Gynecology and Obstetrics audio
Mastectomy
Mastectomy: Surgical removal of the breast, often performed as a treatment for breast cancer. This can include:
Simple or Total Mastectomy: Removal of the entire breast but not the axillary lymph nodes or muscle tissue.
Modified Radical Mastectomy: Removal of the entire breast and axillary lymph nodes. This is a common approach for invasive breast cancer.
Radical Mastectomy: Removal of the entire breast, axillary lymph nodes, and chest wall muscles. This is less commonly performed today.
Skin-Sparing Mastectomy: The skin of the breast is preserved to improve cosmetic outcomes, often followed by immediate reconstruction.
Nipple-Sparing Mastectomy: The nipple and areola are preserved, also to improve cosmetic outcomes, but is only appropriate in certain cases.
Menstruation
Menstruation: The monthly shedding of the uterine lining (endometrium) in non-pregnant women.
Menorrhea: Normal menstruation.
Amenorrhea: Absence of menstruation. Can be primary (never starting) or secondary (stopping after having started).
Primary Amenorrhea typically refers to the absence of menstruation by age 15 or 16, depending on the presence of secondary sexual characteristics.
Secondary Amenorrhea is the cessation of menstruation for three months in women with regular cycles or six months in women with irregular cycles.
Meno refers to menstruation, and site refers to cells.
Abortion
Abortion: Termination of pregnancy.
Spontaneous Abortion (Miscarriage): Loss of pregnancy before 20 weeks gestation, often without medical intervention.
Induced Abortion: Intentional termination of pregnancy through medical or surgical means.
Many spontaneous abortions occur without the woman's knowledge, often very early in pregnancy.
Pregnancy is a complex process involving numerous hormonal and physiological changes.
Uterus and Ovary
Myome: Muscle tumor in the uterus, also known as a fibroid or leiomyoma. These can cause heavy bleeding, pain, and fertility issues.
Metro means uterus.
O means ovum or egg.
Oophorectomy: Surgical removal of the ovary.
Unilateral Oophorectomy: Removal of one ovary.
Bilateral Oophorectomy: Removal of both ovaries.
Hysterectomy: Surgical removal of the uterus.
Partial Hysterectomy: Removal of the uterus while leaving the cervix intact.
Total Hysterectomy: Removal of the uterus and cervix.
Radical Hysterectomy: Removal of the uterus, cervix, part of the vagina, and supporting tissues; often done in cases of cancer.
Salpingitis: Inflammation of the fallopian tube (salpinx), often caused by sexually transmitted infections (STIs) like Chlamydia or Gonorrhea.
Oophorosalpingectomy: Removal of the ovary and fallopian tube, often performed together due to related anatomy and potential spread of infection or disease.
Dilation and Curettage (D&C)
D&C involves dilation of the cervix and removal of tissue from the uterus.
The cervix is dilated using instruments called dilators.
A curette (a surgical instrument) is used to scrape or suction tissue from the uterine lining.
Used for biopsies to diagnose abnormal bleeding, polyps, or cancer.
Also used to clean the uterus after abortions or miscarriages to remove retained tissue.
Hysterectomy Considerations
Hysterectomy involves removing the uterus, leading to the cessation of menstruation and the inability to conceive.
Key decision: whether to leave the ovaries or not.
Usually, at least one ovary is left, especially in young women (around 45 years old) to maintain hormone production and delay menopause.
Menopause
Menopause: Cessation of menstruation, typically occurring between ages 45 and 55.
Pause means stop.
Diagnosed after 12 consecutive months without a menstrual period.
Uterus is removed as the source of menstruation in a hysterectomy. Menopause is a natural biological process.
Hormone replacement therapy (HRT) can help manage symptoms like hot flashes and vaginal dryness, but it also carries risks such as increased risk of blood clots, stroke, and certain cancers. Personal opinion is against it; it's an accessory, not a main artery. Benefits and risks must be carefully evaluated.
Ovaries and Follicles
Every woman has hundreds of thousands of ova (oocytes) at birth, which decrease over time.
Every menstrual cycle, one or more follicles develop, but usually only one ovum is released.
Follicle-stimulating hormone (FSH) causes follicles to grow.
Follicle: A sac-like structure in the ovary that contains an immature egg (ovum). It provides support and nutrients for the developing oocyte.
Ovulation
Ovulation typically happens on day 14 of the menstrual cycle, although this can vary.
Menstrual cycle: Approximately every 28 days, the uterus prepares to receive a fertilized ovum (zygote) by thickening the endometrium.
The fallopian tube grasps the ovum via fimbriae.
Luteinizing hormone (LH) triggers ovulation, causing the follicle to rupture and release the ovum.
Empty follicle transforms into corpus luteum (yellow body), which secretes progesterone to support the early stages of pregnancy.
Corpus luteum supports pregnancy until the placenta takes over around week 12 (end of the first trimester).
Corpus luteum means yellow body.
Uterine Layers
Three layers: endometrium, myometrium, perimetrium.
Endometrium: Innermost layer that lines the uterus; it thickens and sheds during the menstrual cycle and is the site of implantation.
Myometrium: Muscular layer responsible for uterine contractions during labor and delivery.
Perimetrium: Outer serous layer that covers the uterus.
Cervix
Cervix is normally tight and the opening is plugged with mucus to prevent infection and maintain a sterile environment.
Cervical dilation is measured in fingers (e.g., two fingers, three fingers) or centimeters during pregnancy to assess the progress of labor.
Dilation and Curettage (D&C) Procedure
Cervix is dilated to allow insertion of instruments to take a biopsy or remove tissue.
Used to clean the uterus after abortion or miscarriage to prevent infection and hemorrhage.
Miscarriage: Unintended abortion, also known as spontaneous abortion.
Abortion: Induced termination of pregnancy.
Uterus and Urinary Bladder
Uterus lies on top of the urinary bladder in the pelvic cavity.
During ultrasound, women need to drink water to fill the bladder, which provides a better view of the uterus and ovaries.
Douglas Pouch
Douglas pouch: Space between the uterus and rectum, also known as the rectouterine pouch.
Important for ultrasound examination to check for fluid, tumors, or abnormalities.
Presence of blood may indicate a ruptured ectopic pregnancy or a liver tear after an accident.
Fallopian Tube Structure
Fallopian tube has cilia (small hair-like projections) to help move the fertilized ovum toward the uterus.
Fertilized ovum moves within one week.
Tube consists of:
Infundibulum: Funnel-shaped opening near the ovary with fimbriae.
Ampulla: Widest part of the tube where fertilization typically occurs.
Isthmus: Narrower part that connects to the uterus.
Interstitial portion: Section within the uterine wall.
Fimbriae: Finger-like projections that grasp the ovum; they are not directly connected but help guide the egg into the fallopian tube.
Ampulla: Where sperm fertilizes the ovum.
Mesenteries
Mesovarium, mesosalpinx, and mesometrium are peritoneal folds that support the ovary and uterus and carry blood vessels and nerves.
Mesovarium: Supports the ovary.
Mesosalpinx: Supports the fallopian tube.
Mesometrium: Supports the uterus.
Breast Anatomy
Breasts contain 15-20 lobes of glandular tissue.
Suspensory ligaments (Cooper's ligaments) support the breast and give it shape; these ligaments can stretch and sag with age.
Tubes (lactiferous ducts) carry milk to the nipple, connecting to form a network for milk ejection.
Oogenesis
Oogenesis: Creation of ova (eggs) in the ovaries.
Haploid: One set of chromosomes (23), present in sperm and eggs.
Diploid: Two sets of chromosomes (46), present in somatic cells.
Meiosis and mitosis are cell division processes. Meiosis is used to produce gametes (sperm and eggs), while mitosis is for growth and repair.
Menstrual Cycle Purpose
Main purpose: To prepare the uterus to receive a fertilized ovum by thickening the endometrium and providing a nourishing environment.
Uterus develops a thick cushion of tissue and blood vessels.
If no fertilization occurs, blood vessels are shed, leading to tissue death and sloughing off as menstrual flow.
Endometrium: Innermost layer of the uterus.
Menstrual Cycle Phases
Menstrual phase: Bleeding (1-5 days), during which the endometrium is shed.
Endometrium thickens to receive the fertilized ovum during the proliferative phase in response to estrogen.
If no fertilization occurs, the tissue is shed because it is not healthy (becomes necrotic due to lack of hormonal support).
Renewal process takes approximately nine months during pregnancy to prepare the uterus for fetal development.
Estrogen and progesterone from the ovary drive the cycle.
Menopause Defined
Menopause: Cessation of menstruation due to cessation of female sex hormones, primarily estrogen and progesterone.
Diagnosis: No period for one continuous year.
Menopause Symptoms and Treatment
Hot flashes are common due to decreased estrogen levels affecting the hypothalamus.
Hormone replacement therapy (HRT) might relieve symptoms but has risks. It should be used at the lowest effective dose for the shortest possible time.
Treatments are symptomatic, including lifestyle modifications like avoiding caffeine and alcohol, dressing in layers, and using fans.
Osteoporosis
Osteoporosis: Bone fragility after menopause due to decreased estrogen levels.
Estrogen helps maintain calcium in bones, promoting bone density.
Lack of estrogen leads to fragile bones and fractures, particularly in the hip, spine, and wrist.
Birth Control
Birth control is recommended until over 35 to prevent unintended pregnancy, as fertility declines but is still possible.
Options: Injections every three months (e.g., Depo-Provera), which contain progestin to prevent ovulation.
Intrauterine Device (IUD)
IUDs interfere with implantation by creating a hostile environment in the uterus.
Create inflammation and irritation in the endometrium, preventing the fertilized egg from attaching to the uterine wall; types include hormonal (Mirena, Skyla) and copper (ParaGard).
Fallopian Tube Ligation
Laparoscopy: Minimally invasive surgery to grasp and band the fallopian tube; this is a permanent form of contraception.
Cutting the tube prevents recanalization (rejoining), making it more effective.
Reversal is difficult and not always successful; success rates vary depending on the method used for ligation and the woman's age and overall health.
Diagnostic Procedures
Biopsy: Gold standard for diagnosing abnormal diseases, providing a tissue sample for microscopic examination.
Blood test: For hormone levels, detecting abnormalities in estrogen, progesterone, FSH, LH, and other hormones.
Colposcopy: Visualizes the vagina and cervix using a magnifying instrument to identify abnormal areas for biopsy.
Hysteroscopy: Visualizes the uterus using a camera inserted through the cervix to identify polyps, fibroids, or other abnormalities.
Laparoscopy
Laparoscopy: Removal of the uterus through small openings using minimally invasive techniques.
Recovery is easier and shorter compared to traditional open surgery.
Patients spend less time in the hospital, typically one or two days.
Mammogram
Mammogram: X-ray used to detect microcalcification (white dots indicating abnormal calcium) and other abnormalities in breast tissue.
Biopsy Procedure
X-ray detects microcalcification, and ultrasound guides needle placement to take a biopsy for further examination and diagnosis.
Pap Smear
Pap smear: Screens for cervical cancer and human papillomavirus (HPV) by collecting cells from the cervix for examination.
Cervical cancer: Can spread rapidly due to the vascular nature of the cervix.
Detects HPV strains 16 and 18 and cellular changes (metaplasia), which are high-risk strains associated with cervical cancer.
Breast Examination
Mammograms are best for women over 40, as breast tissue density decreases with age.
Ultrasound is better for young women due to dense breast tissue, making it harder to detect abnormalities with mammography.
Dysmenorrhea
Dysmenorrhea: Pain during menstruation.
Pregnancy relieves dysmenorrhea by altering hormone levels and reducing uterine contractions.
Treatment: Rest, valencetide, and exercise can help manage symptoms by reducing inflammation and promoting relaxation.
Abnormal Uterine Bleeding
Dysfunctional uterine bleeding includes:
Menorrhagia (excessive menstruation): Prolonged or heavy bleeding during periods.
Metrorrhagia (bleeding between periods): Bleeding that occurs at irregular intervals.
Source is often the uterus, but can also be caused by hormonal imbalances, polyps, fibroids, or cancer.
Genetic Testing for Cancer
Genetic testing can reveal if a patient carries genes associated with breast cancer, such as BRCA1 and BRCA2.
Example: Angelina Jolie's decision to have a mastectomy and oophorectomy after discovering she carried the BRCA1 gene.
Breast Cancer Treatment
Lumpectomy: Removal of the mass only, preserving the rest of the breast tissue; often followed by radiation therapy.
Mastectomy: Removal of the entire breast; may be necessary for larger tumors or if cancer has spread.
Ovarian Cancer
Ovarian cancer is often detected late because symptoms are vague and nonspecific.
Symptoms: Abdominal discomfort, bloating, digestive issues, fatigue, and changes in bowel habits.
Cancer Detection
Early detection is key in cancer treatment to improve outcomes and survival rates.
Ultrasound can detect ovarian cancer, particularly in women at high risk or with suspicious symptoms.
Inoperable cancers may attach to the urethra, making surgical removal difficult or impossible.
Curette Procedure
Curette: Spoon with a sharp edge used for biopsy and cleaning purposes during gynecological procedures.
D&C: Dilation and curettage, a common procedure involving dilation of the cervix and curettage of the uterus.
D&C Uses
Used to clean the uterus after abortion or miscarriage to remove retained tissue.
Used to take endometrial samples for biopsy to diagnose abnormal bleeding, infertility, or endometrial cancer.
Cervical Dilation
Cervix must be dilated gradually using Hagar dilators or other instruments to avoid complications.
Rapid dilation can damage muscles and cause cervical incompetence.
Potential complications: Habitual abortions (recurrent miscarriages) due to weakened cervical support.
Abortion Limits
There are no medical limits to the number of abortions a woman can have if the D&C is performed correctly and without complications.
Hormonal Replacement Therapy
Hormonal replacement after menopause may increase cancer risk, particularly breast cancer and endometrial cancer.
Thyroid Issues
Thyroid fibroids: Can vary in size and may require monitoring or treatment if they cause symptoms or growth.
Endometriosis
Endometriosis: Endometrium (uterine lining) in an abnormal location outside the uterus, such as the ovaries, fallopian tubes, or pelvic peritoneum.
Causes bleeding and adhesions, leading to pain, infertility, and other complications.
Blood acts as a strong glue in the body, causing tissues to stick together and form adhesions.
Diagnosed by laparoscopy, allowing direct visualization of endometrial implants and biopsy confirmation.
Post-Surgical Cleaning
After C-sections, the pelvis must be thoroughly cleaned to remove blood residuals to prevent infection and adhesion formation.
Blood is a strong adhesive and can lead to complications if not properly removed.
Endometriosis Symptoms
Endometriosis adhesions can cause dysmenorrhea (painful menstruation) and chronic pelvic pain.
Uterine contractions might cause pain if the uterus is attached to other structures due to adhesions.
Sexually Transmitted Diseases
Sexually transmitted diseases can inflame the fallopian tubes, leading to pelvic inflammatory disease (PID) and potential infertility.
Online Course Policies
Online course requires participation and original work to ensure active learning and engagement.
Copy-pasting is prohibited to promote critical thinking and academic integrity.
Students must study and prioritize anatomy to understand the structures and functions of the reproductive system.
Infertility
Couples are considered infertile if they live together without contraception for one year and are unable to conceive.
Ninety percent of infertility cases have a physical cause that can be identified and potentially treated.
Male factors are examined first due to the relative ease and non-invasiveness of semen analysis.
Female Infertility
Female infertility causes include:
Anovulation: Absence of ovulation or irregular ovulation.
Endometriosis: Endometrial tissue outside the uterus.
Fallopian tube damage: Blockage or scarring of the fallopian tubes.
Infections: Pelvic inflammatory disease (PID) or other infections.
Painful Menstruation
Dysmenorrhea: Pain during menstruation, which can be primary (not related to other conditions) or secondary (caused by underlying conditions like endometriosis or fibroids).
Contractions can cause pain if the uterus is attached to other structures due to adhesions or other abnormalities.
Human Reproduction
Fertilization occurs in the fallopian tube, typically in the ampulla.
Millions of sperm are released, but only one fertilizes the ovum, preventing polyspermy.
Fertilization Process
After sperm penetration, a chemical reaction hardens the ovum wall to prevent other sperm from entering.
If another sperm invades, it causes congenital abnormalities due to an incorrect number of chromosomes.
Fertilization results in 46 chromosomes (zygote), the normal diploid number.
Pregnancy Stages
Zygote: Fertilized ovum containing 46 chromosomes.
Blastocyst: From implantation to week 3, a hollow ball of cells that implants in the uterine lining.
Embryo: From week 3 to 8, period of organogenesis where major organs and systems develop.
Fetus: After week 9 until birth, period of growth and maturation.
Blastocyst
Blastocyst: Sac with fluid containing the inner cell mass, which will become the embryo.
Produces hormones to detect pregnancy, such as human chorionic gonadotropin (hCG).
Doctors look for the sac early to confirm pregnancy via ultrasound.
Oogenesis - Oocyte Development
Oocytes start as diploid primary oocytes ( ilda 2 million before birth).
Decrease to ilda 400,000 by puberty.
Only 400 will become secondary oocytes that may be ovulated during a woman's reproductive years.
Primary oocytes remain in prophase I until ovulation.
Follicle: Oocyte and surrounding support cells, including granulosa cells and theca cells.
Oogenesis - Meiosis and Ovulation
Before ovulation, a primary oocyte completes meiosis I, forming a haploid secondary oocyte and a polar body.
Ovulation occurs around day 14 of a 28-day cycle, but this can vary based on hormonal fluctuations.
Typically alternates monthly between ovaries, although this is not always consistent.
The secondary oocyte is released from a mature follicle (Graafian follicle).
Oogenesis - Capture and Transport
Fimbriae draw the ovulated oocyte into the uterine tube through peristaltic movements.
Peristaltic contractions and ciliary activity move it toward the uterus.
Fertilization occurs in the ampulla, the widest portion of the fallopian tube.
Fertilization - Sperm Interaction
During ejaculation, over one-half billion sperm are deposited into the female reproductive tract.
A few thousand reach the ampulla in 10-15 minutes, aided by uterine contractions and sperm motility.
Only one sperm penetrates the secondary oocyte, triggering the completion of meiosis II and the formation of the ovum and another polar body.
Haploid oocyte pronucleus unites with the sperm pronucleus, creating a diploid zygote.
Early Development - Cleavage and Morula
Over 3-4 days, the zygote undergoes cleavage (mitotic divisions) while moving along the uterine tube.
This forms a solid sphere of cells known as a morula, consisting of 16-32 cells.
Early Development - Blastocyst Formation
The morula enters the uterine cavity and transforms into a blastocyst.
The blastocyst differentiates into two groups:
Trophoblast: Outer layer forming the placenta and embryonic membranes; it secretes hormones to support pregnancy.
Embryoblast (inner cell mass): Forms the embryo; it differentiates into the three primary germ layers (ectoderm, mesoderm, and endoderm).
Implantation Preparation
Progesterone and estrogen thicken the endometrium, creating a nutrient-rich environment conducive to implantation.
Implantation - Attachment and Differentiation
Implantation begins about 7 days after fertilization, as the blastocyst attaches to the uterine lining.
Trophoblast cells differentiate into syncytiotrophoblast and cytotrophoblast.
Syncytiotrophoblast invades the endometrium, forming lacunae (spaces) that fill with maternal blood.
The blastocyst becomes embedded superficially in the endometrium.
Trophoblast Function
Mitotic cytotrophoblasts add cells to the syncytiotrophoblast, contributing to its growth and function.
Syncytiotrophoblast forms the maternal-fetal blood barrier for nutrient and gas exchange, allowing transfer of oxygen and nutrients while removing waste products.
Blastocyst Importance in Implantation
Blastocyst: Commonly implanted in the upper posterior wall of the uterus.
Trophoblast: Secretes hormones detectable for pregnancy, including human chorionic gonadotropin (hCG), which is used in pregnancy tests.
Confirmation of Pregnancy
Pregnancy is confirmed by detecting blastocyst-secreted hormones in pregnancy tests, typically hCG in urine or blood.
Implantation Process
Blastocyst embeds into the uterus, preventing a period due to hormonal signals maintaining the endometrium.
Protective Layers
Chorion and amnion layers protect the embryo with amniotic fluid, providing a cushion against physical trauma and maintaining a stable temperature.
Amniotic fluid allows the embryo to grow and move, promoting musculoskeletal development.
Placenta Details
Placenta is the site of exchange between mother and fetus, consisting of chorion and endometrium.
Nutrients are transferred from mother to fetus through blood via diffusion, active transport, and pinocytosis.
Placenta means feeding, reflecting its crucial role in providing nutrients to the developing fetus.
Umbilical Cord
Umbilical cord contains two arteries and one vein that connect the fetus to the placenta.
The vein carries oxygenated blood and nutrients from the placenta to the fetus, while the arteries carry deoxygenated blood and waste products from the fetus to the placenta.
Gastrulation
After blastocyst stage, gastrulation forms three layers: ectoderm, mesoderm, and endoderm.
These layers manufacture organ systems during organogenesis, the development of organs and tissues.
Initial Stage
Limb formation occurs in the first three months, a critical period for development.
Avoid medications, alcohol, and smoking during this time to prevent congenital malformations.
Medication
No medication or alcohol during pregnancy unless prescribed by a doctor due to potential harm to the developing fetus.
Substances can transfer to the baby through the placenta, leading to various complications.
Thalidomide led to limb malformations when used by pregnant women in the 1950s and 1960s.
Teratogens
German measles (rubella) is a powerful teratogen that can cause severe birth defects if contracted during pregnancy.
Teratogen: Generates abnormal states or malformations.
Alcohol: Causes fetal alcohol syndrome, characterized by facial abnormalities, growth deficiencies, and neurological problems.
Smoking: Harmful during pregnancy, increasing the risk of preterm birth, low birth weight, and sudden infant death syndrome (SIDS).
Nutrition
Avoid malnutrition during pregnancy to ensure proper fetal development and prevent long-term health problems.
Workplace Hazards
Avoid working with hazardous fumes during pregnancy to minimize exposure to teratogens and toxic substances.
Fetal Circulation
Pulmonary systems:
Pulmonary vein vs. aorta carries oxygenated blood in the pulmonary circulation.
Temporary changes in the fetal cardiovascular system accommodate the lack of functional lungs.
Umbilical vein carries blood to the right side of the heart due to the lack of functional lungs.
The foramen ovale allows blood to flow from the right atrium to the left atrium, bypassing the pulmonary circulation.
At birth, the foramen ovale closes, and the pulmonary circulation becomes fully functional.
Corpus Luteum
Corpus luteum, or the yellow box, controls pregnancy by secreting hormones to maintain the uterine lining.
Secretes hormones to support pregnancy, communicating with the blastocyst via hormonal signals.
Hormonal Levels
Estrogen levels can be 30 times higher during pregnancy to support uterine growth and placental function.
High estrogen levels stop ovulation by suppressing the release of gonadotropin-releasing hormone (GnRH).
Thyroid hormone changes with a lot of bodily hormones to meet the increased metabolic demands of pregnancy.
Placenta secretes hormones, including hCG, estrogen, progesterone, and human placental lactogen (hPL).
Morning Sickness
Morning sickness is due to high hormone levels, particularly hCG, causing nausea and vomiting.
Hyperemesis gravidarum involves severe vomiting, leading to dehydration, electrolyte imbalance, and weight loss.
Cardiac Output
Cardiac output increases by 50-70% during pregnancy to meet the increased oxygen and nutrient demands of the fetus.
Integumentary Changes
The area around the navel and breasts darkens during pregnancy due to increased melanin production.
Linear alba darkens, forming the linea nigra, a dark line running down the abdomen.
Ultrasound Safety
Ultrasound is safe and noninvasive during pregnancy, using sound waves to create images of the developing fetus.
Delivery Process
During delivery, the cervix dilates to allow passage of the baby.
Dilation
Contractions cause cervical dilation, gradually opening the cervix to 10 centimeters.
Oxytocin stimulates more contractions, helping to progress labor.
Effacement
Effacement: Thinning of the cervix, measured as a percentage (e.g., 50% effaced).
More important than dilation, as effacement prepares the cervix for delivery.
Episiotomy
Episiotomy: Cutting the perineum to enlarge the vaginal opening, but could cause sphincter damage if it's not done instead of tearing.
Prevents tearing into the anal sphincter, but routine episiotomies are no longer recommended due to potential complications.
Placental Delivery
The placental delivery should look complete to ensure no retained placental fragments remain in the uterus.
The placenta has multiple villi called quotilimums, which are essential for nutrient and gas exchange.
Fetal Presentations
Fetal presentation: Position of the baby in relation to the birth canal.
Cephalic (Head down): Normal and optimal for vaginal delivery.
Breech (buttocks down): Abnormal and may require C-section.
Breech Delivery
Breech delivery used to be common, but now C-sections are preferred due to increased risks for both mother and baby.
Complications can occur during breech delivery, including umbilical cord compression and birth trauma.
Abnormal presentations often require C-sections for safe delivery.
C Sections
Anesthesia is safer now, so C-sections are more common and can be planned or performed in emergency situations.