Daniel J. Buysse, MD

• Department of Psychiatry, Pittsburgh, PA, USA

Routine prenatal screening remains the major line of defence against congenital syphilis [C] muscle relaxant histamine release ponstel 500 mg buy lowest price. Prenatal diagnosis of congenital toxoplasmosis with a polymerase-chainreaction test on amniotic fluid spasms between shoulder blades ponstel 500 mg buy without a prescription. An unusual constellation of sonographic findings associated with congenital syphilis spasms behind knee ponstel 250 mg purchase online. Fetal syphilis: correlation of sonographic findings and rabbit infectivity testing of amniotic fluid muscle relaxant walgreens ponstel 500 mg buy free shipping. In the absence of sufficient quantities of this energy infantile spasms youtube buy generic ponstel from india, cells will no longer be able to function and will eventually die. Where oxygen levels are insufficient to support oxidative phosphorylation, anaerobic metabolism occurs. Ultimately, the hypoxic fetus will no longer be able to maintain cellular metabolism, with resultant cell damage and death. The developing brain, myocardium and kidneys are the organs most sensitive to this damage, although fetal demise will eventually occur. In addition, hypoxia leads to build up of byproducts such as lactic acid, resulting in metabolic acidaemia, which in itself may exacerbate the effects of hypoxia on cellular metabolism. This is a more chronic process than respiratory acidosis, which occurs because of an inability of the feto-placental unit to rid the fetus of carbon dioxide. Practical skills · Assess fetal well-being by interpretation of maternal history, cardiotocography and ultrasound assessment. It therefore follows that the majority of fetuses subjected to tests designed to assess fetal well-being will be healthy. Those tests should not only be sensitive in their ability to detect a compromised fetus, but also specific in that they do not give an abnormal result when the fetus is well; poor specificity may lead to unnecessary parental anxiety and rates of intervention. A major problem in the evaluation of tests of fetal wellbeing is the absence of useful outcome criteria. Perinatal mortality is now too rare an occurrence and too late an outcome measure to be useful. The condition of the neonate at birth is of little help, because it is difficult to separate the effects of parturition from factors present antenatally. Long-term neurodevelopment can be assessed, but such an assessment is subject to many influences and is probably best done some five years after birth. The ideal test will be quick and easy to perform and will yield readily interpreted results that are reproducible. However, the causes include: reduced maternal oxygenation such as chronic disease states, utero-placental damage (see Chapter 15, Fetal growth restriction), 248 Tests of fetal well-being impaired fetal blood supply to the placenta, as in cord accidents, intrinsic fetal conditions resulting in poor tissue oxygenation, such as fetal anaemia. These include fetal breathing movements, gross body movements and fine motor movements. The linkage of gross body movements to other behavioural patterns has led to the description of fetal behavioural states. A third state, 4F, occurs when the fetus displays frequent and vigorous gross body movements; this appears to represent fetal wakefulness. Human fetal breathing movements occur 30 per cent of the time and gross body movements 10 per cent of the time during the last 10 weeks of pregnancy. Fetal heart rate variation increases during fetal activity, and accelerations are associated with fetal body movements. During this process, the fetus will demonstrate several adaptations designed to conserve energy and reduce oxygen. One of the first responses of the fetus is to reduce movements, although the human fetus may well adapt to hypoxia in the absence of acidaemia, with breathing movements, in particular, reverting to normal. Blood is distributed preferentially to the brain, myocardium and adrenals at the expense of organs such as the kidney. This renal hypoperfusion results in a reduced glomerular filtration rate, oliguria and hence reduced liquor volume. The majority of the currently available tests of fetal well-being are designed to detect these adaptive changes. However, all too often the mother will present too late, with her fetus already dead. Alternatively, the fetus may well be demonstrating normal activity with the mother failing to recognize those movements. The authors concluded that routine daily counting by women, followed by appropriate action when movements are reduced, seemed to offer no advantage over informal inquiry about movements during standard antenatal care and selective use of formal counting in high-risk cases [B]. It is recommended that women who report a reduction or an alteration in the movements of their fetus should be offered some form of assessment of fetal well-being [E]. The long-term variability of the heart rate is produced by a balance between sympathetic and parasympathetic tone, whereas short-term variability (baseline or bandwidth variability) reflects parasympathetic (vagal) tone. Heart rate variability is usually reduced in the compromised fetus and is virtually always absent prior to fetal death. The basis of this test is to invoke uterine contractions, thereby reducing placental perfusion and unmasking fetal compromise. This can be performed by inducing natural oxytocin release (nipple stimulation) or by maternal oxytocin administration, with the appearance of late fetal heart rate decelerations indicating fetal compromise. The role of this technique has yet to be established and it has been associated with reports of fetal death in cases of unrecognized severe fetal compromise [E]. Stimulation of the fetus by shaking, vibration or even by sound profoundly alters fetal behaviour and heart rate. Fetal heart rate variability has been found to be a better predictor of fetal compromise than the presence or absence of fetal heart rate acceleration or decelerations. However, the study was not large enough to demonstrate any effect on severe perinatal morbidity or mortality rates [B]. Biophysical activity Assessment of fetal activity has been used as a predictor of fetal compromise, with perhaps the best known system being described by Manning in the 1980s. Each component is scored discretely as normal (2) or abnormal (0), with a maximum of 10 and scores under 8 being regarded as abnormal (Table 14. The most advanced and widely used is that developed by the Oxford Group utilizing the Table 14. These episodes of high variation must be greater than the first centile for gestation (11 beats/minute at 38 weeks). There must be no large decelerations (>20 lost beats) the basal heart rate must be between 116 and 160 beats per minute. Fetal heart rate reactivity ­ Normal non-stress test over 20 minutes Amniotic fluid volume evaluation ­ One pocket >3 cm and subjectively normal 250 Tests of fetal well-being per cent and a positive predictive value of 35 per cent for perinatal morbidity including low Apgar scores, acidaemia at birth, fetal distress and fetal growth restriction. In addition, cessation of movements can occur for up to 40­60 minutes due to cycling in fetal behavioural states. Fetal biometry and Doppler ultrasonography these are covered in Chapter 15, Fetal growth restriction. Where fetal growth restriction is suspected, fetal biometry and assessment of umbilical artery waveforms by Doppler ultrasonography should be incorporated. Patterns of gross fetal body movements over 24-hour observation intervals during the last 10 weeks of pregnancy. Short-term fetal heart rate variation, decelerations, and umbilical flow velocity waveforms before labor. Comparison of visual and computerized interpretation of nonstress test results in a randomized controlled trial. A randomized clinical trial of daily nonstress testing versus biophysical profile in the management of preterm premature rupture of membranes. Practical skills · Be able to interpret the ultrasound diagnosis of fetal growth restriction by ultrasound. A better definition would be fetuses whose growth velocity slows down or stops completely because of inadequate oxygen and nutritional supply or utilization. There is little doubt that these fetuses experience not only increased rates of perinatal morbidity and mortality, but also higher levels of morbidity extending into adult life. These infants are also at high risk of perinatal hypoxia and acidaemia, operative delivery and neonatal encephalopathy. Neonatal problems include hypoglycaemia, hypothermia, hypocalcaemia and polycythaemia. Paradoxically, these infants have a slightly reduced incidence of respiratory distress syndrome, presumably because of the intrauterine stress resulting in increased surfactant production. Long-term data from the 1970 Ae tiology 253 fetuses suffering from reduced growth velocity will have a birth weight considered appropriate for gestational age ­ it does not seem to affect neonatal outcomes unless the fetus is also small, with an abdominal circumference under the fifth centile. Where the fetus is symmetrically small, both the head and the abdomen are equally affected. This pattern is seen where the fetal insult occurs in early pregnancy, such as with fetal infection, or where the fetus is abnormal. Of concern is the observation that infants delivered by women exposed to passive smoking are 190 g lighter than babies born to women not exposed to tobacco smoke. The causal mechanism of this effect is not clear, but is probably related to increased levels of fetal carboxyhaemoglobin. Consumption of more than 15 units (120 g) of alcohol has been associated with a small reduction (66 g) in birth weight, leading the Royal College of Obstetricians and Gynaecologists to recommend that pregnant women keep their alcohol consumption below this threshold [C]. Maternal size is of greater importance in determining fetal size than paternal build. In addition, ethnic and socioeconomic factors play a role, male fetuses being on average some 200 g heavier than their female counterparts at term. Maternal factors Nutrition Population studies such as those performed during the Dutch Hunger Winter in 1944 have demonstrated that significant effects were only seen at the extremes of starvation. Even then, the fetus is relatively protected during the first and second trimesters. Many severe maternal debilitating conditions can lead to a reduction in fetal growth. Severe cardiorespiratory compromise resulting in a failure of adaptation to pregnancy and maternal hypoxaemia can result in reduced fetal growth. Maternal conditions such as sickle cell disease, collagen vascular diseases and the antiphospholipid antibody syndrome, which result in reduced placental bed perfusion, can also result in reduced fetal growth. Lastly, maternal chronic hypertension, particularly if associated with renal impairment, is often associated with reduced fetal growth. Infection Reduced fetal growth is frequently seen in intrauterine fetal infection. The adequacy of blood supply to the placenta requires invasions and remodelling of the maternal spiral arteries by fetal extravillous trophoblast cells. The end result is destruction of the smooth muscle in the spiral arteries, converting them from high-resistance vessels to lowresistance circulation, thereby promoting an increase in maternal blood supply to the placental bed. This does not appear to result in hypoxia in the intervillous spaces but in a reduction in oxygen transfer to the fetus. On the fetal side of the placenta, this reduced oxygen transfer leads to high impedance of the fetal blood supply to the intervillous space. This may be due to obliteration or defective angiogenesis leading to a reduction in the tertiary villi. Congenital uterine anomalies have been associated with a reduction in fetal growth, as have large maternal fibroids. Babies born to older mothers are significantly smaller than the offspring of younger women, although this effect seems to be largely confined to nulliparous women over the age of 40. Pre-eclampsia is perhaps the best known, and many of the placental abnormalities are common to both conditions. Retroplacental haemorrhage in the second and third trimesters can impair placental function sufficiently to reduce fetal growth. Screening and detection 255 Maternal serum screening Several biochemical markers measured in the maternal serum in the second trimester are associated with reduced growth in later pregnancy. Palpation of the gravid uterus is the standard technique of clinically assessing fetal size; however, it should be remembered that parous women have proven to be more accurate in the estimate of the size of their fetuses than either care providers or one-off fetal measurement by ultrasound. Ultrasound assessment Ultrasound examination of the fetus allows biometric measurements; the fetal abdominal circumference is the most accurate predictor of the fetal weight. An estimate of the fetal weight can be made using this measurement, the head circumference, biparietal diameter and the femur length. In addition, comparison of the head and abdominal circumferences will indicate whether the small fetus is symmetrically or asymmetrically small. All suffer from poor specificity and sensitivity and are therefore of limited clinical use. Although this policy has been universally adopted, it has not been shown to be of benefit in clinical trials [E]. Mongelli and Gardosi10 have demonstrated that the use of customized fetal growth charts (again adjusted for variables, such as weight of previous children, maternal height, weight and ethnic group) may reduce this [C]. A 4-week measurement interval was shown to be superior to a 2-week interval, in terms of reducing the false-positive rate. Progressive fetal hypoxaemia results in blood flow redistribution, with blood being preferentially directed to the brain, with resultant diminished renal perfusion and fetal urine output. A careful history must be obtained from the mother and detailed fetal anatomical assessment, exclusion of fetal infection and karyotyping should be considered. Umbilical artery Doppler velocity studies Doppler assessment of the umbilical artery waveform demonstrates that, in normal pregnancy, there is forward flow from the fetus to the placenta throughout the cardiac cycle. Intervention by delivery is only appropriate if there is evidence of fetal compromise. The most important aspect of the biophysical profile would appear to be liquor assessment, and it should also be monitored closely (see Chapter 14, Antenatal tests of fetal well-being). Monitoring the growth-restricted fetus Once growth restriction is diagnosed, management options are limited to timely delivery, balancing the risks of continuing with the pregnancy against the risks of prematurity. This policy is based on the assumption that timely delivery will improve the outcome; however, this has never been tested (nor is it ever likely to be) by an interventional trial. This trial found no significant difference in deaths before discharge between immediate delivery and delayed delivery. Most of the observed difference was in disability in babies younger than 31 weeks of gestation at randomization: 14 (13 per cent) immediate versus five (5 per cent) delayed deliveries.

The transverse incision has the advantages of improved cosmetic results muscle relaxant india purchase ponstel 250 mg mastercard, decreased inter-operative and postoperative analgesic requirements and thus less pulmonary compromise and superior wound strength postpartum muscle relaxant 2mg buy generic ponstel online. Haeri demonstrated no difference between the two incisions when comparing overall operative time muscle relaxant natural remedies generic ponstel 250 mg otc, post-operative haemoglobins of <10 g/dL muscle relaxant ointment discount ponstel 500 mg with amex, or post-operative febrile morbidity [D] bladder spasms 5 year old ponstel 250 mg low cost. The Pfannenstiel incision the skin and subcutaneous tissues are incised using a transverse curvilinear incision at a level of two fingerbreadths above the symphysis pubis, extending from and to points lateral to the lateral margins of the abdominal rectus muscles. The subcutaneous tissues are separated by blunt dissection and the rectus sheath is incised transversely along the middle 2 cm. This incision is then extended with scissors or blunt dissection before the fascial sheath is separated from the underlying muscle. Separation is performed cephalad to permit adequate exposure of the peritoneum in a longitudinal plane and perforating blood vessels should be cauterized to minimize the risks of development of subrectus haematomas. The recti are separated from each other, the peritoneum incised and the abdominal cavity entered. It is the policy in many units for a catheter to remain in situ peri-operatively and for a defined period thereafter the Cohen incision this incision is similar to the Pfannenstiel incision, but permits a more rapid and bloodless entry into the peritoneal cavity. A straight transverse incision is made between 406 Caesarean section two points inferior and medial to the anterior superior iliac spine, the subcutaneous tissues are divided in the midline for 3 cm and the central rectus sheath is similarly divided. By blunt dissection and vertical traction, the subfascial space is opened, the peritoneum exposed and the abdominal cavity entered high above the bladder. Entry with this technique into the abdominal cavity is often not suitable for repeat caesarean sections, where scarring may distort the underlying fascial planes. The lower midline incision is made from the lower border of the umbilicus to the symphysis pubis, and may be extended caudally towards the xiphisternum if required. Sharp dissection to the level of the anterior rectus sheath is performed, which is then freed of subcutaneous fat in the midline. The rectus sheath is then incised, taking care to avoid damage to any underlying bowel, and extended inferiorly to the vesical peritoneal reflection and superiorly to the upper limit of the abdominal incision. Uterine incisions As with the skin incision, the nature of the uterine incision is determined by the clinical situation. A low transverse uterine incision is used in more than 95 per cent of caesarean deliveries due to ease of repair, reduced blood loss and lower incidence of dehiscence or rupture in subsequent pregnancies when compared with the alternative incisions. However, these include a lower uterine segment containing fibroids or a lower segment covered with dense adhesions, both of which may make entry difficult. Such obstruction may be associated with heavy bleeding or may distort the anatomy to such an extent that the lower segment approach is not safe. The uterus is palpated to identify the size and presenting part of the fetus and to determine the direction and degree of rotation of the uterus. A Doynes or similar retractor blade is inserted inferiorly and the loose reflection of vesico-uterine serosa overlying the uterus picked up with toothed forceps, opened with scissors and divided laterally. The uterus is then opened in a transverse plane for a distance of 1­2 cm; the incision may be extended laterally with either blunt dissection (lateral and upward pressure with the index fingers) or scissors. Such an incision should be adequate to allow delivery of the fetus without extension into the broad ligament or uterine vessels. If necessary, cutting the incision upward unilaterally (J-incision) or bilaterally (U-shape) will avoid such an extension and provide extra room. Damage to the uterine vessels or broad ligament, when it occurs, is associated with an increase in maternal morbidity (especially blood loss) and prolonged hospitalization. If a midline extension is required, the T-incision, in future pregnancies vaginal delivery will be contraindicated because of an increased risk of uterine rupture [C]. This entry is vertical on the uterus in the sagittal plane, is extended to the level of entry of the round ligaments, but is not taken onto the fundus (unlike a true classical section). If cephalic, the head is flexed and delivered by elevation though the uterine incision, either manually or with forceps. However, this should not be commenced until the presenting part is located within the incision ­ for fear of converting the lie from longitudinal to transverse. Some authors advise confirmation of a patent cervical canal to ensure a patent passage for the drainage of lochia, although this is not necessary in labouring women. Repair of the incision may be performed with the uterus in situ or following exteriorization. Exteriorization is not Complications 407 routinely necessary, but enhances visualization of the lower segment and thus facilitates surgical repair; especially when there have been lateral extensions to the incision margins. One trial reported a decrease in the haematocrit fall with exteriorization compared with intraperitoneal procedures, whereas another did not. The main problems with exteriorization are increases in maternal pain, vagal-induced vomiting and the incidence of venous air emboli, although the incidence of infectious morbidity is not altered. There is currently not enough information to adequately evaluate the routine use of exteriorization of the uterus for repair of the uterine incision. Peritoneal closure is unnecessary and may result in a higher incidence of adhesion formation than would otherwise occur [A]. Abdominal closure Closure is performed in the anatomical planes with highstrength, low-reactivity materials such as polyglycolic acid or polyglactin (Dexon and Vicryl). Interlocking of the sutures should be avoided as this can devascularize the tissues and delay the healing process. Here, repair should be effected with a running continuous suture of polyglycolic acid, large-bore monofilament polypropylene or nylon, which have delayed/prolonged absorption characteristics. The most common involve surgical staples, subcuticular stitches or tension sutures (interrupted or continuous/polyglycolic acid, large-bore monofilament polypropylene or nylon). However, lower transverse abdominal skin incisions closed with a subcuticular stitch result in less post-operative discomfort and are more cosmetically appealing at the 6-week post-operative visit when compared to incisions closed with staples. Closure should be performed in either single or double layers with continuous or interrupted sutures. The initial suture should be placed just lateral to the incision angle, and the closure continued to a point just lateral to the angle on the opposite side. If a second layer is used, an inverting suture or horizontal suture should overlap the myometrium. There are only two reported randomized, controlled trials comparing single-layer versus two-layer closure. A single-layer closure is associated with reduced operating time, with no statistically significant differences in the use of extra haemostatic sutures, incidence of endometritis, decrease in post-operative haematocrit or use of blood transfusion [B]. There have recently been some concerns regarding singlelayer closure, as one widely reported observational study of scar dehiscence in subsequent labours showed a higher incidence than previously reported. One possible aetiological factor that has been suggested is the move to single-layer closure during the period studied. The effectiveness and safety of single layer closure of the uterine incision is therefore uncertain and, except within a research context, the uterine incision should be sutured with two layers. However, vertical lacerations into the vagina or lateral extensions into the broad ligament may be associated with substantial blood loss and the potential for ureteric damage. To minimize bleeding from the perforated myometrial vessels in such cases, the needle must be positioned just distal to the apex of the laceration and, once inserted, should not be withdrawn. The management is dependent on the site of the injury, and is best conducted in conjunction with a general surgeon. Small bowel damage is repaired using a two-layer closure with 2-0 Vicryl or equivalent. Large First stage of labour 408 Caesarean section bowel damage is managed likewise, but in addition a temporary defunctioning colostomy may be required. Post-repair peritoneal lavage is mandatory, as is a treatment course with broad-spectrum antibiotics, for example a cephalosporin and metronidazole. Pre-operative catheterization in association with careful operative technique should reduce the likelihood of damage occurring. If damage to the bladder is suspected, transurethral instillation of methylene blue-coloured saline will help to delineate the extent of the defect. When such an injury is observed, a repair with 2-0 Vicryl as a single continuous or interrupted layer is appropriate. The urinary catheter will need to remain in situ for 7­10 days and prophylactic antibiotics prescribed. Damage to the ureters is uncommon, as reflection of the bladder displaces them rostrally, but if suspected, the ureters should be investigated and repaired in conjunction with a urological surgeon. This complication may be due to the operative procedure as a consequence of damage to the uterine vessels, or may be incidental as a consequence of uterine atony or placenta praevia. There are many manoeuvres that may be employed to manage such cases, which range from bimanual compression, infusions of oxytocin and administration of 15-methyl prostaglandin F2 to conservative surgical procedures such as uterine compression sutures, to the more radical, but lifesaving, hysterectomy. In patients with an anticipated high risk of haemorrhage, for example known cases of placenta praevia, at least four units of blood should be routinely cross-matched, and must be available in theatre before the procedure is commenced. A combined approach to the management of such patients, with the anaesthetists, haematologists and obstetricians working together, will result in the best standard of care. This operation, while a major undertaking, should not be left too late as the risk of operative complications, maternal morbidity and mortality increase with increasing haemorrhage. Although postpartum haemorrhage is relatively common (occurring after about 1 per cent of deliveries), life-threatening haemorrhage requiring immediate treatment affects only 1 in 1000 deliveries. It is important to note that the Confidential Enquiries continue to cite delays in performing definitive surgery, for example a hysterectomy, as an avoidable cause of maternal mortality. This complication alone accounts for 30 per cent of emergency caesarean hysterectomies. It is also important to counsel such patients accordingly, and to gain consent preoperatively for caesarean hysterectomy when appropriate. The incidence of post-operative wound infection has been quoted to be between 1 and 9 per cent. The following factors are associated with an increased risk of postoperative infection: It should be remembered that the pelvic tissues in the pregnant woman are lax, with increased vascularity. They are therefore prone to bleed more freely than in the nonpregnant state, and extra care must be taken to ensure the pedicles are correctly ligated. Identification of the lower margin of the cervix may be exceedingly difficult, and a subtotal procedure may need to be considered. This should include the categorization of the degree of urgency of the procedure and critical timings, i. The type of suture material used, the procedure and any complications must be recorded. The surgeon should include a note that the cavity of the uterus was checked and empty and that ovaries and tubes were inspected. The blood loss must be noted and for all emergency procedures the cord gas results should be recorded. Clear post-operative instructions should include a note on suture removal (or not) and, if there are any specific instructions, these must be clearly recorded and communicated to the midwife caring for the woman. Labour, its duration and the presence of ruptured membranes appear to be the most important factors, with obesity playing a particularly important role in the occurrence of wound infections. The most important source of microorganisms responsible for post-caesarean section infection is the genital tract, particularly if the membranes are ruptured preoperatively. Even in the presence of intact membranes, microbial invasion of the intrauterine cavity is common, especially with preterm labour. The pathogens isolated from infected wounds and the endometrium include: Post-operative complications Infection and endometritis the single most important risk factor for postpartum maternal infection is caesarean delivery, and women undergoing caesarean section have a 5­20-fold greater risk of an infectious complication when compared with a vaginal delivery [D]. These complications include fever, wound infection, endometritis, bacteraemia, other serious infection (including pelvic abscess, septic shock, necrotizing fasciitis and septic pelvic vein thrombophlebitis) and urinary tract infection. Such sequelae are an important and substantial cause of maternal morbidity and are often associated with a significant increase in the length of the hospital stay. It should be remembered that fever can occur after any operative procedure, and a low-grade fever following a caesarean delivery may not necessarily be a marker of infection. Other common causes that enter the differential Escherichia coli and other aerobic Gram-negative rods; group B Streptococcus; other Streptococcus species; Enterococcus faecalis; Staphylococcus aureus; coagulase-negative staphylococci; anaerobes (including Peptostreptococcus species and Bacteroides species); Gardnerella vaginalis and genital mycoplasmas. Although Ureaplasma urealyticum is commonly isolated from the upper genital tract and infected wounds, it is unclear whether it is a pathogen in this setting. Wound infections caused by Staphylococcus aureus and coagulase-negative staphylococci arise from contamination of the wound with the endogenous flora of the skin at the time of surgery. The general principles for the prevention of any surgical infection include careful surgical technique, skin antisepsis and antimicrobial prophylaxis. Without prophylaxis, the incidence of endometritis is reported to range from 20 to 85 per cent and the rates of wound infection and serious infectious complications may be as high as 25 per cent. The reduction in the risk of endometritis with antibiotics appears to be similar across a spectrum of patient groups: First stage of labour 410 Caesarean section Table 31. The common regimens have been subjected to a number of trials and have been summarized by meta-analysis [A]. Almost all trials included endometritis, febrile morbidity, wound infection and urinary tract infection as outcome measures. In only three trials were antibiotics given pre-operatively, making comparison of the timing of the first dose impossible. The analysis examined types of antibiotic prophylaxis, single-dose versus multiple-dose regimens and method of administration (systemic versus peritoneal lavage). The drug regimens compared included comparisons of different types of cephalosporins, extended spectrum penicillins, ampicillin and ampicillin plus gentamicin. The most recent large randomized, controlled trial (not included in the meta-analysis) suggested again that prophylactic antibiotics might be unnecessary [B]. Prophylactic antibiotics did not decrease febrile morbidity, wound infection, endometritis, urinary tract infection and pneumonia. Putting the data from this trial into the meta-analysis gives a relative risk for endometritis in the treatment group of 0.

In the Term Breech Trial muscle relaxant herniated disc cheap 500 mg ponstel otc, the excess neonatal morbidity was approximately 1 per cent and the neonatal morbidity 15 per cent muscle relaxant drugs specifically relieve muscle purchase ponstel 500 mg fast delivery. With the sacrum anterior muscle relaxant suppository 250 mg ponstel purchase, the anterior hip leads and esophageal spasms xanax purchase ponstel now, on meeting the pelvic floor muscle relaxant elemis muscle soak ponstel 500 mg buy with visa, is rotated anteriorly beneath the pubic arch. Should the posterior hip reach the pelvic floor first, it undergoes long anterior rotation. The breech is then held up behind the pubic arch, lateral flexion allowing the posterior hip to be born first. The fetus then straightens as the anterior hip is delivered, the legs and feet following. As the shoulders enter the brim in the oblique or transverse diameters, the trunk undergoes external rotation. The shoulders then descend and undergo internal rotation, which brings them into the antero-posterior diameter of the pelvic outlet. This rotates until the posterior part of the neck becomes fixed under the subpubic arch and the head is born by flexion. Management during the first stage Procedure: breech delivery the principle of vaginal breech delivery is to allow the spontaneous delivery of the fetus through the combination of uterine activity and maternal expulsive efforts. Operator intervention should be limited to a few welltimed manoeuvres, with injudicious traction on the fetal body or limbs avoided at all costs. Not only can traction lead to direct injury, such interventions may also increase displacement of the fetal limbs from their normal attitude, increasing the relative disproportion between fetus and pelvis that may already exist. The mechanism of delivery is divided into three stages: delivery of the fetal hips (bitrochanteric diameter); delivery of the shoulders (biacromial diameter); and delivery of the head (biparietal diameter). With a breech, the presenting part usually engages with the bitrochanteric diameter occupying the oblique Table 35. An epidural anaesthetic may be recommended in order to prevent involuntary expulsive efforts prior to full cervical dilatation, and to permit emergency delivery by caesarean section should the clinical situation demand it. However, epidural anaesthesia is not essential, and in fact there may be a higher chance of obtaining a successful vaginal delivery without it [D]. However, augmentation of uterine activity may still have a place in the management of a few select cases, but only after careful review of the facts, senior obstetric advice and, most importantly, discussion with the mother and her partner concerning their wishes. Management during the second stage Maternal Soft tissue injuries to genital tract with increased morbidity the active second stage of labour only begins with full cervical dilatation and visualization of the fetal anus at the perineum, and must be managed by an operator trained in the delivery of the breech. There are different opinions about the best way to manage a breech delivery and there is no evidence to support one method above the other. In some countries (such as the Netherlands), spontaneous breech delivery is the norm. An episiotomy may be performed at this stage as it will facilitate the manual and forceps manipulation of the after-coming head and may be exceedingly difficult to perform at a later stage of the delivery process. Flexion of the fetal knee by pressure in the popliteal fossa associated with abduction of the thigh will aid delivery of the legs, which should then be supported. Ideally, the remainder of the delivery from this stage should be achieved with the minimum of interference, although this is seldom the case. Once the legs and abdomen have emerged, the fetus should be allowed to hang from the perineum until the wings of the posterior scapula are seen. The arms are frequently folded across the fetal chest, and require no particular manoeuvres to expedite their delivery. No attempt should be made to deliver an arm until the scapula and one axilla are visible. If this technique fails, grasping the arm by hooking a finger over it may result in its delivery ­ but is also likely to result in a humeral fracture. Forceps may be applied in the usual fashion to facilitate and slow delivery of the fetal head. Too rapid an extraction may result in decompression forces on the fetal skull inducing intracranial bleeding or tentorial tears. This allows the head to descend into the pelvis and avoid the complications of hyperextension that can occur with traction at this stage. The duration of time that should be allowed to lapse from the visualization of the umbilicus to the fetal mouth clearing the perineum should be maximally 10­15 minutes ­ this is not based on any specific evidence, rather a pragmatic approach to minimize the duration of the second stage. With the fetus supported on the right forearm of the accoucheur, the middle finger is placed into the fetal throat and the forefinger and ring finger are placed either on the malar eminences. Pressure is applied to the fetal tongue to encourage flexion of the head and thus present the favourable suboccipito-bregmatic diameters to the pelvis. This often allows spontaneous delivery of the fetal head without further intervention, the application of forceps may be required to aid delivery of the head. As the smallest part of the fetal head is lowest in the vagina, the accoucheur must ensure that the forceps blades accommodate the occiput. Premature straightening of the blades may not only result in undue pressures on the fetal head, but may also expose the maternal soft tissues to the perils of instrumental trauma. Should the head fail to descend into the pelvis following delivery of the shoulders: Although these manoeuvres have been practised for many years, they actually bear little resemblance to what happens during a spontaneous breech delivery. Bracht has described an alternative set of manoeuvres, which not only appear to be safe for the mother and baby, but are also less complicated for the accoucheur to perform. Breech extraction With breech extraction, the obstetrician delivers the infant with little or no assistance from the mother. The only indication for performing a breech extraction is to deliver a second twin. Before starting, the accoucheur must ensure that the cervix is fully dilated and that there are no mechanical obstacles to delivery. However, performance of a caesarean section does not prevent the possibility of birth injury, especially with injuries concerning the fetal abdominal organs, spine and head, and precautions similar to those undertaken with a vaginal breech delivery should be observed. As this number can be expected to fall further following the conclusions of the Term Breech Trial, alternative methods of training urgently need to be introduced. It is therefore imperative that any woman who gives birth to a breech vaginally should be cared for by an attendant(s) with suitable experience. Management of the twin breech In the majority of studies to date, the major problems associated with vaginal breech delivery relate to fetal distress in labour and difficult delivery. However, these trials only include singleton pregnancies and do not specifically address the problems for twins. Nevertheless, the plan for delivery will need careful consideration and full discussion with the parents, preferably before the onset of labour. It is equally as important to realize that no changes in neonatal morbidity or mortality in breech-presenting twins (first and second) were noted in one study over a time period during which the caesarean section rate increased dramatically (21 per cent to almost 95 per cent) [D]. Where the second twin is non-vertex (about 40 per cent of twins), it is the consensus opinion that vaginal delivery is safe [E]; studies show no difference in 5-minute Apgar scores or in any other indices of neonatal morbidity or mortality between the two groups. Thirty per cent of breech presentations are not diagnosed until the onset of labour. Abdominal palpation has been shown to have a sensitivity of 28 per cent and specificity of 94 per cent. In a subanalysis of the Term Breech Trial, the risk of the combined outcome of perinatal mortality, neonatal mortality or serious neonatal morbidity with planned caesarean section compared with planned vaginal birth was 16/1006 (1. At term, the first question that must be addressed when confronted by a breech presentation is `Where is the placenta Planned caesarean section greatly reduces both perinatal/ neonatal mortality and neonatal morbidity, at the expense of somewhat increased maternal morbidity. The questions of long-term morbidity and the cost implications of implementing a policy of caesarean section for all breech deliveries have not been addressed. Second stage of labour 446 Breech presentation Evidence from the Term Breech Trial cannot be directly extrapolated to preterm breech delivery. As a consequence, the management of the preterm breech remains an area of clinical controversy. The most experienced obstetrician available should manage labour, with continuous fetal monitoring as standard. Epidural anaesthesia may be provided if the mother so wishes, but is not compulsory. Premature expulsive efforts must be discouraged, as these can lead to head entrapment, nuchal arms and hyperextension of the fetal head. Long-term outcome by method of delivery of fetuses in breech presentation at term: population-based follow up. The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in the Netherland: an analysis of 35453 term breech infants. Reliability of fetal buttock sampling in assessing the acid­base balance of the breech fetus. Second-degree trauma involves injury to the perineum, including the perineal muscles, but not involving the anal sphincter. Third-degree extensions involve any part of the anal sphincter complex (external and internal sphincters) and fourth-degree encompasses extension into the rectal mucosa. In addition, we suggest the following: Theoretical skills · Revise your knowledge of pelvic anatomy. Practical skills · Be able to counsel women in antenatal clinic who have undergone female genital mutilation. It is a cause for concern for many women and in some countries has led to a large increase in the numbers of women requesting elective caesarean section. Fourth degree: injury to the both the external and internal anal sphincter complex extending into the rectal mucosa. It is important to recognize that there are significant differences in extension rates for mediolateral and midline episiotomies. Meta-analyses that do not make this distinction are unlikely to adequately assess the effect of episiotomy. Where episiotomy is restricted, some, but not all trials have shown an increase in anterior vaginal trauma, but this does not equate to an increase in urinary problems. The perineum following delivery is often the source of much discomfort and pain for many women. This can result in a cascade of events such as dyspareunia, psychosexual dysfunction, maladjustment to motherhood and relationship breakdown. Minimizing the risk of perineal trauma should therefore be at the forefront of care during labour. Combining trials for examination of pain after delivery was not possible because of the heterogeneity of reported outcomes, but it is clear that pain scores in the short term were generally lower in all trials in the restricted episiotomy groups (42. Women in the restrictive episiotomy groups were likely to resume sexual intercourse earlier. Malposition of the fetal head in labour is a risk factor for long labour and instrumental delivery and thus perineal trauma. There is considerable high-level evidence that the routine use of episiotomy (trial mean 71. Where an episiotomy is performed, the recommended technique is a mediolateral episiotomy originating at the vaginal fourchette and usually directed to the right side. The angle to the vertical axis should be between 45 and 60° at the time of the episiotomy [A]. This final point is an important practice point, as a common error made by inexperienced practitioners is to angle the episiotomy too medially. Perineal stretching at crowning makes the perineum appear broader and therefore a much more horizontal angle of incision is required than would be expected. Midline episiotomy certainly Conduct of normal birth In nulliparae during the weeks before giving birth, perineal massage appears to protect against perineal trauma (risk difference -0. Thus, conduct of the delivery in terms of a hands-on or hands-off approach showed no advantage of one method over the other. The use of lidocaine spray has been evaluated and shown to have no effect on pain, but possibly a small reduction in trauma rates [B]. Non-supine positions were also associated with higher rates of bleeding, but fewer fetal heart rate abnormalities, a marginally shorter second stage (by 4. It is unacceptable to perform a perineal repair with inadequate anaesthesia, just as performing a caesarean section without adequate anaesthesia would be considered unacceptable. If the practitioner is inexperienced in the examination of the anal sphincter, someone with experience should be called at this stage. One study has shown that when the practitioner is uncertain, re-examination by a trained person identifies significantly more anal sphincter ruptures. Minor first-degree trauma that is not bleeding and where the skin edges are opposed does not need closure; however, a careful examination should be undertaken to ensure there is no damage to the perineal muscles. Women should be advised that second-degree trauma should be sutured, as this leads to faster healing and less gaping of the perineum. Some authors use a continuous suture technique to perform the entire repair, finishing with a subcuticular skin suture. It is vital to ensure that the apex of the vaginal component is secured, as paravaginal haematoma formation can occur if the apex is missed. When individual bleeding arteries are identified, they should be ligated separately. Once the repair is complete, it is important to perform the following: Mode of delivery Mode of delivery has a large impact on rates of perineal trauma. Of course, elective caesarean section prevents damage to the perineum from labour-related events, and reducing the rates of instrumental vaginal delivery will reduce the incidence of perineal trauma. Ventouse delivery appears to be associated with less perineal trauma (see Chapter 34, Instrumental vaginal delivery). Therefore, given that the highest rates of severe perineal damage occur in women for whom two instruments are needed to achieve delivery, the first choice must be the instrument most likely to deliver the baby safely and with which the obstetrician is experienced. Ventouse delivery in a multiparous woman may not require any episiotomy, and an intact perineum may result. However, a forceps delivery in a nulliparous woman is likely to require episiotomy (although even for this, there is no evidence that episiotomy reduces the likelihood of extended trauma). Epidural analgesia has been shown to be associated with an increased risk of instrumental vaginal delivery, with the attendant perineal morbidity. Perform a rectal examination to ensure no sutures have breached the rectal mucosa and to palpate the anal sphincter to ensure it is intact. Therefore, a technique utilizing a continuous technique is likely to produce results as good as any other, with a minimal use of suture material, reducing infection risk.

Persistent vomiting in the first trimester will necessitate intravenous administration of anticholinesterases spasms in your sleep purchase line ponstel. Prolonged labour (associated with delayed gastric emptying and malabsorption) may also be an indication for parenteral drug delivery muscle relaxant that starts with the letter z cheap ponstel 500 mg online. Anticholinesterases are considered safe in pregnancy back spasms 26 weeks pregnant effective 500 mg ponstel, although neonatal intestinal tube muscular hypertrophy has been reported following a pregnancy exposed to very high doses spasms in lower left abdomen generic 500 mg ponstel amex. Although there have been concerns regarding the teratogenicity and fetal effects of corticosteroids and azathioprine muscle relaxant pills over the counter 250 mg ponstel order with amex, their use is not contraindicated [E] and most clinicians will continue using them through pregnancy if an indication exists. Experience with cyclosporin in pregnancy is growing, although there remains an added possible risk of intrauterine growth restriction. Methotrexate should be avoided before and during pregnancy due to its teratogenic effects. The theoretical reduction in serum hormone levels brought about by plasmapharesis has not caused preterm labour in practice. Miscarriage rates and preterm delivery rates are not significantly different from those of a control population [C]. Transplacental passage of the immunoglobulin G autoantibodies may cause two distinct fetal/neonatal problems. Although the aetiology of this syndrome is diverse, severely reduced movement in utero is thought to be the basic mechanism. Animal experiments have shown that sera from women with anticholinergic receptor antibodies can cause a similar range of anomalies in vivo. The onset is usually within 24 hours and most cases are mild, presenting with generalized hypotonia, poor sucking, difficulty in feeding and weak cry. The newborn is usually treated with anticholinesterases but exchange transfusions, plasma exchange and intravenous immunoglobulins have been used in more resistant cases. However, seronegative mothers may be less likely to have an affected baby, and affected babies themselves are usually seropositive. Preterm delivery is only necessary in severe crises and a vaginal delivery should be aimed for [E]. Problems may occur in second stage due to the skeletal muscle fatigue and there should be a low threshold for instrumental delivery. Advice should be taken before any medications are prescribed, as various drugs may precipitate a myasthenic crisis. Magnesium sulphate is contraindicated for the treatment of hypertension or eclampsia. The aetiology of pregnancy-associated stroke is very different from that of stroke in general. In women under 40 years of age, infarcts are more common than haemorrhagic strokes. However, this predominance of infarcts is less marked in the pregnancy-associated group. Various studies have estimated a stroke risk of between five and ten per 100 000 deliveries, although a Canadian retrospective review gave a 6-fold higher risk than this. Outside of pregnancy they are a much less common cause of subarachnoid haemorrhage than aneurysms. A few will present with recurrent headaches and neurological deficit, but without haemorrhage. Subarachnoid haemorrhage may present with headache, vomiting, reduced consciousness, neck stiffness and focal neurology. In view of the high risk of rebleeding, most advocate early treatment rather than an initial delay. Neurosurgery is normally tolerated well by the pregnancy, although decision-making can be complicated by reduced maternal conscious level. A longer passive second stage is usually encouraged to reduce the need for the Valsalva manouevre, with early recourse to instrumental delivery [E]. Poor maternal clinical state (coma, brainstem death) is of course another indication for caesarean section. Paraplegia 121 Epidurals can be used provided there is no evidence of raised intracranial pressure. Special anaesthetic techniques are used to limit the hypertensive responses found with intubation, which carry the risk of precipitating a rebleed [E]. Investigation and treatment of the pregnant patient with stroke obviously require significant input from neurologists and neurosurgeons. However, all those in maternity care have an important part to play in stroke prevention. For example, women with antiphospholipid syndrome and thrombophilias can be treated, once recognized, with prophylactic anticoagulation [D]. Optimal management of hypertension in pre-eclampsia and eclampsia will also help to reduce the associated stroke risk [D]. Clinically, they must be differentiated from much less common but far more serious causes of headache (see below). Making a diagnosis may involve special investigations and the help of a neurologist or radiologist. A classical migraine attack in a woman with a history of migraines does not normally warrant review by a neurologist. Visual disturbance, aphasia and paraesthesia or numbness usually last no more than an hour or so and are followed by a throbbing unilateral headache with associated nausea, vomiting and photophobia. However, as many as one in ten women with migraine in pregnancy have no previous history [D]. In view of the considerable symptom overlap with other diagnoses, a specialized opinion may be warranted. This applies also to women with migraine who suffer a presumed attack with atypical or prolonged neurological deficits. Hemiplegic migraine, for example, may last for many hours and should raise the possibility of an alternative diagnosis. Every effort should be made to avoid precipitating factors, such as chocolate and cheese. Non-drug therapies such as relaxation techniques, sleep, massage and ice packs can be tried. Acute attacks in pregnancy are normally treated with paracetamol (rectal may be better than oral administration) and/or codeine-based drugs along with an anti-emetic such as metoclopramide. Occasional use of non-steroidal anti-inflammatory drugs is permitted, but should be avoided after 32­34 weeks [C]. Ergotamine derivatives should be avoided, although studies have failed to show obvious harm. Initial data collected by the manufacturers of unintended pregnancy exposures have demonstrated no clear problems, but it is still best avoided at present [E]. Prophylaxis against migraine attacks in pregnancy is best provided by low-dose aspirin or amitriptyline (commencing with low doses such as 10 mg per day). Propranolol and atenolol have been used, with the awareness of the associated potential for intrauterine growth restriction. Those women who have cycle-related migraines are most likely to note an improvement. Women with spinal cord lesions at T6 or above are at risk of autonomic hyperreflexia and should be cared for in a setting where invasive monitoring and physicians experienced with autonomic hyperreflexia are available. Pre-eclampsia, fetal growth restriction and stillbirth are not more common in this population, and antenatal testing for fetal wellbeing is not indicated in the absence of other obstetric indications. However, serial cervical assessment (using ultrasound) and home uterine contraction monitoring have not proven useful in detecting women at increased risk of pre-term labour in this population. Antenatal complications: maternal 122 Neurological conditions Intrapartum care Previous recommendations against performing inductions of labour have been made because of concern of autonomic hyperreflexia. Most studies available do not provide enough detail to suggest that induced labour is more difficult to manage than spontaneous labour with regards to autonomic hyperreflexia and it is therefore reasonable to restrict inductions to obstetric indications. However, spasticity and contractures can impair the ability to achieve a vaginal delivery. If the patient has limited abduction and rotation, preventing use of the lithotomy position, she should be assessed for suitability of positioning on her side with flexion of the upper leg at the hip. The surgery will continue to incite the process but can be lifesaving if the time to delivery seems remote. Frequent bladder emptying or catheterization will prevent over-distension in patients with neurogenic bladder. Therefore, patients with lesions above T10 may not perceive labour at all but those with lesions above T5­6 may benefit from anaesthesia to prevent autonomic hyperreflexia. Alternatively, a healthy woman with a previously affected child may come under your care. Such individuals may or may not be interested in recurrence risks in their offspring. Although cerebral palsy usually occurs as a result of various environmental factors, genetic factors are responsible for a few cases, raising the recurrence risk. A careful family history is vital, but help is likely to be needed from neurologists, paediatricians and clinical geneticists. Once the maternal diagnosis has been established, empiric recurrence risks can often be quoted. In a few cases, genetic testing offers the possibility of more precise prenatal prediction. This entire process can take many weeks, and plans should be made before the woman actually becomes pregnant, if possible. The triplet repeat diseases highlight best some of the complexities of prenatal testing. Myotonic dystrophy is the most common muscular dystrophy affecting pregnant women and occurs as a result of the disruption of a gene coding for a protein kinase on chromosome 19. More than 40 is abnormal, and mildly affected individuals will show a degree of expansion beyond this size. Clinical features include muscle weakness, myotonia of hands and tongue, swallowing and speech disability, cataracts and cardiac arrhythmias, testicular atrophy and peripheral insulin resistance. Care should be taken to avoid urinary retention, no matter what the mode of delivery, in order to prevent a deterioration in bladder function and to minimize the risk of urinary infection and autonomic hyperreflexia. Breastfeeding should be encouraged; no deficiency in the let down reflex has been observed, even in patients with high cervical lesions. Acknowledgement 123 Myotonic dystrophy is an autosomal dominant condition, affected individuals having one normal and one abnormal allele. Quite how severely affected the child will be is difficult to predict with any degree of accuracy. A woman with moderate to severe disease herself is likely to have a significantly expanded mutation already. If this is inherited by the fetus, further expansion is likely and the neonate will be born with severe congenital myotonic dystrophy. Preterm delivery is more common, and severe hypotonia and respiratory difficulties are evident at birth. Talipes and facial diplegia may be present and survival beyond the neonatal period is followed by significant developmental delay in most cases. A woman with minimal or absent disease (and therefore a shorter expansion) has a risk of approximately one in ten that her child will be severely affected. However, if such a woman has delivered a severely affected newborn in a previous pregnancy, the risk of another badly affected child is higher (approximately 40­80 per cent). This reflects the greater likelihood that she has an inherently unstable mutation. Inheritance and further expansion of the mutated allele can be detected by molecular testing carried out on placental biopsy material, although precise analysis of expansion size and prediction of outcome can still be difficult. Epilepsy and pregnancy: a prospective study of seizure control in relation to free and total plasma concentrations of carbamazepine and phenytoin. Population based, prospective study of the care of women with epilepsy in pregnancy. Pregnancy is associated with a lower risk of onset and a better prognosis in multiple sclerosis. Practical skills · Be able to provide women with reassurance regarding the normal physiological cutaneous changes in pregnancy. Oestrogen is probably responsible for cutaneous vascular changes such as an increase in spider naevi, palmar erythema and even the occurrence of head and neck haemangiomas. Oedema is almost universal, and venous varicosities of the legs, vulva and rectum often become more prominent or appear for the first time. Striae gravidarum are pinkish purple linear markings on the lower abdomen and breast, which later fade to white and usually persist after pregnancy is over as depressed, irregular bands. Postpartum alopecia, however, is a recognized phenomenon that is usually mild and transient. As with all preexisting maternal conditions, one must consider the effect both the disease and its therapies will have on the pregnancy, the labour, the fetus and the neonate. Conversely, the pregnancy may influence the course and nature of the condition itself. The effect of pregnancy on atopic dermatitis (atopic eczema) and psoriasis is unpredictable. A generalized pustular psoriasis may occur in pregnancy (see below) and is more common in women with previous psoriasis. Sebum secretion increases in pregnancy and may be responsible for the common deterioration of acne during pregnancy. Apocrine gland activity, on the other hand, declines in pregnancy, meaning that the rare conditions affecting these glands (hidradenitis suppurativa and Fox­Fordyce disease) are likely to improve. The pregnancy-associated suppression of cell-mediated immunity is thought to cause the often marked increase in human papilloma virus warty lesions (condylomata acuminata).

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