This topic contains definition, incidence, types, causes, diagnosis, mechanism, management of occipito posterior position and deep transverse arrest and manual rotation of occipito posterior position
When fetal head is delivered, but shoulders are stuck and cannot be delivered it is known as shoulder dystocia.
The anterior shoulder becomes trapped behind on the symphysis pubis, whilst the posterior shoulder may be in the hollow of the sacrum or high above the sacral promontory.
When fetal head is delivered, but shoulders are stuck and cannot be delivered it is known as shoulder dystocia.
The anterior shoulder becomes trapped behind on the symphysis pubis, whilst the posterior shoulder may be in the hollow of the sacrum or high above the sacral promontory.
Cord prolapse is a frightening and life-threatening event that occurs in labor. Rapid identification and immediate appropriate response may well save the life of a neonate. Therefore, clinicians should be knowledgeable in its recognition and management.
This ppt is made by Mr. arkab khan pathan under guidance of Mrs. RAKHI GOAR. this ppt contain the detail and all the lecture notes of HEG.
THANK YOU.
Arkab khan
complcations of third stage of labour, includes PPH, Inversion of uterus, retained placenta, placenta accreta, increta, percreta, amniotic fluid embolism
Malpresentations are all presentations of
fetus other than vertex. Face presentation, brow presentation, shoulder presentation and breech presentation are common malpresentations.
Cord prolapse is a frightening and life-threatening event that occurs in labor. Rapid identification and immediate appropriate response may well save the life of a neonate. Therefore, clinicians should be knowledgeable in its recognition and management.
This ppt is made by Mr. arkab khan pathan under guidance of Mrs. RAKHI GOAR. this ppt contain the detail and all the lecture notes of HEG.
THANK YOU.
Arkab khan
complcations of third stage of labour, includes PPH, Inversion of uterus, retained placenta, placenta accreta, increta, percreta, amniotic fluid embolism
Malpresentations are all presentations of
fetus other than vertex. Face presentation, brow presentation, shoulder presentation and breech presentation are common malpresentations.
Fetal malpositioning & malpresentation can pose a serious threat to maternal & fetal well being. The document discusses the risks, complication, and management of some of the common malpresentation & malpositioning.
This topic contains Gametogenesis- oogenesis and spermatogenesis, ovulation, fertilization, development of fertilized ovum/ zygote, implantation, development of decidua, chorion and chorionic villi, development of inner cell mass.
This topic includes menstruation:- its definition, anatomical aspects- follicular growth and atresia, germ cells, premodial follicle; menstrual cycle/ ovarian cycle:- definition, phases- recruitment of groups of follicles (premature phase), selection of dominant follicle and its maturation, ovulation, follicular atresia; Endometrial cycle:- division of endometrium- basal zone, functional zone and its phases- stage of regeneration, stage of proliferation, secretory phase, menstrual phase, mechanism of menstrual bleeding, role of prostaglandins, hormones in relation to ovarian and menstrual cycle, ovulation, luteal-follicular shift, menstrual symptoms, menstrual hygiene, anovular menstruation, artificial postponement; cervical cycle, vaginal cycle and general changes in follicular and luteal phase.
This topic includes difference between female and male pelvis, various pelvis types, general description of pelvis bones, division of pelvis, landmarks of pelvis, plane, axis, sacral angle, diameters of inlet, cavity and outlet.
This topic includes Introduction for analgesia and anesthesia used in obstetrics, maternal risk factors for anesthesia, anatomical and physiological considerations, analgesia during labour and delivery, sedatives and analgesia, opioid analgesics, combination of narcotics and antiemetics, inhalation methods, commonly used local anesthesia in obstetrics, spinal anesthesia, infiltration anesthesia, patient controlled anesthesia, psychoprophylaxis, general anesthesia for cesarean section, complication of general anesthesia and its management.
This topic includes Introduction, common side effects from maternal medications on infants, guidelines for medication during lactation, effects of various medications on lactation and neonates
This topic contains anticonvulsants used in obstetrics such as magnasium sulphate, diazepam, phenytoin and anticoagulants such as heparin and warfarin.
It is from biochemistry subject and continuation of previous topic from organization of matter. This topic contains definition of Chemistry, Matter, Mass, Weight. Description of physical state of matter and chemical structure of matter.
link for previous topic: organization of matter- important terms
https://www.slideshare.net/priyankagohil10/organization-of-matter-important-terms-237314150
Vital statistics related to maternal health in indiaPriyanka Gohil
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This topic contains introduction of vital statistics, list of important statistics, birth rate, death rate, specific death rates, infant mortality rate, neonatal mortality rate, under five mortality rate, maternal mortality rate (detailed), perinatal mortality rate (detailed), expectation of life, general fertility rate and still births.
This topic contains Meaning and definitions of midwifery, obstetrics, obstetrical nursing, midwife, scope of midwifery, basic competencies of a midwife, history of midwifery in nursing and development of maternity services in India.
This topic contains definition, instruments, indications, contraindications, prerequisites, advantages, procedure, complications and hazards of ventouse or vaccum delivery.
Presentation on this topic is available on link đ
https://youtu.be/d_JgNiYv7eU
This topic contains detail about genital prolapse in pregnancy, It's definition, incidence, types, stages, causes, risk factors, clinical features, effect of prolapse, effect on pregnancy, effect during labour and puerperium, prevention, treatment and nursing management during pregnancy, labour and puerperium.
This topic contains definition, incidence, varieties, causes, risk factors, dangers, diagnosis, prognosis, prevention and management of inversion of uterus.
This topic contains detailed description regarding Normal puerperium, it's definition, duration, phases, involution of uterus and other pelvic organs, lochia, general physiological changes of puerperium, lactation, management of normal puerperium, management of ailments and postnatal care.
This topic contains detailed description about labour, its definition, date of onset of labour, calculations of date of delivery, causes of onset of labour, physiology of normal labour, and events, clinical course and management of each stages of labour.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2â3 criteria; moderate AUD: 4â5 criteria; severe AUD: 6â11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
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RESULTS: Overall life span (LS) was 2252.1Âą1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years â 64.8%, 20 years â 42.5%. 513 LCP lived more than 5 years (LS=3124.6Âą1525.6 days), 148 LCP â more than 10 years (LS=5054.4Âą1504.1 days).199 LCP died because of LC (LS=562.7Âą374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0âN12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0âN12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
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i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Taste
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 structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
micro teaching on communication m.sc nursing.pdfAnurag Sharma
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Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
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Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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, Ganongâs 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
2. MALPOSITION
â Malposition refers to any
position of the vertex other than the
flexed occipito-anterior one.â
OCCIPITO POSTERIOR POSITION
âIn a vertex presentation where
the occiput is placed posteriorly over
the sacroiliac joint, sacrum called
occipito-posterior postion.â
3. ⢠Occiput placed over:- Right sacroiliac
joint called RIGHT OCCIPITO
POSTERIOR
⢠Occiput placed over:- Left sacroiliac
joint called LEFT OCCIPITO
POSTERIOR
⢠Traditionally called 3rd and 4rh position
of the vertex.
4. ⢠Occiput placed over:- sacrum called
DIRECT OCCIPITO POSTERIOR
⢠All the three positions are Primary
(before the onset of labour ) or
Secondary ( developing after labour
starts )
5. ⢠In majority of cases (90 %), ANTERIOR
ROTATION of occiput occurs and
follows the course like that of an
occipito anterior position and it is
favorable position
⢠But as the posterior position
occasionaly gives rise to dytocia, it is
described along with malpositions
6.
7. INCIDENCE
⢠At onset of labour:- About 10 %
⢠Expected to be more during late
pregnancy and less during late second
stage of labour
⢠Right occipito posterior is 5 times more
common than the left occipito posterior
8. ⢠Dextro-rotation of the uterus and the
presence of sigmoid colon on the left,
disfavor Left Occipito Posterior
Position
⢠(Dextro-rotation is movement/rotation
to the right/ clockwise, opp. is
laevorotation)
10. ďą Shape of the pelvic inlet
ďMore than 50 % cases are associated
with the ANTHROPOID OR ANDROID
PELVIC
ďThe wide occiput can comfortably be
placed in the wider posterior segment
of the pelvis
11.
12. ďą FETAL FACTORS
ďMarked deflexion of the fetal head
ďCuases of deflexion:-
1. High pelvic inclination (gedree
of slopping)
2. Anterior attachment of placenta
3. Primary bradycephaly
13. ⢠High pelvic inclination
âInclination of brim is high and the
upper sacrum is relatively vertical
and convex
âOcciput will be placed to posterior
surface
14. ⢠Anterior attachment of placenta
âWell flexed attitude but convexity of
maternal and fetal spine is opposite,
which leads to deflexion of fetal head
and thus the occiput with occupy the
posterior part
15. ⢠Primary bradycephaly (flatened
area at back of the skull)
âDiminishes the effective movement
of flexion
16.
17. ďą Uterine factor
ďAbnormal uterine contraction which
may be cause or effect, lead to
persistent deflexion and occipito
posterior postion
19. ďą UMBILICAL GRIP
ďFetal limbs are more easily palpable near
the midline on either side
ďThe fetal back is felt far away from the
midline on the flank and often difficult to
outline clearly.
ďThe anterior shoulder lies far away from
the midline
20.
21. ďą PELVIC GRIP
ďHead is not engaged
ďSinciput not felt as in well flexed occipito
posterior
ďą AUSCULTATION
ďIntensity of fetal heart sound felt on the
flank and often difficult to locate
22. ďą VAGINAL EXAMINATION
ďElongated bag of membranes which is
likely to rupture during examination
ďSagital suture occupies any obligue
diameters of the pelvis
ďPosterior fontanelle felt near the sacroiliac
joint
ďAnterior fontanelle felt more easily
because of deflexion of the head, lower
than posterior fontanelle
23.
24. MECHANISM OF LABOUR
⢠IN FAVOURABLE:
â Flexion
â Internal rotation of the head (head 3/8 ant.,
shoulder 2/8): occupy RIGHT oblidue
diameter in ROP and LEFT obligue
diameter in LOP
â Further descent : as occipito anterior p.
â Restitution
â External rotation
â Birth of the shoulders and trunk
25. ⢠IN UNFAVOURABLE:
â Incomplete forward rotation: deep
transverese arrest
â Non rotation
â Malrotation
26.
27. ⢠Mechanism of âface to pubisâ delivery
â Further descent occurs until the root of the
nose
â Flexion occurs
â Restitution
â External rotation
â Persistant occipito-posterior
28. MANAGEMENT
⢠Early diagnosis
⢠Watchfull expectancy for decent and
anterior rotation
⢠Early cesarean section: Anticipating
prolonged labour, no progress of
labour, Persistant of deflexion and non-
rotation, Arrest labour, incoordinated
uterine contraction, fetal distress
29. MANAGEMENT OF ARREST OPP
1. Arrest in transverse / obligue occipito
posterior position:-
â Ventouse
â Alternative methods like mannual rotation
and extraction, cesarean section and
craniotomy
2. Occipitosacral arrest:-
â Forceps application followed by etraction
as face-to-pubis
â Liberal mediolateral episiotomy should be
30. DEEP TRANSVERSE ARREST
⢠The head is deep in to the cavity,
sagital suture is placed in the
transverse bispinous diameter and
there is no progress in descent of the
head even after 0.5 to 1 hour following
full dilatation of the cervix
32. DIAGNOSIS
⢠Head is engaged
⢠Sagital suture lies in transverse
bispinous diameter
⢠Anterior fontanelle is palpable
⢠Faulty pelvic architecture
33. MANAGEMENT
⢠If Vaginal delivery not safe: Cesarean
section
⢠If Vaginal delivery safe: ventouse,
mannual rotation, forcep rotation
34. MANNUAL ROTATION OF OPP
⢠The mannual rotation can be
accomplished with whole hand method
or with half hand method.
Steps:-
ďPut the patient under general anesthesia
ďProvide lithotomy position
ďMaintain full surgical asepsis
ďCatheterizaion should be done
ďIdentify direction of occiput by PV Exa.
35. ⢠WHOLE HAND METHOD:-
ďStep I: Gripping of the head
ďStep II: Rotation of the Head
ďStep III: Application of forceps
36. ďśStep I: Gripping of the head
ďIn ROP or ROT the Left hand and in LOP or
LOT the Right hand is usually used.
ďThe correctsponding hand is introduced
into the vagina in cone shapped manner
after seperating the labia by two fingers of
other hand.
37. ďIn Occipito transverse position, the four
fingers are pushed in the sacral hollow to
be placed over the posterior parital bone
and the thumb is placed over the anterior
parital bone.
ďIn oblique posterior position, four fingers
of patially supinated hand are placed over
the occiput and the thumb is placed over
the sinciput.
38. ďśStep II: Rotation of the head
ďSlight disimpaction may be needed for
good grip.
ďBy the movement of pronation of the hand,
the head is rotated to bring the occiput
anterior along the shortest route.
ďSimultaneouslty, the back of the fetus is
rotated by the external hand from the flank
to the midline.
39. ďThis is an essential prerequisite, for
anterior rotation of head.
ďA little over rotation is desirable
anticipating slight recurrence of
malposition before the application of
forceps.
40. ď In the Alternative
method, the four
fingers of the
pronated right hand
are placed over the
sinciput and the
thumb over the
occiput in ROP. The
head is rotated in the
supination movement
of the hand.
41. ďśStep III: Application of the forceps
ď Following Rotation, when the right hand is
placed over the left side of the pelvis, left
blade of the forcep is introduced.
ďWhen the left hand is used, it is placed on
the right side of the pelvis after rotation, as
such the right blade is to be introduced
first and the left blade is then to be
introduced underneath the right blade.
42. ďWhile introducing the blades, it is
preferable that an assistant fixes the head
by suprapubic pressure in a manner of
first pelvic grip.
ďAs it is a mid forceps application, axis
traction device should be used.
43. ďśDIFFICULTIES:-
ďFailure to grip the head adequetly due to
lack of space
ďFailure to dislodge the head from the
impacted position
ďInadequate anesthesia
ďWrong case selection
44. ďśDANGERS-
ďAccidental slipping of the head above the
pelvic brim and prolapse of the cord
ďą It is better to be perform cesarean section
in such a situation.
45. ⢠Half HAND METHOD:-
Steps:
ďThe rotation is done only by using the
right hand.
ďThe four fingers are introduced into the
vagina and tangential pressure is applied
on the head at the level of diameter of
engagement.
46. ďThe pressure is applied on the side and
the parietal eminence of the head.
ďIn ROP or ROTpositions, the fingers are
placed anterior to the head and the
pressure is applied by the ulnar border of
the hand.
ďIn LOP or LOT positions, the fingers are
placed posteriorly and the pressure is
applied by the radial border of the hand.
47. ďThe force is applied intermittently till the
occiput is placed behind the symphysis
pubis.