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Date of quickening: A rough idea about the probable date of delivery can be deduced by adding 22 weeks in primigravidae and 24 weeks in multiparae to the date of quickening treatment yeast uti cheap mentat 60 caps visa. Clinical: Size of the uterus prior to 12 weeks more precisely corresponds with the period of amenorrhea. Investigation records: Investigation records during rst half of pregnancy are invaluable. Recording of positive pregnancy test using immunological principle at rst missed period by earliest. Lightening: Following the appearance of the features suggestive of lightening (see p. Size of the fetus, change in the uterine shape, volume of liquor amnii, hardening of the skull and girth of the abdomen are of value in assessing the maturity of the fetus specially if the examinations are done by the same person at intervals. Vaginal examination: If the cervix becomes shorter and dilated, the labor is fairly not far o. Gestational age determined by sonographic measurement (in first or second trimester) should be compared with the menstrual age. X-ray - Appearance and density of ossification centers in the upper end of the tibia (3840 weeks) and lower end of femur (3637 weeks). The following methods are useful when considered together to have a rough idea about the size of the fetus: A. Conditional centiles depending on individual fetal growth velocity is thought to be more important. Example - Height of the uterus above the symphysis pubis = 32 cm and the station of the head is at - 2. However, the approximate size of the fetus is modi ed by the amount of liquor amnii and thickness of the abdominal wall. Sonography: Fetal weight has been estimated by combining a number of biometric data. It has enough freedom of movement until the later months of pregnancy, when it becomes relatively fixed. Till then, periodic examination is essential to note its lie, presentation, position and attitude. Incidental idea can be gained about the size of the fetus or amount of liquor amnii. Unstable Similarly, the fetal legs in a breech presentation may be flexed (complete breech), extended (frank breech) or a foot may be present (footling). However, the term presentation and presenting part are often used synonymously and expressed more commonly in clinical practice according to the latter definition. During the later months, the head, trunk and limbs of the fetus maintain the attitude of flexion on all joints and form an ovoid mass that corresponds approximately to the shape of uterine ovoid. There may be exceptions to this universal attitude and extension of the head may occur (deflexed vertex, brow or face presentation, according to the degree of extension), or the legs may become extended in breech.
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Among the remaining complicated groups medications education plans buy mentat 60 caps visa, decision has to be taken whether to allow the pregnancy to continue or not. Primary care is aimed to reduce the incidence of preterm labor by reducing the high-risk factors. Secondary care includes screening tests for early detection and prophylactic treatment. Tertiary care is aimed to reduce the perinatal morbidity and mortality after the diagnosis. Investigations: (1) Full blood count; (2) Urine for routine analysis, culture and sensitivity; (3) Cervicovaginal swab for culture and fibronectin; (4) Ultrasonography for fetal well being, cervical length and placental localization and (5) Serum electrolytes and glucose levels when tocolytic agents are to be used (see Chapter 33). Thus, in only negligible proportion of cases (about 1020%) where the fetus is not compromised, the maternal condition remains good and membranes are intact, the following regime may be instituted in an attempt to arrest premature labor. Bed rest- e patient is to lie preferably in left lateral position though the bene ts are doubtful. Tocolytic agents: Various drugs nifedipine, atosiban, progesterone (micronized) have been used to inhibit uterine contractions. Maternal: Uncontrolled diabetes, thyrotoxicosis, severe hypertension, cardiac disease, hemorrhage in pregnancy. Fetal: Fetal distress, fetal death, congenital malformation and pregnancy beyond 34 weeks. Others: Rupture of membranes, chorioamnionitis and cervical dilatation more than 4 cm. Glucocorticoid therapy: Maternal administration of glucocorticoids is advocated where the pregnancy is less than 34 weeks. This is beneficial when the delivery is delayed beyond 48 hours of the first dose. Risks of antenatal corticosteroid use: (a) Premature rupture of the membranes especially with evidence of infection as the infection may flare-up; (b) Insulin-dependent diabetes mellitus where patients need insulin dose readjustment; (c) Transient reduction of fetal breathing and body movements. As such, routine forceps is not indicated the cord is to be clamped immediately at birth to prevent hypervolemia and hyperbilirubinemia To shift the baby to neonatal intensive care unit under the care of a neonatologist Place of cesarean section: Routine cesarean delivery is not recommended. Preterm fetuses before 34 weeks presented by breech are generally delivered by cesarean section. Presence of fetal bronectin in the cervicovaginal discharge between 22 weeks and 34 weeks of pregnancy is a good predictor of preterm labor (see p. Rupture of membranes for > 24 hours before delivery is called prolonged rupture of membranes.
Cesarean section: If the case is detected early with good fetal condition medicine evolution buy 60 caps mentat with amex, cesarean section gives the best result. But in late and neglected cases, even if the fetal heart sound is audible, desperate attempt to do a cesarean section to save the moribund baby more often leads to disastrous consequences. Not infrequently, the baby is either delivered stillborn or dies due to neonatal sepsis. The postoperative period of the mother also becomes stormy and at times, ends fatally. Symphysiotomy: the place of symphysiotomy has to be duly considered in the developing countries as an alternative to risky cesarean section. The causes are: hereditary, race, size of the parents-particularly the mother (obesity), poorly controlled maternal diabetes and gestational diabetes, postmaturity, multiparity and male fetus. Fetal hazards are: surprise dystocia due to cephalopelvic disproportion, shoulder dystocia, brachial plexus injury, asphyxia, birth trauma and meconium aspiration. Management: (i) Prophylactic induction of labor (early) to reduce the risk of shoulder dystocia or (ii) Elective cesarean delivery, especially in diabetic women with big baby to reduce perinatal hazards (shoulder dystocia). Shoulder dystocia occurs when either the anterior or the posterior (rare) fetal shoulder impacts on the maternal symphysis or on the sacral promontory respectively. Complications: (A) Fetal: asphyxia, brachial plexus injury (plexopathy) due to stretch, Erb, Klumpke palsy (see p. Prevention of shoulder dystocia is not possible accurately even with antenatal ultrasonographic assessment. Prediction: Shoulder dystocia neither could be predicted accurately nor could be prevented entirely. Maneuvers to prevent shoulder dystocia may be used prophylactically in cases where it is anticipated. Diagnosis: (1) Definite recoil of the head back against the perineum (turtle neck sign), (2) Inadequate spontaneous restitution, (3) Fetal face becomes plethoric, (4) Failure of shoulder to descend. Considering the need of emergency management, shoulder dystocia drill should be practiced by the birth attendants. Head and neck should be grasped and taken posteriorly while suprapubic pressure is applied by an assistant slightly toward the side of fetal chest. This will reduce the bisacromial diameter and rotate the anterior shoulder toward the oblique diameter. McRoberts maneuver: Abduct the maternal thighs and sharply hyperflex them onto her abdomen.
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Milok, 65 years: In the reversible phase, unlike hypovolemic shock, pallor is absent; on the contrary, the face may be flushed. Color of the liquor in the partograph is recorded as-I: membranes intact; R: membranes ruptured; C: liquor clear; M: liquor meconium stained; B: liquor blood stained. In immunocompromised patients, the disease is more severe and extensive and may become disseminated.
Temmy, 62 years: Immunosuppressed patients and individuals with diabetes mellitus are particularly susceptible. Postpartum hemorrhage is more likely due to atonic uterus and trauma following operative B delivery. After drawing the blood samples for grouping and cross matching, volume replacement with colloids (hemaccel) is to be done.
Flint, 26 years: The woman should be in bed for 30 minutes following application and is monitored for uterine activity and fetal heart rate. The individual should have the liberty to choose any of the currently available well-tested method, which may even vary at each phase in her reproductive life. The membranes below the presenting part overlying the internal os are ruptured to drain some amount of amniotic fluid.
