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It may simulate mastitis carcinomatosa, but is not particularly associated with pregnancy. The skin is stretched, and may ulcerate; there are usually other tumours elsewhere. If the fluid is clear and the lump disappears, as is usual in fibrocystic disease (the commonest cause), no further treatment is necessary. If it is an obvious fibroadenoma, shell it out completely unless it is <1cm in diameter, when you can review it at 3-monthly intervals (24-5). If you are not sure but think it is benign, remove it completely together with a 2cm margin of tissue around the lump and send it for histology. Do not try to perform a trucut biopsy on a small lump, especially if it is mobile; you may well miss it or just biopsy unrepresentative tissue! If there is a lump and a discharge from the nipple, it is likely to be a duct papilloma, adenoma or carcinoma. Otherwise do an open biopsy; it is better to do this on the nodes because the breast may not heal well. Fine needle aspiration cytology is the best method but needs careful immediate expert examination of the slides. Do cytology on axillary nodes: if you find breast cells you have proved metastases. Or, do a trucut biopsy if the lump is big enough and you can hold it firmly in the hand (24-3). Otherwise either excise the lump fully with a 2cm margin of normal tissue and remember to orientate it properly for the pathologist, by marking it with indelible inks or coloured threads. B, introduce the closed biopsy needle into the lesion, with an assisting steadying the lump. Ultrasound is useful to distinguish between cystic and solid lesions, and between discrete lumps and lumpy breasts. Mammography needs special equipment where the breast is squeezed between two plates and X-rayed; it is sometimes painful and does not pick up all carcinomas. Try to screen women with a strong family history of breast cancer before the age of 40yrs, or contralateral breast cancer, especially of the lobular type. A, if the lump is within 5-8cm of the nipple, make a circumareolar incision, not longer than the circumference of the areola. B, if the lump is further away make a curved circumferential incision over it, parallel to the areola. C, if the lump is deep in the breast, you may be able to use a submammary incision. E, if your histology services are good enough to justify taking a biopsy, make a radial incision within the area of a possible later mastectomy, so that you can excise the scar. If you are removing a benign lump from a woman, try not to disfigure the breast or compromise future lactation. Use a circumareolar (24-4A), circumferential (24-4B) (less satisfactory), or submammary incision (24-4C). If you suspect malignancy, excise the lump with a margin of at least 2cm of normal breast, and orientate the specimen carefully for the pathologist. Gently dissect radially through the breast from the areola, in line with the ducts. You can cut round the circumference of the areola without compromising its blood supply. By a circumferential incision over it (24-3B), remove any lump if an inframammary incision is too far away. This produces an obvious scar, but will be much more aesthetic than a radial scar. By a submammary incision (24-3C), approaching the lump rom the underside, remove deep inferiorly placed lumps: this will be less easy than the circumareolar or circumferential incisions.
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After an injury has been repositioned, confirm presence of pulses and sensation in the distal portion. After an injury has been repositioned, the joint above and below, as well as the injured section, should be immobilized. The primary objective of field care for suspected fractures is to provide a rigid external support along the entire length of the injured bone. Splints will be used of sufficient length or design, to allow the member to secure and immobilize the adjacent proximal joint, the injured bone, and the adjacent distal joint. After an injury has been immobilized, confirm the presence of distal pulses or capillary refill less than 2 seconds, and normal sensation. Traction splints are used primarily for treatment of suspected closed, mid-shaft femur fractures. Application of traction reduces the muscle spasm associated with a fractured femur and eliminates much of the pain. It causes alignment of the bone fragments, reduces/controls bleeding and shock, and prevents further nerve, vascular and tissue damage. At the hollow of the knees, gently slide the elastic leg cravats through the space, slide to the appropriate position, and secure. Contraindications of a traction splint associated with a femur fracture: Pelvic fracture. Serious chemical injury requires irrigation at the site of the injury, before the patient is brought to the emergency department. None, but care should be given in cases of possible perforating injury to the eye. Direct the gentle stream onto the sclera (white part) of the eye, letting the entire eye be rinsed. It is recommended to irrigate acid injuries to the eye for a minimum of 5 minutes and to irrigate alkali injuries to the eye a minimum of 15 minutes. Table 8-1: Patient Age Distributions Neonate: "Newly Born" < 1 hour old Infant 1 hour old and < 1 year old Child 1 year old and < 8 years old Adolescent 8 years old and <16 years old Adult 16 years old Table 8-2: Normal Vital Signs by Age Group Pulse / Min. Whenever a patient deteriorates without apparent reason, re-evaluate per C-A-B or A-B-C if age < 8 years old. All patients shall be moved and/or transported in a safe manner in accordance with the "Standard of Care for Patient Movement" guideline. Paramedics are permitted to change the treatment plan from one standing order to another once prior to consulting with an on-line physician. Appropriate treatment of a patient may require the use of more than one protocol simultaneously. All members should employ their best clinical skills with complex medical patients and are encouraged to contact on-line medical control for further guidance. Throughout the protocols, medications specified as intravenously given may be given via the intraosseous route at the same dosage as the intravenous route. It is the responsibility of the paramedic to contact the Base Station in ample time so there is no delay in patient care waiting for an on-line physician. In other words, contact the Base Station prior to the last allowed steps of the standing orders. Cardiac arrest resuscitations are a team effort by the members of the Houston Fire Department. Chest compressions are believed to be the most vital task in a cardiac arrest resuscitation. Any interruption in chest compressions shall be minimal and members on scene should verbalize to all present when chest compressions have been discontinued for more than 10 seconds. There is a decreased demand in the amount of ventilation and oxygenation a pulseless patient requires. Additionally, studies have shown that hyperventilation is detrimental to the successful resuscitation of a cardiac arrest patient because the increased intrathoracic pressure produced by hyperventilation decreases perfusion to the heart. Airway Management Adults: Initial airway management will be performed with Bag Valve Mask ventilation. If these methods fail, proceed with endotracheal intubation ensuring no interruption in chest compressions. Assuming successful ventilations with the supraglottic airway, securing of the airway via an endotracheal tube shall be performed at an appropriate point later in the resuscitation effort that will allow the individual performing the intubation to do so in a controlled, focused fashion. It is unacceptable to interrupt chest compressions more than momentarily while performing endotracheal intubation.
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The infection may have reached the iliac nodes from the leg, the perineal area (including the genitalia), or the buttocks. The abscess lies near the psoas muscle; this goes into spasm and sharply flexes the hip, so that extension beyond 90є and walking is impossible. There is a tense, tender, hard mass in the iliac fossa, which is lower, and closer to the anterior iliac spine, than an appendix mass. Fluctuation is rare, and only occasionally will you find the site of the primary infection. An appendix abscess is quite different, and is inside the peritoneum, whereas all these other conditions are retro-peritoneal. Suggesting an appendix abscess: a different anatomical site: intraperitoneally in the right iliac fossa, with nausea and vomiting, less spasm, and only mild flexion of the hip (14. Suggesting septic arthritis of the hip: severe joint spasm, acute pain on percussing the greater trochanter, no palpable mass, no movement of the hip owing to severe pain, and a radiograph showing a widened joint space. This is equivalent to osteomyelitis because the epiphyseal plate is inside the capsule of the hip joint (7. Suggesting tuberculosis of the hip: a chronic history and radiograph signs of tuberculosis (5. Suggesting a tuberculous psoas abscess arising from the spine: a chronic history, radiographic changes in the spine. A psoas abscess does not usually need drainage, unless it is very large and causing pain. It will resolve slowly on therapy for tuberculosis; incising it can lead to secondary infection. Suggesting acute and usually staphylococcal osteomyelitis of the spine (uncommon): more pain, spasm of the sacrospinalis, radiographic signs in the spine. Feel the exact site of the mass and its consistency and boundaries, and feel for fluctuation. It is more difficult if the right hip is flexed, because the diagnosis on this side includes appendicitis. Suggesting iliac adenitis with periadenitis or an abscess: a septic lesion on the skin which may be minimal and have healed (adenitis may appear 2wks after the primary lesion has settled), a markedly flexed hip with a short history, a mass in the groin or right iliac fossa just above the inguinal ligament, no pain when you percuss the greater trochanter; you can flex the hip a bit more, no spasm of the sacrospinalis, and no radiographic changes. The differential diagnosis may be impossible, and is not important because the treatment is the same. Deep inguinal (iliac) adenitis with periadenitis and without pus formation does not require drainage. If infection is slow to resolve, use skin traction (1/7th of the body weight) to avoid contracture and raise the foot of the bed. The abscess will have pushed the peritoneal lining of the right iliac fossa medially and superiorly. Make an incision 5-10cm or more over the swelling about 2cm above the inguinal ligament, starting just medial to the antero-superior iliac spine (6-12D). Take a long haemostat and push this through the muscle over the abscess until you find pus. Draining an iliac abscess is potentially dangerous: you may injure the caecum or the iliac vessels. A connection between the skin and the anus (a fistula) is the reason why about half of these abscesses recur, or discharge persistently. Abscesses (with no opening to the skin), sinuses (with an opening to the skin, but not to the anus), and fistulae (with openings to both) are thus part of the same disease process (26. Most abscesses settle by discharging spontaneously, or being drained, but a serious life-threatening infection can sometimes spread in the soft tissues, or deeply into the pelvis. Presentation is usually acute because the pain is intense: severe throbbing pain keeps the patient awake at night. Sometimes, there may be little to see and no fluctuation to feel, except mild tenderness at the anal margin, or, the whole perineum may feel tense and tender. But there may now be a persistently discharging sinus or fistula opening on to the skin near the anus.
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Also a focus on running and sprinting technique, as well as a controlled progression of total running load towards the expected running and sprinting exposure in training and matches for the individual player is emphasised. Multi-directional running through the execution of simple football skills can be included. Football circuits and training drills can be introduced and progressed in terms of complexity and decision-making before returning to field sessions with the squad. Pain free running up to maximal speed including change of directions, performed under fatigue, is paramount. Similarly, passing and kicking require controlled progression, as emphasized earlier (see quad section 3. The exercises are increased with controlled load and strengthening exercises may include more specific modifications for the individual player and activation routine before training is introduced. Exercises and activation routine before training is advised to continue, in addition to resumption of partial training with the team. Program which exercises to do with the team, and which to do with medical and performance staff, as well as analysing the locomotor loads. The running is progressed by adding changes in direction and velocity through football-specific drills and tests, including both linear, turns, accelerations and decelerations. Compared to other muscle injury cases that we will show you in this specific muscle injury section. However, in some cases surgery should be performed immediately after the injury occurs. Surgery may also be necessary if conservative treatment fails to achieve a satisfactory result for example if the player has chronic symptoms or recurrent injuries. However, in the elite football player, surgery is often recommended irrespective of which tendon is involved (Figure 15 A-B). Apophyseal avulsions of the ischial tuberosity occur occasionally in adolescent players. Although surgery is rarely necessary for distal hamstring injuries, in some cases it is necessary. The expected return-to-play timeline is similar following surgical repair of complete ruptures at the myotendinous junction, and restoration of full function is also the most likely outcome. Some hamstring injuries become recurrent or lead to chronic symptoms, despite high-quality conservative treatment. Although the research evidence is limited, potential causes of a poor conservative outcome include incomplete healing of partial avulsions, injuries to the central intramuscular tendon, increased compartmental pressure, excessive scarring, sciatic nerve entrapment, and heterotopic ossification. Surgical treatment involves debdridement of the ischial tuberosity and reinsertion of the detached tendon(s) to the bone. In these cases, surgery is often beneficial and the player can often return to optimal performance after approximately 4-5 months. The continuity of the central tendon is restored by suturing, and the attachment of the muscle to the tendon is reinforced. Suture anchors may be used if the tear is located close to the ischial tuberosity. According to a recent paper, operative treatment of recurrent central tendon ruptures seems to lead to a good overall outcome in high level athletes, and return to optimal performance was achieved at 3- 4 months from the surgery with no adverse events during follow-up. Return to preinjury activities is expected in the majority of these cases approximately after 6 months from the operation. This has serious consequences for the recovery time and functional outcomes, which are of upmost importance to the professional footballer. When choosing a treatment, practitioners should remember that hamstring injuries can be career ending. Surgical treatment should always be considered when athletes sustain complete proximal or distal tendon avulsions. Finally, it is important to note that surgery is technically easier if performed soon after the injury has occurred. These symptoms can be a result of so called post traumatic hamstring syndrome or compartment syndrome. After surgery, most of the athletes are able to return to the same level of sporting activity as before the onset of the symptoms. Understanding biology will help when estimating injury prognosis and planning a strategy for appropriate loading through the return to play continuum.
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Do not administer a large quantity, because it may be difficult to wash out, and the patient may vomit and aspirate. Pyloric obstruction causing dehydration and weight loss, or other long-standing obstructive symptoms as described above. Duodenal ulceration with sufficient scarring to contraindicate pyloroplasty; combine it with a truncal vagotomy. As a palliative procedure for stenosis caused by an antral carcinoma or gastric outlet obstruction by pancreatic carcinoma. If you find a large thick walled stomach, the diagnosis of pyloric stenosis is confirmed. Ask your assistant to retract the liver upwards with a deep retractor, and to draw the stomach downwards at the same time. If there are hard nodules, enlarged hard lymph nodes, and perhaps an ulcer crater, just proximal to the pylorus, suspect a gastric carcinoma. If there is a mass in the head of the pancreas pressing on the duodenum from behind, suspect a pancreatic carcinoma. If there is: (1);Puckered scarring on the front of the first part of the duodenum, perhaps with adhesions to surrounding structures. Carcinoma rarely affects the first part of the duodenum, so that lesions there are almost certainly benign. If you are not sure what is obstructing the outlet of the stomach, perform a gastrojejunostomy and biopsy a regional node. Insert stay sutures through the seromuscular coats of the stomach and jejunum at each end. Then remove the clamps and finish the outer anterior layer, and test the anastomosis digitally. The stomach wall is likely to be thick, perhaps very thick, if the pyloric stenosis is long-standing. Complete the layer of continuous seromuscular sutures using 2/0 long-acting absorbable (13-16D). The first should be about 8cm from the duodeno-jejunal flexure, and the second about 6cm distal. If you fail to include them in your sutures, they may bleed, or the suture line may leak. Take care not to rupture the spleen, or the gastrosplenic vessels by pulling on the stomach too much: make sure you have adequate exposure. Make sure a nasogastric tube is in place; if the patient is severely hypoproteinaemic, pass the tube into the jejunum through the gastrojejunostomy, and start enteral feeding as soon as bowel sounds resume. There is no real advantage of performing a retrocolic gastrojejunostomy: do not do this for malignant disease. The stoma will be less likely to obstruct, if you make it big enough to take three fingers. Continue nasogastric suction, unless there is an indication to re-operate, and correct fluid losses. You may be able to encourage it to function by passing an endoscope through it, or inserting a feeding tube into the jejunum. If, some time after the operation, there is bilious vomiting, reassure the patient. Bile and pancreatic juice are accumulating in the afferent loop, and when they are suddenly released into the stomach, he vomits. If there is persistent very loose diarrhoea and vitamin deficiencies develop, you may have made a gastroileostomy in error: perform a Barium meal to check. If you have, reopen the abdomen, take down the anastomosis, resect the portion of ileum you inadvertently used, and perform a gastrojejunostomy! If a recurrent ulcer on the stoma develops (which you will probably only find by endoscopy), treat it medically in the first instance; re-do surgery is complicated.
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This can happen as the result of a lepra reaction, when a thick sheet of inflammatory tissue scars and perhaps ulcerates. Put the hand through a full range of movement daily during the reaction to keep it mobile. If there is one or more severely deformed fingers, such as a terminal phalanx bent to 90є, consider amputation or, better, an arthrodesis with shortening of the bones to allow for the contracted tissue on the front of the joint. Immobilize the infected joint for at least 4-6wks after the infection is controlled, and the ulcer healed, while putting all the other joints through their full range of movement daily. If splinting one finger is difficult, you may be justified in splinting it with one of its neighbours, depending on their condition. If there is a grossly swollen hand, with pitting oedema of the dorsum, and obliteration of the concavity of the palm, there is probably a midpalmar space infection (8. Make a dorsal incision, remove the joint surfaces, and any dead tissues, and splint the joint in a position of function (7. Keep the joint splinted in the position of function, and wait 12wks till the joints are no longer painful. One of the hazards of a shoe is that it may press on the sides of the big toe over a long period, and make the side of the nail grow into the soft tissues and cause pain, inflammation, and the discharge of pus from the nail fold. Carefully cutting away the nail may relieve the symptoms, but if this fails, more radical surgery is indicated. If the toe-nail is not deformed, you can excise a wedge of soft tissue; but if it is deformed, a more comfortable toe will result if you remove the whole toe-nail, including its bed. If the nail grows back in the same way, you can again remove a wedge, including a wedge of the nail bed. A tourniquet gives a bloodless field: you can achieve this with a rubber twisted around the base of the toe. Do not do this operation if there is peripheral vascular disease; use prophylactic antibiotics with diabetics and advise elevation for 24hrs. The exercises shown here are for acute and chronic paralysis, and will prevent a hand like (B) from becoming a stiff claw hand (C) which physiotherapy cannot cure. Instruct the patient like this: D, "Rest the back of your hand on your thigh, or on a table padded by a cloth. E, Use your other hand to rub your fingers as straight as they will go, taking care not to crack any weak skin. H, Use your other hand to straighten the end joint of your thumb, as straight as it will go. I, Pull gently and firmly, as if you were trying to lengthen your thumb, but do not pull it backwards. Use your other hand to support the back of your thumb firmly (to keep its mcp joint flexed). Make sure you extend the incision proximally if there is infection under the nail bed (paronychia). When sepsis has settled, remove the entire germinal matrix (the growth plate) of the nail. Make two 1cm incisions proximally from the corner of the nail to the transverse skin crease over the ip joint (32-38A). Lift up the skin as a flap proximally to expose the nail bed (32-38B,C): continue the dissection on the sides to expose all the germinal matrix (32-38D). Cut across the nail bed to remove the block as far back as the insertion of the extensor tendon on the phalanx. Close the wound with 3/0 monofilament sutures after removing any fragments of germinal matrix left behind (32-38E). Other differential diagnoses include: (4) ordinary fractures (especially if they present late), (5) stress fractures (fatigue fractures, (6) simple bone cysts & exostoses, (7) metastatic tumours, and other primary bone tumours. The tumour extends considerably beyond the area of the bone, which is involved clinically, or radiologically. Most arise de novo, but about 20% arise in patients with multiple chondromas, and <5% from patients with a pre-existing chondromas. They are less aggressive than osteosarcomas, and spread by local infiltration; bloodstream spread is late. Fibrosarcomas arising from the periosteum behave like fibrosarcomas of the soft tissues.
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A hazy cornea or a pupil which does not respond normally to light should make you suspect glaucoma. The end stage of glaucoma is a patient with a blind, or nearly blind eye, with a large pupil that does not react to light. Loss of visual field is an early sign, but is not easy to test with simple equipment. The lamina cribrosa is a mesh-like structure of collagen in the sclera wall which maintains the pressure gradient. This is the most important sign to look out for in glaucoma: you usually need to dilate the pupils. If you shine a light into a normal eye in a semi-dark room, its pupil will constrict (direct response), and so will also the other pupil automatically (consensual response). If the optic nerve is completely destroyed, there will be no direct or consensual response (total afferent pupil defect). If the optic nerve is partly destroyed (for example 90%), the pupil will constrict slowly when the light shines in it (partial afferent pupil defect), and the consensual response will be present. The swinging torch test, is a useful test for early asymmetrical optic nerve damage, and does not need an ophthalmoscope. In a semi-dark room shine a light into the good eye, and then swing it across into the bad eye (the eye with reduced vision). As you swing the light quickly across to the bad eye, its pupil, which was previously constricted, will now dilate. This indicates a relative afferent pupil defect, early optic nerve damage, and a difference in function between the two optic nerves. The practical test is to swing the torch from one pupil to the other and back again in a semi-dark room. If one pupil consistently dilates as light shines on it, that eye has a reduced pupil response, relative to the better eye. To treat glaucoma effectively, measure the intraocular pressure, and monitor the visual fields regularly. E, complete loss of visual field apart from a small central island, and a larger temporal island, in advanced glaucoma. I, pathological cupping of the optic disc due to glaucoma with a cup/disc ratio of 0 7. Use acetazolamide 500mg orally followed by 250mg qid, as soon as the nausea has subsided. This will keep the periphery of the iris away from the angle of the eye, where the aqueous flows out, and so help it to drain. Rainbow-coloured haloes round lights, and misty vision, are important prodromal signs, and need urgent investigation and treatment. Secure the eye by means of a traction suture of 4/0 silk through the belly of the superior rectus muscle. Mark a rectangular sclera flap 5x5mm of half the scleral thickness hinged at the limbus, dissecting this forward till you see the transparent cornea. Then grasp the peripheral iris with forceps, prolapsed it and excise it to make a peripheral iridectomy. If you incise too much sclera, you may reach the ciliary body and cause a choroidal detachment. Return the sclera flap on its hinge to its bed, and close wound, and then close the conjunctiva at each corner both with with 9/0 or 10/0 nylon. Treat the primary condition, and try to arrange referral: in the meantime, treat with acetazolamide, mannitol, or glycerol as above. Use acetazolamide 500mg immediately followed by 250mg qid, and arrange cataract extraction. Try to arrange an urgent incision of the trabecular meshwork to allow flow of aqueous. Microfilariae invade all parts of the eye: the cornea (keratitis), the anterior chamber (iritis), the retina (chorioretinitis), and the optic nerve (optic neuritis).
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If the sac ruptures more than 18 hours before birth occurs, the likelihood of fetal infection is increased, and the hospital staff should be alerted. Furthermore, delivery may be more difficult when the amniotic sac has ruptured prematurely, because amniotic fluid serves as a lubricant. This sensation is caused by the fetal head in the vagina pressing against the rectum and indicates that delivery is imminent. If there is not enough time to-get to the hospital; the paramedic must prepare to assist in the delivery; If the mother is in a crowded or public place; the paramedic should try to find a private; clean area to work: the patient may find it reassuring to have her husband or a friend present: Paramedics should remain calm; because this will exert a calming influence on the patient and any others present. She then should bend her knees and spread her thighs apart, as shown the mother also should be examined to see whether the fetus is crowning. When crowning occurs, vaginal opening will bulge outward and the presenting part of the fetus will be visible at the opening (see. The paramedic should avoid (ditching the mothers anus during delivery: the time of birth should be recorded. After the baby is fully delivered, he or she should be opening is thoroughly covered; If the baby is coming fast, it is more important for the paramedic to assist in the delivery than to put on drapes or gloves. The paramedic should encourage the mother to relax and to take slow; deep breaths through her mouth and should continue to reassure her and explain everything that is being done. Blodd and mucus from the nose and mouth should be wiped away with a piece of sterile gauze. The paramedic should squeeze the bulb before inserting the tip of the aspirator and then place the tip in the mouth or nostrils and release the bulb slowly. The contents of the bulb can be expelled into a waste container; and suctioning can be repeated as often as needed: If the baby does not breathe spontaneously; the paramedic should stimulate the infant by rubbing the back gently or slapping the soles of the feet: If there is still no response, the pararriedic should start mouth-tomouth or mouth-to-nose resuscitation, remembering that newborn infants are very little and; thus, require very small puffs of air: Mechanical resuscitation vices should never be used on a newborn infant. The cord should be cut between the two ties and handled gently, becaUse it will tear easily; the end of the cord that is attached to the infant must be A with a sanitary napkin. Complications of Delivery Three types of problems that can accompany delivery will be discussed in this section: post partum hemorrhage, uterine inversion, and pulmonary embolism. The baby should then be wrapped in a sterile blanket to maintain body temperature. The uterine massage will stim- ulate the uterus to contract, thus constricting blood vessels within its walls and decreasing bleeding. Allowing the infant to nurse following the delivery of the placenta will control bleeding; because nursing stimulates the release of oxytocin. Oxytocin; in addition to causing milk ejection; stimulates uterine contraction; which constricts uterine blood vessels. When the placenta delivered, it should be placed in a basin or plastic bag and taken to the hospital where it will be examined for completeness. This procedure is necessary, because pieces of placenta retained in the uterus cause persistent bleeding. The perineum, the skin between the anus and the vagina, should be examined for lacerations, and pressure applied to any bleeding. Try once to replace the uterus manually by exerting pressure first on the area closest to the cervix. If the uterus cannot be replaced easily, pack all protruding tissues lightly with moist, sterile towels, and move the patient rapidly to the hospital. Field treatment is the same as for any patient with pulniOnary embolism and includes admin- istration of oxygen, electrocardiogram monitoring, and rapid transport to the hospital. Parent-Ai° Aiding Drainage of Mucous Deliveries in which the fetal head does not present first are classified as abnormal deliVeries. Three ab- Post parturn hemorrhagePost partum hemorrhage Odours after delivery and is characterized by internal or external bleeding. Internal bleedingInternal bleeding may be caused by retained placental tissue, inadequate uterine contractions; or clotting disorderi. If bleeding is severe; normal presentations will be discussed in this section: breech presentation, prolapsed umbilical cord; and limb presentation.