METHODICAL INSTRUCTIONS
MINISTRY OF PUBLIC HEALTH OF UKRAINE
National Pirogov Memorial Medical University, Vinnytsya
CHAIR OF OBSTETRICS and Gynecology №1
labor. Malpresentation, malposition, cephalopelvic disproportion and obstetric procedures. Abnormalities of the expulsive forces. Uterine dysfunction. Injuries of the fetus and newborn. Obstetrical trauma
METHODICAL INSTRUCTIONS
for practical lesson
« Abnormal »
MODULE 4: Obstetrics and gynecology
Topic 5
Aim: to learn the causes, clinic, diagnostic, treatment and preventing measures of abnormalities of uterine contractions, to learn the biomechanism of labor in breech presentation, recognise the breech presentation and be able to render the manual assistants in labor in the different types of breech presentation. To learn how to make the diagnosis of malpresentations. To show the causes which results in this. To learn the indications, conditions and the techniques for operation of obstetric versions.
Professional motivation: The breech presentations occur in about 3-4% of all labors. With breech presentation, compared to cephalic presentation both the mother and the fetus are at greater risk. The prognosis for the fetus in a breech presentation is considerably worse than when in a vertex presentation. The operative delivery rate is higher and may be; higher maternal morbidity and mortality. It is very important to know the biomechanism of labor in breech presentation and the correct management-1 of labor. Students have to be able to render the manual aid to avoid the complication coursed by pathological labor.
Malpresentations are very actual obstetrics problem because it results in increasing of maternal and fetal morbidity and mortality. It is also impossible to manage labors through maternal passages and needs using of obstetrics operation, in most cases cesarean section.
Contracted pelvis: learning the main types and peculiarities of labor in contracted pelvis gives a possibility to prevent the main obstetric complications, perinatal and maternal death.
Basic level:
You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:
1. Obstetrics terminology.
2. External and internal obstetric examination.
3. Segments of fetal head
4. Lower segment of uterine and contraction ring.
5. Signs of normal uterine contractions
6. Conduct of normal labor & delivery and their clinic.
7. Classification of uterine contractions abnormalities.
8. Factors that provide normal uterine contractions.
9. Definition of primary and secondary uterine inertia.
10. Incoordinative uterine activity,
11. Excessive uterine activity.
12. Medicines for correction of uterine contractions.
13. Methods of treatment of uterine inertia in the first and second stages of labor.
14. Prevention of uterine contractions abnormalities.
BREECH PRESENTATION
1. Anatomy of fetal head.
2. Anatomy and topography of the uterus, pelvis and pelvic floor.
3. External and internal examination of pregnant women.
4. The structure of the fetal head.
5. Diameters of the fetal body at term.
6. The stages of the labor.
MALPRESENTATIONS
1. Anatomy and topography of the uterus
2. External and internal examination of pregnant women
3. Methods of diagnostic of different fetal positions.
4. Measuring of external pelvis sizes.
5. Kinds of obstetrics operations, indications and contraindincations for cesarean section, craniotomy and embriotomy
6. The preoperative preparing of patients. The deflexed vertex presentation — diagnosis, the cardinal movements of labor, prognosis, the management of labor.
7. The brow presentation — diagnosis, the cardinal movements of labor prognosis, the management of labor.
8. The face presentation - diagnosis, the cardinal movements of labor, prognosis, the management of labor.
9. Prognosis and complications of the labor in deflexed presentation.
10. The deforms of the fetal head in deflexed presentation.
11. The methods of operative delivery in deflexed presentation.
CONTRACTED PELVIS
1. Etiology and pathogenesis of abnormal development of pelvis.
2. Sizes of normal pelvis.
3. Principles of dispensary monitoring for the pregnant women with
contracted pelvis.
4. Methods of pregnant and puerpera investigation.
5. Estimation of external and internal pelvic sizes.
6. Clinic and management of physiologic pregnancy and labor.
7. Cardinal moments of labor in flexed and deflexed vertex presentations.
STUDENTS' INDEPENDENT STUDY PROGRAM
I. Objectives for Students' Independent Studies
You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:
BREECH PRESENTATION
1. Classification of breech presentations.
2. Diagnosis of breech presentations.
3. The biomechanism of the labor in breech presentations.
4. The cardinal movements of labor in breech presentations.
5. The manual aid by Tsovyanov I on the labor in the frank bree< presentation.
6. The classic manual aid on the labor in the complete and incomplete, breech presentation.
7. The manual aid by Tsovyanov II on the labor in the footling breech presentation.
8. The operative delivery in the breech presentation.
9. The complications to the delivery in a breech presentation.
MALPRESENTATIONS
1. The determination of malpresentations.
2. Types oi malpresentations.
3. The making diagnosis of malpresentations, physical and instrumental
methods of investigations.
4. The determination of obstetrics version. Classification.
5. The indications for external obstetrics version.
6. The contraindications and conditions for the operation of extern*
obstetrics version.
7. The indications, contraindications and requirements for the poda"
internal obstetric version.
8. The technique for the operation of the external obstetrics versio
9. The technique for the operation of the internal podalic version
10. Anesthesia for the operations.
1l. The complications caused by obstetrics versions.
12. Management of postoperative period.
CONTRACTED PELVIS
1. Pelvic classification according to form of contractions.
2. Anatomically and clinically contracted pelvis.
3. Diagnosis of contracted pelvis.
4. Pelvic classification according to degree of contraction.
5. Often occurred contracted pelvis: generally contracted pelvis, sial pelvis: simple flat pelvis, flat rachitic pelvis, generally contracted flat pelvis
6. Principles of pregnancy management in contracted pelvis.
7. Principles of labor management in contracted pelvis.
8. Cardinal moments of labor in different types of contracted pelvis-
9. Vasten's and Zangemeister sign.
Key words and phrases: biomechanism, breech presentation, frank
breech presentation, complete and uncompleted breech presentation, descent, flexion, rotation, extension, the manual assistance by Tsovyanov I and by Tsovyanov II, the classic manual assistance, transverse lie, oblique lie, long axis of the fetus, unstable lie, obstetrics versions.
Summary
UTERINE BIRTH ACTIVITY ANOMALIES
Birth activity anomaly is the state when frequency, duration, rhythm and force of parodynia and labor do not provide dynamic, within the physiological parameters of time, advancement of the fetus and its expulsion without delivery biomechanism violation.
Disorders of any index of uterine activity are possible — uterine tone, rhythm, frequency and coordination of contractions, intervals between labor pains, delivery duration.
Correct diagnosis and management of abnormal labor requires evaluation of the mechanisms of labor: in classic terms, the "power," the "passanger,"an the "passage," otherwise refferred to as the uterine contractions, fetal factors (e.g., presentation, size), and the maternal pelvis, respectively: power, or strength, duration and frequency of uterine contractions, evaluated both qualitatively and quantitatively. Frequency and duration of contractions can be subjectively evaluated by manual palpation of the maternal abdomen during contraction. Strength of uterine contractions is often judged by how much the uterine wall can be "indented" by an examiner's finger during a contraction: strong contraction no indetation; moderate contraction, some indentation; mild contraction, considerable indentation. Although subjective, such determinations by experienced examiner are of value. The frequency and duration of uterine tractions may be measured more accurately by using a tocodynamometer while performing external electronic fetal monitoring.
For cervical dilatation to occur, each contraction must generate at least 25 mm Hg of pressure, with 50 to 60 mm Hg being considered the optimal intrauterine pressure. The frequency of contractions is also important in generating a normal labor pattern; a minimum of three contractions in a 10- minute widow is usually considered adequuate.
During the first stage of labor, arrest of labor should not be diagnosed until the cervix is at least 4 cm dilated ( i.e., the latent phase of labor has been completed) and a pattern of uterine contractions that is adequate both in frequency and intensity has been established.
The early part, or latent phase, of labor is involved with softening and effacement of the cervix with minimal dilatation. This is followed by a more rapid rate of cervical dilatation, known as the active phase of labor, which is further divided into acceleration and deceleration phases.
The descent of the fetal presenting part usually begins during the active phase of labor, than progresses at more rapid rate toward after the cervix is completely dilated. A useful method for assessing the progress of labor and detecting abnormalities in a timely manner is to plot the rate of cervical dilatation and descent of the fetal presenting part.
Normal cervical dilatation and descent of the fetus take place in a progressive manner and occur within a well-defined time period. Dysfunctional labor occurs when rates of dilatation and descent exceed these time limits.
The normal limits of the latent phase of labor extend up to 20 hours for nulliparous patients and up to 14 hours for multiparous patients. A latent phase that exceeds these limits is considered prolonged and may be caused by hypertonic uterine contractions, premature or excessive use of sedatives or analgesics, or hypotonic. uterine contractions.
Hypertonic contractions are ineffective, painful and are associated with increased uterine tone, whereas hypotonic contractions are usually less painful and are characterized by an easily indictable uterus during the contractions.
Hypotonic contractions occur more frequently during the active phase of labor. A long, closed, firm cervix requires more time to efface and to undergo early dilatation than does a soft, partially effaced cervix, but it is doubtful that a cervical factor alone causes a prolonged latent phase. Some patients who appear to be developing a prolonged latent phase are shown eventually to be in false labor, with no progressive dilatation of the cervix.
Palpation or recording of uterine contractions and observation of the patient over a period of time usually suggests whether uterine activity is hypotonic or hypertonic or whether the patient is in false labor.
The management of a prolonged latent phase depends on its cause. A prolonged latent phase caused by premature or excessive use of sedation or analgesia usually resolves spontaneously after the effects of the medication have disappeared. Hypertonic activity responds erratically to oxytocin but usually responds to a therapeutic rest with morphine sulfate or an equivalent drug.
Hypo contractile dysfunction usually responds well to an intravenous oxytocin infusion.
When the cervix dilates to approximately 3 to 4 cm, the rate of dilatation progresses more rapidly. Cervical dilatation of less than 1.2 cm/hour in nulliparous women constitutes a protraction disorder of the active phase of labor. During the latter part of the of the active phase, the fetal presenting part also descends more rapidly through the pelvis and continues to descend | through the second stage of labor. A rate of descent of presenting part of less than l.0 cm/hour in nulliparous women and 2.0cm/hour in multiparous women is considered to be a protraction disorder of descent.
During the second stage of labor, the "powers" include both the uterine contractile forces and voluntary maternal expulsive efforts (pushing). Maternal exhaustion, excessive anesthesia, or other conditions such as cardiac disease or neuromuscular disease may already affect these combined forces so that they are insufficient to result in vaginal delivery or cesarean section may then be required.
In the absence of cephalopelvic disproportion or fetal malposition, protraction or arrest disorders are usually caused by hypotonic uterine; contractions, conductions anesthesia, or excessive sedation.
A prolonged latent phase can be managed by either rest or augmentation of labor with intravenous oxytocin once mechanical factors have been ruled out. If the patient is allowed to rest, one of the following will occur; she will cease having contractions, in which case she is not in labor; she will go into active labor; or she will continue as before, in which case oxytocin may be administered to augment the uterine contractions. The use of arnniotomy, or artificial rupture of membranes, is also advocated [or patients with prolonged latent phase.
During the active phase of labor, mechanical factors such as fetal malposition and malpresentation as well as fetopelvic disproportion must be considered before augmentation of uterine contractions with oxytocin. In cases in which the fetus fails to descend in case of adequate contractions, disproportion is likely and cesarean section warranted. If no disproportion is present, oxytocin can be used if uterine contractions are judged to be inadequate. In cases of maternal exhaustion resulting in secondary arrest of dilatation, rest followed by augmentation with oxytocin is often effective.
BREECH PRESENTATION
There is a fundamental difference between delivery in cephalic and breech presentation. With a cephalic presentation, once the head is delivered, typically the rest of the body follows without difficulty. With a breech, however, successively larger or, in case of the head, very much less compressible parts of the fetus are born.
Spontaneous complete expulsion of the fetus that presents as a breech, as described below, is seldom successfully accomplished. As the rule, either cesarean section of vaginal delivery that requires skilled participation by the obstetrician is essential for a favorable outcome.
Etiology. Breeches are much more common at the end of the second trimester of pregnancy than at or near term. Factors other than prematurity that arrear to predispose to breech presentation include uterine relaxation association with great parity,multiple fetuses,hydramnion.hydrocephalus, anencephalus, previous breech delivery, uterine anomalies, and tumors.
Classification. The varying relations between the lower extremities and buttocks of the fetus in breech presentation form the categories of frank breech, complete breech, incomplete breech presentation, footling and kneeling presentation.
In frank breech presentation the lower extremities are flexed at the hips and extended at the knees and thus the feet lie in close proximity to the head.
In complete breech presentation the lower extremities are flexed at hips and at the knees.
In incomplete breech presentation the lower extremities are flexed at nips and at the knees and the one or both feet lie below the breech. »n footling presentation the feet lies lower than breech. 1 tie kneeling presentation is the especial form of the breech, when the fetal knees are lower than the breech.
Diagnosis. The diagnosis of the breech presentation may be making 'he help of external and internal obstetrics investigation. With the first maneuver of the external examination we identify the hard, round ballottable fetal head to occupy he fundus of the uterus. The second maneuver indicates the back to be on one side of the abdomen and the small parts in other. On the third maneuver the breech is movable above the pelvic inlet. The heart sounds of the fetus are usually heard loudest slightly above the umbilicus.
Vaginal examination. In frank breech presentation only buttocks and its characteristics components (both ischial tuberosities, the sacrum, the anus, the external genitalia) are usually palpable. In incomplete breech presentation the buttocks and the feet may be palpated. In footling the fetal feet are lower than buttocks.
Biomechanism of labor in breech presentation,
I moment - the internal breech rotation. The breech rotates and fetal intertrochanteric diameter from one of oblique size of the pelvic inlet to anteteroposterior size of the pelvic outlet.
II moment - the lateral flexion of the body. The anterior hip is stemmed against the pubic arc. By lateral flexion of the fetal body the posterior hip is forced over the anterior margin of the perineum. Then anterior hip is born.
III moment - the internal shoulders rotation. Alter the birth of the breech, there is the slight external rotation as a result of the descends and rotations of the shoulders. The shoulders rotates on the pelvic floor and. diameter biacromialis occupies anteroposterior diameter of the pelvic outlet.
IV moment - the lateral flexion the body in the thoraco-brachial part. The shoulders are born.
V moment - the internal rotation of the head. The rotation begins when the fetal head descends from the plane of greatest pelvic dimensions, to the least pelvic dimensions (midpelvis). The rotation is complete when the head reaches the pelvic floor, the sagittal suture is in the anteroposterior diameter of the pelvic outlet and the small fontanel is under the symphysis
VI moment - the flexion of the fetal head. The head fixes with its, fossa suboccipitalis to the inferior margin of symphysis pubis and flexes. The face,forehead,vertex,and occiput are born.
The manual aids in breech presentations.
The manual aid by Tsovyanov I in frank breech presentations.
The aim of the manual aid: to prepare the maternal ways to the delivery of the head and shoulders and to keep the normal attitude of the fetus.
in the frank breech presentation the fetus extremities are flexed the hips and extended at the knees and thus the feet lie in close proximity to the head. The circumference of the thorax with the crossing on it arms so their circumference is larger than circumference of the head and the after-coming; which deliveries easily.
The technique. The aid begins after the delivery of the buttocks. The physician’s hands are applied over the buttocks, the thumbs placed on fetus sacrum and other fingers on the legs. The doctor gently supports legs to avoid its flexion. If the normal attitude of the fetus is keeping head deliveries easy.
The classic manual aid on the labor in complete and incomplete breech presentation.
The aim of the classic manual aid: to help of the shoulders and the head delivery.
The classic manual aid begins when the lower angular of the anterior scapula became visible. There are 4 moments of the classic manual aid.
I moment - the delivery of the posterior arm. The posterior shoulder must be delivered first. The feet are grasped in one hand and drawn upward over the groin of the mother toward which the ventral surface of the fetus is directed; in this manner, leverage is exerted upon the posterior shoulder, which slides out over the perineal margin, usually followed by the arm and hand.
II .and III moment - the external trunk rotation and removal of the posterior arm The aim of this moment is the reverse of the anterior shoulder to the sacrum and the delivery of second arm. The obstetrician applies his hand on the lateral sides of the fetus trunk and rotates it. The direction of the movement must be in this way: the occiput must go under the symphysis pubis. When the posterior shoulder and arm appears at the vulva the doctor put two fingers into the vagina, the fingers passed along the humorous until the elbow is reached. The fingers are now used to splint the arm, which is swept downward and delivered through the vulva.
IV moment - delivery of the head. After the shoulder' are born, th head usually occupies an oblique diameter of the pelvic with the occiput directed anteriorly. The fetal head may then be extracted by the method of Mauriceau-Levret. Employing the Mauriceau-Levre maneuver to help flex head, the doctor's middle finger of one hand are applied into the fetal mouth, while the fetal body rests upon the palm of the hand and fore arm, which is straddled the fetal legs. Two fingers of the operator's other hand are then hooked over the fetal neck and grasping the shoulders, downward
traction is applied until the suboccipital region appears under the symphysis.
The body of the fetus is then elevated toward the mother abdomen, and mouth, nose, brow and the occiput emerge over the perineum. Gentle traction should be exerted by the fingers over the shoulders.
The manual aid by Tsovyanov II in footling presentation
The aim of the manual aid: To perform the footling presentation the incomplete breech and to prepare the maternal ways to the deliver the head and shoulders.
The doctor covers the area of the vulva with the sterile napkin and puts up resistance to the delivery of the feet. The feet are flexing and the footling presentation becomes incomplete breech presentation. Than the delivery manage as in incomplete breech presentation.
Favorable factors for breech delivery:
1. Gestation age of more than 36 but less than 38 weeks. If the baby small, the head will be lager than the breech and may be trapped i cervix; if too large, the difficulty is obvious.
2. Estimated fetal weight of more than 2500 but less than 3175g
3. The presenting part at or below station -1 at the onset of labor
4. The cervix soft, effaced, and dilated more than 3 cm.
5. Ample gynecoid or anthropoid pelvis (the head will enter th pelvis in the anterior position).
6. A history of a previous breech delivery of a baby weighing more than 3175g or a previous vertex delivery of baby weighing more than 3600g.
Unfavorable factors:
1. Gestation age of more than 38 weeks.
2. Estimated fetal weight of more than 3500 - 3600g.
3. The presenting part is at pelvic inlet.
4- The cervix firm, incompletely effaced, and less than 3 cm dilated
5. No history of prior vaginal delivery, or history of difficult vaginal delivery
6. Android or flat pelvis.
7. Footling or full breech presentations.
8. Extension of the fetus head is extremely unfavorable and is indication for cesarean section.
The presence of any one of the aforementioned unfavorable factors should strongly suggest the desirability of delivery by cesarean. section.
The predelivery examination: its chief purpose is to confirm the conditions for the operation.
Indications for breech extraction:
• The requirement for instant vaginal delivery;
• Cases in which one is already committed to vaginal delivery and cesarean section is not appropriate or feasible (maternal indications -preeclarnpsia, hard heart and puimonal diseases, cord prolapse; fetus indications - acute hypoxia);
• The breech extraction is committed after the operation.
The conditions for breech extraction:
• The cervix must be completely dilated and retracted high in the pelvis (although the breech - especially in footling presentation - may pass the cervix without incident, the shoulders or head will surely be trapped by incompletely dilated cervix);
• The uterus must be relaxed;
• The normal fetopelvic proportion;
• The rupture of membranes.
The techniques for breech extraction.
The techniques for the operation of extraction fetus on the two legs.
Dy\uring total breech extraction, the obstetrician's entire hand should be inserted through the vagina and both feet of the fetus grasped. The breech are held with the second finger lying between them. The feet are brought down the vagina, and gentle traction applied until they appear from the vulva. Now both feet are grasped and pulled through the vulva. As the legs commence to emerge through the vulva, they should be wrapped in sterile towel to obtain a firmer grasp, for the vernix caseosa renders them difficult to hold. Downward gentle traction is then continued.
As the legs emerge, successively higher portion are grasped, first the legs (shins) and later the thighs. When the breech appears at the vulva, gentle traction is applied until the hips are delivered. As the buttocks emerge, the hack of the infant usually rotates to the anterior. The thumbs of the operator are then placed over the sacrum and gentle downward traction is continued until the costal margins, and then, the scapulas become visible. The back of the infant tends to turn spontaneously toward the side of the mother to which it originally directed. If turning does not occur, slight rotation should he added to the traction, with the object of bringing the bisacrorrsial diameter of the fetus in the antero-posterior diameter of the pelvic outlet.
There are two methods of delivery of the shoulders: with the scapulas visible, the trunk is rotated in such a way that the anterior shoulder and the arm appear at the vulva and can easily be released and delivered first. The operator is shown rotating the trunk of the fetus counterclockwise to deliver
the right shoulder and arm. The body of the fetus is then rotated in the reverse direction to deliver the other shoulder and arm. If trunk rotation is unsuccessful, the posterior shoulder must be delivered first. The feet are grasped in one hand and drawn upward over the groin of the mother
toward which the ventral surface of the fetus is directed; in this manner, leverage is exerted upon the posterior shoulder, which slides out over the perineal margin, usually followed by the arm and hand. Then, by depressing the body of the fetus, the anterior shoulders emerges beneath the pubic arch, the arm and hand usually follow spontaneously. Thereafter, the back ends to rotate spontaneously in the direction of the mother's symphysis. If upward rotation fails to occur, it is effected by manual rotation of the body.
Delivery of the head may then be accomplished.
After the shoulders are born,the head usually occupies an oblique diameter of the pelvis with the chin directed posteriorly. The fetal head then be extracted either with forceps, which is the method preferred by many obstetricians, or by so-calted Mauriceau maneuver. Employing the Mauriceau maneuver to help flex the head, the operator'smiddle finger of the hand are applied over the maxilla, while the body rests upon the palm of the hand and forearm, which is straddled by the fetal legs. Two fingers of the operator's other hand are then hooked over the fetal neck, and grasping the shoulders, downward traction is needed until the suboccipital region appears under the symphysis. The body of the fetus is then elevated toward the mother's abdomen, and the mouth, nose brow and eventually the occiput emerge successively over the perineum Gentle traction should be exerted by the fingers over the shoulders. At the same time, suprapubic pressure, appropriately applied by an assistant.
The management of the breech delivery.
To try the minimize infant mortality and morbidity, cesarean section is now commonly used. The indications to the cesarean section:
1. Breech presentation and a large fetus (the weight of the fetus estimated 3500 g and more).
2. Breech presentation and any degree of contraction or unfavorable shape of the pelvis.
3. Breech presentation and deflexed head.
4. Breech presentation and uterine dysfunction.
5. Breech presentation and previous perinatal death of children, suffering from birth trauma.
6. Breech presentation and fetal hypoxia.
MALPRESENTATIONS
The transverse lie is the condition when the long axis of the fetus is approximately perpendicular to that of the uterus. When it forms an acute angle, an oblique lie results. An oblique lie is usually only transitory, however, for either a longitudinal or transverse lie commonly results when labor supervenes. For this reason, the oblique lie is termed unstable lie.
An unstable lie is one in which the presenting part alters from week to week. It may be either a transverse or oblique lie or possibly a breech presentation. These are relatively uncommon events but are found in association with the following conditions:
1. Grand muitipara. This is by far the commonest factor, due to the lax uterine and abdominal walls, which prevent the splinting effect found in women with lesser parity.
2. Poiyhydramnios. The volume of fluid distends the uterus and allows the fetus to swim like a goldfish in a bowi — often taking up an oblique or transverse lie.
3. Prematurity. Here there is a relative excess of fluid to the fetus. If preterm labour occurs, the fetus may be found to have a transverse lie.
4. Subseptate uterus. The septum prevents the fetus from turning in utero.
5. Pelvic tumors such as fibroids and ovarian cysts may not only prevent the lower pole from engaging, but cause it to take up a transverse lie.
6. Placenta praevia. This usually prevents engagement of the presenting part. Because of this it may present with the fetus in an oblique or transverse lie.
7. Multiple pregnancies may present with a transverse lie. If this occur, it is more common in the second twin.
Diagnosis of the transverse and oblique lies: 1- The external inspection shows than the abdomen is unusually wide from side to side, whereas the fundus of the uterus extends scarcely above the umbilicus. On palpation, with the first maneuver no fetal pole is detected. On the second maneuver, a ballottable head is found in one side and the breech in other. The third and fourth maneuvers are negative unless labor is vvoii advanced and the shoulder has become impacted in the pelvis. When the fetal head is situated in the left side of the uterus th first position of the fetus is identified. When the fetal head is situated h the right side of the uterus the second position is recognized. On vaginal examination, in the early stages of labor, the side of the thorax, if it can be reached, may be recognized above the pelvic inlet. When the dilatation is further advanced, the scapula and the clavicle are distinguished on opposite sides of the thorax. Later in the labor, the shoulder becomes tightly wedged in the pelvic canal, and a hand and arm frequently prolapse into the vagina and through the vulva.
Management of transverse and oblique lie. It is not uncommon for the fetus to have a transverse lie until about the 32nd week of pregnancy If the transverse lie persists after this time a cause should be determined. An ultrasound examination should be done to exclude placenta praevia, ovarian tumor or fibroid and if either of these conditions are present an elective cesarean section should be performed at 38-39 weeks of gestation. The ultrasound is also used for identifying twins and a subseptate uterus, whilst a vaginal examination will confirm a pelvic tumor.
The main risk of a transverse or oblique lie is in association with preterrn rupture of the membranes and cord prolapse. When diagnosed the state of the cervix should be checked. If the cervix is dilated, the patient should be admitted to hospital. If, however, the cervix is closed and the membranes are intact the patient may be reviewed on a regular basis. If no easily identifiable cause is found, attempted external cephalic version can be made after 34 weeks. In grand multipara patients,the fetus will usually turn easily but will often swing back to an abnormal lie. If the abnormal lie persists or constantly reoccurs, the woman should be admitted to hospital by the 38th week. If external version is successful at this stage and the patient's cervix is favorable then artificial rupture of the membrane can be performed with the head held over the pelvic brim and an oxytocin drip commenced to augment uterine activity. If the cephalic presentation is maintained, labor may be allowed to continue. If the transverse or oblique lie reoccurs in labor then a cesarean section must be performed. Complications of a transverse lie. If a mother goes into labor with a transverse or oblique lie,several catastrophes may occur. Because this occurs more commonly in multiparous women and their uterine activity is often much stronger, rupture of the uterus is more likely. When the membranes rupture there is a greatly increased danger of cord prolapse-
Obstetrics versions
Operations for correction of abnormal lie or presentation of fetus as obstetrics versions. There are two types of obstetrics versions: external and internal podalic version. Indications for obstetrics versions: fetal malpresentations (breech, transverse and oblique lie).
Contraindications. Complicated pregnancy, multifetal pregnancy, ngenital uterine anomalies, placenta previa, feto-pelvic disproportion.
Conditions: for the external version - 32-36 weeks, intact merribranes, normal movement of the fetus in the uterus, satisfactory fetal and mother condition; for the internal podalic version - cervix must be fully dilated, intact or just rupture membranes, normal movement of the fetus in the uterus, satisfactory mother condition, absence of fetopelvic disproportion.
The internal podalic version consists of such moments:
1. Inserting a hand into uterine cavity.
2. Finding a foot.
3. Grasping one foot.
4. Drawing foot through the cervix while exerting pressure transabdominally in the opposite direction on the upper portion of the body.
The version is finished when fossa poplitea of the grasping foot in presented in the pudendal cleft.
DEFLEXED PRESENTATIONS
There are 3 types of deflexed presentation — deflexed vertex, brow and
face presentation.
Etiology. The causes of deflexed presentation are manifold, there are the factors that Savors extension or prevents flexion the head. Extended position of the head occur more frequently when the pelvis is contracted or fetus is very large. In multiparous women the pendulous abdomen predisposes to deflexed presentation. In exceptional instances, marked tumors of the fetal neck or coils of cord about the neck may cause extension. Anencephalic fetus present by the brow or face because of faulty development of the cranium.
The deflexed vertex presentation. The deflexed vertex presentation is a I degree of head extension.
Diagnosis. The diagnosis of the deflexed vertex presentation bases on the results of the vaginal palpation: the sagittal suture, the large and the small iontanels on the same level. The fetal head presents with a ironto-occipital diameter,a leader point is the large fontanei.
The cardinal movements of labor in deflexed vertex presentation arc:
• deflexion;
• internal rotation;
• flexion;
• extension;
• internal rotation of the fetal body and external rotation of the fetal head. Deflexion. The sagittal suture is in the transverse or oblique
size of the pelvic inlet. The head fixes to the inlet and some deflexed. The large fontanel becomes the leader point.
2. Internal rotation. This movement is a manner that the occiput gradually moves from its original position posteriorly towards the sacrum os. The rotation is complete when the head reaches the pelvic floor; the sagittal suture is in the anteroposterior diameter.
3. Flexion of the head. Flexion begins when the head fixes by its root of the nose (the first fixing point) to the inferior margin of symphysis pubis. The flexion finishes when the occiput comes to the tip of sacrum and the second fixing point forms.
4. Extension of the head. After internal rotation and flexion the fetal head closely touched with the area of the occiput to the tip of the sacrum. The head extends and deliveries.
Internal rotation of the fetal trunk and external rotation of fetal head. This moment realizes as in anterior occiput presentation. The brow presentation is a II degree of extension. With the brow presentation, that portion of the fetal head between the bital ridge and the frontal suture presents at the pelvic inlet. The fetal 0 d thus occupies a position midway between full flexion (ociput) and e II extension (mentum or face). Except when the fetal head is very small the pelvis is unusually large, engagement of the fetal head and subsequent cannot take place as long as the brow presentation persists.
Diagnosis. The diagnosis of the brow presentation bases on the results of the external obstetrics examination and vaginal palpation. The brow presentation may be recognized by abdominal palpation when both the occi put and chin can be easily palpated. The reliable information can be felt by the vaginal examination: the frontal suture, the large fontanel, orbital ridges, eyes, and root of the nose. The nose and mouth can not be palpable.
The fetal head presents with a mento-occipital diameter, a leader point is the middle of the frontal suture.
The delivery at term in brow presentation is impossible. The preterm delivery, when the fetus is small is possible and the characteristically deforms of the head occurred. The caput succedaneum is over the fore head and may be so extensive that identification of the brow by palpation is impossible.
If the labor is possible the cardinal movements in brow presentation are:
1. Deflexion. The frontal suture is in the transverse size of the pelvic inlet. The head fixes to the inlet and deflexed. The middle of the irontal suture becomes the leading point.
2. Internal rotation.
3. Flexion of the head.
4. Extension of the head.
5. Internal rotation of the fetal trunk and external rotation °f the fetal head
Face presentation.
In the face presentation.the head is hyperextended so that the occiput is in contact with the fetal back and the chin (mentum) is presenting part.
Diagnosis. By abdominal palpation the occiput, the chin and the angle between the fetal back and the occiput can be easily palpated. The 'e'al heart sound are the loudest from the side of the fetal thorax. On palpation, the distinctive features of the face presentation are the nose, the malar bones, and the orbital ridges. Face presentation is rarely observed above the pelvic inlet. The brow ;.Ue y presents and is converted to a face presentation after further extension of the head during descent through the pelvis.
The cardinal movements of labor in face presentation are:
1. Deflexion. The face linea is in the transverse size of the p%\v inlet. Descent is brought about by the same factors as vertex presentation The head presented its vertical diameter. The chin is the leading point
2. Internal rotation The object of internal rotation of the face i to bring the chin under the symphysis. Only in this way the neck subtend the posterior surface of the symphysis pubis. If the chin rotates directlv posteriorly, the birth oi the head is impossible.
3. Extension of the head. After the rotation and descent, the chin and mouth appear at the vulva, the undersurface of the chin presses against the symphysis, and the head is delivered by flexion. The nose, eyes, brow and occiput then appeared in succession over the anterior margin of the perineum
4. Internal rotation of the fetal trunk and external rotation of the fetal head. The shoulders are born as in vertex presentations.
CONTRACTED PELVIS
Anatomically contracted pelvis is characterized by shortening of
one diameters of the true pelvis into 1,5 - 2 cm and more. Clinically or functional contracted pelvis is usually defined as jviS with normal dimensions, but vaginally delivery is impossible due to "fetopelvic disproportion".
The main causes of "cephalopelvic disproportion" are fetal macrosomia, postdate pregnancy, uterine inertia, fetal malpresentation, especially fetal head extension — sinciput vertex,brow,face anterior position, ninic signs of clinically contracted pelvis:
1. Head is arrested in the pelvic inlet (absence of fetal descending in complete cervical dilation and adequate uterine contractions).
2. Uterine contractions abnormality.
3. Positive Vasten' sign (if disproportion between fetal head and symphisis pubis is prominent — Vasten' sign is positive, if disproportion between fetal head and symphisis pubis is absent - Vasten' sign is negative).
4. Signs of urinary bladder compression.
5. Edema of the cervix, and vaginal walls, productions of fistulas. When the presenting part is firmly wedged into the pelvic inlet but
does not advance for a considerable time, portions of the birth canal lying between it and the pelvic wall may be subjected to excessive pressure. As a circulation is impaired, the resulting necrosis may become manifest several days after delivery by the appearance of vesicovaginal, vesicocervical, or rectovaginal fistulas.
6. Danger of uterine rupture.
When the disproportion between the head and the pelvis is so pronounced that engagement and descent do not occur, the lower uterine segment becomes increasingly stretched, and the danger of its rupture ecornes imminent. In such cases, a pathologic contractile ring may form and can be felt as a transverse or oblique ridge extending across
e uterus somewhere between the symphysis and the umbilicus. Whenever condition is noted, prompt cesarean delivery must be employed to prevent rupture of the uterus.
'- Pushing occurs if fetal head is situated in the plane of inlet. In the case of clinically contracted pelvis - only cesarean section.
Pelvic classification according to form of contractions:
1. Often occurred
• generally contracted pelvis;
• flat pelvis: simple flat pelvis, flat rachitic pelvis, generally contracted.
Generally contracted pelvis is characterized by diminution of true pelvic diameters (anteroposterior, transverse, and oblique) into 2 cm. Subpubic arch is narrow. Average sizes of the pelvis are: D. spinarum - 23cm, D. cristarum - 26 cm. D. trochanterica - 29 cm, C. externa - ig cm, C. diagonalis — 11 cm, C. vera — 9 cm. Course of labor:
• prolongation of labor;
• considerable fetal head flexion thanks to which it is elongated in the ocipitofrontal diameter (dolichocepaly);
• posterior fontanel is situated into the axis of pelvis;
• considerable molding of the fetal head. Caput succedaneum is formed in the area of posterior fontanel;
• with increasing narrowing of the pubic arch, the occiput cannot emerge directly beneath the symphysis pubis but is forced increasingly farther down upon the ishiopubic rarni. It may play an important part in the production of perineal tears.
Management of labor. Vaginaliy delivery is possible.
Flat pelvis - is usually defined as diminution of anteroposterior diameters of true pelvis,transverse and oblique diameters are normal.
Simple flat pelvis is defined as shortening of anteroposterior diameters at all levels of true pelvis, as a result of this sacrum is inclined anteriorly to pubis.
Average sizes of the pelvis are: D. spinarum - 26cm, D. cristarum ~ 29 cm. D. trochanterica - 31 cm, C. externa - 18 cm, C. diagonalis - H cm, C. vera - 9 cm.
Course of labor:
• prolongation of labor;
• sagittal suture of the fetal head arresting in the transverse diarnetei
of the plane of inlet;
• fetal head extension until bitemporal fetal head diameter would W situated in the anteroposterior diameter of the plane of inlet;
• anterior fontanel is the leading point of the fetal head (lowermost situate"'1
• asynclitism should be presented (anterior or posterior);
• considerable molding of the fetal head. Caput succedaneum is iorme in the area of anterior fontanel.
Flat rachitic pelvis — is characterized by some peculiarities:
1. True conjugate is shortened.
2. Sidewalls tend to converge, as result of this D. spinarum and D. cristarum are equal.
3. Additional promontoriurn may be presented between 1 and 2 vertebrae of sacrum
4. Subpubic arch is shallow and wide.
5. Top of the sacrum is situated posteriorly that's why dimensions of the pelvic outlet are normal or even increased.
Average sizes of the pelvis are: D. spinarum - 26cm, D. cristarum -26 cm.- D. trochanterica — 31 cm, C. externa — 17 cm, C. diagonalis — 10 cm, C. vera - 8 cm.
Course of labor is the same as in the simple flat pelvis. But thanks to normal or even increased anteroposterior size of pelvic outlet perineal tears as result of quick second stage labor may be presented.
Management of labor. Vaginal delivery is possible.
Generally contracted flat pelvis is characterized by combination of the signs of generally contracted and flat pelvis.
Average sizes of the pelvis are: D. spinarum — 24cm, D. cristarum — 25 cm., D. trochanterica - 28 cm, C. externa - 16 cm, C. diagonalis - 9 cm, C. vera — 7 cm.
Course of labor depends from predominance of kind of pelvis contraction.
Management of labor. Cesarean section is the method of choice.
Rare occurred contracted pelvis: obliquely contracted pelvis, obliquely dislocated pelvis,.transverse contracted pelvis.osteomalacic pelvis, lunnel-shaped pelvis, spondylolisthetic pelvis, contracted pelvis as a result °' exostosis and bone tumors. Management of labor. Cesarean section should be performed in all of these types of pelvis.
Pelvic classification according to degree of contraction: Four degrees of pelvic contractions should be distinguished: I degree - True conjugate is 11-9 cm. Vaginal delivery is possible. II degree - True conjugate is 9-7,5 cm. Vaginal delivery is possible. III degree - True conjugate is 7,5 - 5.5 cm Cesarean section is Performed. IV - degree — True conjugate is 5.5 cm. Cesarean section is performed.
POSTNATAL INFECTIOUS COMPLICATIONS
In the International Classification of Diseases of the 10th review (ICD-10,1995) the following postnatal diseases are singled out;
085 Postnatal sepsis.
Postnatal:
— endometritis;
— fever;
— peritonitis;
— septicemia.
086.0 Surgical obstetric wound infection. Infected (after delivery):
— wound of cesarean section;
— perineal suture.
086.1 Other infections of the maternal passages after delivery:
— cervicitis;
— vaginitis.
087.0 Superficial thrombophlebitis in the puerperal period.
087.1 Deep phlebothrombosis in the puerperal period.
Deep vein thrombosis in the puerperal period. Pelvithrombophlebitis in the puerperal period.
Etiopathogenetic factors of infection development:
1. Presence of an infectious agent and its characteristics (the type of the microorganism, its virulence, toxigenicity, invasiveness, and close).
2. The state of the portal of infection entry (localization, the degree of tissues damage).
3. The state of nonspecific protection factors (organism resistance) and specific mechanisms (immunity).
4. Physiological resistance of the microorganism:
- biological barriers (the skin, mucous tunics);
- reticuloendothelial system organs (the liver, spleen, lymph nudes);
- bactericidal component of biological fluids (lysozyme, complement, properdin);
- inflammation reaction and phagocytosis mechanism. Despite the great variety of agents in the majority of cases at postnatal infection the following are singled out:
— gram-positive microorganisms (25%): Staphylococcus aureus — 35 %, Enterococcus spp. — 20 %, Coagulase-negative staphylococ-cus — 15 %, Streptococcuspneumoniae -- 10 %, other — 20 % ;
— gram-negative microorganisms (25 %): Escherichia coli — 25 %., Klebsiella/Citrobacter — 20 %, Pseudomonas aeruginosa — 15 %, En-lerobacterspp. — 10 %, Proteus spp. — 5 %, other — 25 %;
— mixed infection of gram-positive and gram-negative microorganisms — 20 %;
— fungi of the Candida genus — 3'%;
— anaerobic flora — 2 %;
— unestablished flora — 25 % cases.
Microorganism virulence is, in laboratory environment, a minimal dose of microbal bodies capable of causing an infectious process or lethal outcome in experimental animals; in clinical conditions it is detected by the degree of severity and consequences of the pathological process.
Microorganism toxigenicity is the ability to produce toxic1 substances in the form of ferments and toxins, which influence the metabolic processes of the organism.
Ferments produced by pathogenic microorganisms are divided into two groups by the character of influence on the microorganism:
1. Ferments splitting high-molecular compounds of the microorganism and promoting the appearance of aggressive qualities of the agent (hyaluronidase, deoxyribonuclease, fibrinolysin, collagenase, proteinase).
2. Ferments indirectly promoting the pathogenetic action of bacteria (urease, decarboxylase, lipolytic and acid-restorative).
Toxins are divided into two groups:
— exotoxins — high-toxic, have pronounced antigenic and aller-genie properties. Outside a cell exotoxin is thermolabile and high-sensitive to acids and disinfectants. The place of their action is the vessel endothelium, leucocytes, lymphoid tissue, and vegetative nervous system;
— endotoxins are released when a bacterial cell dies; they are less toxic and more thermoresistant.
Invasiveness is the ability of bacteria to overcome protective barriers of the microorganism and spread in tissues by forming ferments (hyaluronidase, phospholipase, elastase, collagenase).
The portal of infection entry is the area of tissue or organ through which pathogenic microflora gets into the patient's organism. There may be a couple of ways of getting into the organism:
— endogenous way (autoinfection) due to microflora in the patient's organism, in case of reduction of the natural organism resistance. It may be: a) opportunistic flora, which vegetates on the skin and mucous tunic of the organism; b) "dormant" infection, which is in chronic infection foci — tonsillitis, caries, osteomyelitis. The patient's organism becomes tolerant to its own microflora — this is a characteristic feature of autoinfection;
— exogenous — infection gets into the patient's organism from the environment through the damaged skin, mucous tunics, wounds;
— iatrogenic is a purulo-infectious process conditioned by the actions of medical workers.
Infection spread in the organism may be: blood, lymphatic, intercellular, intracanalicular (through the vagina, neck, uterine cavity, and uterine fallopian tubes), by combined ways.
The mechanism of wound infection development:
1. Penetration of the agent into tissues or organs.
2. Microorganisms reproduction, toxins and ferments release.
3. Development of the local and general reaction of microorganism response.
Postnatal infection may be caused by:
1) wound infection: infected episiotomy, laparotomy wound, wound of the perineum, vagina, uterine neck;
2) endometritis, parametritis;
3) mastitis;
4) infection of the upper respiratory tract, especially at general anesthesia application;.
5) epidural tunics infection;
6) thrombophlebitis: the lower extremities, pelvis, vein catheterization sites;
7) urinary infection (asymptomatic bacteriuria, cystitis, pyelonephritis);
8) septic endocarditis;
9 appendicitis.
Predisposing factors of postnatal complications development include:
1. Ccsarean section. The presence of suture material and ischemic necrosis of infected tissues alongside with an incision on the uterus create ideal conditions for septic complications.
2. Protracted labor and preterm rupture of membranes leading to chorionamnionitis.
3. Tissue trauma at vaginal delivery: forceps application;
— episiotomy;
— manual placenta removal;
— repeated vaginal examinations during delivery;
— intrauterine manipulations (internal version);
— internal monitoring of the fetal condition and uterine contractions;
— reproductive tract infections.
4. Low social level combined with bad nutrition and unsatisfactory hygiene.
WOUND INFECTION
Wound infection appears as a result of the infection of scratches, fissures, ruptures of the neck, mucous tunic of the vagina and vulva, wounds after excision of the perineum, anterior abdominal wall after cesarean section.
Inflammatory reaction is characterized by such general clinical manifestations:
— local inflammatory reaction: pain, hyperemia, edema, local temperature rise, malfunction of the injured wound;
— generalized reaction of the organism: hyperthermia, intoxication signs (general weakness, tachycardia, ABP decrease, tachypnoe).
Diagnostics takes into account the following data:
— clinical: examination of the injured surface, assessment of the clinical presentation, complaints, anamnesis;
— laboratory: common blood analysis (leucogram), common urine analysis, bacteriological investigation of the exudate, immuno-grara;
— instrumental: US.
Clinical signs of wound infection development in the wounds healing by primary intention:
a) complaints:
— of intensive, often throbbing pain in the region of the wound;
— of body temperature rise — subfebrile or to 38—39 °C;
b) local changes:
— hyperemia around the wound without positive dynamics;
— appearance of tissue edema, which gradually increases;
— palpation detects tissue infiltration, which often increases; appearance of deep infiltrates is possible (necrotizing fasciitis, which may spread to the buttocks, anterior abdominal wall — often a fatal complication);
— serous exudate often changes to pus.
Clinical signs of wound infection development in the wounds healing by secondary intention:
— progressing edema and infiltration of the tissue around the wound;
— appearance of dense painful infiltrates without clear contours;
— signs of lymphangitis and lymphadenitis;
— wound surface is covered with continuous fibrinopurulent incrustation;
— deceleration or cessation of epithelization;
— granulations become pail or cyanotic, their hemorrhagic diathesis sharply decreases;
— exudate quantity increases, its character depends on the agent:
• staphylococcus conditions the appearance of thick yellowish pus, and some strains cause the development of local putrid infection with the formation of the foci of tissue necrosis and grayish pus with sharp smell;
• streptococcus is characterized by the appearance of liquid pus of yellow-green color, ichor;
• colibacillary and enterococcal infections condition the appearance of brown pus with characteristic smell;
• blue pus bacillus, Pseudomonas aeruginosa, leads to the appearance of green pus with specific smell.
The type of the agent also defines the clinical course of wound infection:
• staphylococcosis is characterized by the fulminant development of the local process with evident manifestations of purulo-resorptive fever;
• streptoroccosis has a tendency to diffuse spread in the form of phlegmon, with low-grade local symptoms;
• blue pus bacillus is characterized by the flaccid, protracted course of the local process after acute onset with evident manifestations of general intoxication.
Bacteriological investigation of exudate is conducted with the purpose of detecting the agent and its sensitivity to antibiotics. Material sampling is to be performed before the beginning of antibiotic therapy. Material for the investigation may be the exudate, pieces of tissue, lavage from the wound. Material is taken with sterile instruments and placed in sterile tubes or vials with standard medium. Material is to be inoculated in the course of 2 h after sampling. Simultaneously with material sampling for bacteriological investigation one should perform not less than two Gram-stained smears for express-diagnostics.
There may be used accelerated methods of identifying the wound infection agent with the help of multimicrotest systems, lasting 4— 6h.
In the absence of microbal growth in the clinical material one should exclude such reasons:
— presence of high concentrations of local or systemic antibacterial preparations in the material;
— violation of the regimen of specimen storage and transportation;
— procedural mistakes in the bacteriological laboratory; effective control over the infectious wound process with antibacterial preparations.
You will find the US technique in the chapter Fetal Condition Imaging and Assessment except for fact that the sensor is placed on the lesion area in order to image the infiltration process.
Treatment: in most cases local treatment is sufficient. The treatment includes surgical, pharmacological, and physiotherapeutic methods.
Surgical wound treatment The initial handling of the wound is performed by primary indications. Repeated initial handling is performed if the first surgical intervention was not radical for some reason and repeated intervention was necessary before the development of i nfectious complications in the wound.
Surgical treatment of wound consists in:
— removal of dead tissue -- primary necrosis substrate — from the wound;
— removal of hematomas (especially deep ones), foreign bodies;
— final arrest of bleeding;
— restoration of damaged tissues.
Secondary treatment of the wound is carried out by secondary indications, as a rule, in connection with pyoinflammatory complications of the wound. Repeated secondary treatment of the wound at severe forms of wound infection may be conducted iteratively. In most cases secondary surgical treatment of wound includes:
— removal of the focus of infectious-inflammatory alteration; wide opening of recesses, leakages;
— full-blown drainage providing exudate outflow.
The pharmacological method is antibiotic prophylaxis and antibiotic therapy.
Antibiotic prophylaxis is systemic administration of an antimicrobial preparation till the moment of microbial contamination of the wound or development of postoperative wound infection, and also if there are signs of contamination, on the condition that primary treatment is surgical
Antibacterial prophylaxis principles:
— predominately a single dose of an antimicrobial preparation, in case of long-term anhydrous period and other risk factors of infectious complications development one should resort to full-blown prophylactic doses;
— at noncomplicated cesarean section the first dose of antibiotic is introduced after clipping the umbilical cord and then twice more with an interval of 6 h;
— the same preparation may be used for antibiotic therapy in case of complications arising during surgery or infectious process signs detected;
— prolongation of antibiotic introduction after 24 h from the moment of surgery termination does not lead to any increase of the efficiency of wound infection prophylaxis;
— preterm prophylactic administration of antibiotics before surgical intervention is not expedient.
Antibiotic therapy is the usage of antibiotics for long-term treatment in case of infectious process onset. Antibiotic therapy may be:
— empirical — based on the usage of broad spectrum preparations, active relative to potential agents;
— object-orientated — preparations are used according to the results of microbiological diagnostics.
Local application of antiseptics is very important. For wound cleansing one can use 10 % solution of sodium chloride, 3 % hydrogen peroxide, 1:5,000 furacilinum solution, 0.02 % chlorhexidme solution, etc. For quicker healing one may use liners with levomecol, levosin, synthomycin or solcoseryl ointment, etc.
Physiotherapeutic procedures in the period of reconvalescence include UHF-inductotherapy, ultraviolet irradiation, electrophoresis with medicamental preparations.
Prophylaxis of wound infection consists in rational management of labor and puerperal period, observance of aseptics and antiseptics.
POSTNATAL ENDOMETRITIS
Postnatal endometritis is inflammation of the superficial layer of endometrium. Endomyoinetritis (metroendometritis) is the spread of inflammation from the basal layer of endometrium to mvometrium. Perimetritis is the spread of inflammation from the endometrium and myometrium to the serous uterine layer.
The initial stage of postnatal infectious process may have different intensity
and polymorphous presentation. One should differentiate classical, obliterated and abortive forms of endomyometritis, endornyometritis after cesarean section. The classical form usually develops on the 3rd ~5th day after delivery. This form is characterized .by fever, intoxication, psyche alteration, evident leucocytosis with leucogram shift to the left, pathological discharge from the uterus. At. the obliterated form of endomyometritis disease usually develops on the 8th-9th day after delivery, temperature is subfebrile, local rnanifestations are low-grade. The abortive form has a course similar to the classical form, but is quickly arrested at a high level of immunologic;il protection. Endomyometritis after cesarean section is often complicated with pelviperitonitis, peritonitis, which may develop during the : 1st—2nd day after the surgery.
Diagnostics is based on:
— clinical data: complaints, anamnesis, clinical examination. Vaginal examination shows the moderately sensitive uterus, subinvolution of the uterus, purulent discharge;
— laboratory data: common blood count (leucogram), common urine analysis, bacteriological and bacterioscopic investigation of the cervical and uterine discharge (urine and blood if it is necessary), immunogram, blood biochemistry;
— instrument data: US.
Treatment: in most cases the treatment is pharmacological, but surgical is also possible.
Complex treatment of postnatal endomyometritis includes not only systemic antibacterial, infusion, detosication therapy, but also local treatment. Antibiotic therapy may be empirical and object-orientated (see above). Preference is given to object-orientated antibiotic therapy, which is possible by using accelerated methods of agent identification (using multimicrotest system). If fever lasts during 48—72 h after treatment beginning, one should suspect resistance of the agent to the applied antibiotics. Treatment with intravenous antibiotics is to last for 48 h after disappearance of hyperthennia and other symptoms. Tableted antibiotics are to be administered for 5 more days. Antibiotics get into the maternal milk in small doses. In most cases it does not lead to clinically significant consequences. Nevertheless, the immature ferment system of the newborn may not manage the complete excretion of antibiotics, which may cause a cumulative effect.
Local endomyometntis therapy consists in aspiration-washing drainage of the uterine cavity with the application of a dual-lumen catheter, through which the uterine walls are irrigated with solutions of antiseptics, antibiotics. There are used cooled to +4° C solutions of 0.02 % furacilinum, 0.02 % chlorhexine, 0.9 % isotonic solution with the speed of 10 ml/min. Contraindications to aspiration-washing drainage of the uterine cavity are: inconsistency of sutures on the uterus after cesarean section, infection spread beyond the uterus, up to 3—4 days of puerperal period. If it is not possible to wash the pathological inclusions in the uterine cavity by means of drainage, they are to be removed by vacuum aspiration or careful curettage against the background of the conducted antibacterial therapy and normal temperature if it is possible. Correct treatment of postnatal endomyo-metritis makes the basis of the prevention of widespread forms of infectious diseases in parturient women and their localization at the first stage.
Surgical treatment consists in laparotomy and extirpation of the uterus without the appendages or extirpation of the uterus with, the uterine tubes, or with the appendages, depending on the spread of the inflammatory process. Surgical treatment is resorted to in case of conservative treatment inefficiency and presence of negative dynamics during the first 24—48 h of treatment, development of systemic inflammatory response symptom (SIRS).
THROMBOTIC COMPLICATIONS IN THE PUERPERAL PERIOD
Superficial thrombophlebitis. Acute thrombophlebitis declares itself with pain along the damaged vein. Complaints of the local sensation of fever, reddening and painfulness along the saphenous vein. The vein is palpated as a dense painful cord, hyperemia may spread beyond the borders of vein induration, adjacent tissues infiltration and lymphadenitis may arise. General condition of the parturient woman is slightly affected with subfebrile temperature, rapid pulse.
Thrombophlebitis of deep veins. Complaints of pain in the muscles, more frequently gastrocnemius, which increases at palpation and movement, sensation of spreading, extremity edema, sometimes cyanosis, fever. The evidence of manifestations depends on the site of thrombosis of deep veins. Thrombus localization is detected with the help of Doppler ultrasonic investigation. At iliac-femoral thrombosis clinical presentation declares itself during a couple of hours, impetuously and brightly. There arises sharp pain in the leg, fever, edema of the extremity and external genitals, cyanosis or paleness of cutaneous coverings.
Septic thrombophlebitis of pelvic veins. At endometritis, myometritis the infectious agent gets into the venous blood flow, damages the vessel endothelium and promotes thrombus formation, anaerobic infection prevails. The veins of the ovary are involved in the process, and thrombi may get into the inferior vena cava, renal vein. Complaints of pains in the underbelly with irradiation into the back, groin, abdominal distension, fever. During vaginal examination there is palpated a thickening in the form of a cord in the region of uterine angles. At septic thrombophlebitis migration of small thrombi into the pulmonary circulation may take place.
Diagnostics is based on:
— clinical findings: complaints, anamnesis, clinical examination (see in the text);
— laboratory data: coagulogram, common blood analysis (leucogram), common urine analysis, bacteriological and bacterioscopic investigation of the cervical and uterine discharge (urine and blood if it is necessary), immunogram, blood biochemistry;
— instrument data: US.
The treatment of thrombotic complications in the puerperal period along with antibiotics and disintoxication should include low-molecular anticoagulants, preparations improving the rheological properties of blood (acetylsallcylic acid, pentoxyphillin), elastic compression. In acute period bed rest is obligatory as well as elevated position of the affected limb, anesthesia. Prophylactic measures of thromboembolisms are actions directed at the limitation of stasis in the saphenous veins; active behaviour of the parturient woman after delivery and usage of elastic compression stockings are important.
LACTATIONAL MASTITIS
Lactational mastitis is inflammation of the mammary gland (mostly unilateral) during lactation in the puerperal period. It develops more frequently in 2—3 weeks after delivery.
Most frequently the portal entry of infection is nipple cracks, in-tracanalicular penetration of the infectious agent through the mammary ducts at breast feeding or expression of breast milk; the spread of the agent from endogenous foci is very rare.
Risk factors:
— nipple cracks;
— lactostasis.
Nipple cracks may take place at nipple malformations, late beginning of breast feeding, irregular feeding technique, feeding lasting longer than 20 min, rough expression of milk, individual lability of the epithelial nipple cover, violation of the sanitary-hygienic standards of the puerperal period.
At lactostasis body temperature rise may last up to 24 h, if longer than 24 h — this condition is to be considered mastitis.
By the character of the inflammatory process course mastitis can be: serous; infiltrative; suppurative; infiltrative-suppurative, diffuse, nodular; suppurative (intramammary): areola furunculosis, areola abscess, abscess in the gland thickness, abscess behind the gland;
— phlegmonous, purulo-necrotic; gangrenous.
By focus localization mastitis can be: subcutaneous, subareolar, intramammary, retromammary and total.
The clinical presentation of mastitis is characterized by acute onset, evident intoxication (general weakness, headache), body temperature rise to 38—39° C, chill, pain in the region of the mammary gland increasing at feeding or expression. The mammary gland expands, hyperemia and tissue infiltration without clear margins are marked. This picture is characteristic of serous mastitis. If treatment is ineffective, serous mastitis develops into infiltrative during 1—3 days. Palpation detects dense, sharply painful infiltrate, lymphadenitis. This stage lasts 5—8 days. If the infiltrate does not resolve against the background of the treatment being conducted, its suppuration takes place — suppurative mastitis (intramammary). Intensification of local inflammation symptoms is observed, considerable increase and deformation of the mammary gland; if the infiltrate is located not at a great depth, suppuration is accompanied by fluctuation. Infiltrate suppuration takes place during 48—72 h. If a couple of infiltrates have suppurated in the mammary gland, mastitis is called phlegmonous. Body temperature is 39-40 °C, chills, evident weakness, intoxication. The mammary gland is sharply enlarged, painful, pastose, well-marked surface venous network, the infiltrate occupies almost the whole gland, the skin above the damaged area is edematous, lustrous, red with a bluish tint, often with lymphangitis. At phlegmonous mastitis infection generalization with transition into sepsis is possible. Diagnostics is based on:
— clinical data: examination of the mammary gland (see in the text), assessment of clinical presentation, complaints and anamnesis;
— laboratory: common blood analysis (leucogram), com in on urine analysis, bacteriological and bacterioscopic investigation of the exudate, immunogram, coagulogram and blood biochemistry;
— instrument findings: US is the main method of mastitis diagnostics.
Treatment may be conservative and surgical.
Antibiotic therapy should be started from the first signs of the disease, which promotes the prevention of suppurative inflammation development. At serous mastitis the question of breast feeding is decided individually. One should take into account: opinion of the parturient woman, anamnesis (for instance, suppurative mastitis in the anamnesis, multiple scars on the mammary gland, mammary gland prosthetics), antibiotic therapy, which is being conducted, the data of bacteriological and bacterioscopic investigations, nipple crack presence and evidence. Beginning from infiltrative mastitis breast feeding is contraindicated because of a real threat of child's infection and cumulative accumulation of antibiotics in the child's organism, but lactation may be preserved by means of breast milk expression. If conservative mastitis therapy is ineffective, surgical treatment is administered during 2—3 days. Surgical treatment consists in radical section, removal of the necrotized tissues and adequate drainage. At the same time antibiotic, disintoxication, and desensitizing therapy is being conducted. Timely surgical treatment allows preventing the development of the process and SIRS.
Postnatal mastitis prophylaxis consists in teaching women the rules of breast feeding and personal hygiene. Nipple crack and lactostasis are to be timely detected and treated.
SYSTEMIC INFLAMMATORY RESPONSE SYNDROME
Inflammation is a normal response of the organism to infection and may be defined as local protective response to tissue damage, the main. task of which is to destroy the microbe-agent and damaged tissues. Still, in some cases the organism responses to infection with an excessively massive inflammatory reaction.
Systemic inflammatory reaction is a systemic activation of inflammatory response, secondary relative to functional inconsistency of mechanisms of restriction of microorganisms spread, their waste products from the local lesion zone.
Infection generalization may be caused by:
— irregular surgical approach and inadequate volume of surgical intervention;
— irregular choice of the volume and components of antibacterial, disintoxication, and symptomatic therapy;
— reduced or changed immunoreactivity of the microorganism; a severe concomitant pathology; a wide spread of antibiotic-resistant microorganism strains;
— a change of the etiological structure of the agent of suppurative infection;
— no treatment conducted.
The mechanism of sepsis development consists in homeostasis violation, as an uncontrollable cascade of changes in the system of inflammation, coagulation and fibrinolysis, which take place simultaneously with consequent lesion of vascular endothelium, microvascular dysfunction, ischemia and development of multiple organ failure with possible lethal outcome.
Coagulation is a process associated with inflammation; multiple antiinflammatory cytokines induce production of tissue factor from the endothelial cells and monocytes initiating coagulation;
— normally procoagulation cascade is always balanced with the mechanism of anticoagulation;
— at sepsis anticoagulation systems quickly peter, their activity reduces as sepsis progresses;
— most natural anticoagulation mechanisms and systems are depressed or damaged. Fibrinolysis:
— fibrinolysis is a normal response of the organism to the elimination of excessive thrombus formation while coagulation is being activated;
— fibrinolysis suppression in combination with coagulation activation is dynamic basis of sepsis coagulopathy.
Coagulopathy — in most sepsis cases disbalance between the processes of inflammation, coagulation, and fibrinolysis is reflected in the spread of coagulation and microvascular thrombosis, which is called the syndrome of disseminated intravascular clotting (DIC syndrome). Sepsis patients may have two types of the syndrome;
— diffuse bleeding — fibrinolysis-dominant DIC syndrome;
— diffuse hypercoagulopathy — coagulation-dominant DIC syndrome.
Coagulopathy at sepsis leads to the development of multiple organ failure.
In 1992 the American Society of Anesthesiologists offered the following classification of septic conditions.
Systemic inflammatory response syndrome (SIRS), is manitested with two or more signs; 1
1) body temperature higher than 38 °C or lower than 36 °C;
2) HR more than 90 bpm;
3) respiratory rate more than 20 per minute or PaCO2 lower than 32 mm Hg;
4) leucocyte number more than 12*109/L or less than 4*109)/L, more than 10 % of immature forms.
Sepsis is a systemic response to reliably detected infection in the absence of other possible reasons for the changes characteristic of SIRS. Sepsis is manifested with the same signs as SIRS.
Sepsis can not be considered a result of the direct influence of a microorganism on a macroorganism, it should be considered a consequence of significant violations in the immune system, which develop from the condition of excessive activation, "hypermfl animation phase", to the condition of immunodeficiency, "immune paralysis phase". The immune system of the organism is an active participant of self-destructive process.
Severe sepsis is characterized by the violation of organs funktioning, tissue hyperfusion, and arterial hypotension. Acidosis, oliguria, impairment of consciousness are possible. When severe sepsis develops, the following signs join:
— thrombocytopenia less than 100,000/L, which can not be explained by other reasons;
— C-reactive protein level increase;
— positive blood inoculation for the detection of circulating microorganisms;
— positive endotoxin test (LPS test).
Septic shock (SIRS shock) is defined as severe sepsis with arterial hypotension, which develops irrespective of adequate infusion therapy. The disease is diagnosed if the listed above dinicolaboratory signs are accompanied by:
— arterial hypotension (systolic pressure less than 90 mm Hg or reduction by more than 40 mm Hg from the baseline);
— impairment of consciousness (less than 13 points by the Glasgow scale);
— oliguria (diuresis less than 30 ml/h);
— hypoxemia (PaO2 less than 75 mm Hg at breathing the atmospheric air);
— SpO2 less than 90 %;
— lactate level increase — more than 1.6 mmole/L;
— petechial skin rash, necrosis of a part of skin;
Multiple organ failure syndrome is acute violation of the organs and systems.
Predisposing factors of sepsis development include:
— presence of an infection focus;
— reduction of general organism resistance;
— possible penetration of the agent or its toxins into the bloodstream.
To diagnose sepsis and its consequences one should conduct such measures:
1.) monitoring of arterial pressure, HR, central venous pressure (CVP);
2) calculation of respiratory rate, blood gases, SpO2;
3) hourly diuresis control;
4) taking the rectal body temperature at. least 4 times a day to compare with the body temperature in the axillary parts;
5) inoculation of the urine, blood, obtained from the cervical canal and lesion focus, if possible;
6) detection of the acid-base balance of blood and oxygen saturation of tissues;
7) calculation of thrombocyte number and detection of the content of fibrinogen and fibrin monomers;
8) EGG, US of the abdominal viscera and X-ray thoracic examination.
This will enable to detect the possible source of infection in the puerperal period.
The underlying principles of remedial measures:
1. Hospitalization into the intensive care department;
2. Correction of hemodynamic violations by means of conducting inotropic therapy and adequate infusion therapy.
The volume of infusion therapy is detected during the assessment of arterial pressure, pulse arterial pressure, CVP, HR, diuresis. CVP enables controlled infusion of blood preparations, colloid and crystalloid solutions (a test with volume loads).
To conduct infusion one uses derivatives of hydroxyethylstarch (refortan, venofundin) and crystalloids (0.9 % solution of sodium chloride, Ringer's solution) in the 1:2 ratio. 20—25 % albumin solution is administered for hypoproteinemia correction. The usage of 5 % albumin at critical states promotes the increase of patients lethality.
Infusion should include 600-4000 ml of fresh frozen plasma since it contains antithrombin.
Using glucose is not expedient because its administration to patients in critical states increases lactate and CO,, production, ischemic lesion of the brain and other tissues. Glucose infusion is used only in cases of hypoglycemia and hypernatremia.
Inotropic support is used if CVP remains low. Dopamine is introduced in the dose of 5 —10 mcg/kg/min (maximum to 20 mcg/kg/min) or dobutamine — 5—20 mcg/kg/min. If there is no stable ABP increase, 0.1-0.5 mg/kg/min noradrenalini hydrotartras is introduced, dopamine dose is reduced to 2—4 mcg/kg/min at the same time. Simultaneous administration of naloxone up to 2.0 mg is justified - it promotes ABP increase.
If complex hemodynamic therapy is ineffective, it is possible to use glucocorticoids, hydrocortisone — 2,000 mg/day together with H2-blockers (ranitidine, famotidine).
3. Support of adequate ventilation and gas exchange. Indications to ALV are: PaO2 less than 60 mm Hg, PaCO2 more than 50 mm Hg or less than 25 mm Hg, SpO2 less than 85 %, respiratory rate more than 40 per min.
4. Surgical treatment (see above).
Indications to laparotomy and extirpation of the uterus and uterine tubes are:
— no effect from the conducted intensive therapy (24 h);
— endomyometritis, which can not be treated conservatively (24-48 h);
— uterine hemorrhage;
— suppurative formations in the region of the uterine appendages. Indications to surgical sanation of the focus are:
— presence of nondrainable suppurative cavities at wound infection;
— presence of necrotizing tissue at wound infection.
5. Normalization of the intestine function and early enteral digestion.
6. Timely correction of metabolism under constant laboratory control.
7. Antibacterial therapy. Taking into account that microbiological express-diagnostics is impossible at this stage, one should use broad spectrum antibiotics with low bactericidal effect for antibacterial therapy. Endotoxin formation, induced by antibiotics, increases in the following order: carbapenems (tienam)- to the least extent; aminoglycosides, fluoroquinolones, cephalosporins — to the biggest extent. Monoantibiotic therapy is more expedient for successful treatment of severe forms of puruloseptic diseases. This method is to be preferred to the usage of antibiotic combinations as it is less toxic. In monotherapy carbapenems and cephalosporins of the 3rd generation are used. One should remember that carbapenems do not induce endotoxin shock as opposed to cephalosporins.
Alter microorganism identification and detection of its sensitivity to antibiotics one proceeds to antibiotic therapy by the data of antibioticogram.
If during 48—72 h after treatment beginning there is no positive dynamics, one should suspect agent resistance against the used antibiotic, it should be changed according to the results of bacteriological investigation.
8. Anilmediator therapy is based on the usage of multiclonal im-munoglobulins in combination with pentoxyphillin. Since in Ukraine there arc no multiclonal immunoglobulins, one should use pentoxyphillin and dipiridamol in the complex sepsis therapy.
BREECH PRESENTATION
II. Tests and Assignments for Self-assessment.
Multiple Choice.
Choose the correct answer / statement:
1. What the type of presentation is if the buttocks and feet are palpable:
A - Frank breech presentation;
B - Complete breech;
C - Incomplete breech presentation;
D - Footling ;
E - Kneeling presentation.
2. What the type of presentation is if the feet are palpable than the buttocks:
A - Frank breech presentation;
B - Complete breech;
C - Incomplete breech presentation;
D - Footling;
E - Kneeling presentation.
3. What the estimated weight of the fetus is the indication | cesarean section?
A - 2500 g; B - 3000 g; C- 36OO g; D - 4000 g
4 What type of the manual aids need the patients with a footling?
A- Manual aid by Tsovyanov 1; B - Manual aid by Tsovyanov II; C - Classic manual aid; D - Breech extraction.
5. What type of the manual aids need the patients with a frank breech presentation?
A- Manual aid by Tsovyanov I.
B- Manual aid by Tsovyanov II;
C - Classic manual aid;
D - Breech extraction.
Real - life situations to be solved:
6. N., 21 eyars old, primapara. Full term of pregnancy. The labor started 8 hours ago. The membranes ruptured 15 minutes later. Pelvic sizes: 25,28,31,20 cm. Fetal head rate 140 per minute with satisfactory characteristics. Per vaginum: the cervix is completely dilated. The amniotic sac is absent. Fetal buttocks are palpated in outlet plane of pelvic. Bitrochanter diameter is in the direct size of pelvic outlet. Diagnosis? What type of the manual aids need the patient?
7. Prirnipara F.,25 years old. Pregnancy at term. The labor started 6 hours later. The membranes ruptured 1 hour ago. Pelvic sizes: 23,25,29,18 cm. Fetal head rate 140 per minute with satisfactory characteristics. Uterine contractions are occurring every 7-8 minutes. Per vaginum: the uterine cervix dilatation is 5 sm. The amniotisac is absent. One fetal foot is palpated in the vagina. Buttocks are in the pelvic inlet. Diagnosis? How the delivery must be managed?
III. Answers to the Self- Assessment.
I- C. 2. D. 3. C. 4. B. 5. A. 6. First at term labor. Second stage of
labor. The frank breech presentation. Management: Vaginal delivery. The
manual aid by Tsovyanov I. 7.First at term labour I, first stage of labor.
footling presentation. Contracted pelvis I-II degree. Cesarean section should be performed.
Students must know:
1. Classification of breech presentations.
2. Diagnosis of breech presentations.
3. The biomechanism of the labor in breech presentations.
4. The cardinal movements of labor in breech presentations.
5. The classification of the manual aids lo breech presentations, indications to cesarean section.
Students should be able:
1. To show the cardinal movements of labor in breech presentation on phantom.
2. To determine the movements of the labor.
3. To determine the complications in labor.
4. To show the technique of the manual aids in breech presentat on phantom.
BREECH EXTRACTION
II. Tests and Assignments for Self - assessment. Multiple Choice.
Choose the correct answer / statement:
1. The breech hydrocephalus is best managed by: A — Cesarean section;
B — Destructive procedure;
C - Decompression of the head transvaginally;
D - Decompression of the head transabdominally.
2. If there has been no descent of the presenting breech for over 1 hour during the second stage of labor, and fetal heart rate is l00, the doctor should perform:
A - Breech extraction;
B - Cesarean section;
C - Any active procedure;
D - Destructive procedure.
3. Vaginal delivery of the term breech is generally avoided when the fetus weight is more of how many grams?
A - 2500 - 3000;
B - 3000 - 3500;
C - 3500 - 4000;
D - 4000 - 4500.
Real-life situation to be solved:
4. 38-years-old women at term arrives in active labor, full dilated with a presenting part at the pelvic floor. She has had no prenatal care and four previous vaginal deliveries of four boys all weighing 3000 to 3200 g. Because there are variable decelerations and a questionable loss of long term variability, artificial rupture of membranes is performed, at which time the patient is found to have a frank breech presentation. The FHR is now reassuring. Contractions are strong, occurring every 3 minutes. The fetal heart rate is 110 beat in minute. Which would be the best management?
III. Answers to the Self- Assessment.
1. B. 2. A. 3. CD. 4. Labor V, at term, II stage of the labor. The franc breech presentation. Fetal hypoxia. The best management is the operation of extraction fetus on the groin.
V. Tasks and tests
1.The puerpera of 24 years old, the 2d day after laborC. A common state is satisfactory, a body temperature is 36,6 degrees , sphygmus 82 beets / mines, satisfactory propertieC. There is no pathology from internals . Mammas are enlarged in the dimensions, mild, papillas are whole. The uterus is dense, painless, a bottom of it is on 5 sm above a bosom. A lochia are serouse-bloody, in a small amount. Physiological functions are normal. It is enough for determination of character of lochia:
A * A sighting
B Microscopies lochia
C A luminescent microscopy of lochia
D Bacteriological investigation of lochia
E Vaginoskopy.
2. Puerpera, the 3-d day of the postnatal period, complaints to a fever up to 38,2(С, a pain in the lower part of abdomen, purulent discharge from vagina, delicacy have appeared. Objectively: pulse - 98 heart-rate, the BP – 120/80 mm.Hg, a skin is pale. The abdomen is soft, painless. The uterine fundus is lower than umbilicus up to one transversal finger, has a soft consistence, morbid. At vaginal research: the uterus enlarged till 17 weeks of pregnancy, softened, painful. Appendages of a uterus and vaults of the vagina are without features. Discharge are purulent, in moderate quantity. The analysis of a blood: a leukocytosis 13,5(10 9/l, ESR - 32 mm/h. Establish the preliminary diagnosis.
A Postnatal acute endometritis
B A postnatal thrombophlebitis
C A postnatal adnexitis
D A postnatal parametritis
E A postnatal pelviperitonitis
3. The woman on the seventh day after delivery complicated by uterine bleeding and manual investigation of the uterine cavity started to be feverish up to 38,70C and complains of the bloody purulent vaginal discharge with unpleasant smell. The uterine upper border is located between the pubis and omphalus. The uterus is tenderness and has a dough-like consistency. What is the most probable diagnosis?
A *Puerperal (postpartum) endometritis
B Uterine postpartum subinvolution
C Pelvioperitonitis
D Sepsis
E Physiological puerperal (afterbirth) period
Students must know:
The determination of the operation of breech extraction.
The indications for breech extraction.
The conditions for the operation of breech extraction.
The techniques for breech extraction.
Anesthesia for breech extraction.
The techniques for the operation of extraction fetus on the one on the two legs, on the groin.
The complications caused by breech extraction
Students should be able:
1. To make the external obstetric physical examination.
2. To make the internal obstetric physical examination.
3. To make the diagnosis of type of breech presentation.
4. To choose the methods of delivery.
5. To evaluate of investigation.
6. To perform an operation of extraction on the phantom.
7. To choose the method of treatment.
MALPRESENTATIONS
II. Tests and Assignments for Self - assessment.
Multiple Choice.
Choose the correct answer / statement:
1. Which is the most appropriate treatment for the woman on 34 week of gestation having an oblique lie of the fetus? A - The classic version of the fetus; B - To stimulate delivery: C — Cesarean delivery; D - External version of the fetus.
2- A 17-year-old patient at 39 weeks gestation presents to the hospital av'nga transverse lie of the fetus. Which is the most appropriate treatment? A - External version of the fetus;
B - Rupture of the fetal membranes to stimulate delivery; C - Immediate cesarean delivery; D - An immediate vaginal delivery.
3- What are the requirements for internal podalic version of the fetus? A - Normal temperature of the body
B - Cervix must be fully dilated;
C - Membranes must be ruptured;
D - All of the above.
Real — life situations to be solved:
4. A multipara at 38 weeks of gestation entered the obstetrical department with normal labor activity. Complaints of the cough, headache The temperature of the body is 38,7 °C. Pelvic sizes: 25-28-31-20. Expected weight of fetus is 3000 g. Fetal heart tones are normal. The presenting part is not palpated upon the pelvic inlet. The head is situated in the left part of the uterus. Vaginal examination shows: the cervix is completely dilated. The membranes are intact. Shoulder of the fetus is palpated as a presenting part. Which is the most appropriate treatment?
III. Answers to the Self- Assessment.
1. D. 2. C. 3. D. 4. Labor, at term, second stage. Acute respiratory disease. Transverse fetal lie. The most appropriate management is internal podalic version.
Students must know:
l. The determination of the operation of obstetrics versions.
2. The indications for obstetrics versions.
3. The conditions for the operation of obstetrics versions.
4. The techniques for the external and internal obstetrics versions.
5. Anesthesia for the operation.
6. The complications caused by obstetrics versions.
Students should be able to:
1. To make the external obstetric physical examination.
2. To make the internal obstetric physical examination;
3. To evaluate the indications and contraindications to obstetric versions.
4. To do the operations of the internal and external version on phantom.
DEFLEXED PRESENTATIONS
II. Tests and Assignments for Self - assessment.
Multiple Choice.
Choose the correct answer / statement:
1. What is the first movement of labor in face presentation? A — Internal rotation;
B — External rotation: C — Flexion: D - Extension.
2. What is the first degree of the head extension? A — Deflexed vertex presentation;
B — Breech presentation; C - Brow presentation; D - Face presentation.
3. What is the fixing point in the face presentation?
A - Occiput;
B - Sinciput;
C — Fossa suboccipitalis;
D - The area of the border of the hair part.
4. What is the leader point in the face presentation? A - Anterior fontanel;
B - Posterior fontanel; C — Chin.
D — Area of the border of the hair part. Real ~ life situations to be solved:
5. M., 28 years old, para 2. Full term of pregnancy. Initiation ot labQl was 8 hours ago. The membranes ruptured 20 minutes ago. Fetal heart rate is 132 per minute with satisfactory
cter'istics. Per vaginum: the cervix is completely dilated. The amniotic is absent. Fetal head is in outlet plane of pelvic. The chin is palpated under the symphysis.
Diagnosis? What is the moment of labor biomechanism ?
6. Primipara N.,25 years old. Delivery at term. The labor started 6 ago. The membranes ruptured 1 hour ago. Pelvic sizes: 25,28,31,20. Fetal head rate 140 per minute with satisfactory characteristics. Uterine ntractions are occurring every 7-8 minutes. Per vaginum: the uterine cervix dilatation is 6 cm. The amniotic sac is absent. Fetal head fixed to the inlet of pelvis. Sagittal suture is in the right oblique size. Small and large fontanels are palpated. The large fontanel is lower. Diagnosis?
III. Answers to the Self- Assessment,
1. D. 2. A. 3. C. 4. C. 5. Labor 2, at term, 2 period of labor. Face presentation. Third moment of the labor biomechanism: flexion of the fetal head. Management: normal vaginal delivery. 6. Labour 1, at term. 1 period of labor. The defiexed vertex presentation. Visual Aids and Material Tools:
LMi Students must know:
1. The cardinal movements of labor in deflexed cephalic presentation.
2. The definition of deflexed vertex, brow and face presentation.
3. The mechanism of the head's flexion, rotation, extension, internal body's rotation and external head's rotation.
4. The definition of the leader point and the fixing point. Students should be able to:
1. To make the external obstetric physical examination.
2. To make the internal obstetric physical examination.
3. To show the cardinal movements of labor in deflexed cephalic presentation on phantom.
4. To determine normal and pathological course of the labor.
CONTRACTED PELVIS
II. Tests and Assignments for Self - assessment.
Multiple Choice.
Choose the correct answer / statement:
1. What is the first movement of labor in face presentation? A — Internal rotation;
B — External rotation: C — Flexion: D - Extension.
2. What is the first degree of the head extension? A — Deflexed vertex presentation;
B — Breech presentation; C - Brow presentation; D - Face presentation.
3. What is the fixing point in the face presentation?
A - Occiput;
B - Sinciput;
C — Fossa suboccipitalis;
D - The area of the border of the hair part.
4. What is the leader point in the face presentation? A - Anterior fontanel;
B - Posterior fontanel; C — Chin.
D — Area of the border of the hair part. Real ~ life situations to be solved:
5. M., 28 years old, para 2. Full term of pregnancy. Initiation ot labQl was 8 hours ago. The membranes ruptured 20 minutes ago. Fetal heart rate is 132 per minute with satisfactory
cter'istics. Per vaginum: the cervix is completely dilated. The amniotic is absent. Fetal head is in outlet plane of pelvic. The chin is palpated under the symphysis.
Diagnosis? What is the moment of labor biomechanism ?
6. Primipara N.,25 years old. Delivery at term. The labor started 6 ago. The membranes ruptured 1 hour ago. Pelvic sizes: 25,28,31,20. Fetal head rate 140 per minute with satisfactory characteristics. Uterine ntractions are occurring every 7-8 minutes. Per vaginum: the uterine cervix dilatation is 6 cm. The amniotic sac is absent. Fetal head fixed to the inlet of pelvis. Sagittal suture is in the right oblique size. Small and large fontanels are palpated. The large fontanel is lower. Diagnosis?
III. Answers to the Self- Assessment,
1. D. 2. A. 3. C. 4. C. 5. Labor 2, at term, 2 period of labor. Face presentation. Third moment of the labor biomechanism: flexion of the fetal head. Management: normal vaginal delivery. 6. Labour 1, at term. 1 period of labor. The defiexed vertex presentation.
Students must know:
1. The cardinal movements of labor in deflexed cephalic presentation.
2. The definition of deflexed vertex, brow and face presentation.
3. The mechanism of the head's flexion, rotation, extension, internal body's rotation and external head's rotation.
4. The definition of the leader point and the fixing point. Students should be able to:
1. To make the external obstetric physical examination.
2. To make the internal obstetric physical examination.
3. To show the cardinal movements of labor in deflexed cephalic presentation on phantom.
4. To determine normal and pathological course of the labor.
References:
VI. List of recommended literature
1. Danforth's Obstetrics and gynaecology. - Seventh edition.- 1994.
2. Obstetrics and gynaecology. Williams & Wilkins Waverly Company. - Third Edition.- 1998.
3. Basic Gynecology and Obstetrics. - Norman F. Gant, F. Gary Cunningham. -1993.
4. Clinical Obstetrics of Fetus and Mother – E. Albert Reece&John Hobbins. – Third Edition. – Blackwell publishing. – 2007.
5. Obstetrics Illustrated. – Kevin P. Hanretty. – Sixth Edition. – Churchill Livingstone. - 2003.
6. Manual on Obstetrics. – Arthur T. Evans. – Seventh Edition. - Lippincott Williams & Wilkins. – 2007
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