The two most common types of episiotomy are the midline episiotomy and the mediolateral episiotomy.

There has been significant debate about the advantages and

disadvantages of these two types of episiotomy. In the U.S., midline episiotomy is by far
more common, while medio-lateral episiotomies are more common in and other parts of the
world.
Midline Episiotomy
A midline episiotomy refers to an episiotomy where the incision of the vaginal opening is
directly in the midline, straight down toward the anus. The advantages of a midline
episiotomy include easy repair and improved healing. This type is also less painful and is
less likely to result in long-term tenderness or problems with pain during intercourse. There
is often less blood loss with a midline episiotomy. The main disadvantage of a midline
episiotomy is the likelihood for this type of incision to extend (continue tearing) and involve
the anal sphincter or the lining of the rectum. When this happens, injury to the sphincter can
result in long-term problems, such as fecal incontinence or the development of a rectovaginal fistula (a small channel that connects the rectum with the vagina).
Medio-Lateral Episiotomy
A right medio-lateral episiotomy begins at the vaginal opening in the midline with the
incision directed toward the right buttocks at a 45-degree angle. The main advantage of the
medio-lateral episiotomy is that it is less likely to extend into or involve the anal sphincter
and the rectum. Disadvantages of the medio-lateral episiotomy are significant and include
increased blood loss, increased pain, difficult repair, and an increased risk of long-term
discomfort, especially during intercourse.
First trimester screening is a combination of fetal ultrasound and maternal blood testing
done during the first trimester of pregnancy. This screening process can help to determine
the risk of the fetus having certain birth defects. Screening tests may be used alone or in
combination with other tests.
There are 3 parts of first trimester screening:

Ultrasound test for fetal nuchal translucency (NT). Nuchal translucency

screening uses an ultrasound test to examine the area at the back of the fetal neck
for increased fluid or thickening.

Two maternal serum (blood) tests. The blood tests measure two substances
found in the blood of all pregnant women:
o

Pregnancy-associated plasma protein screening (PAPP-A)--a protein

produced by the placenta in early pregnancy. Abnormal levels are associated
with an increased risk for chromosome abnormality.

Human chorionic gonadotropin (hCG)--a hormone produced by the

placenta in early pregnancy. Abnormal levels are associated with an increased
risk for chromosome abnormality.

When used together as first trimester screening tests, nuchal translucency screening and
maternal blood tests have a greater ability to determine if the fetus might have a birth
defect, such as Down syndrome (trisomy 21) and trisomy 18.
If the results of these first trimester screening tests are abnormal, genetic counseling is
recommended. Additional testing such as chorionic villus sampling, amniocentesis, cell-free
fetal DNA, or other ultrasounds may be needed for accurate diagnosis.
Second trimester prenatal screening tests
Second trimester prenatal screening may include several blood tests, called multiple
markers. These markers provide information about a woman's risk of having a baby with
certain genetic conditions or birth defects. Screening is usually done by taking a sample of
the mother's blood between the 15th and 20th weeks of pregnancy (16th to 18th is ideal).
The multiple markers include:

Alpha-fetoprotein screening (AFP). This blood test measures the level of alphafetoprotein in the mothers' blood during pregnancy. AFP is a protein normally
produced by the fetal liver and is present in the fluid surrounding the fetus (amniotic
fluid), and crosses the placenta into the mother's blood. The AFP blood test is also
called MSAFP (maternal serum AFP).
Abnormal levels of AFP may signal the following:
o

Open neural tube defects (ONTD), such as spina bifida

Down syndrome

Other chromosomal abnormalities

Defects in the abdominal wall of the fetus

Twins--more than one fetus is making the protein

A miscalculated due date, as the levels vary throughout pregnancy

hCG. This is human chorionic gonadotropin hormone (a hormone produced by the

placenta)

Estriol. This is a hormone produced by the placenta

Inhibin. This is a hormone produced by the placenta

An amniocentesis is a procedure used to obtain a small sample of the amniotic fluid that
surrounds the fetus to diagnose chromosomal disorders and open neural tube defects
(ONTDs), such as spina bifida. Testing is available for other genetic defects and disorders
depending on the family history and availability of laboratory testing at the time of the
procedure. An amniocentesis is generally offered to women between the 15th and 20th
weeks of pregnancy who are at increased risk for chromosome abnormalities, such as
women who are over age 35 years of age at delivery, or those who have had an abnormal

maternal serum screening test, indicating an increased risk for a chromosomal abnormality
or neural tube defect.
Chorionic villus sampling (CVS) is a prenatal test that involves taking a sample of some of
the placental tissue. This tissue contains the same genetic material as the fetus and can be
tested for chromosomal abnormalities and some other genetic problems. Testing is available
for other genetic defects and disorders depending on the family history and availability of
laboratory testing at the time of the procedure. In comparison to amniocentesis (another
type of prenatal test), CVS does not provide information on neural tube defects such as
spina bifida. For this reason, women who undergo CVS also need a follow-up blood test
between 16 to 18 weeks of their pregnancy, to screen for neural tube defects. During late
pregnancy and during labor, your doctor may want to monitor the fetal heart rate and other
functions. Fetal heart rate monitoring is a method of checking the rate and rhythm of the
fetal heartbeat. The average fetal heart rate is between 110 and 160 beats per minute. The
fetal heart rate may change as the fetus responds to conditions in the uterus. An abnormal
fetal heart rate or pattern may mean that the fetus is not getting enough oxygen or there
are other problems. An abnormal pattern also may mean that an emergency or cesarean
delivery is needed. An ultrasound scan is a diagnostic technique which uses high-frequency
sound
waves to create an image of the internal organs
A complete blood count (CBC) is a blood test used to evaluate your overall health and detect
a wide range of disorders, including anemia, infection and leukemia.
A complete blood count test measures several components and features of your blood,
including:

Red blood cells, which carry oxygen

White blood cells, which fight infection

Hemoglobin, the oxygen-carrying protein in red blood cells

Hematocrit, the proportion of red blood cells to the fluid component, or plasma, in
your blood

Platelets, which help with blood clotting

Abnormal increases or decreases in cell counts as revealed in a complete blood count may
indicate that you have an underlying medical condition that calls for further evaluation.
A platelet count is often ordered as a part of a complete blood count (CBC), which may be
done at the time of a routine health examination.
It may be ordered when a person has signs and symptoms associated with low platelets or
a bleeding disorder, such as:

Unexplained or easy bruising

Prolonged bleeding from a small cut or wound

Numerous nosebleeds

Gastrointestinal bleeding (which can be detected in stool samples)

Heavy menstrual bleeding

Small red spots on the skin called petechiaemay sometimes look like a rash

Small purplish spots on the skin called purpura, caused by bleeding under the skin

Testing may also be done when it is suspected that an individual has too many platelets. An
excess of platelets can cause excessive clotting or sometimes bleeding if the platelets are
not functioning properly. However, people with too many platelets often have no signs or
symptoms, so the condition may be found only when a platelet count is done as part of a
health check or for other reasons.
There are several different HBV tests. These are the HBV tests most commonly done:

Hepatitis B surface antigen (HBsAg) is the earliest sign of an active hepatitis B

infection. This antigen may be present before symptoms of an HBV infection are
present. If this antigen is present for more than 6 months, then you probably have a
chronic (long-term) HBV infection. This means you can spread HBV to others
throughout your life.

Hepatitis B surface antibody (HBsAb) usually appears about 4 weeks after HBsAg
disappears. The presence of this antibody means that the infection is at the end of its
active stage and you cannot pass the virus to others (you are no longer contagious).
This antibody also protects you from getting HBV again in the future. The test is done
to determine the need for vaccinationthe antibody will be present after receiving
the HBV vaccine series, showing that you have protection (immunity) from the virus.
Occasionally your test may show that you have both the HBsAb antibodies and
HBsAg antigen. In this case you are still contagious.

Hepatitis B e-antigen (HBeAg) is an HBV protein that is only present during an

active HBV infection. This test determines how contagious you are. Testing for this
antigen can also be used to monitor the effectiveness of treatment for HBV.

HBV DNA testing checks for genetic material (DNA) from the hepatitis B virus. The
HBV DNA tests measure how much genetic material is present. A high level of HBV
DNA means that the virus is multiplying in your body and you are very contagious. If
you have a chronic HBV infection, an elevated viral DNA level means you are at an
increased risk for liver damage and may want to consider treatment with antiviral
medicine. Testing for HBV DNA is also used to check the effectiveness of treatment
for long-term (chronic) HBV infection. HBV DNA testing is a more sensitive test than
HBeAg (above) for detecting HBV in the blood.

ALL pregnant women should be screened for hepatitis B before delivery.

It is crucial to identify pregnant women who have hepatitis B in order to protect
their unborn child from the virus.

Testing is especially important for women who fall into a high-risk group. This
could be due to a woman's ethnic background, occupation, or lifestyle.

If a woman tests negative for hepatitis B, then vaccination can be considered if

she is at high risk for an infection. A woman could be at high-risk because of her job, sex
partner, and/or lifestyle choices. According to the CDC, the hepatitis B vaccine can be given
safely to pregnant women and it does not appear to have any adverse effect on the developing
fetus.

If a woman tests positive for hepatitis B, then it is important to protect her

newborn from exposure to the virus. 90% of infants exposed to the hepatitis B virus at
birth will develop life-long chronic infections.
The urinalysis is used as a screening and/or diagnostic tool because it can help detect substances or cellular material
in the urine associated with different metabolic and kidney disorders. It is ordered widely and routinely to detect any
abnormalities that require follow up. Often, substances such as protein or glucose will begin to appear in the urine
before people are aware that they may have a problem. It is used to detect urinary tract infections (UTIs) and other
disorders of the urinary tract. In those with acute or chronic conditions, such as kidney disease, the urinalysis may be
ordered at intervals as a rapid method to help monitor organ function, status, and response to treatment.

BLEEDING COMPLICATIONS: LATE PREGNANCY

Placenta Previa
Placenta previa occurs when the placenta implants in the lower portion of the uterus by the
internal cervical os. Previas are classified according to the degree to which they cover the
os. Specifically, if the lower border of the placenta is close to, but does not quite reach, the
internal cervical os, the previa is considered marginal. If the placenta partly covers the
internal os, the previa is considered a partial placenta previa. The previa is considered a
total previa if the placenta completely covers the internal cervical os (see illustration). As
the pregnancy nears term and the cervix dilates, the placenta implanted near or over the
internal cervical os is disrupted and bleeding can occur. TBLEEDING COMPLICATIONS:
LATE PREGNANCY
INCIDENCE AND RISK FACTORS
The most recent systematic review of placenta previa found that prevalence ranged from 3.5
to 4.6 per 1,000 births (Faiz & Ananth, 2003). There are several factors that place patients at
risk for a placenta previa:

Advanced maternal age

Cesarean section

Smoking or drug use (e.g., cocaine)

Previous placenta previa

Uterine scarring (e.g., endometriosis)

InduAbruptio placentae occurs in 1 in 200 deliveries (Cunningham et al., 2009). Aside

from abruptions occurring as a result of trauma, the cause of abruptio placentae is

largely unknown. However, there are several factors that place patients at risk for an
abruption.

Drug use (e.g., cocaine)

Alcohol abuse

Cigarette smoking

Hypertension

Diabetes mellitus

Advanced maternal age

Multiparity and multiple pregnancy

History of abruptio placentae

Thromboembolic disorders

Premature rupture of membranes (PROM)

Abdominal trauma (e.g., accident, violence)

ced or spontaneous abortion

Maternal and Fetal Implications

Patients with hyperemesis gravidarum frequently become dehydrated and may have metabolic acidosis
as a result of starvation. In addition, patients may become alkalotic from a loss of hydrochloric acid during
vomiting. Electrolyte imbalances such as hypokalemia and vitamin deficiencies are also common in
patients with hyperemesis gravidarum. Ultimately, long-term nausea and vomiting can cause renal and/or
gastrointestinal impairment in the pregnant patient.
Dehydration occurring from hyperemesis gravidarum may result in preterm labor, which can negatively
impact the fetus. In addition, dehydration impairs placental perfusion and affects nutrient intake and
oxygenation of the fetus. Moreover, due to the severe nausea and vomiting associated with hyperemesis,
poor maternal nutrient intake is common and fetal growth may be compromised, causing low-birth-weight
infants.
. GESTATIONAL DIABETES MELLITUS
Gestational diabetes mellitus occurs with the onset of pregnancy and is characterized by the
inability of the pregnant patient to tolerate glucose. Patients who develop gestational
diabetes may develop diabetes later in life. However, gestational diabetes often resolves
after delivery. The cause of gestational diabetes is largely unknown. However, it is believed
that as the fetus grows, glucose demands increase for the pregnant patient. In addition, the
insulin-antagonistic properties of placental hormones affect the patient by causing insulin

resistance (Lowdermilk & Perry, 2010). As a result, the pregnant patient is unable to process
glucose in the body and hyperglycemia occurs.
AMNIOTIC MEMBRANE COMPLICATIONS
Premature rupture of membranes (PROM) refers to the rupture of membranes one hour
or more before the onset of labor, whereas preterm premature rupture of
membranes (PPROM) refers to the rupture of membranes prior to 37 weeks gestation.
PROM and PPROM are often associated with preterm labor and birth.
Incidence and Risk Factors
Preterm premature rupture of membranes (PPROM) occurs in 3% of pregnancies and is the
cause of one third of preterm deliveries (Medina & Hill, 2006). Premature rupture of
membranes (PROM) occurs in 3% to 18% of all pregnancies (Brown, 2000). Risk factors for
preterm premature and premature rupture of membranes include:

Infections, such as sexuality transmitted infections (STIs)

Prematurely dilated cervix

Hydramnios

Multiple pregnancy

Fetal malpresentation

maternal nutrional deficiencies

stress