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Vaginal Delivery
Sadhana Gupta
UNIT 1:
Basics of Vaginal Delivery
Unit Outlines
Planes and Diameter of True Pelvis
Pelvic Inlet (Brim)
Diameters of Pelvic Inlet
Clinical Significance
Mid Pelvis—Pelvic Cavity
Mid Plane
Pelvic Outlet
Planes of Pelvis
Inclination of Pelvic Brim
Obstetrical Significance of Inclination of Pelvic Brim
Axis of Pelvis
Anatomical Axis of Pelvis (Curve of Carus)
Obstetrical Axis of Pelvis
Pelvic Shapes
Clinical Estimation of Pelvic Size
Estimation of Mid Pelvis
Estimation of Pelvis Outlet
ASSESSMENT OF CEPHALIC PELVIC DISPROPORTION
Engagement of Head
Abdominal Examination
Vaginal Method
Abdominal Vaginal Method—Muller Kerr Method
MATERNAL SOFT TISSUES
PELVIC FLOOR
Pelvic Fascia
Levator Ani and Coccygeues Muscle (Pelvic Diaphragm)
Urogenital Diaphragm
Perineal Body
OBSTETRIC DYNAMICS OF PELVIC FLOOR
CONCLUDING REMARK
CONCLUDING REMARK
CARDINAL MOVEMENT OF LABOR
Engagement
Descent
Flexion
Internal Rotation
Mechanism of Internal Rotation
Extension
Mechanism of Extension
Sequence of Movement of Extension
Restitution and External Rotation
Restitution
External Rotation
Expulsion
CONCLUDING REMARK
CALCULATION OF DATE OF LABOR
CAUSE OF ONSET OF LABOR
PHASES OF PARTURITION
Phase Zero—Parturition
Phase One of Parturition—Preparation for Labor
Sign that Precede Labor—Phase I
Phase II of Parturition: The Process of Labor
ONSET OF LABOR
Painful Uterine Contraction (Labor Pain)
Slight Uterine Hemorrhage—the Show
Dilatation of Internal Os
Formation of Bag of Water
FIRST STAGE OF LABOR
Latent Phase
Women's Characteristic Behavior in Latent Phase
Active Labor
Women's Characteristic Behavior in Active Phase
Second Stage of Labor
Duration of Second Stage of Labor
Women Characteristic Behavior in Second Stage Transition
Third Stage or Ejection of After Birth
CONCLUDING REMARK
LOCATION OF LABOR ROOM
SIZE OF LABOR ROOM
EQUIPMENTS
Labor Table/Berthing Bed
Light for Labor Room
Boyle's Anesthetic Trolley
Maternal Monitoring Equipment
Neonatal Resuscitation Station
Fetal Monitoring Equipment
Crash Cart
Sterilization Equipment
Cupboards
Slab
Annexure (Additional) Facilities in Labor Complex
Pre-labor Ward
Emergency Obstetric Room
Scrub Room
Wash Areas
Doctor/Staff Room
CONCLUDING REMARKS
INFORMED CONSENT
CONTENT AND QUALITY
Alteration in Records
Time and Late Entries
CONCLUDING REMARKS
UNIT 2:
Management of Normal Labor
Unit Outlines
GENERAL EXAMINATION
ABDOMINAL PALPATION AND AUSCULTATION
Position of Women
Steps of Abdominal Examination
Level and Descent of Head
Auscultation of Fetal Heart Sound
VAGINAL EXAMINATION
A. Explanation/Information Sharing
B. Consent or Compliance
C. Performing and Documentation of Vaginal Examination
D. Procedure
Before the Examination
Timing of Examination
Procedure of Vaginal Examination
Making the Vaginal Examination
Documenting Vaginal Examination
After the Vaginal Examination
DETECTION OF RUPTURED MEMBRANES
Diagnosis of Pre-labor Rupture of Membrane
CONCLUDING REMARKS
HISTORY
Intermittent Auscultation
EFM—Advantages and Women Experience in Today's Obstetric Practice
Basics and Principle of CTG Machine
Principle of CTG Machine
Method of EFM
Electronic External Fetal Monitoring
Internal Monitoring
Tocography
Interpretation of CTG
Fetal Heart Patterns
FEATURES TO SEE IN CTG TRACING
Baseline Fetal Heart Rate
Abnormalities of Baseline
Variable Deceleration
MANAGEMENT OF ABNORMAL FETAL HEART RATE PATTERNS
ADMISSION FETAL MONITORING LOW RISK WOMEN
Fetal Heart Rate Pattern during Second Stage of Labor
Adjuncts to EFM
Fetal Blood Sampling (FBS)
PHYSIOLOGICAL CHANGES IN PREGNANCY
ORAL INTAKE
MATERNAL KETONURIA
a. Regional Anesthetic
b. Augmentation of Labor
Potential Complication of Oxytocin Infusion
Fluid Balance in Oxytocin Infusion
c. Fluid Management in Special Situation
Fluids and Electrolyte Changes in PIH
MAIN STAY OF FLUID THERAPY
CONCLUDING REMARKS
ANESTHETIC
PAIN PATHWAYS IN LABOR
VARIOUS ANALGESIC/ANESTHETIC
ACTIVE MANAGEMENT OF LABOR PROTOCOL
UNIT 3:
Abnormal Labor Situations
Unit Outlines
PARTURIENT UTERUS
Uterine Contraction
DILATATION OF LOWER UTERINE SEGMENT AND CERVIX
THE RETRACTING UTERINE WALL
TYPE OF UTERINE DYSFUNCTION
VARIOUS METHODS FOR ASSESSING LABOR PROGRESS
How Slow is Too Slow
Fetal Station at Onset of Active Labor
Second Stage Disorder
Reported Cause of Uterus Dysfunction/Prolonged Labor
Age
Parity
Stress Response
Uterine Morphology
Fetal Presentation/Position
Chorioamnionitis
Body Build
Cephalopelvic Disproportion
Maternal Position during Labor
Epidural Analgesia
Less Common Physical Causes
MANAGEMENT OF PROLONGED LABOR
Prolonged Latent Phase
Prolonged Active Phase
General Management
Avoidance of Infection
Augmentation by Oxytocin Infusion
Operative Method
Prolonged Second Stage
Precipitate Labor—Too Strong Action
Maternal Effect of Precipitous Labor
Effects on Fetus and Neonates
Treatment
CEPHALOPELVIC DISPROPORTION
CONTRACTED PELVIC INLET
MID PELVIS CONTRACTION
CONTRACTED PELVIC OUTLET
ESTIMATION OF PELVIC CAPACITY
OCCIPITOPOSTERIOR POSITION
Incidence
Normal Course of Labor in Occipitoposterior Position
Abnormal Course of Labor
Cause of Abnormal Course of Labor in Occipitoposterior Position
1. Deficient Flexion of Head
2. Weak Uterine Contraction
3. PROM/Oligohydramnios
4. Anthropoid and Android Type of Pelvis or Minor Degree of Pelvic Contraction
DIAGNOSIS OF OCCIPITOPOSTERIOR POSITION
Occipitoposterior Position
General Course of Labor
MANAGEMENT
Management of Persistent Occipitoposterior Position (POP)
Technique of Manual Rotation and Forceps Application in Occipitoposterior Position
Application of Forceps to Un-rotated Head
Rotation of Head with Forceps
Vacuum Extraction
Cesarean Section
INCIDENCE
RISK FACTOR FOR FACE PRESENTATION
ATTITUDE AND POSITION IN FACE PRESENTATION
SIGN AND SYMPTOMS IN FACE PRESENTATION Abdominal Palpation
VAGINAL EXAMINATION
MECHANISM OF LABOR IN FACE PRESENTATION
Internal Rotation
Flexion
GENERAL COURSE OF LABOR AND MANAGEMENT
INCIDENCE
DIAGNOSIS
VAGINAL EXAMINATION
MECHANISM OF LABOR
MANAGEMENT
CONCLUDING REMARK ON BROW PRESENTATION
TYPE OF BREECH PRESENTATION
INCIDENCE
ETIOLOGY OF BREECH PRESENTATION
POSITION OF BREECH PRESENTATION
DIAGNOSIS OF BREECH PRESENTATION
VAGINAL EXAMINATION
DIFFERENTIAL DIAGNOSIS AND IMAGING TECHNIQUE
MECHANISM OF LABOR IN BREECH DELIVERY
POINT OF CONCERN IN BREECH VAGINAL DELIVERY
PROGNOSIS
MATERNAL MORBIDITY
PERINATAL MORBIDITY AND MORTALITY
CURRENT STATUS
INTRAPARTUM DECISION MAKING
METHOD OF VAGINAL DELIVERY
MANAGEMENT OF LABOR IN BREECH DELIVERY
SECOND STAGE OF LABOR
Step I
Step II
Step III
Step IV
Burn Marshall Method
Mauriceau—Smellieveit
Prague's Maneuver
Application of Forceps in After Coming Head
Dührssen's Incision
Zavanelli's Maneuver
MANAGEMENT OF COMPLICATED BREECH DELIVERY
HIGH BUTTOCK IN SECOND STAGE OF LABOR
ARREST OF BUTTOCK AT PELVIC OUTLET
1. Bringing Down of Leg
Frank Breech Extraction
Groin Traction Maneuver
Pinard's Maneuver Breech Decomposition
Complete or Incomplete Breech Extraction
2. Delivery of Shoulder in Breech Extraction
3. Difficulty in Delivery of after Coming Head
BREECH EXTRACTION
MATERNAL INJURIES
PRETERM BREECH
BREECH BABY AT BIRTH
CONCLUDING REMARKS
ATTITUDE AND POSITION IN TRANSVERSE LIE
INCIDENCE
ETIOLOGY
DIAGNOSIS
ON VAGINAL EXAMINATION
MECHANISM OF LABOR
MANAGEMENT
INCIDENCE AND CAUSES
MANAGEMENT
PROGNOSIS
PRESENTATION OF FETUS
GENERAL COURSE OF LABOR
INTRAPARTUM MANAGEMENT OF TWIN PREGNANCY
VAGINAL DELIVERY OF SECOND TWIN
INTERVAL BETWEEN 1ST AND 2ND TWIN
THIRD STAGE MANAGEMENT
TRIPLET OR HIGHER ORDER GESTATION
UNIT 4:
Vaginal Delivery in Special Situations
Unit Outlines
VAGINAL DELIVERY IN PRETERM LABOR
INCIDENCE
PLACE OF BIRTH IN PRETERM LABOR
TRANSFER GUIDELINES
DIAGNOSIS
MANAGEMENT
Intervention to Delay Birth
1. Treatment for Bacterial Vaginosis and use of Antimicrobial
2. Prophylactic Corticosteroid
3. Inhibition of Preterm Labor by Tocolysis
4. Emergency Circlage
CARE AND MANAGEMENT OF PRETERM LABOR
First Stage of Preterm Labor
Checklist
Fetal Monitoring in preterm Labor
Second Stage of Labor
Care of Newborn
Third Stage of Labor
PREPARATION OF ENVIRONMENT FOR THE BIRTH
PRE-LABOR RUPTURE OF MEMBRANE
INCIDENCE AND FACTS
DIAGNOSIS
MANAGEMENT
CLINICAL CHORIOAMNIONITIS AND USE OF ANTIMICROBIAL THERAPY
RECOMMENDED MANAGEMENT OF PROM
DEFINITION
INCIDENCE
MATERNAL RISK
FETAL RISK
MANAGEMENT
Assessment of Gestational Age
Induction vs Expectant Management (Fetal Surveillance)
Mode of Induction
Sweeping or Stripping of the Membranes
Prostaglandin Gel
Fetal Macrosomia
Oligohydramnios
DEFINITION
INCIDENCE
DIAGNOSIS
Decision Making
INDUCTION VS EXPECTANT MANAGEMENT
Induction of Labor
THIRD STAGE OF LABOR
POSTPARTUM EXAMINATION
GENERAL MEASURES FOR THE CARE OF PREGNANT PATIENT WITH CARDIAC DISEASE
Monitoring the Cardiac Function during Pregnancy
MEASURES TO DECREASE THE EFFECT ON THE HEART OF THE HEMODYNAMIC CHANGES ELICITED BY PREGNANCY
Antepartum
Bed Rest
Dietary Salt Restriction
Diuretics
Prophylactic Digitalization
Prophylactic Antibiotic
Anemia
LABOR AND DELIVERY
Induction of Labor
LABOR MANAGEMENT
First Stage of Labor
Second Stage of Labor
Third Stage of Labor
Place of Cesarean Section in Cardiac Patient
PUERPERIUM
BLOOD LOSS AT DELIVERY
ELDERLY PRIMIGRAVIDAE
GRANDMULTIPARA
OBESITY
CARE IN LABOR IN HIV POSITIVE WOMEN
IMMUNIZATION PROTOCOL IN RH -VE WOMEN
COURSE OF LABOR IN PLACENTA PRAEVIA
MANAGEMENT
ABRUPTIO PLACENTA
CONDUCT OF VAGINAL DELIVERY
INFORMED CONSENT IN TRIAL OF VAGINAL BIRTH AFTER PREVIOUS CESAREAN SECTION
MANAGEMENT OF TRIAL OF VAGINAL BIRTH AFTER CESAREAN SECTION3
CONTRAINDICATION OF TRIAL OF VAGINAL BIRTH AFTER CESAREAN SECTION
CERVICAL RIPENING AND LABOR STIMULATION IN VAGINAL BIRTH AFTER PREVIOUS CESAREAN SECTION
OXYTOCIN
PROSTAGLANDIN
CONCLUDING REMARKS
UNIT 5:
Obstetric Operations
Unit Outlines
PURPOSE OF EPISIOTOMY
Delayed Complication
Timing of Episiotomy
Several Variety of Episiotomy are Recognized
Midline
Lateral Episiotomy
Posteriolateral Incision
J Shaped Episiotomy
Timing of Episiotomy Repair
Analgesia
TECHNIQUE OF REPAIR OF EPISIOTOMY
Suture Material
METHOD OF EPISIOTOMY REPAIR
Vaginal Mucosa
Muscle Layer
Skin Layer
After Care of Episiotomy
PAIN AFTER EPISIOTOMY
INTRODUCTION
INCIDENCE
HISTORY
CLASSIFICATION OF FORCEPS DELIVERY
Station and Rotation
Design of Forceps
TYPE OF FORCEPS
INDICATION FOR INSTRUMENTAL DELIVERY
MATERNAL INDICATION
PROLONGED SECOND STAGE
Cause of Prolonged Second Stage
Fetal Indication of Instrumental Delivery
PROPHYLACTIC FORCEPS
TRIAL OF FORCEPS
CARE OF WOMEN UNDERGOING INSTRUMENTAL DELIVERY
COMMUNICATION
PRE-REQUIREMENTS OF FORCEPS APPLICATION
PREPARATION FOR FORCEPS DELIVERY
Careful Aseptic Preparation are Necessary
Analgesia
FORCEPS APPLICATION
TRACTION
PRECAUTION
FORCEPS EXTRACTION IN ABNORMAL PRESENTATION AND POSITION
I. Occipitoposterior Position
I-A. Manual Rotation
I-B. Forceps Delivery of Occiput Posterior
I-C. Forceps Rotation of Occiput Oblique Posterior
I-D. Forceps Rotation of Occiput Oblique Transverse Position by Kielland Forceps
II. Forceps Delivery of Face Presentation
III. Forceps Application in after Coming Head
IV. Forceps in Contracted Pelvis
FAILED FORCEPS
MORBIDITY FROM FORCEPS OPERATION
a. Laceration and Episiotomy
b. Urinary and Rectal Incontinence
c. Febrile Morbidity
d. Fetal Risk
e. Long-term Infant Morbidity
CONCLUDING REMARKS REGARDING MORBIDITY FROM FORCEPS
VENTOUSE DELIVERY (VACUUM EXTRACTOR)
History
Indication and Prerequisite
Relative Contraindication
Prerequisite for Ventouse Delivery
Technique
Precaution
Ventouse Instrument—Design
Complication
Recommendation Regarding Vacuum Delivery
Vacuum Extraction vs Forceps Deliveries
CONCLUDING REMARKS
GENERAL CONCEPTS
Elective Induction of Labor
Indicated Labor Induction
Contraindication
METHODS OF INDICATION
PRE-INDUCTION CERVICAL RIPENING
Pharmacological Techniques of Cervical Ripening
Prostaglandin (E2)
Prostaglandin (E1)
Mechanical Technique for Cervical Ripening
Membrane Stripping
Hydroscopic Cervical Dilatation
Transcervical Catheter
LABOR INDUCTION AND AUGMENTATION WITH OXYTOCIN
Intravenous Oxytocin Administration
Oxytocin Dosages
AMNIOTOMY (ARTIFICIAL RUPTURE OF MEMBRANE)
Amniotomy Induction
AMNIOTOMY AUGMENTATION
CONCLUDING REMARK
LACERATION OF CERVIX
Diagnosis
Treatment
LACERATION OF THE VAGINA
INJURIES TO LEVATOR ANI
PUERPERAL HEMATOMA
Type of Hematomas
Diagnosis
On Examination
Treatment
PERINEAL TRAUMA
Facts
Causes
To Suture or Not to Suture
Suturing of Perineal Tear
Suture Material
Suturing Technique
FOURTH DEGREE LACERATION—ANAL SPHINCTER INJURY
INCIDENCE AND FACTS
TECHNIQUE OF 4TH DEGREE PERINEAL LACERATION REPAIR
SUBSEQUENT PREGNANCY
UNIT 6:
Childbirth Emergencies
Unit Outlines
INCIDENCE AND FACTS
CAUSES AND ASSOCIATED RISK FACTOR
FETAL AND MATERNAL RISK
DIAGNOSIS
MANAGEMENT
INCIDENCE
RISK FACTOR
COMPLICATIONS OF SHOULDER DYSTOCIA
Maternal Complication
Fetal Complication
PREDICTION AND PREVENTION OF SHOULDER DYSTOCIA
MANAGEMENT OF SHOULDER DYSTOCIA
Zavanelli's Maneuver
Deliberate clavicle Fracture
Cleidotomy
Symphysiotomy
CONTRAINDICATED MANEUVER
After Care
Post Birth Counseling
Litigation
DEFINITION
PHYSIOLOGY OF HEMOSTASIS AT PLACENTAL SITE
PATIENT AT RISK OF POSTPARTUM HEMORRHAGE
CLINICAL CHARACTERISTICS
DIAGNOSIS
PROPHYLAXIS FOR POSTPARTUM HEMORRHAGE
TREATMENT OF PLACENTAL SITE HEMORRHAGE BEFORE DELIVERY OF PLACEMENT
Manipulation of Uterus Per-abdomen
Brandt Andrews Technique
Crede's Method
MANUAL REMOVAL OF PLACENTA
MANAGEMENT AFTER DELIVERY OF PLACENTA
BLEEDING UNRESPONSIVE TO OXYTOCIN
Ligation of Anterior Division of Internal Iliac Artery
Uterine Compression Suture
Uterus Packing
Recombinant Activated Factor
HEMORRHAGE FROM RETAINED PLACENTAL FRAGMENTS
Diagnosis of Placenta Increta
Management of Adherent Placenta
CONCLUDING REMARKS
EVIDENCE AND FACTS
ASSOCIATED RISK FACTOR
DIAGNOSIS
PRACTICE RECOMMENDATION
TYPES OF UTERUS INVERSION
CAUSES OF INVERSION AND ASSOCIATED RISK FACTOR
DIAGNOSIS
TREATMENT—PRACTICE RECOMMENDATION
SURGICAL INTERVENTION
INCIDENCE AND FACTS
SIGN AND SYMPTOMS
PRACTICE RECOMMENDATION
Treat for Sudden Collapse and Shock
Think ABC
MATERNAL RESUSCITATION
RESUSCITATION PROCEDURE
BASIC LIFE SUPPORT (BLS)
ADVANCED LIFE SUPPORT
Advanced Airway Management
DEFIBRILLATION
RESUSCITATION DRUG
CONCLUDING REMARKS
UNIT 7:
Newborn Resuscitation and Puerperal Care
Unit Outlines
INITIATION OF AIR BREATHING
MANAGEMENT OF NEWBORN AT THE TIME OF DELIVERY
EVALUATION OF NEWBORN
APGAR SCORING SYSTEM
ROUTINE MEASUREMENT OF NEWBORN BABY
SUMMARY OF TOP TO TOE EXAMINATION OF NEWBORN
ROUTINE NEWBORN CARE
VITAMIN K PROPHYLAXIS
INCIDENCE AND FACTS
RISK MANAGEMENT: ANTICIPATION
BASIC NEONATAL RESUSCITATION
BASIC STEPS
VENTILATION
ENDOTRACHEAL INTUBATION
CHEST COMPRESSION
MEDICATION AND VOLUME EXPANSION
Epinephrine
Volume Expansion
Dextrose
Sodium Bicarbonate
Naloxone
DISCONTINUATION OF RESUSCITATION
IN HOSPITAL POSTPARTUM CARE
Common Postpartum Complication
Postpartum Hemorrhage
Postpartum Febrile Morbidity
Hypertension
Immunization
Breast Feeding
Mood Changes
Postpartum Depression
DISCHARGE
TO CONCLUDE - BACK TO NATURE - PAST AND FUTURE OF VAGINAL DELIVERY
Annexures
Annexures Outlines
INTRAPARTUM/POSTPARTUM REGIMENS FOR PREVENTION OF MTCT OF HIV
MATERNAL RESUSCITATION DRUGS
ADVANCED LIFE SUPPORT ALGORITHM FOR THE MANAGEMENT OF CARDIAC ARREST IN ADULTS
RESUSCITATION DRUGS FOR NEONATES
PHARMACOPEIA
A. Analgesia and Regional Local Anesthesia
B. Betamimetic/Tocolytic Therapy
C. Corticosteroids
D. Oxytocic Agents
E. Prostaglandins
F. Vitamins K
REFERRAL BOOKS
INDEX
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