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speculum Examination -name of picture -name the position of patient -ues for what -How to do speculum Examination - is it most common.

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Presentation on theme: "speculum Examination -name of picture -name the position of patient -ues for what -How to do speculum Examination - is it most common."— Presentation transcript:

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2 speculum Examination

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4 -name of picture -name the position of patient -ues for what -How to do speculum Examination - is it most common

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6 -name of picture -name the position of patient -ues for what

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8 Name the manuver Use for what

9 Described the picture

10 Obstetrical maneuvers. Fundal height Using reference points.Using a tape

11 Obstetrical grips (Leopold’s maneuvers). Fundal grip (First maneuver) What fetal part occupies the fundus if soft consistency/ indefinite outline broad & irregular  breech If hard, smooth, well defined, rounded, bullottable  head

12 Obstetrical grips (Leopold’s maneuvers). Lateral grips (Second maneuvers).  On which side is the fetal back ?  Lie.  Position.  Where to auscultate for FHS.

13 Obstetrical grips (Leopold’s maneuvers). First pelvic grip - Pawlik’s grip (Third maneuver).  What fetal part lies over the pelvic inlet?.  Presentation.

14 Obstetrical grips (Leopold’s maneuvers). Second pelvic grip (Fourth maneuver) Engagement Attitude

15 A 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.

16 Structural 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

17 Barr body (arrows) in the epidermal spinous cell layer Nuclear appendage ("drumstick") identified by arrow in white blood cells

18 gonadotropin releasing hormone hypothalamus ant. pituitary LH FSH thecal cells androgens inhibin estrogens Hypothalamic-pituitary- gonadal axis Hypothalamic-pituitary- gonadal axis +/- _ granulosa cells activin + progestins Reproductive tract + +/- CNS +/- LH R FSH R neurons (LH R)

19 when secretion throughout the sexual life of the female?

20 What are the

21 Growth in puberty Girls: – 1-When start growth acceleration ? – 2-When peak growth velocity occurs ?) – 3-When menarche occurs?

22 Growth in puberty Boys: – When Peak growth velocity occurs?

23 Define of this endometrial cycle? How much day each cycle take ?

24 Skin changes 1) identefy ? What is the cause ? - 2) identefy ? What is the cause ? -

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27 الصور الجاية السؤال عليهن In what step of mechanism of labor ? What is the position ? الجواب بالملاحظات

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35 What is the name of this technique? And what we use it for ?

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37 What is the name ? What is it`s component ?

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41 THE BONY PELVIS WHICH BONES COMPOSE THE BONY PELVIS? I ) 2 Innominate bones : a) Illium b) Ischium c) Pubis II) Sacrum III) Coccyx L4 Ischial spineIschial tuberosity 48 Sacral promontoryLeft sacro-iliac jointIliopectineal lineSacrospinous ligamentSacrotuberous ligamentSymphysis pubis

42 False pelvis False pelvis The false pelvis is bounded posteriorly by the lumbar vertebra and laterally by the iliac fossa. In front, the boundary is formed by the lower portion of the anterior abdominal wall.

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44 After you activate your book, you will get Pelvic inlet and its diameters. Printed from: Hacker & Moore's Essentials of Obstetrics and Gynecology 5e (on 05 January 2013) © 2013 Elsevier

45 After you activate your book, you will get The four basic pelvic types. The dotted line indicates the transverse diameter of the inlet. Note that the widest diameter of the inlet is posteriorly situated in an android or anthropoid pelvis. The gynecoid pelvis illustrates the location of the sacrosciatic notch, present in all pelvic types. Printed from: Hacker & Moore's Essentials of Obstetrics and Gynecology 5e (on 05 January 2013) © 2013 Elsevier

46 PELVIC SHAPE 1-GYNECOID Typical female pelvis found in 50% of women Rounded—slightly oval inlet Straight pelvic sidewalls with roomy pelvic cavity Good sacral curve Ischial spines are not prominent Pubic arch is wide

47 PELVIC SHAPE 2-ANDROID Typical male pelvis found in 1/3 white women 1/6 non- white Pelvic brim is heart shaped Pelvis funnels from above downwards (convergent sidewalls) Narrow pubic arch Prominent spines

48 PELVIC SHAPE 3-ANTHROPOID 25% white women & 50% nonwhite Pelvic brim APD > TD Long & narrow pelvic canal with long sacrum Straight pelvic sidewalls

49 PELVIC SHAPE 4-PLATYPELLOID 3% of women Pelvic brim TD >>>APD  kidney shape Sacral promontory pushed forwards

50 FETAL SKULL SUTURES Frontal suture  between 2 frontal bones Sagittal suture  between 2 parietal bones Coronal suture  between parietal & frontal Lambdoid suture  between parietal & occipital Temporal suture  between inferior margin of the parietal & temporal

51 FETAL SKULL FONTANELLES Anterior fontanelle : diamond shaped space between coronal & sagittal suture, ossifies at month Post font (lambda) : triangle shaped space between sagittal & lambdoid suture

52 Diameteres of the fetal skull Biparietal diameter = 9.5cm Suboccto-bregmatic diameter = 9.5cm Occipito-frontal diameter = 11.5cm (occipito-posterior position) The suboccipito-frontal diameter= 10 cm (1 st diameter passes through vulval orifice)

53 Diameteres 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)

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64 Placenta Previa Bleeding results from small disruptions in the placental attachment during normal development and thinning of the lower uterine segment

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66 Placental Abruption external hemorrhage concealed hemorrhage Total Partial

67 Sequelae of Placental Abruption Maternal Shock Consumptive Coagulopathy (DIC) Renal Failure Fetal Death Couvelaire Uterus

68 Vasa Previa Velamentous insertion of the umbilical cord

69 Vasa Previa Succenturiate (Accessory) lobe

70 Nitrazine Test

71 Positive Fern by Microscopic Exam

72 Shoulder Dystocia A review of the risks, physiology, management, and prevention of Shoulder Dystocia Next Slide HL

73 PATHOPHYSIOLOGY The 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

74 Turtle Sign Next Slide More about this in a bit

75 Risk Factors for Shoulder Dystocia Maternal – Abnormal pelvic anatomy – Gestational diabetes – Post-dates pregnancy – Previous shoulder dystocia – Short stature Fetal – Suspected macrosomia – Male sex Labor related – Assisted vaginal delivery (forceps or vacuum) – Protracted active phase of first-stage labor – Protracted second-stage labor Next Slide Put mouse over chart to review pt’s information.

76 Vignette Since 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.HERE

77 Turtle Sign Demonstration Replay Demonstration Next Slide Oh crap, Turtle Sign!

78 HELPERR Mnemonic The 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

79 HELPERR 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.HERE Next Slide

80 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. HELPERR Mnemonic Click Diagram to Dismiss it

81 HELPERR 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

82 HELPERR 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.HERE Next Slide

83 McRobert’s Maneuver Click Diagram to Dismiss it

84 HELPERR 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.HERE Next Slide

85 Suprapubic Pressure Click Diagram to Dismiss it

86 HELPERR 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" Maneuvers 1. 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

88 HELPERR 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.HERE Next Slide

89 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. Removing Posterior Arm Click Diagram to Dismiss it

90 HELPERR 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.HERE Next Slide

91 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. HELPERR Mnemonic Click Diagram to Dismiss it

92 Complications of Shoulder Dystocia Maternal – Postpartum hemorrhage – Rectovaginal fistula – Symphyseal separation or diathesis, with or without transient femoral neuropathy – Third- or fourth-degree episiotomy or tear – Uterine rupture Fetal – Brachial plexus palsy – Clavicle fracture – Fetal death – Fetal hypoxia, with or without permanent neurologic damage – Fracture of the humerus Next Slide

93 Prevention Evidence 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

94 Prevention So, 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

95 Prevention One 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


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