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After the diverticulum has been separated the strip of gauze is removed and the resulting opening of the diverticulum is closed by two layers order cheap viagra vigour online. The cystostomy incision is sutured around a Malecot catheter and the abdominal wall is closed leaving a corrugated drain in the retropubic space purchase genuine viagra vigour on-line. Sometimes the diverticulum is densely adherent to the surrounding structures so that it cannot be freed by­ dissection buy generic viagra vigour 800 mg on line. In this case the neck of the diverticulum is cleared and the ureter is kept safe out of the diverticulum viagra vigour 800mg mastercard. The neck is now cut with diathermy knife so that the diverticulum now becomes separated from the bladder. A separate corrugated drain is placed close to the diverticulum and left there for 2 or 3 days. If there is any enlarged prostate or bladder neck contracture as the cause of urethral obstruction to cause such diverticulum, prostatectomy or operation for bladder neck contracture is performed at the same time as diverticulum. About 1 to 2% of inguinal or femoral hemiae contain such diverticu­ lum of the bladder. This condition is relatively more frequently seen in femoral hemia and in direct inguinal hemia. Malignant tumours — (i) Transitional cell carcinoma — either de novo or secondary to papilloma. Sometimes carcinoma of the pelvic colon or rectum first presents with symptoms of cystitis and cystoscopy reveals an area intense inflammation which is the first site involved by the carcinomatous lesion. It is an established fact that prolonged exposure to certain carcinogens is associated with a high incidence of vesical neoplasm. Recent work suggests that the multiple transitional cell tumours involving the urinary tract e. Whatever may be the chemical nature of these carcinogens, a few industries have been incriminated to cause bladder tumours and that bladder tumours are now considered as occupational hazards. The industries responsible are dyeing industry, rubber and cable industries, certain types of plastic industry, printing industry, leather industry etc. These amines are metabolised to orthoaminophenols by the liver and conjugated there with sulphate or glucuronic acid and then excreted through the kidneys. These materials are attacked in the urine by Beta- glucuronidase, which hydrolyses to form orthophenols which are liberated. These orthophenols are found in increased concentration in the urine of patients who are having vesical tumours. There is evidence that the activity of urinary Beta-glucuronidase is increased by the presence of vesical infection, in presence of other cancers, renal infection, urolithiasis, renal cyst and benign enlargement of the prostate. It has been recently shown that in smokers there is increase in carcinogenic metabolites of tryptophan excreted in the urine. There is also increased urinary excretion of products with the orthoaminophenol structure in persons who are chain smokers. It has been suggested that cigarette smoking contrib­ utes directly to the origin of bladder cancer. On cessation of smokings the levels of carcinogens excreted in the urine return to normal. There is evidence that the activity of urinary Beta-glucuronidase is also increased in schistosomiasis infestation. The villi may spring directly from a small circumscribed area of the mucosa or may arise from a well defined pedicle. In case of the former the villi are longer, fragile and delicate and looks like sea-anemone with delicate tentacles moving with the flow of urine. In these villi there are connective tissue stroma which are exceedingly delicate and vascular consisting largely of capillary loops. The epithelial cells are arranged at right angles to the stroma being separated from it by a basement membrane. It must be remembered that inspite of having all the characteristics of a benign tumour, papilloma of bladder may yet recur after removal, infiltrate the deeper tissues and set up secondary growths So this benign tumour has a strong tendency to become malignant or it is the beginning of a malignant tumour. It cannot be denied that when the pathologist labels a tumour as a benign papilloma, he is in danger of conveying to the surgeon a false sense of security, although not if the surgeon fully realises the usual natural history of these tumours. The disease apparently originates in multiple foci in the bladder mucosa, appears first as one benign tumour and may continue to appear, so repeated biopsy for years are required. For this reason many surgical pathologists no longer call such a tumour as a papilloma, but as a grade I carcinoma. The differentiating feature from a benign papilloma is that malignant tumour has a wider base and the area around the tumour looks oedematous with dilated blood vessels. The most common sites are (i) on the base of the bladder (about 80%) just outside the ureteral orifices, (ii) in and around the trigone area. Generally speaking the larger the tumour and broader the base, the more malignant it is. These are also curable by transurethral resection and these are also radioresistant. These tumours are not good for transurethral resection, but are sensitive to radiotherapy. Two types of staging are used — 1 The inter­ national system, which is mostly used in U. This suggests that the appearance of these tumours is related to increased susceptibility of the urothelial mucosa to neoplastic proliferation, perhaps in response to carcinogens. It is the commonest type of spread which gradually involves the neighbouring viscera. This occurs only when the tumour has invaded the perivesical tissue Most commonly vesical neoplasms metastasise to the superior vesical and inferior vesical lymph nodes, internal iliac and common iliac group of Ivmph nodes and subsequently to the lymph nodes at the bifurcation of the aorta 3. But once the tumour has spread to the perivesical tissue or peritoneum, there is a chance of vascular spread. Through the remnant of allantois growth may spread to the peritoneum where it may form malignant deposits. Squamous cell tumours are usually solid in consistency and often invade the detrusor muscle. These tumours are highly malignant (anaplastic), deeply invasive and metastasise easily. Occasionally adenocarcinoma may develop in other sites This carcinoma may derive from epithelial nests of Brunn Evidence of cystitis cystitica and cystitis glandularis is often present in the neighbourhood of the tumour. Bleeding may be mild or severe, transient or prolonged Bleeding may occur once or twice and then it may stop to start again after many months to cause concern Bleeding may be so profuse as to cause clot retention. Occasionally it may require emergency admission and blood transfusion immediately. It is usually associated with frequency and discomfort or pain during micturition. In late cases pain may be referred to the suprapubic region, the groin, the perineum and to the medial side of the thigh when the tumour has gone extravesically and has involved nerves. Occasionally a suprapubic swelling may be detected which is either a large cancer or due to urinary retention caused by invasion of the bladder neck by the tumour. The bladder must be empty and this examination should be done under general anaesthesia with the patient fully relaxed. This should be performed before and after endoscopic surgical treatment of the tumour. The right index finger is introduced i nto the rectum in case of male or into the vaginum in case of female. The four fingers of the left hand are placed in the suprapubic region and are pushed down. In T2 cases, bimanual examination reveals no more than smooth induration of bladder wall. In T4 cases, the tumour is not only very easily palpable bimanually, but the tumour remains fixed and is not mobile. Blood examination - Anaemia is not uncommon due to loss of blood, infection or uraemia.

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If after considerable attempts with various catheters buy viagra vigour from india, catheterisation into the bladder has not been possible generic viagra vigour 800 mg on line, one of the following four methods may be adopted — 1 purchase 800 mg viagra vigour. The trocar is removed and a self-retaining catheter is introduced through the cannula with an introducer purchase 800mg viagra vigour visa. The abdominal incision is closed with a stitch to secure the catheter to the skin. But it has the disadvantage of doing the operation on a patient with high urea level. So those patients are only chosen who are otherwise fit and the urea level is not that high. Urethral instrumentation — which has been dicussed in detail in the section of ‘dilatation’ in treatment of urethral stricture’ in page 1211 Retention with overflow. It usually follows a neglected chronic retention case, though it may occur rarely in acute retention also. Retention with overflow has also been referred under incontinence and prostatic enlargement. When the volume of urine is sufficient, the pressure increases until it stimulates the spinal cord reflex which is under the control of cortical centres and leads to the contraction of the detrusor muscles. This muscular contraction increases intravesical vesical pressure to 15 to 30 cm of water. Voiding is resisted by the contraction of the striated muscles ofthe perineum and external sphincter. Cystometrogram reveals abrupt increase in pressure during filling, even at low volumes Treatment is parasympatholytic drugs such as banthine (methantheline) 50 mg 4 times daily. When the lesion is above C7, extensive atrophy of the cord takes place below the site of transection and usually prevents the development of a reflex arc. So even if the bladder is not totally full, urination occurs, which cannot be controlled. Such dysfunction may occur in meningomyelocele or occult spina bifida (most common cause). Such dysfunction may also occur from traumatic, neoplastic or congenital lesions ofthe sacral segments or cauda equina. Surgical treatment is directed at reducing the resistance of the urethra by transurethral resection of the bladder neck or sphincterotomy and balancing the detrusor function. Intermittent self-catheterisation may be required to maintain satisfactory emptying of bladder at periodic intervals. A few drugs may be used to increase detrusor tone (cholinergic) and to decrease bladder neck tone (sympatholytic). The sympathetic fibres come from spinal cord segments eleventh thoracic to second lumbar (Til to L2). These fibres pass via pre-sacral hypogastric nerves and the sympathetic chains to the inferior hypogastric plexus and thence to the bladder. The parasympathetic innervation is derived from the anterior primary divisions of the 2nd, 3rd and 4th sacral segments (S2, 3 and 4), of which S3 is the main segment. These fibres pass through the pelvic splanchnic nerves to the inferior hypogastric plexus, from which these fibres reach the bladder. It should be remembered that the spinal cord at its lower end (at vertebral levels Tl 2 to L1) is to certain extent dilated before it ends by tappering This region correlates with the cord segments S2 to S4 which is the micturition centre. Only the trigonal portion of the bladder receives innervation from the sympathetic outflow of the spinal cord alongwith the bladder neck, seminal vesicles and vas deferens. So damage to the sympathetic nerves will disturb function of the trigone, bladder neck and seminal vesicles. As a result seminal emission and bladder neck closure do not occur with ejaculation The external sphincter, which is striated muscle, with the other striated musculatures of the perineum is supplied by the 2nd, 3rd and 4th sacral segments through pudendal nerve. The external urethral sphincter innervation arises principally from the S2 and to a lesser degree from S3 nerves. AfTerents usually pass through sympathetic nerves to the spinal cord segments Tl 1 to L2. Painful stimuli of overdistension also travel through sympathetic nerves and through the spinal cord to the brain. Stretching of the muscle fibres (detrusor) through proprioceptive sensation initiates a reflex which is mediated through the parasympathetic nerves and causes the detrusor muscle to contract. This also causes relaxation of the bladder neck and relaxation ofthe external sphincter. So it is clear that the act of micturition is a stretch reflex which can be inhibited by the cerebral control if the time or place is not suitable. Injury to the sacral cord, if complete enough, may leave the bladder permanently flaccid, which is known as autonomous bladder. Moreoflen however these lesions are partial and a mixed degree of detrusor weakness is noticed. In case of lesions of the spinal cord above the centre of micturition, the bladder becomes hypertonic and this hypertonicity is more in cervical cord injury and decreases in injuries of the thoracic cord. During the spinal shock stage, some type of bladder drainage must be instituted immediately. Chronic over­ distension can damage the detrusor muscle and limit functional recovery of the bladder. Intermittent catheterisation using strict aseptic technique has proved to be the best form of management. On one hand it avoids urinary tract infection, on the other hand it avoids complication due to prolonged indwelling catheterisation. Irrigation of the bladder with antibiotic solutions and use of systemic antibiotics do not significantly lower the long-term risk of bladder infection. When peripheral reflex excitability gradually returns, urodyanamic evaluation should be performed. Ambulation of the patient even in a wheel chair is helpful and should be done as soon as possible. These measures improve urethral transport of urine, reduce stasis and lower the risk of infection. In this condition when the bladder fills to certain limit, the detrusor muscle contracts reflexly and the bladder empties without any cerebral control and hence it is also known as reflex bladder. Such reflex contractions usually occur at the intervals of 1 to 4 hours, however this period will be shortened if there be infection. It must be remembered that emptying is never complete and some residual urine exists. After spinal shock, that the bladder is becoming automatic is indicated by (i) erection of penis (return of bulbo-cavemosus reflex), (ii) return of anal reflexes and (iii) return of perineal sensation. Return of the following reflexes indicate that automatic bladder is in the offing. If erection of penis is maintained alongwith this test, it signifies that the sacral centre is intact. If the sacral centre is destroyed, the internal sphincter no longer grasps the finger. If the lesion in the spinal cord is above the level of the sympathetic supply of the bladder (Tl 1), the sympathetic innervation remains intact and the patient can appreciate the filling of the bladder. So he can understand the warning of automatic voiding and can prepare himself without wetting the bed. Voiding is initiated using trigger techniques — tapping the abdomen suprapubically, scratching the skin of the lower abdomen, squeezing the penis etc. These patients may be helped by low dose anticholinergic medication or by placing an electrode on the pudendal nerve to effect chronic stimulation of the urethral sphincter. Parasympatholytic drug particularly oxybutynin chloride (Ditropan) 5 mg two or three times daily or dicyclomine hypochloride (Bentyl) 80 mg in four divided doses daily have been used with some success. Propantheline bromide (Probanthine) 15 mg 30 minutes before meals and 30 mg at bed time may be used. Patients may be evaluated for a bladder pacemaker primarily by urodynamic monitoring of the bladder. Electrodes are implanted on the motor nerve roots of the sacral nerves (mainly S3, occasionally S4) to produce detrusor contraction on stimulation.

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The rest of the pelvic examination cheap 800 mg viagra vigour free shipping, including a rectovaginal examination cheap viagra vigour 800 mg mastercard, is normal order viagra vigour mastercard. Invasive cervical cancer is cervical neoplasia that has penetrated through the basement membrane buy viagra vigour with amex. Other symptoms include irregular vaginal bleeding and, in advanced stages, lower extremity pain and edema. Cervical carcinoma is the third most common gynecologic malignancy; 45 is the mean age at diagnosis. The initial diagnostic test should be a cervical biopsy; the most common diagnosis is squamous cell carcinoma. Once a tissue diagnosis of invasive carcinoma is made, a metastatic workup should be done that includes pelvic examination, chest x- ray, intravenous pyelogram, cystoscopy, and sigmoidoscopy. Patients treated surgically are evaluated for risk factors for metastatic disease and tumor recurrence. These include metastatic disease to the lymph nodes, tumor size >4 cm, poorly differentiated lesions, or positive margins. Patients with these findings are offered adjuvant therapy (radiation therapy and chemotherapy). Stage I—Most Common (Spread Limited to Cervix) All patients with invasive cervical cancer should be followed up with Pap smear every three months for two years after treatment, and then every six months for the subsequent three years. Patients who have a local recurrence can be treated with radiation therapy; if they had received radiation previously, they might be considered candidates for a pelvic exenteration. On pelvic examination there is a gravid uterus consistent with 14 weeks size, and the cervix is grossly normal to visual inspection. Pregnancy per se does not predispose to abnormal cytology and does not accelerate precancerous lesion progression into invasive carcinoma. A patient who is pregnant with an abnormal Pap smear should be evaluated in the same fashion as when in a nonpregnant state. An abnormal Pap smear is followed with colposcopy with the aid of acetic acid for better visualization of the cervix. Patients with intraepithelial neoplasia or dysplasia should be followed with Pap smear and colposcopy every three months during the pregnancy. At 6–8 weeks postpartum the patient should be reevaluated with repeat colposcopy and Pap smear. Patients with microinvasive cervical cancer on biopsy during pregnancy should be evaluated with cone biopsy to ensure no frank invasion. If the cone biopsy specimen shows microinvasive carcinoma during pregnancy, these patients can also be followed conservatively, delivered vaginally, reevaluated, and treated two months postpartum. If the punch biopsy of the cervix reveals frankly invasive carcinoma, then treatment is based on the gestational age. In general, if a diagnosis of invasive carcinoma is made before 24 weeks of pregnancy, the patient should receive definitive treatment (e. If the diagnosis is made after 24 weeks of pregnancy, then conservative management up to about 32–33 weeks can be done to allow for fetal maturity to be achieved, at which time cesarean delivery is performed and definite treatment begun. Three doses are given: initial, then two months later, then six months later, for an approximate cost of $300. Women with previous abnormal cervical cytology or genital warts also can receive the vaccine, but it may be less effective. This occurs from a developmental problem with a section of both of the Müllerian ducts. These anomalies are commonly associated with urinary tract anomalies because the structures that give rise to the urinary tract lie close to the Müllerian ducts and are affected by the same injurious insult. Unicornuate Uterus When one of the Müllerian ducts fails to form, a single-horn (banana-shaped) uterus develops from the healthy Müllerian duct. However, in 65% of women with a unicornuate uterus, the remaining Müllerian duct may form an incomplete (rudimentary) horn. There may be no cavity in this rudimentary horn or it may have a small space within it, but there is no opening that communicates with the unicornuate uterus and vagina. In the latter case, a girl may have monthly pain during adolescence because there is no outlet for the menses from this rudimentary horn. In some cases, the rudimentary horn contains a cavity that is continuous with the healthy single-horn uterus but is much smaller than the cavity within the healthy uterus. There is a risk that a pregnancy will implant in this rudimentary horn, but because of space limitations 90% of such pregnancies rupture. So each duct develops into a separate uterus, each narrower than a normal uterus and with only a single horn. In 67% of cases, a didelphys uterus is associated with 2 vaginas separated by a thin wall. Bicornuate Uterus Bicornuate uterus (most common congenital uterine anomaly [45%]) results from failure of fusion between the Müllerian ducts at the “top. Alternatively, in a “partial” bicornuate uterus, fusion between the Müllerian ducts occurs at the “bottom” but not the “top. Because the ducts never fuse at the top, these 2 horns are separate structures when seen from the outside of the uterus. The two Müllerian ducts fuse normally; however, there is a failure in degeneration of the median septum. If the failure is “complete,” a median septum persists in the entire uterus, separating the uterine cavity into 2 single-horned uteri that share one cervix. If the failure is “partial,” resorption of the lower part of the median septum occurs in stage 2 but the top of the septum fails to dissolve in stage 3. Thus, there is a single cervix and uterine cavity at the bottom, but at the top that cavity divides into 2 distinct horns. Because this uterine anomaly occurs later in uterine development after complete duct fusion, the external shape of the uterus is a normal-appearing single unit. This is distinct from the bicornuate uterus, which can be seen branching into 2 distinct horns when viewed from the outside. Arcuate Uterus This type of uterus is essentially normal in shape with a small midline indentation in the uterine fundus, which results from failure to dissolve the median septum completely. It is given a distinct classification because it seems to have no negative effects on pregnancy with regard to preterm labor or malpresentation. Intramural: The most common location of a leiomyoma is within the wall of the uterus. When small it is usually asymptomatic and cannot be felt on examination, unless it enlarges to where the normal uterine external contour is altered. Submucosal: These myomas are located beneath the endometrium and can distort the uterine cavity. The distorted overlying endometrium may not respond appropriately to the normal hormonal fluctuations, resulting in unpredictable, often intermenstrual bleeding. Abnormal vaginal bleeding is the most common symptom of a submucosal myoma and can result in anemia. Menorrhagia is defined as heavy menses and metrorrhagia is defined as irregular bleeding in between menses. Menometrorrhagia consists of both heavy menses and bleeding in between the menses. As they grow they distort the external contour of the uterus causing the firm, nontender asymmetry. Depending on their location they can put pressure on the bladder, rectum, or ureters. If they are pedunculated, or attached to the uterus by a stalk, they can become parasitic fibroids. They break away from the uterus and receive their blood supply from another abdominal organ (such as the omentum or the mesentery of the intestine). Submucosal Leiomyoma Changes in size are dependent on the reproductive life stage of the woman. Rapid growth: Estrogen receptors are increased in leiomyomas, causing rapid enlargement during times of high estrogen levels, such as pregnancy. Degeneration: During times of rapid growth, myomas may outgrow their blood supply, resulting in ischemic degeneration of a fibroid. Common degenerations that are seen include hyaline, calcific, and red degeneration. The latter, also known as carneous degeneration, can cause such extreme, acute pain that the patient requires hospitalization and narcotics. Shrinkage: When estrogen levels fall, with estrogen receptors no longer stimulated, leiomyomas will typically decrease in size.

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Duration of stage 2 may be up to 3 h in a primipara (4 h with epidural) or 2 h in a multipara (3 h with epidural) order line viagra vigour. Stage 3 begins with delivery of the fetus and ends with expulsion of the placenta purchase discount viagra vigour line. The mechanism of placental separation from the uterine wall is dependent on myometrial contractions shearing off the anchoring villi buy viagra vigour without a prescription. Signs of stage 3 include gush of blood vaginally safe 800 mg viagra vigour, change of the uterus from long to globular, or “lengthening” of the umbilical cord Duration may be up to 30 minutes in all women. Stage 4 is not an official stage of labor but rather a critical 2 h period of close observation of the parturient immediately after delivery. Vital signs and vaginal bleeding are monitored to recognize and promptly treat preeclampsia and postpartum hemorrhage. Vital signs are blood pressure 125/75 mm Hg, pulse 80 beats/min, respirations 17 breaths/min. The patient is allowed whatever position is comfortable; however, the lateral recumbent position is encouraged as it optimizes uteroplacental blood flow. Cervical dilation and fetal head descent are followed through appropriately spaced vaginal examinations. Amniotomy is performed in the active phase when the fetal head is well applied to the cervix. She states she has been having regular uterine contractions for 24 h but cervical dilation remains at 1–2 cm. Prolonged latent phase requires that, in the face of regular uterine contractions, the cervical dilation is <6 cm for a duration of >20 h in a primipara or >14 h in a multipara. Other causes are contractions, which are hypotonic (inadequate frequency, duration, or intensity) or hypertonic (high intensity but inadequate duration or frequency). This involves (a) therapeutic rest with narcotics or sedatives, (b) oxytocin administration, or (c) amniotomy. Active-phase abnormalities may be caused by either abnormalities of the passenger (excessive fetal size or abnormal fetal orientation in the uterus), abnormalities of the pelvis (bony pelvis size), or abnormalities of powers (dysfunctional or inadequate uterine contractions). Nulliparous women: After complete dilation, no progress in either descent or rotation of the fetus after ≥3 h without epidural anesthesia and ≥4 h with epidural anesthesia. Multiparous women: After complete dilation, no progress in either descent or rotation of the fetus after ≥2 h without epidural anesthesia and ≥3 h with epidural anesthesia. If the head is engaged, consider a trial of either obstetric forceps or a vacuum extractor delivery. During the examination, the patient’s bag of waters suddenly ruptures, and a loop of umbilical cord protrudes through the cervix between the fetal extremities. Umbilical cord prolapse is an obstetric emergency because if the cord gets compressed, fetal oxygenation will be jeopardized, with potential fetal death. Prolapse can be occult (the cord has not come through the cervix but is being compressed between the fetal head and the uterine wall), partial (the cord is between the head and the dilated cervical os but has not protruded into the vagina), or complete (the cord has protruded into the vagina). Rupture of membranes with the presenting fetal part not applied firmly to the cervix, malpresentation. Place the patient in knee-chest position, elevate the presenting part, avoid palpating the cord, and perform immediate cesarean delivery. However, in spite of vigorous pushing efforts by the mother and moderate traction on the fetal head, you are unable to deliver the anterior shoulder. This diagnosis is made when delivery of the fetal shoulders is delayed after delivery of the head. It is usually associated with fetal shoulders in the anterior-posterior plane, with the anterior shoulder impacted behind the pubic symphysis. It occurs in 1% of deliveries and may result in permanent neonatal neurologic damage in 2% of cases. Include maternal diabetes, obesity, and postdates pregnancy, which are associated with fetal macrosomia. Even though incidence increases with birth weight, half of shoulder dystocias occur in fetuses <4,000 grams. Includes suprapubic pressure, maternal thigh flexion (McRobert’s maneuver), internal rotation of the fetal shoulders to the oblique plane (Wood’s “corkscrew” maneuver), manual delivery of the posterior arm, and Zavanelli maneuver (cephalic replacement). American-trained physicians tend to prefer a midline episiotomy whereas British-trained physicians tend to perform mediolateral episiotomies. It is not practiced routinely in the United States today because the arguments made in its favor have not been shown to have scientific support. Pain relief from perineal distention in stage 2 of labor involves sacral nerve roots, S2 to S4. Pregnancy predisposes to hypoxia because of decreased functional residual capacity. Placental transfer of medications exposes the fetus to lipid-soluble anionic substances. Antacids should be given prophylactically because of delayed gastric emptying time in pregnancy. Uterus should be laterally displaced to avoid inferior vena cava compression in the supine position. Disadvantages include temporary high levels of local anesthetic in the uterus that may lead to transitory fetal bradycardia, which is managed conservatively. Pudendal block is a mode of conduction anesthesia that involves bilateral transvaginal local anesthetic injection to block the pudendal nerve as it passes by the ischial spines. Disadvantages include patchy block from nonuniform spread of the local anesthetic around the nerve roots. Anesthetic Options During Labor General anesthesia is seldom used for vaginal delivery and rarely for cesarean section. Indications include need for rapid emergency delivery and maternal medical conditions in which conduction anesthesia is unsafe (e. Complications include aspiration pneumonia, atelectasis, and uterine atony (associated with inhalation agents, e. Advantages are utilization before significant cervical dilation and membrane rupture. Disadvantages are poor quality tracing with maternal obesity and maternal discomfort from the device belts. A continuous ultrasound transducer picks up fetal cardiac motion but also can register maternal great vessel pulsations. It can measure the beginning and ending of contractions but cannot assess contraction intensity. Advantages include optimum signal quality, which is unaffected by maternal obesity. Disadvantages include limitation to labor when cervical dilation and membrane rupture have occurred. It is a reflection of the autonomic interplay between the sympathetic and parasympathetic nervous system. Absent amplitude range undetectable Minimal amplitude range detectable but ≤5 beats/min Moderate (normal): amplitude range 6–25 beats/min Marked: amplitude range >25 beats/min Figure I-16-3. These are mediated by the sympathetic nervous system in response to fetal movements or scalp stimulation. At ≥32 weeks gestation, an acceleration has a peak of >15 beats/min above baseline, with a duration of >15 seconds but < 2 min from onset to return. At <32 weeks gestation, an acceleration has a peak of ≥10 beats/min above baseline, with a duration of ≥10 sec but <2 min from onset to return. These are mediated by parasympathetic stimulation and occur in response to head compression. The nadir of the deceleration occurs at the same time as the peak of the contraction. These are mediated by either vagal stimulation or myocardial depression and occur in response to placental insufficiency. The deceleration is delayed in timing, with the nadir of the deceleration occurring after the peak of the contraction.

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