CEPHALHEMATOMA Definition Cephalhematoma is a collection of blood between the periosteum of a skull bone and the bone itself.

It occurs in one or both sides of the head. It occasionally forms over the occipital bone. The swelling with cephalhematoma is not present at birth rather it develops within the first 24 to 48 hours after birth. Causes 1. upture of a periostal capillary due to the pressure of birth 2. Instrumental delivery Signs and Symptoms 1. !welling of the infant"s head 24#48 hours after birth 2. $iscoloration of the swollen site due to presence of coagulated blood %. &as clear edges that end at the suture lines Management 1. 'bservation and support of the affected part. 2. Transfusion and phototherapy may be necessary if blood accumulation is significant Complication 1. (aundice

Difference bet een a Caput Succedaneum and Cep!al!ematoma I)$IC*T' ! /ocation -0tent of Involvement +eriod of *bsorption Treatment C*+,T !,CC-$*)-,. +resenting part of the head C-+&*/&-.*T'.* +eriosteum of skull bone and bone

1oth hemispheres2 C '!!-! the Individual bone2 $'-! )'T suture lines C '!! the suture lines % to 4 days )one 3ew weeks to months !upport

Forceps Delivery
3orceps are instruments designed to aid in the delivery of the fetus by applying traction to the fetal head. .any different types of forceps have been described and developed. 4enerally5 forceps consist of 2 mirror image metal instruments that are maneuvered to cradle the fetal head and are articulated5 after which traction is applied to effect delivery. 3orceps have 4 ma6or components5 as follows7 1lades7 The blades grasp the fetus. -ach blade has a curve to fit around the fetal head. The blades are oval or elliptical and can be fenestrated 8with a hole in the middle9 or solid. .any blades are also curved in a plane :;< from the cephalic curve to fit the maternal pelvis 8pelvic curve9. !hanks7 The shanks connect the blades to the handles and provide the length of the device. They are either parallel or crossing. /ock7 The lock is the articulation between the shanks. .any different types have been designed. &andles7 The handles are where the operator holds the device and applies traction to the fetal head.

History
The history of obstetrical forceps is long and5 often5 colorful. !anskrit writings from appro0imately 1=;; 1C contain evidence of single and paired instruments2 -gyptian5 4reek5 oman5 and +ersian writings and pictures refer to forceps that were originally used for e0traction following fetal demise to save the mother"s life. The credit for the invention of the precursor of the modern forceps to be used on live infants goes to +eter Chamberlen of -ngland 8circa 1>;;9. .odifications have led to more than ?;; different types and shapes of forceps. In 1?4=5 @illiam !mellie described the accurate application to the occiput5 rather than the previously performed pelvic application5 regardless of the position of the head. In 184=5 !ir (ames !impson developed a forceps that was designed to appropriately fit both cephalic curvatures and pelvic curvatures. In 1:2;5 (oseph $e/ee further modified that instrument and advocated the prophylactic forceps delivery. In an era in which many women labored and delivered under heavy sedation5 forceps deliveries became common.

In current obstetrical practice5 the use of forceps has become much less common. Clinical studies performed before the 1:?;s suggested that the risk of fetal morbidity and mortality was higher when the second stage of labor e0ceeded 2 hours. A1B @ith contemporary obstetrical management5 morbidity rates no longer increase with longer labors if fetal surveillance is reassuring. Thus5 the length of the second stage of labor alone is no longer an absolute indication for operative termination of labor. 'ther factors were also at work to decrease the use of forceps deliveries. In particular5 the availability of blood products and greater choices in antibiotics helped make cesarean delivery a safe alternative to operative vaginal deliveries. In the 1:8;s5 information became available suggesting that some forceps deliveries 8midforceps deliveries9 may be associated with an increased risk of fetal morbidity5 though this issue remains controversial. These factors combined to greatly reduce the appeal of forceps delivery. Currently5 many obstetrical training programs in )orth *merica struggle to teach forceps delivery. +roblems include the lack of adeCuate personnel comfortable with teaching forceps#assisted vaginal deliveries5 changes in consumer attitudes5 and the demand for natural delivery. In addition5 many practitioners fear litigation if a forceps#assisted delivery results in a poor outcome.

"re#uency
The freCuency of operative vaginal deliveries is now estimated to be less than =D of all vaginal deliveries. .ost of these are vacuum deliveries with forceps deliveries comprising less than 1D of total deliveries. *ccording to 1ofill et al5 trained fellows of the *merican College of 'bstetricians and 4ynecologists 8*C'49 were more likely to be taught vacuum e0traction5 and they use vacuum e0traction as their instrument of choice for operative vaginal deliveries. A2B @hen forceps deliveries are performed5 !impson forceps 8see image below9 is the instrument most commonly used for outlet# and low#forceps deliveries. 'ther types of forceps are also available2 one specialiEed type is the +iper forceps5 which is used in the delivery of the after# coming head in breech vaginal deliveries. It is designed to decrease traction on the fetal neck during breech delivery. .ultiple other types of forceps have been designed to rotate the fetal head or for unusual maternal pelvic or fetal head shapes. 3or detailed information on other forceps procedures5 the reader is directed to the book Dennen's Forceps Deliveries.A1B Indications for operative vaginal deliveries are identical for forceps and vacuum e0tractors. )o indication for operative vaginal delivery is absolute. $ndications The following indications apply when no contraindications e0ist7 +rolonged second stage7 This includes nulliparous woman with failure to deliver after 2 hours without5 and % hours with5 conduction anesthesia. It also includes multiparous woman with failure to deliver after 1 hour without5 and 2 hours with5 conduction anesthesia. !uspicion of immediate or potential fetal compromise in the second stage of labor. !hortening of the second stage for maternal benefits7 .aternal indications include5 but are not limited to5 e0haustion5 bleeding5 cardiac or pulmonary disease5 and history of spontaneous pneumothora0. In skilled hands5 fetal malpositions5 including the after#coming head in breech vaginal delivery5 can be indications for forceps delivery. +rereCuisites for forceps delivery include the following7 The head must be engaged. The cervi0 must be fully dilated and retracted. The position of the head must be known. Clinical assessment of pelvic capacity should be performed. )o disproportion should be suspected between the siEe of the head and the siEe of the pelvic inlet and mid pelvis.

The membranes must be ruptured. The patient must have adeCuate analgesia. *deCuate facilities and supportive elements should be available. The operator should be competent in the use of the instruments and the recognition and management of potential complications. The operator should also know when to stop so as not to force the issue. The forceps has been used in delivering babies for about 400 years. The instrument consists of two separate thin steel blades with inner surfaces curved to fit the sides of the infants head. The blades are inserted separately into the vagina, opposite each other. When their handles are brought together, the childs head is securely grasped between the blades. With moderate traction on the handles, exerted in the axis of the vagina, the head is delivered. The word forceps in Latin means a pair of tongs.! "t is said to have been derived from the earlier Latin words fornus # oven and capere # to ta$e. The obstetric forceps, in variations of its modern form, have been used since the early seventeenth century to deliver a living child without in%ury to it or to the mother. &rior to this, single'bladed and even doublebladed instruments, called hoo$s, were in use, but probably only for the extraction of a dead child. The old double'bladed instruments had a permanent articulation so that the blades could not be inserted separately. They loo$ed li$e ice tongs.
"orceps% An $ntroduction To "orceps Deli&ery 3orceps refers to a device that you use in your hand to grip or take hold of something. The basic idea behind the structure of forceps is akin to tongs5 pincers and tweeEers. !ome forceps are specifically designed for use in surgery and other medical procedures. These are known as surgical forceps. There was a time when these were used freCuently for childbirth. Till the later part of last century5 forceps delivery was a common thing. &owever5 in recent years5 it has lost its popularity because of forceps complications. Different Types Of Surgical Forceps 3orceps are very useful for surgeons when they are in surgical theater. ,se of forceps is perfectly hygienic when it comes to handling the needles5 tissues and dressings. &owever5 a surgeon has to use various types of forceps to handle different things. 3or e0ample5 siEe of dressing forceps is larger while tissue forceps are designed in such a way that it does not apply much pressure on tissues because of smaller teeth. Brief Description Of Forceps Delivery &ere is a brief description of how forceps are used for childbirth. 1efore you begin the process make sure that the cervi0 is fully dilated and empty the bladder. 3irst of all the e0pectant mother is placed in lithotomic position. * very light dose of anesthesia is given to help in pain control. 3eel the posterior

fontanel to know about the e0act position of fetal head. )ow the surgeon inserts two forceps in such a way that the head of the baby is locked. !ometimes the fetal head is not in the e0act occipital anterior position where it should have been so you may have to turn it around. 3inal delivery takes place 6ust after episiotomy has been performed. What Are The Indicating Factors? Fou may have to choose forceps delivery in the condition when in spite of all maternal attempts5 childbirth is not taking place. *rterial hypertension and fetal or maternal distress are also indicating factors. 1efore you go for this option you should understand that it has both advantages and disadvantages. The biggest advantage is that you do not have to go for caesarean. .oreover5 it takes less time than the caesarean. *nother benefit is that you can opt for it even when the head of baby is not at the right place. Understand The Ris s Associated With It Before Ta ing Any Decision There are many drawbacks also associated with the forceps deli&ery that you cannot ignore. 3irst one is that you have to be given anesthesia because episiotomy has to be performed. It can hurt the pelvic floor muscles besides many other internal tissues. !ome other negative aspects include anal fissure5 marks on the face of baby5 skull fracture5 nerve damage5 brain damage and cervical in6ury.

'()A$'* 8nalbuphine hydrochloride9 D+(, DESC+$PT$O' ),1*I) 8nalbuphine hydrochloride9 is a synthetic opioid agonist#antagonistanalgesic of the phenanthrene series. It is chemically related to both the widely used opioid antagonist5 nalo0one5 and the potent opioid analgesic5 o0ymorphone. Chemically nalbuphine hydrochloride is 1?#8cyclobutylmethyl9#45=G# epo0ymorphinan#%5>G514#triol hydrochloride. )albuphine hydrochloride molecular weight is %:%.:1 and is soluble in &2' 8%=.= mgHm/ I 2=JC9 and ethanol 8;.8D92 insoluble in C&Cl% and ether. )albuphine hydrochloride has pKa values of 8.?1 and :.:>. The molecular formula is C21&2?)'4L&Cl. The structural formula is7

),1*I) 8nalbuphine hydrochloride9 is a sterile solution suitable for subcutaneous5 intramuscular5 or intravenous in6ection. ),1*I) 8nalbuphine hydrochloride9 is available in two concentrations5 1; mg and 2; mg of nalbuphine hydrochloride per m/. 1oth strengths in 1; m/ vials contain ;.:4D sodium citrate hydrous5 1.2>D citric acid anhydrous5 and ;.2D of a :71 mi0ture of methylparaben and propylparaben as preservatives2 p& is ad6usted5 if necessary5 to %.= to %.? with hydrochloric acid. The 1; mgHm/ strength contains ;.2D sodium chloride.

),1*I) 8nalbuphine hydrochloride9 is also available in ampuls in a sterile5 paraben#free formulation in two concentrations5 1; mg and 2; mg of nalbuphine hydrochloride per m/. 'ne m/ of each strength contains ;.:4D sodium citrate hydrous5 and 1.2>D citric acid anhydrous2 p& is ad6usted5 if necessary5 to %.= to %.? with hydrochloric acid. The 1; mgHm/ strength contains ;.2D sodium chloride.

-HAT A+E THE POSS$)LE S$DE E""ECTS O" 'AL)(PH$'E .'()A$'/0

4et emergency medical help if you have any of these signs of an allergic reaction7 hives2 difficulty breathing2 swelling of your face5 lips5 tongue5 or throat. Tell your caregivers at once if you have any of these serious side effects7

weak or shallow breathing2 fast or slow heart rate2 cold5 clammy skin2 confusion5 hallucinations5 unusual thoughts or behavior2 severe weakness or diEEiness2 or feeling like you might pass out.

/ess serious side effects... $'D$CAT$O'S ),1*I) 8nalbuphine hydrochloride9 is indicated for the relief of moderate to severe pain. ),1*I) 8nalbuphine hydrochloride9 can also be used as a supplement to balanced anesthesia5 for preoperative and postoperative analgesia5 and for obstetrical analgesia during labor and delivery. DOSA,E A'D ADM$'$ST+AT$O' The usual recommended adult dose is 1; mg for a ?; kg individual5 administered subcutaneously5 intramuscularly or intravenously2 this dose may be repeated every % to > hours as necessary. $osage should be ad6usted according to the severity of the pain5 physical status of the patient5 and other medications which the patient may be receiving. 8!ee $nteraction it! Ot!er Central 'er&ous System Depressants under-A+'$',S9. In non#tolerant individuals5 the recommended single ma0imum dose is 2; mg5 with a ma0imum total daily dose of 1>; mg. The use of ),1*I) 8nalbuphine hydrochloride9 as a supplement to balanced anesthesia reCuires larger doses than those recommended for analgesia. Induction doses of ),1*I) 8nalbuphine hydrochloride9 range from ;.% mgHkg to % mgHkg intravenously to be administered over a 1; to 1= minute period with maintenance doses of ;.2= to ;.= mgHkg in single intravenous administrations as reCuired. The use of ),1*I) 8nalbuphine hydrochloride9 may be followed by respiratory depression which can be reversed with the opioid antagonist )* C*)M 8nalo0onehydrochloride9. ),1*I) 8nalbuphine hydrochloride9 is physically incompatible with nafcillin and keterolac. Patients Dependent on Opioids +atients who have been taking opioids chronically may e0perience withdrawal symptoms upon the administration of ),1*I) 8nalbuphine hydrochloride9 . If unduly troublesome5 opioid withdrawal symptoms can be controlled by the slow intravenous administration of small increments of morphine5 until relief occurs. If the previousanalgesic was morphine5 meperidine5 codeine5 or other opioid with similar duration of activity5 one#fourth of the anticipated dose of ),1*I) 8nalbuphine hydrochloride9 can be administered initially and the patient observed for signs of withdrawal5 i.e.5 abdominal cramps5 nausea and vomiting5 lacrimation5 rhinorrhea5 an0iety5 restlessness5 elevation of temperature or piloerection. If untoward

symptoms do not occur5 progressively larger doses may be tried at appropriate intervals until the desired level of analgesia is obtained with ),1*I) 8nalbuphine hydrochloride9 . +arenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit. S$DE E""ECTS The most freCuent adverse reaction in 1;>> patients treated in clinical studies with ),1*I) 8nalbuphine hydrochloride9 was sedation %81 8%>D9. /ess freCuent reactions were7 sweatyHclammy :: 8:D95 nauseaHvomiting >8 8>D95 diEEinessHvertigo =8 8=D95 dry mouth 44 84D95 and headache 2? 8%D9. 'ther adverse reactions which occurred 8reported incidence of 1D or less9 were7 C'S Effects% )ervousness5 depression5 restlessness5 crying5 euphoria5 floating5 hostility5 unusual dreams5 confusion5 faintness5 hallucinations5 dysphoria5 feeling of heaviness5 numbness5 tingling5 unreality. The incidence of psychotomimetic effects5 such as unreality5 depersonaliEation5 delusions5 dysphoria and hallucinations has been shown to be less than that which occurs with penta1ocine2 Cardio&ascular% &ypertension5 hypotension5 bradycardia5 tachycardia. ,astrointestinal% Cramps5 dyspepsia5 bitter taste. +espiratory% $epression5 dyspnea5 asthma. Dermatologic% Itching5 burning5 urticaria. Miscellaneous% !peech difficulty5 urinary urgency5 blurred vision5 flushing and warmth. Allergic +eactions% *naphylacticHanaphylactoid and other serious hypersensitivity reactions have been reported following the use of nalbuphine and may reCuire immediate5 supportive medical treatment. These reactions may include shock5 respiratory distress5 respiratory arrest5 bradycardia5 cardiac arrest5 hypotension5 orlaryngeal edema. !ome of these allergic reactions may be life#threatening. 'ther allergic# type reactions reported include stridor5 bronchospasm5 wheeEing5 edema5 rash5 pruritus5 nausea5 vomiting5 diaphoresis5 weakness5 and shakiness. E&ents Obser&ed during Post3mar4eting Sur&eillance of '()A$' .nalbup!ine !ydroc!loride/ % $ue to the nature and limitations of spontaneous reporting5 causality has not been established for the following adverse events received for ),1*I) 8nalbuphine hydrochloride9 7 abdominal pain5 pyre0ia5 depressed level or loss of consciousness5 somnolence5 tremor5 an0iety5 pulmonary edema5 agitation5 seiEures5 and in6ection site reactions such as pain5 swelling5 redness5 burning5 and hot sensations. $eath has been reported from severe allergic reactions to ),1*I) 8nalbuphine hydrochloride9 treatment. 3etal death has been reported where mothers received ),1*I) 8nalbuphine hydrochloride9 during labor and delivery. Drug Abuse And Dependence There have been reports of abuse and dependence associated with ),1*I) 8nalbuphine hydrochloride9 among health care providers5 patients and bodybuilders. There have been reported instances of psychological and physical dependence and tolerance in patients abusing ),1*I) 8nalbuphine

hydrochloride9 . Individuals with a prior history of opioid or other substance abuse or dependence may be at greater risk in responding to reinforcing properties of ),1*I) 8nalbuphine hydrochloride9 . *brupt discontinuation of ),1*I) 8nalbuphine hydrochloride9 following prolonged use has been followed by symptoms of opioid withdrawal5 i.e.5 abdominal cramps5 nausea and vomiting5 rhinorrhea5 lacrimation5 restlessness5 an0iety5 elevated temperature and piloerection.

Precautions
(se in Pregnancy .Ot!er T!an Labor/ !evere fetal bradycardia has been reported when ),1*I) 8nalbuphine hydrochloride9 is administered during labor. )alo0one may reverse these effects. *lthough there are no reports of fetal bradycardia earlier in pregnancy5 it is possible that this may occur. This drug should be used in pregnancy only if clearly needed5 if the potential benefit outweighs the risk to the fetus5 and if appropriate measures such as fetal monitoring are taken to detect and manage any potential adverse effect on the fetus. (se During Labor and Deli&ery The placental transfer of nalbuphine is high5 rapid5 and variable with a maternal to fetal ratio ranging from 17;.%? to 17>. 3etal and neonatal adverse effects that have been reported following the administration of nalbuphine to the mother during labor include fetal bradycardia5 respiratory depression at birth5 apnea5 cyanosis5 andhypotonia. !ome of these events have been life#threatening. .aternal administration of nalo0one during labor has normaliEed these effects in some cases. !evere and prolonged fetal bradycardia has been reported. +ermanent neurological damage attributed to fetal bradycardia has occurred. * sinusoidal fetal heart rate pattern associated with the use of nalbuphine has also been reported. ),1*I) 8nalbuphine hydrochloride9 should be used during labor and delivery only if clearly indicated and only if the potential benefit outweighs the risk to the infant. )ewborns should be monitored for respiratory depression5 apnea5 bradycardia and arrhythmias if ),1*I) 8nalbuphine hydrochloride9 has been used. CO'T+A$'D$CAT$O'S ),1*I) 8nalbuphine hydrochloride9 should not be administered to patients who are hypersensitive to nalbuphine hydrochloride5 or to any of the other ingredients in ),1*I) 8nalbuphine hydrochloride9 . CL$'$CAL PHA+MACOLO,5 ),1*I) 8nalbuphine hydrochloride9 is a potent analgesic. Its analgesic potency is essentially eCuivalent to that of morphine on a milligram basis. eceptor studies show that ),1*I) 8nalbuphine hydrochloride9 binds to mu5 kappa5 and delta receptors5 but not to sigma receptors. ),1*I) 8nalbuphine hydrochloride9 is primarily a kappa agonistHpartial mu antagonist analgesic. The onset of action of ),1*I) 8nalbuphine hydrochloride9 occurs within 2 to % minutes after intravenous administration5 and in less than 1= minutes following subcutaneous or intramuscular in6ection. The plasma half#life of nalbuphine is = hours5 and in clinical studies the duration of analgesic activity has been reported to range from % to > hours. The opioid antagonist activity of ),1*I) 8nalbuphine hydrochloride9 is one#fourth as potent as nalorphine and 1; times that of pentaEocine. ),1*I) 8nalbuphine hydrochloride9 may produce the same degree of respiratory depression as eCuianalgesic doses of morphine. &owever5 ),1*I) 8nalbuphine hydrochloride9 e0hibits a ceiling effect

such that increases in dose greater than %; mg do not produce further respiratory depression in the absence of other C)! active medications affecting respiration. ),1*I) 8nalbuphine hydrochloride9 by itself has potent opioid antagonist activity at doses eCual to or lower than its analgesic dose. @hen administered following or concurrent with mu agonist opioid analgesics 8e.g.5 morphine5 o0ymorphone5 fentanyl95 ),1*I) 8nalbuphine hydrochloride9 may partially reverse or block opioid#induced respiratory depression from the mu agonist analgesic. ),1*I) 8nalbuphine hydrochloride9 may precipitate withdrawal in patients dependent on opioid drugs. ),1*I) 8nalbuphine hydrochloride9 should be used with caution in patients who have been receiving mu opioid analgesics on a regular basis.