Acute ‘cold’ leg

Important diagnostic features

Isolated arterial embolus
• Sudden-onset, severe ischaemia, no previous symptoms of
vascular disease, previous history of atrial fibrillation/recent
myocardial infarction, all peripheral pulses on the unaffected
limb normal (suggesting no underlying peripheral vascular disease
[PVD]).
• Limb usually acutely threatened due to complete occlusion
with no collateral supply.
• Common sites of impaction are: popliteal bi(tri)furcation, distal
superficial femoral artery (adductor canal), origin of the profunda
femoris. ‘Saddle’ embolus at aortic bifurcation causes
bilateral acute ischaemic limbs.

Trauma
• May be due to direct injury to the vessel or by secondary compression
due to bone fragments or haematoma.
• Direct injuries may be due to: complete division of the vessel,
distraction injury, damage and in situ thrombosis, foreign body,
false aneurysm.

Thrombosis (in situ)
• Usually associated with underlying atheroma predisposing to
thrombosis after minor trauma or immobility (after a fall or illness).
• May be subacute in onset, previous history of known vascular
disease or intermittent claudication, associated risk factors for
peripheral vascular disease, abnormal pulses in the unaffected
limb.
• Paradoxically, the limb may not be as acutely threatened as in
isolated arterial embolus since collateral vessels may already be
present due to underlying disease.

Graft thrombosis
Often subacute in onset, limb not acutely threatened, progressive
symptoms, loss of graft pulsation

Aneurysm thrombosis
• Commonest sitebpopliteal aneurysms.
• Sudden-onset limb ischaemia, acutely threatened, may be
associated embolization as well, non-pulsatile mass in popliteal
fossa, many have contralateral asymptomatic popliteal aneurysm.

THE PARTOGRAPH

Partograph is a graphic that use for monitoring the 1st stage of the labor. The WHO partograph has been modified to make it simpler and easier to use. Thelatent phase has been removed, and plotting on the partograph begins in the active phase when the cervix is 4 cm dilated. Record the following on the partograph:

Patient information: Fill out name, gravida, para, hospital number, date and time of admission, and time of ruptured membranes OR time elapsed since rupture of membranes (if rupture occurred before charting on the partograph began).
Fetal heart rate: Record every half hour.
Amniotic fluid: Record the color of amniotic fluid at every vaginal examination: I: membranes intact; R:membranes ruptured; C: membranes ruptured, clear fluid; M: meconium-stained fluid; B: blood-stained fluid.
Molding: 1: sutures apposed; 2: sutures overlapped but reducible; 3: sutures overlapped and not reducible.
Cervical dilation: Assessed at every vaginal examination and marked with a cross (X). Begin plotting on the partograph at 4 cm.
Alert line: A line starts at 4 cm of cervical dilation to the point of expected full dilation at the rate of 1 cm per hour.
Action line: Parallel and 4 hours to the right of the alert line.
Descent assessed by abdominal palpation (Figure 4-1, below): Refers to the part of the head (divided into five parts) palpable above the symphysis pubis; recorded as a circle (O) at every abdominal examination. At 0/5, the sinciput (S) is at the level of the symphysis pubis.
Hours: Refers to the time elapsed since onset of active phase of labor (observed or extrapolated).
Time: Record actual time.
Contractions: Chart every 30 minutes; count the number of contractions in a 10-minute time period, and their duration in seconds.
Less than 20 seconds:
Between 20 and 40 seconds:
More than 40 seconds:
Oxytocin: Record the amount of oxytocin per volume IV fluids in drops per minute every 30 minutes when used.
Drugs given: Record any additional drugs given.
Pulse: Record every 30 minutes and mark with a dot (ﾁœ).
Blood pressure: Record every 4 hours and mark with arrows.
Temperature: Record every 2 hours.
Protein, acetone, and volume: Record when urine is passed.

Assist in Normal Birth

Clean the woman’s perineum with a cloth or compress, wet with antiseptic or soap and water, wiping from front to back.
Ask the woman to pant or give only small pushes with contractions as the baby’s head is born.

As the pressure of the head thins out the perineum, one way to control the birth of the head is with the fingers of one hand applying a firm, gentle downward (but not restrictive) pressure to maintain flexion, allow natural stretching of perineal tissue, and prevent tears.
Use the other hand to support the perineum using a compress or cloth, and allow the head to crown slowly and be born spontaneously. Do not manipulate the labia or perineum over the baby’s head because this increases the risk of tears.
Wipe the mucus (and membranes, if needed) from the baby’s mouth and nose with a clean cloth. Feel around the baby’s neck to ensure that the umbilical cord is not around it:
If the cord is around the neck but is loose, slip it over the baby’s head.
If the cord is loose but cannot reach over the head, slip it backwards over the shoulders.
If the cord is tight around the neck:
Tie or clamp the cord in two places 2 cm apart.
Cut the cord between the ties/clamps.
Unwind the cord from around the baby’s neck and proceed.