Theme: Delivery stages. Clinical course and labor management of I, II and III delivery stages. Position of the fetal head as it moves along the maternal passages. icon

Theme: Delivery stages. Clinical course and labor management of I, II and III delivery stages. Position of the fetal head as it moves along the maternal passages.




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Head of obstetrics and gynaecology department №2

docent, k. m. n. O. V. Bulavenko

Obstetrics and gynaecology department №2

Methodical recommendations for students of 4th course of stomatological faculty by practical lessons of obstetrics


Theme: Delivery stages. Clinical course and labor management of I, II and III delivery stages. Position of the fetal head as it moves along the maternal passages. The placenta scales off signs. Methods of detachment of placenta. Active management of the third delivery stage. Expectant management of the third delivery stage. Physiological puerperal period. Changes in the woman’s organism in the puerperal period


  1. Scientific and methodological explanation of the topic


Knowledge of the physiology of childbirth gives rise to obstetrics. Maximum adherence of the physiological processes of childbirth is a direct way to reduce maternal and perinatal morbidity and mortality. Study of the main stages of the physiological delivery allows to know the most important methods of examination of women, the ability to evaluate the obstetric situation, assisting in physiological delivery


Il. Scientific and educational goals


To generate skills the student should know:


  1. I, II, III stages of delivery.

  2. Diagnostics and confirmation of delivery beginning.

  3. Detecting the degree of fetal head fitting

  4. Clinical course and management of the first delivery stage

  5. Clinical course and management of the second deliver stage

  6. Clinical course and management of the third deliver stage

  7. Active and expectant types of managing the third delivery stage

  8. Physiological puerperal period

  9. Changes in the woman’s organism in the puerperal period



The student should be able to:



  1. Reproduce on the phantom the moments of I delivery stage.

  2. Reproduce on the phantom the moments of II delivery stage.

  3. Display external mode of isolating of placenta



III. The basic knowledge:


  1. The structure of female pelvis.

  2. Fetus as an object of childbirth

  3. Mature fetal head structure, measurements

  4. Sutures and fontanels of fetal head

  5. The major and minor segments of fetal head

  6. 4th Leopold's maneuver

  7. Fetus position, the type of position, presentation

  8. Biomechanism of childbirth at anterior and posterior vertex presentations



IV. Methodical recommendations for practical training:

Delivery stages

Delivery is divided into three stages:

  • the first — the stage of cervical dilation;

  • the second — fetal expulsion;

  • the third — placental.

The first stage (dilation) is counted from the beginning of regu­lar labor pains till sufficient cervical dilation (10 cm). Diagnostics and confirmation of delivery beginning:

  • after the 37th week the pregnant woman has labor-like pains in the lower part of abdomen and loin with appearance of mucosanguin-eous and watery (in case of amniotic fluid discharge) discharge from the vagina;

  • one labor pain in 10 min, which lasts for 15—20 sec;

  • the uterine neck changes form (its progressing shortening and smoothing) and dilates;

  • gradual descending of the fetal head to the small pelvis relative to the area of brim (by the data of external obstetric examination).

Labor pains are involuntary contractions of uterine muscles. In­tervals between labor pains are called a pause. Regular birth activity is such uterine activity (2—5 pains in 10 min), which leads to struc­tural changes of the uterine neck — its smoothing and dilation.

Smoothing of the uterus is the reduction of its canal length due to the movement of the muscle fibers of internal orifice to the inferior uterine segment.

Cervical dilation is characterized by the increase of cervical canal diameter to 10 cm, which provides fetal advancement. Cervical dila­tion predominantly happens at the expense of contraction and retrac­tion of muscle fibers of the body and fundus of uterus relative to one another, and also at the expense of distraction of cervical muscles and partially of the inferior uterine segment. In pauses between labor pains uterine contraction disappears completely, and retraction — partially.

During each pain intrauterine pressure rise is transmitted to the fetal membranes, amniotic fluid, and fetus. Amniotic fluid under the influence of intrauterine pressure moves down to the outlet from the uterus, as a result of what the fetal sac squeezes into the cervical canal of uterus. The presenting part (the head) is fixed in the brim and forms the internal girdle of fitting the amniotic fluid is thus divided into anterior and posterior. The external girdle of fitting is formed between the pelvic walls and the lower uterine segment.

Smoothing and dilation of the uterine neck happens differently in para I and para II. In para I smoothing takes place before dilation; in para II these processes are simultaneous. At physiological delivery in the end of the first period the fetal sac bursts and amniotic fluid pours out. Such amniotic fluid discharge is consid­ered timely. Amniotic fluid discharge before the beginning of birth activity is called premature, and discharge before 5 cm cervical dila­tion — early.

The first stage of labor is divid­ed into two consecutive phases:

the latent phase — the inter­val of time from the beginning of regular birth activity till complete smoothing of the uterine neck with dilation to 3 cm if delivery is the first or to 4 cm at all further pregnancies. Usually this phase lasts 6—8 and 4—5 h accordingly;

the active phase — cervical dilation from 3—4 to 10 cm. The minimal speed of cervical dilation in the active phase, which is con­sidered normal, makes 1 cm/h both during the first and further delive­ries. Usually dilation speed in para II is bigger than in para I.

The active phase in its turn is divided into three subphases: accele­ration, maximal elevation, and deceleration. The subphase of accele­ration in para I lasts 2 h, in para II — to 1 h. The subphase of maximal elevation lasts the same time accordingly. The subphase of decele­ration in para I lasts 1—2 h, in para II — 0.5—1 h. Deceleration in the end of the first period is explained by the slipping down of the uterine neck from the advancing fetal head.

Uterine activity is detected by palpation of the uterus during 10 min. The presence of 2 or more uterine contractions during 10 min lasting for 20 or more sec is a sign of birth activity.

The conclusion about labor pains efficiency is based on their force, duration, and frequency, on dynamic cervical dilation and the signs of head advancement relative to the area of brim.

In the active phase of the first period of delivery effective contrac­tile uterine activity must correspond to the following characteristics: 3—4 contractions in 10 min, lasting more than 40 sec.

Still, the most objective criterion of birth activity efficiency in the first period is cervical dilation, whose degree may be controlled by different methods.

The second stage (expulsion) lasts from the moment of sufficient cervical dilation till the child is born. It is important to differentiate the early phase of the second stage (from sufficient dilation till con­tractions beginning) from the active phase — the phase of contracti­ons itself.

Important notions of the second stage are:

  • contractions — rhythmical consciously controlled contractions of uterine muscles, prelum abdominale, diaphragm, and pelvic floor;

  • cutting-in of the fetal head — the fetal head appears on the vul­var end only during contraction;

  • disengagement — the head keeps position in the vulvar end af­ter contraction ceases.

The maximum allowed duration of the second stage in para I and para II makes 2 and 1 h accordingly without epidural anesthesia ap­plication. The most part of this time falls on the early phase, when the fetal head gradually advances through the maternal passages to the pelvic floor, first without contractions addition, and then with gradu­al appearance and increase of powerful conmponent during contrac­tions. Organization of contractions during the early phase, if the con­dition of the fetus and mother is normal, usually quickly leads to woman's fatigue, violation of the process of internal turning of the fe­tal head, injuring of the maternal passages and fetal head, cardiac ab­normalities of the fetus, excessive medical intervention.

Full-value power activity appears only after the head is on the pelvic floor (the active phase).

Attention should be paid to the fact that long-term standing of the fetal head in a certain pelvic plane without any advancement dy­namics may lead to the formation of recto- and urovaginal fistulas.

The third stage (placental) lasts from the fetal birth till the de­tachment of placenta and membranes. If there are no signs of hemor­rhage, its duration should not exceed AO min.

The mechanisms of normally located placenta detachment may be different. Detachment of placenta from the centre with formation of a retroplacental hematoma and birth with fetal surface outside is called the Schultze's mechanism. If the placenta scales off not from the centre but from a side, such detachment mechanism is called the Duncan's mechanism.

Integrity of the born placenta is detected visually.

Loss of blood at the placental stage, which does not exceed 0.5 % of the parturient woman's weight, is considered physiological. The only objective method of blood loss calculation is its measurement.

^ External Methods of Evaluating the Degree of Cervical Dilation

It is possible to assess the degree of cervical dilation by means of external methods only approximately: the degree of cervical dilation during delivery is judged by the height of contraction ring standing (the boundary between the contracting empty muscle and the lower segment of the stretching uterus). During delivery the uterine neck is usually dilated as much as many finger breadths the contraction ring is located above the pubic arch.

^ Internal Methods of Evaluating the Degree of Cervical Dilation

In order to detect the dynamics of cervical dilation and location of the fetal head during delivery internal obstetric examination is con­ducted, which is performed when the woman is delivered to the ma­ternity department, in every 4 hours during the first period of delive­ry and after amniotic fluid discharge (for the timely diagnostics of possible prolapse of the umbilical cord and small parts of the fetus with amniotic fluid flow).

The degree of the head fitting also may be detected by external and internal methods.

^ Detecting the Degree of Head Fitting by External Methods

The degree of head fitting may be detected by the 4th Leopold's maneuver.

Detecting the degree of head advancement into the pelvic cavity by the method of abdominal palpation:

5/5 — the fetal head is located above the symphysis by the breadth of 5 fingers, the fetal head is above the pelvic inlet;

4/5 — the breadth of 4 fingers, the head is pressed to the pelvic inlet;

3/5 — the breadth of 3 fingers, the head is in the pelvic inlet with its small seg­ment;

2/5 — the breadth of 2 fingers, the head is in the pelvic inlet with its large seg­ment;

1/5—0/5 — the breadth of 1 finger, the head is in the pelvic cavity.

External palpation of the head is to be conducted right before internal obstetric examination. This allows avoiding mistakes in detecting the position of the head in case of the formation of a large edema of the presenting part of the fetal head. The method of abdominal palpation is also recommended, which detects the height of fetal head sanding by the number of finger breadths above the symphysis:





Detecting the degree of fetal head fitting by the method of in­ternal obstetric examination.

  • The head above the pelvic inlet. The pelvis is free, the head is located high, it does not prevent the palpation of the innominate pel­vic line, promontory; the sagittal suture is in the transverse dimen­sion at the same distance from the symphysis and promontory, the large and small fontanels are at one level.

  • The head is in the pelvic inlet with a small segment. The hollow of the sacrum is free; the promontory may be approached with a bent finger (if it is reachable). The internal surface of the symphysis is ac­cessible to examination, the small fontanel is lower than the large one. The sagittal suture is in slightly oblique dimension.

  • The head is in the pelvic inlet with a large segment. The head takes the upper third of the symphysis and sacra. The promontory is inaccessible, the ischial spines are easily palpable. The head is flexed, the small fontanel is lower than the large one, the sagittal suture is in one of oblique dimensions.

  • The head is in the broad part of the small pelvis. The head has gone through the pelvic plane of greatest dimensions with its largest circumference. Two thirds of the symphysis pubis and the superior half of the hollow of the sacrum are taken by the head. The 4th and 5th sacral vertebrae and ischial spines are easily palpable. The small fon­tanel is lower than the large one, the sagittal suture is in one of oblique dimensions.

  • The head is in the narrow part of the small pelvis. Two upper thirds of the hollow of the sacrum and the whole internal surface of the symphysis pubis are taken by the head. The ischial spines are dif­ficult to reach. The head is close to the pelvic floor, its internal turn­ing is not finished yet, the sagittal suture is in one of oblique dimen­sions, close to the direct one. The small fontanel is lower than the large one by the womb.

  • ^ The head is in the pelvic outlet. The hollow of the sacrum is completely filled with the head, the ischial spines are not detected, the sagittal suture is located in the direct dimension of the pelvic out­let. The small fontanel is lower than the large one by the womb.

Internal examination may also detect the position of the head by relation to the level of the ischial spines — linia interspinalis ("0" po­sition). The distance from the ischial spines to the area of brim equals the distance from the spines to the area of pelvic outlet. The sign "-" means that the head is above the ischial spines (closer to the pelvic inlet). The sign "+" means that the fetal head is lower than the ischial spines (closer to the pelvic outlet).

^ Clinical course and management of the first delivery stage

Observation over the course of the first period of delivery, condition of the mother and fetus is conducted with the help of a partogram (partograph).

Peculiarities of Partogram Conducting

The following indices are graphically represented on the parto­gram relative to the time axis:

1). Delivery course:

  • the degree of cervical dilation detected by the method of inter­nal obstetric examination (every 4 h);

  • fetal head descending detected with the help of abdominal pal­pation (every 4 h);

  • frequency (in 10 min) and duration (in seconds) of contrac­tions (every 30 min).

2). Fetal condition:

  • fetal heart rate evaluated by the method of auscultation or manual Doppler analyzer (every 15 min);

  • the degree of fetal head configuration (every 4 h);

  • condition of the fetal sac and amniotic fluid (every 4 h).

3). Condition of the parturient woman:

  • pulse and arterial pressure (every 2 h);

  • temperature (every 4 h);

  • urine: volume, presence of protein and acetone — by indica­tions (every 4 h).

Partogram advantages:

  • effective observation over delivery course;

  • timely detection of delivery deviations from the normal course;

  • rendering help in the process of making decision concerning necessary and sufficient interventions.

Special attention should be paid to the principles of managing the first period of delivery, which foresee measures aimed at psychological support of the parturient woman — partner delivery (presence of the husband or family members, in certain cases of close friends), prophy­laxis of the woman's fatigue, fetal condition violation, avoiding trauma­tism of the mother and fetus in the course of delivery. An obligatory mo­ment of labor management is that the woman chooses position herself (sitting, standing, forward inclination, lying on one side, etc.); the position on the back is not advisable as it promotes the formation of aortocaval compression, circulatory disturbance in the uterus, nega­tively influences the general condition of the parturient woman, leads to sharp decrease of arterial pressure and fetal condition derangement. Besides, the position on the back reduces the intensity of uterine con­tractions and negatively influences the course and duration of delive­ry. The most justified in the first period of labor is active behaviour of the woman, which accelerates the process of cervical dilation, reduces labor pains and the frequency of fetal cardiac abnormalities.

Clinical course and management of the second deliver stage

Management of the second stage of delivery demands:

  • taking arterial pressure and pulse of the parturient woman eve­ry 10 min;

  • control of the fetal heart function every 5 min during the early stage and after every second contraction during the active phase;

  • control of fetal head advancement along the maternal passages, which is conducted with the help of internal obstetric examination every hour. Because of the increase of the risk of ascending infection of the parturient canal additional obstetric examinations in the second peri­od of delivery are permissible only by indications:

  • conducting amniotomy if there is no timely amniotic fluid dis­charge;

  • at multifetation after the first fetus is born;

  • when the decision about operative vaginal delivery is taken (obstetric forceps, vacuum extraction, extraction of fetus by the pel­vic pole).

The birth of the fetal head requires cautious manual aid aimed not only at the preservation of the integrity of the woman's perineum, but also prevention of intracranial, spinal, and other injuries of the fetus. Perineum protection consists of five maneuvers:

  1. ^ Prevention of premature deflexion of the fetal head — the palm of the left hand rests against the pubis, the fingers restrain rapid ad­vancement of the head, carefully pressing it.

  2. Reduction of perineum tissue tension — the palmar surface of the right hand is located on the perineum, tissues of the large lips of pudendum are moved to the side of perineum with fingers.

  3. Taking the fetal head out of the pudendal fissure — after the point of fixation is formed, out of contraction, carefully removing lat­eral edges of the vulvar ring from the head, giving it a possibility to extend.

  4. Help during internal turning of the shoulders and external turn­ing of the head — the born head is grasped with both hands in such a way that palms are on the area of ears; the head is carefully pulled down till the anterior shoulder gets under the pubic arch.

  5. ^ Release of the shoulder girdle — the head is grasped with the left hand and drawn aside to the womb, perineum tissue is carefully taken off the posterior shoulder.

When the fetal shoulder girdle is born, the child's body is grasped with both hands, the fingertips must be in the fetal armpits. The fetal body is directed upwards, the fetus is taken out.

There exists tactics of managing the second stage of delivery with­out perineum protection. Giving free position to the woman during contractions promotes more dynamic passage of the fetus through the maternal passages; the most effective positions are the crouched posi­tion, sitting on a chair, standing, pulling up on a ladder, lying on one side.

It is important to emphasize that only in case of necessity during the stage of expulsion auxiliary perineum dissection is performed (perineo- and episiotomy).

Indications to perineum dissection (WHO):

  • complicated vaginal delivery (vacuum extraction, obstetric forceps, breech presentation);

  • presence of cicatricial changes of the perineum after dissection in previous delivery, especially after poor regenerative process;

  • fetal distress.

According to modern scientific proofs episiotomy application by the indications of "perineal rupture threat" is not always grounded. The absence of clear objective criteria of "perineal rupture threat" is the basis for a wider usage of episiotomy, which is no other than 2nd degree iatrogenic perineal rupture. In most cases, when in the pres­ence of so-called "perineal rupture threat" the perineum is not dis­sected, there takes place a spontaneous rupture only of the skin of perineum and vaginal mucosa, without any affection of the pelvic floor muscles (1st degree rupture).

It should also be recognized that in a number of cases the perineum is really a substantial obstacle for delivery and its dissection is a neces­sary measure of preventing severe ruptures. The decision to conduct the operation must be clinically grounded and agreed with the woman. The operation is to be conducted after preliminary local anesthesia.

^ Clinical course and management of the third deliver stage

There are two types of tactics of managing the third delivery stage: active and expectant.

Active management of the third delivery stage

Due to a number of advantages the active management of the third delivery stage is the most wide-spread tactics in the world and is recommended by the WHO, International Federation of Gynecolo­gy and Obstetrics and International Confederation of Midwives.

Application of the technique of active management of the third delivery stage during every delivery allows reducing the frequency of postpartum hemorrhage caused by uterine insufficiency by 60 %, and also reducing the quantity of postpartum blood loss and transfusion necessity.

Standard components of the active management of the third de­livery stage include:

  • uterotonics introduction;

  • placenta delivery by way of controlled tractions by the umbili­cal cord at drawing the uterus aside from the womb;

  • massage of the uterus through the anterior abdominal wall af­ter the placenta is born.

Rules of uterotonics introduction: during the first minute after the child's birth the uterus is to be palpated to exclude the presence of another fetus in it; if a fetus is present — 10 IU of oxytocin is intro­duced i.m. Oxytocin is a predominant uterotonic since its effect is evi­dent already in 2—3 min, it may be used in all women.

If there is no oxytocin, ergometrine may be introduced — 0.2 mg i.m.

The woman must be informed about possible side effects of these drugs.

Ergometrine can not be used in women with preeclampsia, ec­lampsia, and hypertension.

Controlled tractions by the umbilical cord:

  • the umbilical cord is to be compressed with a clamp closer to the perineum; the umbilical cord and clamp are held in one hand;

  • the other hand is put directly above the woman's pubis, the uterus is held drawing it aside from the womb;

  • the umbilical cord is slightly tightened, then one waits for a strong uterine contraction (usually in 2—3 min after oxytocin intro­duction);

  • simultaneously with a strong uterine contraction the woman is offered to bear down strongly, the umbilical cord is very carefully pulled down (traction) for the placenta to be born, simultaneous countertraction is continued with the other hand in the direction op­posite to the traction (i.e. pushing the uterus away from the womb);

  • if the placenta does not descend (is not born) during 30— 40 sec of controlled traction, the traction by the umbilical cord is to be stopped, but the cord must be held in the state of light tension, the other hand remains above the womb, holding the uterus;

— one should wait till the uterus contracts again and repeat con­trolled traction by the umbilical cord with countertraction onto the uterus.

One must never conduct traction by the umbilical cord without applying countertraction of the well-contracted uterus above the womb. Conducting traction by the umbilical cord without uterine contraction may lead to uterus inversion.

After the placenta is born, it is held with both hands and carefully rotated, twisting the membranes, then it is carefully pulled down for labor termination.

In case of membranes rupture the vagina and uterine neck are carefully examined in sterile gloves. If membranes are detected, a fe­nestrated clamp is used to remove their remains.

The placenta is carefully examined to make sure it is intact. If the area of maternal surface is absent or there is an area of torn mem­branes with vessels, it is a reason to suspect retention of placenta parts and begin necessary measures.

Massage of the uterus: after the placenta is born the uterus is im­mediately massaged through the anterior abdominal wall till it be­comes dense.

Further on the uterus is palpated every 15 min during the first 2 h to make sure that after massage the uterus is not relaxing and stays dense. In case of necessity repeated massage is conducted.

An ice pack is not put onto the lower part of the abdomen in the early puerperal period.

The active management of the third stage of delivery must be of­fered to every woman since it reduces the frequency of postnatal he­morrhages caused by uterine insufficiency.

The parturient woman must be informed about the active man­agement of the third stage of delivery and give written consent to it.

^ Expectant management of the third delivery stage

After the umbilical cord pulsation is over, but not later than 1 min af­ter the child is born, the umbilical cord is clamped and cut. The gene­ral condition of the parturient woman, signs of placenta detachment, quantity of bloody discharge are thoroughly observed.

If any signs of placenta detachment appear, the woman must be offered to bear down, which will lead to the birth of the placenta.

The signs of placenta detachment are:

The Schroder's sign: if the placenta has detached and descended into the lower segment or vagina, the uterine fundus elevates and lo­cates above and to the right of the navel; the uterus acquires the from of an hourglass.

The Chukalov—Kiistner's sign: when the suprapubic area is pressed with the edge of hand the uterus elevates and the umbili­cal cord is not pulled into the vagina if the placenta is detached

The Alfeld's sign: the ligature, which is on the umbilical cord by the pudendal fissure of the parturient woman, in case of placenta de­tachment descends by 8—10 cm and lower than the vulvar ring.

The Dovzhenko's sign: the woman is offered to breathe deeply: if the umbilical cord is not pulled into the vagina at expiration, the pla­centa has detached.

The Klein's sign: the parturient woman is offered to bear down, if the umbilical cord is not pulled into the vagina, the placenta has de­tached.

To remove the placenta, which has detached, external methods are applied.

The Abuladze's method. After the urinary bladder is emptied the anterior abdominal wall is taken into a fold in such a way to grasp the rectus abdominal muscles. After this the parturient woman is offered to bear down: the placenta is easily born due to considerable reduc­tion of abdominal cavity volume.

The Crede—Lazarevich's method is conducted in the following sequence:

  1. the urinary bladder is emptied;

  2. the uterine fundus is brought into the median position;

  3. the uterus is lightly stroked for the purpose of its contraction;

  4. the uterine fundus is grasped with a hand in such a way that the palmar surfaces of its four fingers are located on the posterior uterine wall, the palm is on the uterine fundus, and the thumb — on the anterior uterine wall;

  5. the uterus is pressed with the whole palm in single stage in two directions (the fingers — front-back, the palm — top-down) to the pubis till the placenta is born from the vagina.

If there are no signs of pla­centa detachment and exter­nal hemorrhage during 30 min after the fetus is born, the pla­centa is detached and extract­ed manually.

If hemorrhage begins, manual detachment and ex­traction of the placenta must be conducted immediately under adequate anesthesia.

After the placenta is ex­tracted it must be thoroughly examined (to make sure the placenta and membranes are intact).

On average the total duration of delivery makes 8—12 h in para I and 6—8 h in para II.

Examination of the maternal passages after delivery (with the help of vaginal specula) is performed only in the presence of hemor­rhage, after operative vaginal delivery or if the doctor is not sure the maternal passages are intact (accelerated labor, labor outside a medi­cal establishment).


^ Physiological puerperal period


Despite the fact that the puerperal period is a physiological process it - requires from the doctor the knowledge of all its'stages and peculiari­ties, namely: the processes of involution in the organs and systems of the woman after delivery, lactation, which allows timely detection of initial signs of diseases and complications, which may arise in a partu­rient woman.

^ The puerperal period (puerperium) begins right after delivery and lasts during 6 weeks. During this time the organs of the reproductive system of the woman returns to the state, which existed before the pregnancy.

The puerperal period is divided into early and late.

The early puerperal period begins from the moment of placenta ex­pulsion and lasts 2 h. In this period the parturient woman is in the maternity department under doctor's supervision, which is connected with the risk of complications, hemorrhage in the first place. The pe­riod is very important and should be viewed as a term of quick adap­tation of the woman's functional systems after big load during preg­nancy and, especially, delivery.

The late puerperal period lasts from the moment of the parturient woman's transfer to the postnatal department (in 2 h after delivery is completed) during 8 weeks. During this period there takes place the involution of all organs and systems, which have changed because of pregnancy and labor. It should be emphasized that the mammary glands are an exception, whose function is activated exactly in the puerperal period. It should also be noted that the rate of involutional processes is maximal" during the first 8—12 days and are the most ex­pressive in the genitals, the uterus in the first place.

^ Changes in the woman’s organism in the puerperal period

The uterus. Right after the placenta is born the uterus begins quick contractions and becomes round. Open vessels of the placental part shrink. Right after the placenta is born the uterine body contracts and its fundus is in the middle of the distance from the pubis to the navel, then elevates slightly. The posterior and anterior uterine walls are 4—5 cm thick and adjoin one another; the uterine cavity is lined with the decidual membrane. During the next 2 days the uterine fun­dus is slightly below the navel; in 2 weeks after delivery the uterus descends below the symphysis. The uterus usually returns to prelimi­nary dimensions in 6 weeks. Uterine involution takes place due to the involution of some.muscles by means of hyaline and fatty degenera-' tion.

During 2—3 days after delivery the decidual membrane remains in the uterus and divides into two layers. The surface layer necrotizes and is released with lochia (postnatal discharge). The basal layer, adja­cent to the epithelium, which contains endometrial glands, remains intact and becomes the basis for the regeneration of new endometrium.

Endometrium regeneration takes place during 3 weeks, excluding the placental area. Complete epithelium regeneration in the place of placentation lasts 6 weeks. Violation of regeneration in the placental area may cause postnatal hemorrhages and infections.

The uterine neck. In 10—12 h after delivery the cervical canal of uterus is funnel-shaped, the internal mouth admits 2—3 fingers, and on the 3rd day — 1 finger. On the 8th—10th day after delivery the uter­ine neck is formed, the internal mouth is closed.

The vagina. In the course of 3 weeks after delivery the vaginal walls remain with edemata, which completely disappear till the end of the puerperal period. Minor injuries of the vaginal mucous tunic re­generate in 5—7 days. The pudendal fissure closes; the muscle tone of the pelvic floor muscles is gradually restored.

The ovaries. In the puerperal period follicles begin to mature. An anovulatory cycle is characteristic, against the background of which there takes place the first menstruation after delivery. Further on ovulatory cycles restore. Due to the discharge of a big quantity of prolactin in women at breast feeding menstruations are absent during a couple of months or during the whole period of breast feeding.

The abdominal wall and pelvic floor. Because of the rupture of elastic fibers of skin and long-term stretch by the pregnant uterus the anterior abdominal wall remains soft and flabby for some time and re­turns to the normal structure in a couple of weeks. Usually the ab­dominal wall returns to the preliminary condition, but at muscles ato­ny may remain flabby and weak. Sometimes diastasis recti abdominis is observed. The pelvic floor muscles also gradually restore their tone, but the presence of an injure during delivery may cause muscles slack­ening and promote the formation of genital hernias (prolapses).

The mammary glands. The function of the mammary glands after delivery reaches the highest development. During pregnancy estro­gens and progesterone stimulate the growth of the ducts and alveolar system of the mammary glands. Under the influence of prolactin there takes place intensified blood supply to the mammary glands, their in­tumescence, which is the most evident on the 3rd day after delivery. Lactation happens as a result of complex reflex and hormonal pro­cesses. Milk formation is regulated by the nervous system and adeno-hypophysis hormone — prolactin. Besides, the optimal level of insu­lin, thyreoid and adrenal hormones plays a secondary role in lactation establishment. Sucking stimulates periodic secretion of prolactin and, by reflex, of oxytocin; the latter stimulates milk let-down fro the al­veoles of mammary glands ducts. It should be noted that this process also intensifies contractions of the postnatal uterus. In the period till the 3rd day after delivery the mammary glands generate colostrum. Colostrum has a high concentration of proteins, mainly globulins, and minerals, and less — of sugar and fat. Colostrum proteins by their aminoacid composition are in the transient state between the protein fractions of human milk and blood serum, which obviously facilitates the newborn's organism in the period of transition from placental feeding to breast feeding. Colostrum contains a high level of immuno­globulins A, G, M, D, and also T- and B-lymphocytes. This is very important during the first days of the newborn's life, when functions of its organs and systems are still immature and immunity is at the stage of formation. Colostrum converts into mature milk during 5 days. The main components of milk are proteins (albumins, globulins, casein), lactose, water, and fat.

The respiratory system. Since the diaphragm descends after de­livery, lung capacity increases, which causes the decrease of respira­tory movements number to 14—16 per min.

The cardiovascular and hematopoietic systems. After delivery there arise changes in hemodynamics connected with the elimination of the uteroplacental circulation and discharge of some fluid from the mother's organism. The heart takes its usual position in connection with phrenoptosis. Right after delivery there is noted pulse lability with inclination to bradycardia, ABP may be lowered in the first days after delivery, and further reaches normal indices. In the end of the first week after delivery the volume of circulating blood reduces to normal. Blood indices often do not differ from normal, still, in the ear­ly puerperal period considerable granulocytes-dominated leukocyto­sis is observed — up to 30 • 109/L. The fibrinogen level in the plasma is increased, which should necessarily be taken into account at the prophylaxis of the development of lower extremities phlebitis.

The system of urinary excretion. The renal function is not vio­lated in healthy parturient women; diuresis is normal, may be slightly increased during the first days after delivery. The function of the uri­nary bladder is rather often disturbed, which is connected with the overexcitation of the sympathetic innervation of the sphincter and relaxation of the urinary bladder caused by its compression between the fetal head and pelvic wall during delivery.

The alimentary organs and metabolism. The digestive system functions normally after delivery. Sometimes bowels atony is ob­served with constipations. Metabolism is usually increased during the first weeks after delivery, and later — till the 3rd—4th week — nor­malizes.

The nervous system. After delivery there usually takes place neu­rosis of different tension, which normalizes during 1—2 days. In this period the parturient woman needs psychological support of the fa­mily, friends, and medical staff.


^ V. Organizational structure of lesson:


Organizational moments-2%;

Topic motivation -3%;

Checking the initial level of knowledge -20%;

Independent work of students under supervision of a lecturer -35%;

Checking the final level of knowledge -20%;

The rating of students` knowledge -15%;

Lecturer`s summary/conclusion, home task-5%.

^ VI. Methodical support:


The place of practical training: classroom, delivery room, compartment of pregnant pathology, children’s compartment.


Visual aids: tables, model of pelvis, centimeter tape, case studies.


Case studies for the assessment of the final level of knowledge


1. A pregnant woman at 40 weeks gestational age was admitted to the obstetrics department. Complaints on the rhythmical abdominal pain and the pain in the small of the back which occurs each 6-7 minutes and lasts 30-40 seconds. On internal obstetric examination it is noted that the uterine neck is effaced, 7 cm dilated, head presenting. During the examination there was discharge of transparent amniotic fluid.


  • What is the period of delivery?

In the active phase of the 1st period of delivery

  • How to characterize the amniotic fluid discharge?

Timely


2. In the lying-in woman on examination with the 4th Leopold method there is noted that occiput part of the head is not palpable above the small pelvis inlet and the facial part is above by two fingers. By means of abdominal palpation the determined height of head standing is 2/5.


  • What is the degree of head engagement?


With its large segment in the pelvic inlet


3. Living full-term boy was born: pink body skin, cyanotic extremities, moves actively, cries loudly, heartbeat is 136 b.p.m.


  • What is the Apgar score of the newborn?

8 points


Test questions for the assessment of final level of knowledge


1. 5 minutes after fetal birth the womb of the lying-in woman deflected to the right and the uterine fundus is determined 3 cm above the umbilicus. There is noted moderate bloody vaginal discharge.

    • Which sign of placenta separation is being observed?

  1. Schreder

  2. Kustner-Chukalov

  3. Alfeld

  4. Dovzhenko


2. On internal obstetric examination there is noted that the lower head vertex is at the level of the interspinal line.

    • What is the degree of head engagement?

      1. With its large segment in the pelvic inlet

      2. With its small segment in the pelvic inlet

      3. The head in the pelvic cavity

      4. The head in the plane of the pelvic outlet



3. On internal obstetric examination there is noted that the head is presenting, in the front, closer to the pubic the smaller fontanel is palpable, the saggital suture is in the right oblique dimension, cranial bones moderately cover each other.


    • What is the degree of head configuration?

      1. Second

      2. Third

      3. First

Zero


The recommended literature:


L. B. Ventskivska Obstetrics/-K.: “Medicine”, 2008.


Appoved at the chair meeting from “___” _____________________ 200__ year,

minutes № ___ .


Revised at the chair meeting from “___” _____________________ 200__year,

minutes № ___ .

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