МІНІСТЕРСТВО ОХОРОНИ ЗДОРОВ’Я УКРАЇНИ
Vinnitsa Nathional Medical University named after N.I. Pyrogov
Head of Obstetrics and Gynaecology department № 2 PhD, prof. Bulavenkо О.V.__________
the «____» ____________of 20___ year
METHODICAL RECOMMENDATIONS
FOR THE STUDENT’S OF STOMATOLOGICAL FACULTY
FOR PREPARING TO PRACTICAL CLASS
|Subject | Obstetrics |
| |Physiological and pathological course of pregnancy, childbirth and the |
| |postpartum period. Perinatal complications. |
|Module 1. | |
| |Physiological and pathological course of pregnancy, childbirth and the |
|Semantic module 1. |postpartum period. Perinatal complications. |
|Subject lessons |Physiology of pregnancy, childbirth and the postpartum period. Survey |
| |methods pregnant. Obstetric terminology. |
|Year of study |4 |
|Faculty |Dental |
|Author |Assistant, Goncharenko O.M. |
Vinnitsa 2013
icality. The main purpose of antenatal surveillance is the prevention of maternal and perinatal mortality. It is generally accepted the fact that pregnancy is determined considerable number of factors, but the primary importance given to the process of fertilization and development of a fertilized egg, placentation, organogenesis, development prolific membranes, functioning of the new body - the placenta, which connects the mother and the fetus.
Reduction of maternal and perinatal morbidity and mortality contribute to knowledge about the teratogenic and embryotoxic effects chynnnykiv environment on embryo and fetus at a critical time.
To ensure the life, growth and development of the embryo and fetus in the mother's of significant changes regarding almost all body systems. Compensatory changes in the orga ¬ tries and body systems of pregnant homeostasis lead to a state of unstable equilibrium hard. Violation of this balance can lead to changes in homeostasis and implementation of an obstetric or extragenital pathology, what you need to know doctors of all specialties.
Diagnosis of pregnancy in the early period (before 12 weeks) is important in the overall preparation of doctor of any profession, because early detection allows time to diagnose pregnancy obstetric and extragenital pathology and decide on appropriate further pregnancy. Only such an approach is the key to favorable ¬ Volyn end of pregnancy for the mother and fetus.
In recent years the practice obstetrics were a number of changes in direction pereusvidomlenni assist mothers that are based on the principles of evidence-based medicine, more humanistic attitude in postpartum women and to avoid pharmacological and drug aggression, which contributed more physiological partum period, reduce the frequency of complications postpartum period, emergency psychological adaptation of women after childbirth.
Despite the fact that the postpartum period is a physiological process, it requires a doctor's knowledge of all its stages and characteristics, namely the processes of involution in the organs and systems of women after childbirth, lactation, allowing detect the initial signs of diseases and complications that may arise a woman in labor.
2. The student must:
Know
1. Physiological changes in women during pregnancy (zina psychological state and the central nervous system, changes in the endocrine system, the changes in the genitals and breasts, changes in the cardiovascular, respiratory system and blood changes in the gastrointestinal tract and kidneys, changes in metabolism. changes in the skin, changes in the musculoskeletal system that occur in pregnant women).
2. Survey methods pregnant.
3. Methods outdoor midwifery examination;
4. Goals and methods of I, II, III, IV techniques Leopold;
5. The method of measuring the height of standing uterus (GMR);
6. Measurement contours of the abdomen;
7. Methods for calculating estimated fetal weight;
8. Methods tazovymiryuvannya;
9. Method of listening to the heartbeat of the fetus;
10. Diagnosis of early pregnancy.
11. Obstetric terminology. Location of the fetus in the uterus (position, positions, types, presentation of the fetus, small and large segments of the head of the fetus).
12. Determination of prenatal vacations (diagnostic methods 30-week pregnancy.) And date of birth.
13. The reasons for the onset of labor, regulation of labor activity.
14. Biomehanizma delivery at the front and rear types occipital presentation.
15. Features involution genital character lohy.
16. The formation and progress of lactation.
17. Features of early and late postpartum period.
18. Measures to prevent complications in the postpartum period.
Be able to:
1. Differentiate physiological changes in the body during pregnancy with abnormal.
2. Carry out inspection of the external genitalia and cervix and assess ix condition.
3. Hold vaginal examination and determine the size of the uterus.
4. Make a plan with additional tests for the diagnosis of pregnancy in the early periods.
5. Conduct external (determining the position, position, type of fetal presenting part, calculating estimated fetal weight) obstetric examination.
6. Set of pregnancy in the later periods, to determine the estimated time of childbirth.
7. Conduct internal obstetric examinations of pregnant women, to assess the maturity of the cervix.
8. Hear out fetal and according to instrumental methods to assess functional status and physical development of the fetus during pregnancy.
9. Demonstrate on the phantom biomehanizm delivery at the front and rear types occipital presentation.
10. Identify the beginning of the first stage of labor, objectively assess the dynamics of labor activity (degree of opening of the cervix, duration Rename).
11. Identify and assess fetal heart (auscultatory and hardware method ¬ ladies).
12. Determine the beginning of the second stage of labor, objectively estimate the moving head of the fetus through the birth canal.
13. Assist in the delivery and conduct Psychophysiological anesthesia delivery.
14. Litter inspect and determine its integrity.
15. Determine the total blood loss in childbirth.
16. Assess the state newborn Apgar.
17. Determine the status of mammary glands and lactation character, teach bears a properly feed your baby and express milk.
To master practical skills:
1. Methods outdoor midwifery survey of pregnant women using techniques Leopold.
2. Conducting auscultation.
3. Form obstetric diagnosis based obstetric terms.
4. Methods for determination of gestational age (according to history and objective research).
5. Methods for determining the gestational age of the fetus and its mass, determining the estimated delivery.
6. Play biomehanizm births in both types of occipital presentation.
7. Maintaining a normal delivery.
8. Based on the survey data puerperas using laboratory methods, performance rate, blood pressure, body temperature to assess the progress of the postpartum period, to provide guidance on hygiene ne postpartum period.
3. Basic knowledge, skills necessary for studying the topic (interdisciplinary integration)
|The names of the preceding disciplines |The skills |
|Department of Human Anatomy |determine the anatomical structure of external and internal genitalia. |
|Department of Biological Chemistry |describe the features of metabolism in pregnant biochemical characterization of amniotic |
| |fluid. |
| |describe the structure of germ cells. fertilization and development of the fertilized egg,|
|Department of histology |placentation, organogenesis, development prolific membranes. |
|Department of Normal and Pathological |identify features of physiological changes in women during pregnancy, effects on embryo |
|Physiology |and fetus environmental hazards. Collect material for Gore-monalnoho and biochemical |
| |studies |
|Department of Internal Medicine |medical history, conduct physical examinations ¬ tion, recognition of clinical syndromes |
| |and symptoms, determine the required volume and sequence ¬ ARRANGEMENTS methods of |
| |examination, evaluation paraclinical methods |
Content topics:
Critical periods of development of the embryo and fetus.
Critical periods of development have the highest sensitivity to adverse environmental factors.
There are 4 main critical periods:
1. Pre embryonic (development and maturation of sex cells).
2. fertilization
3. preimplantation period (from fertilization to 6 days) and implantation (6-9 days after fertilization).
4. Organogenesis (especially the 3.6 week) and placentation (3 - 4 weeks of pregnancy).
5. fetal (fetal) period. starting from the 9th week of pregnancy
Effects on embryo and fetus environmental hazards.
The main groups teratogenic chynnnykiv:
Drugs and chemicals.
Ionizing radiation.
Infections.
Metabolic disorders and bad habits pregnant.
The etiological basis distinguish three groups of defects: a) hereditary, b) exogenous c) multychynnykialni.
Physiological changes in a woman's body during pregnancy.
During pregnancy a woman's body there are substantial changes concerning practically all body systems.
Psychological status
Changes psychological condition manifested in the form of emotional feelings: irritability, depression and others. The development of psychological disorders during pregnancy influence following factors:
• hormonal and physiological changes;
• personal property;
• socio-economic status;
• relation in the family;
• unresolved conflicts;
• Genetic peredlehlist (eg, depression);
• physical and mental illness;
• Alcohol and Other Drugs.
Emotional and physical sensations expectant mothers to doctors to consider during surveillance pregnancy, during delivery and in the postpartum period.
Discomfort status
During pregnancy, there are typical quite often uncomfortable condition, with no serious consequences, but lead to significant discomfort and unpleasant sensations in the pregnant woman. These conditions must be taken: fatigue, morning nausea / vomiting, heartburn, constipation, back pain, hemorrhoids, swelling of the legs.
Timely pregnant clarification of the essence of such feelings and professional doctor's advice greatly improve the quality of life of the pregnant woman.
Immune System
• factors inhibited local and general immunity in the mother's body. Reactions caused by the action of hCG, placental lactogen, glucocorticoids, estrogen, progesterone, alpha-fetoprotein, alpha-2-glycoprotein trophoblast specific globulin;
•formed immunological tolerance between mother body and fatus.
Endocrine System
• hypothalamus: supraoptic and paraventricular nucleus increases the formation
oxytocin and vasopressin, they are also involved in regulating the secretion
adenohypophysis folitropin, lutropin, corticotropin and tyrotropinu;
• pituitary gland: an increase in the anterior pituitary gland due to hyperplasia and hypertrophy of its cells, increases secretion of gonadotrophins increases the production of prolactin, growth hormone production is suppressed;
• thyroid gland: increases in size (in 35-40% of pregnant women) function yiyizbilshuyetsya but remains euthyroid, amplified products thyroxine-binding globulin (estrogen effect), increased levels of total T3 and T4, free T4 level is within normal limits ;
• parathyroid gland function with increased activity in the case of reducing their function develops hipokaltsiemiya, manifesting convulsions, spasms pyloric stomach, asthmatic symptoms;
- strengthen the adrenal glands produce glucocorticoids, which regulate carbohydrate and protein metabolism and mineralocorticoids, which regulate mineral metabolism;
- increased insulin resistance (insulin sensitivity is reduced by 50-80%), decreased tissue glucose use, decreased blood glucose levels;
- ovaries: new forms of endocrine glands - corpus luteum, which produces progesterone (reduces excitability and contractile ability of the uterus, creates conditions for the implantation of a fertilized egg and the proper development of pregnancy), operates the first 3.5-4 months pregnant;
- placenta: with 7 days of pregnancy has been an increasing concentration of human chorionic gonadotropin (beta-hCG) and progesterone estroeeny synthesized predominantly complex placenta-fetus from the mother cholesterol metabolites, and their products are steadily increasing rate that ensures the growth and development of the uterus, the regulation of biochemical processes in the myometrium, increased activity of enzyme systems, improving energy metabolism, the accumulation of glycogen and ATP. Placental lactogen (PL) - formed syntsytiotrofoblaetom placenta with 5-6 weeks of pregnancy (90% SW is in the plasma of pregnant women and 10% - in the amniotic fluid) and its maximum concentration determined at 36-37 weeks of pregnancy, then the level has stabilized and began to decline from 40-41 weeks of pregnancy. Concentration TL directly correlated with fetal weight and dramatically increases with kidney disease in the mother.
Central Nervous System
• excitability of the cerebral cortex is reduced to 3-4 months, and then a gradual increase in excitability (due to the formation of the cerebral cortex foci of increased excitability - gestational dominant, manifested some halmovanistyu pregnant and direction of its interests in pregnancy);
• reduced CNS excitability departments that are below and the turn-reflek apparatus uterus. Before birth excitability of spinal cord and nerve elements of the uterus increases;
• changes the tone of the autonomic nervous system, which leads to early pregnancy symptoms such as drowsiness, irritability, tearfulness, dizziness.
Cardiovascular system
• notes: reduction of adaptation to physical stress, increase
blood jugular veins, edema peripheral tissues;
• Heart: systolic murmur (95%) and systolic gallop rhythm (90%);
• central hemodynamics: an increase in the volume of blood circulating (BCC) begins with 6 weeks of pregnancy, increased rapidly to 20-24 weeks and at 36 weeks an increase of 35-45%. The increase in CBV occurs by increasing the volume of plasma that circulates (ORC);
• cardiac output (CO): increased by 30-40% since early pregnancy and peaking at 20-24 weeks of pregnancy. In the first half of pregnancy increases cardiac output by increasing stroke volume of the heart (at thirty - 40%). In the second half of pregnancy pe ¬ preferably by increasing the heart rate (HR) by 15%. Rising CO explain the action on the myocardium of placental hormones (estrogen and progesterone) and partly as. Consequent formation uteroplacental circulation;
• reduction in systolic and diastolic ATZ early pregnancy before 24 weeks of pregnancy (at 5-15 mm Hg from baseline), decreased systemic vascular resistance ¬ ing a 21% reduction in pulmonary vascular resistance by 35% (due sudynoroz ¬ shyryuvalnoyu action of progesterone) ;
• peripheral vascular resistance decreases (relaksyvna effect on the vascular wall hCG, estrogen, progesterone and formation uteroplacental circulation, which has a low vascular resistance);
• central venous pressure (CVP) in the third trimester is on average 8 (4-12) cm of water. century., in nonpregnant 3.6 (2-5) cm water column;
• increased venous pressure (7-10 mm Hg) in the lower extremities (due to mechanical pressure of the uterus on the inferior vena cava and pelvic more than 10 times increasing uterine blood flow during pregnancy), relaxing effect of progesterone on the vascular wall, lower osmotic blood pressure, increased permeability of capillaries (the action of progesterone and aldosterone) ZRO ¬ a handling interstitial pressure (sodium retention), which explains the tendency to edema, varicose veins and hemorrhoids;
• shift the position of the heart shine to the horizontal and reducing the angle of the arc aorta ¬ ty, which is associated with the raising of the diaphragm and increases the load on the left shlunochyek tion of the heart;
• ECG-shifting electrical axis of the heart to the left
The system of blood
• plasma volume increased from 2600 ml of 45% (1250 ml - first pregnancy, and 1500 ml during subsequent pregnancies) and of 3900-4000 ml;
• total volume of red blood cells increased from 1400 ml of 33%, which is due to erythropoietin, human chorionic gonadotropin and placental lactogen;
• physiological hyperplasmia characterized by reduced numbers of hematocrit 30%, hemoglobin from 135-140 to 110-120 g / l. and necessary for the needs of the mother and fetus, prevents syndrome lower abdominal veins compensate hemorrhage during childbirth, reduces blood viscosity and thereby reduces peripheral resistance;
• The level of hematocrit and albumin decreased by 25% (the result of hemodilution);
• changing the hemoglobin level and on average it is up to 12 weeks of pregnancy 1227L, up to 28 weeks - 1187L, 1297P up to 40 weeks;
• increased number of leukocytes in peripheral blood and in the first trimester of their number is 3000-15000/mm3 in the second and the third trimesters th 6000-16000/mm3 during childbirth WBC count may reach 20 000-30 000/mm3;
• platelet count is within normal (for pregnant women) values, but with the progression of pregnancy, there is a gradual decline in their level;
• hemostasis system: inherent hypercoagulable state (during the pregnancy progresses constantly increasing level of fibrinogen (factor I) 2 times (up to 600 mg%) and factors \ LI-X fibrinolytic activity levels decrease, ESR increased to 40 - 50 mm / h ;
Metabolism
basal metabolic rate is increased by 20%;
increasing need for kilocalories an average of 2000 - 3200 calories per day (150 kcal / day in the first trimester and 350 kcal / day in the II and III trimester of pregnancy);
reinforced plastic processes' (benefits of anabolic processes of catabolism);
increases the synthesis of RNA, which leads to increased protein synthesis in ribosomes;
fat metabolism - increased assimilation of fat, reduced process of oxidation, which leads to the accumulation of ketone bodies in the blood, in-aminobutyric acid and atsetouksusnoyi, increased fat deposition in various organs and tissue (adrenals, placenta, skin, mammary gland and etc.).
carbohydrate metabolism - labile blood sugar (slight excess of normal) and the periodic appearance of sugar in the urine;
obmsh vitamins and minerals increases due to significant activation rotsesiv cellular metabolism in the mother and fetus.
Kidneys
anatomical changes: an increase in the size of the kidneys (on average by 1-1.5 cm), expansion pyelocaliceal system (15 mm on the right and 5 mm in the left kidney), increasing the diameter of the urethra 2 cm (usually right urethra by rotation and displacement of the uterus to the right and pressing the urethra to the terminal line of pelvis), causing an increased risk of pyelonephritis. Dilatation of urinary tract begins in first and reaches a maximum in the I! and III trimester of pregnancy (due to the action of placental progesterone and less compression urinary tract uterus);
functional changes: changing kidney filtration capacity - up to 16 weeks of pregnancy increases renal blood flow by 75%, glomerular filtration increases since 10 days of pregnancy to 50% (due to arteriodilatatsiyeyu and secondary delay N3 and water in the body). In II and NO trimesters of pregnancy reduced glomerular filtration and tubular reabsorption remained unchanged, resulting in an increase of the total amount of fluid in pregnant (up to 7 liters). Creatinine clearance increased by 40%, increases the excretion of glucose, protein filtering does not change. Sometimes it may be physiological (orthostatic) albuminuria (traces of protein) and glycosuria, due to increased capillary permeability.
Genitals
• uterine size increases, volume increases in 1000, the weight of the uterus increases from 50-60 g in non-pregnant state to 1000 g in late pregnancy (increase due mainly hypertrophy myometrial cells);
• shape of the uterus elongated, spherical at 8 weeks and again extended to 16 weeks of pregnancy;
• position of the uterus - a uterus comes from the pelvic cavity, turns and bends to the right;
• consistency of the uterus progressively softened, due to increased vascularization and the presence of amniotic fluid;
• cervix softens and becomes cyanotic;
o distinction between endo- and ectocervix - limit transitional epithelium shifted outwards and formed ectopia columnar epithelium, which can not be regarded as "erosion";
o contractions in the first trimester irregular and painless (Braxton-Hixson), but in later stages it causes discomfort and can cause false maternity pain;
o uterine capacity increases of 4-8 ml in nonpregnant state to 5000 ml in late pregnancy;
o myometrium hypertrophy (estrogen effect) hiperplazuyetsya (progesterone effect), individual muscle fibers elongate 15 times;
o uterine blood vessels dilate, elongate, especially venous, and formed, through which uterine blood flow increases more than 10 times (before pregnancy, it is 2 - 3% of cardiac output (CO), and in later stages of pregnancy 20 - 30% CO - 500-700 ml / min). Formed uterine circulation - "second heart", which is closely associated with placental flow and fruit;
o nerve elements uterus - the number of sensitive baro-, osmotic-, chemo-and other receptors;
o biochemical changes - a significant increase in actomyosin, creatine and glycogen, increasing the activity of enzyme systems (actomyosin ATPase, etc.)., accumulate high-Reunion (glycogen macroergic fossraty), muscle proteins and electrolytes (calcium ions, sodium, potassium, magnesium , chlorine, etc..)
o fallopian tubes - become thicker, blood circulation in them is greatly enhanced;
o ovarian-slightly enlarged, but cyclic processes are terminated. Corpus luteum that after 16 weeks of pregnancy undergoes involution;
o ligament of the uterus - are much thicker and extended, especially round and sacro-uterine;
o cyanosis vulva - the result of increased blood flow, difficulty outflow of blood through the veins to constrict enlarged uterus, and reducing vascular tone;
o skin hyperpigmentation vulva and perineum - due giperestrogeniey and increased concentration of melanin stimulating hormone;
o increase in vaginal white and lower their pH (4.5-5.0) - the result of vaginal epithelial hyperplasia, increased circulation and transudation;
Body Weight
• average increase of 10 - 12 kg, depending on the constitution;
• increase in mass occurs mainly in the second and third trimesters (350 - 400 g / week);
• typed with mass slightly more than half goes to the mother's tissues (blood, uterus, fat, breast), and the rest on the fetus (3000-3500 g), placenta (650 g), amniotic fluid (800 g) and uterus (900 g) .
Skin
• spider veins - on the face, arms, upper trunk;
• palmar erythema - due to an increase of 20% of total metabolism by 16% and the number of capillaries that have never functioned;
• stretching band (zihiae dhauisiahyt) - the lower abdomen, dairy ¬ these glands and thighs that are initially pink or purple color (due to the stretching of connective tissue and elastic fibers of the skin);
hyperpigmentation - in the area of the navel, halos breast, white line of the abdomen, vulva and perineal skin may appear "mask of pregnancy" or chloasma (Melasma);
navel - smoothed out in the second half and stuck the end of pregnancy;
nevi - increase in size and become more pigmented (sharp increase requires specialist advice);
sweat and sebaceous glands hyperproduction sometimes leads to acne;
hair - sometimes on the face, abdomen and thighs marked hair growth, due to increased production of adrenal androgens and partly placenta. There is a significant loss in the first 2-4 months of renovation and upgrade system normal hair growth after 6-12 months after delivery.
Mammary gland
tingling and fullness - is associated with a significant increase in blood supply to the breast;
development ductless (estrogen effect) and alveoli (progesterone effect);
activation of smooth muscle nipples and increase monthomerovyh follicles and small bumps near halos;
mass increase - from 150-250 g (before pregnancy) and 400-500 g (end it);
Colostrum is produced - often in women who gave birth (combined effect of estrogen, progesterone, prolactin, placental lactogen, cortisol and insulin).
Musculoskeletal system
compensatory increase in lumbar lordosis, which is manifested by pain in the lower back;
development relative weakness Communications - Action relaxin and progesterone. Lonnie vaults becomes agile and diverges at 0.5-0.6 cm at about 28-30 weeks, which leads to an unstable gait, loss of balance and falling (simfiziopatiya);
increase the lower aperture of the chest;
calcium metabolism - the concentration of ionized forms of calcium in serum is not changed by increasing production of parathyroid hormone, reduced the total amount of calcium through its mobilization to the needs of fetus.
During physiological pregnancy exchange of salts in the bones increased (influence calcitonin), but bone density is not lost;
• increase hernial defects, especially in the area of the navel and the midline - diastase direct muscles (the result of uterine enlargement and its stamping on the anterior abdominal wall from the inside).
Hygiene and dietary nutrition of pregnant women.
Nutrition during pregnancy should be balanced. Intelligence, culture and spirituality of the modern woman does not allow her to use the principle of "eating for two". Caloric diet pregnant with an average weight of about 2400 kcal / day, which is 300 calories than normal to keep vahitnosti.Vazhlyvo diet, optimal number and ratio of protein, carbohydrates. Vitamins and minerals.
Survey methods of pregnancy:
1. Anamnesis.
1.1. Passport data.
1.2. Complaints.
1.3. Conditions of work and life.
1.4. Heredity in man and woman families (mental disease, blood disorders, metabolism, and the presence of intoxication (alcoholism, drug addiction, smoking).
In order to organize perinatal health of the fetus must clarify age, health man, his blood group and Rh affiliation, and the presence of harmful factors related to the profession and bad habits in marriage.
In the presence of harmful or severe conditions women at the first reference to it, a certificate of exemption from the need for hazardous and difficult conditions pct.
1.5. Postponed disease.
1.6. Menstrual function.
1.7.Sekretorna function.
1.8. Sexual function.
1.9. Fertility.
1.10. The course of the current pregnancy.
2. Physical examination.
• Measuring temperature, pulse, blood pressure determination on both hands;
• Overview of the skin and mucous membranes;
• Examination of organs and systems: conduct auscultation of heart, lung, thyroid and palporalne study of breast lesions for diagnosis, assess the shape of the breast nipples.
• Measurement of body weight women.
3. Special obstetric examination:
External midwifery survey - carried out by inspection, measurement, palpation and auscultation.
Examination of pregnant women.
Pay attention to: height, build, completeness, condition of the skin and breast, stomach.
Examination of internal organs.
Pelvic examination - carried out by inspection, palpation and measurement.
Evaluation sacral character diamond.
Determine the transverse dimensions of the pelvis:
Distantia spinarum - the distance between the anterior upper ostyamy pelvic bone - is 25-26 cm;
Distantia cristarum - the distance between the most viddalynymy points iliac crest - is 28-28 cm;
Distantia trochanterica - the distance between the most viddalynymy points greater trochanter femur - is 30-31 cm;
Conjugata externa - the distance between the mid-upper - outer pubic joints and over the sacral fossa, is 20-21 cm;
Conjugata vera - subtracting the value sonjugata externa 9 cm, we obtain the approximate size of the real conjugates equal to 11cm.
Conjugata diagonalis - the distance from the lower edge of the symphysis to the sacral promontory point that most advocates - is 12,5-13 cm.
If reduction of at least one of the main dimensions of the pelvis at 1.5 - 2 cm should be measured subsidiary size and specify the form and degree of narrowing of the pelvis.
Transverse size of the pelvic outlet - the distance between the inner surfaces of the buttocks - to data obtained 9-9.5 cm add 1.5 - 2 cm transverse size of the output normal pelvis is 11 cm.
Direct pelvic outlet size - the distance between the middle of the lower edge of the pubic joint and the tip of the coccyx. From the data obtained 11 cm subtracted 1.5sm Direct output normal pelvis size is equal to 9.5 cm.
Oblique pelvic dimensions measured when there is a suspected or kosozmischenyy kosozvuzhenyy pelvis.
Measurement of pelvic tilt - the angle between the plane of the entrance to the pelvis and the plane horizon, standing in the position of women 45-55 °.
Research pubic angle - at normal size pelvis it is 90-100 °.
Imagination on the thickness of the bones of the pelvis and is able to index Soloviev - circumference in the area of the wrist (14 cm).
Vaginal examination. Vaginal examination is mandatory inspection of the cervix and vagina in the mirror. In women with physiological pregnancy and in the absence of changes in the area of the cervix and vagina internal midwifery research done 2 times (when registering and gestation 30 weeks). The frequency of these internal investigations determined by obstetric indications.
At various stages of pregnancy uterine size on average meet:
4 weeks - the size of an egg;
8 weeks - size women's fist;
12 weeks - 3 cm above the womb (the size of the head of the newborn);
16 weeks - 12 cm above the womb (in the middle of the distance between the navel and vagina);
20 weeks - 16 cm above the womb (2 cross fingers below the navel);
24 weeks - 20 cm above the womb (at the navel);
28 weeks - 24 cm above the womb (at 2-2.5 cross fingers above the navel);
32 weeks - 28 cm above the womb (in the middle of the distance between the navel and the xiphoid process);
36 weeks - 32 cm above the womb (at the costal arch);
40 weeks - 32 = 34 cm (halfway between the navel and the xiphoid process).
Primary complex laboratory testing pregnant include blood tests, urinalysis, blood grouping and Rh factor, blood test for syphilis, HIV (the agreement), bacterioscopic smears from the vagina, cervical canal, urethra (column B). Polling station obstetrician-gynecologist performed pre - and post-test counseling pregnant women about HIV research.
According to the history and midwifery research, completed medical records, determined by the amount of laboratory research, with the consent of pregnant fills the questionnaire.
The first time obstetrician-gynecologist filled "Individual Card pregnant and mothers" (Form 111 / U) and exchange card (Form 113 / o). Exchange card is pregnant from the moment of its registration vzattya about pregnancy.
The optimal number of doctor visits for pregnant observation period for prenatal stage averages 10 - 12 times.
Upon further observation and provided an uncomplicated pregnancy rate prenatal visits within 30 weeks of - 1 per month, and after 30 weeks - one every two weeks.
4. Measuring abdomen.
Measurement of abdominal perimeter and height standing uterus.
Perimeter abdomen (OJ) measuring measuring tape that passes in front through the navel, back - through the middle of the lumbar.
Height standing uterus (VTSM) measuring tape measure from the top edge of the symphysis ¬ him the most points serving uterus. The measurement results of AMD compared with standard hravidrhramoyu (Fig. 1) (normally up to thirty week increase GMR is 0.7 - 1.9 cm per week in the AOR - 36 weeks. - 0.6 - 1.2 ohm for weeks. , 36 and over -0.1 - 0.4 cm gap size of 2 cm or lack of growth within 2-3 weeks. during dynamic observation gives reason to suspect fetal growth retardation).
5. Palpation of the abdomen using methods outside obstetric examination of Leopold.
Methods of external obstetric examination (admission Leopold)
The first step. Purpose - to determine the height of standing uterus and part of the fetus, which is bottom of the uterus. This doctor is the right of the pregnant woman, her face, the palms of both hands put on the bottom of the uterus, determines the height of her standing above the vagina and of the fetus, located in the bottom of the uterus.
The second step. Purpose - to determine the position and type of fetal position. Both hands move with the uterus and in turn, then right, then left hand palpated part ¬ da plane, facing the side wall of the uterus. Thus finding the back of the fetus, small parts. In the wrong position to one of the side walls of the uterus prylezhyt head.
The third step. Purpose - to determine the nature of the presenting part (presentation). One hand is certainly right that is slightly above the pubic area, covering the pe-redlezhachu of the fetus, then carefully make moves this hand right and left. When cephalic defined dense spherical portion having sharp contours. If the fetal head is not in the plane vstavylasya entrance to the pelvis, it is easily moved between the thumb and the remaining fingers. At the breech on the volume, m'yakuvata part, it is round in shape and not able to "vote".
Fourth step. Purpose - to determine the level of standing presenting part (in particular head) on the plane of the entrance to a small basin, and the degree uu pasting. The doctor is right, facing the lower extremities pregnant, put both hands palms down on the side parts of the lower segment of the uterus and palpable accessible areas presenting part of the fetus, Nama-delay penetrate fingertips between the presenting part and lateral divisions of the entrance to a small bowl.
The method of external research technique Leopold IV are the following:
• head moving over the entrance to a small bowl - if the fingers can be brought under the head.
• Head of oppression to the door in a small bowl - the end of the fingers do not converge under the head, but the back of the head and all facial parts palpable over the entrance to a small bowl.
• The head of a small segment at the entrance of the small pelvis - occipital part of the head above the entrance to a small basin on two fingers and facial part - completely.
• The head of a large segment of the entrance to the small pelvis - occipital part of the head is palpable above the entrance to a small bowl and facial acting on two or three fingers.
• Head in the pelvic cavity - propalpovuyetsya only chin or not is determined by the head of the fetus.
The external methods should measure the external size of the pelvis. Conducted the first survey of pregnant women in consultations and in the hospital. If necessary, repeat the measurement of the pelvis during childbirth.
Ultrasound.
The first ultrasound performed at 9-11 weeks gestation with a mandatory defined size neck folds, tailbone-tim'yachkovoho size (CTE) of the internal os.
Second ultrasound performed at 16-21 weeks of gestation.
In the period of 32-36 weeks a third ultrasound for the following reasons: a syndrome of growth retardation, chronic fetoplacental insufficiency, pathological changes on ECG (CTG), severe obstetric and extragenital pathology to determine fetal biophysical profile.
Obstetric terminology.
Location of the fetus in the uterus.
Fetal position - the ratio of the longitudinal axis of the fetus to the longitudinal axis of the uterus. There are the following provisions of the fetus:
• longitudinal - longitudinal axis of fetus and longitudinal axis of the uterus are the same;
• transverse - longitudinal axis of fetus crosses the longitudinal axis of the uterus at an right angle;
• oblique – longitudinal axis of fetus crosses the longitudinal axis of the uterus at an acute angle;
Position of the fetus - relation back of the fetus to the right and left sides of the uterus. There are two positions:
• first - the back of the fetus is facing left;
• second - the back of the fetus is facing right.
In transverse and oblique position fetal position is determined by the location of the head: the head to the left of the midline of the abdomen of the mother - the first position, right - second position.
Type of position - relation back of the fetus to the front or rear wall of the uterus. There are two types:
• front - the back of the fetus is facing forward;
• back - the back of the fetus returned back.
Presentation of fetus - the ratio of large parts of the fetus (head or pelvis) to the door in a small bowl. There are important and breech.
Presenting part called that part of the fetus, which is closer to the entrance of the small pelvis and birth canal first place. With bent head fetus positioned its lowest part is the neck. This presentation is called sweats, personally and happens often.
Much less is to straighten the head. Thus, depending on the degree of extension presenting part may be the crown (fronthead presentation), forehead (forehead presentation), face (pictorial presentation).
When breech lowest part can be located buttocks (breech presentation), feet (foot presentation). A large segment of the fetal head. The big head segment conditional mean circumference of the largest size head, which it passes through the plane of the pelvis at this inserted. In occipital presentation, when the head is inserted into the pelvis in a bent position, the greatest circumference would be one which meets the circumference of small oblique view. When inserting extensor head large segment will be different (depending on the degree of extension).
A small segment of the fetal head. In the small segment of heads conditional mean less for a large segment of the head as it passes through the plane of the pelvis.
DEFINITION prenatal release and date of birth.
When making vacation due to pregnancy and childbirth obstetrician-gynecologist guided "Procedure issuance medical certificate due to pregnancy and childbirth" (MOH of Ukraine of 13.11.2001, № 455 "On Approval of the Regulations on the procedure for issuing certifying the temporary incapacity of citizens ").
Hospital leaf by pregnancy and childbirth issued for a period 126 days from 30 weeks of gestation (70 days before delivery and 56 days after birth).
In the case of delivery complications or birth of two or more children given additional sick for 14 days.
DEFINITION date of birth.
Formula Naegeli, from the first day of the last menstrual period ticking 3 months ago and added to the received date 7 days.
During ovulation, from the first day of menstruation, which is expected, but do not come, ticking back 14-16 days and the resulting date added 273-274 days.
For the first stirring of the fetus:
- In primigravides to the date of the first movement added 5 months postpartum and get the date of delivery;
- In multigravides to the date of the first movement is added 5.5 months postpartum and receive delivery date.
Determination of gestational age fetus to ultrasound - not sufficiently precise criteria in predicting the due date.
LIFE AND DEATH OF FETUS.
In early pregnancy this issue is resolved shlihom monitor the size of the uterus:
If the size of the uterus corresponding period of gestation, and dynamic monitoring (every 10-12 days) is determined by its growth, then clinically it suggests that the fetus is alive and rozvyvyvayetsya.
When backlog growth of uterine gestation period concludes on the possibility of pregnancy, which does not develop.
Additional evidence of the progression of pregnancy:
• Figures horional gonadotropin, estriol;
• ultrasound data - visualization of the embryo, heartbeat, matching the size of the uterus and the embryo pregnancy term.
In the second half of pregnancy, the death of the fetus shows no movement of the fetus and its heartbeat, halting cancer. Phono-electrocardiogram shows lack of tone and cardiac systems, on ECG - no record cardiac activity of the fetus.
Ultrasound signs of fetal death:
- Fetal heart absent;
- Enlarged heart chambers;
- For long stays dead fetus in the uterus changes the structure of the brain, skull deformed, there are signs of autolysis of internal organs, oligohydramnios.
Diagnosis of early pregnancy.
Signs of pregnancy
Signs of pregnancy are divided into 3 groups.
Dubious signs - a different kind of subjective feelings and objectively determined changes in the body, in addition to changes in the internal genital organs
• subjective effects - nausea, vomiting, loss of or increased appetite, food fads (passion for salty or acidic foods to chalk etc.), changes in olfactory sensations (an abomination to the smell of meat, smoke, etc.) , easy fatigue, drowsiness.
• objective phenomenon - the pigmentation of skin, bilryi lines abdomen, external genitalia, increased pigmentation of the nipples and around them.
Probable signs - is objective evidence to be determined by the genitals, breasts, and by immunological reactions to pregnancy. They are characteristic of pregnancy, but may occur for other reasons. These are signs of a cessation of menstruation in childbearing age women, breast enlargement and nipple discharge from colostrum or milk.
To the probable signs also include data gynecological examination: examination of external genitalia, inspection of the cervix in the mirror, bimanual pelvic examination. It can be observed loosening and cyanosis of vagina most vagina and cervix softening and increase uterine changes its shape, increasing the contractile ability of the uterus (short seal softened uterus).
of features observed in the study of the pregnant uterus, the most important are the following.
Sign of Henter: vaginal examination in early pregnancy on the anterior surface of the uterus, exactly in the midline her find comb performance, which does not apply to the bottom or on the back of the uterus, not the cervix.
Sign of Horvits-Gegara: vaginal examination revealed softening in the region of the isthmus, leaving here easily converge fingers domestic and foreign hands. The cervix feels like a dense corpus.
Sign of Piskachek: vaginal study outlines the uterus and plot its angles are wrong. That angle is misaligned with fertilized egg implantation, appears much larger than the opposite. The entire uterus is asymmetric.
Sign of Snegirev: vaginal examination pregnant uterus is due to mechanical irritation begins when fingers shrink and become more dense.
To the probable signs of pregnancy include immunological reactions to pregnancy, which based on determining urine or plasma human chorionic gonadotropin (hCG), hCG secreted trophoblast, then chorion, placenta. Selection begins with 7-8 days after fertilization, so laboratory diagnosis possible thereafter. To study should take the morning urina, which has the greatest concentration of the hormone as a threshold method. Determination of beta-hCG in plasma is more reliable. It should be noted that although hCG produced trophoblast, the reaction belongs only to the probable signs, because when this pathological condition as chorionepithelioma also observed a positive response to hCG. In addition, after abortion reactions remain positive for 7-10 days, and in pathological conditions (diseases trophoblast) - 2-4 months. The lower limit of sensitivity - 5 IU / l.
Possible signs of a convincing proof of pregnancy in women surveyed. All signs in this group have only objective and come only from the fetus.
These include features that are found in intravaginal ultrasound, other probable signs detected from 20 weeks of pregnancy and do not belong to the early signs of pregnancy period. These are the signs:
• Fetal movements, which are determined by hand or by listening (and not those which feels very pregnant);
• auscultation of fetal heart tones;
probing fetal parts (head, legs, buttocks, arms)
• identifying the fetal heart using kardiotokohrafyiyi.
Currently, the standard for diagnosis of pregnancy in the early period is a combination of two methods:
- Determination of beta-hCG in urine or blood plasma;
- Transvaginal ultrasound.
The size of the uterus during the first 3 months of pregnancy, when it is still in the pelvic cavity, determined by a two-handed gynecological examination, further palpation of the abdomen - the height of standing uterus.
Antenatal period is important for the physiological development of the fetus, the course of labor and the newborn. The development of modern medical technology allows assessment of the fetus throughout pregnancy, from the first days after fertilization until birth of the fetus.
Noninvasive methods
Determining the level alfafetoproteyinu (AFP). AFP is synthesized by the liver of the fetus from 11-12 weeks of pregnancy and is a certain amount of amniotic fluid, where gets into the bloodstream of the mother. In some developmental abnormalities, particularly neural tube defects (anencephaly, cerebral spinal hernia, hydrocephaly) AFP increases dramatically. Thus it is a marker of fetal neural tube defects, as well as their frequency is 1-2/1000, then be screening all pregnant women with the help of AFP. If you raise his level there is a more detailed examination (re-determination of AFP, ultrasound, etc.).. Reducing AFP observed in Down syndrome. AFP levels may vary under the following conditions: intrauterine fetal death, the threat of miscarriage; omfalotsele, Turner's syndrome, sacro-coccygeal teratoma; extrophy bladder syndrome Mekellya; congenital nephrosis.
Ultrasound diagnosis (ultrasound). Using ultrasound can detect specific ultrasound signs (those that come from the fetus), and nonspecific signs (those coming from other elements of the ovum).
Nonspecific ultrasound signs may indicate the presence of anomalies of fetal development. List of nonspecific signs UVR following: poly-, oligo-, anhidramnion, hypoplasia of the placenta, umbilical cord hypoplasia and hyperplasia; aplasia of one umbilical artery, amniotic bands; disproportion of body parts of the fetus; violation echo the contours of the body of the fetus and internal organs, growth retardation; violation of the provisions of fetal presentation and mobility.
In the case of these signs made more detailed ultrasound experienced specialists in genetics, which has syndromologic analysis. Later, a "fetal anatomic screening of the fetus' dynamics.
During pregnancy should be carried out three times screening ultrasound:
1. The first time a woman about the delay menstruation to pregnancy diagnosis, localization of a fertilized egg, the fluctuations in its development;
2. At 16-18 weeks of pregnancy to determine the growth of the fetus, according to gestational age, as well as identifying possible anomalies of the fetus for timely use additional methods of prenatal diagnosis or the issue of abortion;
3. In the period 32-35 weeks to determine the status, location of the placenta and the rate of development of the fetus, chlenoroztashuvannya fetus before birth, estimated fetal weight.
In connection with the improvement of vehicles and equipment ultrasound may diagnose chromosomal syndromes since I-trimester pregnancy. To measure the collar area of the fetus at 11-14 weeks. CP should not exceed 2.5 mm. After 15 weeks can detect Down syndrome, Patau, Turner, Edwards. But the final diagnosis of these syndromes is established only after studying the karyotype in fetal blood.
The method of prenatal Doppler invested Doppler effect, the essence of which is to change the wavelength of a moving object. Research subject: umbilical vein, aorta fetal umbilical artery, internal carotid artery, renal artery of the fetus and uterine artery mother. Research in the circulatory system mother-placenta-fetus using Doppler allows for the topical diagnosis of hemodynamic disturbances further preclinical stage of formation of placental insufficiency. Reduced blood flow in the internal carotid artery of the fetus may indicate the presence of intrauterine infection of the fetus. Increase - the presence of hydrocephalus (infectious Sylvian aqueduct stenosis). Early diagnosis (pre-clinical) gestosis pregnancy possible with uterine artery Doppler.
Cardiotocography (CTG) - Registration of changes in the number of fetal heart rate simultaneously with changes in contractile activity of the uterus and fetal movements on paper using electronic equipment. According to modern concepts, kardiotokohrama consists of three elements:
1. Cardiogram (kardiotahohrama) fetus - registration of fetal cardiac activity by gage kardiodatchyka (cardio transducer);
2. Tokohrama - registration of contractile activity of the uterus using tokodatchyka (toco transducer);
3. Aktohrama - check fetal movements using tokodatchyka. Kardiotokohrama (CTG) - a set of all three elements.
Score CTG should be multifactorial, ie include consideration of all options
Increased basal rate above 160 beats / min is easy, and above 180 beats / min - severe tachycardia. Reduced basal rate below 120 beats / min indicates moderate, and below 100 beats / min of pronounced bradycardia.
Functional tests: a test of the mother's breath, cold test, step test (with exercise); atropinovyy test; inhalation (oxygen) test, test for sound stimulation.
Nestresovyy test (NST) is based on the detection of fetal movements and related changes in fetal heart rate as aktseleratsiy by myocardial reflex. To perform myocardial reflex requires not only sufficient innervation of muscle and heart, but also coordinated the activities of the CNS. The proposed about 35 years ago, NBT received widespread as a screening method of examination and is currently one of the main methods of functional diagnosis in perinatology. Registration NST performed for 30 minutes in supine position on the left side. Motor activity of the fetus recorded by strain gauges or by pressing the - marker when pregnant she said fetal movements. Performing NST to spend an empty stomach or 2 hours after eating to eliminate the influence of hyperglycemia, which enhances motor activity fetus. NBT as outpatient screening can be done in 30 - 32 weeks pregnant with low risk and no later than 28 - 29 weeks pregnant with a high risk (diabetes, cardiovascular disease, chronic hypertension, growth retardation, multiple pregnancy, threatening premature families and others.).
In 1972 were established test criteria, the frequency of the monitoring. The sample was named okcytotsynovym provoking test (oxytocin challenge test - OCT). This name is now well recognized.
Invasive methods
The widespread use of invasive techniques during pregnancy began with the advent of ultrasound, which has a high possibility to provide relative safety for their use.
Fetoscopy - invasive method that allows the optical system to inspect the fruit directly into the uterus. With this method you can make a skin biopsy of fetal kordotsentez, Replacement transfusion in hemolytic disease and more. Fetoscopy performed under ultrasound at 15-20 weeks of gestation (later amniotic fluid loses its transparency).
When fetoscopy can diagnose abnormalities of the head, face, extremities, keels. Taking skin biopsy, diagnose ichthyosis fetus. Having blood can detect fetal chromosomal abnormalities and some fermentopathy.
Chorionic villus sampling. Research conducted chorionic villi in the first trimester of pregnancy to detect chromosomal abnormalities (fetal karyotype study) as well as for the diagnosis of enzyme defects (phenylketonuria, hypothyroidism, cystic fibrosis). Diagnosis is made using the latest biochemical, immunological studies and analysis of DNA (polymerase chain reaction).
Invasiveness prenatal diagnosis is made with 7 weeks of pregnancy in chorionic villus sampling. Research chorionic tissue allows for the diagnosis of a wide range of chromosomal and genetic diseases.
Prenatal diagnosis of hereditary diseases sharing, hemoglobinopathies, and coupled with an X-linked disease carried out by analyzing DNA isolated from chorionic tissue after previous molecular genetic survey of parents and a sick child.
Amniocentesis - a penetration of the amnion to collect amniotic fluid and fetal cells for prenatal diagnostic tests. Through the study of amniotic fluid can determine fetal karyotype, levels of certain enzymes, hormones, ά-fetoprotein, conduct DNA analysis. Amniocentesis performed at 16-18 weeks of pregnancy.
Indications for amniocentesis: a study of bilirubin in isoimmune conflict; diagnosis of fetal lung maturity, genetic diagnosis of chromosomal abnormalities, diagnosis of malformations of the central nervous system in the fetus.
Cordocentesis - a method of transcutaneous puncture of the umbilical cord of the fetus. Getting the blood of the fetus in the second trimester of pregnancy is necessary for the diagnosis of many inherited diseases, blood immunodeficiencies.
Exploring fetal blood lymphocytes for several days can be set karyotype, besides it can solve the question of fetal or postnatal correction and method of delivery.
Biopsy of the skin of the fetus. In the second trimester of pregnancy can fetal skin biopsy followed by morphological examination for prenatal diagnosis of epidermolysis bullosa death and erythroderma Brock. The procedure has the same contraindications as obtaining fetal blood.
There are several methods of fetal skin biopsy. The optimal procedure is to conduct controlled sonography.
Childbirth - physiological process in which the expulsion of the fetus from the uterus, placenta with membranes and amniotic fluid. Physiological childbirth (partus maturus normalis) occur on average after 10 months postpartum (280 days, or 40 too) pregnancy when the fetus becomes mature and fully capable of extrauterine existence, that the onset of labor to some extent programmed.
The mechanism of initiation of labor is not fully defined. Important role in the development of labor activity belongs neurohumoral and hormonal systems of the pregnant woman, placenta, biophysical and morphological mechanisms.
Late pregnancy and early childbirth in women dominate the processes of inhibition in the cerebral cortex and hyperexcitability subcortical structures (hypothalamic-hilofizarnoyi system limbic complex), the spinal cord. In pregnant women formed the basis of tribal dominance, characterized by increased responses to interoceptive stimuli from the cervix and the weakening or absence of responses to exteroceptive stimuli, which is essential for uncomplicated births.
To understand the pathogenesis of labor activity is important to know innervation of the uterus. During childbirth matter stimulation of the receptors of the uterus and maternal passages. As involvement in the process of new receptors change the strength and frequency of uterine contractions, and later joined striated muscle contraction (power). The nature and severity of various reflex responses largely depend on the impact on the nervous system of humoral and hormonal factors as well as the tone of the sympathetic and parasympathetic divisions of the autonomic nervous system.
The uterus is sympathetic or adrenergic (mostly body), and the parasympathetic or cholinergic (mainly neck) innervation. In the body of the uterus are mostly well and p-adrenergic receptors in the lower segment - M-choline and D-serotonshoretseptory in the cervix - chemo-, mechano-and baroreceptors. Activation of (-adrenergic receptors by using estrogens, catecholamines and prostaglandins, oxytocin, serotonin, histamine, kinins and other biologically active substances tonomotornoyi action, the level of which increases in serum mother before delivery. (-adrenergic receptors exert opposite effects on the myometrium (reduced tone, excitability and contractile activity of the uterus) and subject to the influence of progesterone.
During the last two weeks before delivery increased levels of estrogen and progesterone levels decreased in the blood of the mother (removing progesterone blockade of the myometrium). Reduced production of progesterone leads to the activation of spontaneous uterine activity.
During contractions uterus feels pronounced influence on the part of cholinergic system, and in all other parts of the body is a clear sympathotonia (increased blood pressure, tachycardia, dilated pupils, increased sweating, increased dermohrafizmu etc..).
At birth, physiologically occurring under the influence of a certain number of mediator acetylcholine uterine muscle contraction occur, the destruction of acetylcholine cholinesterase accompanied by a gradual fall wave reduction. These contractions occur once a new piece of acetylcholine, but if disturbed mechanism timely, rhythmic destruction of acetylcholine, the latter due to the delay in contact with ganglion cells soon effect a violation of the neuromuscular apparatus replaced depressive effect - the contractions diminish or cease.
Role in fetal raised by birth. Weight fetal genetic perfection development, immune relationship between fetus and mother affect the onset of labor activity and course delivery. The signals coming from the body of the mature fruit, provide competent parent information systems, leading to inhibition of the synthesis of immunosuppressive agents, and therefore changes the reaction of the mother to the fetus as an allograft. In fetoplacental complex changing steroid balance towards accumulation of estrogen, which increases sensitivity to norepinephrine blockers, oksitotsynu, prostaglandins.
On the contractile function of the uterus affects intrauterine pressure, the size of the fetus oposeredkuyetsya irritation chemo-and baroreceptors.
Act of births occurring in the presence of the existing labor dominant, combining dynamic system as higher nerve centers and executive bodies. In the formation of labor dominant importance is the impact of sex hormones on the formation of a variety of central and peripheral nervous system. Central nervous system carries higher and fine regulation of maternity act. Significant growth in the electrical activity of the brain occurs at 1-1.5 weeks before delivery.
Of great importance for the emergence of labor activity and correct its course has preparedness of the female body, the willingness of the uterus and myometrial sensitivity to the effects of contractile substances.
Forerunners and early childbirth
On approaching childbirth show called harbingers:
1. In late pregnancy (usually within 2-3 weeks for delivery) bottom of the uterus falls.
2. Presenting part descends. In primigravides head tightly pressed against the entrance to the pelvis or even playing in a small segment of it. Before childbirth are well defined signs of maturity of the cervix: it lies on the axis of the pelvis, softened, slightly shortened, women who give birth again - cervical canal passes finger. Next shortening and effacement of the cervix (opening and throat) occurs during childbirth.
Before childbirth often determine vaginal discharge stringy mucous secretion glands of the cervix.
In late pregnancy, many women begin to experience contractions. Before birth they acquire the character of dull pain in the sacrum and lower abdomen. Contractions that are precursors are different from maternity Rename: they are weaker, shorter, irregular, not lead to a smoothing of the cervix, throat opening.
Body weight pregnant is decreasing. This is due to increased excretion of water from the body.
Most pronounced harbingers of births are irregular uterine and vaginal discharge of cervical mucus (mucus plug) (preliminary period).
On the onset of labor indicate: a) the appearance of regular contractions of the muscles of the uterus (contractions) from the onset of labor contractions alternate every 10-15minutes, then become more frequent and stronger, and b) the gradual effacement of the cervix and uterine os expansion, c) discharge of mucus .
Since the beginning of labor activity and the end of a woman called women in childbirth (parturiens).
Since the study biomehanizmu childbirth should note the following
especially in the position of the fetal head at the occipital presentation:
- The position of the head to the onset of labor slightly bent neck
and small fontanel are less than great;
- Sagittal suture is in a slightly oblique of the entrance to the
small pelvis, transverse size of the entrance to a small bowl out
low to the sacrum and the muscles slightly smaller posterior-lateral
departments pelvis.
Biomechanism of childbirth - a set of rotating, bending and straightening movements that performs fruit passing through the birth canal. Biomechanism of delivery at the front form occipital presentation consists of 4 moments:
I moment - bending the head and insert it into the plane login
small basin. This is turning heads around its transverse axis. Because of
bending head small fontanel is located at the lower pole
presenting head, approaching the leading axis of the pelvis and becomes
leading point. Because bending the head through the pelvis
smallest circle that corresponds to the small size and is oblique
32 cm.
II moment - internal rotation of the head: is the transition
with its broad to the narrow part of the pelvis. Head slowly back
around its axis so that the neck back to symphysis and face -
to the buttocks. This sagittal suture gradually changes its position,
moving from the transverse size of oblique and then with oblique - in direct output size of the pelvis. In the first position of sagittal suture passes through the right, while the second - through the left oblique size. Internal cephalic is the result of adapting its smallest size to the largest size of the pelvis, as well as through progressive resistance movements head of the muscular organs.
III moment - head extension in the plane of the exit. Sagittal suture
coincides with the right amount out of the pelvis. Fixation point formed
between the middle of the bottom edge lonnogo joints and pidpotylychnyh
fossa. Around this point is unbending head, but clinically it
accompanied the birth of the forehead, face and chin. During
infeed head and torso moving eruption in a small bowl,
and transverse size shoulder pads comes in one size skew
plane entrance.
On the shoulders of pelvic floor exercise internal rotation is the same with rotation of the fetal head. Concluding twist, shoulders set up direct live of the plane out of the pelvis. This rotation is transmitted head shoulders, born that corresponds to the fourth moment biomechanism birth.
IV moment - internal rotation of the shoulder pads and external rotation
head. Head with the back facing the hip mother at
first position - right thigh, the second - to the left. Begins
birth of shoulders. Front shoulder comes under lonnie arc and fixed
near the bottom of the symphysis. Point of fixation - insertion
deltoid muscle to the humerus on the one hand and the middle
lower edge of the symphysis second. Formed around the point of fixation
is flexion of the trunk and the first born back shoulder, back
handle. After the birth of the shoulder girdle is the expulsion of the remaining
of the fruit.
Biomechanism of delivery at the posterior occipital type of presentation
I moment - bending and lowering the fetal head (no
differs from the previous one in the front form occipital before
lying).
II moment - internal cephalic fetus: head returns
neck posteriorly to the sacral hollow, and face - doperedu to
symphysis. Behind the back back back backwards fetus. So
way, small fontanel is directed toward the buttocks and big - to symphysis.
Sagittal suture through the same with the back bevel size goes
in direct size pelvic outlet.
III moment - additional bending head. Bending the head - the head is fixed at the bottom of the front edge of the symphysis area large fontanel, formed the first point of fixation around which is additional bending, which continues until it formed the second point of fixation (suboccipital fossa and the tip of the coccyx).
IV moment - straightening head. Further cutting of head
occurs due to the formation of a new, second point of fixation between
occipital fossa and the tip of the coccyx. So head
face comes from the heart. She erupt slightly higher
circumference than the circumference of the small size of the oblique, which corresponds to the average size of the oblique.
V moment - no different from the fourth moment before
kind occipital presentation.
The configuration at the back of the head form occipital presentation dolihotsefalichna.
Clinical course of sorts at the occipital presentation rear view: greater duration childbirth than at the front form occipital presentation, most maternity costs involved for the additional bending forces head; often occur perineal ruptures, secondary weak labor activity, hypoxia, and more. Labor management expectantly, but we must always be prepared to provide obstetric care, or surgery.
Childbirth is divided into three periods:
First - during opening of the cervix.
Second - the eviction of the fetus.
Third - sequence.
With the onset of labor pregnant women in call.
The first stage of labor is divided into two successive phases:
( Latent (hidden) phase - the time from the start of the regular labor activity until smoothing cervix opening to 3 cm in first delivery or up to 4 cm in all these. Usually this phase falls under, 6-8 hours (primipara) and 4-5 hours (bipara).
( The active phase - the opening of the cervix from 3.4 cm to 10 cm including minimum speed opening of the cervix into the active phase, which is the norm is 1 cm / h in the first and in subsequent births. Usually the rate of disclosure in women who give birth to a second or third more than in ¬ cal and give birth for the first time.
The active phase is divided in turn into three phases: acceleration, maximum rise and deceleration. Phasesacceleration of primipara lasts up to 2 hours, bipara - up to 1 hour. Phases maximum recovery continues as many hours respectively. Phases slowdown in primipara lasts 1-2 hours in bipara - 0,5-1 hour. The slowdown in the late stage of labor and slipping due to cervical fetal head that moves.
The first stage of labor determine the beginning of the regular contractions (obviously not controllable rhythmic contractions of uterine muscle) to complete (10 cm) opening of the cervix. Regular maternity work - is a contractile activity (2-5 contractions per 10 minutes), which leads to structural changes in the cervix - its smoothing and disclosure.
Fallopian activity determined by palpation of the uterus for 10 minutes. The presence of 2 or more uterine contractions in 10 minutes for 20 seconds or more is a sign of labor activity.
Conclusion on the effectiveness Rename based on their strength, duration and frequency at opening of the cervix in dynamics and signs of moving head to the plane of the entrance to a small bowl.
In the active phase of the first stage of labor effective contractile activity of the uterus must meet the following specifications: 3-4 contractions in 10 minutes, lasting more than 40 seconds.
But the most objective criterion of efficiency of labor activity in the first period is the opening of the cervix, the degree of which can be controlled by various methods.
External methods of assessing the degree of opening of the cervix.
External methods estimate the degree of opening of the cervix is possible only at approximately. Indicative of the extent disclosure cervix at delivery judged by height standing contractional ring (boundary between blank muscle, shrinking, and lower segments volume uterus stretch). Cervix during labor is usually disclosed by as much as cross fingers contractional ring is located above lonnoy arc.
Internal methods for assessing the degree of opening of the cervix.
In order to determine the dynamics of opening of the cervix and the location of the head in childbirth conducted internal midwifery research that women perform on admission to the maternity ward, every 4 hours during the first stage of labor and after the outpouring of amniotic fluid (for early diagnosis of possible evaporation provision over amniotic fluid and umbilical cord of small parts of the fetus).
Because of an increased risk of ascending infection birth canal additional internal midwifery research in the first stage of labor allowed only bye-lated:
1. Every 4 hours during the first stage of labor and every hour in the second stage of labor.
2. After rupture membranes
3. Pathological fetal heart rate (less than 100 and size 180 beats / min) to determine the causes that might explain signs of his condition;
4. Umbilical cord prolapse of the vagina;
5. When multiple pregnancy after the birth of the first fruits;
6. When malposition or suspected fetal insertion head at the entrance to the pelvis in a position to determine the extension of obstetric situation;
5. Delayed progress of labor due to inefficient uterine contractions - for amniotomy and oxytocin before stimulation;
7. The need for early delivery (severe preeclampsia, antenatal fetal death and other pathology).
8. In decision making operative vaginal delivery (forceps obstetrical, vacuum extraction, extraction of the fetus for pelvic end)
9. Bleeding after 22 weeks of pregnancy (in operating).
Determination of the insertion head external methods
The degree of insertion heads can determine admission Leopold IV.
Recommended as the method of abdominal palpation, which is determined by the height of standing at the head of the fetus finger widths above the symphysis:
5/5 - fetal head above the symphysis location for width 5 fingers, the fetal head is above the entrance to the pelvis;
4/5 - width 4 fingers, head pressed to the door in a small bowl;
3/5 - width 3 fingers, the head of a small segment of the entrance to the pelvis;
2/5 - the width of two fingers, the head of a large segment of the entrance to the pelvis; 1/5 - 0/5 - width 1 finger head is in the pelvic cavity.
External palpation of the head should be directly in front of the inner obstetric research. This allows you to avoid mistakes in determining the position of the head in the case of formation of a large swelling of the presenting part of the fetal head.
Determination of the insertion head by internal midwifery research
( head over the entrance to a small bowl. Pelvis is free, head is high, it does not prevent the anonymous line palpation pelvis, cape, sagittal suture is transverse dimensions at the same distance from the symphysis and the cape, great little fontanel - on one level.
( the head of a small segment of the entrance in a small bowl. Sacral cavity is free, you can go to cape curved finger (if feasible). The inner surface of symphysis available research, small fontanel below great. Sagittal suture is in a slightly oblique size.
( head at the entrance of a large segment of the small pelvis. Head occupies the upper thirds well symphysis and sacrum. Cape unattainable, gluteus spine easily palpable. Head bent, small fontanel below large, sagittal suture is still with oblique dimensions.
( head in the widest part of the pelvis. Head circumference was the largest plane widest part of pelvic Two-thirds of the inner surface lonnogo junction and the upper half of the sacral hollow busy head. Free palpable IV and V sacral vertebrae and spine buttock. Sagittal suture is located in one of the oblique sizes small fontanel below great.
( head in the narrowest part of the pelvis. Two-thirds of the upper sacral hollow and full inner surface lonnogo busy junction head. Sciatic spine difficult to be achieved. The head is close to the bottom of the pelvis, internal rotation have not yet finished, sagittal suture is located in one of the oblique dimensions close to direct. Small fontanel in the bosom of the great below.
( head in the outlet of the pelvis. Sacral cavity completely filled head, buttock spine are not defined, sagittal suture is located in the forward rate of exit from the pelvis. Small fontanel in the bosom of the great below.
The provisions of the fetal head at an internal study can also find out in relation to the level of sciatic spines - linia interspinalis ("0"). Distance from sciatic spines to the plane of the entrance to a small basin is of such spines to the plane you move pelvis. The sign "-" means that the head is above the sciatic spines (closer to the entres to the small bowl). The sign "+" means that the fetal head is placed below the gluteal spines (near the pelvic outlet). Provisions head is defined as follows:
-3 - Head over the entrance to the pelvis;
-2 - Head pressed against the entrance to a small bowl;
-1 - The head of a small segment of the entrance to a small basin,
-0 - Head of a large segment of the entrance to a small basin,
+1- Head in the wide part of the pelvis,
+2 - Head in the narrowest part of the pelvis,
+3 - Head to the exit from the pelvis.
Assessment of the fetus during labor.
Condition fetus and II periods defined in terms heartbeat, amniotic fluid color and configuration of the head.
( fetal heartbeat recording by periodic auscultation using obstetric stethoscope, hand Doppler analyzer or, if indicated, fetal monitoring (cardiotocography).
Periodic auscultation performed every 15-30 minutes according to the following rules:
( pregnant is in position on the side;
( auscultation begins immediately after the most intensive phase of contractions;
( auscultation lasts for 60 seconds.
The heart rate of the fetus is normal should be 110 to 160 beats per 1 wave lynu. The sharp increase in heart rate (over 180 beats / min) or slow (less than 100 beats / min) with rhythm disturbances are diagnostic sign of fetal disorders.
RECOMMENDATIONS FOR USING labor management partogram
Partohrama (insert history of childbirth (f. 096 / o) - a graphic record flow of labor, and the state of women in the fetus, is designed to store information about the results of monitoring during labor as the mother, fetus, processes opening of the cervix and the moving head of the fetus. Partohrama to clearly distinguish normal from abnormal labor progress and identify complications during childbirth that require intervention.
Benefits of partogram:
• Effective observation of childbirth.
• Timely detection of deviations from normal childbirth course.
• Help with deciding on the necessary and sufficient interventions.
Particular attention should be paid to the principles of first stage of labor, which include measures to support women in psychological - partner genera (presence of spouse or family members, and in some cases close friends), women in the prevention of fatigue, disorders of the fetus, maternal avoidance and di ¬ tyachoho injuries in childbirth.
Mandatory in the management of labor is free choice woman position (sitting, standing, with a slope in front, lying on its side, etc.) is considered undesirable position of women in childbirth on the back, which contributes to aorto-caval compression, the flow of blood in the uterus, the negative impact on women in general state, resulting in a decrease in blood pressure and deterioration of the fetus. In addition, the provisions on the back reduces the intensity of uterine contractions and adversely affect the course and duration of labor.
The most defensible in the first stage of labor is the active behavior women accelerates the opening of the cervix, reduces pain ne Raimi, reduces the frequency of violations of fetal cardiac activity. One should emphasize the need for proper treatment women in breathing - rapid breathing through the nose and exhale through the mouth slow. This method of breathing is promoted as anesthesia contractions and improvement of central and uteroplacental hemodynamics. Among non-pharmacological methods that reduce the pain during the first stage of labor may be used music therapy and other non-pharmacological means of pain relief (shower, bath, massage).
Application of these techniques causes irritation of specific afferent peri-ferychnyh nerve receptors, which leads to increased levels of endorphins in cerebrospinal fluid, which are endogenous analgesic substances.
The use of pharmacologic analgesics during delivery is made only by the presence of clinical indications.
Requirements for medical anesthesia:
( analgesic effect;
( no negative impact on the mother and fetus;
( ease of administration and availability.
anesthesia are using at:
( not inhaled and inhaled anesthetics;
( regional anesthesia;
( systemic analgesics (fenotiozynu derivatives, etc.);
( opioid alkaloids (at the opening of the cervix is not more than 5-6 cm).
The second period (the period of exile) of the complete opening of the cervix before birth. It is important to distinguish the early phase of the second period - from full develop-discovery to the powers and active - directly phase powers.
Note the maximum. Permissible duration of the second period in women who give birth for the first time and second time, respectively, 2 and 1:00 without epidural anesthesia, and consequently 3 and 2 hours with epidural anesthesia. Most of this time is very early phase, when the head moves slowly through birth canal to the pelvic floor without joining first attempts, and then with the gradual emergence of a strong and increasing component during contractions. The organization attempts during early phasa in the presence of normal fetus and the mother usually quickly leads to fatigue women, disrupting the internal rotation of the fetal head, injury, maternity tract and the head of the fetus, fetal cardiac abnormalities and unnecessary medical interventions.
Complete strong activity appears only when the head is tazo-ments days (active phase).
One should note that the long standing head of the fetus in a particular area of the pelvis without promotion dynamics can lead to the formation of recto- and urogenital fistulas.
Possible information about the location of the fetal head to the plane of the pelvis obtained by vaginal ported by research.
Important concepts II period are:
• attempts (strain) - rhythmic, consciously controlled combination of reducing uterine muscles, abdominals, diaphragm and pelvic floor;
• infeed of head - the appearance of the head of the Boulevard ring only when power;
• cutting of the head - head keeps position in Boulevard ring after cessation attempts.
• Conduct second stage of labor requires:
• measurement of blood pressure, heart rate in women in every 10 minutes;
• Control of fetal cardiac activity every 5 minutes during the early phase, and after each power during the active phase;
• monitoring the progress of the fetal head through the birth canal, which is carried out using an internal midwifery studies every st hower.
• Due to increased risk of infection rising birth canal additional internal midwifery research in the second stage of labor allowed only if indicated:
( Conducting amniotomy, if there is no timely outpouring of amniotic fluid.
( When multiple pregnancy after birth of the first baby.
( When decisions operative vaginal delivery (forceps obstetrical, vakuumekstraktsiya, extraction of the fetus for pelvic end).
Birth of the fetal head should be providing manual assistance, which aims not only to preserve the integrity of the perineum women, but also the prevention of intracranial, spinal and other injuries of the fetus.
It is important to emphasize that only when necessary during the period of expulsion can be held auxiliary section perineum (perineo and episiotomy).
Testimony before the crotch section is (WHO):
( Complicated vaginal delivery (vacuum extraction, obstetrical forceps, breech presentation).
( The presence of scarring crotch after straightening in previous births especially after poor healing.
( Fetal distress.
According to modern scientific evidence for the use of episiotomy indications threat perineal is not always justified. Lack of clear objective criteria "threat perineal" is the basis for wider use epizyutomiyi, which is nothing other than iatrogenic rupture of second-degree perineal In most cases, when in the presence of so-called "threat perineal" section pro-mezhyny not performed , there is a spontaneous rupture of a perineal skin and vaginal mucosa, without damage to the pelvic floor muscles (the gap of the first degree).
It should also be recognized that in some cases the perineum indeed poses challenges for the birth, and her autopsy is a necessary measure to prevent severe breaks, but the decision to perform episiotomy should be taken skilled after careful evaluation of obstetric situation.
It should be emphasized that, according to modern scientific evidence:
• The use of episiotomy should be restricted indications (Level A recommendation);
• Prerineotomiya accompanied by a higher frequency of deep ruptures with vaginal lesions straight cats and anal sphincter compared with episiotomy. (Level A recommendation);
• Routine of episiotomy does not reduce the frequency of deep ruptures with vaginal lesions straight cats and anal sphincter. (Level B recommendation);
• If the need for perineal incision is the preferred episiotomy, not lerineotomiyi. (Level B recommendation).
Thus, the decision to perform surgery should be clinically justified and granted to women to obtain permission from her. The operation should be seeing you after prelocal anesthesia.
It should be noted that the provision of a free woman during attempts facilitates more dynamic passage of the fetus through the birth canal, the most effective are the positions Squatting, sitting on a chair, becoming, pulling on drobyntsi, lying on its side.
The third period (sequence) extends from the birth of the fetus to the separation of the placenta from the shells. In the absence of signs of bleeding duration should not be re-vyschuvaty 40 minutes. You must pay attention to the mechanisms normally located placenta abruption (early detachment from the center of the placental surface turning amniotic membrane outside - mechanism Schultz, from the edge of the next contraction placenta in half - mechanism Duncan). Whole litter determined visually.
Hemorrhage in the sequence period, not exceeding 0.5% of women in the mass considered physiological. The only objective method of accounting bleeding is its measurement.
There are two tactics of the third stage of labor active and expectant.
Active management of the third period labor.
With a number of advantages of active third stage of labor is the most develop-povsyudzhenoyu tactic in the world and is recommended by the World Organization of Health, the International Federation of Obstetricians - Gynecologists and the International Confederation of Midwives.
Application techniques of active management of the third period during each birth reduces the incidence of postpartum bleeding caused by uterine atony by 60% and reduce postpartum blood loss and need for blood transfusions.
Standard components of active management of the third period of labor include:
• introduction uterotonykiv;
• birth litter controlled by tractions by the umbilical cord during uterine lead hand from the womb;
• Massage the uterus through the anterior abdominal wall after the birth of the litter.
Disciplines uterotonikiv: within the first minute after the birth of the child palpate the uterus to exclude it second fetus in his absence - enter 10 units of oxytocin intramuscularly. Oxytocin is the preferred by uterotonic because its effect is within 2-3 minutes, it may be you ¬ their used in all women.
If there are no oxytocin can be used - ergometrine - 0.2 mg / m woman should be informed of the possible side effects of these drugs.
You can not use erhometrin women with preeclampsia, eclampsia and hypertension.
Controlled traction from umbilical cord:
• pinched umbilical cord closer to the perineum clamp to keep pinched umbilical cord and clip in one hand;
• put the other arm just above the pubis and women hold the uterus diverting it from the womb:
• gently pull the umbilical cord and wait for a strong uterine contractions (usually after 2-3 min. Following oxytocin);
• simultaneously with strong contractions offer a woman potuzhytys and carefully pull (traction) on the umbilical cord down to saw the birth of the placenta, while at the same time continue to the second hand kontrtraktsiyu in a direction opposite traction (ie pushing the uterus from the womb).
• If the placenta does not fall (ie, not born) for 30-40 seconds.
controlled traction, traction stop by the umbilical cord, but keep keep her in a state of mild tension, the second hand is contracts in the reverse direction of traction.
• wait until the uterus is well again and fall again controlled traction from the umbilical cord of kontrtraktsiyeyu on the uterus.
Never hold traction (pulling) on the umbilical cord without kontrtraktsiyiyi (abduction) is well above the vagina uterine contractions.
Conducting from the umbilical cord traction without contractions can cause you cancer-gate.
After birth, the placenta held her two hands and gently turn, twisting the shell, slowly pull the placenta down to complete delivery.
In case of breakage of shells, carefully examine the vagina and cervix in sterile py-kavychkah. In the case of membranes using vikonchatyy clamp to remove its leftovers.
Carefully inspect the placenta and sure in its entirety. If the surface area of the parent is absent, or is part of dangling shells of vessels, there is reason to suspect the delay plots placenta and initiate necessary action.
Massage uterus: immediately after birth litter massages uterus through the anterior abdominal wall women until it becomes thick.
Further palpable uterus every 15 minutes. during the first 2 h., to be sure that after the massage the uterus is relaxed, but remains tight If necessary, repeat massage.
Ice pack on the lower abdomen in the early postpartum period is not applicable [A].
Active management III stage of labor should be offered to every woman, because it reduces the incidence of postpartum hemorrhage arising due to atony mat-ki
Women in should be informed regarding active management III stage of labor, and is willing to provide written consent to conduct.
Expectant of third stage of labor
Midwife after umbilical cord pulsation, but no later than 1 min. after ¬ nation of the child, pinch and crosses the umbilical cord. A thorough supervision by ¬ eral parturient, signs of placental abruption, the number of bleeding
If signs of placental abruption (signs Schroeder, Alfeld, Klein. Kyushnera Chukalova) - to offer a woman "strain" that will lead to its birth litter.
In the absence of signs of placental abruption and external bleeding within thirty minutes after the birth of the fetus - conducted manual separation and isolation litter
In case of bleeding - manual separation and allocation of manure to be carried out immediately under adequate anesthesia
After selection of the placenta is necessary its thorough review (belief in the integrity of the placental membranes).
The total duration of labor on average for first 8-12 hours in povtornorodil - 6-8 hours.
Browse maternity tract after childbirth (using vaginal mirrors) holds only if bleeding after operative vaginal delivery or when uncertainty doctor for the integrity of tribal ways (rapid delivery, delivery outside the hospital).
Assessment of the newborn
Condition newborn evaluate Apgar at 1, 5 and 10 minutes after birth. The scale includes assessment system for ten five indicators (0-2 points per rate): heart rate, respiration, the skin, muscle tone, reflexes. Ho roshym indicator considered in assessing the state of the newborn no less than 8 points. satisfactory - not less than 7, lower estimates suggest a asphyxia of varying severity.
Subject to a satisfactory state newborn, his teaching on the mother's abdomen, hold obsushuvannya dry diaper and cover with another dry diaper.
After 1 minute after birth exercise klemuvannya and crossing the umbilical cord. If necessary to remove mucus from the mouth pear or electric pumps. Wear a hat, socks.
If the child's condition is satisfactory, it is placed on the mother's breast and covered pa ¬ together with her blanket for conditions "warm chain". Contact "skin to skin" leads to activation of sucking reflex and promotes early child at deconstructing the chest (for the first two hours). Following this, a treatment pu ought, child free spovyvayetsya and is with his mother.
Must conducted follow-up as a child and childbirth, contractions, character of discharge from maternity pathways.
A must is to measure body temperature newborn within the first thirty minutes of record in the map of the newborn. A necessary condition is the temperature regime in the delivery room where the temperature must be at least 25 ° C.
Prevention of ophthalmia all newborns within the first hour of life-drive using erytromitsynovoyi 0.5% or 1% tetracycline ointment.
After 2 hours after the birth of a child dressed in baby clothes (not
spovyvayetsya!) and with her mother is put in postpartum separation on compatible ne-rebuvannya.
Postpartum period (ryerreriyt) - begins immediately after birth and lasts for 6 weeks. During this time the female reproductive system back to the state that existed before pregnancy.
Postpartum period is divided into early and late.
Early postnatal period begins with the expulsion of the afterbirth and lasts 2 hours. During this period the woman in labor is in the maternity ward under medical supervision, which is associated with the risk of complications, especially bleeding. This period is very important and should be considered as a period of rapid adaptation of functional systems of women after a large load during pregnancy and especially labor.
Late postnatal period runs from the date of transferring mothers in the postpartum department (within 2 hours after birth) Continue 8 weeks. During this period, the reverse development (involution) of all organs and systems are changed due to pregnancy and childbirth. It should be emphasized that the exception of mammary glands, whose function is activated with the postpartum period. It should also be noted that the rate of aging processes is maximal in the first 8-12 days and is most pronounced in the genitals, especially in the uterus.
Changes in women in the postpartum period
Uterus. Immediately after the birth of the litter, the uterus begins to rapidly shrink and become rounded. Open areas placental vessels constrict. Immediately after birth the placenta uterine body is reduced and its bottom is at the mid-distance between the pubis and the navel, then rises slightly. Anterior and posterior uterine wall thickness is 4-5 cm and adjacent to one another; uterus vystelyaye decidua. Over the next two days the bottom of the uterus is just below the navel, through 2 weeks postpartum uterus falls below symphysis. By the previous size of the uterus usually returns within 6 weeks. Involution of the uterus occurs due to reverse development of muscles by hyaline and fatty degeneration.
Within 2-3 days after birth detsydutsalna shell remains in the uterus and is divided into two layers. The surface layer nekrotyzuyetsya stands out from Lohia (postnatal discharge). Basal layer adjacent to the endometrium, which contains endometrial cancer remains intact and becomes the basis for the regeneration of new endomyetriya.
Regeneration of the endometrium runs for three weeks, with the exception of placental site. Complete regeneration of the epithelium in the area of attachment of the placenta takes 6 weeks. Excitation regeneration in the placental site may experience postpartum hemorrhage and infection.
Cervix. After 10-12 Guolin postpartum cervical canal is funnel shape, the inner eye skips 2.3 fingers and 3 night - one finger. At 8-10 days postpartum cervix formed, the inner eye closed.
Vagina. Within 3 weeks after birth vaginal wall remain with edema, which finally disappear by the end of the postpartum period. Minor damage the lining of the vagina regenerate for 5-7 days. Gender gap closes, gradually restored the tone of the pelvic floor muscles.
Ovaries. In the postpartum period begins maturing follicles. It is characteristic of anovulatory cycles, against which is the first menstruation after childbirth Later ovulatory cycles resumed. With the release of large quantities of prolactin in women with breast-feeding, no menstruation for several months, or during the period of breast-feeding a baby.
Abdominal wall and pelvic floor. Because rupture of elastic fibers of skin and long stretching pregnant uterus, the anterior abdominal wall while still soft and saggy and returns to the normal structure of a few weeks. Except tuning usually abdominal wall returns to its previous state, but atony muscles can remain flabby and weak. Sometimes there diastase recti. Pelvic floor muscles are gradually restoring its tone, but trauma during childbirth can lead to weakening of muscles and contribute to genital hernias (prolyapsiv).
Mammary gland. The function of breasts after childbirth reaches a climax. Estrogen and progesterone during pregnancy stimulate growth and alveolar ducts of the breast. Under the influence of prolactin is increased blood flow to the mammary glands and their engorgement, which is most pronounced on the third day postpartum period. The secretion of milk is the result of complex reflex and hormonal action. Formation of milk regulated by the nervous system and the adenohypophysis hormone - prolactin. In addition, the optimal level of insulin, and adrenal hormones tyreoidnyh plays a secondary role in establishing lactation. Suckling stimulates prolactin secretion periodic and reflex, oxytocin, the latter stimulates the secretion of milk from the alveoli in the milk duct. Note that this process also enhances the reduction of postpartum uterus. In the period up to 3 days after birth breasts produce colostrum (soyiozihyhp). Colostrum has a high concentration of proteins, mainly globulins, and minerals and smaller - sugar and fat. Protein amino acid composition of colostrum by occupying a transitional state between protein fractions of human milk and serum, which obviously facilitates newborn body during the transition from placental nourishment to breast milk of the mother. Colostrum contains high levels of immunoglobulin A, O, M, O, and T-and B-lymphocytes. This is of great importance in the early days of the newborn, when the functions of its organs and systems still immature, and immunity is in its infancy. Colostrum is converted into mature milk for 5 days. The main components of milk are proteins (albumin, globulin, casein), lactose, water, oil.
Circulatory system and blood. After birth, there are changes in hemodynamics associated with the elimination of the utero-placental circulation and release from the mother a certain amount of liquid. The heart has its usual condition in connection with drooping diaphragm. Immediately after birth marked lability of the pulse with a tendency to bradycardia, with blood pressure in the first days after birth can be reduced, and more - up to normal values. At the end of the first week after birth blood volume is reduced to normal. Blood indices often indistinguishable from normal, however, in the early postpartum period is a significant leukocytosis - to 30h109 / l - with the advantage of granulocytes. There is an increased level of fibrinogen in the plasma must be taken into account in the prevention of phlebitis of the lower extremities.
Urinary system. Renal function in healthy mothers is not broken, normal urine output in the first days after birth may be a bit high. The function of the bladder often enough impaired due to overstimulation of the sympathetic innervation of the sphincter and decreased muscle tone with a bladder edema and small hemorrhages in the neck of the bladder, due to its compression between the fetal head and the wall of the pelvis during childbirth.
Digestive and metabolism. Digestive system is functioning normally after birth. Sometimes there is intestinal atony with the emergence of constipation. Metabolism in the first weeks after birth usually increased, and further, to 3-4 week-normalized.
Nervous System. After childbirth usually occurs manifestation of emotional stress varying degrees, which normalized within 1-2 days. Mothers in this period needs psychological support relatives and medical personnel.
Doing postpartum
Physiological postpartum period is characterized by satisfactory parturient, normal temperature and pulse rate, natural involution of the uterus, the presence of normal quantity and quality lohy sufficient lactation.
The first two hours after birth a woman is in the delivery room individually under the supervision of midwives, obstetrician-gynecologist, while there may also be a man or someone with relatives at the woman's request. This period of time is very important, during which physiological processes occurring maternal adaptation to new conditions of existence, so it is necessary to create the most comfortable conditions that are conducive to effective adaptation after birth. This undoubtedly contributes to finding the child along with his mother in touch "skin-to-skin" and early application of the newborn to the breast, which in turn provides development breastfeeding, baby thermal protection, prevention of infections and the development of emotional connection between the child and mother. Optimal for the mother and child is the ambient temperature is 25-28 ° C. Further, in the absence of contraindications, a newborn baby should be around the clock with his mother in the same room. Joint stay of mother and child provides her nursing on demand, preventing hypothermia and prevention of drug internally infection.
While mothers in the delivery room obstetrician-gynecologist should monitor her pulse, blood pressure, monitor the condition of the uterus: determines its texture, size, height, standing uterus in relation to the symphysis and navel, watching krovovydilennyam of generic ways. It should be noted that the assessment of bleeding in the early postpartum period is required. -Measurement of blood loss made by any measuring cup. The average blood loss in sequence and early postnatal periods equals 250-300 ml or 0.5% of body weight women, but not more than 500 ml.
In the early postpartum period perform inspection of the external genitalia, lonnogo joints, perineum. Examination of the cervix and vagina performed using mirrors if indicated. If performed episiotomy or injury occurred tribal ways, necessarily restore integrity generic ways of application, local anesthesia.
Two hours after delivery woman in labor with baby transferred to the post-office, where the continued supervision of her. It is necessary to measure the temperature of the body 2 times a day, morning and evening, a review of the skin and mucous membranes, the nature and frequency of the pulse blood pressure. Particular attention is paid to breast - determine their srormu, state of nipple cracks and possible swelling of the gland. When lactostasis spend pumping. Orients woman on careful daily inspection of the breast, detection obstinacy; conduct a conversation on the prevention of mastitis, newborn feeding depending on its requirements.
Every day should be performed abdominal palpation mothers to determine the height of standing uterus, its consistency. Height standing uterus measured in cm with respect to lonnogo joints. In the first days after childbirth bottom of the uterus is located above the pubic articulation at 13-16 cm in the second day - 10-12 cm, 3 day - 7-9 cm Speed reparative processes in the uterus is also affected by postnatal discharge - Lohia. Lohii microscopic consist of red blood cells, fragments decidua, epithelial cells, bacteria are neutral or alkaline. In the early days of the presence of blood gives it a red color (Iospia shha), Sat 3-4 days after birth - are lighter (Iospia zehoza), and the 8-S day by the overwhelming presence of leukocytes lohii are yellowish-white (Iospia aIa) .
If there is no deviation from physiological pregnancy postpartum travail of newborns discharged 3 night home under the supervision of obstetrician-gynecologist prenatal and district pediatrician with recommendations, which include:
• fulfilling the rules of personal hygiene;
• respect for the day of rest at least 8 hours per day;
• perform a special exercise postpartum gymnastics;
• dieting and diet of the average caloric 2600-2800 kcal / day, with plenty of protein, vitamins and minerals;
• resuming sexual solved individually depending on the status of women.
After 3-4 weeks postpartum woman should undergo standard examination in antenatal clinics, which comprehensively assessed health status, discuss the further course of the postpartum period and makes recommendations regarding family planning.
3.3. Quiz:
1. What are the critical periods of development of the embryo and fetus. Effects on embryo and fetus environmental hazards?
2. What defects arising under the influence of negative chynnnykiv zovnishnho environment depending on the duration of pregnancy?
3. What is embryotoxic and teratogenic action?
4. What changes and psychological status in the CNS observed in pregnant women?
5. What changes in the endocrine system occur in pregnancy?
6. What changes in the genitals and breasts occur in pregnancy?
7. What changes in the cardiovascular system and blood system observed in pregnant women?
8. What changes in the respiratory system occur in pregnancy?
9. What changes in the gastrointestinal tract and kidneys occur in pregnancy?
10. What changes in metabolism observed in pregnant women?
11. What changes in the skin and musculoskeletal system observed in pregnant women?
12. What is the purpose and rules of implementation techniques Leopold?
13. What distinguished stage insert head?
14. What hravidohrama?
15. What methods of calculating estimated fetal weight?
16. What degree of "maturity" of the cervix?
17. What are the hardware diagnostic techniques in early pregnancy period?
18. What causes the onset of labor?
19. What partohrama?
20. What is the maximum allowable length standing heads in one plane had pelvic ¬ nd what it justified?
21. What mechanisms detachment of the placenta from the uterine wall?
22. What volume of physiological blood loss during delivery and methods of control?
23. What are the principles of assessment of the newborn?
24. Features involution genital character lohy.
25. Functioning of organs and systems of women in various stages of post-natal period.
26. Features of early and late postpartum period.
27. Measures to prevent complications in the postpartum period.
Materials methods of training (basic training materials control students).
Firefox.
Tests.
Number 1. In applying the pregnant woman androgens in the fetus may develop:
1. Shortening of the extremities.
2. Anomalies of the trachea, esophagus.
3. Defects of the cardiovascular system.
4. All of the above. *
Number 2. Physiological prybavlyannya body weight per week for women in the second half of pregnancy is:
1. 100 - 250g;
2. 300 - 350g;
3. 400 - 450 g;
4. 500g.
Number 3. Pregnancies found that the fetus has a longitudinal position, head pressed against the entrance to the small pelvis, back palpated on the left, facing forward. Listen heartbeat left, below the navel. • What kind of presentation, position, type of fruit?
1. The main presentation, the first position, front view. *
2. Breech, the first position, front view.
3. The main presentation, the second position, the rear view.
4. Breech, the second position, front view.
Number 4. At the stage of preimplantation development of damaging factors cause:
1. The death of the embryo or do not work. *
2. Wasting fetus.
3. Placental insufficiency.
4. Teratogenic effect.
Number 5. At the stage of implantation damaging agents cause:
1. Violation of alantoyisa.
2. Failure of implantation or death of the embryo. *
3. Do not act.
4. Congenital deformities.
Number 6. During the period of organogenesis hazards cause:
1. Placental insufficiency.
2. Wasting fetus.
3. Congenital deformities. *
4. Embryotoxic effect.
Number 7. An examination of the uterus in patients with early pregnancy period established asymmetry uterine fibroids left corner serves much more than right. What is the sign of early pregnancy determined?
1. Piskacheka *
2. Hentera
3. Horwitz-Gegara
4. Snegireva
Number 8. By the maternity room entered pershorodillya at term and complaint ¬ we are on regular contractions for 45 seconds after 3 minutes for 7 hours. According to a study of vaginal, uterine cervix is flat, thin, open uterine throat to 6 cm, fetal bladder intact. What is the diagnosis?
1. Pregnancy 40 weeks, and during labor, active phase *
2. Pregnancy 40 weeks, and during childbirth, latent phase
3. Pregnancy 40 weeks, and during childbirth, the phase retardation
4. Pregnancy 40 weeks, II stage of labor
Number 9. After 5 minutes after birth, the fetus in women in the uterus deviated to the right and bottom of the uterus is determined by 3 cm above the navel. From the observed moderate vaginal bleeding. What is the sign of placental separation occurs?
1. Schroeder *
2 Kyustnora-Chukalova
3. Alfeld
4. Dovzhenko
Number 10. When an internal obstetrical study found that the lower pole head is at interspinalnoyi line. What degree of insertion head?
1. Large segments of the entrance to a small bowl *
2. Small segment at the entrance to a small basin
3. Head in the pelvic cavity
4. Head to the exit plane of the pelvis
Situational tasks
1. In pregnant (34 years old) last menstrual period was 5 months ago. Fetal movements not feel. Abdominal perimeter 75 cm, height 14cm uterus. What complementing examination is appropriate?
What is the preliminary diagnosis? What additional tests should be done to establish the final diagnosis?
Preliminary diagnosis: Dead at 20 weeks of pregnancy. Requires review
gynecologist, the test for hCG, ultrasound
2. The patient of 22 years old complains of delayed menstruation for 3 weeks, nausea, loss of appetite, increased stress and breast.
What is the preliminary diagnosis? What additional tests should be done to establish the final diagnosis?
Preliminary diagnosis: Pregnancy 5 weeks. Requires review gynecologist, the test for hCG, ultrasound.
3. The patient 27 years old asked the doctor about prenatal delay menstruation for 3 weeks. On gynecological examination revealed loosening and cyanosis prysinku vagina, cervix, uterus enlarged to the size of 5-6 weeks of pregnancy.
Is it possible to diagnose pregnancy 5-6 weeks to consider the end? What additional tests needed to make a final diagnosis?
Diagnosis can not be the end, do the ultrasound.
4. The external pregnancies found that abdominal perimeter is 92 cm, height of uterus-30 cm.
( What is the estimated weight of the fetus?
( What is the term of pregnancy?
( As the data coincide with the standard hravidohramoyu?
Estimated fetal weight is 2700 ± 200 grams. Gestational age 32-33 weeks. These data are within the limits hravidohramy
Recommended Reading.
Summary:
1. Obstetrics, ed. V.I. Hryshchenko, Kharkov, Basis 1996.-608p.
2. Bodyagyna V.I., Gmakyn K.N., Kyryuschenkov A.P., Obstetrics. - Moscow: Medicine, 1986. - 496 p.
3. Ness V.M., Tsehelskyi M.R., N.M. Rozhkovska, Obstetrics and Gynecology. Tutorial: in 2 vols. V.1. - Odesa.Odes.derzh.med.un-t, 2005.-472s.
4. MOH of Ukraine № 503.
MORE:
1. Handbook of obstetrics and gynecology. / Ed. G.K Stepankovskoy. - K: Health, 1997.
2. Duda I.V., V.I. Duda Clinical obstetrics. - Minsk: Higher school, 1997.
3. Bodyagyna V.I. Obstetrics aid in women advice. - M., 1983.
4. Solskyy YP, Stepankovskaya GK Organization obstetric-hynekolohycheskoy assistance. - Kiev, 1980.
5. Handbook doctor, female advice, / GI Gerasimov,
6. I.V. Duda, A. Zavyrovych etc. - Minsk., 1983.
7. Organization of genetic monitoring (guidelines) / Timchenko O.I., Goyda N.G., Turos A.I., Omelchenko E.M., A.R, Hakobyan, V.A. Galagan, V.V. Elagin - Kyiv, 2001. - 35s.
Author: Goncharenko O.M., assistant
Approved at the meeting of the department "___" _________________ 20___, protocol № __________.
Reviewed by department meeting "___" _________________ 20___,
protocol № __________.
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- Вінницький національний медичний університет ім М І Пирогова
- uterine fibroids are noncancerous growths of the uterus
- МІНІСТЕРСТВО ОХОРОНИ ЗДОРОВ Я УКРАЇНИ
- red m urogyn
- pathology ihmc public cmaps 2