4 cm dilation of the cervix, no contractions. The period of cervical dilation - active phase

By having an understanding of what happens during each stage of the process, a woman will be able to cope more easily with labor and be an active participant in it.

We will try to give a consistent description of what physiological processes occur during childbirth, what a woman feels at this time, and what medical procedures can be carried out during different periods of labor.

Childbirth is the process of expulsion of the fetus from the uterine cavity, its immediate birth and the release of the placenta and membranes. There are three periods of labor: the period of opening, the period of expulsion and the afterbirth period.

Cervical dilatation

During this period, a gradual expansion of the cervical canal occurs, that is, the opening of the cervix. As a result, an opening of sufficient diameter is formed through which the fetus can penetrate from the uterine cavity into the birth canal formed by the bones and soft tissues of the small pelvis.

The opening of the cervix occurs due to the fact that the uterus begins to contract, and due to these contractions the lower part of the uterus, i.e. its lower segment stretches and becomes thinner. Dilation is conventionally measured in centimeters and determined during a special obstetric vaginal examination. As the degree of dilatation of the cervix increases, muscle contractions intensify, become longer and more frequent. These contractions are contractions - painful sensations in the lower abdomen or lumbar region that the woman in labor feels.

The first stage of labor begins with the appearance of regular contractions, which gradually become more intense, frequent and prolonged. Typically, the cervix begins to dilate with the onset of contractions that last 15–20 seconds and are spaced 15–20 minutes apart.

During the first stage of labor, there are two phases - latent and active.

Latent phase continues until approximately 4–5 cm of dilation; during this phase, labor is not intense enough, contractions are not painful.

Active phase the first stage of labor begins after 5 cm of dilation and continues until full dilation, that is, up to 10 cm. At this stage, contractions become frequent, and pain -
more intense and pronounced.

In addition to uterine contractions, an important part of the first stage of labor is the release of amniotic fluid. The time of discharge of water in relation to the degree of dilatation of the cervix is ​​of great importance, as this can affect the course of the labor process.

Normally, amniotic fluid flows out during the active phase of labor, since due to intense uterine contractions, the pressure on the amniotic sac increases and it opens. Usually, after opening the amniotic sac, labor intensifies and contractions become more frequent and painful.
When the amniotic fluid ruptures before the cervix is ​​dilated by 5 cm, they speak of early rupture. It is most favorable if the outpouring of water occurs after the dilation has reached 5 cm. The fact is that at the beginning of labor, before the cervix is ​​dilated by 5 cm, there is an increased risk of developing weakness of labor, that is, a weakening of contractions or their complete cessation. As a result, the course of labor slows down and may drag on indefinitely. If the amniotic fluid has already poured out, then the fetus is not isolated and not protected by the amniotic sac and amniotic fluid. In this case, the risk of developing intrauterine infection increases. To avoid intrauterine infection, labor should be completed within 12–14 hours from the moment of rupture of amniotic fluid.

If the waters break before regular labor begins and the cervix begins to dilate, they speak of premature rupture of water.

How to behave

If you experience regular painful or pulling sensations in your lower abdomen, begin to note the start and end times of these sensations, as well as their duration. If they do not stop within 1–2 hours, last approximately 15 seconds every 20 minutes and gradually intensify, this indicates that the cervix has begun to gradually open, that is, the first stage of labor has begun and you can get ready for the maternity hospital. At the same time, there is no need to rush - you can observe your condition for 2-3 hours and go to the maternity hospital with more or less intense labor, that is, with contractions every 7-10 minutes.

If your amniotic fluid has broken, then it is better not to delay the trip to the maternity hospital, regardless of whether contractions appear or not, since premature or early rupture of amniotic fluid can affect the choice of labor management tactics.

In addition, remember the time when regular contractions began, and also record when the amniotic fluid was released. Place a clean diaper between your legs so that the emergency room doctor can assess the amount of water and their nature, which can be used to indirectly assess the condition of the unborn baby. If the waters have a greenish tint, this means that original feces - meconium - have entered the amniotic fluid. This may indicate fetal hypoxia, that is, that the baby is experiencing a lack of oxygen. If the waters have a yellowish tint, this may indirectly indicate a Rh conflict. Therefore, even if the water leaks just a little or, on the contrary, pours out in large quantities, you should save the diaper or cotton pad with the leaked amniotic fluid.

To relieve pain during uterine contractions, try to take deep breaths through your nose and exhale slowly through your mouth during contractions. During contractions, you should behave actively, try not to lie down, but, on the contrary, move more, walk around the ward.

During a contraction, try different positions that make the pain easier to bear, such as resting your hands on the bed and leaning slightly forward with your feet shoulder-width apart. If your husband is present at the birth, you can lean on him or squat down, and ask your husband to support you.

A fitball, a special large inflatable ball, will help ease the sensations during contractions.

If possible, contractions can be endured in the shower, directing a warm stream of water to the stomach, or immerse yourself in a warm bath.

What does a doctor do?

During the first stage of labor, special obstetric manipulations are required from time to time to help choose the right tactics for labor and assess the risk of possible complications.

An external obstetric examination is performed upon admission of the expectant mother to the maternity hospital. During this procedure, the approximate weight of the fetus is assessed, the external dimensions of the expectant mother's pelvis are measured, the location of the fetus, the standing height of the presenting part are determined, that is, at what level in the birth canal is the presenting part of the fetus - the head or buttocks.

During a vaginal examination, the condition of the cervix, the degree of its dilation, and the integrity of the amniotic sac are assessed. The presenting part is determined: the head, legs or buttocks of the fetus - and the nature of its insertion, that is, which part - the back of the head, forehead or face - the head was inserted into the small pelvis. The nature of the amniotic fluid, its color and quantity are also assessed.

During the normal course of the first stage of labor, a vaginal examination is performed every 4 hours to assess the dynamics of cervical dilatation. If complications occur, this study may need to be performed more frequently.

Every hour during the dilatation period, the mother's blood pressure is measured and auscultation is performed - listening to the fetal heartbeat. It is performed before contraction, during contraction and after it - this is necessary in order to assess how the unborn baby reacts to uterine contractions.

To more accurately assess the nature of the fetal heartbeat and indirectly study its condition during childbirth, each woman in labor undergoes a cardiotocographic study - CTG. Two sensors are installed on the surface of the uterus, one of them records the fetal heart rate, and the other - the frequency and intensity of uterine contractions.

The result is two parallel curves, after studying which the obstetrician-gynecologist can objectively assess the well-being of the unborn baby, notice signs of possible complications in time and take measures to prevent them. During normal labor, CTG is performed once and lasts for 20–30 minutes. If necessary, this study is performed more often; Sometimes, when the birth is high-risk, a continuous recording of a cardiotocogram is performed. This happens, for example, if there is a postoperative scar on the uterus or with gestosis - a complication of pregnancy, which is manifested by high blood pressure, swelling and the appearance of protein in the urine.

Period of expulsion of the fetus

After the cervix has fully dilated, the second stage of labor begins, that is, the expulsion of the fetus from the uterine cavity, its passage through the birth canal and, ultimately, its birth. This period lasts for primiparous women from 40 minutes to 2 hours, and for multiparous women it can end in 15–30 minutes.

After leaving the uterine cavity, the presenting part of the fetus, most often the head, performing certain rotational movements with its smallest size, gradually descends to the pelvic floor with each contraction and emerges from the genital slit. After this, the birth of the head occurs, then the shoulders, and finally the baby is born entirely.

During the expulsion period, uterine contractions are called pushing. This is due to the fact that, descending to the pelvic floor, the fetus exerts significant pressure on nearby organs, including the rectum, as a result of which the woman has an involuntary strong desire to push.

How to behave?

The second stage of labor requires a lot of energy expenditure from both the expectant mother and the fetus, as well as the well-coordinated work of the woman in labor and the obstetrics-gynecology team. Therefore, in order to make the course of this period as easy as possible and avoid various complications, you should listen carefully to what the doctor or midwife says and try to follow their advice exactly.

During the second stage of labor, obstetric tactics are largely determined by the level at which the presenting part of the fetus is located. Depending on this, you may be advised to push as hard as you can, or, conversely, try to hold back.

The desire to push may be accompanied by unpleasant pain. However, if pushing is not recommended at this time, every effort should be made to restrain the pushing, as otherwise cervical rupture may occur. The doctor may ask you to “breathe” through the pushing. In this case, you need to take frequent sharp breaths and exhales through your mouth - this is called breathing “doggy”. This breathing technique will help you control the urge to push.

If you are already in the delivery chair and your baby is about to be born, you will be asked to push as hard as possible while pushing. At this moment, you should concentrate as much as possible on what the midwife says, since she sees what stage the fetus is at and knows what needs to be done to facilitate its birth.

When you start pushing, you should take a deep breath and start pushing, trying to push the baby out. Typically, you may be asked to push 2-3 times during one push. Try not to scream or release air under any circumstances, as this will only weaken the pushing and it will be ineffective. Between attempts you should lie quietly, try to even out your breathing and rest before the next attempt. When the fetal head erupts, i.e. is established in the genital slit, the midwife may ask you not to push again, since the force of uterine contraction is already sufficient for further advancement of the head and its removal as carefully as possible.

What does a doctor do?

During the expulsion period, the mother and fetus are exposed to maximum stress. Therefore, monitoring the condition of both mother and baby is carried out throughout the entire second stage of labor.

The mother's blood pressure is measured every half hour. Listening to the fetal heartbeat is carried out with each push, both during uterine contractions and after it, to assess how the baby reacts to the push.

External obstetric examination is also regularly performed to determine where the presenting part is located. If necessary, a vaginal examination is performed.

When the head erupts, it is possible to perform an episiotomy - a surgical dissection of the perineum, which is used to shorten and facilitate the birth of the head. When giving birth in a breech position, an episiotomy is mandatory. The decision to use an episiotomy is made in cases where there is a threat of perineal rupture. After all, an incision made by a surgical instrument is easier to stitch up, and it heals faster than a lacerated wound with crushed edges due to a spontaneous rupture of the perineum. In addition, an episiotomy is performed when the condition of the fetus worsens in order to speed up its birth and, if necessary, immediately carry out resuscitation measures.

After birth, the baby is placed on the mother's stomach to provide first skin-to-skin contact. The doctor evaluates the condition of the newborn using special criteria - the Apgar scale. In this case, indicators such as heartbeat, breathing, skin color, reflexes and muscle tone of the newborn at 1 and 5 minutes after birth are assessed on a ten-point scale.

Succession period

During the third stage of labor, the placenta, the remainder of the umbilical cord, and the membranes are separated and released. This should happen within 30–40 minutes after the baby is born. In order for the placenta to separate, weak uterine contractions appear after childbirth, due to which the placenta gradually separates from the wall of the uterus. Once separated, the placenta is born; from this moment it is considered that childbirth is over and the postpartum period begins.

How to behave and what does the doctor do?

This period is the shortest and most painless, and practically no effort is required from the postpartum woman. The midwife monitors whether the placenta has separated. To do this, she may ask you to push slightly. If the remainder of the umbilical cord is retracted back into the vagina, then the placenta has not yet separated from the placental site. And if the umbilical cord remains in the same position, the placenta has separated. The midwife will again ask you to push and gently pull the umbilical cord to bring the placenta out.

After this, a thorough examination of the placenta and fetal membranes is performed. If there is any suspicion or indication that part of the placenta or membranes remains in the uterine cavity, a manual examination of the uterine cavity should be performed to remove any remaining parts of the placenta. This is necessary to prevent the development of postpartum hemorrhage and infection. Under intravenous anesthesia, the doctor inserts his hand into the uterine cavity, carefully examines its walls from the inside and, if retained lobes of the placenta or membranes are detected, removes them out. If spontaneous separation of the placenta does not occur within 30–40 minutes, this manipulation is performed manually under intravenous anesthesia.

After childbirth

After the birth of the placenta, a thorough examination of the soft tissues of the birth canal and perineum is performed. If ruptures of the cervix or vagina are detected, they are sutured, as well as surgical restoration of the perineum if an episiotomy has been performed or ruptures have occurred.

Surgical correction is performed under local anesthesia; in case of significant damage, intravenous anesthesia may be required. Urine is released through a catheter so that the postpartum woman does not have to worry about a full bladder for the next few hours. Then, in order to prevent postpartum bleeding, women place a special bag of ice on the lower abdomen, which remains there for 30–40 minutes.

While doctors examine the mother, the midwife and pediatrician perform the first toilet of the newborn, measure his height and weight, head and chest circumference, and treat the umbilical wound.

Then the baby is placed on the mother's breast, and for 2 hours after birth they remain in the maternity ward, where doctors monitor the woman's condition. Blood pressure and pulse are monitored, uterine contractions and the nature of vaginal bleeding are assessed. This is necessary so that if postpartum hemorrhage occurs, the necessary full assistance can be provided in a timely manner.

If the condition of the mother and the newborn is satisfactory, 2 hours after birth they are transferred to the postpartum ward.

Normal and timely labor never begins suddenly and violently. On the eve of childbirth, a woman experiences their precursors, and the uterus and its cervix are prepared for the birth process. In particular, the cervix begins to “ripen” and expand, that is, it enters the stage of opening of the uterine pharynx. Childbirth is a complex and lengthy process and largely depends on the interaction of the uterus, cervix and hormonal levels, which determines its successful completion.

The cervix is...

The lower part of the uterus is called its cervix, which looks like a narrow cylinder and connects the uterine cavity to the vagina. Directly in the cervix, the vaginal part is distinguished - the visible part, which protrudes into the vagina below its fornix. There is also a supravaginal part - the upper part located above the arches. The cervical (cervical) canal passes through the cervix, its upper end is called the internal os, and the lower end is called the external os. During pregnancy, there is a mucus plug in the cervical canal, the function of which is to prevent infection from entering the uterine cavity from the vagina.

The uterus is a female reproductive organ, the main purpose of which is to bear a fetus (fetal receptacle). The uterus consists of 3 layers: the inner one is represented by the endometrium, the middle one is muscle tissue and the outer one is the serosa. The bulk of the uterus is the muscular layer, which hypertrophies and grows during gestation. The myometrium of the uterus has a contractile function, due to which contractions occur, the cervix (uterine os) opens and the fetus is expelled from the uterine cavity during labor.

Periods of labor

The labor process lasts quite a long time, and normally in primiparous women it lasts 10–12 hours, while in multiparous women it lasts approximately 6–8 hours. Childbirth itself includes three periods:

• I period – the period of contractions (opening of the uterine pharynx);
• The second period is called the period of pushing (the period of expulsion of the fetus);
• The third period is the period of separation and discharge of the child's place (placeholder), therefore it is called the afterbirth period.

The longest stage of labor is the period of opening of the uterine pharynx. It is caused by uterine contractions, during which the amniotic sac is formed, the fetal head moves along the pelvic ring and cervical dilatation is ensured.

Period of contractions

First, contractions arise and become established - no more than 2 in 10 minutes. Moreover, the duration of uterine contraction reaches 30–40 seconds, and uterine relaxation reaches 80–120 seconds. Long-term relaxation of the uterine muscles after each contraction ensures the transition of the cervical tissues into the structure of the lower segment of the uterus, as a result of which the length of the visible part of the cervix decreases (it shortens), and the lower uterine segment itself stretches and lengthens.

As a result of the ongoing processes, the presenting part of the fetus (usually the head) is fixed at the entrance to the pelvis, separating the amniotic fluid, and as a result, anterior and posterior waters are formed. A fetal bladder is formed (contains anterior waters), which acts like a hydraulic wedge, wedges into the internal os, opening it.

In first-time mothers, the latent phase of dilatation is always longer than in women giving birth for the second time, which determines the longer total duration of labor. The completion of the latent phase is marked by complete or almost complete effacement of the cervix.

The active phase begins with 4 cm of cervical dilation and continues up to 8 cm. At the same time, contractions become more frequent and their number reaches 3 - 5 in 10 minutes, periods of contraction and relaxation of the uterus are equalized and amount to 60 - 90 seconds. The active phase lasts for primiparous and multiparous women for 3–4 hours. It is during the active phase that labor becomes intense, and the cervix dilates quickly. The fetal head moves along the birth canal, the cervix has completely moved into the lower uterine segment (merged with it), and by the end of the active phase the opening of the uterine pharynx is complete or almost complete (within 8 - 10 cm).

At the end of the active phase, the amniotic sac is opened and the water is released. If the cervical opening has reached 8 - 10 cm and the waters have broken, this is called timely rupture of water, the release of water when the opening is up to 7 cm is called early, with 10 or more cm of opening of the pharynx, amniotomy is indicated (the procedure for opening the amniotic sac), which is called delayed rupture of water.

Terminology

Dilatation of the cervix does not have any symptoms; only a doctor can determine it by conducting a vaginal examination.

To understand how the process of softening, shortening and smoothing of the cervix progresses, you should define obstetric terms. In the recent past, obstetricians determined the opening of the uterine pharynx in the fingers. Roughly speaking, how many fingers the uterine os allows through, so is the opening. On average, the width of the “obstetric finger” is 2 cm, but, as you know, everyone’s fingers are different, so measuring the opening in cm is considered more accurate. So:

• if the cervix is ​​dilated by 1 finger, then they speak of an opening of 2 - 3 cm;
• if the opening of the uterine pharynx has reached 3–4 cm, this is equivalent to the dilation of the cervix by 2 fingers, which, as a rule, is diagnosed already at the beginning of regular labor (at least 3 contractions in 10 minutes);
• almost complete opening is indicated by the opening of the cervix by 8 cm or 4 fingers;
• full dilatation is recorded when the cervix is ​​completely smoothed (thin edges) and is passable for 5 fingers or 10 cm (the head descends to the pelvic floor, turning with an arrow-shaped suture to a straight size, an irresistible desire to push appears - it’s time to go to the delivery room for the birth of the baby - the beginning of the second period childbirth).

How does the cervix ripen?

The appearing harbingers of labor indicate the imminent onset of labor (approximately from 2 weeks to 2 hours):

• the fundus of the uterus descends (for 2 - 3 weeks before the onset of contractions), which is explained by the pressing of the presenting part of the fetus to the pelvis, a woman feels this sign by easier breathing;
• the pressed head of the fetus puts pressure on the pelvic organs (bladder, intestines), which leads to increased urination and constipation;
• increased excitability of the uterus (the uterus “turns to stone” when the fetus moves, the woman moves suddenly, or when the abdomen is stroked/pinched);
• possible appearance - they are irregular and sparse, drawn-out and short;
• The cervix begins to “ripen” - it softens, allows the tip of the finger to pass through, shortens and “centers.”

Dilatation of the cervix before childbirth occurs very slowly and gradually over the course of a month, and intensifies on the last day or two before birth. In primiparous women, the opening of the cervical canal is about 2 cm, while in multiparous women the opening exceeds 2 cm.

To establish cervical maturity, a scale developed by Bishop is used, which includes assessment of the following criteria:

• consistency (density) of the neck: if it is dense - this is regarded as 0 points, if it is softened along the periphery, but the internal pharynx is dense - 1 point, soft both inside and outside - 2 points;
• length of the neck (the process of its shortening) - if it exceeds 2 cm - 0 points, the length reaches 1 - 2 cm - score 1 point, the neck is shortened and does not reach 1 cm in length - 2 points;
• patency of the cervical canal: a closed external pharynx or allows the tip of a finger to pass through - score 0 points, the cervical canal is passed to a closed internal pharynx - this is scored as 1 point, and if the canal allows one or 2 fingers to pass beyond the internal pharynx - scored as 2 points;
• how the neck is located tangentially to the wire axis of the pelvis: directed posteriorly - 0 points, displaced anteriorly - 1 point, located in the middle or “centered” - 2 points.

When summing up the points, the maturity of the cervix is ​​assessed. An immature cervix is ​​considered with a score of 0 - 2 points, 3 - 4 points are regarded as an insufficiently mature or ripening cervix, and with 5 - 8 points they speak of a mature cervix.

Vaginal examination

To determine the degree of readiness of the cervix and not only, the doctor conducts a mandatory vaginal examination (upon admission to the maternity hospital and at 38–39 weeks at an appointment at the antenatal clinic).

If the woman is already in the maternity ward, a vaginal examination to determine the process of opening of the uterine pharynx every 4 to 6 hours or for emergency indications:

• discharge of amniotic fluid;
• carrying out a possible amniotomy (weakness of labor, or flat amniotic sac);
• with the development of anomalies of labor forces (clinically narrow pelvis, excessive labor, incoordination);
• before performing regional anesthesia (EDA, SMA) to determine the cause of painful contractions;
• the occurrence of bloody discharge from the genital tract;
• in the case of established regular labor (preliminary period, turning into contractions).

When conducting a vaginal examination, the obstetrician assesses the condition of the cervix: its degree of dilation, smoothing, thickness and extensibility of the cervical edges, as well as the presence of scars on the soft tissues of the genital tract. In addition, the capacity of the pelvis is assessed, the presenting part of the fetus and its insertion are palpated (localization of the sagittal suture on the head and fontanelles), the advancement of the presenting part, the presence of bone deformities and exostoses. The amniotic sac must be assessed (integrity, functionality).

Based on subjective signs of dilatation and vaginal examination data, a partogram of labor is compiled and maintained. Contractions are considered subjective signs of labor, in particular the opening of the uterine pharynx. The criteria for assessing contractions include their duration and frequency, severity and uterine activity (the latter is determined instrumentally). The partogram of labor allows you to visually record the dynamics of the opening of the uterine pharynx. A graph is drawn up, the horizontal length of which indicates the duration of labor in hours, and the vertical dilatation of the cervix in cm. Based on the partogram, the latent and active phases of labor can be distinguished. A steep rise in the curve indicates the effectiveness of the birth act.

If the cervix dilates prematurely

Dilation of the cervix during pregnancy, that is, long before childbirth, is called isthmic-cervical insufficiency. This pathology is characterized by the fact that both the cervix and the isthmus do not perform their main function during gestation - obturator. In this case, the cervix softens, shortens and smoothes, which does not allow keeping the fetus in the sac and leads to spontaneous abortion. Termination of pregnancy usually occurs in the 2nd – 3rd trimesters. The incompetence of the cervix is ​​indicated by the fact that it shortens to 25 mm or less at 20–30 weeks of gestation.

Isthmic-cervical insufficiency can be organic and functional. The organic form of pathology develops as a result of various cervical injuries - induced abortions (see), cervical ruptures during childbirth, surgical methods for treating cervical diseases. The functional form of the disease is caused either by a hormonal imbalance or by an increased load on the cervix and isthmus during pregnancy (multiple pregnancy, excess water or a large fetus).

How to maintain pregnancy when the cervix is ​​dilated

But even with cervical dilatation by 1 - 2 fingers at a period of 28 weeks or more, it is quite possible to maintain the pregnancy, or at least prolong it until the birth of a completely viable fetus. In such cases, the following are prescribed:

• bed rest;
• emotional peace;
• sedatives;
• antispasmodics (magne-B6, no-spa,);
• tocolytics (ginipral, partusisten).

Treatment is mandatory aimed at producing surfactant in the fetal lungs (glucocorticoids are prescribed), which accelerates their maturation.

In addition, treatment and prevention of further premature dilatation of the cervix is ​​carried out surgically - sutures are placed on the cervix, which are removed at 37 weeks.

The cervix is ​​immature - what then?

The opposite situation is possible, when the cervix is ​​“not ready” for childbirth. That is, hour X has arrived (the expected date of birth), and even several days or weeks have passed, but no structural changes are observed in the cervix, it remains long, dense, deviated posteriorly or anteriorly, and the internal pharynx is impassable or allows the tip of the finger to pass through. What do doctors do in this case?

All methods of influencing the cervix, leading to its maturation, are divided into medicinal and non-medicinal. Medicinal methods include the introduction of special gels and suppositories with prostaglandins into the vagina or cervix. Prostaglandins are hormones that accelerate the process of cervical ripening, increase the excitability of the uterus, and during childbirth their intravenous administration is practiced in case of weakness of labor forces. Local administration of prostaglandins has no systemic effect (no side effects) and contributes to the shortening and smoothing of the cervix.

Non-medicinal methods of stimulating cervical dilatation include:

Sticks – kelp

The sticks are made from dried kelp seaweed, which are highly hygroscopic (they absorb water well). A number of sticks are inserted into the cervical canal so that they fill it tightly. As the sticks absorb liquid, they swell and stretch the cervix, causing it to dilate.

Foley catheter

The catheter for dilating the cervix is ​​represented by a flexible tube with a balloon attached to one end. A catheter with a balloon at the end is inserted by the doctor into the cervical canal, the balloon is filled with air and left in the cervix for 24 hours. Mechanical action on the cervix stimulates its opening, as well as the production of prostaglandins. The method is very painful and increases the risk of infection of the birth canal.

Cleansing enema

Unfortunately, some maternity hospitals have refused to perform a cleansing enema for a woman admitted to give birth, but in vain. Free intestines, as well as its peristalsis during defecation, increase the excitability of the uterus, increase its tone, and, consequently, accelerate the process of cervical dilatation.

Question answer

How can you speed up cervical dilatation at home?

• long walks in the fresh air increase the excitability of the uterus and the production of prostaglandins, and the presenting part of the baby is fixed at the entrance to the pelvis, further stimulating the opening of the cervix;
• take care of your bladder and intestines, avoid constipation and prolonged abstinence from urination;
• eat more salads made from fresh vegetables dressed with vegetable oil;
• take a decoction of raspberry leaves;
• stimulate the nipples (when they are irritated, oxytocin is released, which causes uterine contractions).
• Are there any special exercises for opening the cervix?

At home, cervical ripening is accelerated by walking up stairs, swimming and diving, bending and turning the body. It is also recommended to take a warm bath, massage the ear and little finger, breathing exercises and exercises to strengthen the perineal muscles, and do yoga. In maternity hospitals there are special gymnastic balls, the seat and bounces on which during contractions accelerate the opening of the uterine pharynx.

Does sex really help prepare your cervix for childbirth?

Yes, having sex in the last days and weeks of pregnancy (provided the amniotic sac is intact and there is a mucus plug in the cervical canal) contributes to the ripening of the cervix. First, during orgasm, oxytocin is released, which stimulates uterine activity. And, secondly, sperm contains prostaglandins, which have a beneficial effect on the process of cervical maturation.

At what opening does pushing begin?

Pushing is a voluntary contraction of the abdominal muscles. The desire to push arises in women in labor already at 8 cm. But until the cervix is ​​fully dilated (10 cm) and the head drops to the bottom of the pelvis (that is, it can be felt by a doctor by pressing on the labia), you cannot push.

I share my experiences:
PDR - May 1-2, first pregnancy and childbirth. On Monday, April 20, I surrendered to the maternity hospital’s pathology department to wait for the birth, because on the 19th there were uterine contractions all day (irregular, from very painful to completely painless) and the doctor during the examination said “the cervix is ​​beautiful, the bladder is filling, now you can start giving birth any day.” and recommended staying in the maternity hospital under supervision. I stayed (in fact, I’m still sitting here), but for some reason I decided against having a child. Last week there were several sensitive contractions at night, but since Saturday they have passed. Now the stomach only periodically turns painlessly to stone (this happened before). On April 24, they looked at me again in a chair, the doctor said, “Dilation is 4 cm, the head is in the pelvis. Let’s go give birth right now, huh?” I refused because... I really want the baby to get ready to go out on his own - without haste, in a natural way. the doctor accepted my arguments and promised that on April 25-26 I would probably give birth myself (without her, because she had the weekend). I was happy, but it didn’t matter. She did not give birth to the child. Yesterday, April 28, the doctor looked at my cervix again. She said the dilation is “up to 5 cm.” Again she agitated to go give birth. I refused again. Then she posed the question bluntly: like, decide when we will give birth - on the 29th or 30th. I tried to drag out the old “song about the main thing” - that we had nowhere to rush, we would go the natural way... To which the doctor replied that there were May holidays next, I must understand that she also wants to go to the dacha, she won’t be here Because of me, I’m sitting in the city on May 1-2. Those. If I’m going to give birth on the May holidays, I’ll have to give birth with a team on duty (“there won’t be anyone else here, it’s everyone’s weekend”). In general, I have a contracted birth (with my husband, with the choice of a doctor and postpartum stay in a luxury ward). My doctor is deputy. the head physician of the maternity hospital (she is in charge of the contract childbirth program, and in general, as I understand it, “she does what she wants”). Before concluding the contract, she explained to my husband and me that if it is impossible for the selected doctor to be present at the birth, another doctor will attend the birth (also a doctor who manages “paid workers” - but not the doctor on duty). Why are they now suddenly telling me that there will only be a team on duty - hez... In my opinion, the doctor is trying to put pressure on me for reasons of personal gain. With this approach and attitude of my “selected” doctor towards me, I don’t see what’s worse than giving birth with someone on duty (especially since I didn’t really choose the “selected” doctor, she volunteered herself, citing the fact that the doctors I wanted, either they will be on vacation, or they don’t suit my personality). Out of confusion, I agreed to give birth on the 30th. However, after thinking about it in a calm atmosphere, I came to the conclusion that I still didn’t like the situation. I really want a natural birth, but it turns out that if contractions don’t start on their own by tomorrow, they will induce me. On the other hand, how can it be that there is already such an opening, but there are no contractions? Maybe it's actually time to stimulate? According to the ultrasound, everything seems to be in order, he is full term, the degree of development of the lungs last Thursday was 2nd. Saturday's CTG was ok, the baby was moving as usual. As for the fact that his head is in the pelvis - so, in my opinion, he has had it there since the middle of pregnancy, I did an ultrasound at about the 24th week, so the doctor was tired of looking under my pubic bone with a sensor, and we spent a very long time looking for a position in which the head would have been visible. My belly either hasn’t dropped, or has dropped by 2 centimeters, no more. So it goes. What should I do? Should I go look for a doctor and refuse to give birth tomorrow, or what other options are there?

UPD: Thanks to the collective wisdom. It seems that my head and the accompanying brains fell into place, and I finally decided to squint from the stimulation - at least until the appearance of _medical_ indications other than the doctor’s desire not to miss the May barbecue. I went to the doctor, calmly expressed my doubts to her, complained that I was very worried about the fact that I agreed to stimulation yesterday, and that I thought it would be better if we still waited for active actions on the part of the child. The doctor didn’t argue with me, she just said that this was my business, I didn’t want to be stimulated - she wasn’t going to force me. She repeated that, in any case, she was going to the dacha for May, and I would still have to give birth in her absence with the team on duty. I asked to clarify exactly what this would look like in terms of the contract. It turns out that it will be as originally promised - it’s just that the doctor allocated to the paid workers is part of the duty team. In short, it just relieved my heart :) By and large, I don’t care which doctor I give birth with, the main thing is to ensure that the process is as natural as possible. And there was no sabotage on the part of the deputy chief physician, whom, I must admit, I had already begun to fear. But in the end, everything turned out to be not so scary.

The first stage of labor is the longest. In primiparous women it ranges from 8 to 10 hours, in multiparous women - 6-7 hours. At the same time, the latent phase of labor (from the onset of contractions to the dilatation of the cervix by 4 cm) takes 5-6 hours (on average 5.4 hours in primiparous women and 4.5 hours for multiparous women). This phase is painless or slightly painful.

Management of labor during cervical dilatation

Contractions are established initially with a frequency of 1-2 per 10 minutes, the tone of the uterus is 10 mm Hg. Art. The duration of uterine contraction (contraction systole) is 30-40 s, relaxation (contraction diastole) is 2-3 times longer (80-120 s). Intrauterine pressure during contractions rises to 25-30 mmHg. Art.

This phase is characterized by long-term relaxation of the uterus after each contraction, especially the isthmus (lower segment and cervix), since each contraction causes the tissue of the cervix to move into the structure of the lower segment, as a result of which the length of the cervix decreases (the cervix shortens), and the lower segment of the uterus stretches , lengthens.

The presenting part is tightly fixed at the pelvic inlet. The amniotic sac gradually, like a hydraulic wedge, penetrates into the area of ​​the internal os, facilitating the opening of the cervix.

The period of cervical dilatation - latent phase

The latent phase in primiparous women is always longer than in multiparous women, which mainly increases the total duration of labor. By the end of the latent phase, the cervix is ​​completely or almost completely smoothed out. The speed of cervical dilatation during the latent phase of labor is 0.35 cm/hour.

No drug correction is required during the latent phase of labor. But in women of late or young age, if they have a complicated obstetric-gynecological history or any complicating factors, it is advisable to promote the processes of dilation of the cervix and relaxation of the lower segment. For this purpose, rectal suppositories with antispasmodic drugs (papaverine, no-shpa, baralgin) are prescribed, 1 every hour No. 3.

The period of cervical dilation - active phase

During the active phase (cervical opening from 4 to 8 cm), there is a gradual increase in uterine tone (up to 11-12 mm Hg). The frequency of contractions increases to 3-5 per 10 minutes, the duration of systole and diastole is equalized to 60-90 s. Intrauterine pressure during contractions rises to 40-50 mmHg. Art. The duration of the active phase is almost the same in primiparous and multiparous women and is 3-4 hours. The active phase is characterized by intense labor and rapid opening of the uterine pharynx. The rate of dilatation is 1.5-2 cm/hour in a primiparous woman and 2.5-3.0 cm/hour in a multiparous woman. At the same time, the fetal head moves through the birth canal. At the end of the active phase, complete or almost complete opening of the uterine pharynx occurs. The cervix completely merges with the lower segment of the uterus, the edges of the uterine pharynx are at the level of the spinal plane.

The fetal head moves along the birth canal synchronously with the opening of the uterine os. So, at 6 cm of opening of the uterine pharynx, the head is located as a small segment at the pelvic inlet or is +1 cm from the spinal plane. At 8 cm of opening, the fetal head descends as a segment into the pelvic inlet (+2 cm). When fully opened, it is located in the pelvic cavity, most often already on the pelvic floor. With coordinated labor activity in the active phase of labor, there is reciprocity (conjugation) of the activity of the upper and lower segments of the uterus. Contraction of the fundus and body of the uterus is accompanied by active relaxation of the lower segment of the uterus. The external hysterography curve, reflecting the condition of the lower segment, has a curve opposite to the upper segment (mirror reflection).

The intensity of labor during this phase increases, the tone and frequency of contractions also increase, the speed of cervical dilatation is maximum, and contractions most often become painful. During the active phase of labor, it is especially important to maintain the normal basal tone of the uterus, since with hypertonicity of the myometrium (13 mm Hg or more), the frequency of contractions increases above normal values ​​(more than 5 per 10 minutes), and the amplitude (strength) of contractions decreases. This leads to cervical ruptures, disruption of the uterine, uteroplacental and fetal-placental blood flow, and fetal hypoxia. There may also be a decrease in basal tone (less than 10 mm Hg), leading to a decrease in the frequency of contractions and a decrease in intrauterine pressure. In both cases, labor is delayed.

The discharge of amniotic fluid during uterine hypertonicity helps reduce intramyometrial pressure and can normalize uterine contractions. In order to determine the nature of the contraction disturbances that have arisen, one should first of all evaluate the tone of the myometrium (decreased, increased, normal), as well as the rhythm, frequency, duration and strength of the contraction. Labor activity is the work of the uterus (naturally, and the entire body of the woman in labor), aimed at opening the birth canal, advancing and expelling the fetus, separating and releasing the placenta.

This work is performed mainly due to the mechanical contractile function of the uterus and is provided with the necessary energy of biochemical, metabolic, oxidative processes, intensification of the activity of the cardiovascular, respiratory, neuroendocrine and autonomic nervous systems. With an average amplitude of contraction of the upper segment of the uterus of 50 mm Hg. Art., normal basal tone of the uterus of 10-12 mm Hg. Art., the number of contractions during childbirth ranges from 240 to 300 (24-30 contractions per hour). This work often causes fatigue and fatigue in the woman in labor, especially since contractions are almost always painful and begin at night, which the woman spends in anxiety and excitement.

During the active phase of labor, it is necessary to use drug anesthesia (nitrous-oxygen analgesia or a single injection of promedol 20 mg) in combination with antispasmodic drugs. The latter are especially appropriate for the prevention of cervical ruptures, smoother opening of the cervix and stretching of the vaginal walls. Antispasmodics (no-spa 4 ml or baralgin 5 ml) are administered either intravenously by drip or intravenously at the same time (2 ml with glucose solution).

Amniotic fluid - rupture

The amniotic sac ruptures at the height of one of the contractions when opening 6-8 cm. 150-200 ml of light (transparent) amniotic fluid is poured out.

If spontaneous rupture of amniotic fluid has not occurred, then when the uterine os is dilated by 6-8 cm, an artificial amniotomy is performed. However, in this case, it is advisable to pre-administer antispasmodic drugs so that too rapid reduction in the volume of the uterus does not provoke hypertensive dysfunction of contraction.

Amniotomy is accompanied by a short-term decrease in uteroplacental blood flow and a change in the frequency of fetal cardiac activity (often bradycardia). Therefore, in addition to antispasmodics, before amniotomy, 40.0 ml of a 40% glucose solution and 5 ml of a 5% ascorbic acid solution, 150 mg of cocarboxylase are prescribed, which support the energy level and oxygenation of the fetus.

The period of cervical dilatation - the third phase

The third phase of the first stage of labor (not expressed in all women in labor) is called the deceleration phase. It is determined from the moment the cervix is ​​dilated by 8 cm and continues until the uterine pharynx is fully (10-12 cm) dilated. Its duration ranges from 20 to 60 minutes.

During this short phase of slowing labor activity, the tone of the uterus changes (increases by another 2-3 mm), the strength (amplitude) of contractions weakens somewhat, the frequency remains the same (from 4.4 to 5 contractions per 10 minutes).

The physiological essence of this phase is that the contractile activity of the uterus is reorganized into the function of expelling the fetus. The entire uterus acts in the same direction. Contractions of the uterus occur synchronously from the fundus to the uterine os. There is only one task - to expel the fetus from the birth canal. At the same time, all parts and layers of the uterus contract and relax.

The deceleration phase is considered transitional from the first stage of labor to the second. The slow phase of labor is based on two factors of biological expediency: one is the need for a slower (gentle) advancement of the fetal head through the spinal plane - the narrowest part of the closed bony ring of the pelvis, and the second is the accumulation of the energy potential of the uterus for the most intense work on a relatively in a short period of time.

The slow phase of the first stage of labor is isolated so that the doctor does not rush to diagnose secondary weakness of labor and does not use unindicated labor stimulation.

During the entire first stage of labor, the condition of the mother and her fetus is constantly monitored. They monitor the intensity and effectiveness of labor (the number of contractions in 10 minutes, the duration of contraction and relaxation of the uterus, its tone), the condition of the woman in labor (well-being, pulse rate, respiration, blood pressure, temperature, discharge from the genital tract).

The period of cervical dilatation - the condition of the bladder and intestines

During childbirth, it is necessary to monitor bladder and bowel function. Overfilling of the bladder and rectum prevents the normal course of the period of opening and expulsion, and the release of the placenta. Overfilling of the bladder can occur due to its atony, in which the woman does not feel the urge to urinate, as well as due to the pressing of the urethra to the pubic symphysis by the fetal head. To prevent the bladder from overflowing, the woman in labor is asked to urinate every 2-3 hours. In the absence of independent urination, catheterization is used. Timely emptying of the lower intestine is important (enema before childbirth and during a prolonged period). In the birth history, the presence or absence of spontaneous urination every 2 hours is noted. Difficulty or absence of urination is a sign of pathology.

Vaginal examination during childbirth

A vaginal examination during childbirth is performed to maintain a partogram (WHO, 1993), to orientate the insertion and advancement of the head, to assess the location of sutures and fontanelles, i.e., to clarify the obstetric situation.

Mandatory vaginal examinations are indicated in the following situations:

• upon admission of a woman to the maternity hospital;
• when amniotic fluid breaks;
• with the onset of labor (assessment of the condition and dilatation of the cervix);
• with abnormalities in labor (weakening or excessively strong, painful contractions, as well as early-onset pushing);
• before performing anesthesia (find out the cause of painful contractions);
• when bloody discharge appears from the birth canal.

The results of a vaginal examination reflect the effectiveness of labor (the degree of opening of the uterine pharynx, advancement of the fetal head), the biomechanism of labor.

You should not be afraid of frequent vaginal examinations; it is much more important to ensure their complete safety in terms of asepsis, antiseptics and atraumaticity (carry out with cleanly washed hands, wearing sterile gloves using disinfectant solutions, sterile liquid petroleum jelly). Research must be carried out gently, carefully and painlessly.

During a vaginal examination during childbirth, attention should be paid not only to the degree of dilatation of the cervix, the position of the sutures and fontanelles of the fetus, the pelvic bones and its capacity, but also to the condition of the edges of the cervix.

During normal labor, the edges of the cervix are thin, soft, and easily stretchable. During contraction, the edges of the cervix do not tense, which indicates good tissue relaxation; the amniotic sac is well defined. During the pause between contractions, the tension of the fetal bladder weakens, and through the membranes it is possible to identify identification points on the head: sagittal suture, posterior (small) fontanelle, wire point.

Position of the woman in labor

The position of the woman in labor during labor deserves special attention. Historical data shows that the position of the mother in labor on her back was mainly common in France, starting from the 17th century, when the daughter-in-law of the Countess Duchesse of Monpezier, Marie de Medici, gave birth in this position in the presence of the royal court midwife Louise Burgois and the barber-obstetrician Julien Clemont. Childbirth in the presence of a man led to the spread in the higher spheres of the position of the woman in labor on her back. This custom was widely promoted by such famous obstetricians as Pare and Morisot. Childbirth on the back has become a tradition for a number of centuries. Obstetric practice readily accepted this method as beneficial and convenient, primarily for the obstetrician (it is more convenient to conduct a vaginal examination, listen to the fetal heartbeat, carry out cardiac monitoring, etc.).

However, a comprehensive assessment of various positions of the woman in labor, carried out independently from each other in 3 centers (Germany, Spain and the USA), showed that the position of the woman in labor on her back is not the most beneficial for the contractile activity of the uterus (contractions weaken) and for the fetus (uteroplacental blood flow decreases ) and for the woman herself (danger of compression of the inferior vena cava). In this regard, most obstetricians recommend that women in the first stage of labor sit, walk (for short periods of time), stand or lie on their sides. In the future, apparently, it will be possible for a woman in labor to stay in a warm pool during the first stage of labor.

You can get up and walk with the water intact or poured out, but with the fetal head tightly fixed at the pelvic inlet.

If the location of the placenta is known (according to ultrasound), then the optimal position for the woman in labor is on the side where the back of the fetus is located. In this position, the frequency and intensity of contractions does not decrease, the basal tone of the uterus remains normal. In addition, studies have shown that in this position the blood supply to the uterus, uterine and uteroplacental blood flow improves. The fetus is always positioned facing the placenta.

Woman in labor in the first stage of labor

In the first stage of labor, in the active phase of cervical dilatation, the woman in labor can perform psychoprophylactic pain relief techniques. It is not recommended to feed a woman in labor during labor for a number of reasons: the feeding reflex is suppressed during labor. During childbirth, a situation may arise in which anesthesia is required. The latter poses a risk of regurgitation (aspiration of stomach contents) and the development of Mendelssohn's syndrome.

During labor, the position and advancement of the head is constantly assessed in relation to the pelvic inlet plane and in relation to the spinal plane (the narrowest plane of the pelvis). The fetal heartbeat is listened to (the results are recorded in the birth history), but most often constant cardiac monitoring is carried out. Coordinated contractions of the uterus during labor ensure the normal biomechanism of childbirth.

Identification points for different positions of the fetal head

Let us recall the identification points for different positions of the fetal head in relation to the main planes of the pelvis.

1. The head is above the pelvic inlet. The entire head is located above the pelvic inlet, movable or pressed against the pelvic inlet. During vaginal examination: the pelvis is free, the head stands high, does not interfere with palpation of the border (nameless) lines of the pelvis, the promontory (if it is reachable), the inner surface of the sacrum and the pubic symphysis. The sagittal suture in transverse size is at the same distance from the pubic symphysis and promontory, the anterior and posterior fontanelles are at the same level (in case of occipital presentation). In relation to the spinal plane, the head is in a position of -3 or -2 cm.

2. The head is in the inlet of the small pelvis with a small segment. The head is motionless. Most of it is above the entrance to the pelvis, a small segment of the head is below the plane of the entrance to the pelvis. During vaginal examination: the sacral cavity is free, you can approach the promontory with a bent finger. The inner surface of the pubic symphysis is accessible to research, the posterior fontanel is lower than the anterior one (flexion). Sagittal suture in transverse or slightly oblique size. In relation to the spinal plane, the head is located -1 cm.

3. The head is at the inlet of the small pelvis with a large segment. An external examination determines that the head with its greatest circumference (large segment) has descended into the pelvic cavity.

The smaller segment of the head is palpated from above. During vaginal examination, the head covers the upper third of the pubic symphysis and sacrum, the promontory is not reachable, the ischial spines are easily palpable. The head is bent, the posterior fontanel is lower than the anterior one, the sagittal suture is in one of the oblique sizes. In relation to the spinal plane - "O".

4. The head is in the wide part of the pelvic cavity. During external examination, only a small part of the head can be felt. During vaginal examination, the largest circumference of the head passed the plane of the widest part of the pelvic cavity; 2/3 of the inner surface of the pubic symphysis and the upper half of the sacral cavity are occupied by the head. The SIV and Sv vertebrae and the ischial spines can be easily palpated. The sagittal suture is located in one of the oblique dimensions. In relation to the spinal plane, the head is +1 cm.

5. The head is in the narrow part of the pelvic cavity. A vaginal examination reveals that the upper two thirds of the sacral cavity and the entire inner surface of the pubic symphysis are occupied by the head. Only the SIV and SV vertebrae can be palpated. The sagittal suture is oblique, closer to straight. The head with the lower pole is in position +2 cm.

6. The head is at the outlet of the pelvis. During external examination, the head cannot be felt. The sacral cavity is completely filled with the head, the ischial spines are not defined, the sagittal suture is located in the direct size of the pelvic outlet (relative to the “0” plane +3 cm).

Childbirth is the process of expulsion or extraction from the uterus of a child and placenta (placenta, amniotic membranes, umbilical cord) after the fetus reaches viability. Normal physiological childbirth occurs through the natural birth canal. If the child is removed by caesarean section or using obstetric forceps, or using other delivery operations, then such birth is operative.

Typically, timely birth occurs within 38-42 weeks of obstetric period, counting from the first day of the last menstrual period. At the same time, the average weight of a full-term newborn is 3300±200 g, and its length is 50-55 cm. Childbirth occurs at 28-37 weeks. pregnancy and earlier are considered premature, and more than 42 weeks. - belated. The average duration of physiological labor ranges from 7 to 12 hours for primiparous women, and from 6 to 10 hours for multiparous women. Labor that lasts 6 hours or less is called rapid, 3 hours or less - rapid, more than 12 hours - protracted. Such births are pathological.

Characteristics of normal vaginal delivery

• Singleton pregnancy.
• Head presentation of the fetus.
• Full proportionality between the fetal head and the mother's pelvis.
• Full-term pregnancy (38-40 weeks).
• Coordinated labor activity that does not require corrective therapy.
• Normal biomechanism of childbirth.
• Timely release of amniotic fluid when the cervix is ​​dilated by 6-8 cm in the active phase of the first stage of labor.
• Absence of serious ruptures of the birth canal and surgical interventions during childbirth.
• Blood loss during childbirth should not exceed 250-400 ml.
• The duration of labor for primiparous women is from 7 to 12 hours, and for multiparous women from 6 to 10 hours.
• The birth of a living and healthy child without any hypoxic-traumatic or infectious damage and developmental abnormalities.
• The Apgar score at the 1st and 5th minutes of the child’s life should correspond to 7 points or more.

Stages of physiological childbirth through the natural birth canal: development and maintenance of regular contractile activity of the uterus (contractions); changes in the structure of the cervix; gradual opening of the uterine pharynx up to 10-12 cm; advancement of the child through the birth canal and its birth; separation of the placenta and discharge of the placenta. There are three periods during childbirth: the first is the dilation of the cervix; the second is the expulsion of the fetus; the third is subsequent.

The first stage of labor - dilatation of the cervix

The first stage of labor lasts from the first contractions until the cervix is ​​fully dilated and is the longest. For primiparous women, it ranges from 8 to 10 hours, and for multiparous women, 6-7 hours. In the first period there are three phases. First or latent phase The first stage of labor begins with the establishment of a regular rhythm of contractions with a frequency of 1-2 per 10 minutes, and ends with smoothing or pronounced shortening of the cervix and opening of the uterine pharynx by at least 4 cm. The duration of the latent phase is on average 5-6 hours. In primiparous women, the latent phase is always longer than in multiparous women. During this period, contractions are usually not painful. As a rule, no drug correction is required during the latent phase of labor. But in women of late or young age, if there are any complicating factors, it is advisable to promote the processes of dilation of the cervix and relaxation of the lower segment. For this purpose, it is possible to prescribe antispasmodic drugs.

After the cervix dilates by 4 cm, the second or active phase the first stage of labor, which is characterized by intense labor and rapid opening of the uterine pharynx from 4 to 8 cm. The average duration of this phase is almost the same in primiparous and multiparous women and averages 3-4 hours. The frequency of contractions in the active phase of the first stage of labor is 3-5 per 10 minutes. Contractions most often become painful. Pain sensations predominate in the lower abdomen. When a woman is active (standing, walking), the contractile activity of the uterus increases. In this regard, drug pain relief is used in combination with antispasmodic drugs. The amniotic sac should open on its own at the height of one of the contractions when the cervix opens 6-8 cm. At the same time, about 150-200 ml of light and transparent amniotic fluid is poured out. If spontaneous discharge of amniotic fluid has not occurred, then when the uterine pharynx is dilated by 6-8 cm, the doctor must open the amniotic sac. Simultaneously with the dilation of the cervix, the fetal head moves along the birth canal. At the end of the active phase, the uterine os opens completely or almost completely, and the fetal head descends to the level of the pelvic floor.

The third phase of the first stage of labor is called deceleration phase. It begins after the uterine os is dilated by 8 cm and continues until the cervix is ​​fully dilated to 10-12 cm. During this period, it may seem that labor has weakened. This phase in primiparous women lasts from 20 minutes to 1-2 hours, and in multiparous women it may be completely absent.

During the entire first stage of labor, the condition of the mother and her fetus is constantly monitored. They monitor the intensity and efficiency of labor, the condition of the woman in labor (well-being, pulse rate, breathing, blood pressure, temperature, discharge from the genital tract). The fetal heartbeat is regularly listened to, but most often constant cardiac monitoring is performed. During normal labor, the baby does not suffer during uterine contractions, and its heart rate does not change significantly. During labor, it is necessary to assess the position and advancement of the head in relation to pelvic landmarks. A vaginal examination during labor is performed to determine the insertion and advancement of the fetal head, to assess the degree of opening of the cervix, and to clarify the obstetric situation.

Mandatory vaginal examinations performed in the following situations: when a woman enters the maternity hospital; when amniotic fluid ruptures; with the onset of labor; in case of deviations from the normal course of labor; before anesthesia; when bloody discharge appears from the birth canal. One should not be afraid of frequent vaginal examinations; it is much more important to ensure complete orientation in assessing the correct course of labor.

Second stage of labor - expulsion of the fetus

The period of expulsion of the fetus begins from the moment the cervix is ​​fully dilated and ends with the birth of the child. During childbirth, it is necessary to monitor bladder and bowel function. Fullness of the bladder and rectum interferes with the normal course of labor. To prevent the bladder from overflowing, the woman in labor is asked to urinate every 2-3 hours. In the absence of independent urination, catheterization is used. Timely emptying of the lower intestine is important (enema before childbirth and during a prolonged period). Difficulty or absence of urination is a sign of pathology.

Position of the woman in labor

The position of the woman in labor during labor deserves special attention. In obstetric practice the most popular are back birth, which is convenient from the point of view of assessing the nature of the course of labor. However, the position of the woman in labor on her back is not the best for the contractile activity of the uterus, for the fetus and for the woman herself. In this regard, most obstetricians recommend that women in the first stage of labor sit, walk for a short time, or stand. You can get up and walk both with intact and emptied water, but provided that the fetal head is tightly fixed at the pelvic inlet. In some cases, it is practiced for a woman in labor to stay in a warm pool during the first stage of labor. If the location of the placenta is known (according to ultrasound data), then the optimal location is position of the woman in labor on that side where the back of the fetus is located. In this position, the frequency and intensity of contractions does not decrease, the basal tone of the uterus remains normal. In addition, studies have shown that in this position the blood supply to the uterus, uterine and uteroplacental blood flow improves. The fetus is always positioned facing the placenta.

It is not recommended to feed a woman in labor during labor for a number of reasons: the food reflex is suppressed during labor. During childbirth, a situation may arise in which anesthesia is required. The latter poses a risk of aspiration of stomach contents and acute respiratory distress.

From the moment the uterine os opens completely, the second stage of labor begins, which consists of the actual expulsion of the fetus, and ends with the birth of the child. The second period is the most critical, since the fetal head must pass through the closed bony ring of the pelvis, narrow enough for the fetus. When the presenting part of the fetus descends to the pelvic floor, contractions are joined by contractions of the abdominal muscles. Attempts begin, with the help of which the child moves through the vulvar ring and the process of his birth occurs.

From the moment the head is cut in, everything should be ready for delivery. As soon as the head has erupted and does not go deeper after pushing, they proceed directly to the delivery. Help is necessary because, as the head erupts, it puts strong pressure on the pelvic floor and ruptures of the perineum are possible. During obstetric care, the perineum is protected from damage; carefully remove the fetus from the birth canal, protecting it from adverse effects. When the fetal head is brought out, it is necessary to restrain its excessively rapid advancement. In some cases they perform perineal dissection to facilitate the birth of a child, which avoids failure of the pelvic floor muscles and prolapse of the vaginal walls due to their excessive stretching during childbirth. Usually the birth of a child occurs in 8-10 attempts. The average duration of the second stage of labor for primiparous women is 30-60 minutes, and for multiparous women it is 15-20 minutes.

In recent years, in some European countries, the so-called vertical birth. Proponents of this method believe that in the position of the woman in labor, standing or kneeling, the perineum is easier to stretch and the second stage of labor is accelerated. However, in this position it is difficult to monitor the condition of the perineum, prevent its ruptures, and remove the head. In addition, the strength of the arms and legs is not fully used. As for the use of special chairs for vertical childbirth, they can be classified as alternative options.

Immediately after the birth of the child, if umbilical cord is not compressed, and it is located below the level of the mother, then a reverse “infusion” of 60-80 ml of blood occurs from the placenta to the fetus. In this regard, the umbilical cord should not be crossed during a normal birth and the newborn is in satisfactory condition, but only after the pulsation of the vessels has stopped. In this case, until the umbilical cord is crossed, the child cannot be raised above the plane of the delivery table, otherwise a backflow of blood from the newborn to the placenta occurs. After the birth of the child, the third stage of labor begins - the afterbirth stage.

The third stage of labor is the afterbirth

The third period (afterbirth) is determined from the moment of birth of the child until the separation of the placenta and the discharge of the placenta. In the afterbirth period, during 2-3 contractions, the placenta and membranes are separated from the walls of the uterus and the afterbirth is expelled from the genital tract. In all women giving birth in the afterbirth period, to prevent bleeding, intravenous drugs that promote uterine contraction. After birth, a thorough examination of the child and mother is carried out to identify possible birth injuries. During the normal course of the afterbirth period, blood loss is no more than 0.5% of body weight (on average 250-350 ml). This blood loss is physiological, since it does not have a negative effect on the woman’s body. After expulsion of the placenta, the uterus enters a state of prolonged contraction. When the uterus contracts, its blood vessels are compressed and bleeding stops.

Newborns are given screening assessment for phenylketonuria, hypothyroidism, cystic fibrosis, galactosemia. After the birth, information about the characteristics of the birth, the condition of the newborn, and the recommendations of the maternity hospital are transmitted to the antenatal clinic doctor. If necessary, the mother and her newborn are advised by specialized specialists. Documentation about the newborn is sent to the pediatrician, who subsequently monitors the child.

It should be noted that in some cases, preliminary hospitalization in a maternity hospital is necessary to prepare for delivery. In the hospital, in-depth clinical, laboratory and instrumental examinations are carried out to select the timing and method of delivery. An individual birth management plan is drawn up for each pregnant woman (mother in labor). The patient is introduced to the proposed delivery plan. Obtain her consent to the proposed manipulations and operations during childbirth (stimulation, amniotomy, cesarean section).

Caesarean section is performed not at the woman's request, since this is an unsafe operation, but only for medical reasons (absolute or relative). Childbirth in our country is not carried out at home, but only in an obstetric hospital under direct medical supervision and control, since any birth is fraught with the possibility of various complications for the mother, fetus and newborn. The birth is led by a doctor, and the midwife, under the supervision of a doctor, provides manual assistance at the birth of the fetus and carries out the necessary treatment of the newborn. The birth canal is examined and repaired by a doctor if it is damaged.