Bishop scale in obstetrics table. Preparing the cervix for labor and inducing labor (induction of labor)
Discoordinated labor activity. Diagnosis. Doctor's tactics.
Discoordination of labor – hypertensive uterine dysfunction. These include:
1.hypertonicity of the lower segment of the uterus (reverse gradient),
2.convulsive contractions (uterine tetany),
3.circulatory dystocia (contraction ring).
The essence: displacement of the pacemaker from the uterine angle to the lower part of the uterus or the formation of several pacemakers that distribute impulses in different directions, disrupting the synchronicity of contraction and relaxation of individual parts of the uterus.
1. violation of the formation of the generic dominant and => lack of “maturity” of the cervix at the beginning of labor; 2.dystocia of the cervix (its rigidity, scar degeneration); 3.increased excitability of the woman in labor, leading to a disruption in the formation of the pacemaker; 4. disruption of the innervation of the uterus; 5.genital infantilism.
Clinic based diagnosis:
1.immature cervix at the onset of labor;
2.high basal tone of the uterus with possible tetanus of the uterus (in a state of tension, does not relax);
3. frequent, intense, painful contractions; pain in the lumbar region; (Hysterography - contractions are unequal in strength and duration, pain, different intervals.)
4.lack of dilatation of the cervix or its dynamics;
5. swelling of the cervix;
6. long standing of the presenting part of the fetus at the entrance to the pelvis;
7. untimely rupture of amniotic fluid.
Discoordination can lead to weakness of labor. Complications: uteroplacental blood flow is disrupted and acute fetal hypoxia and ischemic-traumatic damage to its central nervous system develop.
Treatment. It is carried out while monitoring the condition of the fetus.
In the 1st stage of labor - regional anesthesia. For tetanus of the uterus + β-AM (), inhalation halogenated anesthetics (fluorotane, enflurane, isoflurane), nitroglycerin preparations (nitroglycerin, isoket). If epidural anesthesia is not possible => antispasmodics (no-spa, baralgin, buscopan), painkillers (promedol) every 3-4 hours, sedatives (seduxen). Psychotherapy, physiotherapy (electroanalgesia). An early amniotomy is performed (if the cervix is mature). If all methods are ineffective => caesarean section. Uterotonics cannot be administered.
At the 2nd stage of childbirth, epidural anesthesia is continued, or pudendal anesthesia is performed; according to indications, episiotomy is performed.
A differential diagnosis is made with cervical dystonia, which is a consequence of the operation - diathermocoagulation. (cervical dystrophy is formed and this prevents its opening).
Internal obstetric examination. Indications, technique, assessment of the degree of maturity of the cervix.
Internal obstetric examination is performed with one hand (two fingers, index and middle, four - half-hand, whole hand). Internal examination makes it possible to determine the presenting part, the state of the birth canal, observe the dynamics of cervical dilation during childbirth, the mechanism of insertion and advancement of the presenting part, etc. In women in labor, a vaginal examination is performed upon admission to the obstetric institution, and after the rupture of amniotic fluid. In the future, vaginal examination is performed only when indicated.
Internal examination begins with examination of the external genitalia (hair growth, development, swelling of the vulva, varicose veins), the perineum (its height, rigidity, presence of scars) and the vestibule of the vagina. The phalanges of the middle and index fingers are inserted into the vagina and examined (lumen width and length, folding and extensibility of the vaginal walls, the presence of scars, tumors, septa and other pathological conditions). Then the cervix is found and its shape, size, consistency, degree of maturity, shortening, softening, location along the longitudinal axis of the pelvis, and patency of the pharynx for the finger are determined.
During the examination during labor, the degree of smoothness of the cervix (preserved, shortened, smoothed), the degree of opening of the pharynx in centimeters, and the condition of the edges of the pharynx (soft or dense, thick or thin) are determined. In women in labor, a vaginal examination determines the condition of the fetal bladder (integrity, loss of integrity, degree of tension, amount of anterior water). Determine the presenting part (buttocks, head, legs), where they are located (above the entrance to the small pelvis, at the entrance with a small or large segment, in the cavity, at the pelvic outlet). Identification points on the head are sutures, fontanelles, and at the pelvic end - the sacrum and coccyx. Palpation of the inner surface of the pelvic walls makes it possible to identify deformation of its bones, exostoses and judge the capacity of the pelvis.
At the end of the study, if the presenting part is high, measure the diagonal conjugata (conjugata diagonalis), the distance between the promontory and the lower edge of the symphysis (normally 13 cm). To do this, with the fingers inserted into the vagina, they try to reach the promontory and touch it with the end of the middle finger, the index finger of the free hand is brought under the lower edge of the symphysis and mark on the hand the place that directly contacts the lower edge of the pubic arch. Then remove the fingers from the vagina and wash them. The assistant measures the marked distance on the hand with a centimeter tape or a hip meter. By the size of the diagonal conjugate one can judge the size of the true conjugate.
Classification of cervical maturity according to G.G. Khechinashvili:
· Immature cervix - softening is noticeable only at the periphery. The cervix is dense along the cervical canal, and in some cases - in all parts. The vaginal part is preserved or slightly shortened, located sacrally. The external pharynx is closed or allows the tip of the finger to pass through, determined at a level corresponding to the middle between the upper and lower edges of the symphysis pubis.
· The ripening cervix is not completely softened; a patch of dense tissue is still noticeable along the cervical canal, especially in the area of the internal pharynx. The vaginal part of the cervix is slightly shortened; in primigravidas, the external os allows the tip of the finger to pass through. Less often, we pass the cervical canal for the finger to the internal os or with difficulty beyond the internal os. There is a difference of more than 1 cm between the length of the vaginal part of the cervix and the length of the cervical canal. A sharp transition of the cervical canal to the lower segment in the area of the internal pharynx is noticeable. The presenting part is not clearly palpated through the fornix. The wall of the vaginal part of the cervix is still quite wide (up to 1.5 cm), the vaginal part of the cervix is located away from the wire axis of the pelvis. The external pharynx is defined at the level of the lower edge of the symphysis or slightly higher.
· The not fully ripened cervix is almost completely softened, only in the area of the internal pharynx is an area of dense tissue still visible. In all cases, the canal can be passed through the internal os for one finger, but in first-time mothers it is difficult. There is no smooth transition of the cervical canal to the lower segment. The presenting part is palpated through the arches quite clearly. The wall of the vaginal part of the cervix is noticeably thinned (up to 1 cm), and the vaginal part itself is located closer to the wire axis of the pelvis. The external pharynx is defined at the level of the lower edge of the symphysis, sometimes lower, but not reaching the level of the ischial spines.
· The mature cervix is completely softened, shortened or sharply shortened, the cervical canal freely passes one finger or more, is not curved, smoothly passes to the lower segment of the uterus in the area of the internal pharynx. The presenting part of the fetus is quite clearly palpated through the fornix. The wall of the vaginal part of the cervix is significantly thinned (up to 4–5 mm), the vaginal part is located strictly along the axis of the pelvis, the external os is defined at the level of the ischial spines.
Completion of the genetically programmed intrauterine development of the human fetus occurs at 38–40 weeks of pregnancy. There is an intensive synchronous preparation of the organisms of the mother and fetus for the process of childbirth.
Preparation for childbirth primarily causes activation of the function of the fetal adrenal cortex.
The adrenal glands produce the following steroids: dehydroepiandrosterone sulfate (DHEAS) and the glucocorticoid cortisol. At the same time, dehydroepiandosterone sulfate (DHEAS) is produced mainly by the fetal zone, and cortisol is produced by the definitive (adult) zone. Dehydroepiandrosterone sulfate (DHEAS) is the main precursor for steroid biosynthesis in the placenta. Thanks to the activity of sulfatase, the placenta is able to intensively cut off the sulfate chain of dehydroepiandrosterone sulfate (DHEAS) and convert conjugated (bound) steroids into free ones.
The level of estrogen directly depends on the functional state of the fetus (liver, adrenal cortex) and placenta. It is the fetus (on reaching sufficient physiological maturity) that has a decisive influence on the production and level of active estrogens in the placenta and mother’s blood.
Fetal cortisol activates the enzyme systems of the placenta, ensuring the production of unconjugated estrogens. Estrogens saturate the tissues of the maternal body (myometrium, cervix, vagina, joints of the pelvic bones).
The main function of cortisol in the preparatory prenatal period is the formation and maturation of fetal liver enzyme systems, including glycogenesis enzymes. The content of tyrosine and aspartate aminotransferase increases.
Under the influence of cortisol, the epithelium of the gastrointestinal tract (GIT) of the fetus is transformed to switch to a different type of nutrition. There is an acceleration in the maturation of lung tissue and the formation of a surfactant system to ensure external respiration. A lack of surfactant can lead to respiratory distress syndrome in the newborn.
Under the influence of adrenocorticotropic hormone (ACTH) of the fetus and mother, there is an increase in the synthesis of fetal cortisol and dehydroepiandrosterone sulfate (DHEAS). Adrenocorticotropic hormone (ACTH) and fetal cortisol and maternal origin enhance the synthesis of adrenaline and norepinephrine, affecting the medulla adrenal glands
Chromaffin cells of the adrenal glands produce anti-stress substances - opioid enkephalins. Latest have an anti-stress and analgesic effect on the fetus, which is necessary during the birth process.
Preparing the mother’s body for the opening of the uterine os and the launch of the automatic labor mechanism activity includes structural changes in the tissues of the cervix, its lower segment, as well as the myometrium.
Changes occur in the hemostasis system due to the activation of vascular-platelet and procoagulative link and relative enhancement of coagulation to limit inevitable blood loss during separation hemochorial placenta.
In preparing a pregnant woman's body for childbirth, changes in the functioning of the nervous system are important.
The dominant of pregnancy in the central nervous system (CNS) is replaced by a focus of excitation, which inhibits according to the law induction of less necessary reactions (nutritional and defensive). Reflexes come to the fore ensuring the progress of the birth process. Reactions to environmental stimuli become more economical, unstable and unstable. Clinically, this manifests itself in increased drowsiness, decreased loss of appetite, weight loss up to 1 kg within 7 days before birth, mood instability.
Before childbirth, the intensity of interhemispheric connections increases, which enhances the coordination of somatic, immune, hemostatic and neuroendocrine functions. In this way, the mother’s body prepares for difficult and unsafe birth process.
During pregnancy, the weight of the uterus increases on average from 50–75 to 1000 g, and also increases size of myometrial cells. There are two features of smooth muscle tissue: firstly, each cell smooth muscle tissue is capable of generating and propagating action potentials in a manner similar to occurs in skeletal and cardiac muscles, secondly, autonomic contractile activity of smooth muscle tissue is not subject to conscious control. Certain areas of the uterus may have different contractile patterns activity, which helps maintain constant tone and intrauterine pressure both during and outside pregnancy. Preparatory coordinated (precursor) contractions of the uterus are painless and separated by large intervals between individual contractions.
Preparatory contractions can last several hours or even days. The tone of the uterus remains normal. A woman’s behavior does not affect the frequency and intensity of prenatal contractions. Woman suffers them easily.
Precursors of labor are symptoms that occur a month or two weeks before birth. It must be taken into account that the diagnosis “Precursors of labor” is not provided for by ICD-10. Precursors of childbirth include: movement of the center heaviness of the pregnant woman's body forward, deviation of the head and shoulders when walking backwards (“proud gait”), pressing the presenting part of the fetus to the entrance to the pelvis, as a result of which the uterine fundus prolapses (in primiparous women this is occurs a month before birth) and a decrease in the volume of amniotic fluid. It is known that the largest number amniotic fluid (1200 ml) was noted at the 38th week of pregnancy. After this period, the amount of water decreases every week 200 ml. The presenting part of the fetus is tightly fixed at the pelvic inlet due to the disappearance the supravaginal part of the cervix, involved in the expansion of the lower segment of the uterus. Cervix acquires softness, elasticity and extensibility, which reflects the synchronous readiness of the “mother-placenta- fetus" to the birth process. Mucous-sacral discharge (secretion from the glands of the cervix) protrudes from the vagina.
The vaginal walls become swollen, juicy, moist, cyanotic, which indicates high estrogen saturation. There is an increase in the excitability of the uterus: upon palpation, compaction occurs myometrium. Precursor contractions (“false contractions”) begin - separate coordinated contractions, in as a result of which there is a gradual shortening of the cervix. The internal os of the cervix smoothly transitions into lower segment of the uterus. Preparatory contractions occur most often at night, at rest. Happening detachment of the aqueous membranes of the lower pole of the fetal bladder, which causes intense synthesis of prostaglandins. IN in the blood of the mother and fetus, the content of adrenocorticotropic hormone (ACTH) and cortisol increases as a reaction to upcoming birth stress. In the central nervous system (CNS), a “generic dominant” arises - stagnant a source of excitation that regulates the process of childbirth and preparation for it. Softening of the cervix occurs, sharply shortening and occupying a central position along the wire axis of the pelvis. Formation occurs in the uterus pacemaker This function is performed by a group of nerve ganglion cells, most often located in right-handed people. closer to the right tubal angle of the uterus.
The progress of labor largely depends on the body’s readiness for childbirth. Formation readiness occurs 10–15 days before birth. The readiness of the body is determined by the degree of “maturity” of the cervix and sensitivity of the myometrium to uterotonic agents. The “maturity” of the cervix is the main criterion for readiness for childbirth.
The dominant importance is given to neuroendocrine factors leading to a delay in the body’s preparation for childbirth and maturity of the cervix.
● Indirect signs of hormonal imbalance:
Untimely onset of menarche;
- ovarian dysfunction (usually against the background of chronic inflammation of the uterine appendages);
- genital infantilism;
- violation of fat metabolism.
● Disorders of the anatomical structure of the uterus:
Factors that provoke overstretching of the muscular wall of the uterus (polyhydramnios, multiple pregnancy, large size fetus);
- chronic myometritis (sclerosation of the myometrium and reciprocal contractile disorders);
- uterine tumors;
- scars on the uterus;
- malformations of the uterus;
- genital infantilism;
- age over 35 years (the period of the beginning of physiological sclerosis of the myometrium).
● Disorders of energy metabolism of uteromyocytes:
Pathological preliminary period (“fatigue” of myocytes);
- factors preventing childbirth through the natural birth canal [cicatricial changes in the cervix, post-term pregnancy, abnormal configuration of the head (often accompanied by disturbances fetal steroidogenesis)];
- anemia.
There are many different methods for assessing the “maturity” of the cervix. In all methods it is taken into account Please pay attention to the following parameters:
● consistency of the cervix;
● length of the vaginal part and cervical canal of the uterus;
● degree of patency of the cervical canal;
● location and direction of the axis of the cervix in the pelvic cavity;
● the condition of the lower segment of the uterus and the thickness of the wall of the vaginal part of the cervix.
Taking into account these signs, classifications of the degree of “maturity” of the Bishop’s cervix (see Table 1) and G.G. Khechinashvili.
Table 1. Scheme for assessing cervical maturity according to Bishop
| Sign | Points | ||
| 1 | 2 | 3 | |
| Position of the cervix in relation to sacrum |
To the sacrum | Middle | On a wired line |
| Cervical length | 2 cm or more | 1 cm | Smoothed |
| Consistency of the cervix | Dense | Softened | Soft |
| Opening outdoor pharynx | Closed | 1–2 cm | 3 cm |
| Presenting part location | Above the entrance | Between the top and bottom edge womb | On the lower edge of the womb and below |
With a score of 0–5 points, the cervix is considered immature; if the score is more than 10, the cervix is mature (ready for labor) and labor induction can be used.
Classification of cervical maturity according to G.G. Khechinashvili:
● Immature cervix - softening is noticeable only at the periphery. The cervix is rather dense along the way cervical canal, and in some cases - in all departments. The vaginal part is preserved or slightly shortened, located sacrally. The external pharynx is closed or allows the tip of the finger to pass through, determined at the level corresponding to the middle between the upper and lower edges of the pubic symphysis.
● The ripening cervix is not completely softened; a patch of dense tissue is still noticeable along the cervical canal, especially in the area of the internal pharynx. The vaginal part of the cervix is slightly shortened, in primiparous women the external pharynx allows the tip of the finger to pass through. Less often, we pass the cervical canal for the finger to the internal pharynx, or with labor for the internal os. Between the length of the vaginal part of the cervix and the length of the cervical canal there is the difference is more than 1 cm. A sharp transition of the cervical canal to the lower segment in the area of the internal pharynx is noticeable.
The presenting part is not clearly palpated through the fornix. The wall of the vaginal part of the cervix is all
It is also quite wide (up to 1.5 cm), the vaginal part of the cervix is located away from the wire axis of the pelvis. Outer the pharynx is defined at the level of the lower edge of the symphysis or slightly higher.
● The not fully ripe cervix is almost completely softened, only in the area of the internal pharynx there is still an area of dense tissue is identified. In all cases, the channel is passed for 1 finger beyond the internal pharynx, for first-time mothers - with difficulty. There is no smooth transition of the cervical canal to the lower segment. Presenting part palpated through the vaults quite clearly. The wall of the vaginal part of the cervix is noticeably thinned (up to 1 cm), and the vaginal part itself is located closer to the wire axis of the pelvis. The external os is defined at the level of the lower the edges of the symphysis, sometimes lower, but not reaching the level of the ischial spines.
● The mature cervix is completely softened, shortened or sharply shortened, the cervical canal passes freely one finger or more, not curved, smoothly passes to the lower segment of the uterus in the area of the internal pharynx. Through the vaults The presenting part of the fetus is quite clearly palpated. The wall of the vaginal part of the cervix is significantly thinned (up to 4–5 mm), the vaginal part is located strictly along the wire axis of the pelvis, the external os is defined at level of the ischial spines.
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The following tests are used: determination of the “maturity” of the cervix, oxytocin test, mammary test, cytological examination of a vaginal smear.
I. Assessment of “maturity” - cervix- the most reliable and easily performed method (Table 1). The consistency of the cervix, the length of its vaginal part, the patency of the cervical canal, and the position of the cervix in relation to the pelvic axis are assessed (Fig. 1).
Table 1
| Sign | Maturity level | ||
| 0 points | 1 point | 2 points | |
| Consistency of the cervix Cervical length, effacement Patency of the throat canal Cervical position | Dense More than 2 cm The external pharynx is closed, allowing the tip of the finger to pass through Posteriorly | Softened in the area of the internal pharynx + thickened We pass the channel for 1 finger, there is a seal in the area of the internal pharynx Anterior | Soft Less than 1 cm or flattened More than 1 finger, when smoothing the cervix more than 2 cm Middle |
With a score of 0-2 points, the cervix is “immature”, 3-4 points - not “mature enough”, 5-8 points - “mature”.
Rice. 1. The condition of the cervix depending on the severity of its “maturity” (Khechinashvili G.G., 1969)
II. Oxytocin test:
1. Position the pregnant woman lying on her back for 15 minutes.
2. Preparation of an oxytocin solution at the rate of 0.01 IU (oxytocin per 1 ml of 5% glucose solution (1 mg of oxytocin or 5 IU is added to 500 ml of 5% glucose solution).
3. Injection of 5 ml of the prepared solution intravenously, 1 ml per 1 minute, “smoothly”. The administration of the solution is stopped when uterine contractions occur.
4. Registration of uterine contractions by palpation or hysterograph. The test is positive if uterine contractions appear within the first 3 minutes from the start of the injection (birth occurs within the next 24-48 hours).
The test is negative if uterine contractions appear after 3 minutes or are absent (birth occurs in 3-8 days; preparation of the uterus for childbirth is necessary (Fig. 2).
Rice. 2. Hysterography with oxytocin test.
1 - single contraction of the uterus;
2 - set of abbreviations;
3 - long-term reduction of contracture type;
4 - negative oxytocin test.
III. Mammary test:
1. Registration within 15 minutes using the cardiotocography method of uterine activity and fetal cardiac activity.
2. Mechanical irritation of one nipple until adequate uterine contractions occur (three contractions in 10 minutes).
The test is positive if uterine contractions occur within 3 minutes of the start of the test and three contractions of approximately 40 seconds are observed within a 10-minute interval. The test is negative if there are no uterine contractions.
Hyperstimulation of the uterus - prolonged (more than 90 seconds) or frequent (more than 5 or 10 minutes) contractions.
The mammary test is as informative as the oxytocin test and can be used to accelerate the “ripening” of the cervix and to induce labor.
IV. Colpocytological test (Fig. 3).
Type I - “late pregnancy”. In the smear, scaphoid and intermediate cells predominate in a ratio of 3:1. Leukocytes and mucus are absent. Eosinophilic cells less than 1%. Childbirth occurs in 10 days or later.
Type II - “shortly before childbirth.” Intermediate scaphoid cells predominate in a 1:1 ratio. Surface cells are identified. Leukocytes and mucus are absent. Eosinophilic index 2-4%. Childbirth occurs in 4-8 days.
Target- diagnostics.
Indications – biological readiness of a pregnant woman for childbirth. Prenatal preparatory period.
Contraindications – No.
Possible complications- No.
Resources- gynecological chair, individual diaper, disposable sterile rubber gloves, soap, towel.
Action algorithm:
1. Introduce yourself, explain to the woman the importance and necessity of this study, and obtain her consent.
2.
3.
4.
5. Place the woman on the gynecological chair with a clean diaper placed under her, legs bent at the knee and hip joints and spread apart.
6. Perform an internal (vaginal) examination.
Establishing the direction of the cervix in relation to the wire axis of the pelvis;
Palpation and determination of the density of the cervix;
Estimating its length;
Establishing the diameter of the cervical canal when trying to pass it with one or two fingers.
Table No. 1.
Bishop's cervical maturity scale.
0-2 balla - neck "immature";
3-4 balla - neck “not mature enough”;
5-8 balla - neck "mature";
9.
10.
11.
Note: "Maturity" cervix is the main sign of the body's readiness for childbirth.
Documentation:
Internal (vaginal) examination in late pregnancy and childbirth.
Target- diagnostics.
Indications – upon admission to the obstetric hospital, discharge of amniotic fluid and during childbirth every 4 hours.
Contraindications – danger of introducing pathogenic microbes into the birth canal, sexual intercourse at the end of pregnancy.
Possible complications– chorioamnionitis during childbirth, postpartum septic diseases.
Resources– gynecological chair (bed), individual diaper, disposable sterile rubber gloves, soap, towel.
Action algorithm:
1. Introduce yourself, explain to the woman the importance of internal (vaginal) examination, and obtain her consent.
2. Make sure the woman has emptied her bladder.
3. Wash your hands hygienically.
4. Put sterile disposable rubber gloves on your hands.
5. Place the woman on a gynecological chair (bed) with a clean diaper placed under her, legs bent at the knee and hip joints and spread apart. With fingers I and II of your left hand, spread the labia majora and minora and examine the genital fissure, the entrance to the vagina, the clitoris, the external opening of the urethra, and the perineum. Then carefully insert the second and third fingers of your right hand into the vagina (the first finger is moved upward, the fourth and fifth fingers are pressed to the palm).
The width of the vagina and the extensibility of its walls, check for scars, tumors, septa and other pathological conditions;
The degree of “maturity” of the cervix as an indicator of the readiness of the soft birth canal for childbirth;
With a passable cervical canal, the state of the amniotic sac (intact or damaged);
The position of the presenting part of the fetus in the pelvic planes;
The condition of the inner surface of the walls of the pelvis, sacrum, pubic symphysis in order to exclude ecsoses and deformations;
Diagonal conjugate size.
7. Remove disposable rubber gloves and place in a safe disposal box (SRC).
8. Wash your hands with soap and dry with a towel.
9. Make a note in the documentation.
Application. Vaginal examination at the end of pregnancy and childbirth is one of the most reliable diagnostic methods in obstetrics.
Documentation:
3. Order of the Ministry of Health of the Republic of Kazakhstan dated February 24, 2015 No. 127.
4. Order of the Ministry of Health of the Republic of Kazakhstan dated February 28, 2015 No. 176.
Definition and assessment of the Vasten sign.
Target- diagnostics.
Indications – narrow pelvis
Contraindications – No.
Possible complications- uterine rupture.
Resources– bed, individual diaper, soap, towel.
Action algorithm:
1. Vasten's sign is assessed when the cervix is fully dilated, amniotic fluid has broken and the fetal head is pressed to the entrance to the pelvis.
2. Introduce yourself, explain to the woman in labor the need for this study and obtain her consent.
3. Wash your hands hygienically.
4. Put on disposable sterile rubber gloves.
5. Ask the woman in labor to lie on the bed on her back with her legs together and straightened, with her stomach exposed, and place a clean diaper under her. Sit to the right of the woman in labor, facing her.
6. Proceed to determine the Vasten sign.
7. Place the palm of your right hand in the frontal plane on the fetal head above the symphysis pubis.
8. Determine the degree of overhang of the fetal head over the womb:
· if the plane of the palm is below the symphysis pubis, Vasten’s sign is considered "negative";
· if the plane of the palm is at the same level, then the Vasten sign is considered "level";
· if the plane of the palm protrudes above the level of the womb, then the Vasten sign is considered "positive".
9. Remove disposable rubber gloves and place in a safe disposal box (SRC).
10. Wash your hands with soap and dry with a towel.
11. Make a note in the documentation.
Application. If Vasten's sign is positive, vaginal delivery is impossible.
Documentation:
3. Order of the Ministry of Health of the Republic of Kazakhstan dated February 24, 2015 No. 127.
4. Order of the Ministry of Health of the Republic of Kazakhstan dated February 28, 2015 No. 176.
Maintaining a partograph.
Target- diagnostics.
Indications – during the first stage of labor.
Contraindications – complications requiring immediate delivery.
Possible complications- No.
Resources– gynecological chair (bed), individual diaper, disposable sterile rubber gloves, obstetric stethoscope (ultrasound machine), blood pressure measuring device.
Action algorithm:
1. Introduce yourself, explain to the woman the need for this manipulation,
get her consent.
Partogram – This is a graphical display of the results of dynamic monitoring during childbirth of the process of dilatation of the cervix and advancement of the fetal head, labor, and the condition of the woman in labor and the fetus.
2. Fill out the partogram of the woman in labor at the beginning of the first stage of labor, for this you must know components of a partograph:
1). Passport part: is written at the top of the partogram, where the following is indicated: last name, first name, patronymic, number of pregnancies, births, registration (hospital) number, date and time of admission (if the amniotic sac is intact, put a dash (-)).
A partograph consists of three main components:
I – part – fetal condition – heart rate (heart rate), condition of the amniotic sac and amniotic fluid, head configuration;
II - part - the course of labor - rate of cervical dilatation, descent of the fetal head, uterine contraction, regimen of administration of oxytocin and other medications;
III - part - the condition of a woman - pulse, blood pressure, temperature, urine (volume, protein, acetone).
2). Heart rate. Heart rate is recorded to monitor the fetal condition:
· must be listened to immediately after the strongest uterine contraction ;
· make a recording of the fetal heartbeat every 30 minutes in the first period of normal physiological labor;
Listen to the fetal heartbeat every 5 minutes; if there is green or dark meconium in the amniotic fluid or if there is no fluid at the time of rupture of the membranes.
Grade:
up to 6 points – immature
6-8 points - maturing
9 points or more - mature
Induction methods depending on cervical maturity
Mifepristone used only in cases of antenatal fetal death
I. Immature cervix (Bishop score less than 6 points)
1.1.1. Natural dilators (kelp) - 1 time per day until the cervix ripens, up to a maximum of 3 days
1.1.2. Prostaglandins E 1 - Misoprostol - 25-50 mcg (⅛ or ¼ tablet 200 mcg) every 6 hours intravaginally (into the posterior vaginal fornix) until the cervix ripens. Do not use more than 50 mcg per administration. Do not exceed the total daily dose of 200 mcg
1.1.3. Prostaglandins E 2 - Dinoprostone
Labor induction by administering oxytocin intravenously after 6-8 hours from the moment of using prostaglandins.
Rules for using misoprostol:
· informing the pregnant woman and obtaining written consent
After the administration of prostaglandin, you must lie down for 30 minutes
Conduct CTG control or auscultation of the fetus after 30 minutes
· when conditions arise (mature cervix), transfer to the maternity unit and perform an amniotomy. In the absence of spontaneous labor within 2 hours, begin induction of labor with oxytocin according to the scheme
Complications during labor induction:
· Hyperstimulation
Abruption of a normally located placenta
· Uterine rupture
Usage prostaglandin F 2 α (enzaprost) for the purpose of labor induction and labor stimulation is contraindicated, as it has side effects:
Hypertonicity of the uterus up to tetanus
· Nausea, vomiting
· Hypertension
Tachycardia, bradycardia, arrhythmia
· Allergic reactions, bronchospasm and others
With uterine hyperstimulation– immediately stop the administration of oxytocin, place the woman on her left side, provide oxygen supply at a rate of 8 l/min. Carry out an infusion of 500 ml of saline solution over 15 minutes, carry out acute tocolysis (hexoprenoline), or administer 10 mg of salbutamol intravenously in 1.0 liter of saline solution, 10 drops per minute.
From the moment contractions appear, it is necessary to monitor the fetal heart rate using CTG
II. Maturing cervix (Bishop scale 6-8 points)
1.1.4. Natural dilators (kelp) - 1 time per day until the cervix ripens, up to a maximum of 3 days
1.1.5. Prostaglandins E 1 - Misoprostol - 25-50 mcg (⅛ or ¼ tablet 200 mcg) every 6 hours intravaginally (into the posterior vaginal fornix) until the cervix ripens. Do not use more than 50 mcg per administration. Do not exceed the total daily dose of 200 mcg
1.1.6. Prostaglandins E 2 - Dinoprostone
▪ Intravaginal use:
1 mg and repeat 1 mg or 2 mg after six hours as needed
1 mg every six hours for up to 3 doses
2 mg every six hours for up to 3 doses
2 mg every 12 hours for up to 3 doses
▪ Intracervical use:
0.5 mg every six hours for up to 3 doses
0.5 mg every six hours for up to 4 doses (over two days)
0.5 mg 3 times a day for up to two days
Administration of oxytocin intravenously after 6-12 hours from the date of application of prostaglandins.
