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Practical Management of Labour
Arun Nagrath, Manjula Singh
CHAPTER 1:
Normal Labour
NORMAL LABOUR
ABNORMAL LABOUR
CALCULATION OF THE DATE OF LABOUR
THEORIES OF ONSET OF LABOUR
OXYTOCIC HORMONES
RELAXING HORMONES
MODULATING HORMONES
The Steroid Hormones (Oestrogens, Progesterone and Corticosteroids)
Oestrogens
Role of oestrogens during pregnancy
Progesterone
Cortisol
THE ONSET OF LABOUR
Signs of Onset of Labour
PAINFUL UTERINE CONTRACTIONS (Labour Pains)
SLIGHT UTERINE HAEMORRHAGE—THE “SHOW”
COMMENCING DILATATION OF THE INTERNAL OS
FORMATION OF THE “ BAG OF WATERS”
STAGES OF LABOUR
First Stage
Second Stage
Third Stage
STAGE OF DILATATION OF THE CERVIX
DURATION OF FIRST STAGE OF LABOUR
SECOND STAGE OR STAGE OF EXPULSION OF THE FoETUS
BEARING DOWN PAINS
PERINEOTOMY
THIRD STAGE OR EJECTION OF THE AFTERBIRTH
SIGNS OF PLACENTAL SEPARATION
THE ANATOMY AND PHYSIOLOGY OF THE FIRST STAGE AND SECOND STAGE OF LABOUR
THE MATERNAL PASSAGES
THE BRIM Syn: Pelvic brim, inlet, upper pelvic strait
INCLINATION OF THE PLANE OF BRIM
AXIS OF THE BRIM
DIAMETERS OF THE PELVIC BRIM
Antero-posterior Syn: Conjugate, obstetrics conjugate, true conjugate
TWO OBLIQUE DIAMETERS
TRANSVERSE DIAMETER
THE OBSTETRICAL OUTLET OR LOWER PELVIC STRAIT
ANATOMICAL OUTLET
NARROW PELVIC PLANE
PELVIC CAVITY
MID-PLANE
Boundaries
Diameters
ANATOMICAL AXIS OF THE PELVIS OR CURVE OF CARUS
OBSTETRICAL PELVIC AXIS
THE FOETUS
THE DISPOSITION OF THE FOETUS
DIMENSIONS OF THE OVOID OF THE FOETUS
LIE
PRESENTATION
Presenting Part
Cephalic Presentation
Breech Presentation
Position
Variety
Nomenclature
The Shoulder Presentation
Frequency of the Various Presentations and Positions
REASONS FOR PREDOMINENCE OF CEPHALIC PRESENTATIONS AND THEIR CLINICAL SIGNIFICANCE
THE FOETAL SKULL
BONES OF THE SKULL (VAULT)
FONTANELLES
Anterior Fontanelle or Bregma (Fig. 1.25)
Posterior Fontanelle
VERTEX
ENGAGEMENT
Diameter of Engagement (Table 1.1)
THREE TRANSVERSE DIAMETERS OF THE HEAD ARE DESCRIBED (Fig. 1.29)
THE CIRCUMFERENCE OF THE HEAD
THE LIQUOR AMNII
FORCES OF LABOUR
MUSCULAR CONTRACTIONS
THE PARTURIENT UTERUS
As Labour Advances
THE LOWER UTERINE SEGMENT AND THE CERVIX
PHYSIOLOGICAL RETRACTION RING
THE RETRACTING UTERINE WALL
PATHOLOGICAL RETRACTION RING OR THE RING OF BANDLE
DILATATION OF THE LOWER SEGMENT AND THE CERVIX IS BROUGHT ABOUT BY
GENERAL EFFECTS OF LABOUR
On the Foetus
On the Mother
THE MECHANISM OF NORMAL LABOUR
THE PRESSURE EXERTED BY THE UTERUS
ASYNCLITISM OR PARIETAL OBLIQUITY
ANTERIOR ASYNCLITISM, ANTERIOR PARIETAL OBLIQUITY OR NAEGELE'S OBLIQUITY
POSTERIOR ASYNCLITISM, POSTERIOR PARIETAL OBLIQUITY OR LITZMANN'S OBLIQUITY
CARDINAL MOVEMENTS OF LABOUR
ENGAGEMENT
DESCENT
FLEXION
INTERNAL ROTATION
EXTENSION
RESTITUTION
EXTERNAL ROTATION
EXPULSION
CHANGES IN THE SHAPE OF THE FOETAL HEAD MOULDING (Fig. 1.39)
Pathological Moulding
CAPUT SUCCEDANEUM
SECONDARY CAPUT SUCCEDANEUM
MANAGEMENT OF LABOUR
GENERAL CARE OF THE MOTHER
BENEFITS OF LIQUID DIET
PAIN
GENERAL CONDITION
ANTISEPTICS AND ASEPSIS IN CONDUCT OF LABOUR
Instruments
CARE OF THE PATIENT
PREPARATION OF THE VULVA
DIAGNOSIS
IDENTIFICATION OF LABOUR
CONTRACTIONS OF TRUE LABOUR
CONTRACTIONS OF FALSE LABOUR
DIAGNOSIS OF PRESENTATION AND POSITION OF THE FOETUS
ABDOMINAL PALPATION
Leopold'S Manoeuvres
FIRST PELVIC EXAMINATION (Fig. 1.42)
SECOND PELVIC EXAMINATION (Fig. 1.43)
FUNDAL PALPATION (Fig. 1.44)
LATERAL PALPATION (Fig. 1.45)
VAGINAL EXAMINATION
AUSCULTATION OF THE FOETAL HEART SOUNDS
POINT OF MAXIMUM INTENSITY OF FOETAL HEART SOUNDS (Fig. 1.49)
ULTRASONOGRAPHY
DIAGNOSIS OF THE PROGRESS OF LABOUR
Precautions
Signs
Pervaginal Examination
THE BIRTH OF THE FOETUS (Fig. 1.50)
Delivery of the Head
Support of the Perineum
RITGEN'S MANOEUVRE
DELIVERY OF THE SHOULDERS
TIMING OF CORD CLAMPING
ANATOMY AND PHYSIOLOGY OF THE THIRD STAGE OF LABOUR
Shultze Method (Fig. 1.53)
Mathews-Duncan Method (Fig. 1.54)
ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR (Fig. 1.55)
THE BRANDT-ANDREWS TECHNIQUE
THE MODIFIED BRANDT-ANDREWS TECHNIQUE
THE CREDÉ’S METHOD
DISADVANTAGES
CHAPTER 2:
Foetal and Maternal Monitoring during Labour
FOETAL MONITORING DURING LABOUR
METHODS OF FOETAL MONITORING
Clinical
Recording of Progress of Labour
ALERT LINE/ACTION LINE (Fig. 2.2)
The Levels of Foetal Head
Uterine Contractions
Biophysical Indicators of Foetal Asphyxia
Instruments
Requirements (As given in clinical monitoring)
Disadvantages of Periodic Auscultation
Continuous Electronic Foetal Heart Rate Recording
Methods of Recording
Internal or Direct
Advantages
Disadvantages
External or Indirect
Components of Foetal Heart Rate Tracing
Baseline Foetal Heart Rate
Definition
Baseline Bradycardia
Causes of Tachycardia
Prognosis
Bradycardia
Causes
Prognosis
BASELINE VARIABILITY OF THE FOETAL HEART RATE
PERIODIC CHANGES IN THE FOETAL HEART RATE
Accelerations
Interpretation
Decelerations
Classification
Management
Variable FHR Deceleration
Characteristics
Prognosis
Mechanism
Management
Characteristics of a Reassuring FHR Pattern
Characteristics of Ominous FHR Patterns
Characteristics of a Non-reassuring FHR Pattern
BIOCHEMICAL INDICATORS OF FOETAL ASPHYXIA
Definition
Normal Changes in Biochemical Indicators
Indications for Performing Foetal Scalp pH
Technique
Interpretation of Findings
MANAGEMENT OF NON-REASSURING FHR PATTERNS DURING LABOUR
ROLE OF ULTRASOUND IN FOETAL MONITORING
Placentography
Gestational Age
ROLE OF RADIOGRAPHY
Presentation, Position, Station
MATERNAL MONITORING DURING LABOUR
Latent Phase
Active Phase
Deceleration Phase
Abnormalities of Labour
Abnormalities of Expulsive Forces
Hypotonic Dysfunction
Hypertonic Dysfunction
Abnormalities Related to the Passenger—The Foetus
Normal Diameters of Bony Pelvis
Diameters of the Foetal Head
Cephalopelvic Disproportion
Signs of CPD
Hillis-Müller Test
Pelvimetry Suggestive of CPD
MANAGEMENT OF THE ABNORMALITIES OF THE ACTIVE PHASE ASSESS
CHAPTER 3:
Prolonged Labour
DEFINITION
FUNCTIONS OF THE MEMBRANES
INCIDENCE OF PROLONGED LABOUR
MATERNAL AND FOETAL MORTALITY
AETIOLOGY
First Stage
Second Stage
MANAGEMENT OF PROLONGED LABOUR
General Care
Specific Treatment
OXYTOCIN
Operative Treatment
FOETAL CAUSES OF PROLONGED LABOUR
Foetal Macrosomia
SHOULDER DYSTOCIA
Other Method
HYDROCEPHALUS
Diagnosis
Prognosis
Management
In After Coming Head
ANENCEPHALY
Diagnosis
Management
CHAPTER 4:
Abnormal Uterine Action
TYPES OF ABNORMAL UTERINE ACTION
Hypotonic Uterine Dysfunction
Hypertonic Uterine Dysfunction
Incoordinate Uterine Dysfunction
Normal Polarity
Hypotonic Uterine Dysfunction
Primary Hypotonic Uterine Inertia
Aetiology
Diagnosis
Management
General Management
Specific Management to Avoid Infection
Stimulation of the Uterus with Oxytocin
Operative Method
Secondary Uterine Inertia
Aetiology
Diagnosis
Treatment
Hypertonic Uterine Dysfunction (Action is too strong)
Precipitate Labour
Risks
Treatment
Obstructed Labour
Abnormal Polarity (Incoordinate Action)
Treatment
Localized Tonic Contraction (Schroeder's Ring)
Treatment
In the First Stage
In the Second Stage
Generalised Tonic Contraction (Uterine Tetany)
Aetiology
Clinical Features
Treatment
Conservative Management
Operative Treatment
Cervical Dystocia (Rigidity)
Primary, Functional or Spasmodic Rigidity
Treatment
Secondary Rigidity or Organic Rigidity
Treatment
CHAPTER 5:
Preterm Labour
INCIDENCE
PATHOGENESIS
DIAGNOSIS OF PRETERM LABOUR
Identification of Patient at Risk for Preterm Labour
Detection of Early Warning Signs of Preterm Labour
Diagnosis of Established Preterm Labour
MANAGEMENT OF PRETERM LABOUR
Maternal Conditions
Fetoplacental
MANAGEMENT
Aims
Prevention
TO ARREST PREMATURE LABOUR (With Warning Signs)
ISOXSUPRINE
Side Effects
CALCIUM CHANNEL BLOCKERS
Nifedipine
MAGNESIUM SALTS
PROGESTERONE
ETHANOL
DRUGS UNDER INVESTIGATION
Orciprenaune (Alupent)
Mensuprine Hydrochloride
Diazoxide (Hyperstat)
Hydroxyphenyl Isopropyl Arterenol CC25
Short-term Therapy
Long-term Therapy
Glucocorticoid Therapy
MANAGEMENT OF PREMATURE LABOUR
Principles
First Stage of Labour
Second Stage of Labour
CHAPTER 6:
Premature Rupture of Membranes
DEFINITION
AETIOLOGY AND PATHOGENESIS
DIAGNOSIS
MATERNAL AND FOETAL PROBLEMS ASSOCIATED WITH PROM
MANAGEMENT
TECHNIQUE OF AMNIOINFUSION
PATIENTS WITH OVERT INFECTION
DETERMINATION OF GESTATIONAL AGE
MANAGEMENT OF THE PATIENTS WITH PROM AFTER 36 WEEKS
PATIENTS WITH PROM BETWEEN 32 WEEKS AND 36 WEEKS
PATIENTS WITH PROM BETWEEN 26 WEEKS AND 32 WEEKS
PATIENTS WITH PROM BEFORE 26 WEEKS
OTHER METHODS WHICH ARE STILL UNDER INVESTIGATION
CHAPTER 7:
Obstructed Labour
MORBID CHANGES DUE TO OBSTRUCTION
TREATMENT OF CONTRACTED PELVIS WITH RISING BANDL'S RING
TUMOURS OF THE PELVIC BONE
OVARIAN TUMOURS
TUMOURS OF THE UTERUS
Undilatable Stenosis of the Cervix and Vagina
PRIMARY OR FUNCTIONAL RIGIDITY
SECONDARY RIGIDITY
FOETAL CONDITION
MANAGEMENT
HYDROCEPHALUS
FOETAL ABDOMINAL ENLARGEMENT
TUMOURS OF THE LUMBOSACRAL OR BUTTOCK REGION OF THE FOETUS
CONJOINED TWINS
ANENCEPHALY
EFFECTS ON MOTHER
EFFECT ON THE FOETUS
CHAPTER 8:
Complications of Third Stage of Labour
DEFINITION
PHYSIOLOGY OF PLACENTAL SEPARATION
SCHULTZE METHOD
MATHEW-DUNCAN METHOD
When the Placenta has Separated Fully
PRIMARY PPH
CAUSES OF ATONIC PPH
Factors Present during Pregnancy
Factors during and after Labour
Retention of Part or Whole of the Placenta
CAUSES OF TRAUMATIC DELIVERY
THIRD STAGE HAEMORRHAGE
PPH before the Delivery of the Placenta
Diagnosis
PROPHYLAXIS OF PPH
TREATMENT
IF BLEEDING IS FROM A LACERATION
BLEEDING FROM PLACENTAL SITE
PLACENTA STILL WITHIN THE UTERUS
IF PLACENTA HAS NOT SEPARATED
SIGNS OF PLACENTAL SEPARATION
METHODS FOR PLACENTAL EXPRESSION
Brandt-Andrews Technique
MODIFIED BRANDT-ANDREWS METHOD (CONTROLLED CORD TRACTION, CORD TRACTION AND UTERINE COMPRESSION)
THE CREDÉ’S METHOD OF ABDOMINAL EXPRESSION OF THE PLACENTA FROM THE UTERUS
BLEEDING AFTER THE EXPULSION OF THE PLACENTA
SECONDARY PPH
Bleeding after 24 Hours of the Delivery
Treatment
Complications after PPH
RETAINED PLACENTA
Signs of Placental Separation
Retention of a Completely Separated Placenta
Uterine Inertia
Treatment
Treatment
ADHERENT PLACENTA
Simple Adhesions
Morbid Adhesions
Abnormal Adherence of the Placenta may Involve
Aetiology of Placenta Accreta
Clinical Course of Placenta Accreta
Treatment
Complications of Morbid Adherence
Complications of Manual of Removal of the Placenta
DEFINITION
VARIETIES
TYPES
Acute Inversion
Spontaneous Inversion
Induced Inversion
Chronic Inversion
Idiopathic Inversion
SIGNS AND SYMPTOMS
SHOCK IN ACUTE INVERSION IS OUT OF PROPORTION TO THE AMOUNT OF BLEEDING
Chronic
On Examination
In Acute Cases
Chronic Inversion
Diagnosis
Prognosis
Treatment
TREATMENT WHEN THE PATIENT HAS BEEN TRANSFERRED TO HOSPITAL
MANIPULATIVE REPLACEMENT
HYDROSTATIC REPLACEMENT: O’ Sullivan
CASES IN WHICH REPLACEMENT BY VAGINAL MANIPULATION FAILS
Palliative Treatment
Surgical Treatment
Abdominal Procedures
Vaginal Procedures
Haultaim's Method
Vaginal Technique
Küstner's Technique
Spinelli's Operation
Vaginal Hysterectomy
CLASSIFICATION OF SHOCK
I. HYPOVOLAEMIC SHOCK
A. Haemorrhagic Shock
Management
• Monitoring various parameters
• Objectives of Treatment
• Aims of Treatment
General Antishock Measures
Restoring Circulating Blood Volume
Improving Myocardial Contractility
Correction of Hypoxia, pH and Electrolyte Disturbance
Drugs Reducing Ventricular Afterload
Miscellaneous Drugs
Treatment of Underlying Cause
Coagulation Failure
Causes
Clinical Manifestations
Investigations
Treatment
SEPTIC SHOCK (syn. Endotoxic shock, Bacteraemic Shock)
Aetiology
Bacteriology
Mechanism
Investigation
Management
NEUROGENIC SHOCK
Treatment
Treatment of Underlying Cause
Postpartum Haemorrhage
Antepartum Haemorrhage
CHAPTER 9:
Managing Labour in High Risk Cases
HYPERTENSIVE DISORDERS IN PREGNANCY
TYPES
HOSPITALIZATION
TERMINATION
MANAGEMENT OF LABOUR
First Stage
Second and Third Stage
EClAMPSIA
INCIDENCE
ONSET OF FITS
CLINICAL FEATURES
MANAGEMENT
HOSPITAL TREATMENT
General Management
Specific Management
MAGNESIUM SULPHATE REGIME (PRITCHARD)
DIAZEPAM THERAPY (LEAN)
ANTIHYPERTENSIVES AND DIURETICS
MANAGEMENT DURING FIT
STATUS EPILEPTICUS
CONDUCT OF LABOUR
TREATMENT OF COMPLICATIONS
Pulmonary Oedema
Heart Failure
Psychosis
CHRONIC HYPERTENSION IN PREGNANCY
Definition
Essential Hypertension in Pregnancy
MANAGEMENT
General Management
Obstetrical Management
Mild Cases
Severe or Complicated Cases
MEDICAL DISORDERS IN PREGNANCY
ANAEMIA IN PREGNANCY
RISK PERIODS
TIME OF ADMISSION
MANAGEMENT OF LABOUR
HEART DISEASE IN PREGNANCY
GRADES (as per New York Heart Association)
ADMISSION
RULE OF FIVE
CARE DURING LABOUR
First Stage
Second Stage
Third Stage
DIABETES IN PREGNANCY
HOSPITALIZATION
TERMINATION OF PREGNANCY
METHOD OF TERMINATION
CAESAREAN SECTION
Indications
Method
CONDUCT OF LABOUR
First Stage
Second and Third Stage
CARE OF THE BABY
PUERPERIUM
PULMONARY TUBERCULOSIS IN PREGNANCY
PATIENT IN ACTIVE PHASE
PATIENT IN INACTIVE PHASE
CARE DURING LABOUR
PYELONEPHRITIS IN PREGNANCY
Delivery in Patients with Renal Disease
During Labour
Labour in Patients with Known Renal Disease
POLYHYDRAMNIOS
TERMINATION OF PREGNANCY
No Foetal Malformation
Foetal Malformation
MANAGEMENT DURING LABOUR
INTRAUTERINE GROWTH RETARDATION
First Stage
Second Stage
RH IMMUNIZATION
PLAN OF DELIVERY
CONDUCT OF LABOUR
CAESAREAN SECTION
SPECIAL CASES
POSTCAESAREAN PREGNANCY
Hospitalization
CAESAREAN SECTION
Indications
VAGINAL DELIVERY
Indications
CONDUCT OF LABOUR
ELDERLY PRIMIGRAVIDA
During Pregnancy
During Labour
GRAND MULTIPARA
During Pregnancy
During Labour
HIV INFECTION IN PREGNANCY
ANTENATAL MANAGEMENT
INTRANATAL MANAGEMENT
PRECAUTIONS DURING SURGERY
PRECAUTIONS TAKEN DURING LABOUR
FOLLOWING GUIDELINES ARE ALSO USEFUL
DECONTAMINATION OF THE LABOUR ROOM/ OPERATION THEATre
Disposal of Wastes
Liquid Wastes
Sharp Objects
Nonsharp Disposable Waste
Placenta or Abortus or Dead Foetus
Reusable Items
Metal Instruments
Drapes and Linen
Others
GYNAECOLOGICAL DISORDERS COMPLICATING PREGNANCY
FIBROID WITH PREGNANCY
Effect on Pregnancy
Effect on Labour
Effect on Puerperium
Management
During Pregnancy
During Labour
PROLAPSE WITH PREGNANCY
Effect of Prolapse
Effect on Pregnancy
During Labour
During Puerperium
Symptoms
Treatment
During Pregnancy
During Labour
Puerperium
Carcinoma Cervix with Pregnancy
Effect of Pregnancy on Carcinoma Cervix
Effect of Carcinoma Cervix on Pregnancy
Diagnosis
Investigation (Pap Smear)
Treatment
Early Invasive Cancer
Inoperable Stage
Labour
CHAPTER 10:
Postmaturity
FINN BOE'S CRITERIA FOR POST-TERM PREGNANCY
Aetiology
EFFECTS OF POSTMATURITY ON PREGNANCY
FETAL COMPLICATIONS
Clinical Features
Diagnosis
Investigations
Management of Postmaturity
CHAPTER 11:
Intrauterine Foetal Death
CHAPTER 12:
Occipitoposterior Position
AETIOLOGY
Incidence
Normal Mechanism
Abnormal Mechanism
INFLUENCE OF THE PELVIC SHAPE
ANTHROPOID PELVIS
ANDROID PELVIS
DYSTROPHIA DYSTOCIA SYNDROME
DIAGNOSIS
Last Weeks of Pregnancy before the Onset of Labour
After Commencement of Labour
As Labour Proceeds on P/V
If Labour is Well Advanced
Radiography
Mechanism of Labour
In Favourable Circumstances (90%)
In Unfavourable Circumstances (10%)
Causes
Mechanism
COURSE OF LABOUR
First Stage
Second Stage
Third Stage
TREATMENT
Treatment during Labour
MANAGEMENT DURING FIRST STAGE OF LABOUR
MANAGEMENT OF SECOND STAGE OF LABOUR
MANAGEMENT OF THE THIRD STAGE OF LABOUR
TREATMENT OF THE CERVIX AT OR NEAR FULL DILATATION
STEP I
STEP II
STEP III
CAUSES OF FAILURE OF ROTATION
Rotation of the Shoulder
FORCEPS ROTATION
Alternative Method
DEEP TRANSVERSE ARREST
Causes
Management
CHAPTER 13:
Face Presentation
INCIDENCE AND AETIOLOGY
TYPES OF PRESENTATIONS
CAUSES
FOUR POSITIONS
Denominator: Chin (Fig. 13.1)
ATTITUDE
DIAGNOSIS
Later Weeks of Pregnancy and Prior to Labour
After Commencement of Labour
Palpation
Mentoposterior Position
Mentoanterior
Mentolateral
AUSCULTATION
VAGINAL EXAMINATION
PROGNOSIS
Mother
Foetus
MECHANISM OF LABOUR
ENGAGEMENT
DESCENT
INTERNAL ROTATION
FLEXION
RESTITUTION
EXTERNAL ROTATION
EXPULSION
MANAGEMENT
MANAGEMENT
Antenatal Period
Schat's Manipulation
Following Onset of Labour
Mentoanterior Position
Mentoposterior Position
MENTOLATERAL IMPACTION
Labour is Allowed to Run its Course but not Preferred
Internal Manipulation
Rotation of the Chin Anteriorly
Caesarean Section
IMPACTED MENTOPOSTERIOR POSITION (Fig. 13.6)
CHAPTER 14:
Brow Presentation
INCIDENCE
AETIOLOGY
DIAGNOSIS
PROGRESS OF LABOUR
MANAGEMENT
In Early Labour
Attempt to Correction to a Vertex Presentation
Steps
Attempt to Correction to a Face Presentation
In Late Labour
Caesarean Section
CHAPTER 15:
Breech Presentation
TYPES OF BREECH
Incidence
Causes
DIAGNOSIS
Clinical Diagnosis
RADIOLOGICAL DIAGNOSIS
ULTRASONOGRAPHY
DIFFERENTIAL DIAGNOSIS
MECHANISM OF LABOUR
Frank Breech (Fig. 15.5)
Delivery of Breech
Delivery of Shoulders
Delivery of Head
PRINCIPAL FACTORS INFLUENCING FOETAL MORTALITY
DANGERS OF BREECH DELIVERY
ANTENATAL MANAGEMENT
MANAGEMENT DURING LABOUR
UNCOMPLICATED BREECH LABOUR
First Stage
Second Stage
Step I
Step II
Step III
Step IV
Burns-Marshall Method (Fig. 15.7)
Jaw Flexion and Shoulder Traction (Fig. 15.8)
DELIVERY OF THE AFTERCOMING HEAD WITH FORCEPS (Figs 15.9 and 15.10)
ADVANTAGES OF FORCEPS
Protects the Head
MANAGEMENT OF COMPLICATED BREECH
ARREST OF BUTTOCKS AT THE BRIM
MANAGEMENT
ARREST OF THE BUTTOCKS AT THE OUTLET
MANAGEMENT
GROIN TRACTION (Fig. 15.11)
Precaution
BRINGING DOWN THE LEGS
IF LEGS ARE FLEXED (Figs 15.12 and 15.13)
WHEN THE LEGS ARE EXTENDED (PINARD'S)
IF THE UTERUS IS RETRACTED ROUND THE FOETUS
DIFFICULTY IN DELIVERY OF SHOULDERS AND HEAD (EXTENSION OF ARMS)
MANAGEMENT
CLASSICAL METHOD
LOVSET'S MANOEUVRE (Figs 15.18 and 15.19)
NUCHAL DISPLACEMENT
ARREST OF THE HEAD
Causes
MANAGEMENT
CHAPTER 16:
Transverse or Oblique Lie
POSITION
INCIDENCE
AETIOLOGY
Maternal Causes
Uterus
Foetal Causes
Pelvis
DIAGNOSIS
Inspection
Palpation
Fundal Palpation (Fig. 16.4)
PALPATION
Lateral Palpation (Fig. 16.5)
Pelvic Grip
FHS
Vaginal Examination
Late in Labour
On Vaginal Examination
Confirmatory Diagnosis
Mechanism
Spontaneous Version
Spontaneous Rectification
Spontaneous Evolution
Spontaneous Expulsion
Palpation
Prognosis of the Mother and Child
Mother
Foetal
MANAGEMENT
MALPRESENTATION RECOGNISED LATE IN PREGNANCY
External Version (Fig. 16.8)
First Step
Second Step
Third Step
Elective Caesarean Section
MALPRESENTATION RECOGNISED DURING LABOUR
MALPRESENTATION RECOGNISED EARLY IN LABOUR
Requirements for Internal Version
MALPRESENTATION RECOGNISED LATE IN LABOUR
IMPACTED NEGLECTED SHOULDER PRESENTATION (Fig. 16.9)
DIAGNOSIS
On Inspection
Palpation
PERVAGINUM
AUSCULTATION
MANAGEMENT
CHAPTER 17:
Twin Pregnancy
MULTIPLE PREGNANCY
Newman (1928)
Incidence
VARIETIES OF TWIN PREGNANCY
Binovular Twins (Fraternal, dizygotic)
ON EXAMINATION
Uniovular Twin (Identical, Monozygotic)
GENESIS OF MONOZYGOTIC TWINS
CONJOINED TWINS (SIAMESE TWINS)
DETERMINATION OF ZYGOSITY
AETIOLOGY
Sex Ratios with Multiple Foetuses
SUPERFECUNDATION
SUPERFOETATION
FOETUS PAPYRACEOUS OR COMPRESSUS
FOETUS ACARDIACUS
VANISHING TWIN
LIE AND PRESENTATION (Fig. 17.4)
DIAGNOSIS
General Examination
Very Early Diagnosis
Differential Diagnosis of Increased Fundal Height
Abdominal Examination
INFLUENCE ON PREGNANCY
INFLUENCE ON LABOUR
INFLUENCE ON PUERPERIUM
MANAGEMENT
Second Foetus
Third Stage
Twin Locking—0.1%
Varieties
MANAGEMENT
PROGNOSIS
Maternal Morbidity
Maternal Mortality
Perinatal Mortality
SELECTIVE TERMINATION OR REDUCTION OF PREGNANCY
Termination
Reduction
Selective Termination
Reduction of Pregnancy
Reduction of Pregnancy
UNIQUE COMPLICATIONS OF MULTIPLE PREGNANCY
COMPLICATIONS
Foetus Acardiae
Discordant Twin
Foetal Brain Damage
CHAPTER 18:
Unstable Lie
DEFINITION
AETIOLOGY
MANAGEMENT
Antenatal
Hospitalization
TREATMENT
Elective Caesarean Section
Stabilising Induction of Labour
PROCEDURE
AWAITING SPONTANEOUS ONSET OF LABOUR
CHAPTER 19:
Cephalopelvic Disproportion
DEFINITIONS
Obstetric Definition
Anatomical Definition
AETIOLOGY OF CONTRACTED PELVIS
Abnormalities Resulting from Faulty Development
Deformities Resulting from the Disease of Pelvic Bone and Joints
Deformities Resulting from Diseases in the Spinal Column
Deformities Resulting from Diseases of the Lower Extremities
Justo Major Pelvis
Justo Minor or Generally Contracted Pelvis
DIFFERENT TYPES OF PELVIS
FUNNEL PELVIS
Obliquely Contracted or Naegle's Pelvis
Transversely Contracted Pelvis (Robert's Pelvis)
Split Pelvis
ASSIMILATION PELVIS
Low assimilation Pelvis Fusion of 1st Sacral Vertebra to L5
High Assimilation Pelvis Lower Lumbar is Fused with 1st Sacral
DEFORMITIES RESULTING FROM DISEASE OF THE PELVIC BONES AND JOINTS
DEFORMITY FOLLOWING RICKETS
Flat Rachitic Pelvis
Child Sitting in Bed
Child Lying in bed
SCOLIORACHITIC PELVIS
PSEUDOMALACOSTEON PELVIS
OSTEOMALACIC PELVIS OR MALACOSTEANE PELVIS
NEW GROWTHS
FRACTURES OF THE PELVIS
CARIES AND NECROSIS OF THE PELVIS
SACROILIAC JOINT
PUBIC JOINTS
SACROCOCCYGEAL JOINT
DEFORMITIES RESULTING FROM DISEASES IN THE SPINAL CORD
KYPHOSIS
SCOLIOSIS
DEFORMITIES RESULTING FROM DISEASE OF THE LOWER EXTREMITIES
OBSTETRIC OUTCOME IN PARENT PELVIC TYPES
DIAGNOSIS OF CONTRACTED PELVIS
PHYSICAL EXAMINATION
Abdominal Examination
DIAGNOSIS OF PELVIC DEFORMITIES
External Pelvimetry
INTERNAL PELVIMETRY
Clinical Pelvimetry
Procedure
DIAGONAL AND TRUE CONJUGATE (Figs 19.2 to 19.4)
X-RAY DIAGNOSIS OF CONTRACTED PELVIS
Standard Pelvimetry
CEPHALOPELVIC DISPROPORTION
Diagnosis of Cephalopelvic Disproportion
Clinical
Abdominal Examination
Pelvic Examination
Other
ABDOMINAL METHOD
Ian Donald Method (Fig. 19.8)
External Method
Internal (Vaginal) Method
Pinard's Manoeuvre (Abdominal Method)
INFERENCES
COMBINED METHODS
Bimanual (Combined, External and Internal Methods)
Munro Kerr-Müller Method (Fig. 19.9)
First Degree
Second Degree
PURANDRAE'S TEST
HILLIS–MüLLER TEST
LIMITATIONS OF CLINICAL ASSESSMENT
X-ray Pelvimetry
Cephalometry (Fig. 19.10)
MANAGEMENT OF CEPHALOPELVIC DISPROPORTION
Cases Recognised during Pregnancy
MANAGEMENT OF CPD
INDUCTION OF PREMATURE LABOUR
Not Very Favourable
Disadvantages
Trial of Labour
Distinguish between
Contraindication of Trial Labour in Favour of Caesarean Section on Part of the Mother
Contraindication on Part of the Baby
Management of Trial Labour
Head Moulding Directly Related to Stresses
CASES FIRST RECOGNISED DURING LABOUR
CHAPTER 20:
Cord Prolapse
DEFINITION
INCIDENCE
AETIOLOGY
POSITION OF THE PROLAPSED CORD
EXTENT OF PROLAPSE
RISKS
DIAGNOSIS
MANAGEMENT
PRINCIPLES OF MANAGEMENT
TREATMENT IS DIVIDED INTO
Immediate
Subsequent
REPLACEMENT OF THE CORD
METHOD OF REPLACEMENT OF THE CORD
CAESAREAN SECTION
CHAPTER 21:
Version
DEFINITION
TYPES
External Version
Internal Version
Bipolar Version
ACCORDING TO PRESENTING PART
Cephalic Version
Podalic Version
INDICATIONS
TIMING
CONTRAINDICATIONS
PREREQUISITES
CAUSES OF FAILURE OF VERSION
DISADVANTAGES
MANAGEMENT AFTER FIRST VERSION FAILS
STEPS OF PROCEDURE
Breech Presentation
PRELIMINARIES
First Step
Second Step
Third Step
Fourth Step
INSTRUCTIONS
External Version in Transverse Lie (Fig. 21.5)
External Podalic Version
Internal Version
INDICATIONS
PREREQUISITES
CONTRAINDICATIONS
PRELIMINARIES
STEPS
One
Two
Three
Four
INTERNAL VERSION IN HEAD PRESENTATION
DIFFICULTIES IN PERFORMING INTERNAL VERSION
RISKS
Foetal
Maternal
BIPOLAR VERSION (Fig. 21.8)
STEPS
ALTERNATIVELY
PREREQUISITES
CHAPTER 22:
Episiotomy
DEFINITION
ADVANTAGE
INDICATIONS
TYPES OF ANALGESIA
Local Infiltration with 1% Xylocaine (Fig. 22.1)
PUDENDAL NERVE BLOCK
METHODS OF PUDENDAL BLOCK
Transvaginal Route (Fig. 22.2)
Transpereneal Route
TYPES OF EPISIOTOMY
Mediolateral (Fig. 22.3)
Median or Midline (Fig. 22.4)
J Shaped
Lateral
TIMING OF EPISIOTOMY
TIMING OF THE REPAIR OF THE EPISIOTOMY
REPAIR OF THE EPISIOTOMY
PAIN AFTER EPISIOTOMY
CHAPTER 23:
Caesarean Section
DEFINITION
FREQUENCY
Breech Presentation
INDICATIONS
Absolute Indications
Elective Indications
NON-ELECTIVE INDICATIONS
REPEAT SECTION
PRELIMINARIES TO OPERATION
TIMING FOR OPERATION
ANAESTHESIA IN CAESAREAN SECTION
CHOICE OF OPERATION
THE LOWER SEGMENT OPERATION
Technique
STEP 1
Preparations
STEP 2
The Abdominal Wall Incision
STEP 3
STEP 4
STEP 5
STEP 6
STEP 7
Extracting the Foetus
STEP 8
Controlling Haemorrhage
STEP 9
Removing the Placenta
STEP 10
Dilating the Cervical Canal
STEP 11
Stitching the Uterus (Fig. 23.10)
STEP 12
Recovering the Lower Uterine Segment
STEP 13
Closing the Abdomen (Fig. 23.12)
VERTICAL INCISION
ADVANTAGES OF LOWER SEGMENT OPERATION
CLASSICAL CAESAREAN
THE ABDOMINAL INCISION (Fig. 23.13)
THE UTERINE INCISION
EXTRACTION OF THE CHILD
REMOVAL OF THE PLACENTA AND MEMBRANES
STITCHING OF THE UTERINE WOUND
Suture Material
Method of Stitching
CHAPTER 24:
Obstetrical Forceps
GENERAL DESIGN
VARIETIES OF FORCEPS (Fig. 24.1)
CLASSIFICATIONS
TYPE OF PROCEDURE (Fig. 24.2)
Classification
Incidence
MODE OF ACTION OF FORCEPS
Traction
Compression
Rotation
Protection
Choice of Instrument
TYPES OF APPLICATION OF THE FORCEPS
Cephalic Application
Pelvic Application
Indications
PROPHYLACTIC FORCEPS
TRIAL FORCEPS
FAILED FORCEPS
PREREQUISITS FOR FORCEPS APPLICATION
STATION
TECHNIQUES OF FORCEPS OPERATION
APPLICATION OF FORCEPS
IDENTIFICATION OF POSITION
OUTLET FORCEPS DELIVERY
First Step Application
Appropriateness of Application
Second Step Application
Extraction of the Head
TRACTION
REMOVING THE INSTRUMENT
THE MIDFORCEPS APPLICATION
FORCEPS APPLICATION IN ABNORMAL PRESENTATIONS AND POSITIONS
FORCEPS APPLICATION IN ABNORMAL PRESENTATIONS AND POSITIONS
Special Forceps Manoeuvres
Forceps for Face Presentation (Fig. 24.8)
Morbidity from Forceps Operation
CHAPTER 25:
Destructive Operations in Obstetrics
DEFINITION
CRANIOTOMY, CRANIOCLASM, CEPHALOTRIPSY
INDICATIONS
PROCEDURE
PRELIMINARIES
PARTS OF INSTRUMENT
CRANIOTOMY OF THE FORECOMING HEAD
Perforation of the Head
Sites of Perforation
INSTRUMENTS
STEP I
STEP II
STEP III
DELIVERY BY EXPULSIVE FORCES OF LABOUR
EXTRACTION WITH FORCEPS
EXTRACTION OF HEAD
BLUNT HOOK AND CROCHET
CRANIOCLAST
CRANIOCLAST WITH CEPHALOTRIBE
CRANIOCLASM
CRANIOTOMY OF THE AFTERCOMING HEAD
STEPS
Step I
Step II
Site of Perforation
Step III
Step IV
Step V
Extraction by Crochet
ALTERNATIVE METHOD
EVISCERATION
INDICATIONS
PROCEDURE
DECAPITATION
INDICATIONS
PROCEDURE
Preliminaries
STEPS
Use of Decapitating Hook (Fig. 25.3)
DELIVERY OF THE DECAPITATED HEAD
USE OF BLOND HEIDLER THIMBLE AND DECAPITATING WIRE (Fig. 25.6)
CLEIDOTOMY
INDICATION
PROCEDURE
CHAPTER 26:
Maternal Injuries in Parturition
LACERATION OF THE VAGINA
Formation of Vesicovaginal Fistula
TREATMENT
COLPORRHEXIS
TREATMENT
RUPTURE OF VEINS (VAGINAL AND VULVAL HAEMATOMA)
TREATMENT
PERINEAL TEARS
CAUSES
Overstretching of the Perineum
RAPID STRETCHING OF THE PERINEUM
INELASTIC PERINEUM
DEGREE OF TEARS
First Degree
Second Degree
Third Degree (Complete Rupture)
Central Rupture
RUPTURE OF THE POSTERIOR WALL OF THE VAGINA
REPAIR OF TEARS
FIRST AND SECOND DEGREE TEARS
THIRD DEGREE TEARS
POSTOPERATIVE MANAGEMENT
CERVICAL TEARS
CAUSES
Iatrogenic
RIGID CERVIX
STRONG UTERINE CONTRACTIONS
DETACHMENT
TYPES
Longitudinal
Annular
ACCORDING TO THE THICKNESS INVOLVED
TREATMENT
DIAGNOSIS
COMPLICATIONS OF TEARS
Early
Late
TREATMENT
DEEP CERVICAL TEAR
CHAPTER 27:
Rupture Uterus
INCIDENCE
AETIOLOGY
Rupture during Pregnancy
RUPTURE DURING LABOUR
Spontaneous
Traumatic
RUPTURE DUE TO OBSTRUCTED LABOUR
DEFINITION
The direction of Rupture
CLINICAL FEATURES OF RUPTURE DURING PREGNANCY
Symptoms
Incomplete Rupture
TREATMENT
RUPTURE OF THE UTERUS WITHOUT DYSTOCIA
MECHANISM OF RUPTURE
ABNORMALITIES OF THE UTERUS
MISDIRECTION OF UTERINE AXIS
CLINICAL FEATURES
TREATMENT
RUPTURE OF UTERUS FOLLOWING OBSTRUCTED LABOUR OR DIFFICULT DELIVERY
Aetiology
Mechanism of Rupture
CLINICAL FEATURES
Premonitory Symptoms
The Clinical Symptoms after Rupture of the Uterus
RUPTURE RECOGNISED ONLY AFTER DELIVERY
TREATMENT
Prophylaxis against Rupture
TREATMENT WITH RUPTURE THREATENING
If the Child is Dead
Compatible with Mother's Safety
TREATMENT FOLLOWING RUPTURE
CHAPTER 28:
Induced Labour
INDUCTION OF LABOUR
NATURAL ONSET OF LABOUR
RISKS OF INDUCTION
Failure of Labour
Prematurity
Unforeseen Disproportion
Sepsis
PLACENTAL SITE RETRACTION AND FETAL ASPHYXIA
PARTIAL PLACENTAL DETACHMENT AND “BLOODY TAP”
ACCIDENTAL HAEMORRHAGE
FOETAL PNEUMONIA
CORD PROLAPSE
AMNIOTIC EMBOLISM
Neonatal Jaundice
FOETAL MORTALITY
History of Induction of Labour
Indication of Induction of Labour
OBSTETRICAL CONDITIONS
MEDICAL INDICATIONS FOR INDUCTION
ELECTIVE INDUCTION
CONTRAINDICATION
SELECTION OF TIME
WHEN THE INDUCTION IS DONE FOR FOETAL INTEREST
There is Another Classification
METHOD OF RIPENING OF THE CERVIX
METHOD OF INDUCTION
MEDICAL INDUCTION
Simple Medical Induction
Drug Induction
Induction by Oxytocin
Controlled IV Infusion
TWO BOTTLE METHOD REGIME
OXYTOCIN BY PUMP INFUSION
BUCCAL OXYTOCIN
OXYTOCIN SNUFF OR NASAL SPRAY
OBSERVATION
COMPLICATIONS WITH USE OF OXYTOCIN
WHEN TO STOP
PROSTAGLANDINS
USE IN OBSTETRICS
CONTRAINDICATIONS
MECHANISM OF ACTION
ROUTE OF ADMINISTRATION
Oral (for ripening of the cervix)
Intravenous/Intramuscular
Preparation
Extra-amniotic (for unripe cervix)
Vaginal Route of Introduction
Advantages
Complications
Surgical Induction of Labour
Limitations
Methods
ARTIFICIAL RUPTURE OF THE FOREWATERS
ARTIFICIAL RUPTURE OF THE HINDWATERS
PROCEDURE
ADVANTAGES
HAZARDS
STRIPPING OF THE MEMBRANES
COMBINED METHOD
ACCELERATION OR AUGMENTATION OF LABOUR
INDICATIONS
PROCEDURE
ADVANTAGE
CHAPTER 29:
Intrauterine Growth Retardation
DEFINITION
INCIDENCE
ANTEPARTUM COMPLICATIONS
NEONATAL COMPLICATIONS AT BIRTH
AETIOLOGY
MOST FREQUENT CAUSES OF IUGR
Placental Insufficiency
Genetic Syndromes
Less frequent causes of IUGR
Maternal Malnutrition
CLASSIFICATION
Morphological Classification
FEATURES OF SYMMETRICAL AND ASYMMETRICAL IUGR
AETIOLOGICAL CLASSIFICATION
DIAGNOSIS
Clinical Diagnosis
Diagnosis by Ultrasound Examination
Abdominal Circumference
Fetal Weight
Head to Abdomen Ratio
Femur to Abdomen Ratio
Doppler Waveform Analysis
MANAGEMENT
Identification of Patients Carrying Small Foetuses
General
TERMINATION OF PREGNANCY
Methods of Termination
Antepartum Surveillance of the IUGR Foetus
Nonstress Test
Amniocentesis
Delivery of the IUGR Foetus
IMMEDIATE CARE OF THE BABY AFTER BIRTH
FEEDING
LONG-TERM PROGNOSIS
CHAPTER 30:
Obstetrical Hysterectomy
INTRODUCTION
DEFINITION
CLASSIFICATION
INDICATIONS
Emergency Obstetrical Hysterectomy
Elective Obstetrical Hysterectomy
CHOICE OF OPERATION
TOTAL VERSUS SUBTOTAL HYSTERECTOMY
OPERATIVE PROCEDURE
Anaesthesia
OPERATIVE TECHNIQUE
SUBTOTAL HYSTERECTOMY
TOTAL HYSTERECTOMY
REPERITONISATION
COMPLICATIONS
Genitourinary Tract Injuries
Haemorrhage
MORBIDITY
INDEX
TOC
Index
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