CEPHALHEMATOMA (1)

8/13/2019 CEPHALHEMATOMA (1)

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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


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Difference beteen a Caput Succedaneum and Cep!al!ematoma

I)$IC*T'! C*+,T !,CC-$*)-, C-+&*/&-*T'*

/ocation +resenting part of the head +eriosteum of skull bone and bone

-0tent of Involvement oth hemispheres C'!!-! the

suture lines

Individual bone $'-! )'T

C'!! the suture lines

+eriod of *bsorption % to 4 days 3ew weeks to months

Treatment )one !upport

Forceps Delivery

3orceps are instruments designed to aid in the delivery of the fetus by applying traction to thefetal head. any different types of forceps have been described and developed. enerally5forceps consist of 2 mirror image metal instruments that are maneuvered to cradle the fetal headand are articulated5 after which traction is applied to effect delivery.

3orceps have 4 ma6or components5 as follows7

lades7 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 with a hole in the middle9 or solid.any blades are also curved in a plane :;< from the cephalic curve to fit the maternal pelvispelvic 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 appro0imately1=;; C contain evidence of single and paired instruments -gyptian5 reek5 oman5 and+ersian writings and pictures refer to forceps that were originally used for e0traction followingfetal 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 goesto +eter Chamberlen of -ngland circa 1>;;9. odifications have led to more than ?;; differenttypes and shapes of forceps. In 1?4=5 @illiam !mellie described the accurate application to theocciput5 rather than the previously performed pelvic application5 regardless of the position of thehead. In 184=5 !ir (ames !impson developed a forceps that was designed to appropriately fitboth cephalic curvatures and pelvic curvatures. In 1:2;5 (oseph $e/ee further modified thatinstrument and advocated the prophylactic forceps delivery. In an era in which many womenlabored and delivered under heavy sedation5 forceps deliveries became common.


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In current obstetrical practice5 the use of forceps has become much less common. Clinical studiesperformed before the 1:?;s suggested that the risk of fetal morbidity and mortality was higherwhen the second stage of labor e0ceeded 2 hours. A1B @ith contemporary obstetrical management5morbidity rates no longer increase with longer labors if fetal surveillance is reassuring. Thus5 thelength of the second stage of labor alone is no longer an absolute indication for operativetermination of labor.

'ther factors were also at work to decrease the use of forceps deliveries. In particular5 theavailability of blood products and greater choices in antibiotics helped make cesarean delivery asafe alternative to operative vaginal deliveries. In the 1:8;s5 information became availablesuggesting that some forceps deliveries midforceps deliveries9 may be associated with anincreased risk of fetal morbidity5 though this issue remains controversial. These factors combinedto 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 adeuatepersonnel comfortable with teaching forceps#assisted vaginal deliveries5 changes in consumerattitudes5 and the demand for natural delivery. In addition5 many practitioners fear litigation if aforceps#assisted delivery results in a poor outcome.

"re#uency

The freuency of operative vaginal deliveries is now estimated to be less than =D of all vaginaldeliveries. ost of these are vacuum deliveries with forceps deliveries comprising less than 1D oftotal deliveries. *ccording to ofill et al5 trained fellows of the *merican College of 'bstetriciansand ynecologists *C'9 were more likely to be taught vacuum e0traction5 and they usevacuum e0traction as their instrument of choice for operative vaginal deliveries.A2B

@hen forceps deliveries are performed5 !impson forceps see image below9 is the instrumentmost commonly used for outlet# and low#forceps deliveries. 'ther types of forceps are alsoavailable 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 neckduring breech delivery. ultiple other types of forceps have been designed to rotate the fetalhead or for unusual maternal pelvic or fetal head shapes. 3or detailed information on otherforceps 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. )oindication 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 womanwith 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 ofspontaneous pneumothora0.

In skilled hands5 fetal malpositions5 including the after#coming head in breech vaginal

delivery5 can be indications for forceps delivery.+rereuisites 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.


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The membranes must be ruptured.

The patient must have adeuate analgesia.

*deuate 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 notto 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 freuently 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 forcepsare used for childbirth. efore 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


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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. efore 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 Riss Associated With It Before Taing Any Decision

There are many drawbacks also associated with the forceps deli&erythat 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.


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'()A$'*

nalbuphine hydrochloride9

D+(, DESC+$PT$O'

),*I) nalbuphine hydrochloride9 is a syntheticopioidagonist#antagonistanalgesicof the phenanthrene

series. It is chemically related to both the widely used opioidantagonist5 nalo0one5and the potent opioid

analgesic5 o0ymorphone. Chemically nalbuphine hydrochloride is 1?#cyclobutylmethyl9#45=G#

epo0ymorphinan#%5>G514#triol hydrochloride. )albuphine hydrochloride molecular weight is %:%.:1 and is

soluble in &2' %=.= mgHm/ 2=JC9 and ethanol ;.8D9 insoluble in C&Cl%and ether. )albuphinehydrochloride has pKa values of 8.?1 and :.:>. The molecular formula is C21&2?)'4L&Cl. The structural

formula is7

),*I) nalbuphine hydrochloride9 is a sterile solution suitable for subcutaneous5 intramuscular5 or

intravenous in6ection. ),*I) nalbuphine hydrochloride9 is available in two concentrations5 1; mg and 2;

mg of nalbuphine hydrochloride per m/. oth 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

preservatives p& is ad6usted5 if necessary5 to %.= to %.? with hydrochloric acid. The 1; mgHm/ strength

contains ;.2D sodium chloride.
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),*I) nalbuphine 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 anhydrous 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

et emergency medical help if you have any of these signs of an allergic reaction7 hives difficulty breathing

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 breathing

fast or slow heart rate

cold5 clammy skin

confusion5 hallucinations5 unusual thoughts or behavior

severe weakness or diEEiness or

feeling like you might pass out.

/ess serious side effects...

$'D$CAT$O'S

),*I) nalbuphine hydrochloride9 is indicated for the relief of moderate to severe pain. ),*I)

nalbuphine hydrochloride9 can also be used as a supplement to balancedanesthesia5

for preoperativeand postoperativeanalgesia5and 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 intravenously 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. !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 ),*I) nalbuphine hydrochloride9 as a supplement to balanced anesthesia reuires larger

doses than those recommended for analgesia. Induction doses of ),*I) nalbuphine 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 reuired. The use of ),*I)

nalbuphine hydrochloride9 may be followed by respiratory depression which can be reversed with

the opioidantagonist)*C*)M nalo0onehydrochloride9.

),*I) nalbuphine 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 ),*I) nalbuphine hydrochloride9 . If unduly troublesome5 opioid withdrawal symptoms

can be controlled by the slow intravenous administration of small increments ofmorphine5 until relief occurs.

If the previousanalgesicwas morphine5 meperidine5 codeine5 or other opioid with similar duration of activity5

one#fourth of the anticipated dose of ),*I) nalbuphine hydrochloride9 can be administered initially and

the patient observed for signs of withdrawal5 i.e.5 abdominal cramps5 nauseaand

vomiting5lacrimation5 rhinorrhea5an0iety5 restlessness5 elevation of temperature or piloerection. If untoward
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symptoms do not occur5 progressively larger doses may be tried at appropriate intervals until the desired

level of analgesia is obtained with ),*I) nalbuphine 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 freuent adverse reaction in 1;>> patients treated in clinical studies with ),*I) nalbuphine

hydrochloride9 was sedation %81 %>D9.

/ess freuent reactions were7 sweatyHclammy :: :D95 nauseaHvomiting >8 >D95 diEEinessHvertigo =8 =D95

dry mouth 44 4D95 and headache 2? %D9.

'ther adverse reactions which occurred reported incidence of 1D or less9 were7

C'S Effects%)ervousness5 depression5 restlessness5 crying5 euphoria5 floating5 hostility5 unusual dreams5

confusion5 faintness5 hallucinations5dysphoria5feeling 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%&ypertension5hypotension5bradycardia5tachycardia.

,astrointestinal% Cramps5dyspepsia5 bitter taste.

+espiratory% $epression5 dyspnea5asthma.

Dermatologic% Itching5burning5 urticaria.

Miscellaneous% !peech difficulty5urinary urgency5 blurred vision5flushing and warmth.

Allergic +eactions%*naphylacticHanaphylactoid and other serious hypersensitivity reactions have been

reported following the use of nalbuphine and may reuire immediate5 supportive medical treatment. These

reactions may include shock5 respiratory distress5 respiratory arrest5 bradycardia5cardiac arrest5

hypotension5 orlaryngealedema. !ome of these allergic reactions may be life#threatening. 'ther allergic#

type reactions reported include stridor5 bronchospasm5 wheeEing5 edema5 rash5 pruritus5 nausea5vomiting5

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 ),*I) nalbuphine hydrochloride9 7 abdominal pain5 pyre0ia5 depressed level

or loss of consciousness5 somnolence5 tremor5 an0iety5pulmonary edema5agitation5 seiEures5 and in6ection

site reactions such as pain5 swelling5 redness5 burning5 and hot sensations. $eath has been reported fromsevere allergic reactions to ),*I) nalbuphine hydrochloride9 treatment. 3etal death has been reported

where mothers received ),*I) nalbuphine hydrochloride9 during labor and delivery.

Drug Abuse And Dependence

There have been reports of abuse and dependence associated with ),*I) nalbuphine hydrochloride9

among health care providers5 patients and bodybuilders. There have been reported instances of

psychological and physical dependence and tolerance in patients abusing ),*I) nalbuphine
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hydrochloride9 . Individuals with a prior history ofopioidor othersubstance abuseor dependence may be at

greater risk in responding to reinforcing properties of ),*I) nalbuphine hydrochloride9 .

*brupt discontinuation of ),*I) nalbuphine hydrochloride9 following prolonged use has been followed by

symptoms of opioid withdrawal5 i.e.5 abdominal cramps5 nausea and vomiting5rhinorrhea5lacrimation5

restlessness5 an0iety5 elevated temperature and piloerection.

Precautions

(se in Pregnancy .Ot!er T!an Labor/

!evere fetalbradycardiahas been reported when ),*I) nalbuphine 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 from17;.%? 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

birth5apnea5cyanosis5andhypotonia. !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.

),*I) nalbuphine 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 ),*I) nalbuphine hydrochloride9 has been used.

CO'T+A$'D$CAT$O'S

),*I) nalbuphine hydrochloride9 should not be administered to patients who are hypersensitive to

nalbuphine hydrochloride5 or to any of the other ingredients in ),*I) nalbuphine hydrochloride9 .

CL$'$CAL PHA+MACOLO,5

),*I) nalbuphine hydrochloride9 is a potent analgesic. Its analgesic potency is essentially euivalent to

that of morphine on a milligram basis. eceptor studies show that ),*I) nalbuphine hydrochloride9 binds

to mu5 kappa5 and delta receptors5 but not to sigma receptors. ),*I) nalbuphine hydrochloride9 is

primarily a kappa agonistHpartial mu antagonist analgesic.

The onset of action of ),*I) nalbuphine 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 reportedto range from % to > hours.

The opioidantagonist activity of ),*I) nalbuphine hydrochloride9 is one#fourth as potent as nalorphine

and 1; times that of pentaEocine.

),*I) nalbuphine hydrochloride9 may produce the same degree of respiratory depression as

euianalgesic doses of morphine. &owever5 ),*I) nalbuphine hydrochloride9 e0hibits a ceiling effect
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such that increases in dose greater than %; mg do not produce further respiratory depression in the absence

of other C)! active medications affecting respiration.

),*I) nalbuphine hydrochloride9 by itself has potent opioid antagonist activity at doses eual to or lower

than its analgesic dose. @hen administered following or concurrent with mu agonist opioid analgesics e.g.5

morphine5 o0ymorphone5 fentanyl95 ),*I) nalbuphine hydrochloride9 may partially reverse or block

opioid#induced respiratory depression from the mu agonist analgesic. ),*I) nalbuphine hydrochloride9

may precipitate withdrawal in patients dependent on opioid drugs. ),*I) nalbuphine hydrochloride9

should be used with caution in patients who have been receiving mu opioid analgesics on a regular basis.

CEPHALHEMATOMA (1)

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