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The previously damaged fetus lisinopril 17.5 mg visa arteria hyaloidea, now Chapter 11 / Obstetrics and Gynecology 145 with recovered acid–base status generic lisinopril 17.5 mg fast delivery pulse pressure hemorrhage, may demonstrate a reassuring trac- ing. A nonreassuring tracing, particularly with little or no baseline variability, does highly correlate with a neurologically injured fetus. The umbilical cord gases correlate well with neurological injury in the newborn, but they must be assessed immediately after birth. Follow- ing neonatal resuscitation, respiratory gas values typically show a more severe metabolic acidosis than is evident at the time of birth. Accordingly, umbilical cord gases should be obtained in all depressed or resuscitation-requiring newborns. Hypoxic-ischemic encephalopathy (HIE) injury pattern in the new- born must be placed in perspective with all the known pertinent clini- cal information. After dealing with the emergent situation, all actions taken or not taken should be clearly documented in the medical record along with explanations provided to the parents. Communication with the baby’s physician is very important not only to clarify the timing of the baby’s neurological injury but also to facilitate the obstetrician’s trans- lation of the baby’s status to the mother and family. The associations with maternal factors are weak except for an expulsive resolution to the second stage of labor and fetal macrosomia often seen in cases of maternal diabetes. Even making the diagnosis of macrosomia is difficult, and late pregnancy sonography is no better than clinical guesstimate. Elective induction of labor or elective C-section delivery for women suspected of carrying a macrosomic fetus is generally not recommended. On the other hand, the case has been made for elective C-section when the estimated fetal weight exceeds 4500 g in women with diabetes. It is essential to review the nurses’ notes to ascertain their concor- dance with your own notes on clinical events. For example, it is not uncommon for the nurse’s notes to reflect the use of fundal pressure rather than suprapubic pressure. Although there are no data to support the use of one maneuver over another, the McRobert’s patient posi- tioning is simple and resolves about 50% of the cases of anterior shoul- der impaction. Fundal pressure prior to the diagnosis of shoulder dystocia is not a standard-of-care issue. Cervical plexus injury has been reported without documented shoulder dystocia at the time of vaginal birth (9) as well as at the time of planned C-section (10). There is no scientific basis that all or even most brachial plexus injuries result from inappropriate maneuvers at deliv- ery (11). Newborn seizure activity is so rare following delivery with shoul- der dystocia that intracerebral hemorrhage must be ruled out. HIE with mental retardation and/or cerebral palsy is also rare (<1%), unless the time from diagnosis of dystocia at delivery of the head to resuscitation exceeds 10 minutes. Video recording during periods of obstetric emer- gencies should not be allowed. Although the severity of the dystocia cannot be defined as mild, moderate, or severe, a videotape is often very revealing as to the twists and turns exerted on the baby’s neck. Documentation of the sequence and timing of the maneuvers is critical as are APGAR scores, need for resuscitation, and evident plexus in- jury. Obstetric hemorrhage is the most common cause of maternal death when associated complications are included. Death secondary to hem- orrhage would be most unusual in a modern obstetric service in the United States. Accepted risk factors include delays in identification of the site of the bleeding and in volume resuscitation with appropriate blood products. This often follows a failure to appreciate the quantity of blood the obstetric patient can lose before exhibiting shock fol- lowed rapidly by cardiovascular collapse and the morbidity of associ- ated organ injury. Furthermore, tachycardia ( 110 bpm) and systolic hypotension ( 90 mmHg) tend to be late signs in the obstetric patient occurring typically after a volume loss of approx 40%. Orthostatic systolic blood pressure checking is a more reliable indicator of signifi- cant hypovolemia—a 10 mmHg decrease equating in pregnancy to a deficit of 1 L or more.

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The nerve extends in the medial bicipital Thus order 17.5 mg lisinopril fast delivery blood pressure medications with the least side effects, the first pair of nerves supplies the sulcus along the surface of the brachial ulnar side of the thumb and the radial side artery to the elbow proven 17.5 mg lisinopril 7th hypertension, where it passes be- of the index finger, the second pair supplies tween the two heads of the round pronator the ulnar side of the index finger and the muscle to the forearm. It runs between the radial side of the middle finger, and the superficial flexor muscle of the fingers and third pair supplies the ulnar side of the the deep flexor muscle of the fingers to the middle finger and the radial side of the ring wrist. The area innervated by the proper tunnel, it lies superficially between the ten- palmar digital nerves on the posterior side dons of the radial flexor muscle of the wrist includes the end phalanx of the thumb as and the long palmar muscle. In the carpal well as the distal and middle phalanges of tunnel, it ramifies into its terminal the fingers (B). The median nerve gives off branches to the The muscular branches (C2) of the nerve periosteum, elbow joint, radiocarpal joint, supply the pronator muscles and most of the and mediocarpal joint. At the level of the flexor muscles of the forearm, namely, the wrist, there is normally an anastomosis round pronator muscle (A3), the radial with the ulnar nerve. As to the hand, the the anterior interosseous nerve of the forearm thumb, index finger and middle finger can no (AC8) branches off and runs along the inter- longer be flexed at the end and middle phalanges, osseous membrane to the quadrate prona- resulting in a characteristic feature of median pa- tor muscle (A9). On passing long flexor muscle of the thumb (A10) and the carpal tunnel, the nerve can be injured by pressure in older persons (carpal tunnel syn- to the radial part of the deep flexor muscle drome). Autonomic sensory palmar branch of the median nerve zone (dark blue) and maximum zone (light (A–C11) branches off to the skin of the ball blue). After passing through the carpal tunnel, the median nerve divides into three branches: the common palmar digital nerves I–III (A–C12), each of which bifurcates at the level of the metacarpophalangeal joints into two proper palmar digital nerves (A–C13). From the first common palmar digital nerve, a branch extends to the thenar eminence (short abductor muscle of thumb [A14], su- Kahle, Color Atlas of Human Anatomy, Vol. Brachial Plexus 77 A Muscles supplied by the median nerve (according to Lanz-Wachsmuth) 11 1 13 B Skin supplied by the median nerve C 6 C 7 1 C 8 3 T 1 4 5 8 6 7 10 2 9 8 11 16 14 15 12 17 11 D Paralysis of the median nerve 12 (according to Lanz-Wachsmuth) 13 13 C Sequence of branches Kahle, Color Atlas of Human Anatomy, Vol. Medial Fascicle (A–D) Thedeepbranch(AC9)sinksintothedepthof Ulnar nerve (C8–T1). Initially, the ulnar the palm and curves toward the thenar emi- nerve runs in the upper arm in the medial nence. Itgivesoffbranchesforallmusclesof bicipital sulcus without giving off any the hypothenar eminence (C10) (abductor branches. It crosses the lumbrical muscles III and IV (A15), and the elbow joint on the extensor side in a finally, at the thenar eminence, for the ab- bony groove, the sulcus for the ulnar nerve, ductor muscle of thumb (A16) and the deep at the medial epicondyle of the humerus. The Clinical Note: Injury to the ulnar nerve causes nervethenpassesbetweenthetwoheadsof the formation of a so-called clawhand (D), where the ulnar flexor muscle of the wrist to the the fingers are extended in the metacarpo- phalangeal joints but flexed in the proximal and flexor side of the forearm and runs beneath distal interphalangeal joints. It does not posture of the fingers is caused by paralysis of the pass through the carpal tunnel but extends interosseous muscles and lumbrical muscles, over the flexor retinaculum to the palm of which flex the phalanges in the metacarpo- the hand, where it divides into a superficial phalangeal joints but extend them in the proxi- branch and a deep branch. Failure of the flexor muscles causes the fingers to remain in In the forearm, the nerve gives off branches this posture due to the now predominant exten- (C1) to the ulnar flexor muscle of the wrist sor muscles. Since the little finger and the adduc- (A2) and to the ulnar half of the deep flexor tors of the thumb are paralyzed, thumb and little muscle of the fingers (A3). Autonomic arm and runs to the ulnar side of the back of zone (dark blue) and maximum zone (light the hand where it supplies the skin. Another sensory branch, the palmar branch of the ulnar nerve (BC5), branches off in the distal third of the forearm. It extends to the palm and supplies the skin of the hy- pothenar eminence. The superficial branch runs as common palmar digital nerve IV (BC6) toward the interdigital space between ring finger and little finger and divides into the proper palmar digital nerves (BC7), which supply sensory fibers to the volar aspects of the little finger and the ulnar side of the ring finger and reach to the distal phalanges on the extensor side of both fingers. There is a connection to a branch of the median nerve, called the com- Kahle, Color Atlas of Human Anatomy, Vol. Brachial Plexus 79 A Muscles supplied by the ulnar nerve (according to Lanz-Wachsmuth) 5 4 6 7 B Skin supplied by the ulnar nerve (according to Lanz-Wachsmuth) C 8 T 1 2 3 1 9 11 17 5 4 16 12 13 9 15 D Paralysis of the ulnar nerve 10 (according to Lanz-Wachsmuth) 14 14 6 8 7 C Sequence of branches Kahle, Color Atlas of Human Anatomy, Vol. From the nerve fascicle gives rise to the medial cutaneous trunk extending beneath the deltoid muscle nerve of the arm and the medial cutaneous to the front, numerous branches (D6) to the nerve of the forearm; both are exclusively deltoid muscle (D7) branch off and supply sensory nerves supplying the skin on the its various parts. Clinical Note: As a result of its location on the Medial cutaneous nerve of the arm (C8 – capsule of the shoulder joint, the nerve can be in- T1) (A, B). The nerve approaches the ante- jured by dislocation of the humerus or by rior surface of the upper arm below the axil- humeral neck fracture. Here it ramifies and supplies the the skin area over the deltoid muscle. Auto- its anterior branches and to the extensor nomic zone (dark blue) and maximum zone side of the upper arm with its posterior (light blue).

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