Contents Part! S/N Topics Page History Taking and Examination 1 a History taking 2 2__|Obstetrical Examination 14 3__|Puerperal Examination 17 4 [Newborn Examination 18 5___|Thyroid Gland Examination 20 6 __|Precordium Examination 21 7__|General Examination 23 8 __ [Lymph Node Examination 24Part Il Chapters Topics Page | ~Case presentation: Question / Answers 25 | pte 1 70 pester ie 26 iaptet 2 Siro Puerperiut >) 45 | {chapter 3 51. “Tenaptet 4 Pre Eclampsial 7 — (al) ChapterS \) a |X Chapter 6. | Pregnancy with systemic lupus erythromatoses 93 Chaptet 7_1/Placenta Praevia 103 cone) Gestational Diabetes Mellitus(_# Ther (Chapter9 [Pregnancy with Diabetes Mellitus 127 Chapter 10 |Polyhydramnious 131 Chapter 177 Twin pregnancy ~~ | 136 japter 14 Single Fetal Demise ~~ tl | 152 | Chapter 13. |Obstetric Cholestasis # 156 Chapter 14 | Pregnancy with Jaundice # ~ | 160 (Chapter 15. | Premature Rupture Of Membrane & Fey aa 170 | Chapter 6.) | Pregnancy with Rh negative blood group 185 .|Chapter 17 | Pregnancy with Heart Disease — |.201 _ Bhapte(8 Pregnancy with Urinary tact infection =) Ot —sin ~ \Chapter 19 | Pregnancy with Fibroid 218 Chapter 20 | Pregnancy with Previous caeserean section J 222 Chapter 21 | Pregnancy with congenital anomaly (Anencephaly ) 71 233 L- [Chapter 22 |Pregnancy-wit ital anomaly (Hydrocephalus) 239 |- (Chapter 23. Hyperemesis Gravidarum) © a 247 Chapter 24-}Post dated pregnancy 256 / Chapter 25 |Pregnancy with Hypothyroidism 265 ‘Chapter 26. /1UD 275 [Chapter 27 ‘Less Fetal Movement 282 _ Chapter 28.}Breech presentation 286 Chapter 29:|Transverse lie 297 |Chapter 30 [Pregnancy with Acute Watery Diarrhoea 300 _}¢hapter 31 |Pregnancy with Hemorrhoids 305 Chapter 32,;Wound Infection following caeserean section 309 apter 33 [Anaemialin pregnancy Qo 317 Chapter 34 | Thalassaemia in pregnancy 331Y | Obs Clinical Care \0 ~' Puerperal Examination Gain consent: Describe the examination: The woman should lie on her back with her shoulders raised slightly on a pillow and her knees drawn up a little. Her abdomen should be uncovered; the patient should be exposed from xiphisternum to just below the symphisis with one sheet covering the legs upto below the level of symphisis Abdominal Examination: Inspection: * During inspection note the shape of the abdomen, position of the umbilicus, presence of linea nigra, striae gravidarum, striae albicants, are noted. A bandage is seen in the lower abdomen and is dry indicating the wound is healthy. Palpation: Most patients appreciate it if the examinee performing the maneuver warms their hands prior to palpation. \Height of the uterus: The uterus is centralized if deviated, Measure the distance from the symphysis pubis to the height of the uterus with a measuring tape. Following delivery the fundus lies 13.5 cm just above the symphysis pubis. During the first 24 hrs it remains constant there after it decreases by 1.25cm in 24 hrs. By the end of second week the uterus becomes a pelvic organ. Tenderness may be felt during examination because of the wound. Note the condition of the bandage, usually dry. Auscultation: * Auscultate the bowel sound around the umbilicus Vaginal Examination: * Enquiry about the colour, amount of lochia. Ask for any foul smell * Incase of vaginal delivery ask about perineal pain and discharge from episiotomy wound present or not After examination thank the patient, cover the patient and enumerate your findings. Q. Enumerate your findings On examination all vital signs are normal, On abdominal examination shape is normal. Umbilicus is centrally placed and inverted. Linea nigra striae gravidarum. A transverse bandage is seen in the lower abdomen. On palpation fundal height corresponds to the day of puerperium. Bowel sound is present. Lochial discharge is reddish which is normal on this day of puerperium, not foul smelling. GFNFSIS 17Obs Clinical Care Newborn Examination Gain consent from the mother: scribe the examination: Ss] ands with hexiso! 1 gloves: Ph on a warm dry clot e the baby gently: * Start by observing the baby. Does it look and behave “normally”, i.e. colour e.g. jaundice, activity and posture. Is there any obvious bruising or marks from birth. Are there any other marks such as strawberry naevus, Mongolian blue spot? Remember to turn the baby over and inspect its back too. Palpation: * With the baby lying on its back feel the frontanelle gently with your hand. It should be soft; a tense/bulging or sunken frontanelle can suggest the baby is unwell. Using both your hands gently feel the baby’s skull bones checking they are symmetrical on both sides. * Palpate around face, around ears, clavicles (these can be injured during birth if shoulder dystocia occurs), both arms (e.g, Erb’s palsy) down to legs and feet. Open up the baby’s hand and look at the palm for normal palmar creases, count the fingers on each hand. Look at the feet, is there any signs of a sandal gap or talipes and count the toes on each foot. * Palpate the abdomen and check the umbilical stump/clamp to ensure no signs of infection. * Turn the baby over and check down its spine and between buttock cheeks for the sacral dimple. * Atthis point undo the baby’s nappy. Look for any obvious genital abnormalities. If it's a male infant check the scrotum to see if the testicles have descended. + Check the patency of the anus at this point too. Auscultation: Auscultate the baby’s heart using a neonatal/paediatric stethoscope. The normal rate is 120-150 .If you do hear any murmurs assess whether it radiates anywhere. Auscultate the lung fields, The normal respiratory rate is 30-60 in newborns. Are there any extra sounds e.g, grunting or stridor. ure: The length of the baby, OFC Measure the weight There are a number of primitive reflexes present in newborns which you should be elicited.Obs Clinical Care Rooting reflex: Stroke the corner of the cheeks with a finger and the infant will turn to that direction Glabellar tap: Tap gently over the forehead and the eyes will blink Grasping reflex: Place a finger in the open palm of the infant; the infant will grasp the fingers Morro reflex: The infant is supported from behind the upper back with one hand and the baby is allowed to drop back.1cm but not on the mattress. The baby will symmetrically abduct extend the arms and fingers. This is followed by flexsion and adduction of the arms. Sucking reflex: A normal infant starts sucking when something (nipple) touches the palate After examination thank the mother, cover the baby and enumerate your findings.Obs Clinical Care Chapter 1 Normal Puerperium Mrs X, 24 yrs,Para-1(C/S), housewife of a lower middle class family hailing from Bikrampur, got herself admitted in DMCH on ....at her 39 wks\pregnancy with labour pain and rupture membrang.On the day of admission LUCS was done due to prolonged labour “and fetal distress:Now she complaints of — — + Slight lower abdominal pain over the incisional area. According to the patient statement she was in regular antenatal check up and her pregnancy period was uneventful.Her LMP was on....accordingly EDD On..... which was also confirmed by early USG. She started spontaneous labour pain at home 12 hrs prior and rupture of membranes 4 hrs prior to her admission. On admission prolonged labour with fetal distress was diagnosed and caesarean section was performed. Her immediate post operative period was uneventful. She had no breast or urinary complaints or bowel discomfort. Her locial discharge was average with no foul smelling. On the examination day she complaints offild lower abdominal pain over the wound area,dull in nature.pet radiating or re netoarel with fever.Her bowel and bladder habit normal. Regarding her obstetric history she was married for 3 yrs, mother of 1 alive child, aged-3 days.She was regularly menstruating woman with average flow and duration. Cardiorespiratory and other system revealed no abnormality. Thyroid gland and lymph nodes were not enlarged. On per abdominal exam:On inspection-lower abdomen slightly bulged.There was a transverse bandage over suprapubic region which was dry.On palpation-Abdomen was soft and slight tenderness present over the wound area.SFH was 12.5 cn which correspond to her day of puerperium. On P/V/E: Only inspection was done .Vulva and perineum seemed to be normal.Vulval pad was soaked with reddish lochia and there was no foul smell. With due consent, examined the baby and found a female baby ,weight 3.2 kg, ipa Length-52cm,HC-35 cm, skin colour was normal, active and alert(Heart rate)135 ™¥ beats/min, Resp rate-30 breaths /min, Temp-normal, no sign of dehydration, umbilical stump-healthy, all reflexes were normal and there was apparently no visible congenital abnormality, According to the mother she was on breast milk and passed urine and stool. So from history and clinical examination my diagnosis is ~A case of 3**day of normal puerperium following caesarean section. 7 26 GENESIS« Obs Clinical Care Normal Puerperium Q.What do you mean by puerperium? % + Itis the period following childbirth to 6 weeks of delivery whereby all thd body tissue, esp the pelvic organ return back to its pre-pregnant state both anatomically and functionally. fhy do you saying it is a case of normal puerperium? Itis normal puerperium because the patient has no significant complaint. On general examination, no abnormality (her pulse, temperature and BP) is detected. On obstetrical examination, no breasts complication is found, Uterine involution is satisfactory and there is no other abnormality. Hence, it is called normal puerperium. Q. How can it be said that uterus involution is satisfactory? * The height of the fundus from the symphysis pubis ( symphysio fundal height) is 12.5 cm which is expected on the 3rd day. Q:What is the normal height of uterus immediately after delivery & what is the role of involution during puerperium? * Immediately after delivery, the height of the fundus of uterus lies just below the umbilicus or more precisely 13.5 cm(5") above the symphysis pubis. It corresponds to 20 weeks of pregnancy. In first 24 hours, no change occurs and ‘om 2nd day onward, height of fundus decreases by 1.25 cm (%" ) each day and by becomes the pelvic organ.: What do you mean by ‘involution and why only uterus is considered as a “guide for measuring involution? + Returning of the genital organs to a ae aney state is ae involution. Uterus is taken as a guide because\i can be clinically measured, ¢nd this organ is mostly affected by subinvolution. Q. What is the total weight gain in pregnancy? 10-11 kg If the total weight gain is 10 kg in pregnancy, the! g pccurs due to delivery (fetus, placenta and liquor amnii) and furthes{3 kg los due to involution of uterus and loss ofwi rium Hence, mother@ains 3 kg)net weight due to one pregnancy. * Baby3.3kg * Breast 0.4 kg * uterus 0.9 kg * Liquor 0.8 kg * Fat + Protein 3.5 kg * BV1I3kg * ECF12kgObs Clinical Care Q. What is the normal size and weight of the uterus immediately after — childbirth and changes during puerperium? mT + Atthe beginning of puerperium, the length of the uterus measures 20 cm, breadth 12 cmand thickness 8 cm (4 cm each wall) . After 4 weeks, it regaits its pre- pregnant state. + The immediate post-partum uterus weight approximately 1 kg, One week later it reduces to the 500 gm. At the end of second week it is 300 gm andt the end of 6 weeks it reduces to the pre-pregnant weight of about 60 gm. + Endometrium is regenerated by the 10th day, except at the pldcental site which » takes about 6 weeks. Q/ What is the mechanism of involution (Retraction)? v Involution occurs-by the phenomenon offautolysis (enzymatic digestion of excess \o asm) where the total fe cells is not decreased appreciably, juStead the size of the muscle d ses \During the state of pregnancy, the size of the ells increases 10 times in Jength and 5 times in breadth, Vessels become thrombosed and hyaline degeneration but traces of fibroelastic issue remain as evidence of pregnancy. i y is constipation common during puerperium? * Loss of body fluid during labour. * Less intake of solid diet during labour. + _ Less sensitivity of anus by stimulation due to compression of fetus during labour. Recumbent position in bed. _Q. Define Lochia and state the composition? what are the different varieties? Lochia is the normal vaginal discharge/having characteristic fishy odouy/persisting for 3-4 weeks following delivery and one week following abortion. Microscopically, it contains sheds of decidua, erythrocytes, epithelial cells and bacteria. Lochia is fishy odour due to amines. Lochia ‘is of three varieties. + Lochia rubra : First 3-4 days of puerperium , and colour of lochia is red due to presence of blood. * Lochia serosa ; After 3-4 days lochia becometffogressively pale in colour persist for about one week. * Lochia alba : Because of more infiltration oflléGcocytes and reduced fluid content, it becomes white or yellowish-white and persist for another one or two weeks. Q. How will you assess the amount of lochial discharge? * Inan sgpee hygienic women usually the number of pads does not exceed 4-5 in 24 hours. uf more than five pads are needed in 24 hours, lochial amonut is said to be excessive. 28 GENESISObs Clinical Care Q. Different characteristics of lochia with their significances . Excess amount - Retained bits of placenta or membranes , multiple pregnancy, lochiometra and puerperal sepsis. + Excess amount with persistent red colours ~ Retained bits of placenta and membranes with chance of PPH. * Excess amount with pus- like discharge and offensive smell associated with fever — puerperal sepsis . + No lochial discharge or scanty ~ Chance of infection. + Scanty and odourless associated with fever - May be puerperal sepsis due to group -A B-haemolytic streptococcus. Q.When you will call it PPH? * When bleeding is more than 500 ml and the condition of the mother deteriorates. + may be late post partum haemorrhage extending upto 12 weeks. Q. What do you mean by s tnvelaent + Subinvolution meangarrest oyfetardation, dation of involution of organs which normally occurs following childbirth. ~~ Q. How will you diagnosis subinvolution? * Uterus is larger and softer than normal for a particular period of puerperium as evidenced by abdominal and isin examination. * Associated with prolongation oflpchial discharge andjefégular or excessive uterine bleeding and sometimes by nee haemorrha; Q.What are the causes of subinvolution? Aggravating factors: + Retained placental bits * Utrerine sepsis Predisposing factors L Overdistention of uterus - multiple pregnancy, hydramnios. Multiparity. + Uterine fibroid. APH. “Retained placental bits or membranes. Cisse sepsis. *L_Lochiometra. 2 Broad ligament haematoma. Retroversion of uterus GENESISObs Clinical Care Q.What are the effects of subinvolution? * Prolonged red discharge per vagina following childbirth. * After pains, ° Fever. * Chronic ill-health Q What is the treatment of subinvolution? * Postural drainage. * Treatment of puerperal sepsis. + Exploration of uterus to remove any retained bits or membranes under anaesthesia. * Correction of Retroversion with Hodge-Smith pessary, if needed. Q. What do you mean by ‘After pains '? How will you treat ‘After pains '? « + Itis the lower abdominal colicky pain due to contraction of uterus during first 3-4 days of puerperium. This is more common in multipara where the puerperal uterus contacts vigorously at intervals in contrast to primi where the uterus tends to remain tonically contracted. ‘After pains ' is felt more when the baby sucks, which is due to oxytocin release. Usually no treatment is needed - if severe, antispasmodic may be given. / Q:What do you mean by post natal care? * Postnatal care means the systemic examination of the mother and baby, and appropriate advice given to the mother during post partum period. + First postnatal advice is given at the time of discharge and second advice is given after 6 weeks, Q Timimg of PNC? ~ immediate with in 24 hrs. * by 2nd - 3rd day * by 1 week (5-7 days) * at 6 weeks QPrinciples of post natal care ? * To assess the health of the mother and institute effective therapy to rectify it * Advise regarding post partum contraception and post natal exercise * Totreat any gynaecological disorder arising from obstretric legacy . Nite advise regarding breast feeding and immunization of the baby Qh postnatal care what should be checked? * History * Examination GENESIS,Obs Clinical Care History: well-being or any complaint. & * Enquire about breast feeding and engorgement.- gq * Urinary and bowel problems + Lochia + Contraception Examination: BK * Pulse + Blood pressure + Temperature * Abdominal examination - Height of the fundus * Per vaginal examination - *Lochia, : *Episiotomy wound and perineum. Q. When you will ask the mother to come for her next check-up and what are the components (Late postnatal check-up)? at 6 weeks, * The mother will be asked to come after 6 weeks. + Asked whether any problem. * Mother & baby thoroughly examined. * Any problem of breast feeding addressed. * Contraceptive advice. Q. When you discharge the patient if your case isa normal puerperium? + Inmultiparity, (without episiotomy, discharge may be given after 24 hours. \ ~ * Primi or multipara(with episiotomy)is discharged after 48 hours. Hospital stay after normal vaginal delivery should be upto 48 hours and following uncomplicated caesarean delivery up to(96 hourgor till the abdgminal skin stitches are removed if non- absorbable sutures are used @rd-4th POD.) \/ * Incase of forceps delivery the patient may be kept for a few more days of normal vaginal delivery. + Examination of perineum is very important to see whether any vulval haematoma has develo} Q. Advices at the time of discharge? * Rest - Avoidance of household works for at least six weeks * Advice regarding diet - Normal diet +300 calorie extra for breast feeding. * Ironand folic acid for 3 months. Pregnancy : 2500 kcal GENESIS 31Obs Clinical Care Lactation : 2500+300 kcal + Post partum exercises. “ Advice regarding baby care, breast - feeding and baby immunisation. Maintenance of personal hygiene. * Perinealcare. * Contraceptive and family planning advices. 2 Q. What is‘ lying in ' period? + Itis the period of hospital- stay following delivery. Q.What do you mean by' eee + Rooming in means keeping thabdby withhér mothe: "yp catielgiately after delivery the postnatal ward. This pfomotes breast-feeding, imcfeases mother- baby bondage andavoids the cross infection in baby nursery. Q.Few postnatal exercise + Pelvic floor exercise: Jy {ying position , legs are drawn up and slightly apau“Anal passage is tightened to stop the passage of stool and held for few seconds. * Abdominal exercises: Lying on floor, abdominal wall is tightened while taking deep expiration and holding breath followed by relaxation _-* Deep breathing : Several times in a day. + Ubri¢oliraged to work in erect posture. * Bedsides, few waist and foot exercises are also advised. pestle few walsvand loot exe Q. Contraceptive and family planning advice to the puerperal mother? ‘V+ First 6 weeks - no coitus. * 6weeks to six months \Barrier c iceptive oben can be given or bfogesterone (only contraceptive) either initijectable form (injection Depo provera or injection NET-EN) ora pill ( cerazette) are given. As combined pill interferes with breast - feeding it is avoided in first 6 months. Progesterone, the only contraceptive, has no effect on lactation. + Postpartum TUCD. (PPIUCD) * Permanent sterilization in the form of tubectomy is done as early as possible after delivery if family is completed However, first 24 hour is avoided, as this period is very vital so far as neonatal morbidity and mortality is concerned. + LAM (actational amenorrhoea) method -2% chance of conception during first 6 months. Q. Name two injectable contraceptives. What are their composition, advantage, disadvantage, dosages and duration? * The two important contraceptives are depomedroxy progesteron acetate (DMPA) and norethisterone enanthate (NET-EN) . + DMPA is given ina dose of 150 mg every three months intrmuscularly and NET-EN is given in the dose of 200 mg IM every two months. * Important disadvantages of the injectable contraceptive are amenorrhoea and irrigular bleeding.Obs Clinical Care Q. What are the other progestogen used as mini pill? + The other progestogens used as mini pill are levonorgestrel 75 jg, norethisterone 350 pg, lynestrenol 500 ug or norgestrel 30 pg. Q. What are the important problems of progesterone only pill? + Threshold bleeding. *Disadvantage like in injectable form - amenorrhoea and irrigular bleeding. Q. What do you mean by PPIUCD insertion? what are the different types? + Itmeans postpartum IUCD insertion. Different types are — Y Postplacental - Insertion of UCD within 10 minutes after placental delivery on the same delivery table. Immediate postpartum - After 10 minutes of delivery of placenta , but within 48 hours of delivery . Intracaesarean ~ During caesarean section after removal of the placenta and before closure of the uterine incision. Y Extended postpartum / interval- insertion after 4 weeks (according to ‘Government of India after 6 weeks) ae IUCDs should not be inserted between 48 hours and 4 weeks as there is increased risk of perforation and expulsion. v v Q.Technical aspect of insertion of PPIUCD? * For post placental insertion long placental forceps (Kelly's placental forceps) is needed for fundal placement of IUCD. Negotiation of the "bend" where the uterine body flops over the lower uterine segment is the difficult part during insertion. Provi ific training for this, For intra caesarean insertion it is best done manually with the fingers or, alternatively with regular ring forceps. Q.Return of menstruation in puerperium : * Inlactating mother, menstruation usually returns 12 weeks after childbirth or even later. + Tnnon-lactating mothers, menstruation returns 6 weeks after childbirth. + However, Ovulation may occur as early asf weeks in non lactating mother and (Q) weeks following childbirth in lactating mother . + Hence, non-lactating mother should take contraceptive measure after(3weeks and lactating mothers not later than 10 weeks of delivery. avs Mus cent AQwkr ~ Bm GME) ga RM / £1000 bo t+ v aBerakn - ou gum. Gwe GENESIS 33Breast complications in puerperium Q. What anatomical changes occur in breast during pregnancy? Breast enlargement * During pregnancy and lactation the mammary glands are becoming functional * Breast size before pregnancy does not determine the amount of milk a woman will produce Hormones during pregnancy * Estrogen stimulates the ductile systems to grow, then estrogen levels drop after birth * Progesterone increases the size of alueali and lobes) ‘s_ Prolactin contributes to increasing the breast tissue during pregnancy Alveoli secrete milk and contract when stimulated Oxytocin stimulates milk secretion and is released during the ‘let down’ or milk ejection reflex After let down, milk travels into the ductules, then to the larger - lactiferous or mammary ducts Q. Describe the physiology of lactation. a + Mamogenesis (Mammary duct-gland grth & d&velopment.) * Lactogenesis (Initiation Of milk secretion in alveoli) * Galactopoiesis (Maintenance of Lactation) ~~ * Galactokinesis (Removal of Milk from Gland) Hormones during breastfeeding: * Prolactin levels rise with nipple stimulation * Alveolar cells make milk in response to prolactin when the baby sucks * Oxytocin causes the alveoli to squeeze the newly produced milk into the duct system Pathway of milk secretions: Re * Baby sucks the breast > vetlenst travel via_T3,T4,T5 to the hypothalamus > from hypothalamus reflex reach pdSterior pitutary --> oxytocin released from the Posterior pitutary > reaches the lactifeFous sac -> causes contraction of ‘myoepithelial cells > release of milk 34 GENESISObs Clinical Care Q. How do you assess lactational changes of the breast? Assessment: Antepartum Changes * Breasts enlarge [each breast gains ~ 0.6 kg or more] + ‘Glands enlarge + Increased blood flow to breasts, causing blood vessels to enlarge & become more visible. — ~——— + Areola [dark circle around nipple] enlarges and darkens + Small bumps on areola (Montgomery's tubercles] enlarge and produce oils to soften nipples and keep them clean , ee Q. What is the composition & function of colostrum? Colostrum: rich in protein, vitamins, maternal antibodies and sodium chloride Other contents are : sugar, fat, water, minerals Function: <—F * Small in amount for the immature digestive system * Paints’ the digestive tract * Low fat for easy digestion * Contains mothers antibodies which boost infants’ immune system * Acts asa laxative to ease passage of meconium Q. How colostrum is identified? + Itis identified under-fircroscope by the presenceef typical colostrum corpuscles( large polymorphonuclear leucocytes containing numerous fat globules) urge Polymorphonuctear Teucocytes contalaag numerous Ate Q. What is exclusive breast feeding? * It means the newborn is given only breast milk and not a drop of water. Criteria: * Itincludes both day and night time feeding. * Feeding must not be less than 4 hours apart in the daytime and not less than 6 hours apart at night. TO fay * Total duration of feeding should be 1 hour in whole day. Q. When does milk appear in the breast? + After delivery breast milk appear by 3“ to 4** day in response to falling levels of estrogen & progesterone after delivery of the placenta and increased production of aa by anterior pituitary. Milk ducts become distended & fluid turns bluish- white Q. When to start breast feeding? * As early as possible, preferably % hour to 1 hour of birth. In case of caeserean ———__—__—— delivery start within 3 to 4 hours GENESIS. 35Obs Clinicai Lare Q. What is the composition of breast milk? + Itcontains high amount of protein , Vitamin, Chloride, Rich in lysosyme, Lactoferrin, Lactoperoxidase,andimmunoglobulin. SSS Q. How much milk is produced per day? What is the total calorie? * Total milk is produced per day: 500-800ml/day . /Total calorie : 700kcal/day Q/What infant and maternal benefits to breastfeeding? Infant benefit: Lower risk of DiarrheayConstipation}hféctions Ear, respiratory, mefiingitis, urinary tract, SIDS, Allergic diseases, Chronic digestive diseases, Juvenile onset diabete: ate kein dale obesity * Provides immunologic protection while the infant's immune system is maturing because of the presence of Antimicrobial agents, Anti-inflammatory agent, Immunomodulating agents Preterm Infants * Decreased necrotizing enterocolitis * Decreased Retinopathy of prematurity * Decreased infection rates * Better able to tolerate feedings, * Increased IQ ratese~ * Contains long chain polyunsaturated fatty acids that help the infant’s brain develop > these are normally provided by the mother in late pregnancy, therefore preterm infants miss this/ Maternal benefit: + Less postpartum bleeding + More rapid uterine involution + Weight loss * Decreased premenopausal breast cancer rates * Decreased ovarian cancer rates + Lactational amenorrhea \ __ Parents benefit: “y © Saves money * Saves time * Babies love it Q. How do you understand that the baby is feeding well? * Baby gains weight: No more than 7% weight loss, Back to birth weight in 2 weeks, 1oz per day weight gain for the first three months * Mother is comfortable and satisfied * Atleast 3-4 sizeable stool and 6-7 times micturition ef 36 GENESISObs Clinical Care qwhat are the breast complications? + Retracted / cracked nipples * Breast engorgement : _ Meats + Breast abscess + _ Failure of lactation ——— Q. How will you manage breast engorgement? * Cause: when milk enters on 3rd - 4th day after delivery there is stasis of milk within the lactiferous duct + C/F: fever, both breasts hard heavy, painful to touch, difficult lactation * Rx: Warm soaks, hot showers, express milk manually, breast feed 2-3 times a day Use of nursing brassiere. Analgesics Q. How will you manage mastitis? + Infection of the breast (one sided) + Seen 2-3 weeks after delivery * Caused by staphylococ reus * Infected nipple fissure - to ductal system involvement- edema obstructs milk flow in a lobe- mastitis Flu like symptoms * Tender, hot, red area on one breast Breast distention with milk * Rx: express milk manually from affected breast, feed 2-3 times a day from opposite one Use of nursing brassiere Analgesics Antibiotics : Flucloxacillin Q. will you manage breast abscess? * Incision and drainage followed by antibiotic coverage efow will you manage cracked nipple? Sore/Cracked/Bleeding Nipples * Common cause is- from improper positioning or attachment( not enough areola in infant's mouth;) may continue to feed after reposition infant. Reattempt nursing. + Rest the nipple; apply lanolin ointment. + Apply tea bag [tanic acid] natural healing property. GENESIS 37Obs Clinical Care Q. What are the contraindications of lactation? * Mother receiving mood stabilizers [Lithium] * Exposure to radioactive compounds [thyroid testing] * Breast Cancer; HIV * Infant galactossaemia * Premature infant at are the positions of breast feeding? Side lying * cradle position * cross craddle position * dutch position Q. How to collect and store breast milk? * Room temperature- 4 hrs + Refrigerator- 24 hrs + Deep freezer- months * Use oldest milk first * Thawing- place in warm water never microwave-creates hot spots and decreases anti-infective properties * Thawed milk never refreeze Q, What are points of position and attachment? Position: + mother and baby in same plane * mothers back straight * baby close to the mother Attachment: + mouth wide open + chin touching the breast + lower lips curled outwards * Nose facing opposite breast Qa Whati is the nursing care of the breast? Encourage first feeding + Emptying of breasts @ 20 minutes interval + Teach: start on breast where she left off - maintains good supply. + Rest, relaxation, increases fluids by 4 to 8 glasses/day. * Not enough fluids, anxiety may lower milk production. * Nutritional Counseling: increased by 500 calories/day. 38 GENESISObs Clinical Care Q. What drugs enhances lactation? + Metochlopromide) ("Intranasal oxytocin + Sulpride Domperidone | I drugs enhances prolactin secretions except oxytocin which causes contraction of myoepithelial cells / Q. What drugs inhibit lactation? “+ Bromocriptine + Cabergoline GENESIS 39Obs Clinical Care w born Infant |Q. Whatisa neni 4 * Ahealthy infantBorn at term should have ar4verage birth wei s immediately after birth, 38weeks Entire sole covered with crease 7mm small, few rugae Breast nodule | 2mm 4mm Scalp hair Fine, Wooly, Fuzzy Fine, Wooly, Fuzzy Coarse, Silky _ Ear lobule No cartiladge Moderate amount of Stiff cartiladge : cartiladge Testes and Testes partially Scrotum descended, scrotum GENESIS 41Newborn complications Q.When does umbilical cord fall and how? + Iffalls off within 5 to 7 days by the process oflry gangrend) Q. What will you think if the umblical cord does not fall within normal period? * “fhfection of the umbilicus . + fife condition where umbilical cord is kept long e.g Rh-isoimmunisation, diabetic mother and premature bab} = Q. What is infection of Umbilical cord called? * Umbilical sepsis / Omphalitis Q. Umbilical sepsis / Omphalitis. * Clinical features : ¥ Cord fails to drop off within reasonable period of time. v There may be rise of temperature. Y Baby may refuse feed . * On local examination : Y Incase of mild sepsis — umbilicus is moist ie.offensive discharges from umbilicus. Y Acute sepsis — evidenced byaelling and wiGeration at umbilicus may be found. * Management: Y Prevention — by maintaining local asepsis. ¥ Curative — by dressing the wound regularly. Proper antibiotics are given in severe infections. ¥ Umbilical abscess — managed by local drainage. Q. Suppose a baby is not sucking properly. What angie causes? + Any sick baby whatever may be the caus? of illnes: sfefuses breast-feeding . * One important cause of refusal of breast-feeding is6ral thrush. * Incase ofiglefflip and cleft palate, baby cannot suck properly. Q. What is oral thrush? + tis the fungal infection of the baby’s mouth caused by fungus e.g.candida albicans. + OnJocal examination there are extensive white patches on the tohgue!palate and I mucous membrane. On rubbing the white patch, itbleeds. + Examination of the smear from oral thrush followed by staining with methylene blue demonstrates the branched fungi, 42 GENESISbs Clinical Care Q. How does the oral thrush occur commonly? * Oral thrush usually occurs due to transmission during vaginal delivery of the mother who had a monilial vulvovaginitis. Q.Treatment of oral thrush? * Prevention ~#etection andsfanagement of vulvovaginal moniliasis during antenatal period. * Local management is done by application of 1% Gentoin Violet or Nystatin lotion. Q. Mention some common swelling of the head of newborn baby. * Caput Succedaneum. * Cephalhaematoma. * Meningocele Q. What do you mean by Caput succedaneum? + Itis the localised swelling over the fetal scalp outside the periosteum which appears during labour. Ss + This occurs due to theintferference of the venous and lymphatics drainage of the area of the scalp by the pressure of theadjacent birth canal like cervix and vulval rin + The site of the caput varies depending on the position of the head. In LOA position, caput is formed on right parietal bone and ROA position, itis found on left parietal bone. — + Caput is formed usually after rupture of membranes. Q.What is the Clinical importance of caput succedaneum? * Small caput is normal finding. 8: Caput denotes the static position of the head for a significant period of time. Larger caput indicates significant disproportion, and occurs in prolonged labour. Site of caput gives an idea about the position of head. Determination of station may be misguided by the formation of caput. Abdominal method (fifth formula) of determination is preferred in that case. r ‘Chignon "is artificial moulding created during ventouse application. Q.When does caput disappear? * Ittakes 24 to 48 hours to disappear , whereas Cephalhaematoma may take about 6 weeks for regression. Q.Management of caput succedaneum ? * Itneeds no treatment and spontaneous regresses within 24 hours to 48 hours. GENESIS 43— ae ae Wet be ary hees Themen sets, a s - Chelmer tre eelerane fad Diode ceaqutconlnen aint te + We eematy wowed by terwery Gaterery tne cone ter Callieming wor voat Jefe sftan, - Be rey et 0 Ne es we Lanes weer Let ny end be weet Pepe oe be De me eT Oe nd temeteed by meters Peet Pe reer te et aoe - eee rms comer nt phe? nerve terest, a ety agrees Mths Of peda al DeemerObs Clinical Care Chapter 2 Abnormal Puerperium Post partum haemorrage Q. Define PPH + Any amount of bleeding/from or into the genital tract/fter the birth of the baby/tll the end of the puerperium that adversely affect the health of the mother characterized by a rise in pulse and a fall in BP Q. What are the types of PPH 1. Depending on time + Primary PPH (within 24 hours) * Third stage haemorrage before the expulsion of placenta * True post partum haemorrage subsequent to the expulsion of placenta * Secondary PPH (beyond 24 hrs upto the end of puerperium) 2. Depending on the amount of blood loss ———— aN * Minor <1L * Major >1L causes of primary PPH icity 'rauma : * Cervical lacerations + Vaginal lacerations + _Hematomas of vulva, vagina or peritoneal areas + Uterine inversion \Pissue retained * Retained placenta + Retained bitsof placenta LPtirombin * Release of thromboplastin -Tocolytics GENESISObs Clinical Care Q. Causes of atonicity + Grand multipara +wfineddling and fiddling of the utery, * Over distension of the uterus due to e Pulling the cord polyhydramnious, big baby, twin * Manual seperation of the placenta in * Prolong labour c/s * Precipitate labour * Initiation and augmentation by * Anaemia oxytocin * Anaesthesia . yaraiole adherent placenta * Mismanagement of 3" stage +~Malnourishment * Too rapid delivery of the baby * Malformation of uterus * Premature attempt to deliver the / * Uterine fibroid/ placenta before seperation Q. How will you diagnose atonic PPH? + The uterus is found flabby and becomes hard on massaging / Q. How will you diagnose traumatic PPH? * The uterus is found well contracted in spite of severe bleeding Q. Principles of management of primary PPH? * To empty the uterus * To replace the blood * To ensure effective haemostasis Q. Surgical management of atonic PPH * Blynch + Uterine artery enmass ligation * Ovarian artery ligation * Internal iliac artery ligation + Hysterectomy / Q. Causes of secondary PPH + Infection and separation of slough * Retained bits of cotyledons and membranes * Endometrities and _subinvolution * Secondary haemorrhage N * Rare causes: chorionepithelioma, cancer cervix, infected fibroid { 46 GENESISwus cunical Care Qa principles of management of secondary PPH? * To assess theamount of blood loss and to replace it + Identification of the cause and treatment of the cause Q. Treatment of retained bits of placenta + When the placenta is not expelled even after 30 mins of delivery is called retained placenta (WHO 15 minutes) Phases of seperation Separation through the spongy layer of decidua a hecent into the lower segment and vagina Finally expulsion to outside v“Interference in any of these physiological processes results in its retention Management + Placenta is separated and retained - placenta is expelled by controlled cord traction * Unseperated retained placenta manual removal of placenta under G/A Complicated retained placenta vfelained placenta with shock but no haemorrage: To treat shock when the condition improves manual removal of placenta is done Retained placenta with haemorrage: To treat haemorrage when the condition proves manual removal of placenta is done etained placenta with sepsis: Usually such patients are delivered at home later gets admission, broad spectrum antibiotics, blood transfusion, improvement of general conditign then manual removal + Retained placenta with episiotomy wound: manual removal followed by repair Q. What is pelvic haematoma? Collection of blood anywhere in the area between the pelvic peritoneum and the perinal Sa ee skin is called pelvic hematoma. Types ¥“Infralevator hematoma ‘Supralevator hematoma Q. What is the cause of pain in Perineum in puerperium? Mild pain is common in episiotomy wound. In case of non -healing and infection in the episiotomy wound, the pain aggravates. When the pain becomes severe and there is increased swelling over the perineum, the vulval haematoma is suspected GENESIS 47Obs Liinieat Gare: Q.How will you manage a case of vulval haematoma, if does it occur symptoms: * Persistent pain in perineal region -—~ + There may be rectal tenesmus _- + Retention of urine Signs: * Variable degree of shock Local Examination: tense swelling in the vulva, dusky and purple in colour, tender tote —— Purple Oy Treatment : * Small haematoma (<5cm) may be treated conservatively with cold compressio, + Large haematoma should be explored in the operation theatre under general anaesthesia a 48 GEnrecYous Gunitcal Care Psychiatric problems in puerperium Q. Psychiatric problems in puerperium? + Postnatal blues. «Postnatal depression. * Puerperal psychosis. Q. What are the relevant histories necessary for psychiatric illness? + Past history: Psychiatric illness «Family history: Major psychiatric illness, martial conflicts, poor social situations « Present pregnancy: Young age , gaesarean, delivery, difficult labour, * Unmet expectations 5 Q. What is postnatal blues? * Mild form of psychiatric problem - it is not actually,mood illnesg but the mood disturbances. . ante arevfesnesswfinesotubanc of sleepalack of concentration, fe: -arfulness}emotional liability anduxfidue anxiety for the baby. * Usually starts 2nd day of the delivery and lasts for maximum of 5-7 days. + Psychological support*@assurance and,gatenatal counselling are enough. * Half of the puerperal mothers may suffer from this problem. Q. Postnatal depression? + Depression starts usually after-6ne month and is usually found in first postnatal year. * The features are irritability, tiredness, undue anxiety for baby, loss of, confidence , decreased libido and depression. * Treatment is counselling, psychotherapy and antidepressant. * Outcome is usually good . * About 25% of puerperal mothers may suffer from postnatal depression. Q. Puerperal psychosis? * Most dangerous of all puerperal psychiatric problems. * Usually starts within one week and maximun intensity occurs within two weeks. * Mother may be violent in few cases (4%) and may kill the baby. sometimes mother may commit suicide (5%). * Patient may have past history of manic depressive psychosis. * Hospital treatment is necessary. * Prognosis is usually good. * Recurrence in next pregnancy and in non-pregnant condition is common. GENESIS 49Obs Clinical Care Puerperal emergencies Q. What are the puerperal emergencies? Immediate: * Post Partum Haemorrage , THYEUSTVY + Shock * Post partum Eclampsia + Pulmonary Embolism Early: (Shey Atak) + Acute retention of uring, UTT. « Anuria . paiee . east abscess + Pulmonary infection. RTL, Anuria following abruptio/ + Secondary Post Partum Haemorrage + thrombo embolic phenomenons + Psychosis + Post partum cardiomyopathy ;444J$ * Q. What are the Gynecological problems in puerperium? * Chronic pelvic pain + Menstruation irregularities * 2eSufertility * Chronic PID ~ =. GENESISObs Clinical Care Chapter 3 Puerperal Sepsis Mrs X,25 years of age, Para- 2 , (Both LSCS 2004 & 2012) and 1 MR (2007), housewife ofa lower middie class family, hailing from Comilla got admitted in BSMMU on ...with the history $£LSCS on ...due_to 3" gravida, 38 weeks twin pregnancy with PTH with severe cligohydromnios with HbsAg + ve_now complaints of High grade fever for 17days + Progressively increasing mid and lower abdominal pain after delivery * Breathlessness for same duration * Passage of excessive foul smelling, reddish brown vaginal discharge for 3 days + Known case of HBsAg +ve, diagnosed during pregnancy Patient stated that she was a regularly menstruating women. It was her planned pregnancy. Her LMP was on... & EDD was on4.. She was on irregular antenatal care. However she was immunized with Tetanus Toxoid. She started having Iron and Calcium from the 6th month of pregnancy. At her 8 month due to raised blood pressure and bilateral leg swelling she came to Dhaka for treatment but did not contonue her medicines regularly.In the last month, she was in improper antenatal care in Raerbag Family Clinic. She also had high grade fever (101/102oF) with cough and breathlessness for 2-3 weeks before C/S for which she only took paracetamol . On..., Emergency Caesarean section was done in that clinic with the indications of 3"’gravida,38weeks twin pregnancy with PROM with H/0 previous C/S and HBsAg +ve,Patient stated that beth babies cried after birth Both were female{both 2.5kg) & healthy. They were immunjzed by vaccine & immunoglobulin for HBV after birth. Her immediate postoperative period was uneventful. 7 Fromthe 4*" day of puerperium, she developed igh grade (documented102/1030F) Wxtermittent fever which was,pot associated with chill & rigor. She also developed progressively increasing dull aching pain in mid & lower abdomen wale was not associated with increased frequency or painful micturition or constipation. She also complained of breathlessness for same duration specially in supine position which was not associated with cough and cold. “rn She noticed her post operative vaginal discharge became reddish brown in color, foul smelling & copious in amount in the last 3 days before admission. Se ee EE eereas For fever and pain she consulted at her clinic but complaints did not subside with repeated change of oral antibiotics.With these complaints she admitted in BSMMU for further management. She gave H/O PIH in her previous pregnancy. She had no other surgical history except LSCS. Both of her parents are hypertensive. GENESIS 51Obs Clinical Care With due consent & maintaining adequate privacy, | examined her on 22.3.2012 & found her toxic, anxious looking but co operative. She was moderately anaemic,dehydrated edematous with average body built. Her temp was 1020 F, Pulse- 132b/mins and BP- 130/70mm of Hg. Lymph node was not palpable.Breast showed normal pregnancy change, Heart sound audible, breath sound vesicular Abdominal Examination: Inspection : Abdomen was distended , Umbilicus centrally placed, Wound of C/S was healthy, Stria albicans was present Palpation: Uterus was subinvoluted.Tenderness was present in umbilical & hypogastriac region. SFH-25em Percussion: Dull Auscultation: Bowel sound was present Per Speculum Examination: Foul smelling copious Reddish brown vaginal discharge came out, Cervix could not be delineated properly due to severe pain Bimanual ExaminationUterus - enlarged up to 25weeks pregnancy sized, soft, tender, mobile Diagnosis: Puerperal Sepsis with anaemia with respiratory distress with HBsAg (+)Ve * 52 GENESISObs Clinical Care Puerperal Sepsis Q. What are the different causes of pain during puerperium? @ After pains @ Pain lower abdomen - puerperal sepsis, broad ligament hematoma, Pain over the perineum - mild to moderate pain over episiotomy wound, episiotomy wound infection and severe in case of vulval hematoma. \e Whole body pain - puerperal sepsis. @s> Pain during micturition -cystitis. & Pain in the suprapubic region -cystitis. Pain associated with vomiting and diarrhea ~ peritonitis. Q Define puerperal pyrexia or puerperal fey; Puerperal pyrexia or fever is defined as ee temperature of 100.4°F (38°C) or higher dyfing the first ten days of puerperium occurring eff two occasions with more than 6 hours apart, exclusive of the first 24 hours. ~ a Q. What is milk fevey + Milk fever isohee of temperatury6y 1 to 2°F duegoengorged breasts, which always lie below 100.4°F and passes usually within 24 hours, Q. what are the causes of puerperal pyrexia? Puerperal sepsis - commonest * Urinary tract infections -cystitis and pyleonephritis. * Breast infection - mastitis, breast abscess. + Intercurrent infections -respiratory tract infection, enteric fever, influenza, pulmonary tuberculosis etc. + Leg vein thrombosis. Qa What are the causes of puerperal pyrexia as per day? 1st day: Fluid and blood reaction * 2nd -3rd day: Breast engorgement, RTI, UTI + Sth -6th day: Mastitis, Breast abscess, Puerperal sepsis, wound infection * >7th day: DVT + Any time: Intercurrent infections Q. Organism responsible for puerperal sepsis? Most of the genital tract infections are polymicrobial, * Aerobes - Group A streptococcus, Group B streptococcus, Staphylococcus, E.coli, Klebsiella and Pseudomonas. * Anaerobes ~ Anaerobic streptococcus, Bacteriodes , Fusobacterium, Mobiluncas clostridia. GENESIS 53Obs Clinical Care Q. What are the risk factors for puerperal sepsis? Preterm PROM Preterm PROM >18hrs +| Pretermlabour ‘| ‘olong labour. + Unrepaired tears * Repeated per vaginal examination etes mellitus + Anaemia & Malnourishment + Immunocompramised * obstructed labour * Immunocompromised + Tfaumatic vaginal delivery Q. What are the types of puerperal sepsis? + Endometrities * Endomyomytrities * Endoparametrities * Pelvic cellulities Qa erevention of sepsis Antenatal prophylaxis includes improvement of nutrition, eradication of septic foci + Intranatal prophylaxis pcludecdadielca asepsis, aS aipeeeres * Postnatal prophylaxis includes maintance of personal hygiene, use of sterile vulval pads, antibiotics a Q. Treatment of sepsis General care: + Isolation of the patient * Adequate hydration by I/V fluid * Correction of anaemia by oral hematinics or by blood transfusion + Indewelling catheter to relieve urinary retention Medical treatment: Depending on culture and sensitivity report Surgical treatment: © Perineal wound: R6moval of stiches,«afainage of pusrSfe bath * Retained uterine ducts: Surgical evacutation after anti ic coverage + Pelvic abscess: Danedbveemmy fo a A GENESISObs Clinical Care Thromboembolic phenomenons Q Various thrombo embolic phenomenons during puerperium? * Deep vein thrombosis * Thrombophlebitis + Pulmonary embolism Q. Why thromboembolic manifestations are more common during puerperium? Q. What is the Pathophysiology of venous thrombosis? Pregnancy is associated ie 10 fleirease of thromboembolic manifestations. In puerperium it increases more and further increase occurs after emergency caesarean section, + Venous stasis due toon impression of enlarged uterus and/fnmobilization of lower limbs after delivery. —=—— — * Hypercoagulable state in pregnancy and puerperium due to the rise in concentration of other coagulation factors |, II, VII, VIII, IX, X, XII etc. * Other factors like trauma to the vessel wall, dehydration, anaemia, infection, multiparity and advanced age. * Thromboembolic phenomenons are more common in western countries in comparisons to Asian and African countrie: rompar’sons to Astand Aiican counties Q. What are the indications of prophylactic anticoagulant in puerperium with duration of therapy? * _Risk assessment of postnatal Thromboprophylaxis. . risk} (Continue antenatal thromboprophylaxis throughout pregnancy up to 6weeks postnatal) * Any previous thromboembolism. * Anyone requiring antenatal low molecular weight heparin . (momma cig antenatal thromboprophylaxis throughout pregnancy up to 7 days postnatal) * Caesarean section in labour . 3ymptomatic thrombophilia ( inherited or acquired) + \BMI> 40 kg /m2 * fprolonged hospital admission * Medical co-morbidities like: heart or lung diseases, SLE, cancer, Inflammation conditions Nephrotic syndrome, Sickle cell disease, intravenous drugs etc, + “Age> 35 years Denydn ob * Obesity (BMI >30kg/m2) 7 Mubhel-e + Parity23 ~~ + Smoker Ripenere * Elective caesarean section. : died GENESIS 55Obs Clinical Care + Any surgical procedure in the puerperium * Gross varicose veins, Current ison OS ion, Immobility e.g., paraplegia, long distance travel ; SPD, pre-eclampsia,#fid- cavity rotational operative forceps, prolonged labour (>24 hours) and PPH > 1 litre or blood transfusion¢ Q. What are the preventive measures for VTE? Prevention of trauma, sepsis, anaemia correction of dehydration %" Barly ambulation * Use of elastic compressionstockings ae sooheyertijund: A female < Leg exercise * Anticoagulant * Inferior venecava filters * Fibrinolytic agents + Venous thrombectomy Q. Which is the preferred anticoagulant for thromboembolism? + Low molecular weight heparin (LMWHs) is the treatment of choice, can be switched over to oral warfarin in prolong therapy. Qa sprantage of LMWHs * By aress placenta an@fatient can self administer it. LMWH and Warfarin are safe in breast feeding women. Q. What are the different anticoagulant used and their doses? Anticoagulants : * Unfractionated heparin - conventional heparin. + Low molecular weight heparin - Enoxaparin, Deltaparin. = Oral anticiagulants - Warfarin. * Unfractionated heparin - 10000 units twice daily S/C. \ + ILMWH - Now the treatment of choice: + Enoxaparin - 40 mg $/C once daily up to 6-11 days * Deltaparin - 5000 units $/C daily «-Fortreatment of DVT-and PE. » + Unfractionated heparin - 1/V bolus dose (80 units /kg body weight) followed by 1/V ion (18 units/kg/3 hourly), maximum 40000 units in 24 hoyrs, changed to Gees ria Monitored by activated partial thromboplastin time (APTT) and platelet count. / * “LMWH - Enoxaparin 1 mg/kg S/C pwice daily or Deltaparin 100 units/kg S/C twice daily. * Oral anticiagulant - Can be given simultaneously with parental therapy or to start after few days of parental therapy and monitored by prothrombin time INR (2-3). 56 GENESISObs Clinical Care Q. Deep vein thrombosis (DVT). + Symptoms : Pain over the calf with redness and swelling, Homan's sign and Moses' sign positive + Investigation : Compression ultrasound[ invasive test]- venography with contrast media gives a good view of veins. Others are D-dimer, CT & MRI. + Management: Foot end raised good analgesiq, afiticoagulants, graduated elastic stocking sbretokinase and antibiotics. Q. What are the features of pulmonary embolism? How will you manage? * One of the most common cause of maternal mortality in developed country. More common in puerperium, but occur in antenatal period at any time. * May be fatal, if not diagnosed. * Most common symptom is mild respiratory distress, or inspiratory chest pain, slight tachycardia (> 90 / pm) and low grade temperature. In massive pulmonary embolism, there may be cardio respiratory collapse, severe sf (Sed chest pain, air hungerand death. : en investigation OSG of lower limb to diagnose DVTHEC@A-ray chestABG are done » to exclude other cause. A ventilation perfusion (V/Q) scan or CT pulmonary wf angiogram are done in suspected pulmonary embolism. D-dimer is done as a £ screening test for thromboembolism; its value is less in pregnancy. * Management - Resuscitation with I.V fluid, 02 inhalation, cardiac massage and dopamine / adrenaline, anticoagulant (I/V bolus dose followed by infusion) and streptokinase for thrombolysis. ee eee vegol ebb legmasia Alba Dolens (White le; * Definition & Pathology: Phlegmast a Dolens or white leg is a condition where there is development offndurated painful swollen white leg which occurs due to rombosi: veins. This is due to ¢xtra pelvic spread of infection from jelvic Thrombophlebitis, * Clinical features : - It develops usually in the Second week of puerperium. -Symptoms ~ Severe pain and swelling in the lower limbs, high fever with rigor. Pain is due to arterial spasm following irritation from the thrombosed veins. -Signs - High temperature, tachycardia. * P/V examination: Tender indurated parametrium, sub involution of uterus and foul smelling lochia. The legs become swollen, pale, glistening and pit on pressure. * Investigation ; -Leucocytosis. - USG. -CT scan. -MRI GENESIS 57