Q. Discuss various stages of labour.

First stage: latent phase The first stage of labor is divided into latent and active phases. The latent phase of labour is also called prodromal labour or pre-labour. It is a subclassification of the first stage". The latent phase is generally defined as beginning at the point at which the woman perceives regular uterine contractions.In contrast, Braxton Hicks contractions, which are contractions that may start around 26 weeks gestation and are sometimes called "false labour", should be infrequent, irregular, and involve only mild cramping. Cervical effacement, which is the thinning and stretching of the cervix, and cervical dilation occur during the closing weeks of pregnancy and is usually complete or near complete, by the end of the latent phase. The degree of cervical effacement may be felt during a vaginal examination. A 'long' cervix implies that effacement has not yet occurred. Latent phase ends with the onset of active first stage, and this transition is defined retrospectively. First stage: active phase The active stage of labour (or "active phase of first stage" if previous phase is termed "latent phase of first stage") confers an accelerated cervical dilation. The UTHSCSA describes it as occurring at a cervical dilation of 3 to 4 centimeters while

ACOG describes it as occurring at 5 cm for multiparous women and at 6 cm for nulliparous women.The onset of the active phase of labor is defined as when two of the following criteria are met

three to four contractions every ten minutes rupture of membranes cervical dilation of 3 to 4 centimeters

Health care providers may assess a laboring mother's progress in labor by performing a cervical exam to evaluate the cervical dilation, effacement, and station. These factors form the Bishop score. The Bishop score can also used as a means to predict the success of an induction of labor. During effacement, the cervix becomes incorporated into the lower segment of the uterus. During a contraction, uterine muscles contract causing shortening of the upper segment and drawing upwards of the lower segment, in a gradual expulsive motion. The presenting fetal part then is permitted to descend. Full dilation is reached when the cervix has widened enough to allow passage of the baby's head, around 10 cm dilation for a term baby. The duration of labour varies widely, but active phase averages some 8 hours for women giving birth to their first child ("primiparae") and shorter for women who have already given birth ("multiparae"). Active phase prolongation is defined as in a primigravid woman as the failure of the cervix to dilate at a rate of 1.2 cm/hr over a period of at least two hours. This definition is based on Friedman's Curve, which plots the typical rate of cervical dilation and fetal descent during active labour.Some practitioners may diagnose "Failure to Progress", and

consequently, propose interventions to optimize chances for healthy outcome.

Sequence of cervix dilation during labour

Second stage: fetal expulsion This stage begins when the cervix is fully dilated, and ends when the baby is born. As pressure on the cervix increases, women may have the sensation of pelvic pressure and an urge to begin pushing. At the beginning of the normal second stage, the head is fully engaged in the pelvis; the widest diameter of the head has passed below the level of the pelvic inlet. The fetal head then continues descent into the pelvis, below the pubic arch and out through the vaginal introitus (opening). This is assisted by the additional maternal efforts of "bearing down" or pushing. The appearance of the fetal head at the vaginal orifice is termed the "crowning". At this point, the woman will feel an intense burning or stinging sensation.

Complete expulsion of the baby signals the successful completion of the second stage of labour. The second stage of birth will vary by factors including parity (the number of children a woman has had), fetal size, anesthesia, and the presence of infection. Longer labours are associated with declining rates of spontaneous vaginal delivery and increasing rates of infection, perineal laceration, and obstetric hemorrhage, as well as the need for intensive care of the neonate. Third stage: delivery of the placenta

A newborn baby with umbilical cord ready to be clamped

Breastfeeding during and after the third stage, the placenta is visible in the bowl to the right. The period from just after the fetus is expelled until just after the placenta is expelled is called the third stage of labour. Delaying the clamping of the umbilical cord until at least one minute after birth improves outcomes as long as there is the ability to treat jaundice if it occurs. In some birthing centers, this may be delayed by 5 minutes or more, or omitted entirely. Delayed clamping of the cord decreases the risk of anemia but may increase risk of jaundice. Clamping is followed by cutting of the cord, which is painless due to the absence of nerves. Placental expulsion begins as a physiological separation from the wall of the uterus. The period from just after the fetus is expelled until just after the placenta is expelled is called the third stage of labour. The average time from delivery of the baby until complete expulsion of the placenta is estimated to be 1012 minutes dependent on whether active or expectant management is employed] as many as 3% of all vaginal deliveries, the duration of the third stage is longer than 30 minutes and raises concern for retained placenta.

Placental expulsion can be managed actively or it can be managed expectantly, allowing the placenta to be expelled without medical assistance. Active management is described as the administration of a uterotonic drug within one minute of fetal delivery, controlled traction of the umbilical cord and fundal massage after delivery of the placenta, followed by performance of uterine massage every 15 minutes for two hours. When the amniotic sac has not ruptured during labour or pushing, the infant can be born with the membranes intact. This is referred to as "delivery en caul. Fourth stage The "fourth stage of labour" is the period beginning immediately after the birth of a child and extending for about six weeks.. Mothers are often allowed a period where they are relieved of their normal duties to recover from childbirth.

Q . What are the signs and symptoms of pregnancy? Most pregnant women experience a number of symptoms, which can signify pregnancy. The symptoms can include nausea and vomiting, excessive tiredness and fatigue, cravings for certain foods that are not normally sought out, and frequent urination particularly during the night. A number of early medical signs are associated with pregnancy. These signs typically appear, if at all, within the first few weeks

after conception. Although not all of these signs are universally present, nor are all of them diagnostic by themselves, taken together they make a presumptive diagnosis of pregnancy. These signs include the presence of human chorionic gonadotropin (hCG) in the blood and urine, missed menstrual period, implantation bleeding that occurs at implantation of the embryo in the uterus during the third or fourth week after last menstrual period, increased basal body temperature sustained for over 2 weeks after ovulation, Chadwick's sign (darkening of the cervix, vagina, and vulva), Goodell's sign (softening of the vaginal portion of the cervix), Hegar's sign (softening of the uterus isthmus), and pigmentation of linea alba Linea nigra, (darkening of the skin in a midline of the abdomen, caused by hyperpigmentation resulting from hormonal changes, usually appearing around the middle of pregnancy). Breast tenderness is common during the first trimester, and is more common in women who are pregnant at a young age. Despite all the signs, some women may not realize they are pregnant until they are far along in pregnancy. In some cases, a few have not been aware of their pregnancy until they begin labour. This can be caused by many factors, including irregular periods (quite common in teenagers), certain medications (not related to conceiving children), and obese women who disregard their weight gain. Others may be in denial of their situation. Q . Discuss various complications of pregnancy. Complications of pregnancy are symptoms and problems that are caused by pregnancy. There are both routine problems and serious, even potentially fatal problems. The routine problems

are normal complications, and pose no significant danger to either the woman or the fetus. Serious problems can cause both maternal death and fetal death if untreated. Maternal routine problems Back pain

Common, particularly in the third trimester when the patient's center of gravity has shifted.

Carpal tunnel syndrome

Occurs in between an estimated 21% to 62% of cases, possibly due to edema.

Constipation

Cause: decreased bowel motility secondary to elevated progesterone (normal in pregnancy), which causes the "smooth muscle" along the walls of the intestines to relax. Thus, making sure that the future mother will absorb as much nutrients from her diet as possible in order to nourish the fetus and herself. As a side effect the feces can get extremely dehydrated and hard to pass.

Contractions

occasional, irregular, painless contractions that occur several times per day are normal and are known as Braxton Hicks contractions

Caused by: dehydration

Dehydration

Caused by: expanded intravascular space and increased Third spacing of fluids

Edema

Caused by: compression of the inferior vena cava (IVC) and pelvic veins by the uterus leads to increased hydrostatic pressure in lower extremities.

Gastroesophageal Reflux Disease (GERD)

Caused by: relaxation of the lower esophageal sphincter (LES) and increased transit time in the stomach (normal in pregnancy)

Hemorrhoids

Caused by: increased venous stasis and IVC compression leading to congestion in venous system along with increased abdominal pressure secondary to constipation.

Pica

cravings for nonedible items such as dirt or clay. Caused by Iron deficiency which is normal during pregnancy and can

be overcome with Iron supplements, prenatal vitamins or if severe enough parenteral iron

Lower abdominal pain

Caused by: rapid expansion of the uterus and stretching of ligaments such as the round ligament.

Increased urinary frequency

Caused by: increased intravascular volume, elevated GFR (glomerular filtration rate), and compression of the bladder by the expanding uterus.

Varicose veins

Caused by: relaxation of the venous smooth muscle and increased intravascular pressure.

Diastasis recti or abdominal separation During pregnancy, many women experience a separation of their stomach muscles, known as diastasis recti. It affects the rectus abdominis muscle. Serious maternal problems The following problems originate mainly in the mother. 1.Hyperemesis gravidarum

Hyperemesis gravidarum is the presence of severe vomiting and dehydration, which causes the mother to lose weight. It is more severe than the more common morning sickness. 2.Pelvic girdle pain (PGP) 3.Severe hypertensive states 4.Deep vein thrombosis 5.Anaemia Serious fetal problems The following problems occur in the foetus or placenta, but may have serious consequences on the mother as well. 1.Ectopic pregnancy (implantation of the embryo outside the uterus)

2.Placental abruption (separation of the placenta from the uterus) 3.Multiple pregnancies 4.Prenatal infection Q . Describe in detail Antenatal care. Prenatal care (also known as antenatal care) refers to the regular medical and nursing care recommended for women

during pregnancy.Prenatal care is a type of preventative care with the goal of providing regular check-ups that allow doctors or midwives to treat and prevent potential health problems throughout the course of the pregnancy while promoting healthy lifestyles that benefit both mother and child. During check-ups, women will receive medical information over maternal physiological changes in pregnancy, biological changes, and prenatal nutrition including prenatal vitamins. Recommendations on management and healthy lifestyle changes are also made during regular check-ups. The availability of routine prenatal care has played a part in reducing maternal death rates and miscarriages as well as birth defects, low birth weight, and other preventable health problems. Prenatal care generally consists of:

monthly visits to the doctors during the first two trimesters (from week 128) fortnightly visits to doctor from 28th week to 36th week of pregnancy weekly visits to doctor after 36th week till delivery(delivery at week 3840) Assessment of parental needs and family dynamic

Prenatal Examinations At the initial antenatal care visit and with the aid of a special booking checklist the pregnant women become classified into either normal risk or high risk.

Prenatal diagnosis or prenatal screening (note that "Prenatal Diagnosis" and "Prenatal Screening" refer to two different types of tests) is testing for diseases or conditions in a fetus or embryo before it is born. Obstetricians and midwives have the ability to monitor mother's health and prenatal development during pregnancy through series of regular check-ups. Physical examinations generally consist of:

Collection of (mother's) medical history Checking (mother's) blood pressure (Mother's) height and weight Pelvic exam Doppler fetal heart rate monitoring (Mother's) blood and urine tests Discussion with caregiver

Ultrasound Obstetric ultrasounds are most commonly performed during the second trimester at approximately week 20. Ultrasounds are considered relatively safe and have been used for over 35 years for monitoring pregnancy. Among other things, ultrasounds are used to:

Diagnose pregnancy (uncommon) Check for multiple fetuses Assess possible risks to the mother (e.g., miscarriage, blighted ovum, ectopic pregnancy, or a molar pregnancy condition) Check for fetal malformation (e.g., club foot, spina bifida, cleft palate, clenched fists)

Determine if an intrauterine growth retardation condition exists Note the development of fetal body parts (e.g., heart, brain, liver, stomach, skull, other bones) Check the amniotic fluid and umbilical cord for possible problems Determine due date (based on measurements and relative developmental progress)

Generally an ultrasound is ordered whenever an abnormality is suspected or along a schedule similar to the following:

7 weeks confirm pregnancy, ensure that it's neither molar or ectopic, determine due date 1314 weeks (some areas) evaluate the possibility of Down Syndrome 1820 weeks see the expanded list above 34 weeks (some areas) evaluate size, verify placental position

Q . What is Puerperal sepsis and what are its symptoms? Puerperal sepsis is known to be caused by an infection of haemolytic streptococci (1). Haemolytic Streptococci are bacteria that produce active haemolysins causing a clear zone of hemolysis on a blood agar medium in the area of the colony). The main bacterial strain seen is known as Streptococcus pyogenes (1). S. pyogenes is a group A streptococcus that is known to be gram positive, spherical bacteria that grows in long chains. It is the cause of all group A streptococcal infections that

can infect a number of body systems. S. pyogenes has an incubation period of ten days. S. pyogenes produces beta hemolysis when placed on a blood agar plate. S. pyogenes has several virulence factors that enable it to host tissues, evade the immune response and spread by penetrating host tissue layers. A carbohydrate capsule composed of hyaluronic acid surrounds the bacterium protecting it from phagocytosis caused by neutrophils. The Capsule and the M protein embedded in the cell wall facilitate an attachment with the host cell. Humans are the only known reservoir for Puerperal Sepsis.

SYMPTOMS Symptoms of Puerperal Sepsis include chills, soreness in the womb, fever, cold sweats and excessive thirst . Symptoms that appear to a lesser extent include headache, back pain, nausea and vomiting . Puerperal Sepsis is diagnosed based on accumulation of the symptoms listed above and an examination of the body systems involved. In the case of Puerperal Sepsis the body system involved is the uterus, however other systems such as the lungs, brain urinary tract and bowels. In the 1800s when Puerperal Sepsis was seen in a high incidence rate all doctors could do to diagnose this condition was observe the symptoms as this deadly disease took its course. Today tests can be run to identify a sepsis infection. These tests include a white blood count, bodily fluid cultures and chest x-rays .

Q. Discuss the essentials of infant care and infant feeding. Infants cry as a form of basic instinctive communication. A crying infant may be trying to express a variety of feelings including hunger, discomfort, overstimulation, boredom, wanting something, or loneliness. Breastfeeding is the recommended method of feeding by all major infant health organizations.If breastfeeding is not possible or desired, bottle feeding is done with expressed breast-milk or with infant formula. Infants are born with a sucking reflex allowing them to extract the milk from the nipples of the breasts or the nipple of the baby bottle, as well as an instinctive behavior known as rooting with which they seek out the nipple. Sometimes a wet nurse is hired to feed the infant, although this is rare, especially in developed countries. Adequate food consumption at an early age is vital for an infants development. From birth to four months, infants should consume breast milk or an unmodified milk substitute. As an infants diet matures, finger foods may be introduced as well as fruit, vegetables and small amounts of meat. As infants grow, food supplements are added. Many parents choose commercial, ready-made baby foods to supplement breast milk or formula for the child, while others adapt their usual meals for the dietary needs of their child. Whole cow's milk can be used at one year, but lower-fat milk should not be provided until the child is 2 to 3 years old. Weaning is the process through which breast milk is eliminated from the infant's diet through the introduction of solid foods in exchange for milk.

Until they are toilet-trained, infants require diapers. Infants need more sleep than adultsup to 18 hours for newborn babies, with a declining rate as the child ages. Until babies learn to walk, they should be carried in the arms, held in slings or baby carriers, or transported in baby carriages or strollers.

Q .What is abortion? What are its types and methods? Abortion is the termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior to viability. An abortion can occur spontaneously, in which case it is usually called a miscarriage, or it can be purposely induced. The term abortion most commonly refers to the induced abortion of a human pregnancy. Types Induced Approximately 205 million pregnancies occur each year worldwide. Over a third are unintended and about a fifth end in induced abortion. Most abortions result from unintended pregnancies.A pregnancy can be intentionally aborted in several ways. The manner selected often depends upon the gestational age of the embryo or fetus, which increases in size as the pregnancy progresses.Specific procedures may also be selected due to legality, regional availability, and doctor or patient preference.

Reasons for procuring induced abortions are typically characterized as either therapeutic or elective. An abortion is medically referred to as a therapeutic abortion when it is performed to save the life of the pregnant woman; prevent harm to the woman's physical or mental health; terminate a pregnancy where indications are that the child will have a significantly increased chance of premature morbidity or mortality or be otherwise disabled; or to selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy.An abortion is referred to as an elective or voluntary abortion when it is performed at the request of the woman for non-medical reasons. Confusion sometimes arises over the term "elective" because "elective surgery" generally refers to all scheduled surgery, whether medically necessary or not. Spontaneous Spontaneous abortion, also known as miscarriage, is the unintentional expulsion of an embryo or fetus before the 24th week of gestation. A pregnancy that ends before 37 weeks of gestation resulting in a live-born infant is known as a "premature birth" or a "preterm birth".[15] When a fetus dies in utero after viability, or during delivery, it is usually termed "stillborn".Premature births and stillbirths are generally not considered to be miscarriages although usage of these terms can sometimes overlap. The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities of the embryo or fetus, accounting for at least 50% of sampled early pregnancy losses. Other causes include vascular disease (such as lupus), diabetes, other hormonal problems, infection, and abnormalities

of the uterus. Advancing maternal age and a patient history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion. A spontaneous abortion can also be caused by accidental trauma; intentional trauma or stress to cause miscarriage is considered induced abortion or feticide. Methods

Practice of Induced Abortion Methods MVA D&E EVA Hysterotomy D&C Intact D&X Mifepr. Induced Miscarr. 0-12 weeks 12-28 weeks 28-40 weeks Gestational age may determine which abortion methods are practiced. 1.Medical Medical abortions are those induced by abortifacient pharmaceuticals. Medical abortion became an alternative

method of abortion with the availability of prostaglandin analogs in the 1970s and the antiprogestogen mifepristone in the 1980s. The most common early first-trimester medical abortion regimens use mifepristone in combination with a prostaglandin analog (misoprostol or gemeprost) up to 9 weeks gestational age, methotrexate in combination with a prostaglandin analog up to 7 weeks gestation, or a prostaglandin analog alone.Mifepristonemisoprostol combination regimens work faster and are more effective at later gestational ages than methotrexatemisoprostol combination regimens, and combination regimens are more effective than misoprostol alone.This regime is effective in the second trimester. In very early abortions, up to 7 weeks gestation, medical abortion using a mifepristonemisoprostol combination regimen is considered to be more effective than surgical abortion (vacuum aspiration), especially when clinical practice does not include detailed inspection of aspirated tissue.Early medical abortion regimens using mifepristone, followed 2448 hours later by buccal or vaginal misoprostol are 98% effective up to 9 weeks gestational age. If medical abortion fails, surgical abortion must be used to complete the procedure. 2.Surgical

A vacuum aspiration abortion at eight weeks gestational age (six weeks after fertilization). 1: Amniotic sac 2: Embryo 3: Uterine lining 4: Speculum 5: Vacurette 6: Attached to a suction pump Up to 15 weeks' gestation, suction-aspiration or vacuum aspiration are the most common surgical methods of induced abortion. Manual vacuum aspiration (MVA) consists of removing the fetus or embryo, placenta, and membranes by suction using a manual syringe, while electric vacuum aspiration (EVA) uses an electric pump. These techniques differ in the mechanism used to apply suction, in how early in pregnancy they can be used, and in whether cervical dilation is necessary. MVA, also known as "mini-suction" and "menstrual extraction", can be used in very early pregnancy, and does not require cervical dilation. Dilation and curettage (D&C), the second most common method of surgical abortion, is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion. Curettage refers to cleaning the walls of the uterus with a curette.

From the 15th week of gestation until approximately the 26th, other techniques must be used. Dilation and evacuation (D&E) consists of opening the cervix of the uterus and emptying it using surgical instruments and suction. Premature labor and delivery can be induced with prostaglandin; this can be coupled with injecting the amniotic fluid with hypertonic solutions containing saline or urea. After the 16th week of gestation, abortions can also be induced by intact dilation and extraction (IDX) (also called intrauterine cranial decompression), which requires surgical decompression of the fetus's head before evacuation. IDX is sometimes called partial-birth abortion. In the third trimester of pregnancy, abortion may be performed by IDX as described above, induction of labor, or by hysterotomy. Hysterotomy abortion is a procedure similar to a caesarean section and is performed under general anesthesia. It requires a smaller incision than a caesarean section and is used during later stages of pregnancy. First-trimester procedures can generally be performed using local anesthesia, while second-trimester methods may require deep sedation or general anesthesia.

Other methods Historically, a number of herbs reputed to possess abortifacient properties have been used in folk medicine: tansy, pennyroyal, black cohosh, and the now-extinct silphium (see history of abortion).The use of herbs in such a manner can cause serious

even lethalside effects, such as multiple organ failure, and is not recommended by physicians. Abortion is sometimes attempted by causing trauma to the abdomen. The degree of force, if severe, can cause serious internal injuries without necessarily succeeding in inducing miscarriage.In Southeast Asia, there is an ancient tradition of attempting abortion through forceful abdominal massage.One of the bas reliefs decorating the temple of Angkor Wat in Cambodia depicts a demon performing such an abortion upon a woman who has been sent to the underworld. Reported methods of unsafe, self-induced abortion include misuse of misoprostol, and insertion of non-surgical implements such as knitting needles and clothes hangers into the uterus. These methods are rarely seen in developed countries where surgical abortion is legal and available.

Q. Discuss Ectopic Pregnancy. Ectopic pregnancy, or eccysis, is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the mother, since internal haemorrhage is a life-threatening complication. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen.

An ectopic pregnancy is a potential medical emergency, and, if not treated properly, can lead to death. In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow. About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes. In a typical ectopic pregnancy, the embryo adheres to the lining of the fallopian tube and burrows into the tubal lining. Most commonly this invades vessels and will cause bleeding. This intratubal bleeding hematosalpinx expels the implantation out of the tubal end as a tubal abortion. Tubal abortion is a common type of miscarriage. There is no inflammation of the tube in ectopic pregnancy. The pain is caused by prostaglandins released at the implantation site, and by free blood in the peritoneal cavity, which is a local irritant. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. Usually this degree of bleeding is due to delay in diagnosis, but sometimes, especially if the implantation is in the proximal tube (just before it enters the uterus), it may invade into the nearby Sampson artery, causing heavy bleeding earlier than usual. If left untreated, about half of ectopic pregnancies will resolve without treatment. These are the tubal abortions. The advent of methotrexate treatment for ectopic pregnancy has reduced the need for surgery; however, surgical intervention is still required in cases where the Fallopian tube has ruptured or is in danger of doing so. This intervention may be laparoscopic or through a larger incision, known as a laparotomy.

Classification Tubal pregnancy The vast majority of ectopic pregnancies implant in the Fallopian tube. Pregnancies can grow in the fimbrial end (5% of all ectopic pregnancies), the ampullary section (80%), the isthmus (12%), and the cornual and interstitial part of the tube (2 Nontubal ectopic pregnancy Two percent of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal. Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. While a fetus of ectopic pregnancy is typically not viable, very rarely, a live baby has been delivered from an abdominal pregnancy. Heterotopic pregnancy In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus and the other inside. This is called a heterotopic pregnancy. Often the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful emergency nature of ectopic pregnancies. Since ectopic pregnancies are normally discovered and removed very early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound.

Persistent ectopic pregnancy A persistent ectopic pregnancy refers to the continuation of trophoplastic growth after a surgical intervention to remove an ectopic pregnancy. Signs and symptoms Early signs include:

Pain in the lower abdomen, and inflammation (pain may be confused with a strong stomach pain, it may also feel like a strong cramp). Pain while urinating. Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal pregnancy may give very similar symptoms. Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. This can be indistinguishable from an early miscarriage or the 'implantation bleed' of a normal early pregnancy. Pain while having a bowel movement.

Patients with a late ectopic pregnancy typically experience pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms:

External bleeding is due to the falling progesterone levels. Internal bleeding (hematoperitoneum) is due to hemorrhage from the affected tube.

More severe internal bleeding may cause:

Lower back, abdominal, or pelvic pain. Shoulder pain. This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm, and is an ominous sign. There may be cramping or even tenderness on one side of the pelvis. The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse.

Causes There are a number of risk factors for ectopic pregnancies. However, in as many as one third to one half no risk factors can be identified. Risk factors include: pelvic inflammatory disease, infertility, use of an intrauterine device (IUD), previous exposure to DES, tubal surgery, intrauterine surgery (e.g. D&C), smoking, previous ectopic pregnancy, and tubal ligation. Diagnosis An ectopic pregnancy should be considered as the cause of abdominal pain or vaginal bleeding in every woman who has a positive pregnancy test. An ultrasound showing a gestational sac with fetal heart in the fallopian tube is clear evidence of ectopic pregnancy. An abnormal rise in blood -human chorionic gonadotropin (hCG) levels may indicate an ectopic pregnancy. While some

physicians consider that the threshold of discrimination of intrauterine pregnancy is around 1500 IU/ml of -hCG

A laparoscopy or laparotomy can also be performed to visually confirm an ectopic pregnancy. Often if a tubal abortion or tubal rupture has occurred, it is difficult to find the pregnancy tissue. A laparoscopy in very early ectopic pregnancy rarely shows a normal looking fallopian tube. Culdocentesis, in which fluid is retrieved from the space separating the vagina and rectum, is a less commonly performed test that may be used to look for internal bleeding. In this test, a needle is inserted into the space at the very top of the vagina, behind the uterus and in front of the rectum. Any blood or fluid found may have been derived from a ruptured ectopic pregnancy. Cullen's sign can indicate a ruptured ectopic pregnancy. Treatment Medical Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical treatment. Surgical If hemorrhage has already occurred, surgical intervention may be necessary.

Complications The most common complication is rupture with internal haemorrhage which may lead to hypovolemic shock. Death from rupture is rare in women who have access to modern medical facilities. Q . What are the tests to confirm pregnancy? A pregnancy test attempts to determine whether a woman is pregnant. Markers that indicate pregnancy are found in urine and blood, and pregnancy tests require sampling one of these substances. The first of these markers to be discovered, human chorionic gonadotropin (hCG), was discovered in 1930 to be produced by the trophoblast cells of the fertilised ova (eggs). While hCG is a reliable marker of pregnancy, it cannot be detected until after implantation:[1] this results in false negatives if the test is performed during the very early stages of pregnancy. Obstetric ultrasonography may also be used to detect pregnancy. Modern tests The test for pregnancy which can give the quickest result after fertilisation is a rosette inhibition assay for early pregnancy factor (EPF). EPF can be detected in blood within 48 hours of fertilization.However, testing for EPF is expensive and timeconsuming.

With obstetric ultrasonography the gestational sac sometimes can be visualized as early as four and a half weeks of gestation (approximately two and a half weeks after ovulation) and the yolk sac at about five weeks' gestation. The embryo can be observed and measured by about five and a half weeks. The heartbeat may be seen as early as six weeks, and is usually visible by seven weeks' gestation. Timing of test False negative readings can occur when testing is done too early. Quantitative blood tests and the most sensitive urine tests usually begin to detect hCG shortly after implantation, which can occur anywhere from 6 to 12 days after ovulation. hCG levels continue to rise through the first 20 weeks of pregnancy, so the chances of false test results diminish with time. Less sensitive urine tests and qualitative blood tests may not detect pregnancy until three or four days after implantation. Menstruation occurs on average 14 days after ovulation, so the likelihood of a false negative is low once a menstrual period is late. Ovulation may not occur at a predictable time in the menstrual cycle, however. A number of factors may cause an unexpectedly early or late ovulation, even for women with a history of regular menstrual cycles. Using ovulation predictor kits (OPKs), or charting the fertility signs of cervical mucus or basal body temperature give a more accurate idea of when to test than daycounting alone.

The accuracy of a pregnancy test is most closely related to the day of ovulation, not of the act of intercourse or insemination that caused the pregnancy. It is normal for sperm to live up to five days in the fallopian tubes, waiting for ovulation to occur. It could take up to 12 further days for implantation to occur, meaning even the most sensitive pregnancy tests may give false negatives up to 17 days after the act that caused the pregnancy. Because some home pregnancy tests have high hCG detection thresholds (up to 100 mIU/mL), it may take an additional three or four days for hCG to rise to levels detectable by these tests meaning false negatives may occur up to three weeks after the act of intercourse or insemination that causes pregnancy. False positives False positive test results may occur for several reasons, including errors of test application, use of drugs containing the assay molecule, and non-pregnant production of the assay molecule. Viability Pregnancy tests may be used to determine the viability of a pregnancy. Serial quantitative blood tests may be done, usually 34 days apart. Below an hCG level of 1,200 mIU/ml the hCG usually doubles every 4872 hours, though a rise of 5060% is still considered normal. Between 1,200 and 6,000 mIU/ml serum the hCG usually takes 7290 hours to double, and above 6,000 mIU/ml, the hCG often takes more than four days to double. Failure to increase normally may indicate an increased risk of miscarriage or a possible ectopic pregnancy.

Ultrasound is also a common tool for determining viability. A lower than expected heart rate or missed development milestones may indicate a problem with the pregnancy. Diagnosis should not be made from a single ultrasound, however. Inaccurate estimations of fetal age and inaccuracies inherent in ultrasonic examination may cause a scan to be interpreted negatively. If results from the first ultrasound scan indicate a problem, repeating the scan 710 days later is reasonable practice. Q . What do you understand by Antepartum hemorrhage? Antepartum haemorrhage (APH), also prepartum hemorrhage, is bleeding from the vagina during pregnancy from the 24th week (sometimes defined as from the 20th week gestational age to term. Treatment It should be considered a medical emergency (regardless of whether there is pain) and medical attention should be sought immediately, as if it is left untreated it can lead to death of the mother and/or foetus. Causes of APH

Obstetric o Placenta Maternal blood Bloody show (benign) - most common cause of APH

Placental abruption - most common pathological cause Placenta previa - second most common pathological cause Fetal blood (can be distinguished with Apt test) Vasa previa - often difficult to diagnose, frequently leads to fetal demise Uterus Uterine rupture

Non obstetric o Bleeding from the lower genital tract Cervical bleeding - cervicitis, cervical neoplasm, cervical polyp Bleeding from the vagina itself - trauma, neoplasm o Bleeding that may be confused with vaginal bleeding GI bleed - haemorrhoids, inflammatory bowel disease Urinary tract bleed - urinary tract infection

Q . Discuss nutrition during pregnancy? Nutrition during pregnancy The conception and the subsequent weeks afterwards is the time when it is at its most vulnerable, as it is the time when the organs and systems develop within. The energy used to create

these systems comes from the energy and nutrients in the mother's circulation, and around the lining of the womb, such is the reason why correct nutrient intake during pregnancy is so important. During the early stages of pregnancy, since the placenta is not yet formed, there is no mechanism to protect the embryo from the deficiencies which may be inherent in the mother's circulation. Thus, it is critical that an adequate amount of nutrients and energy is consumed. Additionally, the frequent consumption of nutritious foods helps to prevent nausea, vomiting, and cramps.Supplementing one's diet with foods rich in folic acid, such as oranges and dark green leafy vegetables, helps to prevent neural tube birth defects in the baby. Consuming foods rich in iron, such as lean red meat and beans help to prevent anemia and ensure adequate oxygen for the baby. A necessary step for proper diet is to take a daily prenatal vitamins, that ensure their body gets the vitamins and minerals it needs to create a healthy baby. These vitamins contain folic acid, iodine, iron, vitamin A, vitamin D, zinc and calcium. Potentially harmful determinants during pregnancy It is advised for pregnant women to pay special attention to food hygiene during pregnancy in addition to avoiding certain foods in order to reduce the risk of exposure to substances that may be harmful to the developing fetus. This can include food pathogens and toxic food components, alcohol, and dietary supplements such as vitamin A. Dietary vitamin A is obtained in two forms which contain the preformed vitamin (retinol), that can be found in some animal

products such as liver and fish liver oils, and as a vitamin A precursor in the form of carotenes, which can be found in many fruits and vegetables. Intake of retinol, in extreme cases, has been linked to birth defects and abnormalities. Excessive amounts of alcohol have been proven to cause foetal alcohol syndrome. Pregnant women are advised to pay particular attention to food hygiene and to avoid certain foods during pregnancy in order to minimize the risk of food poisoning from potentially harmful pathogens such as listeria, toxoplasmosis, and salmonella. Pregnant women are therefore advised to avoid foods in which high levels of the bacteria have been found, such as in soft cheeses. Listeria are destroyed by heat and therefore pregnant women are advised to reheat ready-prepared meals thoroughly. Pregnant women should also wash their fruit and vegetables very thoroughly in order to minimize risk. Salmonella poisoning is most likely to come from raw eggs or undercooked poultry. Recommended nutrients during pregnancy Recommendation (Extra = Maximum/Total Nutrient Above RDA) amount Increase by 200 kcal (840 kJ) Energy RDA per day in last trimester only. Proteins Extra 6 g per day 51 g per day Increase in line with energy; Thiamin 0.9 mg per day increase by 0.1 mg per day Needed for tissue growth; Riboflavin 1.4 mg per day extra 0.3 mg per day

Niacin

Folate Vitamin C Vitamin D Calcium Iron Magnesium, zinc, and copper Iodine Folate

Regular supplementation/diet of RDA substance. No increase required. Maintain plasma levels; extra 300 g per day 100 g per day Replenish drained maternal 500 mg per day stores; extra 120 mg per day Replenish plasma levels of RDA vitamin 10 g per day. Needs no increase RDA Extra 3 mg per day needed RDA Normal supplementation or RDA consumption. Extra 100 g per day. 250 g per day

Folic acid, which is the synthetic form of the vitamin folate, is extremely critical both in pre-and peri-conception. Deficiencies in folic acid may cause neural tube defects; women who had 4 mg of folic acid in their systems due to supplementing 3 months before childbirth significantly reduced the risk of NTD within the fetus. This is now advocated by the UK department of health, recommending 400 g per day of folic acid. The development of every human cell is dependent on an adequate supply of folic acid. Folic acid governs the synthesis of

the precursors of DNA, which is the nucleic acid that gives each cell life and character. Folic acid deficiency results in defective cellular growth and the effects are most obvious on those tissues which grow most rapidly. Leafy green vegetables, such as cabbage, avocado, broccoli and greens are all good sources of naturally occurring form of folic acid, folate. Water During pregnancy, one's mass increases by about 12 kg.Most of this added weight (6 to 9 L) is water because the plasma volume increases, 85% of the placenta is water and the foetus itself is 70-90% water. This means that hydration should also be considered an important aspect of nutrition throughout pregnancy. Q . Discuss in general immunization during pregnancy. Immunization during pregnancy, that is the administration of a vaccine to a pregnant woman, is not a routine event as it is generally preferred to administer vaccines either prior to conception or in the postpartum period. When widespread vaccination is used, the risk for an unvaccinated pregnant patient to be exposed to a related infection is low, allowing for postponement, in general, of routine vaccinations to the postpartum period. Nevertheless, immunization during pregnancy may occur either inadvertently, or be indicated in a special situation, when it appears prudent to reduce the risk of a

specific disease for a potentially exposed pregnant woman or her fetus. As a rule of thumb the vaccination with live virus or bacteria is contraindicated in pregnancy. Live attenuated bacterial vaccine BCG vaccine is used against tuberculosis and is contraindicated in pregnancy. Inactivated bacterial vaccine Inactivated bacterial vaccine is used during pregnancy for women who have a specific risk of exposure and disease. Vaccination against pneumococcus or meningococcus infections, or typhoid fever show no confirmed side effects regarding the fetus, however data are limited. Data regarding anthrax vaccination during pregnancy are very limited but show no confirmed effect on the fetus. Toxoids Tetanus toxoids are considered safe during pregnancy. Immune globulins Immune globulins are used for post exposure prophyllaxis and not associated with reports that harm is done to the fetus. Such agents are considered in pregnant women exposed to hepatitis B, rabies, tetanus, varicella, and hepatitis A.

Q . What do you understand by Lactation and Breast Feeding? Discuss. Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process occurs in all female mammals,In humans the process of feeding milk is called breastfeeding or nursing.

Galactopoiesis is the maintenance of milk production. This stage requires prolactin (PRL) and oxytocin. Purpose The chief function of lactation is to provide nutrition and immune protection to the young after birth.

Human lactation

When the baby sucks its mother's breast, a hormone called oxytocin compels the milk to flow from the alveoli, through the ducts (milk canals) into the sacs (milk pools) behind the areola and then into the baby's mouth Hormonal influences From the twenty-fourth week of pregnancy (the second and third trimesters), a woman's body produces hormones that stimulate the growth of the milk duct system in the breasts:

Progesterone influences the growth in size of alveoli and lobes; high levels of progesterone inhibit lactation before birth. Progesterone levels drop after birth; this triggers the onset of copious milk production. Estrogen stimulates the milk duct system to grow and differentiate. Like progesterone, high levels of estrogen

also inhibit lactation. Estrogen levels also drop at delivery and remain low for the first several months of breastfeeding. Prolactin contributes to the increased growth and differentiation of the alveoli, and also influences differentiation of ductal structures. Growth hormone is structurally very similar to prolactin and contributes to its galactopoietic function. ACTH (adreno-cortico-tropic hormone) and glucocorticoids have an important lactation inducing function in several animal species. ACTH is thought to contribute as it is structurally similar to prolactin. Glucocorticoids play a complex regulating role in the maintenance of tight junctions. TSH is a very important galactopoietic hormone whose levels are naturally increased during pregnancy. Oxytocin contracts the smooth muscle of the uterus during and after birth, and during orgasm(s). After birth, oxytocin contracts the smooth muscle layer of band-like cells surrounding the alveoli to squeeze the newly produced milk into the duct system. Oxytocin is necessary for the milk ejection reflex, or let-down to occur. Human placental lactogen (HPL) From the second month of pregnancy, the placenta releases large amounts of HPL. This hormone appears to be instrumental in breast, nipple, and areola growth before birth. Follicle stimulating hormone (FSH) Luteinizing hormone (LH)

By the fifth or sixth month of pregnancy, the breasts are ready to produce milk. Secretory Differentiation During the latter part of pregnancy, the woman's breasts enter into the Secretory Differentiation stage. This is when the breasts make colostrum (see below), a thick, sometimes yellowish fluid. At this stage, high levels of progesterone inhibit most milk production. It is not a medical concern if a pregnant woman leaks any colostrum before her baby's birth, nor is it an indication of future milk production. Secretory Activation At birth, prolactin levels remain high, while the delivery of the placenta results in a sudden drop in progesterone, estrogen, and HPL levels. This abrupt withdrawal of progesterone in the presence of high prolactin levels stimulates the copious milk production of Secretory Activation. When the breast is stimulated, prolactin levels in the blood rise, peak in about 45 minutes, and return to the pre-breastfeeding state about three hours later. The release of prolactin triggers the cells in the alveoli to make milk. Prolactin also transfers to the breast milk. Some research indicates that prolactin in milk is greater at times of higher milk production, and lower when breasts are fuller, and that the highest levels tend to occur between 2 a.m. and 6 a.m. Other hormonesnotably insulin, thyroxine, and cortisolare also involved, but their roles are not yet well understood. Although biochemical markers indicate that Secretory

Activation begins about 3040 hours after birth, mothers do not typically begin feeling increased breast fullness (the sensation of milk "coming in the breast") until 5073 hours (23 days) after birth. Colostrum is the first milk a breastfed baby receives. It contains higher amounts of white blood cells and antibodies than mature milk, and is especially high in immunoglobulin A (IgA), which coats the lining of the baby's immature intestines, and helps to prevent pathogens from invading the baby's system. Secretory IgA also helps prevent food allergies. Over the first two weeks after the birth, colostrum production slowly gives way to mature breast milk. Autocrine control - Galactapoiesis The hormonal endocrine control system drives milk production during pregnancy and the first few days after the birth. When the milk supply is more firmly established, autocrine (or local) control system begins. During this stage, the more that milk is removed from the breasts, the more the breast will produce milk. Research also suggests that draining the breasts more fully also increases the rate of milk production.Thus the milk supply is strongly influenced by how often the baby feeds and how well it is able to transfer milk from the breast. Low supply can often be traced to:

not feeding or pumping often enough inability of the infant to transfer milk effectively caused by, among other things:

jaw or mouth structure deficits o poor latching technique rare maternal endocrine disorders hypoplastic breast tissue inadequate calorie intake or malnutrition of the mother
o

This is the mechanism by which milk is transported from the breast alveoli to the nipple. Suckling by the baby stimulates the paraventricular nuclei and supraoptic nucleus in the hypothalamus, which signals to the posterior pituitary gland to produce oxytocin. Oxytocin stimulates contraction of the myoepithelial cells surrounding the alveoli, which already hold milk. The increased pressure causes milk to flow through the duct system and be released through the nipple. This response can be conditioned e.g. to the cry of the baby. Milk ejection is initiated in the mother's breast by the act of suckling by the baby. The milk ejection reflex (also called letdown reflex) is not always consistent, especially at first. Once a woman is conditioned to nursing, let-down can be triggered by a variety of stimuli, including the sound of any baby. Even thinking about breastfeeding can stimulate this reflex, causing unwanted leakage, or both breasts may give out milk when an infant is feeding from one breast. However, this and other problems often settle after two weeks of feeding. Stress or anxiety can cause difficulties with breastfeeding. The release of the hormone oxytocin leads to the milk ejection or let-down reflex. Oxytocin stimulates the muscles surrounding the breast to squeeze out the milk. Breastfeeding mothers describe the sensation differently. Some feel a slight tingling, others feel

immense amounts of pressure or slight pain/discomfort, and still others do not feel anything different. A poor milk ejection reflex can be due to sore or cracked nipples, separation from the infant, a history of breast surgery, or tissue damage from prior breast trauma. If a mother has trouble breastfeeding, different methods of assisting the milk ejection reflex may help. These include feeding in a familiar and comfortable location, massage of the breast or back, or warming the breast with a cloth or shower.

Afterpains A surge of oxytocin also causes the uterus to contract. During breastfeeding, mothers may feel these contractions as afterpains. These may range from period-like cramps to strong labour-like contractions and can be more severe with second and subsequent babies. Q . What is placenta and what are its functions ? The placenta is an organ that connects the developing fetus to the uterine wall to allow nutrient uptake, waste elimination, and gas exchange via the mother's blood supply.

The placenta functions as a fetomaternal organ with two components: the fetal placenta (Chorion frondosum), which develops from the same blastocyst that forms the fetus, and the

maternal placenta (Decidua basalis), which develops from the maternal uterine tissue. Structure The placenta grows throughout pregnancy. Development of the maternal blood supply to the placenta is complete by the end of the first trimester of pregnancy (approximately 1213 weeks). Placental circulation

Maternal blood fills the intervillous space, nutrients, water, and gases are actively and passively exchanged, then deoxygenated blood is displaced by the next maternal pulse. Functions of placenta Nutrition The perfusion of the intravillus spaces of the placenta with maternal blood allows the transfer of nutrients and oxygen from the mother to the fetus and the transfer of waste products and carbon dioxide back from the fetus to the maternal blood supply. Nutrient transfer to the fetus occurs via both active and passive transport. Active transport systems allow significantly different plasma concentrations of various large molecules to be

maintained on the maternal and fetal sides of the placental barrier.

Human Placenta after childbirth Adverse pregnancy situations, such as those involving maternal diabetes or obesity, can increase or decrease levels of nutrient transporters in the placenta resulting in overgrowth or restricted growth of the fetus. Excretion Waste products excreted from the fetus such as urea, uric acid, and creatinine are transferred to the maternal blood by diffusion across the placenta. Immunity IgG antibodies can pass through the human placenta, thereby providing protection to the fetus in utero. This transfer of antibodies begin as early as the 20th week of gestational age,

and certainly by the 24th week. This passive immunity lingers for several months after birth, thus providing the newborn with a carbon copy of the mother's long-term humoral immunity to see the infant through the crucial first months of extrauterine life. IgM, however, cannot cross the placenta, which is why some infections acquired during pregnancy can be hazardous for the foetus. Furthermore, the placenta functions as a selective maternal-fetal barrier against transmission of microbes. However, insufficiency in this function may still cause mother-to-child transmission of infectious diseases. Endocrine function In humans, aside from serving as the conduit for oxygen and nutrients for fetus, the placenta secretes, from the syncytial layer of chorionic villi, hormones that are important during pregnancy.

Human Chorionic Gonadotropin (hCG): The first placental hormone produced is hCG, which can be found in maternal blood and urine as early as the first missed menstrual period (shortly after implantation has occurred) through the 100th day of pregnancy. This is the hormone analyzed by pregnancy test; a false-negative result from a pregnancy test may be obtained before or after this period. Women's blood serum will be completely negative for hCG by one to two weeks after birth. hCG testing is proof that all placental tissue is delivered. hCG is present

only during pregnancy because it is secreted by the placenta. hCG also ensures that the corpus luteum continues to secrete progesterone and estrogen. Progesterone is very important during pregnancy because, when its secretion decreases, the endometrial lining will slough off and pregnancy will be lost. hCG suppresses the maternal immunologic response so that placenta is not rejected.

Human Placental Lactogen (hPL [Human Chorionic Somatomammotropin]): This hormone is lactogenic and growth-promoting properties. It promotes mammary gland growth in preparation for lactation in the mother. It also regulates maternal glucose, protein, and fat levels so that this is always available to the fetus. Estrogen: referred to as the "hormone of women" because it stimulates the development of secondary female sex characteristics. It contributes to the woman's mammary gland development in preparation for lactation and stimulates uterine growth to accommodate growing fetus. Progesterone: necessary to maintain endometrial lining of the uterus during pregnancy. This hormone prevents preterm labor by reducing myometrial contraction. Levels of progesterone are high during pregnancy.

Cloaking from immune system of mother Further information: Immune tolerance in pregnancy

The placenta and fetus may be regarded as a foreign allograft inside the mother, and thus must evade from attack by the mother's immune system. For this purpose, the placenta uses several mechanisms:

It secretes Neurokinin B-containing phosphocholine molecules. This is the same mechanism used by parasitic nematodes to avoid detection by the immune system of their host. There is presence of small lymphocytic suppressor cells in the fetus that inhibit maternal cytotoxic T cells by inhibiting the response to interleukin 2.

However, the Placental barrier is not the sole means to evade the immune system, as foreign foetal cells also persist in the maternal circulation, on the other side of the placental barrier. Other functions The placenta also provides a reservoir of blood for the fetus, delivering blood to it in case of hypotension and vice versa, comparable to a capacitor.

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