Tocolytic Agents

➯Definition of Tocolytic Agents

Tocolytic Agents are also called anti-contraction medications or labor suppressants. those agents prevent preterm labor and immature birth by suppressing uterine contractions.

➯Indications of Tocolytic Agents

• Generally 24 gestational weeks onward.
• Before 37 weeks of gestation.
• Spontaneous premature contraction.
• No evidence of infection
• No life-threatening

➯TOCOLYTICS(UTERINE RELAXANTS)

        “It’s Not My Time!“

I – Indomethacin (NSAID)

N – Nifedipine (CA Channel Blocker)

M – Magnesium Sulfate

T – Terbutaune (Adrenergic Agonist)

Female Pelvis: True Pelvis and False Pelvis

There are 4 types of pelvis humans have.

1. Gynecoid
2. Android
3. Anthropoid
4. Platypelliod

Female pelvis are Gynecoid pelvis and the male pelvis are Android pelvis. A gynaecoid pelvis is a very good pelvis for females for childbearing and labor. The female pelvis plays a very vital role in pregnancy to give birth of a child.

Structure of Female Pelvis:

The female pelvis consists of 2 innominate bones, one sacrum and a coccyx. These innominate bones consist of a pair of ilium, a pair of ischium and a pair of the pubis.

Landmarks of Female Pelvis:

Female Pelvis

1. Sacral promontory
2. Ala of Sacrum
3. Sacroiliac joint
4. Iliopectineal line
5. Iliopubic eminence
6. Pectineal line
7. Pubic tubercle
8. Pubic Crest
9. Symphysis pubis

Landmark of Female Pelvis

Joints of Female Pelvis:

3 joints are present in the female pelvis.

• Sacroiliac Joint
• Sacrococcygeal Joint
• Symphysis Pubis

Classification of Female Pelvis:

The female pelvis is divided into two parts:

A. False Pelvis:

It is formed by the upper flared-out portion of the ilium. It protects the abdominal organs. It has no obstetrical importance.

B. True Pelvis:

The true pelvis is the bony canal through which the fetus passes during birth.

✩ The true pelvis has three parts:

Diameter of True Pelvis:

⇨ True pelvis has

• Inlet (Brim)
• Cavity
• Outlet

⇨ All the diameters of the inlet, cavity and outlet are described below:

INLET

It is formed by the sacral promontory, the iliac bones laterally and the pubic bones anteriorly
Shape: Transversely oval or Heart shape

➥Diameter of Brim or Inlet:

➢Anteroposterior Diameter(11 cm)

It is the line from the sacral promontory to the upper border of the symphysis pubis.
This diameter is of three types-
➩True Conjugate or Anatomical Conjugate
It extends from the sacral promontory to the top of the symphysis pubis.
●Its normal measurement is 11 cm or more.
➩Obstetrical conjugate
It is the distance between the midpoint of the sacral promontory to prominent bony projection in the midline of the symphysis pubis
●Its measures 10 cm
➩Diagonal Conjugate
Distance between the lower border of the symphysis pubis to the down point on the sacral promontory.
●It is 12 cm

➢Transverse Diameter(13 cm)

It is the distance between the two far ther points on the pelvic brin over the iliopectineal lines.

➢Oblique Diameter(12cm)

It starts from the sacroiliac joint to the opposite iliopubic eminence.

CAVITY

The cavity extends from the brim above to the outline below.
The shape is almost rounded
Anterior border: symphysis pubis
Posterior border: sacral hollow
Lateral border: soft tissue

➥Diameter of cavity:

Anteroposterior diameter – From the midpoint of the surface of the pubic symphysis to the junction of the 2nd and 3rd sacral vertebra.
All diameters – As there are other organs, tissue and mass present in the cavity, it is very difficult to measure other diameters. So all the diameters of the cavity are considered as 12 cm.

 

OUTLET

MTP Act, 1971

➢Introductions:

The Medical Termination of Pregnancy (MTP) Act, 1971, provides an overview of the legislation governing the termination of pregnancies in India. Enacted in 1971 and amended in 2002, the act aims to ensure safe and legal abortions.

➢Objectives:

1. The primary objective of the MTP Act is to provide a legal framework for the termination of pregnancies in a safe and medically supervised manner.
2. Protecting Women’s Health and Rights.
3. The MTP Act aims to prevent sex-selective abortions and discourage the practice of female foeticide.
4. Promoting Access to Reproductive Healthcare.
5. Maintaining Confidentiality and Privacy.
6. The act recognizes a woman’s right to make decisions about her own reproductive health and respects her autonomy and choice in matters related to pregnancy termination.

➢Legal Abortion:

• Termination is performed by the medical practitioners(assisted in at least 25 MTP & degree in OBG) by the act.
• Termination is done at the place approved under the act.
• Termination is done for condition & within the gestation week prescribed by the act.
• The abortion has to be reported to the director of the health service of the state.

• Continuation of pregnancy is a risk to the life of a pregnant woman or it can cause grave injury to her physical and mental health.
• A substantial risk is that the child if born, would be seriously handicapped due to physical or mental abnormalities.
• Pregnancy caused by rape.
• Failure of contraceptives in married women.

➦Experience minimum 3yr who is registered in state medical register
➦6 months of house surgeon-ship in gynaecology or experience of working in the department of gynaecology –1yr
➦A Practitioner who has assisted RMP in 25 cases of Medical termination of pregnancies, at least 5 of which have been performed independently in a hospital established or maintained by the Government or a training institute approved for this purpose by the Government.

➢Required by a RMP (Registered Medical Practitioner)

➨Up to 20 wks PG Degree or Diploma in OBG

➨Completed 6 months as House Surgeon in OBG

➨At least one yr experience in dept of OBG at any hospital that has all facilities.

➢Where pregnancy can be terminated? – PLACE

1. Hospitals established or maintained by the Government
2. A Place approved by the Government or DLC constituted by the Government.

➢Consent:

1. Only the consent of women is required.
2. If the Age is <18 yrs or a mentally ill patient, consent of a guardian is required.

Violation of The ACT:

1. Any person doing MTP and not a RMP can be punished with rigorous imprisonment for 2-7 yrs.
2. If terminated at a place that is not approved can be punished 2-7 yrs rigorous imprisonment.
3. The owner of an unapproved place, performing termination can also be punished with rigorous imprisonment for 2-7 years

Psychological changes in first stage of labour:

The first stage of labor is the longest phase. This phase can take 9 hours for primigravida mothers and 5 hours for multigravida mothers.

✩The Changes are listed below:-

1) Cervical Dilation:

The cervix begins to open or dilate to allow the baby’s passage through the canal. This is achieved through uterine contraction.

2) Uterine Contractions:

The muscles of the uterus contract and tighten that causing the cervix to dilate. This contraction became more intense as labor progresses.

3) Rupture of the amniotic sac:

In the first stage of labor, the amniotic sac surrounding the breaks which leads to the release of amniotic fluid. This event is referred to as “water breaking”.

4) Effacement:

The cervix gradually thins out and becomes softer. It is measured in percentages.      100% Effacement = A Completely Thin Cervix5) Increase pelvic pressure:As labor progresses, pelvic pressure gets increases. A mother may feel pressure in the pelvic region.

6) Backache and cramping:

A mother will experience backaches and cramps during all the stages of pregnancy.

7) Increase vaginal discharge:

An increase in vaginal discharge may happen in the first stage. Marcus and blood often come out through the vagina.

8) Changes in vital signs:

Blood pressure, heart rate and respiration rate increase due to maternal stress.

9) Hormonal Changes:

During the first stage, a huge amount of hormonal changes, especially estrogen and progesterone level changes happen in the mother’s blood.

PARTOGRAPH

✯Definition of Partograph:-

A partogram or partograph is a composite graphical record of maternal and fetal data on the progress of labour on a single sheet of paper.

✯Inventor of Partograph:-

Sample of Partograph by WHO

✯Components of Partograph:-

1. Patient identification: Patient Name, Gravida Para, Patient ID Number, Date of Admission, Ruptured Membranes.
2. Time: It was recorded at an interval of one hour.
3. Fetal Heart Rate: recorded every 30 minutes.
4. State of membranes and colour of liquor:
   ‘I’ – Intact
   ‘C’ – Clear
   ‘M’ – Meconium stained
5. Cervical dilatation of the head.
6. Uterine contraction.
7. Drugs and fluids.
8. Blood pressure at every 2 hr, and pulse at every 30 min.
9. Oxytocin: Concentration is noted in the upper box and dose is noted in the lower box.
10. Urine analysis.
11. Temperature record.

✯Advantages of Partograph:-

REFERENCE: World Health Organization

UTERINE PROLAPSE

🔎Definition:

Uterine prolapse is a condition where the uterus slips from its normal position and pelvic cavity into the vagina. It happens when your tissue or muscle of the uterus becomes weak.

Complete uterine prolapse, in which the uterus protrudes through the vaginal hymen is known as procidentia.

🤔Etiology/Cause:

1. Pregnancy/childbirth with normal or complicated vaginal delivery.
2. Weakness in the pelvic muscles due to age.
3. Weakening tissue tone due to menopause.

⚠️Risk Factor:

• Chronic Obstructive Pulmonary Disorder (COPD)
• Obesity
• Chronic cough
• Pelvic tumours
• Straining due to Constipation
• Heavy lifting

🔴Using tobacco and smoking makes your lung condition bad and due to chronic cough you may leads to uterine prolapse.

𛲢Stages:

⇨First degree: The cervix drops into the vagina.

⇨Second degree: The cervix drops to the level just inside the opening of the vagina.

⇨Third degree: The cervix is outside the vagina.

⇨Fourth degree: The entire uterus is outside the vagina. This condition is also called procidentia.

🤧Signs and Symptoms/ Clinical Manifestation:

Most of the people with uterine prolapse have not experienced any signs or symptoms, but some uterine prolapse symptoms are listed below:

• A feeling of fullness or pressure in the pelvis.
• Pain in the pelvis or in the lower back. 
• Pain during sex or intercourse.
• Urination problems, Pee incontinence.
• Constipation

If the situation goes to the level of procidentia, then symptoms may include bleeding, vaginal discharge and ulceration.

🩺Diagnostic Evaluations:

• History collection
• Physical examination
• Vaginal examination, often with a speculum
• Pelvic exam
• Urine culture
• Ultrasound
• MRI

🏥Management:

⇒NON-SURGICAL MANAGEMENT:-

1. Exercise: Pelvic Floor Muscle Training (PFMT) or Kegel exercises can help strengthen your pelvic floor muscles. This may be the only treatment needed in mild cases of uterine prolapse.
2. Vaginal pessary: A pessary is a rubber or plastic doughnut-shaped device that fits around or under the lower part of your uterus. This device helps prop up your uterus and hold it in place.
3. Diet and Lifestyle: Drink plenty of fluids and eat high-fibre foods, such as fruits, vegetables, beans and whole grains to avoid constipation and avoid too much heavy lifting or do that correctly.
4. Estrogen cream: It helps in restoring the strength of vaginal tissue. Sometimes doctors may prescribe this cream to heal uterine prolapse.

⇒SURGICAL MANAGEMENT:-

1. Hysterectomy – surgical removal of the uterus
2. Prolapse repair without hysterectomy

🛡️Prevention:

• Exercise regularly 
• Avoid becoming constipation
• Take healthy diet
• Maintain healthy weight