stages of labor.pptx....................

Stages of labour........

1. STAGES OF LABOUR events and clinical features

2. STAGES OF LABOUR There are four stages of labour. FIRST STAGE(CERVICAL STAGE): It starts from the onset of true labour pain and ends with full dilatation of cervix. Its average duration is 12 hours in primigravidae and 6 hours in multiparae.

3. SECOND STAGE : It starts from the full dilatation of the cervix and ends with expulsion of fetus from the birth canal. Its average duration is 2 hours in primigravidae and 30 min multiparae. SECOND STAGE PROPULSIVE PHASE EXPULSIVE PHASE Starts from the full Starts with the maternal d ilatation of the cervix bearing down efforts and up to the descent of the ends with delivery of the p resenting part to the baby. p elvic floor.

4. THIRD STAGE: Begins with the expulsion of the fetus and ends with expulsion of the placenta and membranes. Its average duration is about 15 minutes in both primigravidae and multiparae.

5. Fourth stage Stage of observation for atleast one hour after expulsion of the after births. Condition of the uterus and general condition of the patient are carefully monitored.

6. EVENTS IN THE FIRST STAGE OF LABOUR The first stage is chiefly concerned with the preparation of the birth canal so as to facilitate expulsion of the fetus in the second stage. The main events that occur are: 1) dilatation and effacement of the cervix 2) full formation of the lower uterine segment.

7. Dilatation of the cervix Prior to the onset of labour, in the pre-labour phase, there may be certain amount of dilatation of the cervix, especially in multiparae and in some primigravidae. PREDISPOSING FACTORS FAVOURING DILATATION OF CERVIX : Softening of cervix Fibromusculoglandular hypertrophy Increased vascularity Accumulation of fluid in between the collagen fibers Breaking down of the collagen fibrils by collagenase and elastase. Increase in the hyaluronic acid and decrease in the dermatan sulphate levels in the matrix of the cervix.

8. FACTORS RESPONSIBLE FOR DILATATION OF THE CERVIX UTERINE CONTRACTION AND RETRACTION : The longitudinal muscle fibres of the upper segment are attached to the circular muscle fibres of the lower segment and the upper part of the cervix in a bucket holding fashion. With each contraction the canal is opened from above down and also becomes shortened and retracted.

9. While the upper segment contracts, retracts and pushes the fetus, the lower segment and the cervix dilate in response to the forces of contraction of the upper segment. This coordination between the fundal contraction and cervical dilatation is called “ POLARITY OF THE UTERUS”

10. BAG OF MEMBRANES In vertex presentation, the girdle of contact of the head (that part of the circumference of the head which first comes in contact with the pelvic brim) being spherical , may well fit with the wall of the lower uterine segment. Thus the amniotic cavity is divided into two compartments .The part above the girdle of contact contains the fetus with bulk of the liquor called hindwaters and the one below it containing small amount of liquor called forewaters .

11. BAG OF MEMBRANES

12. With the onset of labour, the membranes attached to the lower uterine segment are detached and with the rise of intrauterine pressure during contractions there is herniation of the membranes through the cervical canal . Uterine contractions generate hydrostatic pressure in the forewaters that in turn dilate the cervical canal like a wedge.

13. EFFACEMENT OR TAKING UP OF CERVIX Effacement is the process by which the muscular fibres of the cervix are pulled upwards and merges with the fibres of the lower —uterine segment. In primigravidae effacement precedes dilatation of the cervix, whereas in multiparae, both occurs simultaneously.

14. CLINICAL COURSE OF FIRST STAGE OF LABOUR The first symptom to appear is intermittent painful uterine contractions followed by expulsion of blood stained mucus (show) per vaginam. Only few drops of blood mixed with mucus is expelled and any excess should be considered abnormal.

15. PAIN : The pains are felt more anteriorly with simultaneous hardening of the uterus . Initially, the pains are not strong enough to cause discomfort and come at varying intervals of 15-30 minutes with duration of about 30 seconds . Gradually the interval becomes shortened with increasing intensity and duration so that in late first stage the contraction comes at interval of 3-5 minutes and lasts for about 45 seconds . Pains are usually felt shortly after the uterine contractions begin and pass off before complete relaxation of the uterus .

16. Clinically, the pains are said to be good if they come at intervals of 3-5 minutes and at the height of contraction the uterine wall cannot be indented by the fingers.

17. DILATATION AND EFFACEMENT OF CERVIX Cervical dilatation relates with dilatation of the external os and effacement is determined by the length of the cervical canal in the vagina . in multiparae, dilatation and taking up occur simultaneously The anterior lip of the cervix is the last to be effaced. The first stage is said to be completed only when the cervix is completely - retracted over the presenting part during contractions.

18. Cervical dilatation is expressed either in terms of fingers — 1, 2, 3 or fully dilated or better in terms of centimetres (10 cm when fully dilated ) usually measured with fingers but recorded in centimetres. One finger equals to 1.6 cm on average effacement of the cervix is expressed in terms of percentage- 100% (cervix less than 0.25 cm thick)

19. Partograph Freidman (1954) first devised it composite graphical record of cervical dilatation and descent of head against duration of labour in hours Cervical dilatation is a sigmoid curve . the first stage of labour has got two phases: latent phase active phase

20. Partograph

21. The active phase has got three components: Acceleration phase of cervical dilatation of 2.5-4 cm. Phase of maximum slope of 4-9 cm dilatation. phase of deceleration of 9-10 cm dilatation. In primigravidae, the latent phase is often long ,about 8 hours, during which effacement occurs; the cervical dilatation averaging only 0.35 cm/hour . In multiparae, the latent phase is short ,about 4 hours, and effacement and dilatation occur simultaneously.

22. Dilatation of the cervix at the rate of 1 cm per hour in primigravidae and 1.5 cm in multigravidae beyond 3 cm dilatation (active phase of labour ), is considered satisfactory.

23. FETAL EFFECT During contractions , slowing of fetal heart rate by 10-20 beats per minute occurs which soon returns to its normal rate of about 140 per minute as the intensity of contraction diminishes.

24. EVENTS IN SECOND STAGE OF LABOUR begins with the complete dilatation of the cervix and ends with the expulsion of the fetus This stage is concerned with the descent and delivery of the fetus through the birth canal. Second stage has two phases : Propulsive — from full dilatation until head touches the pelvic floor . Expulsive — since the time mother has irresistible desire to ‘bear down and push’ until the baby is delivered.

25. After full dilatation of the cervix, the membranes usually rupture and there is escape of good amount of liquor amnii . The volume of the uterine cavity is thereby reduced. Simultaneously, uterine contraction and retraction become stronger . The uterus becomes elongated during contraction, while the antero -posterior and transverse diameters are reduced . The elongation is partly due to the contractions of the circular muscle fibers of the uterus to keep the fetal axis straight.

26. Delivery of the fetus is accomplished by the downward thrust offered by uterine contractions supplemented by voluntary contraction of abdominal muscles against the resistance offered by bony and soft tissues of the birth canal . Tendency to push the fetus back into the uterine cavity by the elastic recoil of the tissue of the vagina and the pelvic floor is effectively counterbalanced by the power of retraction . With increasing contraction and retraction, the upper segment becomes more and more thicker with corresponding thinning of lower segment. Endowed with power of retraction, the fetus is gradually expelled from the uterus against the resistance offered by the pelvic floor. After the expulsion of the fetus, the uterine cavity is permanently reduced in size only to accommodate the after-births.

27. CLINICAL COURSE OF SECOND STAGE OF LABOUR PAIN : The intensity of the pains increases. Pain comes at intervals of 2-3 minutes and lasts for about 1-1 ½ minutes . It becomes successive with increasing intensity in the second stage.

28. BEARING DOWN EFFORTS Additional voluntary expulsive efforts that appear during the second stage of labour (expulsive phase). I nitiated by nerve reflex (Ferguson Reflex) set up due to stretching of the vagina by the presenting part. Sustained pushing beyond the uterine contraction is discouraged. Slowing of FHR may occur during pushing. It should come back to normal once contractions are over.

29. MEMBRANES STATUS: Membranes may rupture with a gush of liquor per vaginam. Rupture may occasionally be delayed till the head bulges out through the introitus.

30. DESCENT OF THE FETUS ABDOMINAL FINDINGS: progressive descent of the head, assessed in relation to the brim. Rotation of the anterior shoulder to the midline . change in position of the fetal heart rate - shifted downwards and medially. INTERNAL EXAMINATION FINDINGS: Descent of the head in relation to ischial spines. Gradual rotation of the head evidenced by position of the sagittal suture and the occiput in relation to the quadrants of the pelvis.

31. VAGINAL SIGNS As the head descends down, it distends the perineum, the vulval opening looks like a slit through which the scalp hairs are visible. During each contraction, the perineum is markedly distended with the overlying skin tense and glistening and the vulval opening becomes circular. adjoining anal sphincter is stretched and stool comes out during contraction. head recedes after the contraction passes off but is held up a little in advance because of retraction. the maximum diameter of the head ( biparietal ) stretches the vulval outlet and there is no recession even after the contraction passes off-CROWNING OF HEAD

32. After a little pause, the mother experiences further pain and bearing down efforts to expel the shoulders and the trunk. Immediately thereafter, a gush of liquor (hind waters) follows, often tinged with blood.

33. MATERNAL SIGNS features of exhaustion. Respiration is slowed increased perspiration face becomes congested ,neck veins become prominent during bearing down efforts. Immediately following the expulsion of the fetus, the mother heaves a sigh of relief.

34. FETAL EFFECTS Slowing of FHR during contractions is observed which comes back to normal before the next contraction.

35. EVENTS IN THE THIRD STAGE OF LABOUR The third stage of labour comprises the stage of placental separation, its descent into the lower segment and finally its expulsion with the membranes

36. PLACENTAL SEPARATION At the beginning of labour the placental size roughly corresponds to an area of 20 cm in diameter. No appreciable diminution of the surface area of the placental attachment during first stage. During second stage , slight but progressive diminution of the surface area following successive retractions occur, and attains its peak immediately following the birth of the baby.

37. Mechanism of separation of placenta Marked retraction reduces the effectively the surface area of the placental site to its half. Placenta being inelastic can’t keep pace with such an extent of diminution resulting in its debuckling. A shearing force is instituted between the placenta and the placental site which brings about the separation of the placenta from the decidua. The plane of separation runs through the spongy layer of decidua basalis . So variable thickness of decidua covers the maternal surface of the separated placenta.

38. There are two ways of separation of the placenta: CENTRAL SEPARATION (SCHULTZE METHOD):detachment of the placenta from the uterine wall attachment starts at the centre resulting in opening of a few uterine sinuses and accumulation of blood behind the placenta. With increasing contractions , more and more detachment occurs facilitated by weight of placenta and retroplacental blood until the whole of the placenta gets detached.

39. MARGINAL SEPARATION (MATTHEWS- DUNCAN): separation starts at the margin as it is mostly unsupported. with progressive uterine contraction, more and more areas of the placenta get separated.

40. SEPARATION OF THE MEMBRANES The membranes are attached loosely in the active part. They are thrown into multiple folds. Those attached to the lower segment are already separated during its stretching. separation is facilitated partly by uterine contraction and mostly by weight of the placenta as it descends down from the active part. The membranes so separated carry with them remnants of decidua vera giving the outer surface of the chorion its characteristic roughness.

41. EXPULSION OF THE PLACENTA After complete separation of the placenta, it is forced down into the flabby lower uterine segment or upper part of the vagina by effective contraction and retraction of the uterus. Thereafter , it is expelled out by either voluntary contraction of abdominal muscles (bearing down efforts) or by manual procedure.

42. MECHANISM OF CONTROL OF BLEEDING After placental separation, innumerable torn sinuses which have free circulation of blood from uterine and ovarian vessels have to be obliterated. The occlusion is effected by complete retraction where by the arterioles, as they pass tortuously through the interlacing intermediate layer of the myometrium , are literally clamped(LIVING LIGATURE). living ligature is the principal mechanism of haemostasis . T hrombosis also occurs which occludes the torn sinuses. This phenomenon which is facilitated by hyper- coagulable state of pregnancy . Apposition of the walls of the uterus following expulsion of the placenta (myotamponade) also contributes to minimise blood loss.

43. CLINICAL COURSE OF THIRD STAGE OF LABOUR PAIN: patient experiences no pain for a short time. intermittent discomfort in the lower abdomen reappears, corresponding with the uterine contractions.

44. BEFORE SEPARATION OF PLACENTA ABDOMINAL FINDINGS: Uterus becomes discoid in shape firm in feel and non- ballottable . Fundal height slightly below the umbilicus . PER VAGINAM: slight trickling of blood

45. AFTER SEPARATION PER ABDOMEN : Uterus becomes globular, firm and ballottable . fundal height is slightly raised as the separated placenta comes down in the lower segment and the contracted uterus rests on top of it . There may be slight bulging in the suprapubic region due to distension of the lower segment by the separated placenta . PER VAGINAM: slight gush of vaginal bleeding. Permanent lengthening of the cord is established.

46. EXPULSION OF THE PLACENTA AND MEMBRANES E xpulsion is achieved either by voluntary bearing down efforts or aided by manipulative procedure . Followed by slight to moderate bleeding amounting to 100-250 ml.

47. MATERNAL SIGNS chills and occasional shivering. Slight transient hypotension

48. PURPERIUM ( postpartal complications)

49. Minor Disorders of Puerperium 1 . After pains caused by spasmodic uterine contractions and can be relieved by analgesics. 2. Hemorrhoids. due to pressure from the baby’s head, can be treated with Saline soaks. 3. Retention of Urine sometimes follows a .difficult labour, which caused bruising and leading to lack of bladder tone. Retention can also be caused. by painful sutures Give analgesics PRN, if it persists insert catheter . 4. Postnatal Blues: is often caused by worry about the baby, and not being able to cope with him. Give the necessary support, and involve the husband. She may need help in the house for a few weeks, it is also necessary that she gets enough sleep.

50. Complications of the Puerperium Puerperal Pyrexia Puerperal Sepsis. Endo toxic Shock Venous Thrombosis Puerperal Eclampsia Puerperal Psychosis Urinary Complication

51. Puerperal Pyrexia Puerperal Pyrexia is a raised temperature of 38.5 degrees Centigrade and a raised pulse during the puerperium. Causes: Puerperal Sepsis or genital tract infection Breast Infection Urinary tract infection Thromboembolic disorders Wound infection (caesarean Section) , Non Infectious Disorders. e.g Breast Engorgement or problems not associated with pregnancy, e.g. Malaria, Chest infection, or Meningitis Management : treating the underlying cause

52. Puerperal Sepsis ( Metritis ) Definition : Puerperal sepsis is any bacterial infection of the genital tract which occurs after the birth of a baby. It is usually more than 24 hours after delivery before the symptoms and signs appear . If, however, the woman has had prolonged rupture of membranes or a prolonged labour without prophylactic antibiotics, then the disease may become evident earlier.

53. Bacteria which cause puerperal sepsis Some of the most common bacteria are: streptococci staphylococci escherichia coli ( E.coli ) clostridium tetani clostridium welchii chlamydia Gonococci (bacteria which cause sexually transmitted diseases).

54. Cont … Symptoms and signs of puerperal sepsis The following symptoms and signs occur in puerperal sepsis: fever (temperature of 38°C or more) chills and general malaise lower abdominal pain tender uterus sub involution of the uterus Purulent, foul-smelling lochia .

55. Risk factors for puerperal sepsis Some women are more vulnerable to puerperal sepsis, including for example those who are anaemic and/or malnourished. protracted labour, prolonged rupture of the membranes, frequent vaginal examinations, a traumatic delivery, caesarean section and Retained placental fragments all predispose to puerperal infection

56. Urinary tract infections A urinary tract infection (UTI) is defined as a bacterial inflammation of the bladder or urethra. Greater than 105 colony-forming units from a clean-catch urine specimen or greater than 10,000 colony-forming units on a catheterized specimen is considered diagnostic of a UTI.

57. Etiology Risk factors for postpartum UTI include cesarean delivery, forceps delivery, vacuum delivery, tocolysis, induction of labor, maternal renal disease, preeclampsia, eclampsia, epidural anesthesia, bladder catheterization, length of hospital stay, and previous UTI during pregnancy. The most common pathogen is E coli. In pregnancy, group B streptococci are a major pathogen. Other causative organisms include Staphylococcus saprophyticus , E faecalis , Proteus, and K pneumoniae .

58. Incidence Postpartum bacteruria occurs in 3-34% of patients, resulting in a symptomatic infection in approximately 2% of these patients. History A patient may report frequency, urgency, dysuria , hematuria , suprapubic or lower abdominal pain, or no symptoms at all. Physical On examination, vital signs are stable and the patient is afebrile . Suprapubic tenderness may be elicited on abdominal examination.

59. Differential diagnosis Acute cystitis Acute pyelonephritis Diagnosis Appropriate laboratory tests include urinalysis, urine culture from either a clean-catch or catheterized specimen, and CBC count.

60. Treatment Treatment is started empirically in uncomplicated infection because the usual organisms have predictable susceptibility profiles. When sensitivities are available, use them to guide antimicrobial selection. Treatment is with a 3- or 7-day antibiotic regimen. Commonly used antibiotics include trimethoprim / sulfamethoxazole , ciprofloxacin, and norfloxacin ..

61. Treatment cont.. Amoxicillin is often still used, but it has lower cure rates secondary to increasing resistance of E coli. The quinolones are very effective but are considerably more expensive than amoxicillin and trimethoprim / sulfamethoxazole and should not be used in breastfeeding mothers

62. Mastitis Mastitis is defined as inflammation of the mammary gland. Etiology Milk stasis and cracked nipples, which contribute to the influx of skin flora, are the underlying factors associated with the development of mastitis. Mastitis is also associated with primiparity , incomplete emptying of the breast, and improper nursing technique.

63. The most common causative organism, isolated in approximately half of all cases, is Staphylococcus aureus . Other common pathogens include Staphylococcus epidermidis , S saprophyticus , Streptococcus viridans , and E coli. Incidence The incidence of postpartum mastitis is 2.5-3%. Mastitis typically develops during the first 3 months postpartum, with the highest incidence in the first few weeks after delivery.

64. Morbidity and mortality Neglected, resistant, or recurrent infections can lead to the development of an abscess, requiring parenteral antibiotics and surgical drainage. Abscess development complicates 5-11% of the cases of postpartum mastitis and should be suspected when antibiotic therapy fails. Mastitis and breast abscess also increase the risk of viral transmission from mother to infant. The diagnosis of mastitis is solely based on the clinical picture.

65. Clinical Feature Fever, chills, myalgias , erythema , warmth, swelling, and breast tenderness characterize this disease. Focus examination on vital signs, review of systems, and a complete examination to look for other sources of infection. Typical findings include an area of the breast that is warm, red, and tender. When the exam reveals a tender, hard, possibly fluctuant mass with overlying erythema , a breast abscess should be considered.

66. Differential diagnosis Mastitis Breast abscess Cellulitis Diagnosis No laboratory tests are required. Expressed milk can be sent for analysis, but the accuracy and reliability of these results are controversial and aid little in the diagnosis and treatment of mastitis.

67. Treatment Milk stasis sets the stage for the development of mastitis, which can be treated with moist heat, massage, fluids, rest, proper positioning of the infant during nursing, nursing or manual expression of milk, and analgesics .

68. Cont … When mastitis develops, penicillinase -resistant penicillins and cephalosporins , such as dicloxacillin or cephalexin, are the drugs of choice. Erythromycin , clindamycin, and vancomycin may be used for patients who are resistant to penicillin. Resolution usually occurs 48 hours after the onset of antimicrobial therapy.

69. Breast Abscess A fluctuant swelling develops in a previously inflamed area. Pus may discharged from nipple. Can be managed by simple needle aspiration or incision and drainage may be necessary . Even though it is not possible to feed from the affected breast, milk removal should be continued to reduce chance of further abscess.

70. Wound infection Wound infections in the postpartum period include infections of the perineum developing at the site of an episiotomy or laceration, as well as infection of the abdominal incision after a cesarean birth. Wound infections are diagnosed on the basis of erythema , induration , warmth, tenderness, and purulent drainage from the incision site, with or without fever. This definition can be applied both to the perineum and to abdominal incisions.

71. Etiology Perineal infections : Infections of the perineum are rare . In general, they become apparent on the third or fourth postpartum day. Known risk factors include infected lochia , fecal contamination of the wound, and poor hygiene. These infections are generally polymicrobial , arising from the vaginal flora.

72. Abdominal wound infections : Abdominal wound infections are most frequently the result of contamination with vaginal flora. However , S aureus , either from the skin or from an exogenous source, is isolated in 25% of these infections. Genital Mycoplasma species are commonly isolated from infected wounds that are resistant to treatment with penicillins .

73. Abdominal wound infections cont Known risk factors include: diabetes, hypertension, obesity, treatment with corticosteroids, immunosuppression , anemia, development of a hematoma, chorioamnionitis , prolonged labor, prolonged rupture of membranes, prolonged operating time, abdominal twin delivery, and excessive blood loss.

74. Incidence The incidence of perineal infections is 0.35-10%. The incidence of incisional abdominal wound infections is 3-15% and can be decreased to approximately 2% with the use of prophylactic antibiotics.

75. Morbidity and mortality The most common consequence of wound infection is increased length of hospital stay. About 7% of abdominal wound infections are further complicated by wound dehiscence. More serious sequelae , such as necrotizing fasciitis, are rare, but patients with such conditions have a high mortality rate.

76. Differential diagnosis Perineal infection Hematoma Hemorrhoids Perineal cellulitis Necrotizing fasciitis Abdominal wound infection Cellulitis Necrotizing fasciitis Wound dehiscence

77. History Patients with perineal infections may complain of an inordinate amount of pain, malodorous discharge, or vulvar edema. Abdominal wound infections develop around postoperative day 4 and are often preceded by endometritis . These patients present with persistent fever despite antibiotic treatment.

78. Physical Perineal infections : An infected perineum often looks erythematous and edematous and may be accompanied by purulent discharge. Perform an inspection to identify hematoma, perineal abscess, or stitch abscess. Abdominal wound infections : Infected incisions may be erythematous , warm, tender, and indurated . Purulent drainage may or may not be obvious. A fluid collection may be appreciated near the wound, which, when entered, may release serosanguinous or purulent fluid.

79. Diagnosis The diagnosis of wound infection is often made based on the clinical findings. Serial CBC counts with differentials may be helpful, especially if a patient does not respond to therapy as anticipated. Treatment Perineal infections : Treatment of perineal infections includes symptomatic relief with NSAIDs, local anesthetic spray, and sitz baths. Identified abscesses must be drained, and broad-spectrum antibiotics may be initiated.

80. Abdominal wound infections : These infections are treated with drainage and inspection of the fascia to ensure that it is intact . Antibiotics may be used if the patient is afebrile . Most patients respond quickly to the antibiotic once the wound is drained.

81. Antibiotics are generally continued until the patient has been afebrile for 24-48 hours. Patients do not require long-term antibiotics unless cellulitis has developed. Recent studies have shown that closed suction drainage or suturing of the subcutaneous fat decreases the incidence of wound infection when the subcutaneous tissue is greater than 2 cm in depth.

82. Thrombo -embolic disorders Are divided in to two: Superficial vein thrombosis Deep vein thrombosis (DVT)

83. Septic pelvic thrombophlebitis Septic pelvic thrombophlebitis is defined as venous inflammation with thrombus formation in association with fevers unresponsive to antibiotic therapy

84. Etiology Bacterial infection of the endometrium seeds organisms into the venous circulation, which damages the vascular endothelium and in turn results in thrombus formation. The thrombus acts as a suitable medium for proliferation of anaerobic bacteria. Ovarian veins are often involved because they drain the upper half of the uterus

85. Etiology cont.. . When the ovarian veins are involved, the infection is most often unilateral, involving the right more frequently than the left. Occasionally, the thrombus has been noted to extend to the vena cava or to the left renal vein. Ovarian vein involvement usually manifests within a few days postpartum. Disease with later onset more commonly involves the iliofemoral vein. Risk factors include low socioeconomic status, cesarean birth, prolonged rupture of membranes, and excessive blood loss.

86. Incidence Septic pelvic thrombophlebitis occurs in 1 of every 2000-3000 pregnancies and is 10 times more common after cesarean birth (1 per 800) than after vaginal delivery (1 per 9000). The condition affects less than 1% of patients with endometritis . Morbidity and mortality Septic thrombophlebitis may result in the migration of small septic thrombi into the pulmonary circulation, resulting in effusions, infections, and abscesses. Only rarely is a thrombus large enough to cause death.

87. History Septic pelvic thrombophlebitis usually accompanies endometritis . Patients report initial improvement after an intravenous antibiotic is initiated for treatment of the endometritis . The patient does not appear ill. Patients with ovarian vein thrombosis may describe lower abdominal pain, with or without radiation to the flank, groin, or upper abdomen . Other symptoms include nausea, vomiting, and bloating. Frequently, patients with enigmatic fever are asymptomatic except for chills.

88. Physical Vital signs demonstrate fever greater than 38°C and resting tachycardia. If pulmonary involvement is significant, the patient may be tachypneic and stridulous . On abdominal examination, 50-70% of patients with ovarian vein thrombosis have a tender, palpable, ropelike mass extending cephalad beyond the uterine cornu .

89. Differential diagnosis Ovarian vein syndrome Pyelonephritis Appendicitis Broad ligament hematoma Adnexal torsion Pelvic abscess

90. Diagnosis Important laboratory studies included urinalysis, urine culture, and CBC count with differential. Imaging : CT scan and MRI are the studies of choice for the diagnosis of septic pelvic thrombophlebitis . MRI has 92% sensitivity and 100% specificity, and CT imaging has a 100% sensitivity and specificity for identifying ovarian vein thrombosis . These imaging modalities are capable of identifying both ovarian vein and iliofemoral involvement. Homan’s sign (Pain in the calf muscles during dorsi flexion of the foot

91. Treatment The standard therapy after diagnosis of septic pelvic thrombophlebitis includes: anticoagulation with intravenous heparin to an aPTT that is twice normal and continued antibiotic therapy . A therapeutic aPTT is usually reached within 24 hours, and heparin is continued for 7-10 days. In general, long-term anticoagulation is not required.

92. Treatment cont… Antibiotic therapy is most commonly with gentamicin and clindamycin . Other choices include a second- or third-generation cephalosporin, imipenem , cilastin , or ampicillin and sulbactam . All of these antibiotics have a cure rate of greater than 90%. Initially, it was thought that patients defervesce within 24-28 hours.

93. More recent studies show that it takes 5-6 days for the fevers to resolve. In a recent prospective randomized study, women who were treated with heparin in addition to antibiotics responded no faster than patients treated with antibiotics alone. These findings do not support the empiric practice of heparin therapy for septic pelvic thrombophlebitis and raise the question of whether a new standard protocol should be developed.

94. Psychiatric Disorders

95. Three psychiatric disorders may arise in the postpartum period: Postpartum blues(Third day): is a transient disorder the lasts hours to weeks and is characterized by bouts of crying and sadness. Postpartum depression (PPD ): is a more prolonged affective disorder that lasts for weeks to months. PPD is not well defined in terms of diagnostic criteria, but the signs and symptoms do not differ from depression in other settings. and Postpartum psychosis : occurs in the first postpartum year and refers to a group of severe and varied disorders that elicit psychotic symptoms

96. Etiology: The specific etiology of these disorders is unknown. The current view is based on a multi factorial model. Psychologically , these disorders are thought to result from the stress of the peripartum period and the responsibilities of child rearing. Other authorities ascribe the symptoms to the sudden decrease in the endorphins of labor and the sudden fall in estrogen and progesterone levels that occur after delivery. Low free serum tryptophan levels have been observed, which is consistent with findings in major depression in other settings. Postpartum thyroid dysfunction has also been correlated with postpartum psychiatric disorders

97. Risk factors: include undesired pregnancy, feeling unloved by mate, age younger than 20 years, unmarried status, medical indigence, low self-esteem, dissatisfaction with extent of education, economic problems with housing or income, poor relationship with husband or boyfriend, being part of a family with 6 or more siblings, limited parental support (either as a child or as an adult), and past or present evidence of emotional problems.

98. Women with a history of PPD and postpartum psychosis have a 50% chance of recurrence. Women with a previous history of depression unrelated to childbirth have a 30% chance of developing PPD. Incidence Approximately 50-70% of women who have given birth develop symptoms of postpartum blues. PPD occurs in 10-15% of new mothers. The incidence of postpartum or puerperal psychosis is 0.14-0.26%.

99. Morbidity and mortality Psychiatric disorders can have deleterious effects on the social, cognitive, and emotional development of the newborn. These ailments can also lead to marital difficulties.

100. History Postpartum blues is a mild, transient, self-limited disorder that usually develops when the patient returns home. It commonly arises during the first 2 weeks after delivery and is characterized by bouts of sadness, crying, anxiety, irritation, restlessness, mood lability , headache, confusion, forgetfulness, and insomnia.

101. History cont… PPD : Patients suffering from PPD report insomnia, lethargy, loss of libido, diminished appetite, pessimism, incapacity for familial love, feelings of inadequacy, ambivalence or negative feelings toward the infant, and an inability to cope . Consult a psychiatrist when PPD is associated with comorbid drug abuse, lack of interest in the infant, excessive concern for the infant's health, suicidal or homicidal ideations, hallucinations, psychotic behavior, overall impairment of function, or failure to respond to therapeutic trial.

102. Postpartum psychosis : The signs and symptoms of postpartum psychosis typically do not differ from those of acute psychosis in other settings. Patients with postpartum psychosis usually present with schizophrenia or manic depression, which signals the emergence of preexisting mental illness induced by the physical and emotional stresses of pregnancy and delivery.

103. Treatment Postpartum blues , which has little effect on a patient's ability to function, often resolves by postpartum day 10; therefore, no pharmacotherapy is indicated. Providing support and education has been shown to have a positive effect.

104. Treatment cont… PPD generally lasts for 3-6 months, with 25% of patients still affected at 1 year. PPD greatly affects the patient's ability to complete activities associated with daily living.

105. PPD… Supportive care and reassurance from healthcare professionals and the patient's family is the first-line therapy for patients with PPD . Research on pharmacological treatment for PPD is limited because postpartum women are often excluded from large clinical trials . Empirically, the standard treatment modalities for major depression have been applied to PPD.

106. PPD… First-line agents include selective serotonin reuptake inhibitors (SSRIs) or secondary amines. Studies on these drugs show that they can be used by nursing mothers without adverse effects on the infant . Consider electroconvulsive therapy for patients with PPD because it is one of the most effective treatments available for major depression. Treatment is recommended for 9-12 months beyond remission of symptoms, with tapering over the last 1-2 months

107. Postpartum psychosis : Treatment of postpartum psychosis should be supervised by a psychiatrist and should involve hospitalization. Specific therapy is controversial and should be targeted to the patient's specific symptoms. Patients with postpartum psychosis are thought to have a better prognosis than those with non puerperal psychosis . Postpartum psychosis generally lasts only 2-3 months.

108. Cont … Secondary to the overlap between the normal sequelae of childbirth and the symptoms of PPD, the former is often under diagnosed. Screening for PPD increases the identification of women suffering from this disorder. The Edinburgh Postnatal Depression Scale has proven to be an effective tool for this type of screening. It requires little extra time and is acceptable to both patients and physicians.