4-name the position of patient -ues for what -name of picture-name the position of patient-ues for what-How to do speculum Examination- is it most common1- Cusco’s or bivalve speculum2-women in the dorsal position3-examine the cervix4-Use a warm and well lubricated speculum.The labia minora must be adequately parted with the left hand.Insert the speculum upwards and backwards (direction of vagina)Advance into vagina fully.Directly visualize as you open the plates to expose the cervix.If cervix not seen: close plates, withdraw slightly, change direction and open again.5- Cusco’s bivalve is more frequently used
6-name the position of patient -ues for what -name of picture-name the position of patient-ues for what1-a sims speculum2-left lateral position3-used in pelvic organ prolapse.For examine posterior vaginal wall
8Name the manuver Use for what 1-Bimanual Vaginal Examination 2- to palpat the the uterus and adenexia
9Described the picture Adnexae:to assess Mal ovaries are usually not palpableAny masses systic/solid and described approximate sizeTenderness is assessed by direct digital pressure into the fornices and cervical
10Obstetrical maneuvers. Fundal height Using reference points.Using a tape
11Obstetrical grips (Leopold’s maneuvers). Fundal grip (First maneuver) What fetal part occupies the fundus if soft consistency/ indefinite outline broad & irregular breechIf hard, smooth, well defined, rounded, bullottable head
12Obstetrical grips (Leopold’s maneuvers). Lateral grips (Second maneuvers).On which side is the fetal back ?Lie.Position.Where to auscultate for FHS.
13Obstetrical grips (Leopold’s maneuvers). First pelvic grip - Pawlik’s grip (Third maneuver).What fetal part lies over the pelvic inlet?.Presentation.
14Obstetrical grips (Leopold’s maneuvers). Second pelvic grip (Fourth maneuver)EngagementAttitude
15A and B. Children with Down syndrome, which is characterized by a flat, broad face, oblique palpebral fissures, epicanthus, and furrowed lower lip.C. Another characteristic of Down syndrome is a broad hand with single transverse or simian crease.
16Structural chromosome abnormalities Patient with Prader-Willi syndrome resulting from a microdeletion on paternalchromosome 15.If the defect is inherited on the maternal chromosome, Angelmansyndrome occurs
17Barr body (arrows) in the epidermal spinous cell layer Nuclear appendage ("drumstick") identified by arrow in white blood cells
18Hypothalamic-pituitary- gonadal axis CNS+/-hypothalamus+/-neuronsgonadotropin releasing hormone+/-+_ant. pituitary+/-LHFSH(LH R)thecal cellsandrogensinhibingranulosa cellsLH Rهذي الصوره متكرره مرتين بالمحاضره يمكن يحط فراغات باماكن الهرمونات واحنا نعبيها أو يتنيذل ويقول اشرحي عمل الهرموناتThe Hypothalamus Secretes GnRH, Which Causes the Anterior Pituitary Gland to Secrete LH and FSH: the pulsatile nature of GnRH release (lasting 5 to 25 minutes that occur every 1 to 2 hours) is essential to its functionEstrogen in small amounts has a strong effect to inhibit the production of both LH and FSH. Also, when progesterone is available, the inhibitory effect of estrogen is multiplied, even though progesterone by itself has little effect.These feedback effects seem to operate mainly on the anterior pituitary gland directly, but they also operate to a lesser extent on the hypothalamus to decrease secretion of GnRHHormone inhibin from the corpus luteum inhibits FSH and LH SecretionHormone activin from the stimulates FSH SecretionFSH Rprogestinsactivinestrogens+Reproductive tract
19when secretion throughout the sexual life of the female? The increasing levels of estrogen secretion at puberty,the cyclical variation during the monthly sexual cycle,the further increase in estrogen secretion during the first few years of reproductive life,the progressive decrease in estrogen secretion toward the end of reproductive life, and, finally,almost no estrogen or progesterone secretion beyond menopause.
21Growth in puberty Girls: 1-When start growth acceleration ? 2-When peak growth velocity occurs ?)3-When menarche occurs?1-Growth acceleration begins at the onset of puberty2-Peak growth velocity occurs earlier (6-9 months after thelarche)3-Menarche occurs after peak growth velocity
22Growth in puberty Boys: When Peak growth velocity occurs? Boys: Peak growth velocity occurs relatively late in puberty
23Define of this endometrial cycle? How much day each cycle take ? proliferative phase: proliferation of the uterine endometrium;secretory phase: development of secretory changes in the endometrium; anddesquamation of the endometrium, which is known as menstruation..Define of this endometrial cycle? How much day each cycle take ?
24Skin changes 1) identefy ? What is the cause ? - 1)Skin changes in pregnancy Pigmentation: chloasma gravidarum: Butterfly pigmentation of the face (mask of pregnancy)due to increased melanocyte stimulating hormone2) Striae gravidarum :- stretch of the abdominal wall rupture of the subcutaneous elastic fiberspink lines in flanks- become white after labor
25ماادري وش ممكن يكون عليه سؤال بس حطيته للذمة عشان يشمل كل الصور
31Delivery by Extension: As the fetal head reaches the maternal symphysis pubis it hitches under the bone.The pressure by the uterine contractions causes the neck of the baby to get extended
32External Rotation:The shoulders rotate into an oblique or frankly anterio-posterior orientation with further descent. This encourages the fetal head to return to its transverse position. This is also known as Restitution .
33External Rotation:نفس اللي قبل The shoulders rotate into an oblique or frankly anterio-posterior orientation with further descent. This encourages the fetal head to return to its transverse position. This is also known as Restitution
37What is the name ? What is it`s component ? Partogram- It include :fetal heart rateUterine contractionpulse, blood pressure, tempfluid intake, oxyotcindilation of the cervixstation of the presenting part, status of membranes, meconium, blood
46PELVIC SHAPE 1-GYNECOID Typical female pelvis found in 50% of women Rounded—slightly oval inletStraight pelvic sidewalls with roomy pelvic cavityGood sacral curveIschial spines are not prominentPubic arch is wide46
47PELVIC SHAPE2-ANDROIDTypical male pelvis found in 1/3 white women 1/6 non-whitePelvic brim is heart shapedPelvis funnels from above downwards (convergent sidewalls)Narrow pubic archProminent spines47
48PELVIC SHAPE 3-ANTHROPOID 25% white women & 50% nonwhite Pelvic brim APD > TDLong & narrow pelvic canal with long sacrumStraight pelvic sidewalls48
49PELVIC SHAPE 4-PLATYPELLOID 3% of women Pelvic brim TD >>>APD kidney shapeSacral promontory pushed forwards49
51FETAL SKULL FONTANELLES Anterior fontanelle :diamond shapedspace between coronal &sagittal suture,ossifies at monthPost font (lambda) :triangle shaped spacebetween sagittal & lambdoid suture
52Diameteres of the fetal skull Biparietal diameter = 9.5cmSuboccto-bregmatic diameter = 9.5cmOccipito-frontal diameter = 11.5cm(occipito-posterior position)The suboccipito-frontal diameter= 10 cm(1st diameter passes through vulval orifice)
53Diameteres of the fetal skull Mento-vertical diameter =13cm(Brow presentation)Submento-bregmatic diameter = 9.5cm(face presentation)Bis-acromial diameter =12cm(diameter of the shoulder)Bitrochanteric diameter =10cm(Diameter of the breech)
72HLShoulder DystociaA review of the risks, physiology, management, and prevention of Shoulder DystociaNext Slide
73PATHOPHYSIOLOGYThe anterior shoulder can then slide under the symphysis pubis for delivery.If the fetal shoulders remain in an anterior-posterior position during descent or descend simultaneously rather than sequentially into the pelvic inlet, then the anterior shoulder can become impacted behind the symphysis pubis and/or the posterior shoulder may be obstructed by the sacral promontory.Then you get the dreaded “Turtle Sign” of doom.Next Slide
75Risk Factors for Shoulder Dystocia MaternalAbnormal pelvic anatomyGestational diabetesPost-dates pregnancyPrevious shoulder dystociaShort statureFetalSuspected macrosomiaMale sexLabor relatedAssisted vaginal delivery (forceps or vacuum)Protracted active phase of first-stage laborProtracted second-stage laborPut mouse over chart to review pt’s information.Next Slide
76VignetteSince she is post-term and nothing good happens after 41 weeks…you decide to induce Jaquita.Labor has been fine, she has progressed like she should, and is now complete and ready to push.You gown up and are ready to catch this baby.The head begins to come out and…Oh crap…..Turtle Sign.Click HERE for a purely representative and graphical demonstration.
78HELPERR MnemonicThe HELPERR mnemonic is a clinical tool that offers a structured framework for coping with shoulder dystocia.These maneuvers are designed to do one of three things:Increase the functional size of the bony pelvis through flattening of the lumbar lordosis and cephalad rotation of the symphysis (i.e., the McRoberts maneuver)Decrease the bisacromial diameter, the breadth of the shoulders, of the fetus through application of suprapubic pressure.Change the relationship of the bisacromial diameter within the bony pelvis through internal rotation maneuvers.Next Slide
79HELPERR Mnemonic H Call for Help: This refers to activating the pre-arranged protocol or requesting the appropriate personnel to respond with necessary equipment to the labor and delivery unit.Click HERE for Diagram.Next Slide
80HELPERR Mnemonic H Call for Help: This refers to activating the pre-arranged protocol or requesting the appropriate personnel to respond with necessary equipment to the labor and delivery unit.Click HERE for Diagram.Click Diagram to Dismiss it
81HELPERR Mnemonic E Evaluate for episiotomy: Episiotomy should be considered throughout the management of shoulder dystocia but is necessary only to make more room if rotation maneuvers are required. Shoulder dystocia is a bony impaction, so episiotomy alone will not release the shoulder.Because most cases of shoulder dystocia can be relieved with the McRoberts maneuver and suprapubic pressure, many women can be spared a surgical incision.Next Slide
82HELPERR Mnemonic L Legs (the McRoberts maneuver): This procedure involves flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. This position flattens the sacral promontory and results in cephalad rotation of the pubic symphysis. Nurses and family members present at the delivery can provide assistance for this maneuver.Click HERE for McRobert’s Diagram.Next Slide
84HELPERR Mnemonic P Pressure (Suprapubic): The hand of an assistant should be placed suprapubically over the fetal anterior shoulder, applying pressure in a cardiopulmonary resuscitation style with a downward and lateral motion on the posterior aspect of the fetal shoulder. This maneuver should be attempted while continuing downward traction.Click HERE for Diagram.Next Slide
86HELPERR Mnemonic E Enter maneuvers (internal rotation): These maneuvers attempt to manipulate the fetus to rotate the anterior shoulder into an oblique plane and under the maternal symphysis.Next Slide
87"Enter" Maneuvers126.96.36.199. Rubin II At vaginal examination apply pressure as indicated. If shoulders move into the oblique diameter, attempt delivery.2. Rubin II + Woods corkscrew maneuver If unsuccessful, add the Woods corkscrew maneuver and continue rotation in the same direction. Use both hands and apply pressure as indicated. If shoulders now move into the oblique, attempt delivery. If this is unsuccessful, continue rotation 180 degrees and deliver.3. Reverse Woods corkscrew maneuver If the last maneuver is unsuccessful, change to reverse Woods corkscrew maneuver. Slide fingers down to back of posterior shoulder and attempt 180-degree rotation in the opposite direction.Next Slide
88HELPERR Mnemonic R Remove the posterior arm: Removing the posterior arm from the birth canal also shortens the bisacromial diameter, allowing the fetus to drop into the sacral hollow, freeing the impaction.The elbow then should be flexed and the forearm delivered in a sweeping motion over the fetal anterior chest wall.Grasping and pulling directly on the fetal arm may fracture the humerus.Click HERE for Diagram.Next Slide
89Removing Posterior Arm R Remove the posterior arm:Removing the posterior arm from the birth canal also shortens the bisacromial diameter, allowing the fetus to drop into the sacral hollow, freeing the impaction.The elbow then should be flexed and the forearm delivered in a sweeping motion over the fetal anterior chest wall.Grasping and pulling directly on the fetal arm may fracture the humerus.Click HERE for Diagram.Click Diagram to Dismiss it
90HELPERR Mnemonic R Roll the patient: The patient rolls from her existing position to the all-fours position.Often, the shoulder will dislodge during the act of turning, so that this movement alone may be sufficient to dislodge the impaction.In addition, once the position change is completed, gravitational forces may aid in the disimpaction of the fetal shoulders.Click HERE for Diagram.Next Slide
91HELPERR Mnemonic R Roll the patient: The patient rolls from her existing position to the all-fours position.Often, the shoulder will dislodge during the act of turning, so that this movement alone may be sufficient to dislodge the impaction.In addition, once the position change is completed, gravitational forces may aid in the disimpaction of the fetal shoulders.Click Diagram to Dismiss it
92Complications of Shoulder Dystocia MaternalPostpartum hemorrhageRectovaginal fistulaSymphyseal separation or diathesis, with or without transient femoral neuropathyThird- or fourth-degree episiotomy or tearUterine ruptureFetalBrachial plexus palsyClavicle fractureFetal deathFetal hypoxia, with or without permanent neurologic damageFracture of the humerusNext Slide
93PreventionEvidence is lacking to support labor induction or elective cesarean delivery in women without diabetes who are at term when a fetus is suspected of having macrosomia.In two studies of 313 women without diabetes, induction for suspected fetal macrosomia did not lower the rates of shoulder dystocia or cesarean delivery, nor did it improve the rates of maternal or neonatal morbidity.While labor induction in women with gestational diabetes who require insulin may reduce the risk of macrosomia and shoulder dystocia, the risk of maternal or neonatal injury is not modified.Not enough evidence is available to routinely support elective delivery in this population.Next Slide
94PreventionSo, prophylactic cesarean delivery is not recommended as a means of preventing morbidity in pregnancies in which fetal macrosomia is suspected.Analytic decision models have estimated that 2,345 cesarean deliveries, at a cost of nearly $5 million annually, would be needed to prevent one permanent brachial plexus injury in a patient without diabetes who had a fetus suspected of weighing more than 4,000 g.Next Slide
95PreventionOne method of preliminary intervention for shoulder dystocia in a patient with risk factors involves implementing the "head and shoulder maneuver" to "deliver through" until the anterior shoulder is visible.This step is accomplished by continuing the momentum of the fetal head delivery until the shoulder is visible.After controlled delivery of the head, the physician proceeds with immediate delivery of the anterior shoulder without stopping to suction the oropharynx.Next Slide