Abdominal Palpation in Pregnancy

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Abdominal Palpation in Pregnancy

Abdominal examination in pregnancy comprises of four steps such as

• Inspection
• Palpation 
• Percussion
• Auscultation

Preparation of the patient

• Ask the mother to empty the bladder
• Check height, weight and blood pressure of the mother
• Position the patient in supine position at an angle of 30 degree
• Provide privacy
• Expose the abdomen from below chest to symphysis pubis and keep a drape sheet to cover the abdomen when you are not examining her
• Stand on the right side of the mother and warm up your hands

Inspection

Remember 'SSSFU' during inspection of the abdomen which means size, scars, skin changes, fetal movements and umbilicus.

Size and shape of the uterus should be appropriate to the gestational age and symmetrical. It might be in round or ovoid in shape.

Transverse scars, laparoscopic or laparotomy scars indicates previous surgeries including LSCS.

Skin changes includes striae gravidarum, striae albicantes and linea nigra.  Striae gravidarum is caused by hormonal changes and appears early in prenancy.  Striae albicantes are stretch marks from previous pregnancies. Linea nigra is a dark coloured straight line from below chest to symphysis pubis.

Fetal movements are visible from 24 weeks which indicates viability.

Umbilicus  may become flattened.

Palpation

Before proceeding into palpation, measure abdominal girth in inches or centimeters by keeping a inch tape around the abdomen. Then, palpate the fundus by ulnar border of the left hand and measure the gestational weeks using fingerbreadth method. Up to umbilicus, it is to be considered as 24 weeks. Keep four fingers of right palm above the umbilicus and measure it by considering one finger width is one week.

To measure the fundal height, keep the inch tape from symphysis pubis to fundus. The fundal height in centimeters is equal to gestation weeks with a difference up to +/-3 cm.

1. Fundal grip- Palpate the superior border of the fundus by using palms of two hands determine the pole of the fetus.
2. Lateral grip- Palpate the lateral sides of the abdomen to determine the spine and limbs of the fetus. If the fetus lies at a right angle to the axis of the uterus, it is in a transverse lie. If the head and buttocks are palpable on lateral sides, it indicates the fetus is in a oblique lie.
3. Pelvic grip-Turns into foot end of the patient and move both of your hands from lateral sides to pubis. If the hands are converged, it indicates head is not engaged. If the hands are not converged, it indicates engaged head.
4. Pawlick grip-  Grasp the lower portion of the abdomen using the fingers and thumb of the right hand to feel the ballotment of the head, which indicates the floating head and the progress of the labour.

Percussion

This technique can be used in mothers with polyhydramnios.

Auscultation

Fetal Heart Sounds (FHS) can be heard by fetoscope/ stethescope/ hand held doppler monitor. The fetal heart rate is normally between 110 and 160 b.p.m.

Sahli's Acid Hematin Method

Sahli's Acid Hematin Method

Principle- The hydrochloric acid in the acid hematin solution converts the hemoglobin into acid hematin and the value is determined by matching with the color comparator

Article needed are:

• Pipette, marked at the 20 mm level
• Stirring rod
• Color comparator
• 0.1N Hydrochloric Acid Solution- Add 1 ml of concentrated HCL to 99 ml of distilled water
• Graduated tube with scale on two sides, percentage scale reads from 0 to 170 and gram scale reads from 0 to 24.
• Distilled water

Procedure

1. Pour 5 drops of 0.1N HCL solution in graduated tube.
2. Wear gloves and aspirate the blood from the finger tip with pipette up to 20 mm mark .
3. Pour blood into graduated tube and note the time.
4. Shake the tube well and add distilled water drop by drop until the color of the solution matches the color comparator. Stir it well using stirring rod.
5. After five minutes, read the result from the scale by noting the lower edge of the meniscus.
6. Finding are reported in gm per 100 ml of whole blood

Normal Values

Male- 14-16 gm/ 100 ml of whole blood

Female- 12-14 gm/100 ml of whole blood

Spinothalamic tract

(By Sauledeg (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons)

Why our left brain does control the right part of the body and our right brain controls the left part of the body?

The human brain separates into two cerebral hemispheres such as right and left, connected by corpus callosum. The human brain passes and receives information from different parts of the body through Mid-brain, Pons, Medulla and Spinal Cord. Regarding spinal cord, outer part consists of white matter and inner part is grey matter. A collection of nerve fibers that connects human body to brain is called tract. There are two types of tracts; corticospinal tract and spinothalamic tract. The tract begins from human brain and passes through the spinal cord to the body parts  is called as corticospinal tract. The tract begins from body parts and passes through the spinal cord to human brain is called spinothalamic tract. The spinothalamic tract divides into three order neurons called Neuron 1, Neuron 2 and Neuron 3.

When one feels touch or pain or temperature on right leg, the sensation passes to the right side of the spinal cord through dorsal nerve root ganglion (Nerve 1) and enters into the right side of the dorsal gray column of the spinal cord (Nerve 2). Then, it crosses to the left side of the gray column of the spinal cord, passes through the upper part of the white matter of left side of the spinal cord, comes out from the same side of the spinal cord, moves upwards through the medulla, pons, mid-brain (Nerve 3) and finally reaches in the left part of human brain (cerebral cortex). This tract is called as spinothalamic tract.

The left part of the human brain receives the sensation from the right leg through spinothalamic tract and as part of reply to the sensation; left sided brain sends the impulses to left part of spinal cord through the mid-brain, pons, medulla and crosses to right part of spinal cord. Finally, it comes out from the spinal cord and  reaches to right sided body parts, this tract is being called as corticospinal tract. An example of result of an impulse is withdrawal of leg from pain or temperature. Thus, the right side of the brain controls the left side of the body and the left side of the brain controls the right side of the body through the spinothalamic tract and corticospinal tract.

Pulse Polio Program 2015

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Pulse polio Program 2015

In India, the fight against polio was started by launching Expanded Program in Immunization (EPI) in 1978. This program was able to cover 40% of all infants. In 1985, Universal Immunization Program (UIP) was launched to cover all districts, despite of having around 28,000 reported cases in India. Meanwhile, World Health Organization has initiated Polio Eradication program in all countries in 1988.In 1995, India has launched Pulse Polio Program, with an aim to eradicate poliomyelitis by vaccinating all under five children at 100% with two doses in a year in addition to routine immunization schedule. Here, the 'pulse' means 'post resuscitation and initial utility in life saving efforts'.

To eradicate the polio, Govt. of India focuses on three strategies such as

• Routine immunization of infants with three doses of polio vaccine
• Supplementary Immunization activities (SIAs) including National Immunization Days (NIDs) to cover the entire country, Sub National Immunization Days (SNIDs) to cover some parts of the country and Mop-up activities to cover 100%.
• Surveillance and investigation of cases of Acute Flaccid Paralysis (AFP)

The main aim of NIDs to immunize the children at booths on the first day and follow up on missed children on the following two days. When a child comes for polio vaccine, health care provider enters the name and address and administers two drops of oral polio vaccine (0.1ml). It is considered as a single dose of vaccine and subsequently, child has to receive the second dose of vaccine in second round. Then, the health care provider marks the left little finger with black ink. 

On the following two days, the health care providers have to conduct house to house survey to immunize the missed cases on the spot and marks the house as "P" with white chalk in front of the house . If the house is locked or not receptive, they mark the house as "X" in front with an indication of revisit the house on coming days. This is for the implementation of mopping up strategy.

Vaccine Vial Monitor also plays a vital role in the program. It suggests the quality of vaccine by indicating the color changes of inner square to outer circle. If the inner square is in white color, the vaccine can be used. Otherwise, it has to be discarded.

The time to add the name of polio in the list of eradicated disease is near by. The Govt. of India has announced the dates of NIDs, first round on 18-01-2015 and second round on 22-02-2015. Let us intertwine our hands to push the name of polio to the pages of  small pox from the present to the past.

Cardiopulmonary Resuscitation (CPR)

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Cardiopulmonary Resuscitation (CPR)

It is an emergency procedure in cardiac arrest to maintain the blood flow to the brain and vital organs by compressing chest manually in an unconscious patient with no pulse and no breathing or abnormal breathing such as agonal gasping.

During CPR in an emergency, one has to focus on critical concepts such as

• push hard and fast
• allow maximum chest recoil during compression
• compression a rate of at least 100/min 
• should not interrupt compression often or for long

Follow these steps to perform chest compression:

• Ensure the scene is safe
• Rescuers should wear gloves 
• Keep the patient in supine position and on a flat and firm surface
• Remove the clothes from the chest of the patient
• Keep the heel of the one hand on the middle and center of the chest and place the other hand on the top of it with fingers intertwined ( draw an imaginary line between the nipples)
• Push hard and fast and count it loudly

Depth of the compression is

• For adults- 2 inch/ 5 cm
• For children-2 inch/ 5 cm
• For infants- 1.5 inch/ 4 cm

Facts to be considered:

• If the rescuer's hands and wrists are arthritic, keep one hand on the chest and grasp the wrist of the hand with the other hand to support it for deep chest compression. This technique may be useful to push hard and fast.

Handigodu Syndrome

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Handigodu Syndrome

Handigodu syndrome or Handigodu Joint disease is an inherited disorder mainly characterized by osteoarthropathy. It was mainly endemic to Malnad region in Karnataka state, India. It is scientifically known as spondylo epi (meta) physeal dysplasia. It affects spine, epiphyses and metaphyses of the long bones of the limbs. 

Prevalence of this disease is not relevant nowadays, as it confined to specific geographic parts of the villages, Karnataka, India.It is a progressive skeletal disorder, starting with severe hip and joint pain, forces the patient to crawl and then, cripples. Most of them are short statured because of spine involvement.

The causative factors are uncertainly defined. It may be due to consanguinity, low protein intake and environmental toxins.

Regarding management of the handigodu disease, patients are treated for pain and swelling with analgesics but no cure.

Coronary Artery Diseases

Coronary Artery Diseases

The epidemic of coronary artery diseases is widely prevalent among Indian population. Four people die of heart attack every minute in India and the age group is mainly between 30 and 50 years. This is not frighten you, but to provide a wake-up call.

Risk factors of coronary artery diseases

It might be due to genetic predisposition leading to premature coronary artery diseases and anatomical abnormalities such as dilated coronary arteries called ectasia with pro thrombotic (easy clot forming) tendency.

Other risk factors are diabetes mellitus, high blood pressure, high blood lipid levels, obesity, smoking, sedentary life style, smoking, alcoholism, consumption of fast foods and high level of stress.

Symptoms

• Unstable Angina- Central crushing chest pain or discomfort, which may spread to the arms, neck, jaw, stomach and back. Constant dull pain or heavy feeling on chest, not relieved by rest, Glyceryl Trinitrate tablets or sublingual spray.
• Stable Angina- Chest pain on physical activity but settles after a period of rest, Glyceryl Trinitrate tablets or sublingual spray.

Management

• Emergency management for unstable angina- It is life threatening, so that, seek medical help immediately. Call an ambulance, go to nearby specialist hospital.
• Emergency management for stable angina- Consult specialist soon. Medical management includes drugs e.g. cholesterol lowering medications, beta blockers, nitroglycerin and calcium antagonists etc.
• Surgical management- It includes coronary interventions such as angioplasty, coronary stent and coronary artery bypass grafting.

Prevention

The public should be educated about risk factors through awareness programs. Focus on ‘stop smoking and alcoholism’ and 'dietary approach' means avoid fatty foods and eat at regular intervals. The regular exercises and outdoor games are essential to keep every one healthy.

They should watch their BMI (for details see (http://understandhealthtips.blogspot.in/2014/10/body-mass-index.html)) and waist hip ratio (for details see(http://understandhealthtips.blogspot.in/2014/10/waist-hip-ratio.html)). Keep blood pressure, blood sugar and blood lipids under control. Do annual screening periodically (for details see(http://understandhealthtips.blogspot.in/2014/11/annual-health-check-up.html)).