query: medical_specialty postpartum bleeding
supports: Pudendal anesthesia, also known as a pudendal block, or saddle block, is a form of local anesthesia commonly used in the practice of obstetrics to relieve pain during the delivery of baby by forceps. The pudendal nerve block prevents fainting during forceps delivery which was common before pudendal nerve block use was available. The anesthesia is produced by blocking the pudendal nerves near the ischial spine of the pelvis. The ischial spine separates the greater and lesser sciatic foramina at the exit of the bony pelvis. Pelvis in Latin means 'saucepan' and one can view the bony human pelvis as a saucepan, with circular/cylidrical walls, but without a base and a flailed upper rim, or wings to which the gluteal muscles (hip bone stabilisers) attach. The pelvic bony cylindrical walls also have a curve, which follows that of the curve of the sacrum, the fused vertebral bones of the lower end of the spine.  Obstructed labour, also known as labour dystocia, is when, even though the uterus is contracting normally, the baby does not exit the pelvis during childbirth due to being physically blocked. Complications for the baby include not getting enough oxygen which may result in death. It increases the risk of the mother getting an infection, having uterine rupture, or having post-partum bleeding. Long term complications for the mother include obstetrical fistula. Obstructed labour is said to result in prolonged labour, when the active phase of labour is longer than twelve hours.
  The main causes of obstructed labour include: a large or abnormally positioned baby, a small pelvis, and problems with the birth canal. Abnormal positioning includes shoulder dystocia where the anterior shoulder does not pass easily below the pubic bone. Risk factors for a small pelvis include malnutrition and a lack of exposure to sunlight causing vitamin D deficiency. It is also more common in adolescence as the pelvis may not have finished growing. Problems with the birth canal include a narrow vagina and perineum which may be due to female genital mutilation or tumors. A partograph is often used to track labour progression and diagnose problems. This combined with physical examination may identify obstructed labour.
  The treatment of obstructed labour may require cesarean section or vacuum extraction with possible surgical opening of the symphysis pubis. Other measures include: keeping the women hydrated and antibiotics if the membranes have been ruptured for more than 18 hours. In Africa and Asia obstructed labor effects between two and five percent of deliveries. In 2013 about 5.1 cases of obstructed labour occurred. This resulted in 19,000 deaths down from 29,000 deaths in 1990 (about 8% of all deaths related to pregnancy). Most deaths due to this condition occur in the developing world. Postpartum bleeding or postpartum hemorrhage ( PPH ) is often defined as the loss of more than 500 ml or 1,000 ml of blood within the first 24 hours following childbirth . Some have added the requirement that there also be signs or symptoms of low blood volume for the condition to exist . Signs and symptoms may initially include : an increased heart rate , feeling faint upon standing , and an increased breath rate . As more blood is lost the women may feel cold , their blood pressure may drop , and they may become restless or unconscious . The condition can occur up to six weeks following delivery . The most common cause is poor contraction of the uterus following childbirth . Not all of the placenta being delivered , a tear of the uterus , or poor blood clotting are other possible causes . It occurs more commonly in those who : already have a low amount of red blood , are Asian , with bigger or more than one baby , are obese or are older than 40 years of age . It also occurs more commonly following caesarean sections , those in whom medications are used to start labor , and those who have an episiotomy . Prevention involves decreasing known risk factors including if possible procedures associated with the condition and giving the medication oxytocin to stimulate the uterus to contract shortly after the baby is born . Misoprostol may be used instead of oxytocin in resource poor settings . Treatments may include : intravenous fluids , blood transfusions , and the medication ergotamine to cause further uterine contraction . Efforts to compress the uterus using the hands may be effective if other treatments do not work . The aorta may also be compressed by pressing on the abdomen . The World Health Organization has recommended non-pneumatic anti-shock garment to help until other measures such as surgery can be carried out . In the developing world about 1.2 % of deliveries are associated with PPH and when PPH occurred about 3 % of women died . Globally it results in 44,000 to 86,000 deaths per year making it the leading cause of death during pregnancy . About 0.4 women per 100,000 deliveries die from PPH in the United Kingdom while about 150 women per 100,000 deliveries die in sub-Saharan Africa . Rates of death have decreased substantially since at least the late 1800s in the United Kingdom . Oxytocin (Oxt ) is a human peptide hormone and neuropeptide that is used as a medication to facilitate childbirth. Oxytocin is normally produced by the paraventricular nucleus of the hypothalamus and released by the posterior pituitary. It plays a role in social bonding, sexual reproduction in both sexes, and during and after childbirth. Oxytocin is released into the bloodstream as a hormone in response to stretching of the cervix and uterus during labor and with stimulation of the nipples from breastfeeding. This helps with birth, bonding with the baby, and milk production. Oxytocin was discovered in 1952.  Episiotomy also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician during second stage of labor to quickly enlarge the opening for the baby to pass through. The incision, which can be done at a 90 degree angle from the vulva towards the anus or at an angle from the posterior end of the vulva (medio-lateral episiotomy), is performed under local anesthetic (pudendal anesthesia), and is sutured after delivery. The placenta (also known as afterbirth) is an organ that connects the developing fetus to the uterine wall to allow nutrient uptake, provide thermo-regulation to the fetus, waste elimination, and gas exchange via the mother's blood supply, fight against internal infection and produce hormones to support pregnancy. The placenta provides oxygen and nutrients to growing babies and removes waste products from the baby's blood. The placenta attaches to the wall of the uterus, and the baby's umbilical cord develops from the placenta. The umbilical cord is what connects the mother and the baby. Placentas are a defining characteristic of placental mammals, but are also found in some non-mammals with varying levels of development. The homology of such structures in various viviparous organisms is debatable, and in invertebrates such as Arthropoda, is analogous at best. Childbirth, also known as labour and delivery, is the ending of a pregnancy by one or more babies leaving a woman's uterus. In 2015 there were about 135 million births globally. About 15 million were born before 37 weeks of gestation, while between 3 and 12% were born after 42 weeks. In the developed world most deliveries occur in hospital, while in the developing world most births take place at home with the support of a traditional birth attendant.
  The most common way of childbirth is a vaginal delivery. It involves three stages of labour: the shortening and opening of the cervix, descent and birth of the baby, and the pushing out of the placenta. The first stage typically lasts twelve to nineteen hours, the second stage twenty minutes to two hours, and the third stage five to thirty minutes. The first stage begins with crampy abdominal or back pains that last around half a minute and occur every ten to thirty minutes. The crampy pains become stronger and closer together over time. During the second stage pushing with contractions may occur. In the third stage delayed clamping of the umbilical cord is generally recommended. A number of methods can help with pain such as relaxation techniques, opioids, and spinal blocks.
  Most babies are born head first; however about 4% are born feet or buttock first, known as breech. During labour a woman can generally eat and move around as she likes, but pushing is not recommended during the first stage or during delivery of the head, and enemas are not recommended. While making a cut to the opening of the vagina is common, known as an episiotomy, it is generally not needed. In 2012, about 23 million deliveries occurred by a surgical procedure known as Caesarean section. Caesarean sections may be recommended for twins, signs of distress in the baby, or breech position. This method of delivery can take longer to heal from.
  Each year complications from pregnancy and childbirth result in about 500,000 maternal deaths, 7 million women have serious long term problems, and 50 million women have health negative outcomes following delivery. Most of these occur in the developing world. Specific complications include obstructed labour, postpartum bleeding, eclampsia, and postpartum infection. Complications in the baby include birth asphyxia. Caesarean section, also known as C-section, is the use of surgery to deliver one or more babies. A Caesarean section is often performed when a vaginal delivery would put the baby or mother at risk. This may include obstructed labour, twin pregnancy, high blood pressure in the mother, breech birth, problems with the placenta, umbilical cord or shape of the pelvis, and previous C-section. A trial of vaginal birth in some of these situations, including after C-section, may be possible. Some C-sections are also performed upon request. The World Health Organization recommends that they should be done based on medical need and in many cases they are lifesaving for the mother and baby.
  A C-section typically takes 45 minutes to an hour. It may be done with a spinal block such that the woman is awake or under general anesthesia. A urinary catheter is used to drain the bladder and the skin of the abdomen is then cleaned with an antiseptic. An incision of about 15 cm (6 inches) is then typically made through the mother's lower abdomen. The uterus is then opened with a second incision and the baby delivered. The incisions are then stitched closed. A woman can typically begin breastfeeding as soon as she is awake and out of the operating room. Often a number of days are required in hospital to recover sufficiently to return home.
  C-sections result in a small overall increase in poor outcomes in low risk pregnancies. They also typically take longer to heal from, about six weeks, than vaginal birth. The increased risks include breathing problems in the baby and amniotic fluid embolism and postpartum bleeding in the mother. Established guidelines recommend that caesarean sections not be used before 39 weeks of pregnancy without a medical reason. The method of delivery does not appear to have an effect on subsequent sexual function.
  In 2012, about 23 million C-sections were done globally. The international healthcare community has previously considered the rate of 10% and 15% to be ideal for caesarean sections. Some evidence finds a higher rate of 19% may result in better outcomes. More than 45 countries globally have C-section rates less than 7.5% while more than 50 have rates greater than 27%. There are efforts to both improve access to and reduce the use of C-section. In the United States about 33% of deliveries are by C-section. The surgery has been performed at least as far back as 715 BC following the death of the mother with the occasional baby surviving. Descriptions of mothers surviving date back to the 1500s. With the introduction of antiseptics and anesthetics in the 1800s survival of both the mother and baby became common. Infection is the invasion of an organism's body tissues by disease-causing agents, their multiplication, and the reaction of host tissues to these organisms and the toxins they produce. Infectious disease, also known as transmissible disease or communicable disease, is illness resulting from an infection.
  Infections are caused by infectious agents including viruses, viroids, prions, bacteria, nematodes such as parasitic roundworms and pinworms, arthropods such as ticks, mites, fleas, and lice, fungi such as ringworm, and other macroparasites such as tapeworms and other helminths.
candidates: infection infectious disease obstetrics surgery
answer: obstetrics