Maternal Care: Skills workshop General examination of the abdomen in 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
Maternal Care: Skills workshop General examination of the abdomen in 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
A 32-year-old woman, gravida 5,Para1 ,Living 1 And abortion 3 presented to emergency department for bleeding per vagina at 33 weeks and 3 days,have GDM that is controlled by diet and previous LCSC 7 years ago. She is not in labor.
Topic 03: Health Assessment of the Newborn
The newborn requires thorough skilled observation to ensure a satisfactory adjustment to extra uterine life.
Health assessment of newborn after delivery can be divided into:
1. Initial Assessment
2. Transitional Assessment
3. Assessment of gestational age
4. Behavioural asessment
5. Systemic physical examination
Initial Assessment:
Initial assessment is done by using the APGAR scoring system.
APGAR score: It is method use to assess the newborn’s immediate adjustment to extra uterine life.
• The score based on five signs
1. Appearance (colour)
2. Pulse (Heart rate)
3. Grimace (Reflex irritability )
4. Activity (Muscle tone)
5. Respiratory rate
• Each item is given a score 0, 1, or 2
• 0-3 severe distress
• 4-6 moderate difficulty
• 7-10 no difficulty adjusting to life
• Evaluations of all five categories are made on 1-5 min after birth.
APGAR score:
Sign 0 1 2
Appearance (colour) Blue or pale Body pink, Extrimities Blue Completely Pink
Pulse (Heart rate) Absent Slow (<100 /> 100/m
Grimace (Reflex irritability ) No response Grimace Cough Or Sneeze
Activity(Muscle tone Limp Some flexion Active movement
Respiratory rate Absent Slow, Irregular Good, Crying
Other initial assessment are-
• Stabilization
• Measuring weight.
Transitional Assessment during the period of reactivity
First period of reactivity (6- 8 hours after birth):
During the first 30 minutes the newborn is very alert, cries vigorously, may suck a first greedily, and appears very interested in the environment. Physiologically the respiratory rate can be as high as 80 breaths/ min, crackles may be heard, heart rate may reach 180 beats/min, bowel sound are active, mucus secretions are increased and temperature may decrease slightly.
Second period of reactivity:
Began when the newborn awake from the deep sleep, it lasts about 2-5 hours. The newborn is alert and responsive, heart and respiratory rate are increased, gastric and respiratory secretions are increased, and passage of meconium commonly occurs.
Following this stage is a period of stabilization of physiologic systems & vacillating patern of sleep & activity.
Gestational Age Assessment
An accurate assessment of age is important for 2 reasons
• Age and growth patterns appropriate to that age aid in identifying neonatal risks
• Help in developing management plans
Gestational age can measure by weight for gestational age chart.
Gestational Age Number of weeks that have elapsed since the first day of the last menstrual period to the time of birth. This is usually retrieved from mother’s Antenatal History.
Gestational Age:
• SGA- small for gestational age-weight below 10th percentile •
• AGA-weight between 10 and 90th percentiles
• LGA-weight above 90th percentile
Behavioural Assessment
While babies may not speak their first word for a year, they are born
A 32-year-old woman, gravida 5,Para1 ,Living 1 And abortion 3 presented to emergency department for bleeding per vagina at 33 weeks and 3 days,have GDM that is controlled by diet and previous LCSC 7 years ago. She is not in labor.
Topic 03: Health Assessment of the Newborn
The newborn requires thorough skilled observation to ensure a satisfactory adjustment to extra uterine life.
Health assessment of newborn after delivery can be divided into:
1. Initial Assessment
2. Transitional Assessment
3. Assessment of gestational age
4. Behavioural asessment
5. Systemic physical examination
Initial Assessment:
Initial assessment is done by using the APGAR scoring system.
APGAR score: It is method use to assess the newborn’s immediate adjustment to extra uterine life.
• The score based on five signs
1. Appearance (colour)
2. Pulse (Heart rate)
3. Grimace (Reflex irritability )
4. Activity (Muscle tone)
5. Respiratory rate
• Each item is given a score 0, 1, or 2
• 0-3 severe distress
• 4-6 moderate difficulty
• 7-10 no difficulty adjusting to life
• Evaluations of all five categories are made on 1-5 min after birth.
APGAR score:
Sign 0 1 2
Appearance (colour) Blue or pale Body pink, Extrimities Blue Completely Pink
Pulse (Heart rate) Absent Slow (<100 /> 100/m
Grimace (Reflex irritability ) No response Grimace Cough Or Sneeze
Activity(Muscle tone Limp Some flexion Active movement
Respiratory rate Absent Slow, Irregular Good, Crying
Other initial assessment are-
• Stabilization
• Measuring weight.
Transitional Assessment during the period of reactivity
First period of reactivity (6- 8 hours after birth):
During the first 30 minutes the newborn is very alert, cries vigorously, may suck a first greedily, and appears very interested in the environment. Physiologically the respiratory rate can be as high as 80 breaths/ min, crackles may be heard, heart rate may reach 180 beats/min, bowel sound are active, mucus secretions are increased and temperature may decrease slightly.
Second period of reactivity:
Began when the newborn awake from the deep sleep, it lasts about 2-5 hours. The newborn is alert and responsive, heart and respiratory rate are increased, gastric and respiratory secretions are increased, and passage of meconium commonly occurs.
Following this stage is a period of stabilization of physiologic systems & vacillating patern of sleep & activity.
Gestational Age Assessment
An accurate assessment of age is important for 2 reasons
• Age and growth patterns appropriate to that age aid in identifying neonatal risks
• Help in developing management plans
Gestational age can measure by weight for gestational age chart.
Gestational Age Number of weeks that have elapsed since the first day of the last menstrual period to the time of birth. This is usually retrieved from mother’s Antenatal History.
Gestational Age:
• SGA- small for gestational age-weight below 10th percentile •
• AGA-weight between 10 and 90th percentiles
• LGA-weight above 90th percentile
Behavioural Assessment
While babies may not speak their first word for a year, they are born
Recurrent Pregnancy Loss Sharing Personal Experience (10 years) Lifecare Centre
Complete over view of the causes diagnosis management of Recurrent Pregnancy Loss
it is a personal experience of treating recurrent miscarriages with excellent result
IVF Pregnancy -Is it different? A presentation by Dr Laxmi Shrikhande the leading IVF specialist in India
IVF (In Vitro Fertilization) pregnancy can be both similar to and different from natural conception in several ways. In IVF, fertilization of the egg occurs outside the body in a laboratory setting, typically involving the extraction of eggs from the ovaries and combining them with sperm in a petri dish. Once fertilization is successful, the resulting embryos are transferred to the uterus for implantation
When a lady visits her Obstetrician, she may be advised Ultrasonography Scan at some stage in pregnancy. It is a frequently asked question as to how many scans should she undergo during pregnancy? When? Why? (for what purpose?). I have explained this in simplified manner. Ultrasonography is an ideal and safe screening tool in pregnancy.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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.
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
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdf
Mdcu Obstetrics Tutorial
1. MD Chula 2010
TUTORIAL IN
OBSTETRICS
รศ. น.พ. ศักนัน มะโนทัย
หนวยเวชศาสตรมารดาและทารกในครรภ
y
ภาควิชาสูติศาสตร-นรีเวชวิทยา คณะแพทยศาสตร
nl
จุฬาลงกรณมหาวิทยาลัย
O
email : manotaya@hotmail.com
se
U
Obstetrics
al
rn
¨ Overview & vital statistics
te
¨ ANC
¨ Early pregnancy complications
In
¨ Late pregnancy complications
¨ Intrapartum care
¨ Postpartum care
2. MD Chula 2010
Overview & vital statistics
¨ Maternal mortality rate
¤ Maternal death Per 100,000 LB
¤ Direct / Indirect / Nonmaternal
¨ Stillbirth rate (per 1,000 births)
y
¨ Neonatal death (per 1,000 LB) – early/late
nl
¨ Perinatal mortality rate
¤ Per 1,000 births
O
¨ Infant mortality rate
se
U
Antenatal care
al
rn
¨ Objective
te
¨ Routine care
¨ Common complaints
In
¨ High risk pregnancy
3. MD Chula 2010
Objective of ANC
¨ GA estimation
¤ LMP , PE , USG
¨ Identify high-risk pregnancy
¤ History , PE , Lab
y
nl
¨ Management
¨ Advice
O
¨ Appointment
se
U
al
Normal findings
rn
Naegele’s rule EDC = LMP – 3 mo. + 7 days (+1year)
Weight gain total 10-12 kg
te
trimester 1/5/5 kg
weekly 0.3-0.5 kg
In
Fundal height 12/16/20 1/3 , 2/3 , Θ
24/28/32 1/4 , 2/4 , 3/4 > Θ
Jimenez (cm) 18-32 weeks ( ± 2 cm)
Quickening nulliparous 18-20 wk
multiparous 16-18 wk
4. MD Chula 2010
General advice
First trimester Avoid drugs, X-ray, infection
Food intake
How to reduce N/V
Second trimester Food supplement
Common complaints
Third trimester Fetal movement count
y
Count-to-10
modified Sardovsky
nl
Braxton-Hicks
When to go to hospital
O
Any trimester Daily activity
Sex
seRest
Drug use
U
Common complaint
al
rn
Complaints Advice & Rx
N/V Diet – small, frequent meals
Reassure, time of improvement
te
Rx : dimenhydrinate, plasil
Constipation High fiber diet
In
Rx : fiber (Mucillin, Fybogel), senokot
Cramps Activity
Calcium supplement
Bleeding per gum Soft toothbrush, vitamin C
Uterine contraction Advice Braxton-Hicks
What is abnormal?
Leukorrhea (non itching) reassure
Numbness of hands reassure
Back pain reassure
5. MD Chula 2010
High-risk pregnancy
¨ ประวัติความผิดปกติในครรภกอนๆ
¨ ประวัติปจจุบันและโรคประจําตัว
¨ การตรวจรางกาย
y
¨ การตรวจครรภและการตรวจภายใน
nl
¨ การตรวจทางหองปฏิบัติการ
O
se
U
Risk Action
al
Age 35 yrs at EDC Genetic counseling
Screen DM
rn
Beware HT
Hx preterm birth Assess cause, prevention
te
Hx ectopic pregnancy R/O ectopic by USG
Obese, FHx of DM Screen GDM (50g GCT at 24-28 wk)
In
VDRL positive Confirm by TPHA or FTA-Abs
Benzathine Penicillin 2.4 MU IM weekly*3
HBsAg positive HBeAg – assess infectivity
HBIG for newborn, HBV vaccination
Rh negative Anti-D or ICT – sensitized/unsensitized
Husband - Rh
Unsensitized – RH Ig at 28-32wk, PP
Thalassemia carrier Identify high-risk couple -> PND
(MCV < 80 fl, HbA2 > 3.5%, HbE)
Rubella Ig – non-immune Postpartum vaccination (if desire more baby)
6. MD Chula 2010
y
nl
O
se
U
Early pregnancy complications
al
rn
¨ Abortion (miscarriage)
te
¨ Molar pregnancy
¨ Ectopic pregnancy
In
¨ Hyperemesis gravidarum
7. MD Chula 2010
Abortion
• 10-15% of clinical pregnancy
• Clinical term
– Threatened , incomplete , complete , missed
– Time/symptom sequence
y
• USG term
nl
– Anembryonic preg (Blighted ovum), embryonic death
• Management
O
– Expectant / Prostaglandins / Curettage
• Septic abortion
–
se
Antibiotics / Prevention of tetanus / Beware of septic shock
U
Ectopic pregnancy
al
rn
• 0.5-1 % , Tubal abortion vs Tubal rupture
Diagnosis
te
•
– Symptoms and signs
Pain by Hx/PE – cervical tenderness, rebound tenderness
In
•
• Bleeding – spotting
• Missed period – not always present
– Urine pregnancy test
– Ultrasound – absence of IUP, free fluid in CDS, adnexal mass
– Culdocentesis – unclotted blood
– Beta-hCG Beta-hCG vs USG / Rising level in 48 hours
– Laparoscopy
8. MD Chula 2010
Ectopic pregnancy
¨ Management
¤ Salpingectomy
¤ Conservative Sx of tubes
¤ Medical Rx (MTX)
y
¤ Laparoscopic Sx
nl
¨ Counseling
¤ Risk of recurrence
O
se
U
Hydatidiform Mole
al
rn
• Symptoms and signs
Bleeding 90%
te
–
– Size > Date 50%
Hyperemesis 20%
In
–
– PIH 25%
– Theca lutein cysts, Hyperthyroidism
– Passing molar vesicles
• Diagnosis
– High hCG level
– USG snow storm, vesicles
9. MD Chula 2010
Hydatidiform Mole
¨ Management
¤ Evacuation
n Suctioncurettage
n Hysterectomy
y
¤ Follow-up
nl
n Regression of hCG in 8-10 weeks
n Clinical, CXR
O
n Contraception at least 1 yr
se
U
Hyperemesis gravidarum
al
rn
• Definition
severe vomiting with
te
– weight loss, dehydration
In
– acid-base disturbance
– hypokalemia
• Management
– Dietary modification
– Supportive Rx
– Antiemetics
– Identify cause
10. MD Chula 2010
y
nl
O
se
U
Late pregnancy complications
al
rn
• Preterm labor
te
• PROM
• Hypertensive disorder
In
• IUGR (Intrauterine growth resttriction)
• Twins
• Placenta previa
• Hydramnios
• Postterm
11. MD Chula 2010
Preterm labor
¨ Definition
¤ GA 28-36 weeks
¤ Regular uterine contractions
¤ Cervical change , 2 cm, 80% effacement
¨ GA >= 34 weeks
y
¨ GA < 34 weeks
nl
¤ Look for contraindications for labor inhibition
¤ Dexamethasone 6 mg IM q 12 h for 4 doses
O
¤ Terbutaline/Salbutamol/Nifedipine/Indomethacin/MgSO 4
¤ Precautions for each tocolytic agent
se
U
PROM/PPROM
al
rn
¨ ROM before onset of labor cough test/nitrazine/Nile
blue/fern
te
¨ Cord compression / infection
¨ Term pregnancy
In
¤ Induction of labor / Cesarean / wait for 12 hr
¤ GBS prophylaxis in active labor if > 18 hr
¨ Preterm
¤ No PV,PR
¤ R/O infection
¤ Antibiotics to prolong latency
¤ Steroid if < 34 weeks
¤ GBS prophylaxis
12. MD Chula 2010
GBS prophylaxis
¨ Screening-based approach culture at 35-37 wk
¨ Risk-based approach
Ø preterm birth
Ø ROM > 18 hr
y
Ø intrapartum fever
nl
Ø GBS in urine culture
Ø Hx of GBS infection previous birth
O
¨ Ampicillin 2g IV then 1g IV q 4 h until delivery
(or vancomycin if allergic to penicillin)
se
U
Hypertensive disorder
al
rn
¨ Classification
te
¤ ChronicHT / PIH / PAH
¤ Gestational HT / Preeclampsia / Eclampsia
In
¨ Hypertension SP 140 mmHg or DP 90 mmHg
¨ Proteinuria 300 mg/24h or dipstick 1+
13. MD Chula 2010
สิ่งตรวจพบ Mild preeclampsia Severe preeclampsia
ความดันโลหิต นอยกวา 160/110 mmHg ตั้งแต 160/110 mmHg ขึ้นไป
โปรตีนในปสสาวะ นอยกวา 5 กรัม/วัน มากกวา 5 กรัม/วัน
(dipstick 1+ หรือ 2+) (dipstick 3+ หรือ 4+)
ปวดศีรษะ ไมมี มี
ตามัว ไมมี มี
จุกแนนลิ้นป ไมมี มี
Oliguria (<500 ml/24 h) ไมมี มี
y
ชัก ไมมี มี (eclampsia)
nl
Serum creatinine ปกติ สูงผิดปกติ
เกร็ดเลือด ปกติ ตากวา 100,000 ตอ มม.3
O
Liver enzyme ผิดปกติเล็กนอย ผิดปกติชัดเจน
ทารกโตชาในครรภ ไมมี มี
Pulmonary edema ไมมี
se มี
ACOG Recommendations based primarily on consensus and expert opinion (Level C)
U
al
Concept of Management
Delivery is always the best treatment for mother,
rn
but not always for the fetus
te
Severity Preterm Term
In
Mild Expectant Termination
ACOG Level C
recommendation
Severe ??? Termination
Eclampsia Termination Termination
14. MD Chula 2010
Mild preeclampsia
¨ Hospitalization, bed rest, sedation
¨ Laboratory tests to rule out severe disease,
HELLP syndrome
y
¨ Observe worsening clinical signs&symptoms
nl
¨ Monitor fetal well-being
Continue pregnancy until term, fetal distress,
O
¨
or severe preeclampsia develops.
se
U
Severe preeclampsia
al
rn
¨ Prevention of seizure
te
¨ Control of high blood pressure
In
¨ Termination of pregnancy
depending on GA
route
15. MD Chula 2010
Effects vs Serum Mg levels
4-7 mEq/L Anticonvulsant prophylaxis
(Therapeutic level)
8-10 mEq/L Loss of DTR
y
12 mEq/L Respiratory paralysis
nl
15 mEq/L Cardiac arrest
O
se
U
al
Magnesium sulfate
rn
Dosage 5 gm IV in 5 minutes
te
1-3 gm IV drip per hour until 24 h PP
Monitoring Urine output > 30 mL/h
In
DTR
Respiratory rate > 12 per minute
Antidote 10% Calcium gluconate 10 mL IV
16. MD Chula 2010
Severe hypertension in pregnancy
Definition
DP more than 110 mmHg
Why is it dangerous?
Intracranial hemorrhage / hypertensive
encephalopathy
Aim of Rx
y
DP 90-100 mmHg, SP 140-150 mmHg
nl
Treatment
First choice Hydralazine IV
O
Alternatives Nifedipine PO
Nicardipine IV
Labetalol IV
se
U
al
Severe Preeclampsia Remote from Term
rn
¨ GA >= 34 weeks
¤ Stabilize then TOP
te
¨ GA 32-34 weeks
In
¤ Stabilize
¤ Steroid to enhance fetal lung maturity
(option for lung maturity testing)
¤ Maternal & fetal evaluation
¤ TOP after 48 hours
17. MD Chula 2010
Severe Preeclampsia Remote from Term
¨ GA 24-32 weeks
¤ Stabilize
¤ Steroid toenhance fetal lung maturity
(option for lung maturity testing)
¤ Maternal & fetal evaluation
y
¤ TOP vs continuation of pregnancy under close
nl
surveillance
¨ GA <24 weeks
O
¤ Stabilize then termination
se Skip
U
Twins
al
rn
¨ Type dizygotic, monozygotic
te
dichorion, monochorion (DA, MA)
¨ Chorionicity sex, membrane, placenta
In
¨ MC Twin-twin transfusion
¨ F/U growth by USG q 2-4 weeks discordant twin
¨ Delivery vaginal if cephalic, bigger fetus first
second twin – internal podalic version
¨ Beware PPH
18. MD Chula 2010
y
nl
O
se
U
IUGR
al
rn
¨ Definition EFW < 10th centile
less than growth potential
te
¨ Type symmetrical
In
asymmetrical (small AC)
¨ Cause uteroplacental insufficiency
maternal (heart, SLE,….)
fetal (structural, chromosomal)
constitutional
19. MD Chula 2010
IUGR
¨ Asymmetrical IUGR oligohydramnios
grade 3 placenta
abnormal Doppler
¨ Rx identify type, cause
y
assess fetal wellbeing NST, BPP, Doppler
nl
steroid if < 34 weeks
USG FU growth
O
deliver if no growth, distress, term
se
U
Placenta previa
al
rn
¨ Type totalis / marginalis / lowlying
te
anterior / posterior
¨ Dx USG in 3rd trimester
In
painless bleeding in 3rd trimester
¨ Rx expectant if preterm, no severe bleeding
no PV, PR
steroid if < 34 weeks
tocolytics
20. MD Chula 2010
Placenta previa
¨ Cesarean if term or severe bleeding
M/G at least 4 units
Expert consultation
Counseling
y
Option for Classical C/S in anterior previa
nl
O
se
U
Abruptio placentae
al
rn
Symptoms & signs
te
¨ Frequent, strong, tetanic uterine contractions
¨ Vaginal bleeding +
In
¨ Severity severe FDU, board-like rigidity
moderate Fetal distress
mild Preterm labor
21. MD Chula 2010
Abruptio placentae
Rx
¨ Beware coagulapathy , M/G
¨ ARM to reduce pressure
¨ If FDU Vaginal delivery
y
distress Cesarean section
nl
O
se
U
Vasa previa
al
rn
¨ Risk factor velamentous insertion
twins
te
lowlying placenta
abnormal placenta
In
¨ Ruptured vasa previa ROM with blood-stained AF
fetal bradycardia
high fetal death rate
¨ Diagnosis suspicion
nucleated RBC/Apt/Kleihauer
¨ Prevention pulsation of vessel before ARM
22. MD Chula 2010
Postterm (GA>42+0 wk)
¨ Oligohydramnios / MAS / asphyxia
¨ Verify GA (wrong GA is the most common cause)
¨ If definite postterm -> terminate pregnancy
¨ Induction of labor vs Cesarean section
y
¤ Indicationfor CS
nl
¤ Bishop score
O
n FavorableCx (>=6) Induction
n Unfavorable Prostaglandin
se
U
Hydramnios
al
rn
¨ Definition AFI > 25 cm
te
DVP > 8 cm
¨ Cause idiopathic / DM / twins (TTTS)
In
fetal anomalies
¨ Rx 100g OGTT, detailed USG
amnioreduction if respiratory distress
¨ Labor beware abruption, prolapsed cord
beware PPH
23. MD Chula 2010
y
nl
O
se
U
Medical and surgical complications
al
rn
¨ Heart disease
te
¨ Acute pyelonephritis
¨ DM
In
¨ HT
¨ Acute appendicitis
24. MD Chula 2010
Heart diseases
¨ Physiologic changes CO
¨ Functional class and pathology
Eisenmenger complex, Severe AS, Severe MS
¨ Management
y
¤ Reduce cardiac load anemia, infection
nl
¤ According to FC , option for TOP
¤ Rheumatic -> AB , Congenital -> fetal echo
O
¤ Vaginal delivery, shorten 2 nd stage, IE prophylaxis
se
U
Acute pyelonephritis
al
rn
¨ Asymptomatic bacteriuria > 105 cfu/ml
te
¨ Dx fever, CVA tenderness, UA
3rd trim , right > left
In
¨ Rx
¤ Correct dehydration, beware septic shock
¤ Parenteral AB (Ampi / Genta / Cephalosporins)
¤ Beware preterm labor
¤ FU urine culture
25. MD Chula 2010
DM
¨ Pregestational DM vs Gestational DM
¨ Complications
GDM macrosomia, hydramnios,
hypoglycemia, hypocalcemia, ………
y
Overt anomaly
nl
¨ Screening (50g GCT) 140 mg/dl
O
Age/FHx/obese/macrosomia
anomaly/stillbirth/glycosuria
se
U
DM
al
rn
¨ Diagnosis (100g OGTT)
te
105/190/165/145 mg/dl
In
¨ GDM A1 vs GDM A2 fasting 105 / 2hPP 120
¨ Rx blood glucose monitoring, diet control
insulin sc
monitor fetus, mother
intrapartum PG 80-120 mg/dl
26. MD Chula 2010
Chronic HT
¨ 15-25 % incidence of superimposed
preeclampsia
¨ Work up Identify cause of HT
y
End-organ damage
nl
¨ Appropriate control of BP
O
¨ Close monitoring and early detection of
superimposed preeclampsia is important
se
U
Medical Rx of Chronic HT
al
rn
Aim of treatment DP 90-100 mmHg
te
Alpha-methyldopa drug of choice
In
ARB, ACE inhibitor contraindicated
Beta-blockers IUGR increases
27. MD Chula 2010
Acute appendicitis
¨ Location upward, more lateral
¨ More difficult to Dx
¨ DDx red degeneration of myoma
(Alder’s sign)
y
ovarian cyst with complications
nl
¨ Early explor. lap. in questionable case
O
se
U
al
rn
te
In
28. MD Chula 2010
Intrapartum care
¨ Routine care
¤ Oxytocin use , analgesia
¨ Dystocia
¨ Fetal distress (non-reassuring fetal status)
y
¨ Emergency
nl
¤ Prolapsed cord
¤ Eclampsia
O
¤ Shoulder dystocia
se
U
al
Initial Assessment of Parturients
rn
¨ GA Assessment
¤ Preterm, Term, Postterm
te
¨ Stage/Phase of labor
In
¤ 1st (Latent, Active) , 2nd , 3rd , Not in labor
¨ Pelvic assessment
¨ Low risk VS. High risk cases
¤ Maternal/Fetal wellbeing
29. MD Chula 2010
Monitoring of Parturients
¨ Fetal wellbeing
¤ AF color/volume, FHS auscultation, EFM
¨ Maternal wellbeing
¤ Pain
relief, hydration, psychological
y
support
nl
¨ Progression of labor
O
¤ Friedman’s curve
¤ Partogram se
U
al
rn
te
In
30. MD Chula 2010
y
nl
O
se
U
Dystocia
al
Nulliparous Multiparous
rn
Prolonged latent phase > 20 hr >14 hr
Active phase (maximum slope)
te
Protracted active phase dilatation < 1.2 cm/hr < 1.5 cm/hr
Secondary arrest of dilatation no progress for 2 hr no progress for 2 hr
In
Deceleration phase (8 cm to FD)
Protracted descent < 1 cm/hr < 2 cm/hr
Arrest of descent no progress for 1 hr no progress for 1 hr
Prolonged deceleration phase > 3 hr > 1 hr
Prolonged second stage > 2 hr > 1 hr
31. MD Chula 2010
Mx. of Prolonged Latent Phase
¨ Assess maternal wellbeing
¤ No obstetric and medical complications
¨ Assess fetal wellbeing
¤ EFM
y
¤ USG : normal AFI , no IUGR
nl
¨ Bed rest or Therapeutic rest
¨ Induction of labor
O
se
U
Mx. of Abnormal Active Phase
al
rn
¨ Assess Power-Passage-Passenger (3P)
te
¤ If CPD -> Cesarean section
In
¤ If Hypotonic contraction -> Oxytocin
¨ Supportive care e.g. IV fluid, Pain relief
¨ Careful fetal monitoring
¨ Reassessment after 2 hours
32. MD Chula 2010
y
nl
O
se
U
NST
al
EFM
rn
te
In
§ NST or EFM
§ Rate 1 or 3 cm/min
§ Baseline 120-160 bpm
§ Baseline variability 6-25 bpm
§ Periodic change
Acceleration 2 in 20 min,
15 bpm for 15 sec
Deceleration
35. MD Chula 2010
Fetal distress
(non-reassuring fetal status)
¨ Intrauterine resuscitation
¤ Off oxytocin
¤ Left lateral position
y
¤ Oxygen mask
nl
¤ Close fetal heart rate monitoring
O
¨ Immediate delivery if not improved by 15-20 min.
se
U
Shoulder dystocia
al
rn
¨ Call for help
te
¨ Suction
¨ deep episiotomy, bladder catheter
In
¨ Maneuver Suprapubic pressure
McRoberts’ maneuver
Wood’s corkscrew
deliver posterior shoulder
36. MD Chula 2010
Eclampsia - Severe Preeclampsia
¨ Airway maintenance
¨ Prevention of seizure / re-seizure
n Magnesium sulfate IV loading + drip
¨ Beware abruption , fetal distress
y
¨ Termination of pregnancy
nl
O
se
U
Prolapsed cord
al
rn
¨ How to prevent ARM
te
¨ Rx
¤ Assess fetal status USG, Doptone, cord pulse
In
¤ If alive fetus reduce cord compression
Trendelenburg position
push fetal head
fill bladder, tocolytics
emergency CS
¤ If FDU vaginal delivery
37. MD Chula 2010
Operative Obstetrics
¨ Cesarean section
¨ Forceps extraction
¨ Vacuum extraction
¨ Shoulder dystocia
y
¨ Amniotomy
nl
¨ Induction of labor
O
se
U
Amniotomy (ARM)
al
rn
¨ Timing early / late
¨ Precaution vasa previa / prolapsed card
te
abruption / infection
In
38. MD Chula 2010
Oxytocin
¨ Start dose 1-6 mu/min (2-12 drops/min)
¨ Half-life 3-5 min. Adjust dose q 20-30 min.
¨ Max dose 20-30 mu/min
y
¨ If tetanic contraction off, intrauterine resusc
nl
restart at half dose
O
se
U
Forceps extraction
al
rn
¨ Conditions to be fulfilled FD/MR/no CPD/2+/alive
te
¨ Indications prolonged/HT/heart/distress
prophylactic/preterm
In
¨ Instruments Simpson/Kielland/Piper
¨ Levels outlet/low/mid/high
¨ Steps pudendal block/empty bladder
orientate/apply/lock/FHS/trial
39. MD Chula 2010
Vacuum extraction
¨ Conditions to be fulfilled FD/MR/no CPD/2+/alive
¨ Indications prolonged/poor expulsion/DTA
¨ C/I preterm/HIV
¨ Instruments metallic cup/silastic cup
y
¨ Steps pudendal block/empty bladder
nl
apply/reduce pressure/trial
¨ Advantage autorotation (>45 o ,Deep transverse arrest)
O
less maternal injury
¨ Disadvantage longer duration / limited power
se
U
al
rn
te
In
40. MD Chula 2010
Postpartum care
¨ Routine care
¨ Postpartum hemorrhage
¨ Puerperal infection
y
nl
O
se
U
Puerperal infection
al
rn
¨ Puerperal morbidity 38 C x 2 in 10 days (excl first 24h)
te
¨ S&S
¤ Postpartum fever
In
¤ Pelvic pain, subinvolution
¤ Foul smell lochia
¤ Leucocytosis
¨ DDx UTI, atelectasis, breast engorgement
41. MD Chula 2010
Early postpartum hemorrhage (before 24 h)
¨ DDx atony / birth canal injury
ruptured uterus
¨ Rx M/G , IV fluid loading
atony uterine massage
y
oxytocin/methergin/sulprostone
nl
bimanual compression
hypogastric/uterine artery ligation
O
hysterectomy
birth canal repair with adequate exposure
se
U
al
rn
te
In