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Cell components

NUCLEUS


  • The nucleus  is the site of deoxyribonucleic acid (DNA) replication and transcription of DNA into precursor ribonucleic acid (RNA) molecules. 
  • It contains all of the enzymes required for replication and repair of newly synthesized DNA, as wel as for transcription and processing of precursor RNA molecules. 
  • It is enclosed by the nuclear envelope and contains the nuclear lamina, nucleolus, and chromatin.

Nuclear Envelope

  • The nuclear envelope is a double membrane containing pores that are approximately 90nm in diameter. The outer nuclear membrane is continuous with the endoplasmic reticulum.

Nuclear lamina

  • The nuclear lamina is a lattice like network of proteins that include lamins. 
  • Lamins attach chromatin to the inner membrane of the nuclear envelope and participate in the breakdown and reformation of the nuclear envelope during the cell cycle. 
  • Phosphorylation of the lamina (by lamin kinase) during prophase of mitosis initiates nuclear disassembly into small vesicles.



Nucleolus

  • The nucleolus is responsible for ribosomal RNA (rRNA) synthesis and ribosome assembly.
  • It contains three morphologically distinct zones:
  • Granular zone-found at the periphery; contains ribosomal precursor particles in various stages of assembly.
  • Fibrillar zone-centrally located; contains ribonuclear protein fibrils.
  • Fibrillar center-contains DNA that is not being transcribed.



Chromatin

  • Chromatin is a complex of DNA, histone proteins, and nonhistone proteins.
  • DNA-a double-stranded helical molecule that carries the genetic information of the cell. It exists in three conformations: B DNA,Z DNA, and A DNA.
  • Histone proteins-positively charged proteins enriched with lysine and arginine residues. They are important in forming two types of structures in chromatin: nucleosomes and solenoid fibers. 
  • The nucleosomes are the basic repeating units of the chromatin fiber, having a diameter of approximately 10 nm.
  • Nonhistone proteins-include enzymes involved in nuclear functions such as replication, transcription, DNA repair, and regulation of chromatin function. They are acidic or neutral proteins.

Forms of chromatin
  • Heterochromatin-highly condensed (30-nm solenoid fibers or higher states of condensation) and transcriptionally inactive. In a typical eukaryotic cell, approximately 10% of the chromatin is heterochromatin. Almost the entire inactive X chromosome (Barr body) in each somatic cell in a woman is condensed into heterochromatin.
  • Euchromatin---,a more extended form of DNA,which is potentially transcriptionally active. In a typical cell, euchromatin accounts for approximately 90% of the total chromatin, although only about 10% is being actively transcribed in the 10-nm fiber of nucleosomes.



CYTOPLASM

Ribosomes

  • Ribosomesare composed of rRNA and protein. They consist of large (60S)and small (405) subunits.
  • Ribosomes are assembled in the nucleus and transported to the cytoplasm through the nuclear pores. The large ribosomal subunits are synthesized in the nucleolus, whereas the small subunits are synthesized in the nucleus. 
  • Polysomes-Ribosomes often form polysomes, which consist of a single messenger RNA (mRNA) that is being translated by several ribosomes at the same time. The ribosomes move on the mRNA from the 5' end toward the 3' end. The two ribosomal subunits associate on the mRNA, with the small subunit binding first.



Forms of ribosomes


  • Ribosomes exist in two forms:
  • Free polysomes are the site of synthesis for proteins destined for the nucleus, peroxisomes, or mitochondria. 
  • Membrane-associated polysomes are the site of synthesis of secretory proteins, membrane proteins, and lysosomal enzymes.



Endoplasmic Reticulum

The endoplasmic reticulum exists in two forms, rough endoplasmic reticulum (RER) and smooth endoplasmic reticulum (SER).


Rough endoplasmic reticulum

RER is a single, lipid bilayer continuous with the outer nuclear membrane. It is organized into stacks of large flattened sacs called cisternae that are studded with ribosomes on the cytoplasmic side.
RER synthesizes proteins that are destined for the Golgi apparatus, secretion, the plasma membrane, and lysosomes. RER is very prominent in cells that are specializedin the synthesis of proteins destined for secretion (e.g., pancreatic acinar cells).

Smooth endoplasmic reticulum

SER is a network of membranous sacs,vesicles, and tubules continuous with the RER, but lacking ribosomes.
SER contains enzymes involved in the biosynthesis of phospholipids, triglycerides, and sterols.


Functions of SER


Detoxification Reactions

These are reactions that make compounds water soluble so that they can be excreted. Two types of reactions that increase solubility are:

Hydroxylation reactions-by way of hydroxylase complexes containing cytochrome P450, a flavoprotein, and a nonheme iron protein

Conjugation reactions-the transfer of polar groups (i.e., glucuronic acid) from the active carrier UDPglucuronic acid to the toxic water-insoluble molecule

Steroid synthesis
  • Glycogen Degradation and Gluconeogenesis

Removal of the phosphate group from glucose-6-phosphate by the enzyme glucose-6 phosphatase, an integral membrane protein of the SER. This controls the formation of free glucose from glycogen and via gluconeogenesis.

  • Reactions in Lipid Metabolism

Lipolysis begins in the SER with the release of a fatty acid from triglyceride. The SER is also the site where lipoprotein particles are assembled

  • Sequestration and Release of Calcium Ions

In striated muscle the SER is known as the sarcoplasmic reticulum (SR).The sequestration and release of calcium ions takes place in the SR.


Golgi Apparatus

The Golgi apparatus consists of disc-shaped smooth cisternae that are assembled In stacks (dictyosomes), having a diameter of approximately 1micro.m and associated with numerous small membrane-bound vesicles.
The Golgi apparatus has two distinct faces:
The cis (forming) face is associated with the RER.
The trans (maturing) face is often oriented toward the plasma membrane.
The transmost region is a network of tubular structures known asthe trans-Golgi network (TGN)


Functions of the golgi apparatus

Proteins and Lipids
The Golgi apparatus is the site of post translational modification and sorting of newly synthesized proteins and lipids.
Glycoproteins
Further modification of the carbohydrate moiety of glycoproteins produces complex and hybrid oligosaccharide chains. This determines which proteins remain in the Golgi apparatus or leave the Golgi apparatus to become secretory proteins, lysosomal proteins, or part of the plasma membrane. Two diseasesare caused by a breakdown in this process,I-cell disease and
hyperproinsulinemia .


I-Cell Disease


  • Phosphorylation of mannose in glycoprotein targets proteins to Iysosome. Phosphate is addedin a two-step sequence of reactions that are catalyzed by N-acetylglucosamine-phosphotransferase and N-acetylglucosaminidases.
  • A deficiency in N-acetylglucosamine-phosphotransferases  results in I-cell disease(mucolipidosis II),in which a whole family of enzyme is sent to the wrong destination. It is characterized by huge inclusion bodies in cells caused by the accumulation of undegraded glycoconjugates in Iysosomes missing the hydrolase that normally degrade these macromolecules. The missing enzymes are found in the plasma and other body fluids, where they have normal levels of activity. The absenceof the mannose-6-phosphotase  on the hydrolase results in their secretion rather than their incorporation into Iysosomes.
  • The disease results in skeletal abnormalities,coarse features, restricted joint movements, and psychomotor retardation. Symptoms are generally noted at birth, and the life span is less than 10 years.
  • A somewhat less severe form of the disease with a later onset and potential survival into adulthood is called pseudo-Hurler polydystrophy.
  • There is no treatment for either disease, but prenatal diagnosis is available.

Hyperproinsulinemisia

Characterized by elevated levels of proinsulin in the serum resulting from the failure of a peptidase to cleave proinsulin to insulin and C- peptide in the Golgi apparatus.
The clinical manifestations are similar to those seen in patients with noninsulin dependent diabetes.


Lysosomes

Lysosomes are spherical membrane-enclosed organelles that are approximately 0.5 micro.m in diameter and contain enzymes required for intracellular digestion.

Lysosomes consist of two forms:

  • Primary Iysosomes have not yet acquired the materials to be digested. They are formed by budding from the trans side of the Golgi apparatus.
  • Secondary Iysosomes are formed by the fusion of the primary lysosome with the substrate to be degraded and have contents that are in various stages of degradation.
  • Lysosomes contain approximately 60 hydrolytic enzymes. These include nucleases for degrading DNA and RNA, lipases for degrading lipids, glycosidases for degrading glycoconjugates (glycoproteins, proteoglycans, and glycolipids), proteases and peptidases for degrading proteins, and a variety of phosphatases. . All lysosomal enzymes are acid hydrolases, with optimal activity at a pH of approximately 5.0.
  • The synthesis of the lysosomal hydrolases occurs in the RER; the hydrolases are transferred to the Golgi apparatus, where they are modified and packaged into lysosomes.



Peroxisomes



  • Peroxisomes are a heterogeneous group of small, spherical organelles with a single membrane and a diameter that ranges from approximately 0.15 to 0.5 micro.m.
  • Peroxisomes contain a number of enzymes that transfer hydrogen atoms from organic substrates (urate, D-amino acids, and very long chain fatty acids) to molecular oxygen with the formation of hydrogen peroxide. Catalase, the major peroxisomal protein, degrades the hydrogen peroxide to water and oxygen.
  • Peroxisomal enzymes are synthesized on free polysomes. After translation, the enzymes are incorporated directly into peroxisomes.


Peroxisomes have several functions:


  • Synthesis and degradation of hydrogen peroxide . 
  • Beta-0xidation of very long chain fatty acids (>C24) starts in the peroxisome and proceeds until the carbon chain has been reduced to a length of approximately 10carbons. Oxidation of the residual 10 carbons is completed in the mitochondria.
  • Phospholipid exchange-peroxisomes contain enzymes that convert phosphatidylserineand phosphatidylethanolamine.
  • Bile acid synthesis



Peroxisome Deficiency

Several genetic diseases are associated with the impairment or absence of peroxisomes. These patients fail to oxidize very long chain fatty acids and accumulate bile acid precursor.The four most common disorders are:

  • Zellweger (cerebrohepatorenal) syndrome
  • Neonatal adrenoleukodystrophy
  • Infantile Refsum disease
  • Hyperpipecolatemia



Mitochondria

Mitochondria have two membranes. They are about 0.5 micro.m in width and vary in length from 1 to 10 micro.m. They synthesize adenosine triphosphate (ATP), contain their own double-stranded circular DNA, and make some of their own proteins.
Mitochondria have several compartments.

Outer membrane


  • The outer membrane is smooth, continuous, and highly permeable. It contains an abundance of porin, an integral membrane protein that forms channels in the outer membrane through which molecules of less than 10kD can pass.


Inner membrane


  • The inner membrane is impermeable to most small ions (Na+, K+, H+) and small molecules (ATP, adenosine diphosphate, pyruvate). The impermeability is likely related to the high content of the lipid cardiolipin.
  • The inner membrane has numerous infoldings, called cristae. The cristae greatly increase the total surface area. They contain the enzymes for electron transport and oxidative phosphorylation.
  • The number of mitochondria and the number of cristae per mitochondrion are proportional to the metabolic activity of the cells in which they reside.


Intermembrane compartment

The intermembrane compartment is the space between the inner and outer membranes. It contains enzymes that use ATP to phosphorylate other nucleotides (creatine phosphokinase and adenylate kinase).


Matrix

The matrix is enclosed by the inner membrane and contains:
  • Dehydrogenases-oxidize many of the substrates in the cell (pyruvate, amino acids, fatty acids), generating reduced nicotinamide adenine dinucleotide (NADH) and reduced flavin adenine dinucleotide (FADHz) for use by the electron transport chain and energy generation.
  • A double-stranded circular DNA genome encodes a few of the mitochondrial proteins. Mitochondrial DNA is always inherited from the mother, resulting in the maternal transmission of diseases of energy metabolism.
  • RNA,proteins, and ribosomes-although there is some protein synthesis, most mitochondrial proteins are synthesized in the cytoplasm and are transferred into the mitochondria.
  • Intramitochondrial granules-contain calcium and magnesium. Their  function is not known, but it is believed that they may represent a storage site for calcium.



Cytoskeleton

The cytoskeleton provides a supportive network of tubules and filaments in the cytoplasm of eukaryotic cells. It is composed of microtubules, intermediate filaments, and microfilaments.

Microtubules


  • Microtubules are polymers of tubulin that undergo rapid assembly and disassembly. They are found in the cytoplasmic matrix of all eukaryotic cells.
  • Tubulin
  • The major component of microtubules is tubulin, a protein dimer composed of two different polypeptides, a-tubulin and l3-tubulin.
  • Polymerization of tubulin to form microtubules is accomplished by microtubule organizing centers and two types of accessory proteins, tau proteins and microtubule-associated proteins. Microtubules grow from the organizing centers. Calcium ions can block or reverse polymerization.
  • Microtubules playa role in:
  • Chromosomal movement during meiosis and mitosis. Microtubule assembly is an
  • important event in spindle formation.
  • Intracellular vesicle and organelle transport. Two specific microtubule-dependent ATPases, kinesin and dynein, are involved in generating the force that drives transport, with the microtubular structure playing a more passive role in intracellular transport.
  • Ciliary and flagellar movement.



Intermediate filaments



  • Intermediate filaments are intermediate in thickness (10-nm diameter) between microtubules and micro filaments. They function primarily in structural roles and contain several types of tissue- specific proteins:
  • Cytokeratins-found in epithelial tissue .
  • Desmin-found in smooth muscle; Z disks of skeletal and cardiac muscle
  • Vimentin-found in cells of mesenchymal origin (endothelial cells, fibroblasts, chondroblasts, vascular smooth muscle) .
  • NeurofIlaments-found in neurons
  • Glial fibrillary acidic protein (GFA)-found in astrocytes



Microfilaments


  • Microfilaments have a diameter of 6 nm and are composed of actin. Each actin filament (F-actin) consists of two strands of actin twisted into a helical pattern with 13.5 molecules of globular actin (G-actin) per turn of the helix.
  • Two types of movement are associated with microfilaments:
  • Local movement takes advantage of the polymerization and depolymerization properties of microfilaments.
  • Sliding filament movement is generated by the interaction of actin filaments with myosin filaments.



Clinical correlates

Chediak-Higashi syndrome


  • Chediak-Higashi syndrome is characterized by defect in microtubule polymerization.
  • This leads to defects in cytoplasmic granules including:
  • Delayed fusion of phagosomes with Iysosomes in leukocyte,thus preventing phagocytosis of bacteria.
  • Increased fusion of melanosomes in melanocytes, leading to albinism.
  • Granular defects in natural killer cells and platelets.


Actin-binding drugs


  • Actin-binding drugs(e.g. cytochalasin B) can interfere with the polymerization-depolymerization cycle of microfilaments. Process such as endocytosis, pagocytosis, cytokinesis, cytoplasmic and amoeboid movements are all inhibited by cytochalasin B.



CELL SURFACE


Basement Membrane


  • The basement membrane is a sheet like structure that underlies virtually all epithelia. It consists of the following:
  • Basal lamina-composed of type IV collagen, glycoproteins (e.g.,laminin), and proteoglycans (e.g., heparan sulfate).
  • Reticular lamina-composed of delicate reticular fibers.



Lateral Surface


Tight junction(zonula occludens)


  • The tight junction is formed by the fusion of opposed cell membranes. These ridges of fusion present as "sealing strands" seen in freeze-fracture replicas. It extends completely around the apical cell borders to seal the underlying intercellular clefts from contact with the outside environment. It constitutes the anatomic component of many barriers in the body.



Zonula adherens


  • A zonula adherens (adherent junction) often lies basal to the zonula occludens.
  • It is a band like junction that serves in the attachment of adjacent epithelial cells.



Desmosome


  • The desmosome (macula adherens) is formed by the juxtaposition of two disk-shaped plaques
  • contained within the cytoplasm of each adjacent cell .
  • Intermediate filaments (tonofilaments) radiate away from the plaques . These intermediate filaments are anchored by desmoplakins (plaques)that also bind to trans membrane linker proteins, linking adjacent cells.
  • Desmosomes are most common in lining membranes, are subject to wear and tear, and are considered spot welds that hold cells together.



Gap junction


  • The gap junction is an area of communication between adjacent cells that allows the passage of very small particles and ions across a small intercellular gap within the junction.
  • The gap junction consists of a hexagonal lattice of tubular protein subunits called connexons, which form hydrophilic channels connecting the cytoplasm of adjacent cells.
  • This permits the direct passage of ions and small molecules between cells to conduct electrical impulses.


Apical (Free) Surface

Microvilli


  • Microvilli are apical cell surface evaginations of cell membranes that function to increase the cell surface area available for absorption. A thick glycocalyx coat covers them. The core of each microvillus contains actin microfilaments. It is anchored in the apical cell cytoplasm to the terminal web, which itself is anchored to the zonula adherens of the cell membrane.


Cilia


  • Cilia are apical cell surface projections of cell membrane that contain microtubules. They are inserted on centriole-like basal bodies present below the membrane surface at the apical pole.
  • Cilia contain two central microtubules surrounded by a circle of nine peripheral microtubule doublets. The peripheral doublets are fused so that they share a common tubule wall and form two subtubules, A and B. Adjacent doublets are connected to one another by nexin links.


Movement of Cilia


  • A pair of dynein arms is attached to each A subtubule. The arms bind to ATP and rearrange themselves so that a binding site for the B subtubule in the tip of the arm is exposed. The B tubule interacts with the binding site, causing the arm to snap back and movement to occur. Each cycle of a single dynein arm slides adjacent doublets 10nm past each other.
  • Cilia move back and forth to propel fluid and particles in one direction. They are important in clearing mucus from the respiratory tract.



Clinical correlates:


  • Stereocilia are elongated microvilli found at the apices of cells lining the epididymis, ductus deferens, and haircells of the inner ear, where they play a role in auditory sensation.
  • Flagella are longer than cilia but have the same microstructure, a prominent example is in the sperm, where the single flagellum provides motility.


Kartagener Syndrome


  • Absent or aberrant dynein arms are found in the cilia and flagella of individuals suffering from Kartagener syndrome (a subset of immotile cilia syndrome).
  • Such individuals often have chronic sinusitis and bronchiectasis as well as infertility and, in some cases, situsinversus.


Puerperium

Definition

Normal puerperium
  1. The time from the delivery of the placenta through the first few weeks after the delivery
  2. 6 weeks in duration. 
  3. By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery resolves and the body reverts to the non pregnant state.

The puerperium has been referred to as the “ fourth trimester” of pregnancy, encompassing the period between the delivery and complete physiologic involution and psychological adjustment. 

Abnormal Puerperium

  • Puerperal Pyrexia
  • postnatal psychosis and depression

Puerperal Pyrexia

Definition

P pyrexia is defined as temperature of 38oC ( 100.4oF) or higher on any two occasions persisting after the first 24 hrs of delivery, and within 10 days postpartum taken by mouth by a standard technique.

Cause of P. Pyrexia
  1. P. Sepsis- Genital tract infection
  2. UTI
  3. Breast Complications
  4. Wound Infections
  5. Thrombophlebitis and DVT
  6. Respiratory infections

Puerperal Sepsis

Definition

An infection of the genital tract which occurs as a complication of delivery is termed as P sepsis.

Vaginal flora
  1. L bacillus ( 60-70%)
  2. Yeast like fungus- Candida albicans ( 25%)
  3. Staph albus or aureus
  4. Strepto β haemolyticus
  5. E coli and bacteroids
  6. Cl welchii-rare


These organisms remain dormant and are harmless during normal delivery conducted in aseptic conditions. 

Predisposing factors to P Sepsis


  1. Conditions lowering the resistance 
  2. Malnutrition & anaemia
  3. PROM
  4. Chronic debilitating diseases
  5. Repeated PV examination after rupture membrane
  6. Traumatic manipulative & operative delivery
  7. Haemorrhage 
  8. RPOC- retained product of conception
  9. Placenta previa




Organism responsible for P sepsis
  • Aerobic- Staph, Ecoli, Klebsiella, Pseudomonas, Non-haemolyticus Strepto, 

  • Anaerobic- Anaerobic streptococcus, Bacteroids, Cl welchii and tetani

Pathology and the primary site of infection

Uterus

Endomyometritis- is the most common and usually mildest form of genital infection.

4 Classical signs:
  • Pyrexia 37.8-38o C
  • Pulse 100-120
  • Fundal height- not decreasing
  • Lochia red &offensive smell


Clinical examination & Daily Charting

Investigations

  1. High vaginal smear and endocervical swab for C/S
  2. MSU for R/M/E & C/S
  3. Blood for Hb,TC, DC & C/S
  4. Blood for MP
  5. Widal Test
  6. X-ray chest


Treatment 

1.Adequate fluids, rest and movement of bowel- Milk of magnesia
2.Correction of anaemia
3.Antibiotics- Broad spectrum
        I/V Ampicillin 500mg  6 hrly
        I/V Metronidazole 500 mg  8 hrly
        I/V Gentamycin  3-5 mg/kg body wt in divide dose
                                    OR
        I/V Ceftriaxone / Cefotaxim 1 gm 12 hrly
                    Change according to C/S             

Urinary tract infection
  • Incidence is 1-5%
  • Organisms- E coli, klebsiella, Proteus, Staph aureus
  • Causes- Frequent catheter, stasis of urine due to lack of bladder tone & less desire to pass urine, Asymptomatic bacteriuria becomes symptomatic, 
  • Present- Fever with chills & rigor, burning micturition, frequency, nausea, vomiting, acute pain in the loins radiating to groin.
  • Investigation- Urine for R/M/E and C/S
  • Treatment -Antibiotics

Causes of retention urine in puerperium

1.Bruising and oedema of the bladder neck
2.Reflex from the perineal injury
3.Unaccustomed position
4.Haematoma

Treatment
  • General measures
  • Indwelling catheter for 48 hrs- It helps in regaining the normal bladder tone and the sensation of fullness.
  • Antibiotics

Breast Complications

Common breast complications are

1.Breast engorgement
2.Cracked & retracted nipples
3.Mastitis and breast abscess
4.Failing lactation

Breast engorgement
  • Due to exaggerated normal venous & lymphatic engorgement preceding lactation, preventing escape of milk from lacteal systm.
  • Manifest after the milk secretion- 3rd -4th PPD
  • S/S- Pain, feeling of tenseness and heaviness in both breast, malaise, ↑tempt
  • Treatment-Support breast with binder & brassiere, ice bag, express milk or frequent breast feeding, analgesic
  • Prevention- Manual expression of the remaining milk & frequent breast feedings

Cracked Nipple
  • Due to a) loss of surface epithelium, causing a raw area b) fissure at the tip or base of nipple
  • Caused by 1)unhygiene –crust over the nipple 2) retracted nipple 3) vigorous suckling
  • Asymptomatic usually but if infection, it is painful due to mastitis
  • Treatment-keep nipple clean & dry, nipple shield during each feed, rest if worst and feed by expression, antibiotics ( oral & applicant)  and analgesic
  • Prevention-Local cleanliness during pregn and puerperium

Retracted nipple
  • Primigravida
  • If left uncorrected may predispose to cracked nipple- difficulty in breast feeding
  • Manual lifting of the retracted nipple during pregnancy is advisable.
  • After delivery, use of nipple shield is advisable.

Acute Mastitis

Mode of infection


2 different types of mastitis

  • Infection follows a cracked nipple to involve the breast parenchymal tissues leading to cellulites.
  • Infection gains access through the lactiferous duct leading to development of primary mammary adenitis
  • Responsible organism is Staph aureus- infection comes from nasopharynx of the baby.

Clinical feature
  • Symptom- Generalised malaise, headache, fever with chills
  • Severe pain and tender, swelling in 1 quadrant of the breast.
  • Sign- Wedge shaped swelling on the breast with the apex at the nipple
  •  Over lying skin is hot, flushed, tense and tender

Treatment

  • Antibiotics- Cloxacillin, Cefalosporin
  • Analgesic 
  • Antenatal-Wash the nipple periodically to keep the patency of the duct opening.
  •  Breast feeding on the affected is suspended
  • Manual expression & prevention of engorgement of breast.

Breast Abscess
  • Swinging tempt
  • Reddened breast
  • Marked tenderness with fluctuation.

Treatment
  • Antibiotics
  • Incision and drainage

Wound infection
  • Wound can be that of a CS or an episiotomy wound
  • Infection in the wound usually develops around the 5th to 6th POD
  • Take Swab from the wound and send for C/S 
  • Treat with antibiotics and daily dressing
  • Followed by secondary suture,

Chest infections
  • Usually following general anaesthesia in CS
  • Take x-ray chest and sputum for C/S
  • Treatment is with physiotherapy, warm saline gurgle, steam inhalation and antibiotics

Deep Vein Thrombosis (DVT)
  • Usually occurs at around 7-10th PPD
  • Begins in the deep veins of the calf or soles of the feet and extend upwards
  • Often symptomless
  • Sharp dorsiflexion of the foot elicit pain in the calf-Homan’s sign
  • Slight rise of tempt & pulse.
  • These early S/S may be missed and detected only when pulmonary embolism has developed or when the generalised oedema of the leg has set.
  • Exercise in early puerperium is beneficial.
  • The foot end of the bed is elevated to increase the venous flow from the leg.
  • Antibiotics to prevent infection
  • Anticoagulant to prevent clot formation-Heparin.
  • After being afebrile the pt is encouraged to walk about with the affected leg supported by elastic bandage.



Post Partum Blues, Depression and Psychosis


Post partum Blues



  • Occurs in around 50% of the women
  • Around 4th to 5th PPD
  • Usually self limiting though in rare circumstances progresses to postnatal depression.
  • Cure by support of medical practitioner is all that is required



Post natal depression


  • Onset at around 4th week PP 
  • Lasting for around 6 months
  • Family H/O mental disorder is usually present.
  • C/F are that of sleep disturbance, depression, social withdrawal, lack of worthiness of being a mother, suicidal thoughts, concern that she may harm her child
  • Management- Social support, refd to psychiatrist



Puerperal Psychosis


  • Occurs in 0.2% of the mothers
  • Onset is earlier than the postnatal depression
  • The chance that a mother may harm her baby is very high.
  • Serious condition the requires an expert psychiatric evaluation and treatment


Assessment of Fetal Well-being

FETAL MONITORING 

Definition of fetal monitoring
 -  Method of assessing fetal status before and during labor

Why is fetal monitoring important?
To provide insight that may affect fetal outcome

ANTENATAL FETAL MONITORING

WHAT IS THE AIM OF MONITORING?


  • To decrease perinatal morbidity & mortality 
  • It should guide future care                                               
  • Reassurance
  • More frequent testing
  • Admission to hospital
  • Delivery 


WHICH PATIENTS ARE EXPECTED TO BENEFIT 
FROM THIS TESTING?


Patients at risk
  • IUGR
  • decrease fetal movement
  • Post-term pregnancy > 42 wk
  • Preeclampsia 
  • DM
  • Insulin requiring GD 
  • PPROM
  • stable abruption       

INTRAPARTUM FETAL MONITORING

WHAT ARE THE METHODS AVAILABLE FOR FETAL MONITORING IN LABOR? 

Electronic fetal heart monitoring --> External or internal
Intermittent auscultation 
Fetal scalp sampling --> pH determination
Color of the amniotic fluid

WHAT IS THE AIM OF MONITORING ?
To decrease the risk of intrapartum fetal asphyxia

  • Intrapartum fetal monitoring means simply to watch the fetal behaviour during labour.


Aim:

         To detect hypoxia and so prevent asphyxia which may cause either death or permanent neurological damage as cerebral palsy, mental deficiency or both.


ANTEPARTUM FETAL MONITORING
  • Two thirds of fetal deaths occur before the onset of labor.
  • Many antepartum deaths occur in women at risk for uteroplacental insufficiency.
  • Ideal test: allows intervention before fetal death or damage from asphyxia.
  • Preferable: treat disease process and allow fetus to go to term.



Methods for antepartum fetal assessment
  • Fetal movement counting
  • Assessment of uterine growth
  • Antepartum fetal heart rate testing
  • Biophysical profile
  • Doppler velocimetry



Fetal movement counting
Maternal perception of a decrease in fetal movements may be a sign of impending fetal death
3 movements in 30 minutes.
 10 fetal movements noticed in 10hrs or less, the fetus must probably is in good health


Assessment of uterine growth

General rule: Symphysofundal height in centimeters after 24 weeks till 36 weeks will equal the weeks of gestation.
Exceptions: maternal obesity, multiple gestation, polyhydramnios, abnormal fetal lie, oligohydramnios, low fetal station, and fetal growth restriction.
Abnormalities of fundal height should lead to further investigation.



Antepartum fetal heart rate testing

When to begin testing
Single factors with minimal to moderate increased risk for antepartum fetal death: 32 weeks.
Highest maternal risk factors: 26 weeks.


Which test to use?
Nonstress test
Contraction stress test
Low incidence of unexpected fetal death
Increase in time, cost and inconvenience
Biophysical profile, modified biophysical profile
Doppler velocimetry


Nonstress test (NST)

The nonstress test (NST) is performed by auscultation of the fetal heart rate using an electronic monitor.


  • Healthy fetuses display normal oscillations and fluctuations of the baseline FHR.
  • Absence of these patterns is associated with increase in neonatal depression and perinatal mortality.
  • Accelerations of the FHR during stress testing correlates with fetal well being .
  • Accelerations of the FHR occur with fetal movement, uterine contractions, or in response to external stimuli.
  • FHR accelerations appear to be a reflection of CNS alertness and activity.
  • Absence of FHR accelerations seems to depict CNS depression caused by hypoxia, drugs, fetal sleep, or congenital anomalies. 





Performing the NST
External monitors for contraction and FHR measurement applied.
Patient in left lateral tilt (to minimize supine hypotension).



Interpreting the NST

Reactive: 2 or more accelerations in 20 minutes.
Accelerations: an increase of at least 15 BPM above the baseline lasting at least 15 seconds.
Fetal stimulation by sound (vibroacaustic stimulation) may be used to elicit a response.

Interpreting the NST

Non reactive: Less than 2 accelerations in a 20-minute period.
May extend the testing period to 40 minutes or perform a back-up test.

Reactive/Nonreactive with decelerations: individualize management


Baseline FHR

Normal baseline FHR in a term fetus 37 completed weeks or more is 110-160 bpm.

Determination of the baseline FHR is done between contractions
Baseline is rounded in increments of 5 bpm example; if the FHR is running 125-135 then the baseline FHR should be documented as 130


FHR Pattern  

Baseline :
1.   Normal = 110 – 160 beats/min
2.   Tachycardia – Moderate 160 – 180 beats/min
3.   Severe > 180 beats/min 

4.   Bradycardia – Moderate 100 – 110 beats/min
                            Severe < 100 beats/min

Variability:
Normal        > 5    beats/min
Reduced     3 – 5 beats/min
Absent        < 3    beats/min 


FHR Variability
  • Normal changes and fluctuations in the FHR over time. 
  • Best assessed between contractions
  • Considered to be the best indicator of fetal well-being
  • Variability can be influenced by hypoxic events, maternal hemodynamic issues, drugs, etc.



Examples of Variability

Absent: Not detectable from baseline
Minimal: Less than 5 bpm from baseline 
May occur with: 
normal fetal sleep patterns
mother has received analgesia for pain
Moderate : 6-25 bpm from baseline (optimal pattern)
Marked: More than 25 bpm from baseline


How Do Uterine Contractions Affect Fetal Heart Rate?  

Can affect FHR by increasing or decreasing the rate in association with any given contraction. 
3 primary mechanisms by which UCs can cause a decrease in FHR are by compression of
  •          Fetal head 
  •          Umbilical cord
  •          Uterine myometrial vessels 

    




Periodic and Episodic FHR Characteristics

Periodic: Refers to changes in the FHR that occur with or in relationship to contractions

Episodic: Refers to changes in the FHR that occur independent of contractions


Late Deceleration


Occur in response to utero-placental insufficiency. Blood flow to the fetus is compromised and there is less oxygen available to the fetus)


Prolonged Deceleration

  • Deceleration of the FHR from the baseline lasting more than 2 minutes but less than 10 minutes. 
  • No explanation for why these occur
  • Commonly associated with uterine hyperstimulation.
  • Can also occur without any uterine activity



Characteristics of Contractions

Frequency: How often they occur? They are timed from the beginning of a contraction to the beginning of the next contraction.
Regularity: Is the pattern rhythmic?
Duration: From beginning to end - How long does each contraction last?
Intensity: By palpation mild, moderate, or strong.
By IUPC (intra-uterine pressure catheters) intensity in mmHg
Subjectively: Patient description



Methods of Electronic Fetal Monitoring

External (cardiotocography)
Noninvasive method
Utilizes an ultrasonic transducer to monitor the fetal heart 
Utilizes the tocodynamometer (toco) to monitor uterine contraction pattern


Methods of Electronic Fetal Monitoring

Internal Fetal Monitoring

Invasive
FHR is monitored via a fetal scalp electrode
Uterine activity is monitored by an intrauterine pressure catheter (IUPC)


ANTEPARTUM FETAL MONITORING

Contraction stress test (CST)
  • Uterine contractions producing an intra-amniotic pressure in excess of 30 mm Hg, create an intra-myometrial pressure that exceeds mean intra-arterial pressure, therefore temporarily halting uterine blood flow.
  • A hypoxic fetus will manifest late decelerations.
  • Late decelerations correlate with stillbirth, IUGR, and low Apgar scores.
  • Oxytocin challenge test (OCT))
  • Breast (nipple) stimulation

  • How to perform the CST
External monitors for contraction and FHR measurement applied.
Patient in left lateral tilt (to minimize supine hypotension).
oxytocin infusion or breast stimulation.
Goal: three contractions in ten minutes.

  • Interpretation of the CST
Suspicious: Late decelerations are present with less than half of the contractions.
Hyperstimulation: Decelerations after contractions lasting more than 90 seconds
Unsatisfactory: Cannot induce adequate contractions or FHR recording is of poor quality.

Contraindications to CST

  • PROM
  • Previous classical cesarean delivery
  • Placenta previa
  • Incompetent cervix
  • History of premature labor in this pregnancy
  • Multiple gestation

Biophysical profile (BPP)

The BPP is another test for the evaluation of fetal well-being . It combines the NST with the observation by ultrasound of 4 variables:

  •  fetal breathing movements
  •  fetal body movements
  •  fetal tone
  •  amniotic fluid volume 

Each variable 
When normal: 2
When abnormal: 0
Highest Score: 10, Lowest Score: 0
Accuracy improved by increasing the number of variables assessed.
Overall false negative rate: 0.6/1000

Fetal tone: 7.5 to 8.5 weeks
Fetal movement: 9 weeks
Fetal breathing: 20 to 21 weeks
NST: 24 to 28 weeks


Modified Biophysical Profile

The MBBP is an excellent test for evaluation of the fetal well being. 

Start  NST in standard manner. If a spontaneous acceleration not seen within 5 min, a single1-2sec, sound stimulation is applied in the lower abdomen with the artificial larynx. This stimulus may be repeated up to three times if necessary.  

A four quadrant amniotic fluid volume is assessed by placing an ultrasound transducer perpendicular to the wall of the uterus in four abdominal quadrants and measuring the largest vertical amniotic fluid pocket. A four-quadrant sum of 5 cm or greater is considered normal.

Doppler velocimetry
     
The  use of  Doppler ultrasound for the evaluation of the fetal circulation is based on the physical principle of change in frequency of a sound wave when it is reflected by a moving object. During Doppler studies fetal and maternal vessels are interrogated with ultrasound waves .

    
The Doppler frequency shift caused by the moving red cells is submitted to spectrographic analysis and represented graphically as a waveform. These waveforms represent  changes in the velocity of the blood flowing through the vessels.                                           


  • Doppler velocimetry


A poor indicator of fetal compromise or adaptation to the placental abnormality but does identify patients at risk for increased perinatal mortality.
Strong association between high systolic to diastolic ratios and IUGR.


  • Doppler velocimetry


An increase in the vascular resistance of the fetoplacental unit leads to a decrease in end diastolic flow velocity or its absence in the flow velocity waveform.
Abnormal waveforms reflect the presence of a structural placental lesion.
Abnormal Doppler results require specific management protocols and intensive fetal surveillance.



Uses : plays a vital role in the diagnosis of fetal cardiac defects .
assessment of the hemodynamic responses to fetal hypoxia and anemia. 
diagnosis of other  non-cardiac malformations. 



Doppler velocimetry of the umbilical arteries

40% of combined ventricular output is directed to the placenta by umbilical arteries.
Assessment of umbilical blood flow provides information on blood perfusion of the fetoplacental unit.
Low vascular impedance allows a continuous forward blood flow throughout the cardiac cycle


Basic Principals


The volume flow in the UAs increases with advancing gestation. The high detected in the first trimestvascular impedance er gradually decreases. It is attributed to growth of placental unit and increase in the number of the functioning vascular channels.

 

UMBILICAL ARTERY FLOW 

characteristic saw-tooth appearance of arterial flow in one direction and continuous umbilical venous blood flow in the other. 



Umbilical artery

  • With advancing gestation, umbilical arterial Doppler waveforms demonstrate a progressive rise in the end-diastolic velocity and a decrease in the pulsatility index. 

  • Absent end diastolic flow in the UA wave forms obtain by Doppler ultrasound  is important  evidence of fetal compromise and demands frequent  and intensive fetal surveillance .

  • Reversed end diastolic  flow in the UA is a sign that is shortly followed by fetal demise. Fetuses with reversed end diastolic flow in the UA are acidotic and required prompt delivery.

Uterine artery Doppler
  • Doppler  interrogation of the uterine arteries is usualy performed with transabdominal ultrasound .
  • An important variable in the interpretation of uterine artery Doppler is the gestational age at the time the test is performed.



  • Test is done before 20 weeks of gestation, the no. of false positive results is high, after 24 weeks, trophoblastic invasion has ended and false positive results will decrease.



  • Abnormal uterine artery doppler wave forms indicate increase resistence in the maternal side of the placenta and their main use is as a screening tool for preeclampsia.



ANTENATAL CARE



Case: A 35 year old lady G4 P2 A1 comes to you for the first time for her pregnancy check up. She does not clearly remember her LMP. She says she hasn’t been menstruating for a few months. On PA examination you find uterus palpable 4cm above the pubic symphysis. What would you like to do the next?

What  is antenatal care ?
Why is it important , what is the aim  of doing ANC?
What do we do in antenatal care?

Definition

It is the clinical assessment and care  of mother and fetus during pregnancy for the purpose of obtaining the best possible outcome for both mother and child

Ideal situation

Women to be seen prepregnancy, take advise offered and enter pregnancy in optimum health and mental condition
                                            |
Early booking, adequate ANC visits, recognition and management of complications
                                            |
Normal vaginal delivery
                                            |
Healthy baby and healthy mother

AIM
  • To promote ,protect and maintain the health of the mother during pregnancy
  • To detect high risk cases and give them special attention
  • To forsee complications and manage them
  • Maternal education regarding elements of child care, nutrition, personal hygiene , birth preparedness
  • To remove anxiety and fear associated with pregnancy and childbirth

Decrease the maternal and infant mortality




Ensure that the whole pregancy and childbirth is a happy and fruitful  experience

What do we do in ANC ?
  • EVALUATE : history, examination, investigations

  • RECOGNIZE /ADVICE / TREAT
          recognize complications,
          give advice /educate mother,
          treat  complications , treat specific 
           conditions, supplement deficiencies etc

Women comes to hospital

DETAILED HISTORY

     Identification, education, occupation 
      Menstrual history : LMP
      calculate her POG and EDD (Naegeles formula: 9months +7 days from the first day of LMP)

      Presenting complaint : early/late pregnancy
      Obstetric History: Parity,gravida,year of birth, spacing, abortions, ANC ,labour , delivery and outcome of each preceding pregnancy in detail
      G        P        A           L

      Contraception used
      

Booking visit

Medical history : HTN, DM,Anaemia,bleeding disorders,Heart disease etc
Surgical history : any previous surgery on uterus eg myomectomy,pelvic surgery,VVF repair 
Family History: congenital anomalies,inherited disorders , twinning, HTN,DM etc
Personal history : allergies, diet, smoking , drugs and alcohol intake 

EXAMINATION
GENERAL EXAMINATION
      height, weight , nutrition status
       vitals
      Pallor,oedema,jaundice
      Neck
 CHEST EXAMINATION 
     Lung, Heart
    breast examination

OBSTETRIC EXAMINATION
      
PA: size of uterus (corresponding or not with POG) ,diagnose pregnancy, any scar
      If 20 weeks and more, palpate fetal parts, FHS

      
PS : examine cervix/vagina

      
PV: to diagnose pregnancy, size of uterus, exclude any other pelvic pathology , pelvic size  assessment not done at this time
      

INVESTIGATION
     
Blood : Hgb, ABO and Rh
                  blood sugar /OGT esp in high risk cases
                  VDRL, HBsAg, HIV
      Urine : routine
      Stool : routine
      USG : bleeding PV,not sure of dates,previous history of nonviable fetus, twin history,disparity between POG and clinical assessment
                    

Subsequent visits
  • Monthly till 28 weeks, then 2 weekly till 36 weeks and then weekly till delivery
  • History: Fetal movement, danger symptoms and signs   ( bleeding PV, pain abdomen, persistent headache, persistent vomiting, leaking PV, marked swelling of hands and legs)
  • EXAMINATION: weight, BP ,pallor , edema ,Obstetric examination : SFH , lie, presentation, FHS , engagement etc as the pregnancy advances

PV : after 37 weeks to assess the size of the pelvis, assess cervix (bishops scoring) if planning induction.
INVESTIGATION
        Urine alb and sugar at every visit
        Blood sugar after 28 weeks
        Anti D titre in case RH negative at 28 and 36
        weeks
         USG at 16-20 weeks

INTERVENTION
    * check all investigations and treat accordingly
    * maintain record at every visit : ANC card
    * Supplementation
       i) Iron : 60mg of elemental iron (ferrous sulphate tabs) daily, start after 20 weeks   
       anaemia is  very common in pregnancy
       symptomless
       easily correctable 
       adverse effect on fetus   
ii) folic acid supplementation : 500 microgram daily also to combat anaemia
iii) calcium : 1000mg /daily
iv) vitamins : vit C 50mg/day, thiamine, riboflavin , vit B 12 etc
* Immunization:  to prevent neonatal tetanus with 2 doses of 0.5ml adsorbed TT injection 
      first dose at 16-20weeks and the second dose  after 4 weeks
     if already immunized then single booster dose can be given

* Reinforce advice on nutrition ,personal care and hygiene, FP (Family Planning) method usage, Fetal movement
     As the pregnancy reaches term ,advise regarding signs  of labor, symptoms of complications , birth preparedness
* Referral in case of anticipated complications where facilities are not available
* Special attention to high risk cases

High risk cases

Elderly primi (> 35 years),grand multipara (>5 births)
APH (Antepartum hemorrhage)
PIH (Pregnancy Induced Hypertension)
Malpresentation
Anaemic
Twins
Previous LSCS
Previous SB (Still birth), IUFD (Intrauterine Fetal Death), MTP (Medical Termination Of Pregnancy)
Associated any medical conditions

Simple advises

Diet : increased demand of pregnancy
     Daily calorie requirement :
       2200KC nonpregnant state
       2500KC in pregnancy
       2900KC during lactation
The diet should be healthy and nutritious, affordable and should contain protein (55g/day)and also include milk(1/2 liter to 1 liter /day) ,vitamins ,plenty of water, green leafy vegetables, fruits and nuts.
Help to achieve adequate weight gain ~12 kg

Personal hygiene
Activity   : can do all normal activities,avoid hard work towards the end of pregnancy
Adequate rest with 8hrs sleep at night and 2
     hr rest in day time
Preventing constipation: plenty of fluids, fibre in diet , try and avoid laxatives
Care of teeth, breast 
Coitus : preferably avoided in first trimester and in the last 6 weeks 

Smoking : to be avoided 
       risk of LBW, hypoxia in fetus
Alcohol : to be avoided as increased risk of teratogenicity, spontanous abortion, MR (Mental Retardation) , IUGR (Intra-uterine Growth Retardation)
Drugs: to avoid use of any drugs in pregnancy specailly those that are teratogenic eg gentamycin, sodium valprotae, tetracycline, LSD etc . To change to safer alternatives in case of any medical conditions needing treatment
Avoid Radiation of any kind

Conclusion
  • ANC is an integral part of maternal and fetal health helping to ensure that the mother and fetus are in optimum health before going into labour .
  • Helps prepare the patient mentally and physically for labour
  • Every pregnant women should be encouraged to attend ANC


Management of Normal Labour


Maximum observation with minimal active intervention.

Aim:

Non intereference with watchful expectancy  so  as  to prepare  the  patient  for natural birth.
To monitor carefully the progress  of  labour, maternal condition and fetal behaviour so as to detect any intrapartum complication early.


General Principle:

-Initial assessment
-Observation and intervention if labour becomes abnormal
-close monitoring of the fetal  and maternal condition
-Adequate pain relief
-Emotional support
-Adequate hydration

Initial Assessment:

- Detailed History
- Clinical Examination
- Basic investigation
Aim:
 - To identify as high risk before the onset of labour


O/E:
Vitals 
General sign
Chest/CVS

P/A:
Fundal Height
Lie
Presentation
Engagement
Contraction
FHS



V/I:
P/V:- Dilatation,Effacement,Consistency,Position,Station,
    Membrane Status ,CPD

Investigation:


Diagnosis and Confirmation of Labour:

Admission
1.Encouragement and Assurance
2.Maintain cleanliness of women and her enviroment
3.Rest and ambulation
4.Diet(Liquid and a few biscuits, I/V fluid)
5.Bladder(Encourage women to empty regularly)
6.Bowel(Donot give  enema routinely)
7.Relief of pain:
 - Suggest change of position
 - Encourage mobility
 - Massage her back
 - Encourage breathing exercise
 - If necessary pethidine 1 mg/kg body weight or morphine 0.1 mg/kg IM
 - Epidural
8.Assessment of progression of labour by partograph
 - Patient information 
 - FHR every 30 minutes
 - Amniotic fluid:Record the color of amniotic fluid at every P/V.

I: Membrane intact
C: Clear fluid
M:  Meconium stained fluid
B: Blood stained fluid

Moulding:

1.Sutures apposed
2.Sutures overlapped but reducible
3.Suture overlapped but not reducible


Cervix Dilatation:
-Assess at every vaginal examination and marked with a cross 
-Begin plotting on the partograph  at 4 cm

Alert line:
A line starts at 4 cm of cervical dilatation to the point of expected full dilatation  at the rate of 1 cm/hr.

Action line: Parallel and 4 hrs to the right of the alert line.
Descent: Assessed by P/A. Head divided into five parts. Refers to the part of the head palpable above the s.pubis.
Hours: Refers to the time elapsed since onset of ASOL.
Time: Record actual time

Contraction: Chart every half and hourly.Palpate the no.of contraction in every 10 min.and duration in sec.
< 20 sec: mild
20-40 sec : moderate
>40 sec : Strong
Oxytocin: Amount ofoxytocin/ltr, Drops/min

  • Drugs: Record if additional  drugs given 
  • Pulse: Half hourly
  • B.P: Every 4 hourly
  • Temperature: 2 Hrly
  • Protein,Acetone volume:  Record every time urine is passed

Protraction - as a slow rate of cervical dilatation or descent
 Primiparas - less than 1.2 cm dilatation per hour or less than 1 cm descent per hour.  
 multiparas - less than 1.5 cm dilatation per hour or less than 2 cm descent per hour.  


   Arrest disorders - as a complete cessation of dilatation or descent. Arrest of dilatation  is defined as 2 hours with no cervical change,  Arrest of descent as 1 hour without fetal descent. 

SECOND STAGE OF LABOUR

Progress of second stage of labour:
1.Increasing intensity of uterine contraction
2.Appearance of bearing down effort
3.Urge to defecate with descent of presenting part 
4.Complete dilatation of cervix as evidenced by P/V

AIM

1.To assist in the natural expulsion of the fetus slowly and steadily.
2.To prevent perineal  injury


General measures:

Pt should be in bed
Constant supervision for progress of fetal  &  maternal  condition.
Fetal condition:
If  there  is  FHS  less than 100 or  more than 160 suspect  fetal distress.
Position & presentation: other than occiput  anterior with well flexed head  are considered malposition.   

Maternal  conditions:
Evaluate the women for sign of distress:
Pulse: If the women’s pulse’s  increased ,she
may be dehydrated or  in pain.
BP: If BP decreased suspect APH.
Acetone: If acetone is present in the
urine,suspect poor hydration & nutrition and give dextrose IV.

Preperation for delivary:
 once the cervix is fully
dilated & the women in expulsive
phase,encourage  to assume  position she
prefers & encourage to push.
  • Clean hand:
  • Clean surface:
  • Clean cutting & ligating of the cord:

Delivery of Head
  • Ask the women to pant or give only small pushes with contractions as the baby’s head delivers.
  • To control birth of the head, place the fingers of one against the baby’s head to keep it flexed(bent).
  • Continue to gently support the perineum as the baby’s head delivers.
  • Once the baby’s head delivers, ask the women not to push.
  • Suction the baby’s mouth and nose.



Feel around the baby’s neck for the umbilical cord:
    - If the cord is around the neck but is loose,slip it over the baby’s head;
    - If the cord is tight around the neck,doubly clamp and cut it before unwinding it from around the neck.
 Hooking the fingers in the axillae should be avoided  - injure the nerves of the upper extremity, producing a transient or possibly even a permanent paralysis. 
  Immediately after delivery of the newborn, there is usually a gush of amnionic fluid, often tinged with blood but not grossly bloody.

Delivery of shoulder
Completion of delivery


Clamping the Cord
The umbilical cord is cut between two umbilical cord clamps –
  -  one clamp at 4 to 5 cm from the fetal abdomen,  
  -  other clamp at 2 to 3 cm from the fetal abdomen.  

Timing of Cord Clamping
If after delivery, the newborn is placed at or below the level of the vaginal introitus for 3 minutes and the fetoplacental circulation is not immediately occluded by clamping the cord, an average of 80 mL of blood may be shifted from the placenta to the neonate.
  This provides about 50 mg of iron, which reduces the frequency of iron deficiency anemia later in infancy.
    The risk of circulatory overloading from gross hypervolemia is high, especially in preterm and growth-retarded neonates.
  


Management of the Third Stage of Labor

Immediately after delivery of the newborn, the size of the uterine fundus and its consistency are examined.
 If the uterus remains firm and there is no unusual bleeding, watchful waiting until the placenta separates is the usual practice. 
Massage is not employed, but the fundus is frequently palpated to make certain that the organ does not become atonic and filled with blood from placental separation.
When the placenta has separated, it should be determined that the uterus is firmly contracted.
 The mother may be asked to bear down, and the intra-abdominal pressure may be adequate to expel the placenta. 
If these efforts fail, or if spontaneous expulsion is not possible,  then after  pressure is exerted with the hand on the fundus to propel the detached placenta into the vagina 


FOURTH  STAGE:  usually about 1-2 hrs after delivery

Vital signs
BP , Pulse
Full Bladder
Trauma
Uterine  Relaxation / Atony
Sudden Collapse / Shock

VULVAL HAEMATOMA / RUPTURED UTERUS
pains -  Analgesia if needed

Transfer to inpatient if all signs are normal