Breastfeeding: Good Vs Poor Latch

Hello friends!

On International Breastfeeding week, I would like to discuss the difference between Good and Poor Latching during Breastfeeding.

Technique of Breastfeeding

Hello friends!

On International Breastfeeding Week, I am sharing the proper technique for Breastfeeding. 

Must know methods for everyone.

Techniques of Breastfeeding 

Breastfeeding is nature's precious gift for infants. Breastfeeding is advised because human milk is species-specific nourishment for the baby, produces optimum growth and development, and provides substantial protection from illness. Lactation is beneficial to the mother's health and biologically supports a special MOTHER-BABY relationship.

But most breastfeeding problems are caused by the poor attachment of the baby to the breast. Thus, it is very important to learn how to feed the baby with the correct position and attachment.

Support the mother's body as support back well and use pillow, cushion, or footstool to provide comfort. Before breastfeeding, every mother should wash their hands. 

The correct way to support baby -

1. In sitting position 

a) Cradle hold-

Hold the baby horizontally facing the mother. When nursing from the right breast, use the right arm to rest on the forearm, baby's back supports on the same forearm and holds baby's bottom with hand. Support the breast with the left hand. 

b) Transition hold (cross over hold)

When nursing from the right breast, use the left arm to hold the baby. Support baby back with the left forearm, while placing the thumb and fingers at the base of the baby's head below the ears of the baby. Support the breast with the right hand. 

c) Football hold

Hold the baby under the mother's arm and let the baby face towards the breast. Support the baby with a pillow underneath. Hold the baby close the mother with the nose pointing to the nipple, use the forearm to support baby back and neck, and the hand to hold the baby head. This position is suitable for mothers who have had a Caesarean section. Since mother does not put pressure on the abdomen. 

2.Inside lying hold 

Baby and mother lying on their sides facing each other. The mother should be relaxed. The baby needs to well supported and secure as tuck a rolled-up towel or small pillow firmly behind baby' back to keep in position. Adjust the baby's distance from the lower breast by placing a folded blanket under the baby's head. To assist with the latch on using the opposite hand to support the breast(right hand for left breast vice-versa) 

Getting baby latch on to the breast -support the base of the baby's head. Baby's head slightly extended, so that the nipple is aimed at the roof of the baby's mouth. Lightly touch the baby's lip with the nipple and wait till baby opens his/her mouth wide. Bring baby to mother's breast. Not mother breast to the baby. 

Signs of good attachment-baby open his/her mouth wide with lips flanged out, more areola is seen above the baby's lip then below baby's chin is pressed onto the breast. 

Breastfeeding should not hurt if the mother keeps a finger into the corner of baby's mouth to break the suction and gently take baby off mother's breast.

By- 

Shashikala Kumari

2nd year MBBS

GMC Bettiah

Thioamides in pregnancy

Hello

Propylthiouracil is a pro. It always comes first (used in first trimester of pregnancy).
Methimazole causes Malformations in the embryo (teratogenic).

There are two M's in MethiMazole. This drug is used in second (and third trimester of pregnancy).
Propylthiouracil piles up, causing liver toxicity, thus limiting its use.

Hope it helps
- Jaskunwar Singh

Importance of Ischial spine

Following are the important points of the ishial spine :-

Mnemonic SID BPL

1) Station of fetal head is calculated with respect to Ischial spine.

2) Internal rotation of fetal head occurs at this level.

3) Deep transverse arrest occurs at this level.

4) It is site for giving pudendal block.

5) Place at which ring pessory inserted.

6) Levator ani muscle is attached here.

PS : Question which was asked in central institute examination (I felt it should be mentioed here)

Which ligament is felt while giving pudendal block?

Sacrospinal ligament.

COVID-19 and Pregnancy: Should Mothers Be Concerned?

Pregnancy is a special phase in a woman’s life, more so because of the various changes which her body undergoes during these 9 months. Perhaps that is why, the concern about the threat of the novel coronavirus is valid- after all pregnancy is a state of slight immunocompromise, and also because there are two lives at stake. WHO declared the COVID-19 outbreak a pandemic on March 11, 2020. Most countries have taken stringent measures to control the spread of this disease, but do pregnant women need to take more measures? So, avid obstetricians out there, let’s find out deeply about the connection between these two:

WHO’s official stand is that there is no higher risk in pregnancy of severe illness BUT because there are trials underway and due to the bodily changes in pregnancy, one can not know the extent of COVID-19 in these patients. [1] Due to the evolving crisis, we are seeing newer studies every day with new results. A study conducted in early February on 38 pregnant women showed that it did not lead to maternal deaths, and neither were there any confirmed cases of intrauterine transmissions, with rt-PCR being negative in all the neonatal specimens tested, hence leading to the belief that there is no intrauterine or transplacental transmission. [2] Even the CT scans done on pregnant women with COVID-19 positive samples, did not show major changes and recovered from pneumonia adequately. [3]

Schroeder's Vs Bandl's ring

Schroeder's  Vs Bandl's ring

Bandl's ring:- 

1) It is seen in obstructed labour

2) It is a pathological ring

3) It is a retraction ring

4) It moves up with uterine contractions

5) It can be palpable per-abdominally but not pervaginally

(Remember- Bandl has A after B which stands for per-abdominally)

6) Management: Like obstructed labour, C-section and antibiotics.

Schroeder's ring:-

1) Seen when oxytocin is used judiciously.

2) It is a physiological ring.

3) It is a constriction ring.

4) It is fixed ring, does not move with uterine contractions

5) It can be palpable pervaginally but not per-abdominally.

6) Management: It dissolves on it's own.

If not, then management in first stage of labour includes C-section.

Management in second stage includes forceps or c section.

That's it!

Demotional bloke

Post Partum Hemorrhage - Updates

Following bleeding scenarios amount to PPH under the latest WHO document

1. Blood loss >500 mL in c/o Vaginal delivery
2. Blood loss > 1 L in c/o C Section + in c/o twins
3. Blood loss > 1.5 L in c/o Hysterectomy
4. Blood loss on any case more than what is expected over a period of 24 hours

Following bleeding scenarios amount to PPH as per the latest ACOG recommendations

1. Blood loss equal to or more than 1 L irrespective of mode of delivery
2. Bleeding with signs and symptoms of hypovolemia

Updates in Management of PPH

1. Uterine massage is added along with uterotonics
2. PGE1 if given Per Rectally (not recommended), 1000 micrograms is advised
3. Inj Tranexamic Acid is recommended in all bleeding diasthesis - 1 gram slow IV (over 20 minutes) 
4. Mechanical Devices allowed
1. Sengstaken Blakemore Catheter
2. Bakri Balloon Catheter

Sonographic diagnostic features of monochorionic monoamniotic twin pregnancy

1. Absence of dividing amniotic membrane

2. Presence of single placenta

3. Same gender fetus

4. Adequate amniotic fluid around each fetus

5. Both fetus moving freely 

Risk factors for puerperal sepsis mnemonic

Hi!

Risk factors for puerperal sepsis mnemonic:
PUERPERAL SEPSIS

Maternal complications of diabetes in pregnancy mnemonic

Hi!

Maternal complications of Diabetes in pregnancy mnemonic:
PREGNANCy

Peripartum heart failure associated with prolonged tocolytic therapy

Did you know?

Kleihauer–Betke test

Kleihauer–Betke test: KB test.

1) Why do we do this test?

- To calculate Fetal RBCs in blood. This helps us to measure amount of Anti-D required to neutralize it.

2) How do we do it?

- Basically, we are going to take blood sample and add acid to it and measure red blood cells under microscope.

3) How do you differentiate Fetal and Maternal blood?

- Fetal RBCs are acid resistant. Adding acid in the preparation leads to lysis of the Maternal RBCs.

4) What are important points regarding this test that should be kept in mind while solving MCQs?

- Do not confuse it with APT test. APT is done in Alkali and it is a Qualitative test. It helps in differentiating Maternal and Fetal blood only. On the other hand, in KB test (Also know as Acid dilution test), we use Acid and we quantify Fetal blood.

- Minimum dose even after KB test is 300 microgram.

5) How do we calculate amount of Anti-D required to neutralize Fetal RBCs?

- If 20 RBCs in HPF are seen, then it means 1 ml Fetal blood is in circulation.

-‎1 ml fetal blood requires 10 microgram of Anti-D for neutralization

6) What if they don't mention "Fetal RBCs" and instead, mention "Fetal blood" in the question?

- Here is a trick. Always remember, 1 ml Fetal blood has 0.5 ml Fetal RBCs.

Applied calculations:

Q1) A Multigravida with twin pregnancy has 20 ml Fetal RBCs. How much Anti-D will be required to neutralize it?

(Take a deep breath. You don't need to worry about twin pregnancy. All the important points are already covered in above segment)

- 20 ml Fetal RBCs = 40 ml Fetal blood.
- ‎1 ml Fetal blood = 10 micrograms Anti-D

Answer = 400 micrograms Anti-D

400 micrograms is the enough amount of blood given to neutralize 40 ml fetal blood or 20 ml Fetal RBCs.
‎
(Done easily? Perfect ! Let's level up.
I want you to go through blog once again before heading down.)

Q2) This time patient comes with same clinical presentation but with 20 ml fetal blood.

- 1 ml fetal blood = 10 micrograms of the Anti-D
- ‎20 ml Fetal blood will require 200 micrograms Anti-D.

Perfect. We calculated correctly but my question is - Will you administer 200 micrograms Anti-D to the patient showing 20 ml Fetal blood to neutralize it?

Answer is big 'NO'.

Go back to bullet (4) point 2:

Minimum amount is still 300 micrograms after KB test. So you cannot administer 200 micrograms. You have to give 300 micrograms.

I hope this blog is better than my previous blogs. Any important points you have regarding KB test, do comment in comment box

That's it

-Demotional bloke

AASLD guidelines for treatment of chronic hepatitis B in pregnancy

Hello!

Here is a quick summary.

Cardiovascular changes in pregnancy

At term
- Blood volume increases by 50%
- increased uterine blood flow 500-800ml/min
- uterus recieves 10-15% cardiac output

Massive blood transfusion strategy

In patients with massive haemorhage with a loss of more than 40% of blood volume - rapid transfusions are given with colloids, crystalloids and packed RBCs.

This causes coagulopathy by diluting the a clotting factors.

Hence, prophylactic infusion of platelets and fresh frozen plasma is done.

Initially, it was given in a ratio of 1:1:4
One part platelet & ffp transfusion to every 4 bags of blood.

It has been renewed now to 1:1:1 ratio

It has caused significant reduction in mortality 40% versus 60%

Thank you!

40% blood loss translates to grade 4 hemorrhagic shock or grade 1 degree of urgency per the urgency grid for obstetric hemorrhage. I removed the grading in the initial part of the post to avoid confusion as different grades mean different severity of shock based on the scale used.

- sakkan

LMR (Last minute revision) Stuff for obstetrics and gynecology drugs

Hello Awesomites!

In LMR sessions, I will share final year MBBS Viva things on drugs and specimen.You can add your list in the comments below. 
Today I will share the Obstetric and gynaecology viva on drugs. 
Lets get started.

1.Tranexamic acid and mefanemic acid combination

Tranexamic acid:

• anti-fibrinolytic
• Amino caproic acid derivative 
• CONVERTS plasmin to plasminogen
• given during menstruation
• Adverse effect:- Intracranial thrombosis

Mefanemic Acid:

• COX inhibitor.
• Given during menstruation
• Adverse effect:- dyspepsia,gastric ulcer

USE:-

• Ovulatory cycles of DUB
• Post IUCD bleeding
• Post sterilization mennorhagia
• Fibroid

2.Doxylamine and Vitamin B6 combination

Doxylamine is anti histaminics that has effects on acetylcholine and serotonin release. And you know their receptor is present on CTZ centers.
Vitamin B6 is pyridoxine.
In pregnancy and poor diet the amount decreases.

USE:- Emesis during pregnancy at bedtime (not more than 2 tablet in a day).

3.Dinoprostone gel

• Prostaglandin E2
• 500 micro gram into the cervical canal below the level of internal os
• Or 1-2 mg in the posterior fornix 
• maximum 3 doses 6 hourly
• Applied in posterior fornix when membrane is ruptured
• applied in internal os when membrane is intact
• USE- Cervical ripening in IOL.
• Before and after CTG monitoring is must.
• C/I- Previous CS, Impending scar rupture,fetal distress,asthma,severe heart disease

S/E- hyperstimulation of uterus,fetal distress

4.L-Arginine+Folic acid+isothiocyanidin

• L-Arginine is precursor for Nitric oxide generation that will lead to vasodialtion
• USE: In IUGR, Severe oligohydroamnios, preventing pre-eclampsia

5.Misoprostol

• PGE1
• ROUTE= sublingual,vaginal,rectal (never parentral)
• S/E:Fever,chills,shivering
• Teratogenic: Mobius syndrome (Category X drug)
• USES:-

1. OBSTETRIC USES:

• Termination of pregnancy
• PPH prevention and treatment.

     2.GYNECOLOGICAL USE:

• Pe hysterectomy
• IUI
• Cervical pregnancy

    3.GIT USE:

• Treatment of peptic ulcer caused by NSAIDs.

6.Frusemide:

• Loop diuretic.
• prior to blood transfusion in severe anemia
• congestive cardiac failure
• used in complications not as anti hypertensives
• PIH with massive edema

7.Clindamycin+Clotrimazole 

• USE: Mixed bacterial and fungal vaginosis 

8.Omeprazole+Ondansetron:

• USE: GERD, peptic ulcer

9.Heparin:

• Injectable Anti-coagulant
• In 1st trimester
• Antidote: Protamine sulfate
• USE: DVT, APLA, PE, recurrent abortion (Prophylaxis:ASPIRIN+HEPARIN)

10.Iron folic acid:

• Prophylactic: 100mg elemental iron+500 micro gram folic acid daily from 2nd trimester throughout pregnancy +6 month postpartum
• Treatment: Oral  iron 200 mg elemental iron daily
• Folic acid deficiency lead to abortions, abruptio, IUGR, NTD
• In folic acid deficiency dose is 4000mg

11.Anti-D Immunoglobulin:

• IgG, intramuscular
• 300 micro gram=15 ml of D positive red cell/ 30 ml of fetal whole blood 
• If ICT -VE at 28 weeks

12.Hydrocortisone:

• 2 doses 12 mg betamethasone i/m 24 hours apart
• 4 doses 6 mg dexamethasone 12 hours apart

13.Sodium Bicarbonate:

• IV for Heart resuscitation, poor kidney function, Cocaine toxicity
• Poisoning cases
• Reviving newborn
• Preventing chemotherapy side effects
• Hyperkalemia
• metabolic acidosis

14.Diazepam:

• Central Muscle relaxant and anti convulsant, Tranquilizer
• S/E:- Maternal (Hypotension) and Fetal (Respiratory depression, hypotonia)

15.Nifedipine:

• Direct arteriolar vasodilator
• Calcium channel blocker
• USE:Tocolytics
• A/E: Flushing, Hypotension, headache, Inhibition of labor

16.Labetalol:

• Anti-hypertensive
• combined alpha and beta blocker
• orally 100mg tid to 2.4 g daily
• USE: Hypertension and hypertensive crisis
• S/E:tremor, headache, CCF.
• C/I: Hepatic disorder, asthma, CCF

17.Magnesium Sulphate:

• Top 10 series by AP Burkholderia

18.Drotaverin:

• Anti-spasmodic (PDE-4 Inhibitor)
• Enhance cervical dilatation during childbirth
• USE: Acute renal colicky, augment labor.

19.Oxytocin:

20.Methergine:

21.Prostaglandins:

More is coming up !

-Upasana Y. :)

Anti-Ro/SSA antibodies and neonatal lupus

Hello everyone!

Did you know? Anti-Ro/SSA antibodies are associated with neonatal lupus (congenital heart block (CHB), neonatal transient skin rash, hematological and hepatic abnormalities).

How do I remember this? 

Congenital syphilis picmonic

This was submitted by Ri. Thanks girl!

With reference to this post: http://www.medicowesome.com/2017/03/buzz-words-for-congenital-syphilis.html

-IkaN 

Age of Gestation and Estimated Date of Delivery (EDD)

Hello,

This is a nice video explanation by Jay!

Nonstress test and biophysical profile mnemonic video

The video is up!

Video notes, Nonstress test and biophysical profile mnemonic: http://www.medicowesome.com/2018/03/nonstress-test-and-biophysical-profile.html

Biophysical profile mnemonic and step 2 CK notes: http://www.medicowesome.com/2016/09/biophysical-profile-mnemonic-and-step-2.html

-IkaN