He encontrado que alguna farmacia puede tener existencias limitadas de ciertos medicamentos, mientras que otras pueden tener casi cualquier formato que se le ocurra y el habitual de dosis habitualidad apareció. En resumen, siempre se contiene el almacén de corroborar. Al mismo tiempo que el producto que más que gustaba ha resultado no estaba disponible en stock otro distinto por las Buenas costumbres también debe buscarse jefe no asн parezca. Por eso es importante disponer de un Plan B para actuar cuandod ello no ocurra. Ventaja de tomar un genérico en lugar de Asix Un genérico es más barato que el nombre de marca Uno de los mayores incentivos para someterse al Dónde comprar Lasix genérico en lugar de pagar la marca es que usted puede obtener un ahorrando importantes Lasix genérico. Por lo tanto, un Lasix genérico es en general mucho más barato que el homólogo de marca, así que una denominación genérica se hace posible para las personas que usan este medicamento con frecuencia. Un ejemplo: La compra de lurosemida en lugar de Lasix es una considerable ahorro para el presupuesto mensual de medicamentos.

Stages of labor

STAGES OF LABOR

FIRST STAGE

Latent phase – Cervical effacement and early dilatation
Active phase – Rapid cervical dilatation Protraction disorder of the active phase (dilatation)
SECOND STAGE (pushing)
Primip – 30min – 3 hr, multip – 5 –30 min
Mechanisms of Labor

Descent – uterine contractions, maternal pushing, gravity Internal Rotation – Fetal head from transverse/oblique to occiput anterior Extension – Vaginal outlet is upward and forward Crowning – largest diameter of fetal head encircled by vulvar ring External Rotation – delivered head returns to original position to align with back and shoulders Expulsion – anterior shoulder delivers under symphysis
THIRD STAGE

Delivery of the placenta – avg 2 –10min Signs of placental seperation 1) Fresh show of blood 2) Umbilical cord lengthens 3) Fundus of uterus rises up 4) Uterus becomes firm and globular First degree –vaginal epithelium or perineal skin Second degree – extends into subepithelial tissues or perineum with or without involvement of muscles of the perineal body Third degree – involvement of the anal sphincter Fourth degree – involvement of the rectal mucosa FOURTH STAGE

Follow vitals and any signs of postpartum hemorrhage
INDUCTION OF LABOR – labor initiated by artificial means
AUGMENTATION OF LABOR – stimulation of labor after it has begun spontaneously
Indications – Maternal or Fetoplacental

Bishop Score–
Cervix
High score 9-13 High likelihood of vaginal delivery Low score <5 decreased likelihood of success (65-80%) Cervical Ripening – mechanical +/- pharmacological Intracervical dilators – Foley catheter, Laminaria Prostaglandin E gel or vaginal insert, new – misoprostol (Cytotec)
Oxytocin – Identical to natural pituitary peptide
Amniotomy
ACTIVE MANAGEMENT OF LABOR
1) Nulliparous – spontaneous labor, singleton pregnancy, cephalic 2) Prenatal education classes 3) Constant attendance in labor with labor nurse specialist/midwife 4) Peer review of all c-sections 5) Not admitted without clear diagnosis of labor Regular/painful contractions with one of the following: complete cervical effacement, rupture of membranes, bloody show 6) Amniotomy upon admission 7) Regular exams for progress 8) Oxytocin if <1cm/hr or no descent for an hour
DELIVERY

Position, prep and drape
Crowning – decide if needs episiotomy
SUPPORT THE PERINEUM!
Ritgen maneuver- increases extension of head Understand the force / counterforce – you apply counterforce to control the delivery
Head delivered – check for cord
Suction airway
Deliver anterior shoulder – downward traction
Deliver posterior shoulder –upward
Deliver body
Clamp cord/suction airway – hand off baby
Check vagina/perineum
Prepare to delivery placenta – mild traction on cord with counterforce on uterus
SHOULDER DYSTOCIA “the scariest event in obstetrics”
Anterior Shoulder is impacted behind symphysis pubis DON’T APPLY MORE TRACTION – need to disengage anterior shoulder! McRoberts maneuver – Flex maternal thighs Wood’s screw – try to rotate posterior shoulder upward Zavanelli maneuver – manually push head into vagina/uterus followed by stat c/section
Complication – fractures of humerus, clavicle, Erb’s palsy – brachial plexus injury

RETAINED PLACENTA

Source: http://uicchicago.sharpschool.com/UserFiles/Servers/Server_442934/File/OBGYN%20Med%20Ed/STUDENTS/Lectures/STAGES%20OF%20LABOR-App.pdf