Obstetrics 12

• Stage I   -  T10-12
• Stage II  -  S2-S4  -  pudendal nerve

Narcotics

• Active phase of  stage I.
• Do not give if multi is 8 cm dilated or primi is 10 cm dilated. It is because we do not want to have the sedative effect of narcotics when the baby is born because baby has to take its first breath after its delivery. 

[Note: Pudendal nerve block is given in second stage of labor]

• Transitory Fetal Bradycardia.
• Management is conservative. Just wait and the Heart rate comes to normal.

[Note: Anesthesia is injected in Frankenhauser's ganglion on either side of  cervix.]



(LUNA - Laparoscopic Uterine Nerve Ablation)

• Outlet  forcep –  fetal head on pelvic floor 
• Low – below +2 station but not reached  pelvic floor 
• Mid  - Below 0 station, but not reached +2 station 
• High – is unengaged, above 0  station

Prolonged second stage 

• It can be used in unrotated and malrotated occipito-posterior position [IOM 2061] of the head. 
• It can be applied even through incompletely dilated cervix. (1st stage of labor)[UP 94] 
• It is not a space occupying device like forceps blades. 
• Lesser traction force is needed.

• - Collection of blood in between the pericranium and the flat bone of the skull, usually unilateral and over parietal bone. 
• -It is never present at birth but gradually develops after 12-24 hours. [AI 92]
• - The swelling is limited by the suture lines of the skull.
• - It is soft, fluctuant, and imcompressible.
• - The swelling reabsorbs slowly within 2-12 weeks of birth, depending on their size.

• Caput succedaneum is a diffuse edema  of the fetal scalp that crosses the suture lines.
• Head compression against the cervix impedes venous return, forcing serum into the interstitial tissues.
• The swelling reabsorbs within 1-3 days.

Caput succedaceum -  above periosteum, crosses midline. 

Cepahlohematoma – below periosteum, [since it is below the bone, it is limited to periosteum and is limited to the bone, thus,  doesnot cross the midline]

• Subgaleal hemorrhage or hematoma is bleeding in the potential space between the skull periosteum and the scalp galea aponeurosis.
• 90% of hemorrhage is because of  vacuum delivery.

• [Note: Going from outer to inner we get --
• Caput - Subgaleal hemorrhage - Cephhalhematoma]

External cephalic version is a procedure to turn the fetal presenting part from a non cephalic presentation to a cephalic presentation. Because cephalic version is performed by manipulating the fetus through the abdominal wall, the maneuver is known as external cephalic version. 

Timing - It is done at 37 weeks. If it is done earlier, spontaneous turning is common. After 37 weeks, external cephalic version is difficult.

• Indications: 
• 1. Breech presentation - successful version is likely in case of complete breech (flexed breech) that is unengaged. 
• 2. Transverse lie/ Oblique lie - External version is much easier here than in breech presentation. 

• Contraindications:
• 1. Antepartum hemorrhage- Placental previa or abruption 
• 2. Fetal causes - congenital abnormalities, dead fetus 
• 3. Multiple pregnancy
• 4. Known congenital malformation of uterus 
• 5. Contracted pelvis 
• 6. Obstetrics complications - severe preeclampsia, [AI 07] obesity, elderly primigravida

• 1. Type 4/ Central placenta previa [AI 93,IOM 11]
• 2. Contracted Pelvis 
• 3. Cephalopelvic disproportion (absolute)
• 4. Pelvic mass causing obstruction
• 5. Advanced carcinoma cervix
• 6. Vaginal obstruction (atresia, stenosis)

• 1. Cephalo-pelvic disproportion 
• 2. Previous C/S 
• 3. Fetal distress [IOM 07]

• It is the disparity in the relation between the head and the pelvis. It may be due to:
• - average size baby with small pelvis
• - big baby with normal pelvis (hydrocephalus) or
• - combination of both

• Diagnosis can be done by:
• 1. Clinical method:
• - Abdominal method
• - Abdomino-vaginal method (Muller-Munro Kerr)
• 2. Imaging pelvimetry
• 3. Cephalometry
• - USG
• - MRI
• - X-ray

VBAC-TOL is Vaginal Birth After Caesarian - Trial Of Labour.

• Selection criteria for VBAC-TOL:
• - Previous Lower segment transverse scar
• - Pelvis adequate for fetus
• - Continued labour monitoring possible
• - Availability of resources for Em. CS
• - Informed consent of pt

• Contraindications for VBAC-TOL (Indications for CS):
• - Previous classical or inverted "T" shaped uterine incision
• - Previous 2 or more lower segment caesarean section
• - Pelvis contracted or suspected CPD
• - Presence of other complications in pregnancy- Obstetric (preeclampsia, malpresentation, placenta previa) or medical
• - Resources limited for em. caesarean
• - Pt. refusal for VBAC-TOL

B) Breech presentation

Lactation is reliable only for 3 months.

• Diaphragm and IUD – after uterus comes in its normal anatomy – 6 wks 
• E + P – estrogen increases the chance of thrombosis, start only after 3 weeks,  if she is breastfeeding, avoid estrogen. 
• Progestins – can be  used immediately.