Shoulder dystocia occurs when the fetal shoulders become lodged at the maternal pelvis during birth, prolonging delivery. It represents an obstetric emergency. Risk factors include macrosomia, gestational diabetes, and prolonged labor. Management involves maneuvers like McRoberts position, suprapubic pressure, and rotational maneuvers to disimpact the shoulders. Complications for the baby include brachial plexus injury. Early diagnosis and treatment are important to prevent neonatal asphyxia. Simulation training is useful for practicing the management of shoulder dystocia.
Forceps delivery Guest lecture presented at thr West Zone YUVA FOGSI Udaipur in July 2018, Dfination, Clasification, Prerequisites, Indications, Contraindications, Complication Maternal and Fetal,
Prelabour Rupture of Membrane (PROM) by Sunil Kumar Dahasunil kumar daha
Please find the power point on Prelabour Rupture of Membrane (PROM). I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
“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.
Forceps delivery Guest lecture presented at thr West Zone YUVA FOGSI Udaipur in July 2018, Dfination, Clasification, Prerequisites, Indications, Contraindications, Complication Maternal and Fetal,
Prelabour Rupture of Membrane (PROM) by Sunil Kumar Dahasunil kumar daha
Please find the power point on Prelabour Rupture of Membrane (PROM). I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
“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.
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.
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
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
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.
2. Definition
Difficulty in delivery of fetal shoulders
Failure to deliver fetal shoulder without
utilizing facilitating maneuvers
Prolonged head-to-body delivery time
>60 seconds
Incidence: 0.2-3% of all live births;
represents an obstetric emergency
3.
4. Bilateral Shoulder
Dystocia
The posterior
shoulder is not in the
hollow of the pelvis.
This presentation
often requires a
cephalic
replacement.
8. D - Diabetes
O- Obesity
P- Post term pregnancy, prior large baby
E- Excessive weight gain during
pregnancy
No evidence based data:
Male
Short maternal stature
Abnormal pelvic shape/size
9. Unpredictable
25-50% have no defined risk factor!
50% of cases occur in infants whose birth
weight is <4000g
TURTLE SIGN: represented by the
retraction of the fetal head after expulsion,
may herald shoulder dystocia, shoulder
dystocia is not diagnosed until the usual
attempts at the delivery of the head fail.
10. Complications
Maternal
Hemorrhage
4th degree laceration
Fetal
Fx of humerus or clavicle
Brachial plexus injury (Erb’s/Klumpke’s
palsy)
Asphyxia/cord compression
Physician
Litigation: 11% of all obstetrical suits
11.
12. Management
Goal: Safe delivery before neontal
asphyxia and/or cortical injury
7 minutes!!!
Episiotomy
Suprapubic Pressure
McRoberts Maneuver
Woods or Rubin Maneuvers
Zavenelli
Push back the delivered fetal head into birth
canal and perform an emergent c/s
13. HELPERR Algorithm
H: Call for Help; Shoulder dystocia is
called if shoulders cannot be delivered
with gentle traction
E: Evaluate for Episiotomy: Not routinely
indicated; maybe needed when
attempting intra-vaginal maneuver
L: Legs (McRoberts): Hyperflexion and
abduction of hips—initial maneuver
14. P (Suprapubic Pressure): No fundal pressure; combination of
McRoberts and suprapubic pressure resolves most shoulder dystocias
Enter (Internal Maneuvers): oblique diameter rotational maneuvers
Woods screw (1943): Insert two fingers into posterior vagina and
apply pressure to the anterior aspect (clavicular) of the posterior
shoulder and abduct and rotate that shoulder, the posterior
shoulder could be rotated 180° degrees to the anterior, and this
would disimpact the obstructed anterior shoulder. The subsequent
addition of gentle downward traction with a contraction would then
result in delivery.
Rubin(1964): either the anterior or posterior shoulder, which ever
was more accessible, be adducted and brought toward the fetal
chest. Insert two fingers on the posterior aspect (scapular) of the
anterior or posterior shoulder and also rotate the baby 180° to
reduce the obstruction.
Remove: Delivery posterior arm
Roll the patient: Gaskin maneuver or all four positions
15. McRoberts Maneuver
42% success rate
+ Suprapubic pressure = 54-58%
Brings pelvic inlet and outlet into more vertical
alignment
Flattens sacrum
Cephalad rotation of pubic symphysis
Elevates anterior shoulder and flexes fetal spine
Increases IUP by 97%
Increases amplitude of contractions
+31N of pushing force
16. Preliminary Measures:
Gentle pressure on the fetal
vertex in a dorsal direction will move
the posterior fetal shoulder deeper
into the maternal pelvic hollow,
usually resulting in easy delivery of
the anterior shoulder.
Excession angulation (>45
degrees) is to be avoided.
(Gabbe, et al., Obstetrics: Normal and Problem
Pregnancies, Churchill Livingstone, New York, 1986)
18. Suprapubic Pressure
Moderate suprapubic pressure is often the
only additional maneuver necessary to disimpact
the anterior fetal shoulder. Stronger pressure can
only be exerted by an assistant.
(Gabbe, et al., 1986)
19. Oblique Diameter
Rotational Maneuver
Delivery may be facilitated by
counterclockwise
rotation of the anterior
shoulder to the more
favorable oblique pelvic
diameter, or clockwise
rotation of the posterior
shoulder.
During these maneuvers,
expulsive efforts should
be stopped and the head
is never grasped !!
20. Delivery of the
Posterior Arm
To bring the fetal wrist
within reach, exert
pressure with the index
finger at the antecubital
junction.
(E. Sandberg. American Journal of Obstetrics and Gynecology, 1985; 152: 481.)
22. Delivery of the
Posterior Arm
If less invasive
maneuvers fail to affect
this impaction, delivery
should be facilitated by
manipulative delivery of
the posterior arm by
inserting a hand into the
posterior vagina and
ventrally rotating the arm
at the shoulder with
delivery over the
perineum.
24. The Chavis Maneuver
Described in 1979.
A “shoulder horn” consisting of a
concave blade with a narrow handle is
slipped between the symphysis and the
impacted anterior shoulder.
This used like a shoe-horn as a lever
where the symphysis is the fulcrum.
25. The Hibbard Maneuver
Release of the anerior shoulder
is initiated by firm pressure
against the infant's jaw and neck
in a posterior and upward
direction. An assistant is poised,
ready to apply fundal pressure
after proper suprapublic
pressure
As the anterior shoulder slips
free, fundal pressure is applied,
and pressure against the neck is
shifted slightly toward the
rectum.
Proper suprapubic pressure is
continued.
26. The Hibbard Maneuver
Continued fundal and
suprapublic pressure
results in an upward-
inward rotation of the
newly freed anterior
shoulder and a further
descent in a position
beneath the pubic
symphysis.
27. The Hibbard Maneuver
As a result of the previous maneuvers,
the transverse diameter of the shoulders
is reduced.
Lateral (upward) flexion of the head
releases the posterior shoulder into the
hollow of the sacrum.
28. Fracture of the
Clavicle
The anterior clavicle is pressed against
the ramis of the pubis.
Care should be taken to avoid puncturing
the lung by angling the fracture
anteriorly.
Theoretically, a fracture of the clavicle is
less serious than a brachial nerve injury
and often heals rapidly.
29. The Zavanelli
Maneuver
First described in 1988
Consists of cephalic replacement and
then cesarean delivery.
Mixed reviews in the literature.
30. Summary
Cannot accurately predict
BE PREPARED!
Consider risk factors
Be prepared to perform various maneuvers
Diagnose and treat quickly
Obtain assistance from nursing staff and
NICU
31. Prophylactic
Cesarean?
Not recommended by ACOG
Exceptions:
Consider if…
>5000g in mother without DM
>4500g in mother with DM
32. Shoulder dystocia is well suited for
simulation training.
The obstetric birth simulator NOELLE
(Gammard Scientific, FL, USA) is one
such model.