Science topic

Obstetric Delivery - Science topic

Obstetric Delivery is a delivery of the FETUS and PLACENTA under the care of an obstetrician or a health worker. Obstetric deliveries may involve physical, psychological, medical, or surgical interventions.
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Under COVID_19, most evidence and data are on adults, but more and more paediatric cases with some mortality are ongoing.
Let's gather all the paediatric related COVID-19 research here for referencing.
1) Yung CF, Kam K, Wong MS, et al. Environment and Personal Protective Equipment Tests for SARS-CoV-2 in the Isolation Room of an Infant With Infection. Ann Intern Med. 2020; [Epub ahead of print 1 April 2020]. doi: https://doi.org/10.7326/M20-0942
2) Brooks Samantha K, Smith Louise E, Webster Rebecca K, Weston Dale, Woodland Lisa, Hall Ian, Rubin G James. The impact of unplanned school closure on children’s social contact: rapid evidence review. Euro Surveill. 2020;25(13):pii=2000188. https://doi.org/10.2807/1560-7917.ES.2020.25.13.2000188
3) Dong L, Tian J, He S, et al. Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn. JAMA. Published online March 26, 2020. doi:10.1001/jama.2020.4621
4) Iqbal SN, Overcash R, Mokhtari N, Saeed H, Gold S, Auguste T, et al. An Uncomplicated Delivery in a Patient with Covid-19 in the United States. N Engl J Med. 2020 Apr 01.
DOI: 10.1056/NEJMc2007605
5) Qiu H, Wu J, Hong L, Luo Y, Song Q, Chen D. Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study. Lancet Infect Dis. 2020 Mar 25.
6) Zeng H, Xu C, Fan J, et al. Antibodies in Infants Born to Mothers With COVID-19 Pneumonia. JAMA. Published online March 26, 2020. doi:10.1001/jama.2020.4861
7) Zeng L, Xia S, Yuan W, et al. Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatr. Published online March 26, 2020. doi:10.1001/jamapediatrics.2020.0878
8) Chen D, Yang H, Cao Y, Cheng W, Duan T, Fan C, et al. Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection. Int J Gynaecol Obstet. 2020 Mar 20.
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The aim of this study is to search for any causes of fetal stress.
We're looking for the relationship between frequency of the contractions and the duration of the fetus in the pelvis (Hodge 3).
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Though the origin of fetal distress is hypoxia, there are various related factors. Currently it is preferable to call None reassuring fetal heart pattern. The causes may include compression of umbilical cord between the maternal pelvic bones, abrasio placenta, inadequate perfusion of nutrients and oxygen through placenta, titanic uterine contractions and possible other causes.
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what is the best management?
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Thanks Jelena
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I need to calculate the probability for delivery packets at the sink node. Each link has the probability for failure (p) so the probability for successful is (1-p). there are relay nodes between the sensor nodes and sink node, some relay nodes are forward the packets and another they do network coding.
if the relay just forwards the correctly received , How can calculate the probability of successful reception at the destination?
When relay nodes are applied network coding on the packets. How can compute the probability of successful delivery?
Could you explain by example?please
Best regards
Hisham
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Dear Hisham,
In order to calculate the probability of successful delivery of packets to the destination node you have to model your network precisely. As you describe it , one can not perform the needed calculations. 
Wish you success
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what are the other options?
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Dear Dr. Ahmed Abbas,
It has been stated that "Misoprostol facilitates insertion of an IUD, and reduces the number of difficult and failed attempts of insertions in women with a narrow cervical canal" by Sääv I, Aronsson A, Marions L, Stephansson O, Gemzell-Danielsson K at their article "Cervical priming with sublingual misoprostol prior to insertion of an intrauterine device in nulliparous women: a randomized controlled trial."  in Hum Reprod. 2007;22(10):2647.  You can reach the article in PubMED
Best regards. 
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For a dilatation more than 2cm is a high risk for rupture of membrane during the cerclage. From 24 weeks of gestation the fetus is viable (OMS definition).
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I wish the subject were so simple as some of the answers above indicate. It is unfortunate that most if not all of the studies (RCTs) regarding cerclage in singleton as well as twin gestations were poorly designed, poorly executed, poorly analyzed and poorly interpreted. Our specialty has been unable to resolve the question, "does cerclage improve outcomes?" for more than 6 decades now. Is it not time then to realize and accept that the paradigm of incompetent cervix needs total overhaul?
The entire treatment scheme in patients with short cervix with or without dilation is based on the concept of cervical incompetence. Such intrinsic cervical failure is rare and we all know the possible causes for such a failure. Instead, the main cause of cervical shortening is intrauterine proinflammatory changes; and I do not mean to indicate here the highly overrated intrauterine infection, which is usually a secondary event. I mean non-infectious pro-inflammatory changes which lead to breakdown of the collagen structure of the cervix (proteolysis) and at the same time create a low level of uterine contractility, which might be felt or not by the patient. Careful and properly guided history in such patients reveals always symptomatology that is identifiable but for the most part discounted by obstetricians as well as their patients, as normal pregnancy nuisances.
1.     Low pelvic pressure
2.     Lower back pain in the coccygeal area
3.     “Gas pains”
4.     Pulling sensation in the lower pelvis
5.     Feeling of wetness in the vagina; not excess discharge, just feeling wet.
The above symptoms can be elicited in the vast majority of patients who present with a short cervix with or without dilation, if one only knew what questions to ask.
The inflammatory changes in the uterine environment that are responsible for such cervical injury are the result of subchorionic clots, placental thrombosis with necrotic changes in the chorionic villi (fetal thrombotic vasculopathy), decidual ischemia and thrombosis. Such pathology is almost always overlooked prenatally and it is only realized after the poor outcome has happened and only when the placenta is sent to pathology. This is not the way it should happen. We have the technology and the know how to assess such intrauterine changes, identify their cause and treat them accordingly. There is nothing that can stop preterm labor unless the primary cause of the inflammation is addressed and treated. Therefore, any role of the cerclage should be only secondary to address the potential cervical weakness that might have been caused by the inflammation and the primary treatment should be to address the cause of inflammation, eliminate it and at the same time treat the patient with anti-inflammatory agents. Synthetic and natural progesterone exert a mild anti-inflammatory effect and can be helpful but if one truly wishes to stop the inflammatory process in its tracks, Indomethacin is the best choice and well proven to prolong the pregnancy significantly as well as reduce prematurity. {Zuckerman H, et al. Obstet Gynecol 1974;44:787, Niebyl J. et al. Am J Obstet Gynecol 1980;136:1014, Zuckerman H. et al. J Perinat Med 1984;12:2}
We have presented evidence of superior outcomes when progressive cervical shortening is treated with Indomethacin; 70% of patients responded to Indomethacin only and 30% required cerclage placement due to partial response to Indomethacin. {J Matern Fetal Neonatal Med. 2011 Jan;24(1):79-85 } It is clear that Indomethacin can be used safely and achieves excellent results.
One need be aware however of the complications and the fact that fetal cardiac assessment is in order prior to the use of the drug as well as during the treatment. We have treated as of today more than a thousand patients and we have never experienced any fetal side effects beyond mild and temporary increase in the ductal peak systolic velocity, which however remained always well within the normal ranges. (data to be published soon) There were never a need to stop the medication due to side effects and we have treated patients on an intermittent fashion until 34 weeks.  The best that can be achieved with progesterone (natural or synthetic) is a 30% prematurity; well, this is almost 3 times the national USA average prematurity rate. Is it really wise to consider this a successful treatment modality?
In all the studies that progesterone was successful it was not because it reduced prematurity below the national average but below the control group, which for some unknown reasons presented unnaturally high levels of prematurity { N Engl J Med. 2003 Jun 12;348(24):2379-85}.
What works well for singleton pregnancies, usually works well also for multiple gestations, albeit, less successfully. The minimum goal of every obstetrician should be to get any such pregnancy to 32 weeks by all means. This is the time where quality of life can be acceptable without serious immediate and long-term consequences. To be comfortable with any baby been delivered before 28 weeks is insanity. Survival is not the important requirement here; high “quality of life” survival should be the demanded outcome. One should understand that no matter what we do, we will fail in a number of cases; failing after intense effort is part of life but failing because of lack of effort should be unacceptable. There is enough evidence for those willing to find it that doing nothing should be only a rare event and not the norm.  
Therefore, and with the above in mind, the answer to your question is as follows:
1.     Prepare the pregnancy for the worst possible outcome, early delivery
a.     Steroids
b.     Possible neuroprophylaxis with MgS04.
2.     Rule out infection
a.     Possible amniocentesis (controversial) of twin A to rule out intra-amniotic infection (10% of twin A have evidence of bacteria in the amniotic cavity when the cervix is dilated, most likely a secondary event). {Am J Obstet and Gynecol, 1990 Sep;163(3):757-61}.
b.     Cervical and vaginal cultures
3.     If you consider antibiotics (controversial), the use of Macrolides is a better choice due to inhibition of proteolysis that reduces the risk for amniotic sac damage.
4.     Indomethacin 50 mg p.o. stat and then q6h for a minimum of 7 days.
a.     Evaluate ductus arteriosus prior to indomethacin initiation and complete fetal echo (any MFM specialist should be able to do so).
b.     Baseline amniotic fluid for further evaluation during indomethacin treatment. Mild and clinically insignificant reduction of fluid is common in such cases but it reverses within 24 hours post discontinuation of treatment.
c.      After initial 7-day course, use Indomethacin for 2-3 days per week until 32-34 weeks and as long as the fetal ductus remains normal.
d.     Nifedipine XL 60 mg p.o. BID
5.     When infection has been ruled out, cerclage should be performed unless the cervical length responded well and improved after the start of Indomethacin.
a.     If the cervix remains dilated, use of 30 cc Foley balloon should be used to push the membranes back into the cavity so the cerclage can be placed at least 2-3 cm above the external cervical os. The mild reduction of the amniotic fluid from the use of Indomethacin will help also reduce the pressure of the amniotic sac and make it easier to push back again during the cerclage. In rare occasions, amniocentesis for amnioreduction might be the only way to place a cerclage. {Evans DJ, Kofinas AD, King K. Obstet Gynecol. 1992 May;79(5 ( Pt 2)):881-2.}
This might be the best treatment plan that could help you get this pregnancy to a safe gestational age assuming she has not been infected already.
Educate your patients about the mild symptoms mentioned above so you will identify such patients at an earlier stage at which time you will have a much better chance to succeed and prevent prematurity.
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some gynecologist advise the pregnant with twin to take dexamethasone 12 mg injection several time ( 2 or 4 times) in the third trimester of pregnancy, what are the expected benefits and what are the risks for the pregnant and fetus. 
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 betamethasone is usually preferred over dexamethasone, if it is available in your country. Benefits are reported when used in accordance with guidelines in case of preterm deliveries. They should not be administered to twins prophylactically with the fear of preterm delivery.  Use should be reasonable and with clear indications. Apparently solid data supports the use of betamethasone earlier than 32 weeks of gestation. Initial concern should be the survival of the preterm fetus with as little complications as possible, everything else comes second.  Still, this should be well documented and written consents should be received from the parents with good counseling if it seems that antenatal corticosteroids could be detrimental to the health of the mother.  
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some traditional practices cause harm to the mother and her baby
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I suspect that most traditional practices, though they may seem odd nowadays, are not harmful to either mother or child. Most have benefits such as the provision of extra social support for the mother which probably helps prevent postpartum blues and helps to keep distraught fathers out of the way. It is also a comfort for the mother to have a precise recipe for what to do and not do - otherwise she feels she is doing things wrong when the baby cries or doesn't sleep or doesn't feed. 
What can be harmful though is when traditional ways (recommended by mothers and mothers-in-law) are contradicted by friends and visiting nurses. Then the mother is in a real quandary.
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As almost all samples are hyperosmolar, what kind of bias should I search?
I have already excluded a problem of temperature storage (at -20°C). It's an expected healthy population.
Thanks!
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A logical explanation could be found in the oestrogens effect on endotelial permeability.  High level of oestrogens increases endothelial permeability, causing oedema, mild hyponatraemia and  intra-vascular hyperosmolality. However, water deprivation during labour or fasting before planned cesarens can matters on osmolarity. I acknowledge that this topic is not well investigated in literature. Hoping be useful for your investigations...
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Need details of tocodynamometers from a mechanical engineer perspective.
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Speaking of external tocodynamometers, they are fragile equipment which should be protected from the coupling gel, usually used in close proximity due to the ultrasonic transducer that records the cardiac activity of the fetus  .
Those are tied on maternal uterine fundus where the uterine contractions are most prominantly detected but tend to change its position with maternal movement and contractions.
After placing an external tocodynamometer, one should reset it to the baseline level when there is no uterine contraction, otherwise there would be faulty readings.
whether it is piezoelectronic or a conventional pressure sensor, keep them dry and away from the gel.
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I deliver placentas in squatting at 5 minutes postpartum, so when the delivery is delayed, it is noteworthy. I delivered a woman who got pregnant with IUD in place. The placenta did not separate for 50 minutes, even pushing in squatting. So, while in squatting i pulled quite hard and even on the cord and finally it started coming down and delivered. The IUD was not in the placenta but in the sac and I think it was stuck into the uterus and that is what made it hard to deliver. Anyone else have this experience? 
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Yes Sir,
   There is no dispute. The points declared here are against guidelines. 
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Two different obstetrical cases were observed in female camels. In both cases, severing straining of mothers resulted in prolapse of the (uterus???) or (vagina??). Meanwhile with continuous straining, this prolapsed part was teared with appearance of the fetal parts. In the second case, the intestines were dislocated after fetal removal.
The questions are:
1. Is this prolapsed/teared part vagina or uterus? I suggest it is uterus, it seem very similar to the endometrium.
2. What is the pathogensis? How did this part come to outside during parturition? Is this the non-pregnant horn?
We would like to understand both cases.
Thank you    
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Here, I re-attached the pictures with some labels,  Question was for (A and B) and C is only for comparison.
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This scale is used to describe the extent to which women feel in control during childbirth.
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I don't think that you need any permission. You can use this validated scale for your researc. Good luck from Trudy
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Are you sure from it? There was a 6-year research in Iran about this. The result of this research showed that there isn't significant relation between the kind of delivery (cesarean and vaginal delivery ) and icter in neonates.... 
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Some hospitals are attempting the "Golden Hour" after the mom gets out of the Operating Room from a Cesarean delivery. It seems that some hospitals have taken the extra step of keeping the baby with the mom from the time of the incision. How soon does the mom get the baby after a Cesarean in you institution? How long are you delaying the bath? How are you handling the delay of the bath?
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We also advocate skin-to-skin contact immediately after cesaraen birth. Mother and baby are not separated afterwards. They leave the operation theatre and recovery together on their way back to the postnatal ward. In the recovery room they are accompanied by a obstetric nurse in the encouragement of breast feeding 
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NICE guideline does not recommend starting syntocinon infusion in 2nd stage.
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Thanks for replying Junaid ! I apologise for the spelling mistake in my answer - "stafe" should read "stage".
Kind regards,
Johan (JT) Nel.
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Women with spinal cord injuries (SCI) represent a rising population. Unfortunately, there is limited information about labor care and delivery for women with SCI.
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These patients didn't feel labor pains so we must palpate them frequently .evacuate the bladder regularly as common associated with retention and uterine atony.good analgesia is needed to avoid autonomic dysreflexia .
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Should I measure a specific kind of infection instead? Or are there ways in measuring infections in general?
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There are more chances of early onset sepsis from maternal genital tract flora. But this is depends on risk factors e.g. poor handling, maternal febrile illness, multiple per vaginal examination, preterm babies etc. Theoretically there are more chances of getting sepsis in vaginal delivery. You can go for sepsis screen as well blood culture, urine culture.