|Normal Blood Pressure||
P-E symptoms plus SEIZURES
|Developed world maternal mortality ratio is ___ per every 100,000 live births||
("hatching" en français)
• Custom in which father of a newborn child must observe a variety of postpartum restrictions in diet, activities etc.
|Three Types of Shock||
Septic, Hypovalemic, Cardiogenic
• Older women
• Mothers themselves
• Past the reproductive age
• Illiterate or poorly educated
• May lack stamina
swelling, swelling caused by excess fluid in the body tissues
• Prenatal and postnatal restrictions on diet on part of the father
• Father builds separate birth hut somewhere away from the main communal house. When labor starts, man and woman move into birthing hut to not contaminate the communal house. The two weeks after birth the man must live in the birth hut.
o Child gets 2 names:
• Family name
• Deceased relative
• Spirit name
• Retrieved from a shaman from the spiritual world
• Restrictions on activities may last as long as three years, depending on if the child is sickly or thriving
• Believe newborn children's soul is weak and can come and go as it pleases. When the soul is away from the child, he or she is much more vulnerable to spiritual attack.
o Little corpse
• Explanation for high infant and mortality rates
o Tenuous attachment between soul and child helps make sense of phenomenon
- Author and socio-anthropologist
- One of the most famous anthropological papers in the last 75 years on Kuhna Indians
|1/3 of pregnancy related deaths = __||
|Types of Pregnancy-Induced Hypertension||
The presence of viable bacteria within the blood. May or may not be serious.
- preformed first surviving c-section in UK on Jane Foster
o Published a report of operation in 1798
|Eliminators of Pain||
- Self-efficacy and confidence
- Familiar environment
- Calm attitude of those present during labor
- Understanding of origin of pain (dilatation)
o Woman can recognize pain as progress
- Presence of a doula
- Common in undeveloped countries where rickets and tuberculosis run rampant
- Contraction of pelvic inlet, midpelvis or both
Maternal Mortality in Honduras
How did this happen?
o Jeremy Schiffin
• "Emergence of Political Priority for Safe Motherhood in Honduras"
how the political will was generated to undertake this initiative
maternal mortality remains high in other countries because its reduction is not a priority for political parties
o International Policy Networks
• Epistemic Communities
Groups of professionals that due to their area of knowledge, are able to influence certain areas
Recognized body of expertise in an area
• Transnational Advocacy Networks
Multinational organizations working in various countries working with similar goals
o Policy Transfer
• Voluntary transfer of policy, willingly adopted
• Involuntary transfer → under coercion
• Discussion about adopting policies
o Agenda Setting Theory
• How does an issue get on the agenda?
• What does it take to move it up the list of priorities?
• Streams Model
Agenda setting is random, all issues are flowing and randomly meet with various windows of opportunity
• Problems stream
• Policy stream
• Politics stream
• Fear and measurable indicators for problem help drive it up the agenda
• Political entrepeneurs
• 1980s other countries in central America were fighting but Honduras was not fighting so could use money for healthcare (12% of budget when to healthcare in 1987)
• USAD lots of money for Honduras
Chronic underlying HBP that is there before pregnancy and remains level during and after pregnancy
|Indirect Obstetric Pregnancy Associated Death||
Resulting from pre-existing diseases (Dixie)
- Leading cause of maternal death in industrialized countries (because of bed-rest- especially following c-section surgery)
- Clot in deep veins (of legs and pelvis usually)---Clot develops and breaks free and then moves through the circulatory system and gets trapped in the lungs or heart
- If it gets trapped in one of the main arteries of the lungs it is called a PULMONARY EMBOLISM
|Direct Obstetric Pregnancy Associated Death||
Resulting from obstetric complications, from intervention, incorrect treatment or a bad chain of events
Weak contractions. Easier to deal with (juice mom up with oxytocin)
|Magnifiers of Pain||
- Back pain
- Non-terminal cancer pain
- Anxiety (release of stress hormones)
- Fear of pain in labor
- Reportedly gave a c-section and sewed it back up herself
- British Isles
- Mother was injected with morphine and scopolamine (a drug that caused amnesia) so that she'd be in a state of finely balanced semi-consciousness, without feeling pain and with scant memory of what happened.
major reason for prolonged labor and maternal death
- baby's head is too big
• Risk of hemorrhaging increases because uterus is too tired and wont contract after delivery
Contractions that are so strong that they are uncoordinated and therefore ineffective. Harder to deal with (usually results with an intervention that involves a c-section)
Buttocks first, baby folded in ½, knees extended
Leading point is brow, also an unstable position that usually corrects itself
|"Toxemia" of Pregnancy||
• Same thing as eclampsia
• People used to think that there must be some sort of toxin circulating that body
• Actual cause is still unknown
|Primary Shock (and symptoms)||
- lack of oxygen, anaerobic environment, Decreased urine volume, rapid respiration
|Pre-Eclampsia Symptoms/physiological changes||
1. Generalized Edema
o Swelling of the body
o Spilling protein into urine
Only symptom is HBP that goes away after birth of baby
|"Walking Back to Happiness"||
• Addid Ababa Fistula Hospital (1st hospital of its kind)
• A 17 year-old girl (Wubbit) travels 200 miles to get to hospital. Had a stillborn and got a fistula.
• Normal for girls to go through at least 10 pregnancies in a lifetime -start in early teens
• 1 in 3 fistulas involve the rectum as well as the bladder -makes situations much worse
• Sometimes you cant operate right away because women are so weak
o Often women lie in bed for upwards of 6 months hoping to get better -muscle atrophies and joints become week
o Must make girls strong before you operate
• Yuhusba suffered from fistula for 12 year because she didn't think anything could be done. She wasn't as fortunate as Wubbit, who only had to suffer for 5 months.
|Ina May Gaskin||
- Midwifery farm school
- Ina May developed the Gaskin Maneuver. The first obstetrical maneuver to be named after a midwife, it embodies the essence of midwifery by using simple body movements to facilitate a difficult birth.
- Founder and director of the Farm Midwifery Center, located near Summertown, Tennessee. Founded in 1971, by 1996, the Farm Midwifery Center had handled more than 2600 births, with remarkably good outcomes.
- Her promotion of a low-intervention but extremely effective method for dealing with one of the most-feared birth complications, shoulder dystocia, has resulted in that method being adopted by a growing number of practitioners. The Gaskin maneuver is the first obstetrical procedure to be named for a midwife. Her statistics for breech deliveries and her teaching video on the subject have helped to spark a reappraisal of the policy of automatically performing cesarean section for all breech babies. As the occurrence of vaginal breech births has declined over the last 25 years, the knowledge and skill required for such births have come close to extinction.
|Nerve that transmits all labor pains||
What is Pundendial Nerve
|Grantly Dick Reed||
- A British obstetrician who is regarded by many as the father of natural childbirth movement.
- He dedicated his life to educating expectant parents about the benefits of giving birth naturally, with as little intervention from obstetricians and health professionals as possible. Much of the pain in childbirth, he argued, came from society's attitude towards childbirth, which often emphasized the pain.
|Major twilight drugs & side effects||
Ether and chloroform
|3 Components of Pain||
a. "nociception"= the neural processes of encoding and processing an actually or potentially tissue damaging event
2. Emotional Response of Individual
3. Social Response of Others
originates in the heart and is a form of pump failure
two basic kinds
• heart failure
• massive shutdown of heart from pulmonary embolism
o blood clot in peripheral circulation that migrates to heart and lungs*******
o most common reason for maternal death in industrialized countries
o clot that moves from body into heart and through right atria and ventricle and gets stuck in an arteriole in the lung
- > 100 mmHg for BP
- Proteinuria is ++ or >
-Vision Changes (bluriness)
-Abdominal Pain (right upper quadrant)
-Lowered Urine Output (indication that kidneys are becoming involved)
-Increased Creatinine (indication of kidney function)
-Lowered platelet count (platelets are getting chewed up by the turbulence in the blood vessels)
-Increased Bilirubin (pigment that makes blood cells red- turbulence breaks up pigments resulting in jaundice and dark urine)
-Increased liver enzymes
-IUGR (Intrauterine growth restriction) (reaction of crappy placenta)
- Pulmonary Edema
|Arnold Van Gennep||
Les Rites de Passage
• Having a baby is one of the main rites of passage for a woman
• Childbirth in aggregate- most women will deliver their babies without too much difficulty
|TBA Study: Ghana||
• TBAs are older women with poor education and stamina
• Only did a few deliveries each year
• Despite of attempts to educate TBAs, they continued to not send women to hospitals when they needed to be sent
o Used herbal remedies
• Very limited experience with complicated, high-risk deliveries
• When TBAs DID refer women, they often didn't go because they lacked confidence in the institution or feared that they would be treated poorly because they were from a rural area
|Abnormal Kidney Function and P-E||
o Normal Pregnancy
o Filtration rate and blood flow to kidney both increase
o Pre-Eclamptic Pregnancy
o Both drop
o Explain why Creatinine goes up
o Falling GFR and progressive damage to vessels involved in the kidneys as well
o Normally if kidney function goes down, you fill up with fluid and its all better
o With pre-eclamptic patients, the kidney isn't going to filter the fluid, its just going to stay there and possibly leak out into organs etc.
o Protein increases
o Shows inability of kidneys to reabsorb at the end of filtration process
|Maternal Mortality Rate||
• Number of deaths per 100,000 women of reproductive age
• Reproductive Age= 14-45
• Very difficult to get rate because it is very difficult to know # of women of reproductive age
|What are the KIDNEY/RENAL manifestations of shock?||
If not perfusing kidneys adequately, amount of urine produced is decreasing → eventually low to no urine output at all
|A lag time of __ between the slowing of labor and need for intervention is probably safe and wont compromise fetus or mother||
|3 Factors that affect dystocia||
-Powers- Mechanical forces involved in expulsion
-Passage- Birth canal, boney framework through which the baby needs to be delivered and the surrounding soft tissues
-Passenger- The fetus and its presentation, size etc
|Soft tissue abnormalities||
- Usually refers to excess fat
- Obese women often have difficult labors because there is too much fat and not enough room for the baby to get through the birthing canal
|Origins of Labor Pain||
- First Stage = lower uterine distension and stretching of cervix
- Later Stages = Stretching of vagina/ pelvic floor and perineum
- Fetus birth weight is > 4500 grams (9.92 lbs)
- 5 % of U.S. births -including me!
- Usual from...
o Big Parents (weight wise or bone structure wise)
o Birth order (babies get bigger with successive pregnancies)
o Having previous fat baby births
|Parts of Forceps||
• Parts that look like salad tongs → blades
o Sephalic Curve → goes around fetal head
o Pelvic Curve → go up inside the pelvis
• Tip is called the toe
• End of blade is called the lock
• Long thin part is called shank
• Pulls at appropriate curve
|Dangers of Breech Presentation||
1. Head (widest diameter) comes out last. So if cervix is not fully dilated, the head might get trapped, which could cause neck/spinal injuries with attempted delivery
2. Umbilical cord is in an unfavorable position because the baby's head can press on the cord (its oxygen supply) and become asphyxiated
3. Higher chance of prematurity and fetal congenital abnormalities
4. Higher fetal morbidity rate (probably because of higher rate of operative delivery)
|What is the treatment for hemorrhagic shock?||
-Stop the bleeeding
-Increase blood volume
|What Causes Eclampsia: The Worm Theory||
• Hydatoxa lualba
• Women with pre-eclampsia have a parasite -universal finding in the blood of women with pre-eclampsia but no one could replicate the study...where are the parasites?
• Parasite was actually glove dust! Womp womp.
|What are the VASCULAR manifestations of shock?||
Low low low hematocrit
|What are the CARDIOVASCULAR manifestations of shock?||
Blood pressure falls: low, even non detectable blood pressure
Rapid pulse: Heart beats faster to make up for low B.P.
But pulse will be "thready" and weak
|Late Maternal Death||
Death of a woman who has been pregnant between 43 days and 1 year after the termination of a pregnancy.
|Bodily Responses to Sepsis: SIMPLE SEPSIS||
Systematic response of body to infection, manifested by at least two or more of the following conditions as a result of the infection:
a. Fever of 38 C (104 F)
b. HR > 90
c. Respiratory Rate > 20 breaths per minute
d. Increased WBC count on a peripheral smear (12,000 WBC)
|Disadvantages of vantouse over forceps||
• Less force
• Suction cup isn't entirely benign
• Used to be made out of metal → could pull the scalp off a babies head
|Metaphorical viewing of the Jesus' birth narrative||
• Immaculate conception → affirms that the teachings of Jesus came from GOD. In the life and teaching of Jesus, something divine is present
• Star → Story of light in our personal darkness. Jesus is the light of the world that enlightens every person. Story of enlightenment, not daytime and nighttime
• Wise men → Affirms that Jesus is the light for ALL nations, not just Israel
• Shepherds → The first who find out about Jesus' birth. Good news is especially for the marginalized members of society
• Song of the angels → Implication is rather astonishing. The emperor of Rome, Caesar Augustus, is therefore NOT the Lord and savior as Roman ideology claimed
• Main reason Christians got into trouble with Roman authorities was because they were thought of as traitors to the state who did not accept the divine nature of Augustus and the Roman gods.
• Going to Egypt → Jesus is like a new Moses, and a new exodus is about to happen
o The metaphorical nature of these stories is the reason they have persisted for so long.
|Kuhna Birthing Theory||
- Muu = the spirit in charge of childbirth and fetal development of the uterus
- Purba = soul of a pregnant woman
o Each organ has a Purba that is essential for its proper functioning
- During a difficult childbirth, the Muu has captured the Purba and the Shaman has to venture to the supernatural world to take back the Purba so that delivery can commence
|Evolutionary Reasons for Labor Pain (3)||
1. Females gain survival and reproductive advantages through pain
2. Pain warns women to get to a safe place for birth
3. Provides a signal to bring others to her side to provide emotional and physical support
|Criteria for Diagnosing Hypertensive Disorder||
- BP= 140/90 or greater
- Edema (least important because 1/3 of women get this when they are pregnant) -if she cant put on rings, it is an issue
- Proteinuria --> 300 mg of protein in a 24 hr supply (but variable) (only 10% of women develop P-E without proteinuria)
|"Duniya Mace Da Ciki Ce"||
the world is like a pregnant woman, don't know what you are going to get
Things can change at any minute, you never know whats going to happen
|Birth of Jesus of Nazareth||
o "Christ" - means "anointed" or the "chosen one", it's not a last name dummy.
o Jesus was conceived by the spirit of GOD and the virgin Mary
o Importance of the birth of Jesus for early Christians
• For early Christians, birth isn't important at all
• Miraculous stories don't start appearing until later Christians
• Story probably emerged after a lot of the stories of miraculous birth from above.
o Paul, writer of New Testament, makes not reference to Jesus' birth. What matters to Paul is the death of Jesus and his reported resurrection
o If you got to the earliest gospel in the New Testament (of 4), written by Mark, you will find no mention of Jesus' birth (60 A.D.). Only in the 2nd and 3rd gospels do you find birth narratives about Jesus (Matthew and Luke).
• Problem: the two accounts are different! Very different.
o In the 4th gospel, according to John, the birth narrative is missing too.
• John says that Jesus is GOD in the flesh.
• HUGE transformation
• "logos" → reason that rules the universe.
o Isaiah 12:14 → birth narrative discrepancies
• "Almah" in Torah means young woman → lay men could no longer speak Hebrew so the Torah had been translated into a Greek document call Septuagint and they translate as "pathemos" which not only means young woman, but also virgin.
• Hebrew text does not require for there to be a virginal conception.
• ---MISSED 10 MINUTES TO PEE---
o Infancy Gospel of James
• Reports to have been written by James right after the death of King Herrod. James is the brother of Jesus.
• Probably written some time in the 2nd century after the birth of Jesus
• Mixes information from the first 2 birth narrative gospels and adds his own spice
• "Popularizing gospel" to promote the extraordinarily virtuous nature of Mary
|how is the partograph TECHNOLOGY||
o Needs to be accompanied by a training program if its going to be effective
|WHEN TO USE FORCEPS:||
• Head must be engaged, ought to be engaged deep in the pelvis
• Fetus must be head first
• Must know precisely where fetal head is so you can apply forceps correctly
• Cervix must be completely effaced and dilated
• Membranes must be ruptured
• No boney obstruction to delivery
|(+) of TBA....why is it important to collaborate with them?||
• Most TBAs have altruistic motivation
• Try to get them to stop doing things that are directly harmful
• Get pregnant women to get pre-natal care
o Introduces women to medical care
• Train TBAs on early warning signs of complications
• Encourage family planning and clean delivery environments
|Acute Pyelonephritis and how to treat||
• UTI infection that moves up the bladder to the kidneys, entering the body's blood system
• Most common serious medical complication of pregnancy
o 1-2% of all pregnant women
o 85,000 women are hospitalized each year
o More common in later ½ of pregnancy, when uterus is larger
o 50% of cases involve right kidney
o 25% involve left
o 25% involve both
• Because pregnant uterus tips to right side because of the location of the sigmoid colon and puts more pressure on the right pelvis and affects urine flow more on that side
o 15-20% go on to have Bacteremia and sepsis
• Goes to lungs and can develop pneumonia or respiratory failure
• How to Treat
o Intravenous antibiotics
• 1-2 weeks
• Emergency, must be treated quickly and aggressively
|Difficult Labor With No Intervention Leads To...||
(1) Uterus becomes so tired from hard contractions that the uterus ruptures
• Chances are, woman and fetus will die
• More common in women who have had multiple pregnancies or previous c-section delivery
(2) Labor goes on so long that woman gets infected, bleeds to death or dies of exhaustion with the fetus still inside of her
(3) Labor goes on so long that after a few days, the fetus dies inside the mother and starts to decay inside the mother and begins to soften up and slides out as a stillbirth.
|Birth of Alexander the Great||
o Son of the King of Macedonia, King Phillip
o Most renowned military leader of his time, potentially in all of history
o Descendent of Hercules, on fathers side and Pericles on mother's side (know for exam)
o Olyimpus fell in love with and married Phillip and had a dream about a lightening bolt before they were married
|How does HBP increase the risk of a fetus dying or becoming ill||
HBP in mother interferes with profusion of placental bed in uterus so that placenta doesn't function as well
|Some reasons for hemorrhagic death after delivery...just have a field day with this one, im getting tired||
o Lose a lot of blood during labor/ Cesarean
• 500 cc to one liter (C/S)
o anemia if you lose a lot of blood
o 2% of deliveries require a blood transfusion during delivery
o could get a laceration on cervix or in vagina from forceps or otherwise
o young girl in false labour, went home.
• 6 hours later came back bleeding a lot, about to have a baby
• cervix was completely split from cervical os up to uterus on both sides
• grandmother at home made her push for 6 hours when she wasn't even in labor yet
o prolonged obstructed labor, uterus ruptures and fetus and placenta get expelled into abdomen. Woman will die if she doesn't have surgery
o placenta doesn't separate
o normal way that women don't bleed to death is for uterus to contract down over placental site. Muscle fibers close off spiral arterioles that have been feeding placenta
o if someone is bleeding after delivery → make uterus contract!
• Massage internally, externally
• Give oxytocin
• Other hormonal injections
• Breastfeeding → oxytocin release
o Turn uterus inside out during delivery → won't contract properly
o Misoprostel is a drug that can be inserted into the vagina or rectum that causes vigorous uterine contractions.
• Can be misused: do not want to give to a laboring woman
• Fairly efficient way of causing abortions in early pregnancy
|Robert Felkin, January 1884 - "Notes on Labor in Central Africa"||
• Got woman drunk
• Rapid cut that went through all layers
• Removed child
• Hot caudery to stop bleeding points
• Gave uterus a squeeze or two
• Dilated cervix to let fluids drain
• Cleared uterus of clots and placenta, tried to keep intestines in
• Grass mat over wound, to drain out fluids
• Then seven pins, banana leaf, and firm bandage/cloth
• 10 days after, not much milk
• 1 pin removed on third morning, 2 more on 5th, rest on 6th. Redressed wound etc
• wound entirely healed 11 days after operation
• pretty good operatives, at least as good as would have gone on at the same time in England or the USA
|How do we account for couvade as a ritualistic practice?||
o Tyler suggested it was a technique concerned with the protection of those most involved with childbirth.
• There is some kind of spiritual connection between the parents and the child and the actions of one could supernaturally affect the other.
• Fool evil influences into attacking the father instead of the mother because father is less vulnerable. Therefore leaves mother safe to care for newborn child.
• Spirits must be pretty stupid.
|Why might it be a good idea to rupture the amniotic membrane if you pass the alert line?||
• If we rupture the membranes we find that prostaglandins are synthesized in amniotic membranes and there is a release of them when the membranes are ruptured that stimulate uterine contractions.