heart?
person to exclude multiple pregnancy or a You need only listen to the fetal heart if a
congenital abnormality in the fetus. patient has not felt any fetal movements
during the day. Listening to the fetal heart
7. 50 MATERNAL CARE
is, therefore, done to rule out an intra- 4. Recording of fetal movements. The fetal
uterine death. movements should be recorded on a chart
3. How long should you listen for? You should as shown in Figure 1B-6.
listen long enough to be sure that what Figure 1B-6: An example of fetal movements
you are hearing is the fetal heart and not recorded on a fetal-movement chart
the mother’s heart. When you are listening
to the fetal heart, you should, at the same Between 08:00 and 09:00 on 3 July the fetus
time, also feel the mother’s pulse. moved six times.
Between 11:00 and 12:00 on 4 July the fetus
N. Assessment of fetal movements moved nine times.
The fetus makes two types of movement: Between 08:00 and 09:00 on 5 July the fetus
1. Kicking movements, which are caused by moved three times.
movement of the limbs. These are usually Date Time Total
quick movements.
2. Rolling movements, which are caused by 3 July 8–9 6
the fetus changing position. 4 July 11–12 9
When you ask a patient to count her fetal
movements, she must count both types of 5 July 8–9 3
movement.
Every time the fetus moves, the patient
If there is a reason for the patient to count fetal must make a tick on the chart so that all the
movements and to record them on a fetal- movements are recorded. The time and day
movement chart, it should be done as follows: should be marked on the chart. If the patient
1. Time of day. Most patients find that the is illiterate, the nurse giving her the chart can
late morning is a convenient time to record fill in the day (and times if the chart is to be
fetal movements. However, she should be used more than once a day). It is important to
encouraged to choose the time which suits explain to the patient exactly how to use the
her best. She will need to rest for an hour. It chart. Remember that a patient who is resting
is best that she use the same time every day. can easily fall asleep and, therefore, miss fetal
2. Length of time. This should be for one movements.
hour per day, and the patient should be
able to rest and not be disturbed for this O. Assessment of the state of fetal wellbeing
period of time. Sometimes the patient
It is very important to assess the state of
may be asked to rest and count fetal
fetal wellbeing at the end of every abdominal
movements for two or more half-hour
palpation. This is done by taking into account
periods a day. The patient must have
all the features mentioned in this skills
access to a watch or clock, and know how
workshop.
to measure half- and one-hour periods.
3. Position of the patient. She may either sit or
lie down. If she lies down, she should lie on
her side. In either position she should be
relaxed and comfortable.