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ЗмістExternal Methods of Evaluating the Degree of Cervical Dilation
Internal Methods of Evaluating the Degree of Cervical Dilation
Detecting the Degree of Head Fitting by External Methods
The head is in the pelvic outlet.
Clinical course and management of the first delivery stage
Prevention of premature deflexion of the fetal head —
Release of the shoulder girdle —
Clinical course and management of the third deliver stage
Expectant management of the third delivery stage
Physiological puerperal period
The puerperal period
Changes in the woman’s organism in the puerperal period
V. Organizational structure of lesson
VI. Methodical support
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
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:
The student should be able to:
III. The basic knowledge:
IV. Methodical recommendations for practical training:
Delivery is divided into three stages:
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:
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:
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.
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.
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.
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.
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).
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:
2). Fetal condition:
3). Condition of the parturient woman:
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:
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:
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):
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.
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:
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:
— 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.
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:
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).
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.
^ (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.
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.
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%.
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.
In the active phase of the 1st period of delivery
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.
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.
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.
2. On internal obstetric examination there is noted that the lower head vertex is at the level of the interspinal line.
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.
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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