Diagnosis of labor – each stage has its own analyzes and studies. "Normal Childbirth Clinic"
Partogram (according to Friedman)
Latent phase of labor
: from the moment regular contractions are established until the uterine os opens by 3-4 cm, characterized by a frequency of low-painful contractions of 2-3 per 10 minutes, the speed of cervical dilation is 0.35 cm/hour.
Active phase of labor
: from 3-4 cm to 8-9 cm. Contractions are intense, at least 3 in 10 minutes. with painful sensations at the height of contraction, average speed cervical dilatation of at least
1.5-2 cm/hour in primiparous women and 2-2.5 cm/hour in multiparous women.
Deceleration phase: from 8-9 cm until expulsion of the fetus. It is characterized by a decrease in the pain of contractions, their frequency and rhythm remain the same, and the fetus moves intensively through the birth canal.
Performance evaluation criteria labor activity
I stage of labor
Frequency, duration, intensity, rhythm of contractions, their increase in the active phase. Normally, the tone of the uterus in the first stage of labor ranges from 30 to 50 mm Hg. Contractile activity of the uterus is expressed in Montevideo units (E.M.) - the average duration of contractions multiplied by the number of contractions in 10 minutes - ranges from 150-300 E.M.
Progression of opening of the uterine pharynx with vaginal examination and external techniques according to Rogovin, Schatz-Unterbreganz-Zinchenko.
II stage of labor
Frequency, duration, intensity of contractions and pushing, uterine tone (90-100 mm Hg).
Advancement of the presenting part of the fetus along the birth canal along the external and internal research and Piskacek techniques.
Criteria for the location of the presenting head
|
Head location |
External research data |
Internal research data |
|
The head is movable above the entrance to the pelvis |
The head runs above the entrance to the pelvis |
The sacral cavity is free, the inner surface of the womb is free |
|
The head at the entrance to the pelvis as a small segment |
The head is motionless, the small segment of the head is below the plane of entry into the pelvis |
The promontory is reachable with a bent finger, the sacral cavity is free, the inner surface of the pubis is free |
|
The head is at the entrance to the pelvis with a large segment |
Most of the head is below the entrance of the plane of the scarlet pelvis, any debts are palpable |
The head covers the upper third of the pubis and sacrum, the promontory is unreachable, the ischial spines are free |
|
Head in the widest part of the pelvic cavity |
Any part of the head, neck of the fetus is determined |
The head overlaps the upper half of the sacrum and pubis (2), free IV and V sacral vertebrae and ischial spines |
|
Head in the narrow part of the pelvic cavity |
Head not detected |
The head fills the upper two thirds of the sacrum and the inner surface of the pubis; the ischial spines are difficult to reach |
|
Head on the pelvic floor |
Head not detected |
The sacral cavity is filled with the head completely, the ischial spines are not defined |
Cervical maturity scale (according to Burnhill, 1962)
|
Sign |
0 points |
1 point |
2 points |
|
Consistency of the cervix |
Dense |
Softened in the area internal pharynx compacted |
Soft |
|
Cervical length, effacement |
More than 2 cm |
1-2 cm |
Less than 1 cm and flattened |
|
Patency of the throat canal |
The external os is closed |
The channel is passable for 1 finger, the internal pharynx is tight, the tip of the finger passes through |
More than 1 finger, with a smoothed neck more than 2 cm |
|
Cervical position |
Posteriorly |
Anterior |
Middle |
Clinical parameters for assessing the condition of the mother and fetus during labor
Heart rate, blood pressure, respiration, body thermometry 3-4 times a day.
Assessment of vegetative balance (see topic 2)
The shape of the uterus, its tone, the height of the uterine fundus, the condition of the lower uterine segment, contraction ring and round uterine ligaments.
Physiological functions.
Assessment of the nature and intensity of labor, painful sensations women in labor associated with uterine contractions.
Location of the presenting part.
Listening and counting the fetal heart rate during the period of cervical dilatation with a whole amniotic sac every 15-20 minutes, with the release of amniotic fluid every 10-15 minutes. Pay attention to the rhythm and sonority of heart sounds. In II During labor, fetal cardiac activity is assessed after each effort.
The average fetal heart rate over a certain period of time ranges from 120-160 per minute - basal heartbeat. The intraminute amplitude of oscillations of the fetal heart rate is in the range of 6-25 beats.
An increase in fetal heart rate with an amplitude of more than 15 per minute and a duration of more than 15 seconds is called acceleration. Periodic monotonous acceleration indicates moderate fetal hypoxia. A decrease in fetal heart rate with an amplitude of more than 15 per minute and a duration of more than 15 seconds is called deceleration. In relation to the contraction, early, late, variable decelerations are distinguished. Late, prolonged and variable decelerations indicate intrauterine suffering of the fetus.
Principles clinical management childbirth
Correction of water and electrolyte balance by taking liquid in small portions.
Antispasmodics and analgesics in the active phase of labor during its uncomplicated course, taking into account the effect of drugs on the basal autonomic balance.
A woman can only be allowed to push when the fetal head is lowered to the pelvic floor (early pushing with a high head is dangerous for intracranial and spinal cord injury for the fetus).
From the moment the head is cut in, provide obstetric care:
preventing premature extension of the head
reduction of perineal tension
regulation of pushing
removal of the head from the genital slit outside of contraction
release of the shoulder girdle and birth of the fetal torso
If the perineum is a significant obstacle to the nascent head, then an episiotomy or perineotomy should be performed. Episiotomy is indicated for cases of threatened rupture of the “low” perineum, narrow pubic arch, infantilism, breech fetus, cicatricial changes in the perineum, obstetric vaginal operations, the threat of central rupture of the perineum; perineotomy - if there is a threat of rupture of the “high” perineum. Dissection is performed when the presenting part of the fetus is lowered onto the pelvic floor and tension in the perineum appears. According to the WHO recommended perinatal technology for childbirth, the systematic use of episiotomy is not justified.
After the birth of the head, it should only be supported, without actively turning the head or pulling it with a fixed shoulder girdle: danger of spinal cord injury at level C 4 , where the respiratory center is located (neurogenic asphyxia of the newborn), damage to the wall of the arteries in the transverse processes of the cervical vertebrae, the blood supply to the medulla oblongata and the cervical spine (even minor damage to the wall of the vertebral artery can cause its spasm, disruption of vertebrobasilar blood flow - instant death of the fetus or the development of paralysis in newborn (A.Yu. Datner, 1978).
If it is necessary to remove the shoulder girdle, you should act carefully. After turning the fetus to face in the required direction, the fetus is deviated posteriorly until the front shoulder at the border of the upper and middle thirds comes under the womb. Then the head is raised anteriorly and the perineum is shifted from the rear shoulder. When the shoulder girdle is released, armpits The index fingers are inserted and the fetal torso is created by pulling it towards the mother’s abdomen. If the birth of the shoulder girdle is difficult, the “posterior” arm of the fetus is first removed, and then the fetal body is inserted.
After the birth of the fetus, the third, postpartum period of labor begins, the shortest, but dangerous with the possibility of bleeding. It is carried out actively and expectantly, and if there is a risk of bleeding, prophylaxis is carried out: intravenous administration of 1 ml of 0.002% methylergometrine solution or 5 units of oxytocin with the last expulsion attempt or immediately after the birth of the fetus.
To establish signs of placental separation, one should be guided by the principles of Schroeder, Alfred, Küstner-Chukalov-Dovzhenko, Klein. In case of separated placenta, if it is not released, use the separation of the placenta according to Abuladze, Crede-Lazarevich, etc.
After the birth of the placenta, it must be examined and the total blood loss is determined, which should not exceed 0.5% of the mother’s body weight. Speculum examination of the cervix, vagina and external genitalia is carried out in both primiparous and multiparous women. When identifying soft tissue ruptures birth canal and their perineums are sutured under anesthesia.
As recommended by the WHO international meeting on perinatal technology, there is no justification for the rate of caesarean sections during childbirth in any particular region to be more than 10-15%. There are no indications for women to shave their pubic hair before childbirth, and there is no advantage to performing enemas before childbirth. During labor or childbirth, pregnant women should be placed in a comfortable position. In no single geographic region should the proportion of labor induced exceed 10%. Painkillers and anesthetics medicines Use only as indicated.
Artificial rupture of membranes early stages not justified. Attention should be paid to emotional, psychological and social aspects serving during childbirth (Medical newspaper, 20.24.90).
In prognostic terms, the biorhythmology of the onset of labor should also be taken into account. In 68% of observations, the onset of labor occurs in the first half of the day (0-12 hours). When labor begins in the second half of the day, the average duration of labor increases by 2-4 hours, the frequency of anomalies of labor forces, afterbirth and postpartum hemorrhage doubles. Average duration uncomplicated childbirth in primiparous women within 7-12 hours. (10 hours, 0.5 hours, 0.25 hours), for multiparous women - within 6-8 hours. (7 hours, 0.25 hours, 0.2 hours).
Childbirth is the process of expulsion from the uterus of the fetus, placenta with membranes and amniotic fluid after the end of its development cycle. Physiological birth occur on average after 10 obstetric months (280 days or 40 weeks).
Mechanisms of childbirth. The mechanisms of labor initiation remain unclear, despite a large number of research on this issue. U different types organisms, these mechanisms differ. For example, in rabbits, the onset of labor is associated with the cessation of the action of progesterone. But this mechanism does not have convincing evidence in relation to a person. The roles of oxytocin and prostaglandins in initiating labor are currently being investigated. It is known that towards the end of pregnancy, the number of receptors sensitive to oxytocin increases in the decidua and myometrial cells. Oxytocin, by binding to these receptors, stimulates the release of prostaglandins, especially PGE 2. In addition, oxytocin can increase the permeability of calcium ions, which activate actin and myosin. Decidual prolactin has also been suggested to be involved in the modulation of oxytocin action.
Most interesting hypothesis put forward by Liggins, that the signal for the onset of labor is the release of cortisol by the fetus. Studies were conducted on sheep and the pituitary gland or adrenalectomy led to a prolongation of pregnancy, and the administration of cortisol and ACTH to the fetus caused premature birth. In 1933, Malpas described delayed labor in anencephalic pregnant women and suggested that the cause was a defect in the hypothalamic-pituitary-adrenal axis.
The beginning of the preparatory period for childbirth coincides with the beginning of maturation of the epiphyseal-hypothalamic-pituitary system of the fetus. The release of fetal adrenal hormones into the fetoplacental and maternal circulation changes the metabolism of steroids: a decrease in progesterone levels due to the effect of fetal cortisol on 17-a-hydroxylase and 17-20-lyase of the placenta in favor of an increase in estrogen production. The release of cortisol causes the urinary excretion of heat-stable protein, a substance that activates phospholipase, which leads to the release arachidonic acid And sharp increase production of prostaglandins. Perhaps cortisol plays a role in the process of degeneration of the epithelium of the decidua and amnion, due to hemoconstrictive ischemia of the membranes, which leads to the release of lysosome enzymes that stimulate the production of PG and limits the duration of gestation.
The influence of childbirth on the mother's body.
Energy consumption. Childbirth is a period of significant energy expenditure, mainly due to uterine contractions. Energy is primarily provided by glycogen metabolism. Currently in obstetric practice a woman does not receive nutrition at the onset of labor and thus glycogen reserves are quickly depleted, and energy is generated through fat oxidation. This can lead to the accumulation of ketones in the blood, the formation of D-3 hydroxybuteric acid and, to a lesser extent, lactic acid. Subsequently, moderate metabolic acidosis develops. This mainly occurs in the second stage of labor, although the blood pH remains in normal range from 7.3 to 7.4 due to compensation for moderate respiratory alkalosis, arising from hyperventilation, which is common at this time. Additional energy expenditure leads to a moderate increase in body temperature, accompanied by sweating and loss of fluid from the body. Body temperature during childbirth, in the absence of ketoacidosis, increases no more than 37.8 C. Changes of cardio-vascular system. The functional work of the heart increases by 12% during the opening period and by 30% during the expulsion period, Increased functional work heart rate is expressed by an increase in stroke volume and heart rate. Average arterial pressure increases by about 10%, and at the moment of contraction it can be significantly greater. These changes in cardiac function progressively increase in accordance with the strength of uterine contractions. At the end of labor, pressure increases by 40-50 mmHg. Art. and increased blood flow big circle. After childbirth, further changes occur in the functioning of the heart. Typically, moderate bradycardia and an increase in stroke volume are observed within 3 to 4 days. These changes can be dangerous in women with decompensated cardiac pathology or severe anemia.
PRELIMINARY PERIOD (from 38 weeks before the onset of birth), characterized by:
- formation of a generic dominant in the central nervous system on the side of the placenta (clinic: drowsiness, weight loss by 1-2 kg),
- predominance of the activity of the adrenergic nervous system, increased activity of acetylcholine,
- increased secretion of estriol with a change in the estrogen/progesterone ratio,
- changes in the electrolyte composition of the blood: increased potassium and calcium levels, decreased magnesium levels,
- formation of the lower segment of the uterus,
- fixation of the presenting part of the fetus,
- structural changes cervix (“mature” cervix),
- increased secretion of cortisol by the fetus,
- detachment of the lower pole of the amniotic sac,
- the appearance of “harbingers” of childbirth.
Ancestral expelling forces:
1. Contractions are periodic, repeated contractions of the uterus.
2. Pushing - contractions simultaneous with contractions abdominal wall arising reflexively when the head presses on the muscles pelvic floor.
DURING THE 1ST PERIOD OF LABOR (dilatation period)
Myometrial changes:
Contraction is the contraction of muscle fibers,
Retraction is a displacement of muscle fibers with increasing thickening of the uterine body, stretching of the lower segment and smoothing of the cervix.
Distraction is a stretching of the cervical muscles associated with retraction rearrangement of muscle fibers. Distraction leads to complete opening of the uterine os.
° Ferguson effect - increased production of oxytocin by the pituitary gland in response to cervical distension and upper third vagina.
Processes of the first stage of labor:
- smoothing and dilation of the cervix, deployment of the lower segment,
- formation of the INTERNAL CONTACT BELT - the place where the head is covered by the walls of the lower segment with the division of amniotic fluid into anterior and posterior. The hydraulic action of the amniotic sac occurs only when sufficient quantity amniotic fluid,
- formation of the fetal bladder - parts of the membranes of the lower pole ovum, which penetrate with amniotic fluid into the cervical canal and promote smoothing of the cervix and opening of the pharynx,
- formation of a CONTRAJUTION RING - the border between the thickened myometrium of the upper segment and the stretched lower segment of the uterus. It is determined only when water breaks out. The process of retraction leads to the formation of the ring. The normal height of the contraction ring = 8 cm. The contraction ring is palpated only when amniotic fluid is released. Contraction standing height. rings indirectly indicate the degree of opening of the uterine pharynx: 1 finger above the pubis = 4 cm, 2 fingers = 6 cm, 3 fingers = 8 cm, and 4 fingers above the pubis = 10 cm. ( full opening obstetric pharynx), - timely release of amniotic fluid
To diagnose water leakage, the following are used: a smear of secretions (symptom of the paper), a diagnostic “amniotest”, intra-amnial administration of indigo carmine (a control sterile tampon is inserted into the vagina), observation (with a control pad) under the control of body temperature.
Phases of the first stage of labor (Freedman).
1. Latent phase - before the obstetric opening by 4 cm = 5 -8 hours.
2. Active phase - from 4 cm to full opening of the obstetric pharynx = 2 - 4 hours, the average speed of opening of the obstetric pharynx in primiparous women = 1.0° 1.2 cm/hour, in multiparous women = 1.5 - 2.0 cm /hour.
a) acceleration phase
b) maximum lifting phase
c) deceleration phase2 - from 8 cm to full opening, duration in 1st birth = 1 hour (no more than 3 hours), in multiparous women = 15 minutes. (no more than 1 hour).
PARTOGRAM (Friedman curve): graphical registration of labor with assessment of the degree of opening of the cervix, advancement of the presenting part of the fetus along the birth canal, blood pressure and body temperature of the mother, fetal heart rate.
Criteria for assessing labor activity.
1. ASSESSMENT OF BASAL TONE - the lowest myometrial tone outside of contraction. The normal tone of the uterus in the 1st stage of labor is compared with the tone of the quadriceps femoris muscle equal to 10±2 mmHg
2. FREQUENCY OF CONTRACTIONS (increases in the supine position): normal - 2-5/10 min, tachysystole - more than 5/10 min, bradysystole - less than 2/10 min.
3. REGULARITY.
4. INTENSITY (STRENGTH) OF CONTRACTIONS3 (in the first birth more than in subsequent ones) is determined by the intrauterine pressure during contractions. In the 1st period, the normal strength of contractions is 30-60 mmHg, and in the 2nd period - 80-100 mmHg.
5. DURATION OF CONTRACT - from the beginning of contraction to complete relaxation myometrium: in the 1st period it is equal (according to tocography) ° 80-90 sec., in the 2nd period – 90 - 120 sec.
6. EFFICIENCY. Determined by the degree of opening of the uterine pharynx.
7. DEGREE OF PAIN.
Physiological sources of pain: nerve plexuses cervical canal, parametrium, sacral and round ligaments, uterine vessels. Clinical reasons severe pain: excessive rigidity of the cervix, dense membranes, pinching of the anterior lip of the cervix, overstretching of the lower segment.
8. UTERUS ACTIVITY ° product of contraction intensity and frequency in 10 minutes. A = 1 x V, norm = 150-240 IU Montevideo.
DURING THE 2nd STAGE OF LABOR (period of expulsion)
Processes of the second stage of labor:
- complete opening of the obstetric pharynx,
- advancement of the fetus through the birth canal,
- birth of a fetus.
DURING THE 3rd STAGE OF LABOR (postpartum period)
After the birth of the fetus, intrauterine pressure increases to 300 mmHg, which is many times higher than the blood pressure in the myometrial vessels and contributes to normal hemostasis. After the birth of the fetus, the placenta contracts, the pressure in the umbilical cord vessels increases to 50°80mmHg. and if the umbilical cord is not clamped, then a transfusion of 60°80 ml occurs. blood to the fetus. Therefore, umbilical cord clamping is indicated after pulsation has stopped. Over the next 2°3 contractions, the placenta separates and the placenta is released.
Placenta separation options:
1. Central (Schultz).
2. Regional (Duncan).
Signs of placental separation:
1. Schroeder's - change in shape, height of the fundus of the uterus and its displacement to the right (since the right round ligament is shorter than the left).
2. Alfreda - the ligature from the genital slit is lowered by 10 cm.
3. Mikulich - urge to push.
4. Klein - elongation and lack of reverse retraction of the umbilical cord when straining.
5. Kostner - Chukalov absence of retraction of the umbilical cord when pressing with the edge of the palm on suprapubic region.
6. Strassmann - lack of blood supply to the pinched end of the umbilical cord during straining.
MANAGEMENT OF CHILDREN.
Indications for vaginal examination:
1. With the onset of labor.
2. Every 6 hours to assess the obstetric situation.
3. Release of amniotic fluid.
4. Fetal distress.
5. To perform amniotomy.
6. Before administering narcotic analgesics.
7. Before the upcoming operation.
8. When multiple pregnancy after the birth of the first fetus.
9. Bleeding during childbirth (with the operating room deployed).
10. Suspicion of weakness and incoordination of labor.
11. Suspicion of incorrect insertion of the presenting part.
Determined parameters during vaginal examination.
1. Condition of the external genitalia and soft birth canal (septum, scars, stenosis, varicose veins).
2. The degree of shortening of the cervix or opening of the uterine pharynx.
3. Consistency (degree of softening, rigidity) of the cervix or the edges of the uterine pharynx.
4. Conditions of the amniotic sac.
5. The presenting part and its relationship to the planes of the pelvis.
6. Identification points of the presenting part of the fetus.
7. Diagonal conjugate size.
8. Features of the pelvis (exostoses, tumors, deformities).
9. The nature and amount of discharge from the genital tract.
MANAGEMENT OF THE 1st STAGE OF LABOR.
Clinical signs of the first stage of labor:
- regular contractions with a frequency of at least 2 per 10 minutes, accompanied by effacement of the cervix (in primiparous women) or opening of the external cervix (in multiparous women),
- opening of the obstetric pharynx,
- timely release of amniotic fluid (when the obstetric opening is at least 6 cm),
- insertion of the head as a small segment at the entrance to the small pelvis in primiparas when the uterine pharynx opens more than 8 cm. The fetal head is considered inserted when the amniotic fluid ruptures and the obstetric pharynx opens at least 6 cm.
Position of the woman in labor: recommended semi-Fowler's position on the back with an elevated top part torso (semi-Fowler). In this case, the axis of the fetus and the uterus coincide and are perpendicular to the plane of the entrance to the pelvis, which contributes to the correct insertion of the head.
Principles of managing the first stage of labor:
- control over the dynamics of labor,
- prevention of anomalies of generic forces,
- prevention of fetal hypoxia: intravenous/venous drip administration 500° 1000ml. 5% glucose solution, cardiac monitoring, atropinization.
- functional assessment of the pelvis: Vasten, Zangemeister, Gilles-Muller signs.
Advantages of induced tachycardia (atropinization):
1. Increase in minute volume.
2. Improving gas exchange between mother and fetus.
3. Increased release of acidic products.
4. Decrease pCO2. Disadvantages of atropinization: depletion of the energy potential of the fetal myocardium and a decrease in blood supply to the heart when the critical level of tachycardia is exceeded.
Indications for amniotomy:
1. At the end of the 1st period, when the obstetric opening is 6-7 cm.
2. Flat amniotic sac(oligohydramnios, incomplete placenta previa).
3. Polyhydramnios.
4. Incomplete placenta previa (only with the development of regular labor).
5. Hypertension syndrome, nephropathy or pathology of the cardiovascular system.
6. Planned amniotomy with a tendency to post-term and other indications for “programmed” childbirth.
Pain relief during childbirth.
1. Epidural anesthesia during childbirth (L II -LIV) (S. Marcaim 30mg or S.Lidocaini 60mg) - duration of action 1.5-2 hours.
2. Narcotic analgesics(Meperidine(Demerol)1, Promedoli 2, Phentanyli 3).
3. Pudendal analgesia (10 ml of 1% lidocaine solution (or 0.5% novocaine solution) is injected into the projection of both ischial tuberosities.
MANAGEMENT OF THE 2ND STAGE OF LABOR.
Clinical signs of the second stage of labor:
- complete opening of the uterine os,
- the appearance of attempts,
- advancement of the fetus along the birth canal (head in the pelvic cavity),
- cutting and eruption of the fetal head, birth of the fetus
External methods for determining the location of the head in the pelvic cavity:
1. Piskachek's maneuver - pressure with the 2nd and 3rd fingers along the edge of the labia majora, parallel to the walls of the vagina.
2. Genter's maneuver - pressure outside the contraction with fingers located around the anus.
Interpretation: the fingers reach the head if it is in a narrow part of the small pelvis or on the pelvic floor.
Principles of managing the second stage of labor:
- control of the dynamics of advancement of the head in the pelvic cavity,
- prevention of fetal hypoxia,
- prevention of bleeding in the third and early postpartum period,
- prevention of trauma to the mother and fetus (episiotomy or perineotomy, position of the woman in labor, change in the angle of the pelvis).
The angle of the pelvis can change with different body positions. In a supine position with hanging hips (Walcher position), the direct size of the entrance to the small pelvis (true conjugate) increases by 0.75 cm. With a pronounced degree of posterior parietal (Litzmann) insertion, the angle of inclination of the pelvis must be reduced (ex.: place a pad under the sacrum ), and if there is an anterior parietal (non-Gel) increase (example: place a pad under the lower back).
In order to maintain the integrity of the perineum and pelvic floor, it is important to create a large pelvic tilt. When releasing the shoulders, it is necessary to place a pad under the sacrum, which prevents the occurrence of a fracture of the collarbones.
Points of obstetric care for cephalic presentation.
1. Preventing premature extension of the head. The bent head is erupting smallest size less stretching of the perineum. The head is held with the palmar surface of four bent fingers(but not with your fingertips!). Forcibly bending the head too far can cause injury cervical region spine.
2. Removing the head from the genital slit without pushing. The vulvar ring is carefully stretched over the erupting head with a large and index fingers right hand.
3. Reducing perineal tension. It is achieved by borrowing tissue from neighboring areas (the area of the labia majora) with the thumb and forefinger located on the perineum.
4. Regulation of pushing. When establishing the suboccipital fossa under the womb, the woman in labor is asked to breathe frequently and deeply through her mouth. Right hand they move the perineum from the forehead, and with the left ° they straighten the head, asking the woman in labor to push.
5. Release of the shoulder girdle and birth of the torso. The head, grasped by the palms of the temporo-buccal areas, is turned to the side depending on the position of the fetus (in the 1st position, “facing the right thigh, in the 2nd, facing the left). To determine the position, you can focus on the birth tumor. At 1 In the 1st position of the anterior view, the birth tumor is located on the left parietal bone, in the 2nd position - on the right, in the posterior view ° vice versa. It must be remembered that at the level of segment CIV there are cells of the spinal respiratory center. Spinal trauma at this level due to active rotation of the head can lead to neurogenic asphyxia.
MANAGEMENT OF THE 3rd STAGE OF LABOR.
Principles of conduct postpartum period:
- emptying Bladder immediately after the birth of the fetus.
- control of maternal hemodynamic parameters.
- control of blood loss.
- at normal course childbirth after the birth of the fetus any mechanical impact on the uterus (palpation, pressure) until signs of placenta separation appear is prohibited.
Techniques for releasing the placenta:
1. Abuladze - pushing while taking tissue from the anterior abdominal wall.
2. Gentera - pressure from the fundus along the ribs of the uterus downwards and inward outside of pushing (not currently used).
3. Kredo-Lazarevich - squeezing the placenta after grasping the bottom with the palmar surface of the hand (not currently used).
Blood loss during childbirth.
During childbirth, a woman loses an average of 300°500 ml. This figure may vary. U healthy woman it has no clinical consequences, since this does not exceed the blood volume increased during pregnancy.
Physiological blood loss is 0.5% of body weight (200-250 ml).
Discoordinated labor activity - DRD (hypertensive dysfunction of uterine contractility during labor) is the most difficult to recognize and correct. In obstetric practice, it is advisable to distinguish following forms DRD:
Discoordination of contractions.
Hypertonicity of the lower segment (reverse gradient or dominant of the lower segment).
Circular dystocia (contraction ring). Most often, cervical dystocia is the absence of relaxation of the cervix at the time of contraction of the muscles of the uterine body.
Convulsive contractions (uterine tetany, total uterine dystocia) - spasm of the muscles of all parts of the uterus.
All of these forms are united by a common factor—hypertonicity of the myometrium, against the background of which the contractile activity of the uterus is distorted.
Precursors of DRD (occur before birth, allow predicting DRD).
Immature or insufficiently mature cervix in full-term (38-40 weeks) pregnancy at the due date and even when labor has begun.
Pathological preliminary period.
Prenatal rupture of amniotic fluid with a tight, “immature” cervix.
Hypertonicity of the uterus before the onset of labor (over 10 mm Hg). Hypertonicity can be determined by comparing the consistency of the uterus with the tone of the patient's lateral thigh muscle.
Before childbirth and even with the onset of labor, the head remains mobile or slightly pressed to the entrance to the pelvis (if the fetus and pelvis are proportional).
Often oligohydramnios is combined with fetoplacental insufficiency.
Postterm pregnancy (42 weeks or more).
DRD Clinic
DRD is most often observed in the first stage of labor (usually before the cervix is dilated by 5-6 cm).
Contractions are unequal in strength and duration, irregular (occur after 1-3-5-7 minutes). Between contractions, hypertonicity of the uterus persists, making it difficult to determine the position of the presenting part (pressed or by a small segment at the entrance to the pelvis).
Sharp pain in contractions, even at the very beginning of the latent phase (the neck is not smoothed, the opening is small). Pain of a breaking nature is localized in the sacrum and lower back. The sensation of pain persists between contractions.
The woman’s behavior is restless, she screams and asks for pain relief. Possible autonomic disorders varying degrees severity (nausea, vomiting, tachycardia, bradycardia, arterial hypertension or hypotension, pallor or flushing of the face, sweating, fever up to 38 degrees. and higher, chills). Urination is difficult. With seemingly “strong” labor, the pace of labor is slow (shortening, smoothing and opening of the cervix slowly occurs, latent and active phase childbirth). Prenatal or early rupture of amniotic fluid is characteristic (with an unsmoothed cervix and a small opening).
During vaginal examination - tense pelvic floor muscles, spastic narrowing of the vagina, the edges of the pharynx are thick, dense, stubborn or thin, but “stretched like a string” (impaired blood and lymph circulation). At the height of the contraction, the pharynx does not stretch, but spasms, and the density of the cervix increases (spastic contraction of the circular muscles - cervical dystocia). Sometimes in dynamics it seems that the discovery not only does not progress, but becomes smaller. Opening of the pharynx during DRD often occurs at the cost of its rupture
Cervical dystocia is a functional pathology and should be distinguished from anatomical rigidity.
With whole waters, there is often a functionally defective flat amniotic sac. The anterior waters are practically absent, the membranes are dense, not detached from the walls of the lower segment and are adjacent to the fetal head, as if “stretched” over the head.
Due to hypertonicity of the lower segment it is possible; violation of the biomechanism of childbirth (posterior view, extensor insertion of the head, prolapse of the umbilical cord, arms, extension of the spine). With DRD, anomalies of head insertion and posterior appearance are 10 times more likely. Early education possible birth tumor on the fetal head even with a small opening of the pharynx (corresponds to the place of pinching by a spasmodic pharynx).
Fetal hypoxia develops and progresses.
As a result of the mechanical effect of segmental contractions of the uterus (especially against the background of placental insufficiency, fetal hypoxia, lack of water), the newborn may have intracranial hemorrhages, spinal cord injuries.
The period of expulsion lengthens, the presenting part stands for a long time in each plane of the small pelvis. Premature pushing often occurs when the head is high (the cause may be pinching of the neck between the head and the pelvic bones, as well as swelling of the cervix, vagina, or the presence of a large birth tumor).
Severe injuries to the cervix (overcoming spasm), vagina, and perineum are possible.
With DRD, there is a high risk of uterine rupture (even in primiparas with OAA) as a result of ischemia of a separate area of the uterus (more often left rib lower uterine segment, anterior wall). Higher risk of amniotic fluid embolism premature detachment placenta during childbirth, massive bleeding in the afterbirth (usually placental strangulation) and early postpartum period (combination of the pathology of uterine contraction with coagulopathy - development of disseminated intravascular coagulation against the background of severe protracted labor, amniotic fluid embolism).
The predominance and severity of individual symptoms depends on the form and severity of DRD. Clinical forms often reflect the dynamics of pathology progression, but can also arise initially.
Diagnosis of DRD is based on the above clinical manifestations. Using multichannel hysterography, asynchrony and arrhythmia of contractions of various parts of the uterus, violations of the triple descending gradient, and systole-diastolic ratio are established.
Differential diagnosis:
- · weakness of labor;
- · clinically narrow pelvis (may also be the cause of incoordination);
- · anatomical rigidity of the cervix (may also be the cause of DRD).
When choosing delivery tactics (conservative, surgical), after establishing the diagnosis, the individual prognosis of childbirth for the mother and fetus should be assessed, taking into account risk factors.
When a diagnosis of incoordination of labor is made and the following factors are present that significantly aggravate the prognosis, it is advisable to complete the birth with a cesarean section without a previous attempt at corrective therapy. A) Prenatal factors (occurring before birth).
- · Aged primigravida.
- · Complicated obstetric history (infertility, induced pregnancy, IVF, recurrent miscarriage, stillbirth,
- · birth during a previous birth of a child with hypoxic, anemic, hemorrhagic damage to the central nervous system or spinal cord).
- · Anatomically narrow pelvis.
- · True post-term pregnancy.
- · Scar on the uterus.
- · Severe preeclampsia or EGP, in which prolonged labor poses an additional risk.
- · Breech presentation.
- · Large fruit
- · Chronic hypoxia fetus, IUGR.
- B) Intranatal factors (arising during childbirth),
- · Critical anhydrous interval (10-12 hours).
- · Anomalies of insertion of the fetal head.
- · Signs of fetal hypoxia according to CTG.
In the absence of risk factors (as well as in the presence of contraindications to caesarean section or a woman’s refusal to undergo surgery) - childbirth continues through the natural birth canal, correcting the DRD.
Correction of DRD is usually multicomponent. Kinds therapeutic effects can be divided (maybe somewhat conditionally) into activities of stages 1 and 2.
Stage 1 events
- · Psychotherapy, sedatives, tranquilizers (seduxen).
- · If possible, electroanalgesia, electrorelaxation of the uterus.
- · Estrogen-energy complex (EEC).
- · Antispasmodics and analgesics.
Stage 2 events
- · Medicinal sleep-rest, obstetric anesthesia.
- · Tocolysis (3-adrenergic agonists.
- · Eghidural analgesia.
Antispasmodic therapy
- · Antispasmodics are administered throughout the 1st and 2nd stages of labor intravenously continuously or intramuscularly every 3 hours (no-spa, baralgin, aprofen, spasmolitin, gangleron).
- · Antispasmodics begin to be administered from the latent phase of labor (from the moment of diagnosis or suspicion of DRD) until full birth fetus, since it is possible that the shoulders may be pinched in the spasmodic uterine os.
- · Antispasmodics must be administered after spontaneous rupture of water or before amniotomy.
- · In severe forms of DRD, childbirth is carried out with a catheter in a vein. Antispasmodics are constantly injected dripwise; the base solution for them can be a glucose-novocaine mixture (10% glucose solution and 0.5% novocaine solution in equal proportions) or a 5% glucose solution with agupurine (5 mg).
Amniotomy. In case of DDD, it is necessary to eliminate the defective amniotic sac and dilute (remove from the fetal head) the membranes. If the shells are fixed to the lower segments, they must first be peeled off. But you should not try to perform digital expansion of the cervical canal! Amniotomy is performed immediately after the administration of antispasmodics (noshpa 4 ml, baralgin 5 ml i.v.) so that the decrease in the volume of the uterus occurs against the background of their action.
Tocolysis with beta-adrenergic agonists (ginipral, partusisten, bricanil). Carrying out tocolysis is the most effective method eliminating basal hypertonicity of the uterus, discoordinated uterine contractions, reducing the amplitude and frequency of contractions. Tocolysis can be carried out according to the scheme of massive or long-term tocolysis (see Appendix 3). More often used the following diagram. The therapeutic dose of the drug (ginipral - 5 ml (25 mcg) is dissolved in 500 ml of isotonic sodium chloride solution or 5% glucose, administered intravenously slowly, starting with 5-8 drops per minute, then every 15 minutes the frequency of drops is increased by 5 -8, reaching a maximum frequency of 35-40 per minute. After 20-30 minutes, contractions almost completely stop. Tocolysis ends 30 minutes after the complete cessation of labor. After some time, contractions spontaneously recover against the background of normal basal tone.
If DRD occurs again after tocolysis, consider a caesarean section.
If after tocolysis labor becomes weak (or DRD spontaneously turns into weakness), carefully perform labor stimulation with prostaglandin E2 preparations (1 mg Prostenon per 500 ml of 5% glucose). The use of oxytocin and PGF2-alpha is permissible only in the absence of PGE.
Epidural analgesia - blocks spinal segments T8-S4, inhibits the effect of oxytocin, has an antispasmodic and analgesic effect, significantly reduces or eliminates hypertonicity and spastic contractions of the uterus. Preloading with crystalloids is carried out. Adrenaline should not be administered if tocolysis has been performed.
General principles of labor management during DDD
- · Childbirth during DRD should be conducted by an experienced obstetrician-gynecologist (senior doctor of the duty team), with severe forms Together with the anesthesiologist, a neonatologist must be present at the birth of the child.
- · Cardiac monitoring and hysterographic control are indicated; maintaining a partogram is mandatory. Contractions are recorded using a stopwatch for 10 minutes of every hour of labor. If necessary, more often (assessment of the effectiveness of tocolysis).
- · Multicomponent correction of DRD is carried out. Attention! Oxytocin and PGR2-alpha are contraindicated in any form of DRD. You should not attempt digital dilatation of the uterine os.
- · In severe forms of DRD, childbirth is carried out “with a catheter in a vein” (iv administration of antispasmodics, solutions that improve microcirculation, tocolytics, etc.).
- · Since DRD is accompanied by a decrease in uteroplacental blood flow, it is advisable to administer: vasodilators (aminophylline), drugs that improve microcirculation (reopolyglucin, glucose-novocaine mixture with trental, drugs that improve metabolism (cocarboxylase, ATP, cytochrome C).
- · Drug protection of the fetus (seduxen 0.07 mg/kg body weight bodies - women or sub-narcotic doses of GHB 14.2-28.4 mg/kg body weight). Seduxen acts on the limbic structures of the fetal brain, providing protection against pain and mechanical overload that occurs with DDD.
- · With a long anhydrous period - antibacterial therapy.
- · In the second stage of labor - episiotomy (to reduce the mechanical impact on the fetal head), since DRD is characterized by tension in the perineal muscles.
- · Prevention of bleeding is indicated (1 ml of istilergometrine, or syntometrine - methylergometrine and oxytocin 0.5 ml in one syringe is administered).
Obstetric tactics depend on specific situation, determined by a combination of factors:
- · timely diagnosis of DRD, its clinical form and severity;
- · condition of the woman in labor (fatigue, signs of ascending infection, severity of vegetative dysfunction);
- · fetal condition (appearance of signs of hypoxia, nature of head insertion);
- · condition of the amniotic sac (flat), duration of the anhydrous interval.
WITH situation 1 Conditions:
- DRD light or medium degree;
- · the diagnosis was established in time during the labor phase;
- · the woman in labor is not tired;
- · amniotic sac is intact.
Obstetric tactics:
- 1. Stage 1 measures (psychotherapy, amniotomy, EEC, antispasmodics IM every 2-3 hours). Assess effectiveness within 2 hours.
- 2. If effective (normalization of the tone and nature of contractions), continue labor management according to general principles with DRD (see above).
- 3. If ineffective, proceed to stage 2 measures: tocolysis with beta-agonists or epidural analgesia (depending on individual characteristics patients - presence of contraindications, consent, etc.).
- 4. When DRD transforms into weakness of labor (against the background of tocolysis, EA or spontaneously), labor stimulation of PGE2 is possible. In the absence of PGE2 drugs, the use of oxytocin is permissible (caution!)
- 5. If it is impossible to carry out tocolysis (presence of contraindications, intolerance to ginipral) and epidural analgesia, as well as if signs of fetal hypoxia appear, complete the birth by cesarean section.
Situation 2
Conditions are similar to those in situation 1, but the water has broken out (prenatal or early rupture of water), the anhydrous interval is not long, there are no signs of infection.
Obstetric tactics
- 1. During a vaginal examination, remove the membranes from the fetal head.
- 2. Stage 1 measures (antispasmodics, EEC, psychotherapy), then as in situation 1 (points 2,3,4,5).
Situation 3 Conditions:
- · DRD of mild or moderate degree in the latent phase of labor;
- · amniotic sac is intact;
- · the woman in labor is tired (the birth was preceded by a long pathological preliminary period).
Obstetric tactics
- 1. Amniotomy, antispasmodics.
- 2. Medication sleep - rest for 2-3 hours.
- 3. Assess the nature of labor after rest.
- 4. When normalizing labor, conduct it in accordance with the basic principles for DRD.
- 5. If previous ones are ineffective therapeutic measures(points 3,4,5 of situation 1).
Situation 4
The conditions are similar to those in situation 3, but the waters have flowed out. Obstetric tactics
- 1. After the water has broken out, administer antispasmodics.
- 2. With a short anhydrous interval, provide the woman in labor with medicated sleep-rest, then as in the situation^ (points 3,4,5).
- 3. In case of a critical anhydrous interval, it is advisable to perform a cesarean section.
Situation 5 Conditions:
- moderate to severe incoordination;
- · the diagnosis was made late, the woman is tired;
- · signs of fetal hypoxia.
Obstetric tactics
- 1. Optimal method delivery should be considered a cesarean section.
- 2. If there are contraindications to cesarean section or the woman refuses this operation, correct DRD (antispasmodics, with a whole bladder - amniotomy, sleep-rest, then tocolysis or EA, treatment of fetal hypoxia, with a long anhydrous interval - antibacterial therapy, prevention bleeding).
- 3. Reuse promedol, seduxen, fentanyl or relanium in combination with antihistamines.
- 4. In case of a dead fetus, correction of DDD; in case of ineffectiveness of therapeutic measures and the presence of conditions, a fetal-destroying operation is performed.
- 5. As a last resort!!! It is allowed to dissect the neck around the circumference at 10, 14, 16 and 20 o'clock to a depth of 1 cm (elimination of the spastic ring).
Situation 6
tetanus of the uterus (total uterine dystocia);
the mother's condition is serious;
the condition of the fetus is severe (acute hypoxia or death);
a real threat of amniotic fluid embolism or premature abruption of a normally located placenta.
Obstetric tactics
If uterine tetanus develops against the background of labor stimulation with oxytocin or PGT2-alpha, immediately stop administering uterotonics.
Give the woman in labor fluorothan anesthesia (quickly relieves labor) or start acute tocolysis with ginipral Ginipral 2 ml (10 mcg) per 10 ml saline. IV solution slowly over 5-10 minutes.
If the fetus is alive, the birth should be completed by cesarean section.
If there are contraindications to CS (signs of chorioamnionitis, a “dying” fetus), or the woman refuses CS), continue conservative management of labor (depending on the specific situation --- medicinal sleep, rest, epidural analgesia, or continued tocolysis until contractions cease completely). If after tocolysis labor does not resume or is insufficient, labor induction is PGE.
If the fetus is dead and conditions are present, a fruit-destroying operation is performed.
Labor expelling forces include contractions and pushing.
Contractions– periodically repeated contractions of the uterine muscles.
Attempts– rhythmic contractions of the abdominal muscles and parietal muscles of the pelvis and pelvic floor that join the contractions.
Thanks to contractions, the cervix opens, which is necessary for the passage of the fetus and placenta from the uterine cavity; contractions contribute to the expulsion of the fetus, pushing it out of the uterus.
Each contraction develops in a certain sequence, according to triple downward gradient rule. First, contraction of a group of cells begins in one of the upper parts of the uterine body, contractions spread to the fundus of the uterus, then to the entire body of the uterus and, finally, to the area of the lower segment and cervix.
Contractions of the uterus gradually increase, reach their highest degree, then the muscles relax, turning into a pause.
Characteristics of the contraction: duration, frequency, strength, rate of increase and decrease, pain. When determining the frequency, duration and strength of contractions, one cannot take into account only information received from the woman in labor. The woman calculates the duration of the contraction, focusing on pain. This subjective information may not be accurate. A woman may react very painfully to subthreshold precursor contractions, sometimes she does not feel the beginning of a contraction or may feel pain after the contraction stops and relaxes. The midwife, examining contractile activity, places the palms of her hands with fingers apart on the anterior wall of the uterus, i.e. controlling contractions in all parts of the uterus. Such contractions and relaxations of the uterus must be monitored for at least three contractions, and the strength, regularity, and direction of propagation of myometrial contractions must be noted. Provides more objective data tocometry. Grip strength at ultrasonic tocometry is estimated in mm Hg. Art.
When palpation is determined, the strength of the contraction is determined by a qualitative sign; this skill is transferred from teacher to student during practical classes in the clinic. The pain of contractions is characterized by the woman herself. Soreness is very subjectively divided into weak, moderate and strong.
At the beginning of labor, the duration of contractions is only 20 seconds, by the end - almost 1 minute. The pauses between contractions at the beginning of labor last 10 minutes, then shorten; by the end of the period of expulsion of the fetus, contractions occur every 3 minutes. As labor progresses, contractions become stronger and more painful. Contractions may be frequent, prolonged and painful, but weak. In this case, they already talk about anomalies of labor.
There are three types of contractions of the uterine muscles: contraction, retraction and distraction.
Contractions are contractions of the muscles of the uterus, followed by their relaxation, they are characteristic of the body of the uterus, thanks to them the fetus is pushed out of the fetal sac. Contractile contractions are the most active view abbreviations.
Retractions are contractions of the uterine muscles, which are combined with their displacement. Some fibers are pushed into others, and after displacement they do not return to their place. In this way, the lower muscle fibers are shortened, which improves distraction and cervical opening. The neck and lower segment stretch, become thinner and move upward. At the same time, at the border with the upper parts of the uterus, above which retraction is not observed, but only contraction contractions take place, a border, or contractionary, ring. It is formed by muscle fibers displaced upward. The contraction ring is located above the upper edge of the symphysis, as transverse fingers or centimeters as the cervix is open.
Distraction is the relaxation of the circular muscles of the cervix, which promotes dilatation of the cervix.
Consequently, due to contractions, the cervix opens. The body of the uterus and cervix have different structure and different innervation. In the area of the uterine body there is a longitudinal arrangement of fibers, and in the area of the isthmus and cervix - circular. The body of the uterus is innervated sympathetic fibers, and necks - parasympathetic. During childbirth, the muscles of the uterine body contract, and the muscles of the cervix relax, which contributes to the expulsion of the fetus.
During contractions, intrauterine pressure increases, and during pushing, intra-abdominal pressure increases.
Attempts occur reflexively due to irritation by the presenting part of the fetus of the nerve elements embedded in the cervix, pelvic floor muscles and parametric tissue.
Attempts occur involuntarily, but the woman in labor can regulate them to a certain extent.
The simultaneous increase in intrauterine pressure promotes the advancement of the fetus in the direction of least resistance, i.e. into the small pelvis and further out.
The course and management of the first stage of labor - the period of dilatation
The period of dilation begins with the appearance of regular (repeating every 10 minutes) contractions, accompanied by the process of formation of the uterine pharynx (fusion of the external and internal pharynx of the cervical canal). Usually, during this period of time, amniotic fluid is discharged; it can be early or timely.
When starting to write this section of the academic history of childbirth, the student must remember the general principles of managing the first stage of labor.
1. Monitoring the general condition of the woman in labor. To do this, it is necessary to monitor the condition of the woman in labor, her complaints, and the color of the skin. Every hour it is necessary to measure the mother’s blood pressure, count and evaluate the pulse, and enter this data into the birth history.
In case of violations of the mother's condition, it is necessary first of all to identify their causes, and then decide on methods for its correction.
2. Assessment of the nature of labor - frequency, duration, intensity of contractions.
To assess the nature of labor, the doctor sits to the right of the woman in labor and, placing his palm on her stomach in the area of the fundus of the uterus, uses a stopwatch to determine the duration of 3-4 contractions in a row and pauses between us. The intensity of contractions is assessed by palpation by the degree of increase in uterine tension during contractions.
The nature of labor can be assessed through its objective registration. In particular, in practical obstetrics, devices of various brands of the “Fetal Monitor” type (cardiotocographs) are currently used for simultaneous assessment of the condition of the fetus and the nature of contractions. If monitoring of the condition of the fetus and the nature of uterine contractility (SMA) was carried out during labor, then it is necessary to describe the results of this study. With a score of 8 points, the condition of the fetus is assessed as good, 7 points - borderline, with a score of 6 (or less) points, the compensatory capabilities of the fetus are sharply reduced.
3. Assessing the effectiveness of labor. The effectiveness of labor is assessed by the degree of opening of the uterine pharynx and by the control of the forward movement of the head.
The degree of opening of the uterine pharynx can be controlled by external techniques (Schatz-Unterberger and Rogovin techniques) and with internal obstetric examination performed according to appropriate indications.
The Schatz-Unterberger maneuver can be used during a contraction with the bladder emptied and the pharynx opening more than 4 cm. At the height of the contraction, a contraction ring is palpated, which is defined as a roller running horizontally, parallel to the symphysis pubis. The degree of opening of the uterine pharynx corresponds to the distance from the symphysis pubis to the contraction ring (in cm or in transverse fingers). When the pharynx is fully dilated, the contraction ring is located 4-5 p/p (10 cm) above the upper edge of the pubis.
Rogovin's technique is less accurate; it is informative only in women of average height with average fetal weight. The Rogovin maneuver should be used outside of a fight. As the uterine os opens, the fundus of the uterus approaches the xiphoid process of the sternum. The closer the fundus of the uterus is located to the xiphoid process of the sternum, the greater the degree of opening of the pharynx. Before the onset of labor, the uterine fundus is usually located 5 subsections below the xiphoid process of the sternum. Outside of the contraction, you should determine how many p/p is placed between the fundus of the uterus and the xiphoid process of the sternum, and then subtract this number from 5. The resulting figure will indicate the degree of opening of the pharynx in the p/p. For example, the fundus of the uterus is located 3 p/p below the xiphoid process of the sternum, 5-3=2. Consequently, the opening of the pharynx is 2 p/p = 4 cm. With full dilation of the pharynx, the fundus of the uterus outside the contraction is determined at the xiphoid process of the sternum.
The forward movements of the head during labor are monitored using 3-4 Leopold-Levitsky techniques, with the 4th technique being more informative. When lowering the head into the pelvic cavity, you can use the Piskachek maneuver, which is used if, when performing the III and IY Leopold-Levitsky maneuver, the head above the entrance to the m/s is not detected. The woman in labor lies on her back with her knees bent and legs apart.
Comments. It should be remembered that external methods for assessing the degree of opening of the uterine pharynx are subjective and may not always reflect true picture birth process. An objective method for assessing labor activity is internal obstetric examination. Based on the results of this study and the advancement of the presenting part of the fetus, a graphical recording is made - a partogram. The partogram allows you to predict the weakening of labor and carry out its timely correction.
The examining doctor, wrapping the index and middle fingers with a sterile napkin, places them along the lateral edge of the labia majora at the border of the lower and middle thirds. Stretching the tissues of the labia majora, fingers are directed along the wire axis of the pelvis, palpating the head (through the soft tissues of the labia, without inserting fingers into the vagina of the woman in labor). If the head has descended into the pelvic cavity, it can be easily reached with an examining finger.
4. Monitoring the condition of the fetus.
Assessment of the condition of the fetus during labor can be carried out using monitoring devices. In the absence of hardware monitoring, the fetal heartbeat is listened to with an obstetric stethoscope for a minute every 30 minutes. until amniotic fluid ruptures, every 10 minutes. after the rupture of amniotic fluid. The fetal heartbeat is heard during the pause between contractions. When the fetus is in satisfactory condition, its heart rate fluctuates between 120-160 beats per minute. If monitoring is carried out during labor, it is necessary to give a qualitative assessment of the fetal cardiotocogram using the Fisher grading scale. With a score of 8 points, the condition of the fetus is assessed as good, 7 points - borderline, with a score of 6 (or less) points, the compensatory capabilities of the fetus are sharply reduced.
5. Observation of the nature of discharge from the birth canal. During the physiological course of labor, amniotic fluid usually pours out at the end of the period of dilatation with complete or almost complete dilatation of the uterine pharynx - this is a timely discharge of amniotic fluid. The discharge of amniotic fluid during childbirth with incomplete opening of the throat is called early. When amniotic fluid is released, its nature should be assessed. Amniotic fluid should be colorless, without any impurities, and odorless. The appearance of meconium impurities in amniotic fluid, their dark color, indicate chronic or acute fetal hypoxia. The unpleasant odor of discharged amniotic fluid and its turbidity indicate infection of the membranes (chorioamnionitis).
The rupture of amniotic fluid can be complicated (in the absence of a full contact belt) by prolapse of the umbilical cord or soft parts of the fetus. Therefore, rupture of amniotic fluid (timely or untimely) is a mandatory indication for immediate internal obstetric examination. In this case, the procedure for the study and its description are the same as for the admission of a woman in labor.
After each internal obstetric examination, the doctor must formulate a diagnosis (characterizing this particular stage of labor) and write a conclusion in which he determines his tactics for further management of labor.
The appearance of bleeding or other pathological discharge from the birth canal indicates a serious complication of childbirth and requires immediate medical intervention.
The first clinical sign indicating the end of the period of opening and the beginning of the period of expulsion is usually the complete opening of the uterine pharynx and the appearance of attempts - contractions of the uterus (contraction) are joined by contractions of the diaphragm, muscles of the anterior abdominal wall, and later, as the presenting part moves along the birth canal, contractions of the parietal pelvic muscles and pelvic floor muscles. However, among the above signs of the expulsion period, the main confirmation of the end of the dilation period is the establishment of complete dilatation of the uterine pharynx. The presence of complete dilatation of the uterine pharynx can be detected using the Schatz-Unterberger and Rogovin techniques. If it is at this time that amniotic fluid is released, then an internal obstetric examination is performed, which confirms the data of the external examination.
The end of the first stage of labor and the beginning of the expulsion period are confirmed by the forward movement of the head, which is determined using the IY Leopold-Levitsky maneuver and the Piskachek maneuver.
It should be noted exact time the end of the first and the beginning of the second stage of labor.
The course and management of the expulsion period (2 stages of labor)
The period of expulsion begins with the complete opening of the uterine pharynx and ends with the expulsion of the last fetus.
During the period of exile, they adhere to the same principles of labor management as in the first period, with a number of features taking place:
1) monitoring and correction of the mother’s condition;
2) control of the nature and effectiveness of generic expelling forces (pushing);
3) monitoring the condition of the fetus (the fetal heartbeat is heard after each attempt in the middle of the pause!);
4) control over the advancement of the presenting part of the fetus;
5) the condition of the birth canal
6) assessment of the nature of discharge from the birth canal
7) monitoring the condition of the lower segment of the uterus. When palpated at the height of the attempt, the contraction ring should not rise above 4-5 p/p above the level of the pubis. Outside of contractions, palpation of the lower segment of the uterus should be painless
8) guidance of attempts
Active management of the expulsion period begins after completion of the internal rotation phase of the fetal head.
With the correct course of the expulsion period, the forward movement of the fetus occurs quite quickly. When the fetal head moves from the narrow part of the pelvis to the plane of the pelvic outlet, the head begins to appear from the genital slit at the height of the attempt, disappearing outside the attempt (embedding of the head). At this stage of the expulsion period, preparations for delivery begin.
With the beginning of the eruption of the head (the head, having appeared from the genital slit of the woman in labor at the height of the attempt, does not disappear after its end), they begin to provide benefits for the protection of the perineum. The purpose of this manual is to prevent rapid extension of the head, which prevents trauma to the fetal head and rupture of the mother's perineum.
The benefit consists of the following points:
1) prevention of premature extension of the head;
2) bringing the head out of the attempt;
3) reducing perineal tension due to surrounding tissues;
4) regulation of pushing;
5) removal of the shoulder girdle.
Comments. It is necessary to describe the clinical management of the 2nd stage of labor, in particular how the condition of the woman in labor, the fetus, and discharge was monitored. A detailed description of the perineal protection benefit is not recommended.
The birth history should indicate the exact date and time of birth of the fetus.
After birth, the newborn’s condition is assessed using the Apgar scale - at the end of the 1st and after 5 minutes. after birth.
It is necessary to describe the Apgar score in the form of a table and give an assessment of the newborn. Draw a conclusion about his condition. Healthy newborns have a score of 8-10 points, that is, they are in satisfactory condition.
Indicate in the history whether the newborn was immediately attached to the mother's breast; if not, then note why.
Newborn's first toilet
The first toilet of a newborn is carried out in two stages, but one should remember modern approaches to individual management of labor and the role of staff in supporting close skin-to-skin contact between mother and child.
Stage I (carried out on the birth table):
1) suction of mucus from the upper respiratory tract of a newborn is carried out according to indications. The student must indicate whether these activities were carried out
2) clamping and intersection of the umbilical cord (describe when, at what distance from the umbilical ring, how and with what instruments it is performed and in what period of time from birth):
3) prevention of conjunctivitis (describe in detail the procedure - with what drug, with what material, in what sequence).
After the first stage of treatment, immediately on the birth table, sterile “bracelets” are tied to the newborn’s arms indicating the full name of the woman in labor, the gender of the child, the hour and date of birth, and N of the birth history. The newborn is placed on the mother's breast in the absence of contraindications, which are determined by the neonatologist, paying attention to the mother's gender, the presence or absence of developmental defects.
After “skin” contact with the mother, the newborn is transferred to a heated table, where the second stage of the newborn’s toileting is carried out:
1) treatment of the umbilical cord (carried out under strictly aseptic conditions) - describe in detail at what distance from the umbilical ring a ligature or plastic bracket is applied, at what distance from the ligature (brace) the remainder of the umbilical cord is cut off, how hemostasis is checked in the umbilical cord vessels, what tools and materials are used. Justify the choice of umbilical cord treatment technique.
2) anthropometry of a newborn: measuring the circumference of the head by its direct size, circumference chest, measuring the growth of a newborn, his weight.
A newborn is examined in the delivery room by a neonatologist. After this, the newborn is dressed and placed again on the mother's chest. Fill out the “History of Development of the Newborn.” In the absence of contraindications, he and his mother are subsequently transferred to the postpartum unit of the “Mother and Child” joint stay.
Describe the goals of early attachment of the newborn to the mother's breast.
Management of the third stage of labor
The afterbirth period begins immediately after the birth of the fetus (the last one, if it is a multiple pregnancy) and ends with the birth of the placenta. Its physiological duration in most women is 5-10 minutes. The maximum duration of 3 periods is 30 minutes. Management of the succession period depends on its phase:
Phase 1 (tonic contraction of the uterus) lasts 3-4 minutes - management is conservative, but at the very beginning (end of the expulsion period - beginning of the afterbirth period) bleeding is prevented with a single injection of 1.0 (5 IU) oxytocin intramuscularly or intravenously 0 .02% solution of methylergometrine (0.05 or 1.0 ml per 20 ml of saline solution). The drug is administered slowly over 3-4 minutes, stimulating prolonged tonic contraction of the uterus.
II) phase (separation of placenta) - management continues conservatively, because Intervention in this phase can cause discoordination of uterine contractions and strangulation of the placenta, which can result in bleeding.
Phase III (discharge of placenta) - active management.
During the afterbirth period, the woman in labor is under the constant supervision of a doctor and midwife.
When describing the course and management of the succession period, it is necessary during phase I:
1) assess the condition of the woman in labor;
2) describe how and when bleeding was prevented;
3) how blood loss was recorded.
During phase II, monitor the size and shape of the uterus and the appearance of signs of placenta separation.
It is necessary to describe 2-3 visual signs of placental separation (Schroeder’s sign, hourglass sign, Alfeld’s sign, etc.), after the appearance of which the palpation sign of Küstner-Chukalov is checked.
The appearance of signs of placenta separation indicates the end of phase II of the afterbirth period and the beginning of the placenta release phase (III).
In the birth history, you should indicate what signs of separation of the placenta were observed, how the separation of the placenta occurred, whether it was necessary to resort to methods of separation of the separated placenta (Abuladze, Crede-Lazarevich), and describe in detail their methodology, if they were used. Describe how the birth of the placenta occurred (by the fetal surface of the placenta or the maternal one) and on this basis make a conclusion about the mechanism of separation of the placenta (according to Schultze or Duncan).
The method of examining the placenta is described in detail in the birth history.
The conclusion about the result of examination of the placenta (size, integrity, features, rupture of the membranes), about the amount of blood loss during childbirth and its compliance with acceptable blood loss is recorded in the history. In situations where blood loss during childbirth exceeds the permissible limit, it is necessary to replenish the volume of circulating blood.
Indicate the duration of labor by period and total.
Management of the early postpartum period
The early postpartum period lasts 24 hours. The postpartum woman remains in the maternity ward for 2 hours. Describe for what reasons the postpartum woman needs constant monitoring during this time. Know the features of hemostasis of the placental site, the rules of transfer to the “Mother and Child” department.
In the early postpartum period:
1) monitoring the condition of the postpartum woman (blood pressure, pulse rate, body temperature);
2) control over the height of the uterine fundus, its size, and density.
3) control over the volume and intensity of bloody discharge from the birth canal.
The results of this observation are recorded in the birth history.
Examination of the birth canal is carried out according to indications. In the absence of external bleeding, perineal injuries, or soft birth canals, you can abstain from it. If indicated, the birth canal is examined immediately after birth using mirrors. Describe the result of the inspection, if any. If injuries to the soft birth canal were detected, describe the technique for restoring their integrity, blood loss during the examination, and methods of pain relief.
Epicrisis of labor pain relief. It should indicate the effect of psychoprophylactic preparation for childbirth. It is rated as “complete”, “partial”, “absent”.
Before transferring a postpartum woman to the postpartum ward, write a transfer epicrisis, which very briefly describes the features of the course of labor, assesses the condition of the postpartum woman at the time of her transfer from maternity ward(indicate the total blood loss during childbirth and the early postpartum period), appointments are made for the management of the postpartum woman in the postpartum department.
Forecast of the course of the postpartum period, which takes into account the nature and duration of labor, the duration of the anhydrous interval, blood loss, the presence or absence of injuries to the birth canal, etc.
Caring for a postpartum mother in the postpartum department
The supervised postpartum woman is examined by the student in the postpartum department at least twice. To get acquainted with the physiology of the postpartum period, correctly assess the involution of the genital organs after childbirth, and the formation of lactation, it is necessary to examine the postpartum woman soon after childbirth (1-2 days) and before her discharge from the hospital. obstetric hospital(4-5 days).
Management of the postpartum period is described according to the following scheme:
1) date of examination, day of the postpartum period of the postpartum woman:
2) assessment general condition postpartum women (complaints, skin color, body temperature, pulse, blood pressure):
3) the condition of the mammary glands (the formation of lactation, the presence or absence of signs of lactostasis), nipples (their shape, the presence or absence of cracks);
4) palpation of the abdomen, palpation of the uterus - its density, the presence or absence of pain on palpation, the position of the fundus of the uterus in relation to the navel or the upper edge of the symphysis pubis;
5) the nature of the lochia (their color, quantity, smell);
6) condition of the vulva and perineum (swelling, inflammatory changes, condition of sutures, if they were applied);
7) physiological functions.
After describing the diary, it is necessary to make appointments for the day of examination of the postpartum woman.
Epicrisis of childbirth
It is necessary to briefly reflect the nature and outcome of childbirth:
1) repeat briefly the personal data (age of the woman in labor, parity of births)
2) indicate the stage of labor and the mother’s complaints upon admission to the maternity ward
3) duration, features of the course and management of the first stage of labor
4) duration, features of the period of exile
5) describe the sex, weight, length of the newborn, Apgar score, the presence or absence of any diseases, its malformations
6) duration and characteristics of the afterbirth period, integrity of the placenta, total blood loss during childbirth
7) results of examination of the soft birth canal, restoration of the integrity of the birth canal in the presence of injuries
Forecast for the further course of the postpartum period.
Literature
The list of references is drawn up according to the rules of bibliography.
Student's signature.
It is necessary to fill out the birth history clearly, competently, with page numbering, leaving fields for the teacher’s comments.
