Complications of Epidural Anaesthesia

During epidural anaesthesia may result complications as:

1.Hypotension: becose block of symphatetic nerve supply to the lower part of the body leads to peripheral vasodilatation.
2.Accidental dural puncture: There is 50% possibility of a low pressure headache which last for few days from leakage of cerebrospinal fluid into the epidural space.
As treatment is recomanded:
-lactate solution infused into the epidural space
-bed rest for 4 days
-analgesics
-blood patch,if the previous methods failed.
3.Subarachnoid injection:
The usual dose needed for spinal block is less than that required for epidural block so if accidentally injected into the subarachnoid space it m result in paralysis of the respiratory muscle.
4.Increased incidence of foreceps delivery: as the maternal perineal reflex and urge to push is blocked leading to prolonged second stage.
5.Neurological complications:
Patches of numbness on the outer side of the thighs or legs for few days.
6.Fracture of the cathered:
Fragments are left in situ as it cause no problems.

The Relief of Pain in Labour

During the first stage the pain arises from the uterus,cervix and upper vagina passes through Frankenhouser's ganglion to the hypogastric and thenthe pre-aortic plexuses to enter the spinal cord.
The pain is do to increased pressure with each contraction and due to cervical dilatation.
The highest degree of pain is felt during the transitional period between the first and second stage.

During the second stage the pain arises from the vagina and perineum is transmitted through the pudendal nerves to enter the spinal cord.

See LABOUR STAGES

Physiological Effects of Labour on Mother

Effects on Mother:
During first stage of pregnancy minimal effects.
During second stage (see Labour Stages ):
-the temperature slight rise to 37.5 degree
-the pulse increases up to 100/min
-systolic blood presure may rise slightly due to pain,anxiety and stress
-oedema and congestion of the conjunctiva
-minor injuries to the birth canal and perineum may occur,particularly in first pregnancy.

During third stage can occur:
-blood loss from the placenta (100-200 ml) and from laceration or episiotomy (100 ml).The total avarage blood loss in normal labour is 250 ml.

Labour Stages- Mechanism of Cervical Dilatation

In case of first pregnancy the cervical canal dilates from above downwardsor from the internal os to the external os.So its legth shorts gradually from more than 2 cm to thin rim of few millimeters continuous with the lower uterine segment.This process is called effacement and expressed in procentage so when we say effacement is 70% it means that 70% of the cervical canal has been taken up.
Dilatation of the cervix (external os) starts after complete effacement of the cervix.

In case of past delivery effacement and dilatation occur simultaneously.

In normal presentation and position,the head is appled well to the lower uterine segment dividing the amniotic sac by the girdle of contact into hindwaters above it containing the foetus and a forewaters below it.This reduces the pressure in the forewaters preventing early rupture of membranes.After full dilatation of the cervix the hind and forewaters become one sac with increased pressure in the bag of forewaters leading to its rupture.

Phases of cervical dilatation:
1.Latent phase:
-this is the first 3 cm of cervical dilatation which is slow takes about 8 hours first pregnancy and 4 hours in multiparae
2.Active phase:
It had 3 components:
-acceleration phase
-maximum slope
-deceleration phase.
The phase of maximum slop is the most detectable and two other phases are of shorter duration and can be detected only by frequent vaginal examination.
The normal rate of cervical dilatation in active phase is 1.2 cm/hour in case of first pregnancy and 1.5 cm/hour in case of 2nd opregnancy.If the rate is less than 1 cm/hour it is considered prologed.

Labour Stages

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Labour is devided into four stages:
1.First Stage:
-it is the stage of cervical dilatation
-starts with the onset of true labour pain and ends with full dilatation of the cervix (10 cm diameter)
-it takes about 10-14 hours for first time pregnant and about 6-8 hours if exist other delivery in the past

2.Second Stage:
-it is the stage of expulsion of the foetus
-begin with full cervical dilatation and ends with the delivery of the foetus
-its duration is about 1 hour in cases of first time pregnant and 1/2 hour in cases with past delivery

3.Third Stage:
-it is the stage of expulsion of the placenta and membranes
-begin after delivery of the foetus and ends with expulsion of placenta and membranes
-its duration is about 10-20 minutes in both cases (first pregnancy or not)

4.Fourth Stage:
-it is the stage of early recovery
-begins immediatly after expulsion of the placenta and membranes and last for 1 hour
-during which careful observation for the patient particularly for signs of postpartum hemorrhage is essential.Routine uterine massage is usually done every 15 minutes during this period.

Lactation and Breast Disorders after Delivery

Lactation:
The sudden fall in oestrogen level after delivery is associated with reduction in the secrection of prolactin inhibiting factor from the hypothalamus and relese of prolactin from the anterior pituitary.

Prolactin is responsible for milk formation.
Oxytocin released from the posterior pituitary due to suckling is responsible for milk ejection.

1.Breast Engorgement:
Usually occurs in the 3rd day after delivery when secretion of milk begins.
Symptoms:
-breasts are overdistanded with visible dilated veins
-breasts are painful and tender
Is necessary breast evacuation.In early stage baby suckling can be sufficient but later on congestion press on the ducts preventing flow of milk so an electric or manual  breats pump is needed.

2.Deficient Lactation:
Causes:
-constitutional
-bad general condition and malnutrition
-infrequent or irregular suckling.
Is necessary a regular breast feeding,to have a good diet and consume plenty of fluids.

3.Cracked Nipples:
Causes:
-lack of cleanness and dryness of the nipple
-vigorous suckling of an hungry baby in deficient lactating breast
-leaving the baby to long at the breast
-repeated taking and leaving the nipple by the baby to breath if its nose is obstructed by the breast
-monilial infection.
In this case take a rest,the baby should not put on the affected breast till healing occurs while it is emptied manually.Gradual going back to the breats is recommended to prevent recurrence.

4.Acute Mastitis:
Causative organism is staphylococcus aureus which may reach the breast from infected baby.
Symptoms:
-breast is tender,painful,red,tense and hot
-axillary limph nodes are enlarged
-high fever may reach.
Proper treatment is indicated otherwise breast abscess will develop.
Stop lactation from affected breast and breats is emptie manually or by an electric pump.When the acute phase is over breast feeding can be resumed.
Support the breats over a pad of cotton wall.

5.Breast Abcess:
A segment of the breast becomes painful and tender and fluctuationcan be detected.
Fever and enlarged xillary limph nodes.
As soon as an abcess is formed it should be incised and drained under general anaesthesia.

Essential Nutrients and Source Food

Vitamin A: provitamin A,beta-caroten in orange fruits and dark green vegetables.
As retinol: fish liver oil,egg yolk,fortified dairy products.

Vitamin D: fortified diary products,egg yolk,liver,fish liver oil.
The main source is exposure to ultraviolet rays.

Vitamin E: vegetable oils,vegetable margarine,wheat germ,leafy vegetables,beans.

Vitamin K: cabbage,cauliflower,green leafy vegetables,egg yolk,liver,

Vitamin B1: meat,whole grains,dried fruits,beans,fortified cereals.

Vitamin B2: dairy products,liver,meat,eggs,enriches cereals.

Vitamin B6: cereal grains,beans,fish.

Vitamin B7: liver,kidney,egg yolk,cauliflower,yeast,dried fruits.

Folic acid: fresh green leafy vegetables,fruit,liver,yeast.

Vitamin B12: egg,meat,only animal products.

Vitamin C: citrus,kiwi,starwberries,tomatoes,cabbage,green pepper.

Calcium: milk,beans,meat,cereals.

Zinc: meat,liver,egg,cereal,peanuts.

Chlorine: table salt.

Copper: dried fruit,pulses,entrails.

Chronium: yeast,liver,processed meat,cereal grains,spices.

Phosphorous: milk and dairy products,fish poultry,meat,cereal,beans.

Flouride: fish products,vegetables,cereals,coffee,tea,flouride water.

Iron: meat,soy beans,spinach.

Magnesium: green leafy vegetables,cereal,dried fruit,fish fruits.

Manganese: cereal grain,leafy vegetables,dried fruits,tea.

Potassium: milk,bananas,plums,raisins,meat.

Selenium: meat and animal productsn general.

Sodium: table salt.

Iodine: fish products.

Multiple pregnancy-Incidence and Types

Multiple pregnancy refers to pregnancy carrying more than one foetus.

Incidence of multiple pregnancy:
The fallowing factors are associated with higher incidence:
-familial:wether the wife's or husband's family has a history of multiple pregnancies
-induction of ovulation
-maternal age: incidence increases with increasing age up to 40
-previous multiple pregnancy

Types of multiple pregnancies:
1.Binovular (Dizygotic=non-identical) Twins:
-developed from two separate ova which may or may not come from the same ovary and fertilized by two separated spermatozoa.
-the twins are of the same or different sex
-the similarity between them is not more than that between members of the same family
-they have two placenta,two amnions,two chorions and two umbelical cords
-binovular twins are 4 times more common than the uniovular variety.

2.Uniovular (Monozygotic=identical) Twins:
-developed from a single ovum which after fertilization by a single sperm has undergone division to form two embryos
-the twins are of the same sex
they have similar physical and mental characters as well blood group but not finger prints

Superfecundation:  is fertilization of two ova produced in the same menstrual cycle by two spermatozoa depositted in separate acts of coitus.

Labour Symptoms-Signs of neer labour

The fallowing clinical manifestations may occur in the last weeks of pregnancy.

• Shelfing:

It is falling forwards of the uterine fundus making the upper abdomen looks like a shelf during standing position.This is due to engagement of the head which brings the fetus perpendicular to the pelvic inlet in the direction of pelvic axis.

• Lightening:

It is the relief of upper abdominal pressure symptoms as dyspnea,dyspepsia and palpitation due to:
-descendent in the fundal level after engagement of the head
-shelfing uterus

• Pelvic pressure symptom:

With engagement of the presenting part the fallowing symptoms may occur:
-frecvency of micturition
-difficulty in walking
-rectal tenesmus

• Increased vaginal discharge
• Fals labour pain:

This are different from true labour pain as fallow:
The true labour pain is:
-regular
-increase progressively in frequency,duration and intensity
-pain is felt in the abdomen and radiating to the back
-progressive dilatation and effacement of the cervix
-membranes are bulging during contractions
False Labour pain is:
-irregular
-do not increases progressiely
-pain is felt mainly in the abdomen
-no effect on the cervix

• Onst of labour:

It is caracterized by:
-true labour pain
-"the show"= it is an expelled cervical mucus plug tinged with blood from ruptured small vessels as a result of separation of the membranes from the lower uterine segment.Labour starts usually hours to few days after "show".
-dilatation of the cervix: a closed cervix is a reliable sign that labour has not began
-formation of the bag of fore-waters: which hulges through the cervix and becomes tense during uterine contractions.

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Delivery