Saturday, April 28, 2012

Multi-fetal Pregnancy Reduction

Carried out in a quadruplet pregnancy.

First fetus - injected amniotic fluid 5 ml intra-thoracically, but as it failed, injected 2 ml KCL intra-thoracically. It's important to verify that heart stopped for sometime, and then withdraw the needle.

Second fetus, repeated the injection of amniotic fluid, and it acted to cause a temponade on the heart, and stop it. amniotic fluid may be useful in mono-amniotic twins, in which continuation of pregnancy is very risky to both fetuses, and reduction carries risk too, due to intense vascular anastamoses.

Sunday, April 1, 2012

Day Care Delivery

An Invitation Article by -
       Dr Shruti Malvi

        KBPN Malvi Hospital
        Hoshangabad [M.P.]

Let’s Redefine Labour, with “Day-Care-Delivery” [DCD].

Advances in Medical Science all over the Globe, aim at Predictable Planned and Personally tailored Management Protocol that is least Invasive, Cost-effective and Simple…
We have succeeded too, mostly everywhere, except probably, Obstetrics, which still remains a completely unpredictable entity, bringing on helplessness in the obstetricians.
Its comparatively, the most unnoticed, unpredictable, and neglected process.

Well...maybe not anymore…
In an effort to combat this problem, we, at our hospital, started a Closely Monitored Labor management protocol which we named –The Day-Care Delivery Protocol [DCD Protocol], with subsequently Favorable Outcomes, without waiting for the Complications to actually set in.

The Concept of DCD-
Day-Care-Delivery can be defined as a planned activation and augmentation of labour at 38+ wks gestation, managed with the intention of vaginal delivery before nightfall.
It can result in a safe and predictable Feto-maternal Outcome in a manner which is very personal to the patient
The Latent Phase of Labor may extend to long and unpredictable lengths, and the active pains may start at any time which again is unpredictable and may pose problems.
Here with the DCD Protocol we aim at cutting short the latent phase ,pushing the parturient forward to enter the Active Phase, which also relieves the unnecessary stress and tension in the patient and outcome is better.

It is well known that a soft and favourable cervix becomes responsive and thereby facilitates the momentum of the ongoing labor progress
Our efforts are targeted at this Latent Phase to trigger the more predictable Active Phase in a planned way. Once achieved, the active phase will take its own natural course.

The DCD Protocol-
The dcd protocol is a comprehensive process which involves adequate counseling and informed consent with application of a dcd criteria prior to admission.
This is followed by activation of labor under close monitoring with assessment of outcomes and routine follow-up.
Patient selection begins during the 1st antenatal visit provided she’s a healthy ANC
Inclusion depends on her willingness after DCD counseling.
  • gestational age of >/= 38 wks,
  • uncomplicated pregnancy,
  • clinically adequate pelvis,
  • suitable usg findings,
  • suitability/qualifying for trial of labour,
  • informed consent form the check list prior to DCD.

After admission, the active phase is triggered once the dcd criteria are fulfilled. This is the final check…
Which includes,
  • DCD Trigger criteria
  • Regular FHS,
  • Irritable uterus,
  • Cephalic presentation
  • Intact membranes
  • Hd at brim
  • Bishop’s 4-5

Once the trigger point is confirmed, Labour is activated with
Intracervical dinoprostone instillation under close monitoring
Oxytocin drip commenced as indicated.
ARM done at a 3 cm dilated >50% effaced soft cx.
Augmentation continued aided by Drotaverine and epidosin injections an hr apart.
All being well pt is expected to deliver by late evening

So, what are the benefits of the Day Care Delivery Option as opposed to the conventional vaginal deliveries?

*From the pt’s perspective,
-its s a planned admission
-less transportation problems
-family support available .
*From the hospital perspective,
-senior medical and nursing staff will be available when the patient arrives.
Hence the emphasis changes from Masterly Inactivity and watchful expectancy to Masterly Activity and watchful expectancy.

Such mode of delivery is cost-effective and helps the women, resume their duties faster both in personal and professional fronts. These modalities make both the Rural as well as Urban clientele more receptive to the idea.

Advantages of Day care are always there, everything is planned and help is available, for instance, the Neonatologist, Anaesthetist, Blood, Pathological Investigations etc are at hand, compared to that in the middle of the night,

So the bottom line is, DCD may prove to be a suitable option for the patient and her obstetrician ensuring quality labour and Optimal perinatal outcome in the present day, helping the Pleasant Births of both a Cute Baby and Its Mommy.