This document discusses malpositions during labor, specifically occipito-posterior position. It defines malposition as any position other than flexed occipito-anterior. Occipito-posterior position occurs when the occiput is placed posteriorly over the sacrum. It describes the types, incidence, causes, diagnosis, and management of occipito-posterior position. Management may involve expectant monitoring, assisted vaginal delivery techniques like manual rotation or vacuum extraction, or cesarean section if labor is not progressing.
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
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
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.
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.
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
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
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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.
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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.
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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
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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2. MALPOSITION
Malposition refers to any
position of the vertex other than the
flexed occipito-anterior one.
OCCIPITO POSTERIOR POSITION
In a vertex presentation where the occiput
is placed posteriorly over the sacroiliac
joint or directly over sacrum is called
occipito-posterior postion.”
3.
4. • 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, so it is described
along with malpositions
5.
6.
7. ⚫When the occiput is placed over right sacro iliac
joint it is called Right occipito-posterior(ROP)
/3RD vertex
⚫When the occiput is placed over left sacroilliac joint,
Left occipito -posterior(LOP) or also called 4th
position of vertex.
⚫When placed directly over sacrum, it is called
Direct occipito-posterior.
TYPES OF O-P POSITION
8. Right occipito posterior is 5 times more
common than the left occipito posterior
Dextro-rotation of the uterus and the presence of
sigmoid colon on the left, disfavor Left Occipito
Posterior Position
9. All the three positions can be:
• Primary - (before the onset of labor )
• Secondary - ( developing after onset of
labor
10. INCIDENCE
At onset of labour:- About 10 %
Expected to be more during late pregnancy and
less during late second stage of labour due to
spontaneous long anterior rotation of occiput.
12. Shape of the pelvic inlet
More than 50 % cases are associated
with the Anthropoid Or Android Pelvic
The wide occiput can comfortably be
placed in the wider posterior segment of
the pelvis
13.
14. FETAL FACTORS
Marked deflexion of the fetal head
Cuases of deflexion:-
1. High pelvic inclination
2. Anterior attachment of placenta
3. Primary brachycephaly
4. Pelvic tumors
15. • High pelvic inclination
–Inclination of brim is high due to
sacralization of lumbar vertebra and the
upper sacrum is relatively vertical and
convex
–Occiput will be placed to posterior
segment of pelvis
16. • Anterior attachment of placenta
–favors posterior position of occiput. But
convexity of maternal and fetal spine is
opposite, which leads to deflexion of
fetal head.
17. • Primary bradycephaly (flatened
area at back of the skull)
–Diminishes the effective movement of flexion
18. Uterine factor
Abnormal uterine contraction which may be
cause or effect, lead to persistent deflexion
and occipito posterior postion
20. On Palpation :-
Fundal height :- corresponds with period of
amenorrhoea.
Fundal grip : breech
Lateral grip:
• Fetal limbs are more easily palpable anteriorly
near the midline
• Fetal back is felt far away from the midline in
the flank and often difficult to outline clearly.
• Anterior shoulder lies far away from midline
21.
22.
23. Pelvic grip:
• Head is not engaged
• Sinciput is not felt as in well flexed occipito
anterior
On auscultation:-
FHS is often difficult to locate, heard on
the flank and iintensity is low
24. VAGINAL EXAMINATION
Finding depends upon degree of flexion of head.
Confirmation made during 2nd stage of labor:-
Elongated bag of membranes which is
likely to rupture during examination
Sagital suture occupies any obligue
diameters of the pelvis
Posterior fontanelle felt near the sacroiliac
joint
Anterior fontanelle is felt more easily
because of deflexion of the head at a level
lower than posterior fontanelle
25.
26. Sometimes the position is not recognized until
there is delay in the second stage of labour.
The diagnosis by vaginal examination may be
difficult due to the formation of caput over the
presenting part.
In this case the fingers may be passed higher to
feel the free margin of the ear which will point to
the occiput
27. MECHANISM OF LABOUR
• IN FAVOURABLE: Good uterine contraction
results in good flexion of head. normal descent occur up
to pelvic floor.
– Flexion and descent
– Long anterior Internal rotation of the head
(head 3/8 and shoulder 2/8)
– Further descent and delivery of head as
occipito anterior position
– Restitution
– External rotation
– Birth of the shoulders and trunk
28. COURSE OF LABOR
⚫Avg duration of both 1st& 2nd stage of labor is
increased.
⚫FIRST STAGE-
Engagement is delayed due to persistence of
deflexion of head and increased anterio- posterior
diameter of engagement
Driving force transmitted through the fetal axis is
not alignment with axis of inlet.
29. CONTD…
Early rupture of membrane occur as deflexed
head does not fit well in spherical LUS.
Abnormal uterine contraction
SECOND STAGE-delayed due to long internal or
due to malrotation , with at times arrest of head.
THIRD STAGE- increased incidence of postpartum
hemorrhage & trauma to genital tract due to long
emerging diameter
30. UNFAVOURABLE CASES:
Causes are-
Deflexion of the head
Weak uterine contraction
Flat sacrum
Prominent ischial spine
Convergent side walls
Weak pelvic floor muscles
Big baby
Early drainage of liquor
31. • IN UNFAVOURABLE CASES:
– Incomplete forward rotation: deep transverse
arrest
– Non rotation
– Malrotation: backward rotation (face to pubis
delivery or sacral arrest)
32.
33. • Mechanism of “face to pubis” delivery
– Further descent occurs until the root of the
nose
– Flexion occurs
– Restitution
– External rotation
34. Fate of
OPP OPP
Engaging diameter :- occipito-
frontal 11.5cm orsub-occipitofrontal
10cm.
Favorable (90%)
Unfavorable (10%)
3/8th rotation
occiput comes under
symphysis pubis (rt/lt
occipitoanterior)
Normal vaginal delivery
Mild deflexion Severe deflexion
Moderatedeflexion
Occiput rotate by
1/8th circle
Deep
transverse
arrest
Non-rotation
Oblique
posterior
arrest
Occiput rotate
posteriorly by 1/8th
POPP/ occipito-
sacral position
Face to pubis
delivery
Arrest
35. MANAGEMENT
• Early diagnosis
• Strict vigilance and watchful expectancy for
decent and long anterior rotation
• Early cesarean section: Anticipating prolonged
labour, no progress of labour, persistentce of
deflexion and non- rotation, Arrest labour,
incoordinated uterine contraction, fetal distress
36. Management of the first stage:
The 1st stage is managed as in a normal case.
Nothing can be done to correct the Malposition or to
influence the rotation of the head at this stage.
A partograph is maintained to monitor :Uterine
contraction (frequency, duration and strength), Fetal
heart and dilatation of the cervix.
37. CONTD…
If progressive cervical dilatation does not
occur augmentation with an oxytocin drip may be
tried.
If still no progress obtained in a few
hours caesarian section (C/S) is performed.
Also if there is fetal distress C/S is done
38. Management of the 2nd stage:
In most cases when uterine contractions are strong and the
woman is able to make good bearing down efforts the
occiput rotates forward and normal delivery takes place.
In other cases the baby may be delivered face-to-
pubes with out difficulty but there is a great risk of a
perineal tear.
In other cases there is failure of the presenting part to
rotate and descend and such cases delivered by C/S
or rotation can be enhanced by assistance .
39. Management Of Arrested Transverse / Obligue
Occipito Posterior Position
Ventouse- is suitable in cases where the pelvis is
adequate & non-rotation of the occiput due to
weak contraction or lack of tone of pelvic floor.
Alternative methods like manual rotation, forceps
rotation and extraction, cesarean section and
craniotomy
40. Occipito sacral arrest
⚫Below the
spine
Station of head
Above the
level of ischial
spine
C/S
Ventouse or
forceps with
deep
episiotomy
41. DEEP TRANSVERSE ARREST
• The head has descended deep in to the cavity up
to the level of ischial spines & sagital suture is
placed in bispinous diameter. There is no progress
in descent of the head even after 0.5 to 1 hour
even after full dilatation of the cervix
• It is only diagnosed during second stage of labor
and usually results in obstructed labor.
43. DIAGNOSIS
• Head is engaged
• Sagital suture lies in transverse bispinous
diameter
• Anterior fontanelle is palpable
• Faulty pelvic architecture
44. MANAGEMENT
• If Vaginal delivery not safe: Cesarean
section eg pelvic inadequacy, big baby
• If Vaginal delivery safe: ventouse,
mannual rotation, forcep rotation
and extraction
45. Management of DTA
DTA or oblique posterior
arrest
Assisteddelivery
Pelvis adequate Inadequate pelvis
-Manual rotation of occiput to
anteriorposition followed by forceps
extraction
- vacuum delivery
- forcepsrotation
Dead baby
Craniotomy
C/S
46. MANNUAL ROTATION OF OPP
• The mannual rotation can be
accomplished with whole hand method or
with half hand method.
Steps:-
Put the patient under general anesthesia
Provide lithotomy position
Maintain full surgical asepsis
Catheterizaion should be done
Identify direction of occiput by PV Exa.
47. • WHOLE HAND METHOD:-
Step I: Gripping of the head
Step II: Rotation of the Head
Step III: Application of forceps
48. Step I: Gripping of the head
In ROP or ROT the Left hand and in LOP or
LOT the Right hand is usually used.
The correctsponding hand is introduced into
the vagina in cone shapped manner after
seperating the labia by two fingers of other
hand.
49. In 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.
In oblique posterior position, four fingers of
patially supinated hand are placed over the
occiput and the thumb is placed over the
sinciput.
50. Step II: Rotation of the head
Slight disimpaction may be needed for
good grip.
By the movement of pronation of the hand,
the head is rotated to bring the occiput
anterior along the shortest route.
Simultaneouslty, the back of the fetus is
rotated by the external hand from the flank to
the midline.
51. This is an essential prerequisite, for
anterior rotation of head.
A little over rotation is desirable
anticipating slight recurrence of
malposition before the application of
forceps.
52. 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.
53. Step III: Application of the forceps
Following Rotation, when the right hand is
placed over the left side of the pelvis, left
blade of the forcep is introduced.
When 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.
54. While introducing the blades, it is
preferable that an assistant fixes the head
by suprapubic pressure in a manner of
first pelvic grip.
As it is a mid forceps application, axis
traction device should be used.
55. DIFFICULTIES:-
Failure to grip the head adequetly due to
lack of space
Failure to dislodge the head from the
impacted position
Inadequate anesthesia
Wrong case selection
56. DANGERS-
Accidental slipping of the head above the
pelvic brim and prolapse of the cord
It is better to be perform cesarean section
in such a situation.
57. • HALF HAND METHOD:-
Steps:
The rotation is done only by using the
right hand.
The four fingers are introduced into the
vagina and tangential pressure is applied
on the head at the level of diameter of
engagement.
58. The pressure is applied on the side and
the parietal eminence of the head.
In ROP or ROTpositions, the fingers are
placed anterior to the head and the
pressure is applied by the ulnar border of
the hand.
In LOP or LOT positions, the fingers are
placed posteriorly and the pressure is
applied by the radial border of the hand.
59. The force is applied intermittently till the
occiput is placed behind the symphysis
pubis.