(Leopold-Levitsky techniques)
Target: Determination of the position of the fetus in the uterus.
Sequencing:
The pregnant woman lies down on the couch, on a diaper. We ask you to free your stomach from clothes, bend your legs at the knees and hip joints.
First appointment. Determination of the height of the fundus of the uterus and the large part of the fetus located in the fundus.
The palmar surfaces of both hands are located on the bottom of the uterus, we clasp it tightly, the fingers should be facing each other. We determine the height of the uterine fundus and the large part of the fetus located in the fundus. If a large soft part is identified - the buttocks; if the large dense voting part is the head.
Second appointment. Determination of fetal position, position and type of position.
The palms descend from the bottom of the uterus to its right and left sides at the level of the navel and slightly below. One hand remains motionless, the second carefully palpates the lateral surface of the uterus, then the hand movements change. If a wide, smooth, curved surface is palpated under the arm, this is the back, if small movable tubercles are small parts.
Fetal position- this is the ratio of the longitudinal axis of the fetus to the longitudinal axis of the pelvis. The position of the fetus can be longitudinal, oblique, transverse.
Position- this is the relationship of the back of the fetus to the right or left side of the uterus.
Position type- this is the ratio of the back of the fetus to the anterior or posterior surface of the uterus.
Backrest on the left – 1st position, on the right – 2nd position. The front back is a front view, the back is a rear view.
Third reception. Determination of the presenting part of the fetus.
The presenting part is the part of the fetus that is located above the entrance to the pelvis and is the first to pass through the birth canal.
The right hand is located above the womb. We cover the presenting part of the fetus with our fingers, so that the thumb is on one side, and the other four are on the other side of the lower segment of the uterus, carefully immerse our fingers deep into it. The left hand is placed on the fundus of the uterus for comparison. We determine: the presenting part of the fetus and its mobility. If a round, voting, dense part is palpated above the pubis, the presentation is cephalic; if the large, soft part is palpated, the presentation is pelvic. The mobility of the presenting part is determined with reasonable effort.
Fourth technique. Determination of the standing height of the presenting part of the fetus.
It is carried out during childbirth. The midwife stands facing the woman's feet. The palms of both hands are located on the right and left on the lower segment of the uterus, the fingertips touching the upper edge of the symphysis.
We determine how much the presenting part of the fetus is pressed against the entrance to the pelvis or has descended into the pelvic cavity.
If the entire fetal head is palpated above the upper edge of the symphysis and is motionless, the head is pressed against the entrance to the pelvis (the fingers converge or almost converge).
If most of the head is palpated, the head has descended into the pelvic cavity in a small segment (the fingers diverge slightly).
If a smaller part of the head is palpated, the head has descended into the pelvic cavity in a large segment (the fingers are parallel).
If the neck and the large soft part of the fetus above the symphysis are palpated, the head has dropped into the pelvic cavity (the fingers diverge).
Listening to and counting the fetal heartbeat
Target: Listening to the fetal heartbeat and assessing it.
Indications: Monitoring the condition of the fetus during pregnancy and childbirth.
Prepare: couch, diaper, obstetric stethoscope.
Sequencing:
Lay out the diaper, wash your hands.
The pregnant woman is placed on the couch on her back.
Leopold-Levitsky's techniques determine the position of the fetus, presentation, position and type of position.
- The fetal heartbeat is heard from the back of the fetus, closer to the head!
Therefore, the stethoscope is installed
depending on the position of the fetus:
on the left - at 1st position,
on the right - at 2nd position,
depending on the presentation of the fetus:
with cephalic presentation - just below the navel,
with the pelvic - just above the navel,
with a transverse position of the fetus - at the level of the navel.
The stethoscope is pressed tightly between the pregnant woman's belly and the midwife's ear (do not hold the stethoscope with your hand).
When calculating the fetal heartbeat, it is necessary to compare it with the mother’s pulse. Then use a stopwatch to count the number of fetal heartbeats in 15 seconds and multiply by 4.
Evaluate: frequency, sonority, rhythm of tones.
During childbirth:
1st period: The heartbeat is heard as well as during
pregnancy.
2nd period: The heartbeat is heard directly above the pubis
linea alba.
Note: During childbirth, the heartbeat is heard only during the pause between contractions, 10 seconds after its end.
There may be a slight increase or decrease in heart rate immediately after a contraction, but it should recover quickly.
Determining the duration of pregnancy and childbirth
1. According to the last menstruation– from the 1st day of the last menstruation.
According to the first movement of the fetus
Primigravidas begin to feel the first movement of the fetus at 20 weeks of pregnancy. Multipregnant women - at 18 weeks of pregnancy.
Upon first appearance at the antenatal clinic
According to the height of the uterine fundus
· 5-6 weeks – about the size of a chicken egg
· 8 weeks – about the size of a goose egg
· 12 weeks – the size of a newborn’s head
· 16 weeks – 5-6 cm above the pubis, midway between the navel and the pubis
· 20 weeks – 11-12 cm, 2 cross fingers below the navel
· 24 weeks – 18-20 cm, at the level of the navel
· 28 weeks – 24 cm, 2-3 cross fingers above the navel
· 32 weeks – 28-30 cm, in the middle of the distance between the navel and the xiphoid process of the sternum, coolant – 85-90 cm. The navel is smoothed, the diameter of the head is 9-10 cm.
· 36 weeks – 34-36 cm, at the level of the xiphoid process, the navel is smoothed. Coolant – 90-102 cm
· 38 weeks – under the xiphoid process
· 40 weeks – 28-30 cm, navel protrudes. The head descends to the entrance to the pelvis, the diameter of the head is 12 cm.
By formulas
· Sutugina: gestational age = fruit length x 2
· Skulsky: gestational age = fruit length x 2 – 5
· Jordania: gestational age = Z + C, where
Z – fruit length
C – fronto-occipital size of the fetal head
By ultrasound
Estimated due date:
first day of last menstruation – 3 months + 7 days
Determination of estimated fetal weight
Jordan's formula:
M = abdominal circumference(coolant) x fundal height of the uterus(VDM)
Lebedova's formula:
M = abdominal circumference + VYD
Lankowitz formula:
M = ( coolant + VYD + woman's height(in cm) + woman weight(in kg)) x 10
Johnson's formula:
M = (VDM – 11) x 155
11 – conditional coefficient for a pregnant woman’s weight up to 90 kg,
12 - with a pregnant woman weighing more than 90 kg.
Childbirth table
1. Oilcloth, three layers of diaper.
2. Midwife's robe.
3. Pediatrician's robe.
4. Gloves for midwives.
5. Gloves for pediatricians.
6. Kidney-shaped tray for recording blood loss.
7. Rubber catheter for releasing urine.
8. Disposable catheter for suctioning mucus in a newborn.
9. Jar for sterile solution (rinsing the catheter for a newborn).
10. Sterile material.
11. Sterile diapers, at least three.
12. First toilet bag for a newborn.
Management of childbirth by period
Target: Prevention of complications during childbirth.
Management of the first stage of labor:
· Identify and solve problems of the mother in labor
· Promote the active behavior of the woman in labor (use of various positions, rocking chairs, inflatable balls, etc.)
· Take blood for compatibility
· Measure blood pressure every hour
· Listen to the fetal breath every 15-20 minutes when the waters are still intact, every 5-10 minutes when the waters have broken
· Monitor the strength, frequency, duration, effectiveness and pain of contractions.
· Conduct external obstetric examination and determine the degree of opening of the uterine pharynx using external techniques.
· Maintain a partograph.
· Carry out biomonitor monitoring of fetal s/w and uterine contractions (as prescribed by a doctor).
· Conduct a vaginal examination of the woman in labor as indicated.
· Teach methods of self-anesthesia during childbirth, administer medicinal pain relief as prescribed by a doctor.
· Monitor genital tract discharge, bladder and bowel function.
· If a complication is detected during childbirth, call a doctor.
Management of the second stage of labor:
· Set the sterile delivery table.
· Transfer the woman in labor to Rakhmanov’s bed:
Primipara - from the moment the head is cut in,
· multiparous – from the moment of complete opening of the cervix.
· Vertical birth is possible upon request.
· Treatment of the external genitalia with an antiseptic.
· Manage pushing – during 1 contraction you need to push 3 times.
· Listen to the fetal breath after each push.
· Provide obstetric benefits.
· Prevent bleeding from the moment of extension of the head.
· Monitor the general condition of the woman in labor.
Management of the third stage of labor:
· After the baby is born, place a tray in the woman’s genital tract to record blood loss.
· Catheterize the bladder.
· Observe the woman’s condition, skin color, pulse, blood pressure, complaints.
· Observe for signs of placenta separation.
· If there are positive signs of separation of the placenta, invite the woman in labor to push and accept the placenta.
· If the placenta is not born on its own, use external methods for releasing the placenta (if there are positive signs of placental separation).
Preparing for a vaginal examination during labor
Target: Production of vaginal examination.
Indications: upcoming birth.
Prepare: gynecological chair, 0.02% solution KMO 4 (warm), solutions, sterile material, disinfected oilcloth, sterile diaper, Esmarch mug.
Sequencing:
1. Place the woman on a gynecological chair on an individual disinfected oilcloth.
2. Treat the external genitalia with 0.02% KMO 4 solution - spray of disinfectant. solution from Esmarch's mug washes the genitals from the pubis to the perineum.
3. Dry with a sterile swab held in a forceps.
4. Treat the external genitalia with a sterile swab, iodonate or chlorhexidine according to the principle from the center to the periphery (pubis upward, labia majora, upper third of the inner thighs, grabbing the buttocks, but not touching the anus; lastly, the anus is treated with one wide stroke) . The tool is reset.
5. Place a sterile diaper under the woman.
When examining a pregnant woman or woman in labor, general and special history data are used, a general objective and special obstetric examination, laboratory and additional research methods are carried out. The latter include hematological, immunological (serological, etc.), bacteriological, biochemical, histological, cytological studies; study of cardiac activity, endocrinological, mathematical research methods to identify possible diseases, pregnancy complications and fetal development disorders. When appropriate, fluoroscopy and radiography, amniocentesis, ultrasound and other modern diagnostic methods are used.
SURVEY OF PREGNANT AND WOMEN IN LABOR
A survey of a pregnant woman and a woman in labor is carried out according to a specific plan. The survey consists of a general and a special part. All data obtained is entered into the pregnant woman’s chart or birth history.
General anamnesis
Passport details : last name, first name, patronymic, age, place of work and profession, place of birth and residence.
Reasons that forced a woman to seek medical help (complaints).
Working and living conditions.
Heredity and past diseases. Hereditary diseases (tuberculosis, syphilis, mental and oncological diseases, multiple pregnancies, etc.) are of interest because they can have an adverse effect on the development of the fetus, as well as intoxication, in particular, alcoholism and drug addiction in parents. It is important to obtain information about all infectious and non-infectious diseases and operations undergone in early childhood, during puberty and adulthood, their course and methods and timing of treatment. Allergy history. Previous blood transfusions.
Special anamnesis
Menstrual function: the time of the onset of menarche and the establishment of menstruation, the type and nature of menstruation (3 or 4 week cycle, duration, amount of blood lost, presence of pain, etc.); did menstruation change after the onset of sexual activity, childbirth, abortion; date of the last normal menstruation.
Secretory function : the nature of vaginal discharge, its quantity, color, smell.
Sexual function: at what age did you begin sexual activity, what type of marriage, duration of marriage, period from the beginning of sexual activity to the onset of the first pregnancy, time of last sexual intercourse.
Husband's age and health.
Childbearing (generative) function. In this part of the anamnesis, detailed information is collected about previous pregnancies in chronological order, what the current pregnancy is, the course of previous pregnancies (were there any toxicoses, gestosis, diseases of the cardiovascular system, kidneys, liver and other organs), their complications and outcome. The presence of these diseases in the past prompts a woman to be especially closely monitored during a current pregnancy. It is necessary to obtain detailed information about the course of the abortions, each birth (duration of labor, surgical interventions, gender, weight, growth of the fetus, its condition at birth, length of stay in the maternity hospital) and postpartum periods, complications, methods and timing of their treatment.
Past gynecological diseases : time of onset, duration of disease, treatment and outcome
The course of this pregnancy (by trimester):
1st trimester (up to 12 weeks) – general diseases, pregnancy complications (toxicosis, threat of miscarriage, etc.), date of first appearance at the antenatal clinic and gestational age established at the first visit.
2nd trimester (13-28 weeks) - general diseases and complications during pregnancy, weight gain, blood pressure numbers, test results, date of first fetal movement.
3rd trimester (29 – 40 weeks) – overall weight gain during pregnancy, its uniformity, results of blood pressure measurements and blood and urine tests, diseases and complications of pregnancy. Reasons for hospitalization.
Determining due date or gestational age
GENERAL OBJECTIVE EXAMINATION
A general objective study is carried out to identify diseases of the most important organs and systems that can complicate the course of pregnancy and childbirth. In turn, pregnancy can cause exacerbation of existing diseases, decompensation, etc. An objective examination is carried out according to generally accepted rules, starting with an assessment of the general condition, temperature measurement, examination of the skin and visible mucous membranes. Then the circulatory, respiratory, digestive, urinary, nervous and endocrine systems are examined.
SPECIAL OBSTETRIC EXAMINATION
Special obstetric examination includes three main sections: external obstetric examination, internal obstetric examination and additional research methods.
EXTERNAL OBSTETRIC EXAMINATION
External obstetric examination is carried out by inspection, measurement, palpation and auscultation.
Inspection allows us to identify the correspondence of the type of pregnant woman to her age. At the same time, attention is paid to the woman’s height, physique, condition of the skin, subcutaneous tissue, mammary glands and nipples. Particular attention is paid to the size and shape of the abdomen, the presence of pregnancy scars (striae gravidarum), and skin elasticity.
Pelvic examination is important in obstetrics because its structure and size have a decisive influence on the course and outcome of childbirth. A normal pelvis is one of the main conditions for the correct course of labor. Deviations in the structure of the pelvis, especially a decrease in its size, complicate the course of labor or present insurmountable obstacles to it. The pelvis is examined by inspection, palpation and measurement of its size. When examining, pay attention to the entire pelvic area, but give special importance to the lumbosacral rhombus (Michaelis diamond). The Michaelis rhombus is a shape in the sacral area that has the contours of a diamond-shaped area. The upper corner of the rhombus corresponds to the spinous process of the V lumbar vertebra, the lower - to the apex of the sacrum (the origin of the gluteus maximus muscles), the lateral angles - to the superoposterior spine of the iliac bones. Based on the shape and size of the rhombus, you can evaluate the structure of the bony pelvis and detect its narrowing or deformation, which is of great importance in the management of childbirth. Its dimensions: horizontal diagonal rhombus is 10-11 cm, vertical- 11 cm. With different narrowings of the pelvis, the horizontal and vertical diagonals will be of different sizes, as a result of which the shape of the rhombus will be changed.
During an external obstetric examination, measurements are made with a centimeter tape (circumference of the wrist joint, dimensions of the Michaelis rhombus, abdominal circumference and height of the uterine fundus above the womb) and an obstetric compass (pelvis gauge) in order to determine the size of the pelvis and its shape.
Using a centimeter tape, measure the largest circumference of the abdomen at the level of the navel (at the end of pregnancy it is 90-100 cm) and the height of the uterine fundus - the distance between the upper edge of the pubic symphysis and the fundus of the uterus. At the end of pregnancy, the height of the uterine fundus is 32-34 cm. Measuring the abdomen and the height of the uterine fundus above the womb allows the obstetrician to determine the duration of pregnancy, the expected weight of the fetus, and identify disorders of fat metabolism, polyhydramnios, and multiple births.
By the external dimensions of the large pelvis one can judge the size and shape of the small pelvis. The pelvis is measured using a pelvic meter. Only some measurements (pelvic outlet and additional measurements) can be made with a measuring tape. Usually four sizes of the pelvis are measured - three transverse and one straight. The subject is in a supine position, the obstetrician sits to the side of her and faces her.
Distantia spinarum - the distance between the most distant points of the anterior superior iliac spines (spina iliaca anterior superior) is 25-26 cm.
Distantia cristarum - the distance between the most distant points of the iliac crests (crista ossis ilei) is 28-29 cm.
Distantia trochanterica - the distance between the greater trochanters of the femurs (trochanter major) is 31-32 cm.
Conjugata externa (outer conjugate) - the distance between the spinous process of the V lumbar vertebra and the upper edge of the symphysis pubis is 20-21 cm. To measure the external conjugate, the subject turns on her side, bends the underlying leg at the hip and knee joints, and extends the overlying leg. The pelvic meter button is placed between the spinous process of the V lumbar and I sacral vertebrae (suprasacral fossa) at the back and in the middle of the upper edge of the symphysis pubis at the front. By the size of the outer conjugate one can judge the size of the true conjugate. The difference between the external and true conjugate depends on the thickness of the sacrum, symphysis and soft tissues. The thickness of bones and soft tissues in women is different, so the difference between the size of the external and true conjugate does not always exactly correspond to 9 cm. To characterize the thickness of the bones, they use the measurement of the circumference of the wrist joint and the Solovyov index (1/10 of the circumference of the wrist joint). Bones are considered thin if the circumference of the wrist joint is up to 14 cm and thick if the circumference of the wrist joint is more than 14 cm. Depending on the thickness of the bones, with the same external dimensions of the pelvis, its internal dimensions may be different. For example, with an external conjugate of 20 cm and a Solovyov circumference of 12 cm (Solovyov index - 1.2), we need to subtract 8 cm from 20 cm and get the value of the true conjugate - 12 cm. With a Solovyov circumference of 14 cm, we need to subtract 9 cm from 20 cm, and at 16 cm, subtract 10 cm, - the true conjugate will be equal to 9 and 10 cm, respectively.
The size of the true conjugate can be judged according to the vertical size of the sacral rhombus And Franc size. The true conjugate can be more accurately determined along the diagonal conjugate.
Diagonal conjugate (conjugata diagonalis) they call the distance from the lower edge of the symphysis to the most prominent point of the sacral promontory (13 cm). The diagonal conjugate is determined during a vaginal examination of a woman, which is performed with one hand.
Straight pelvic outlet size - this is the distance between the middle of the lower edge of the symphysis pubis and the tip of the coccyx. During the examination, the pregnant woman lies on her back with her legs apart and half-bent at the hip and knee joints. The measurement is carried out with a pelvis meter. This size, equal to 11 cm, is 1.5 cm larger than the true one due to the thickness of the soft tissues. Therefore, it is necessary to subtract 1.5 cm from the resulting figure of 11 cm, and we obtain the direct size of the exit from the pelvic cavity, which is equal to 9.5 cm.
Transverse size of the pelvic outlet - this is the distance between the inner surfaces of the ischial tuberosities. The measurement is carried out with a special pelvis or measuring tape, which is applied not directly to the ischial tuberosities, but to the tissues covering them; therefore, to the resulting dimensions of 9-9.5 cm, it is necessary to add 1.5-2 cm (thickness of soft tissues). Normally, the transverse size is 11 cm. It is determined in the position of the pregnant woman on her back, with her legs pressed as close as possible to her stomach.
Oblique pelvic dimensions have to be measured with oblique pelvises. To identify pelvic asymmetry, the following oblique dimensions are measured: the distance from the anterosuperior spine of one side to the posterosuperior spine of the other side (21 cm); from the middle of the upper edge of the symphysis to the right and left posterosuperior spines (17.5 cm) and from the supracruciate fossa to the right and left anterosuperior spines (18 cm). The oblique dimensions of one side are compared with the corresponding oblique dimensions of the other. With a normal pelvic structure, the paired oblique dimensions are the same. A difference greater than 1 cm indicates pelvic asymmetry.
Lateral dimensions of the pelvis – the distance between the anterosuperior and posterosuperior iliac spines of the same side (14 cm), measured with a pelvis. The lateral dimensions must be symmetrical and at least 14 cm. With a lateral conjugate of 12.5 cm, childbirth is impossible.
Pelvic angle - this is the angle between the plane of the entrance to the pelvis and the horizontal plane. In the standing position of a pregnant woman, it is 45-50. Determined using a special device - a pelvis angle meter.
In the second half of pregnancy and during childbirth, the head, back and small parts (limbs) of the fetus are determined by palpation. The longer the pregnancy, the clearer the palpation of parts of the fetus. External obstetric examination techniques (Leopold-Levitsky) are sequential palpation of the uterus, consisting of a number of specific techniques. The subject is in a supine position. The doctor sits to her right, facing her.
First appointment of external obstetric examination. The first step is to determine the height of the uterine fundus, its shape and the part of the fetus located in the uterine fundus. To do this, the obstetrician places the palmar surfaces of both hands on the uterus so that they cover its bottom.
Second appointment of external obstetric examination. The second step determines the position of the fetus in the uterus, the position and type of the fetus. The obstetrician gradually lowers his hands from the bottom of the uterus to its right and left sides and, carefully pressing with his palms and fingers on the lateral surfaces of the uterus, determines the back of the fetus along its wide surface on one side, and the small parts of the fetus (arms, legs) on the other. This technique allows you to determine the tone of the uterus and its excitability, palpate the round ligaments of the uterus, their thickness, pain and location.
Third appointment of external obstetric examination. The third technique is used to determine the presenting part of the fetus. The third technique can determine the mobility of the head. To do this, cover the presenting part with one hand and determine whether it is the head or the pelvic end, a symptom of voting of the fetal head.
Fourth appointment of external obstetric examination. This technique, which is a complement and continuation of the third, makes it possible to determine not only the nature of the presenting part, but also the location of the head in relation to the entrance to the pelvis. To perform this technique, the obstetrician stands facing the legs of the examinee, places his hands on both sides of the lower part of the uterus so that the fingers of both hands seem to converge with each other above the plane of the entrance to the pelvis, and palpates the presenting part. When examined at the end of pregnancy and during childbirth, this technique determines the relationship of the presenting part to the planes of the pelvis. During childbirth, it is important to find out in which plane of the pelvis the head is located with its largest circumference or major segment. The major segment of the head is the largest part of it that passes through the entrance to the pelvis in a given presentation. With an occipital presentation of the head, the border of its large segment will pass along the line of the small oblique size, with an anterior cephalic presentation - along the line of its direct size, with a frontal presentation - along the line of the large oblique size, with a facial presentation - along the line of the vertical size. The small segment of the head is any part of the head located below the large segment.
The degree of insertion of the head by a large or small segment is judged by palpation data. During the fourth external technique, the fingers are moved deeper and slide upward along the head. If the hands come together, the head is a large segment at the entrance to the pelvis or has sunk deeper; if the fingers diverge, the head is a small segment at the entrance. If the head is in the pelvic cavity, it cannot be determined by external methods.
Fetal heart sounds are listened to with a stethoscope, starting from the second half of pregnancy, in the form of rhythmic, clear beats repeated 120-160 times per minute. With cephalic presentations, the heartbeat is best heard below the navel. In case of breech presentation - above the navel.
M.S. Malinowski proposed the following rules for listening to the fetal heartbeat:
in case of occipital presentation - near the head below the navel on the side where the back is facing, in posterior views - on the side of the abdomen along the anterior axillary line,
in case of facial presentation - below the navel on the side where the breast is located (in the first position - on the right, in the second - on the left),
in a transverse position - near the navel, closer to the head,
when presented with the pelvic end - above the navel, near the head, on the side where the back of the fetus is facing.
The dynamics of the fetal heartbeat is studied using monitoring and ultrasound.
INTERNAL (VAGINAL) EXAMINATION
Internal obstetric examination is performed with one hand (two fingers, index and middle, four - half-hand, whole hand). Internal examination makes it possible to determine the presenting part, the state of the birth canal, observe the dynamics of cervical dilation during childbirth, the mechanism of insertion and advancement of the presenting part, etc. In women in labor, a vaginal examination is performed upon admission to the obstetric institution, and after the rupture of amniotic fluid. In the future, vaginal examination is performed only when indicated. This procedure allows for timely identification of complications during labor and provision of assistance. Vaginal examination of pregnant women and women in labor is a serious intervention that must be performed in compliance with all rules of asepsis and antiseptics.
Internal examination begins with examination of the external genitalia (hair growth, development, swelling of the vulva, varicose veins), the perineum (its height, rigidity, presence of scars) and the vestibule of the vagina. The phalanges of the middle and index fingers are inserted into the vagina and examined (lumen width and length, folding and extensibility of the vaginal walls, the presence of scars, tumors, septa and other pathological conditions). Then the cervix is found and its shape, size, consistency, degree of maturity, shortening, softening, location along the longitudinal axis of the pelvis, and patency of the pharynx for the finger are determined. During the examination during labor, the degree of smoothness of the cervix (preserved, shortened, smoothed), the degree of opening of the pharynx in centimeters, and the condition of the edges of the pharynx (soft or dense, thick or thin) are determined. In women in labor, a vaginal examination determines the condition of the fetal bladder (integrity, loss of integrity, degree of tension, amount of anterior water). Determine the presenting part (buttocks, head, legs), where they are located (above the entrance to the small pelvis, at the entrance with a small or large segment, in the cavity, at the pelvic outlet). Identification points on the head are sutures, fontanelles, and at the pelvic end - the sacrum and coccyx. Palpation of the inner surface of the pelvic walls makes it possible to identify deformation of its bones, exostoses and judge the capacity of the pelvis. At the end of the study, if the presenting part is high, measure the diagonal conjugata (conjugata diagonalis), the distance between the promontory and the lower edge of the symphysis (normally 13 cm). To do this, with the fingers inserted into the vagina, they try to reach the promontory and touch it with the end of the middle finger, the index finger of the free hand is brought under the lower edge of the symphysis and mark on the hand the place that directly contacts the lower edge of the pubic arch. Then remove the fingers from the vagina and wash them. The assistant measures the marked distance on the hand with a centimeter tape or a hip meter. By the size of the diagonal conjugate one can judge the size of the true conjugate. If Solovyov index(0.1 from Solovyov’s circumference) to 1.4 cm, then subtract 1.5 cm from the size of the diagonal conjugate, and if more than 1.4 cm, then subtract 2 cm.
Determining the position of the fetal head during labor
At first degree of head extension (anterocephalic insertion) the circumference of which the head will pass through the pelvic cavity corresponds to its direct size. This circle is the large segment when inserted anteriorly.
At second degree of extension (frontal insertion) the largest circumference of the head corresponds to the large oblique size. This circle is a large segment of the head when it is inserted frontally.
At third degree of head extension (facial insertion) the largest circle is the one corresponding to the “vertical” size. This circle corresponds to the large segment of the head when it is inserted face-on.
Determining the degree of insertion of the fetal head during labor
The basis for determining the height of the head during vaginal examination is the ability to determine the relationship of the lower pole of the head to the linea interspinalis.
Head above the pelvic inlet: When you gently press upward with your finger, the head moves away and returns to its original position. The entire anterior surface of the sacrum and the posterior surface of the pubic symphysis are accessible to palpation.
The head is a small segment at the entrance to the pelvis: the lower pole of the head is determined 3-4 cm above the linea interspinalis or at its level, the sacral cavity is 2/3 free. The posterior surface of the pubic symphysis is palpable in the lower and middle sections.
Head in the pelvic cavity: the lower pole of the head is 4-6 cm below the linea interspinalis, the ischial spines are not defined, almost the entire sacral cavity is filled with the head. The posterior surface of the pubic symphysis is not palpable.
Head on the pelvic floor: the head fills the entire sacral cavity, including the coccyx area, only soft tissues can be palpated; the internal surfaces of bone identification points are difficult to access for research.
TOPIC No. 5
BIOMECHANISM OF LABOR IN ANTERIOR AND POSTERIOR TYPES OF OCCUPITA PRESENTATION
The natural set of all movements that the fetus makes while passing through the mother’s birth canal is called biomechanism of childbirth. Against the background of forward movement along the birth canal, the fetus performs flexion, rotation and extension movements.
Occipital presentation This is called a presentation when the fetal head is in a bent state and its lowest located area is the back of the head. Births in the occipital presentation account for about 96% of all births. With occipital presentation there may be front And back view. The anterior view is more often observed in the first position, the posterior view in the second.
The head enters the pelvic inlet in such a way that the sagittal suture is located along the midline (along the pelvic axis) - at the same distance from the pubic symphysis and the promontory - synclitic(axial) insertion. In most cases, the fetal head begins to insert into the entrance in a state of moderate posterior asynclitism. Later, during the physiological course of labor, when contractions intensify, the direction of pressure on the fetus changes and, in connection with this, asynclitism is eliminated.
After the head has descended to the narrow part of the pelvic cavity, the obstacle encountered here causes an increase in labor activity, and at the same time an increase in various movements of the fetus.
BIOMECHANISM OF CHILDREN IN ANTERIOR VIEW OF OCCIPITAL PRESENTATION
First moment - flexion of the head.
It is expressed in the fact that the cervical part of the spine bends, the chin approaches the chest, the back of the head goes down, and the forehead lingers above the entrance to the pelvis. As the back of the head descends, the small fontanel is positioned lower than the large one, so that the leading point (the lowest point on the head, which is located on the wire midline of the pelvis) becomes a point on the sagittal suture closer to the small fontanel. In the anterior form of occipital presentation, the head is bent to a small oblique size and passes through the entrance to the small pelvis and into the wide part of the pelvic cavity. Consequently, the fetal head is inserted into the entrance to the small pelvis in a state of moderate flexion, synclitically, transversely or in one of its oblique dimensions.
Second point - internal rotation of the head (correct).
The fetal head, continuing its forward movement in the pelvic cavity, encounters resistance to further movement, which is largely due to the shape of the birth canal, and begins to rotate around its longitudinal axis. The rotation of the head begins when it passes from the wide to the narrow part of the pelvic cavity. In this case, the back of the head, sliding along the side wall of the pelvis, approaches the pubic symphysis, while the anterior section of the head moves towards the sacrum. The sagittal suture from the transverse or one of the oblique dimensions subsequently transforms into the direct dimension of the outlet from the pelvis, and the suboccipital fossa is installed under the pubic symphysis.
Third point - extension of the head.
The fetal head continues to move along the birth canal and at the same time begins to unbend. Extension during physiological childbirth occurs at the pelvic outlet. The direction of the fascial-muscular part of the birth canal contributes to the deviation of the fetal head towards the womb. The suboccipital fossa abuts the lower edge of the symphysis pubis, forming a point of fixation and support. The head rotates with its transverse axis around the fulcrum - the lower edge of the pubic symphysis - and within several attempts it is completely unbent. The birth of the head through the vulvar ring occurs with a small oblique size (9.5 cm). The back of the head, crown, forehead, face and chin are born sequentially.
Fourth point - internal rotation of the shoulders and external rotation of the fetal head.
During extension of the head, the fetal shoulders are already inserted into the transverse dimension of the entrance to the small pelvis or into one of its oblique dimensions. As the head follows the soft tissues of the pelvic outlet, the shoulders move helically along the birth canal, that is, they move down and at the same time rotate. At the same time, with their transverse size (distantia biacromialis), they transform from the transverse size of the pelvic cavity into an oblique one, and in the exit plane of the pelvic cavity - into a direct size. This rotation occurs when the fetal body passes through the plane of the narrow part of the pelvic cavity and is transmitted to the born head. In this case, the back of the fetal head turns towards the mother’s left (in the first position) or right (in the second position) thigh. The anterior shoulder now enters under the pubic arch. Between the anterior shoulder at the site of attachment of the deltoid muscle and the lower edge of the symphysis, a second point of fixation and support is formed. Under the influence of labor forces, the fetal torso bends in the thoracic spine and the fetal shoulder girdle is born. The anterior shoulder is born first, while the posterior one is somewhat delayed by the coccyx, but soon bends it, protrudes the perineum and is born above the posterior commissure during lateral flexion of the torso.
After the birth of the shoulders, the rest of the body, thanks to the good preparation of the birth canal by the born head, is easily released. The head of a fetus born in an anterior occipital presentation has a dolichocephalic shape due to the configuration and birth tumor.
BIOMECHANISM OF BIRTH IN POSTERIOR VIEW OF OCCIPITAL PRESENTATION
With occipital presentation, regardless of whether the occiput at the beginning of labor is facing anteriorly, towards the womb or posteriorly, towards the sacrum, by the end of the expulsion period it is usually established under the pubic symphysis and the fetus is born in 96% of cases in the anterior view. And only in 1% of all occipital presentations the child is born in the posterior position.
Childbirth in the posterior form of occipital presentation is a variant of the biomechanism in which the birth of the fetal head occurs when the back of the head faces the sacrum. The reasons for the formation of a posterior view of the occipital presentation of the fetus can be changes in the shape and capacity of the small pelvis, functional inferiority of the muscles of the uterus, features of the shape of the fetal head, a premature or dead fetus.
During vaginal examination a small fontanel is identified at the sacrum, and a large fontanel at the womb. The biomechanism of labor in posterior view consists of five points.
First moment - flexion of the fetal head.
In the posterior view of the occipital presentation, the sagittal suture is installed synclitically in one of the oblique dimensions of the pelvis, in the left (first position) or in the right (second position), and the small fontanel is directed to the left and posteriorly, to the sacrum (first position) or to the right and posteriorly, to sacrum (second position). The head bends in such a way that it passes through the entrance plane and the wide part of the pelvic cavity with its average oblique size (10.5 cm). The leading point is the point on the sagittal suture, located closer to the large fontanelle.
Second point - internal wrong turning the head.
An arrow-shaped suture of oblique or transverse dimensions makes a turn of 45 or 90, so that the small fontanelle is behind the sacrum, and the large one is in front of the womb. Internal rotation occurs when passing through the plane of the narrow part of the small pelvis and ends in the plane of the exit of the small pelvis, when the sagittal suture is installed in a straight dimension.
Third point - further ( maximum) flexion of the head.
When the head approaches the border of the scalp of the forehead (fixation point) under the lower edge of the pubic symphysis, it is fixed, and the head makes further maximum bending, as a result of which its occiput is born to the suboccipital fossa.
Fourth point - extension of the head.
A fulcrum point (anterior surface of the coccyx) and a fixation point (suboccipital fossa) were formed. Under the influence of labor forces, the fetal head extends, and first the forehead appears from under the womb, and then the face, facing the womb. Subsequently, the biomechanism of childbirth occurs in the same way as with the anterior view of the occipital presentation.
Fifth point - external rotation of the head, internal rotation of the shoulders.
Due to the fact that an additional and very difficult moment is included in the biomechanism of labor in the posterior form of occipital presentation - maximum flexion of the head - the period of expulsion is prolonged. This requires additional work of the uterine and abdominal muscles. The soft tissues of the pelvic floor and perineum are subject to severe stretching and are often injured. Prolonged labor and increased pressure from the birth canal, which the head experiences when it is maximally flexed, often lead to fetal asphyxia, mainly due to impaired cerebral circulation.
TOPIC No. 6
BIRTH CLINIC FOR CIVIC PRESENTATION
Childbirth is a complex biological process that results in the expulsion of the fertilized egg from the uterus through the natural birth canal after the fetus reaches maturity. Physiological birth occurs on the 280th day of pregnancy, starting from the first day of the last menstruation.
REASONS FOR LABOR
Childbirth- this is a reflex act that occurs due to the interaction of all systems of the body of the mother and fetus. The reasons for the onset of labor are still not well understood. There are many hypotheses. Currently, the search and accumulation of factual material to study the causes of labor continue.
Childbirth occurs in the presence of a formed generic dominant, in which nerve centers and executive organs take part. In the formation of a generic dominant, the influence of sex hormones on various formations of the central and peripheral nervous system is important. A significant increase in the electrical activity of the brain was noted 1-1.5 weeks before the onset of birth (E. A. Chernukha, 1991). The onset of labor should be considered as the result of a process of gradual connection between morphological, hormonal, and biophysical conditions. Reflexes begin with uterine receptors that perceive irritation from the fertilized egg. Reflex reactions depend on the influence of humoral and hormonal factors on the nervous system, as well as on the tone of the sympathetic (adrenergic) and parasympathetic (cholinergic) parts of the nervous system. The sympathetic-adrenal system is involved in the regulation of homeostasis. Adrenaline, norepinephrine and catecholamines are involved in the motor function of the uterus. Acetylcholine and norepinephrine increase uterine tone. Various mediator and hormonal receptors have been identified in the myometrium: α-adrenergic receptors, serotonin, cholinergic and histamine receptors, estrogen and progesterone, prostaglandin receptors. The sensitivity of uterine receptors depends mainly on the ratio of sex steroid hormones - estrogen and progesterone, which plays a role in the occurrence of labor. Corticosteroids are also involved in the development of labor. An increase in the concentration of corticosteroids is associated with an increase in their synthesis by the adrenal glands of the mother and fetus, as well as their increased synthesis by the placenta. Along with hormonal factors, serotonin, kinins, and enzymes take part in the regulation of the motor function of the uterus. The hormone of the posterior lobe of the pituitary gland and hypothalamus - oxytocin - is considered the main one in the development of labor. The accumulation of oxytocin in the blood plasma occurs throughout pregnancy and affects the preparation of the uterus for active labor. The enzyme oxytocinase (destroys oxytocin), produced by the placenta, maintains the dynamic balance of oxytocin in the blood plasma. Prostaglandins also take part in the occurrence of labor. The mechanism of their action on the uterus continues to be studied, but its essence is the opening of the calcium channel. Calcium ions take part in the complex process of transferring the uterine muscle from a resting state to an active state. During normal labor in the myometrium, there is an increase in protein synthesis, accumulation of RNA, a decrease in glycogen levels, and an increase in redox processes. Currently, in the onset of labor and the regulation of contractile activity of the uterus, great importance is attached to the functions of the feto-placental system and the epiphysio-hypothalamic-pituitary-adrenal system of the fetus. The contractile function of the uterus is influenced by intrauterine pressure and the size of the fetus.
The onset of labor is preceded by harbingers of childbirth And preliminary period.
Harbingers of childbirth- these are symptoms that occur one month or two weeks before birth. These include: movement of the center of gravity of the pregnant woman's body anteriorly, the shoulders and head are retracted back ("proud gait"), prolapse of the uterine fundus due to pressing of the presenting part of the fetus to the entrance to the pelvis (in first-time mothers this occurs a month before birth), a decrease in the volume of amniotic fluid water; removal of the “mucus” plug from the cervical canal; no weight gain in the last two weeks or a decrease in body weight to 800 g; increased tone of the uterus or the appearance of irregular cramping sensations in the lower abdomen, etc.
Preliminary period lasts no more than 6-8 hours (up to 12 hours). It occurs immediately before childbirth and is expressed in irregular painless contractions of the uterus, which gradually turn into regular contractions. The preliminary period corresponds to the time of formation of the generic dominant in the cerebral cortex and is accompanied by the biological “ripening” of the cervix. The cervix softens, takes a central position along the pelvic axis and sharply shortens. A pacemaker is formed in the uterus. Its function is performed by a group of nerve ganglion cells, which is most often located closer to the right tubal angle of the uterus.
Regular contractions indicate that labor has begun. From the beginning of labor to its end, a pregnant woman is called woman in labor, and after childbirth - mother in labor. The birth act consists of the interaction of expelling forces (contractions, pushing), the birth canal and the object of childbirth - the fetus. The process of childbirth occurs mainly due to the contractile activity of the uterus - contractions.
Contractions- These are involuntary rhythmic contractions of the uterus. Subsequently, simultaneously with involuntary contractions of the uterus, rhythmic (voluntary) contractions of the abdominal press occur - attempts.
Contractions are characterized by duration, frequency, strength and pain. At the beginning of labor, the contraction lasts 5-10 seconds, reaching 60 seconds or more towards the end of labor. The pauses between contractions at the beginning of labor are 15-20 minutes, towards the end their interval is gradually reduced to 2-3 minutes. The tone and strength of uterine contractions are determined by palpation: the hand is placed on the fundus of the uterus and the time from the beginning of one to the beginning of another uterine contraction is determined using a stopwatch.
Modern methods of recording labor (hysterograph, monitor) make it possible to obtain more accurate information about the intensity of uterine contractions.
The interval from the beginning of one contraction to the beginning of another is called the uterine cycle. There are 3 phases of its development: the beginning and increase of uterine contraction; maximum myometrial tone; relaxation of muscle tension. Methods of external and internal hysterography during uncomplicated childbirth made it possible to establish the physiological parameters of uterine contractions. The contractile activity of the uterus is characterized by features - a triple descending gradient and a dominant uterine fundus. Contraction of the uterus begins in the area of one of the tubal angles, where the " pacemaker"(the pacemaker of the muscle activity of the myometrium in the form of ganglia of the autonomic nervous system) and from there gradually spreads down to the lower segment of the uterus (first gradient); at the same time, the strength and duration of contraction decreases (second and third gradients). The strongest and longest contractions of the uterus are observed in the bottom of the uterus (fundus dominant).
Second - reciprocity, i.e. the relationship between contractions of the uterine body and its lower parts: contraction of the uterine body promotes stretching of the lower segment and an increase in the degree of dilatation of the cervix. Under physiological conditions, the right and left halves of the uterus contract simultaneously and in a coordinated manner during contractions - horizontal coordination of contractions. Triple descending gradient, fundus dominance and reciprocity are called coordination of contractions vertically.
During each contraction, a simultaneous contraction of each muscle fiber and each muscle layer occurs in the muscular wall of the uterus - contraction, and displacement of muscle fibers and layers in relation to each other - retraction. During the pause, contraction is completely eliminated, and retraction is partially eliminated. As a result of contraction and retraction of the myometrium, the muscles shift from the isthmus to the body of the uterus ( distraction- stretching) and the formation and thinning of the lower segment of the uterus, effacement of the cervix, opening of the cervical canal, tight fitting of the fertilized egg with the walls of the uterus and expulsion of the fertilized egg.
PERIODS OF LABOR
During each contraction, intrauterine pressure increases to 100 mmHg. Art. (M.S. Malinovsky). The pressure is transferred to the fertilized egg, which, thanks to the amniotic fluid, takes the same shape as the cavity of the laboring uterus during each contraction. Amniotic fluid rushes down to the presenting part with the lower pole of the membranes - the amniotic sac, irritating the endings of the nerve receptors in the walls of the cervix with pressure, contributing to increased contractions.
When the muscles of the body and lower segment of the uterus contract, they stretch the walls of the cervical canal to the sides and upwards. Contractions of the muscle fibers of the uterine body are directed tangentially to the circular muscles of the cervix, this allows the cervix to open in the absence of the amniotic sac and even the presenting part. Thus, different directions of the muscle fibers of the body and cervix during contraction of the muscles of the body of the uterus (contraction and retraction) lead to the opening of the internal pharynx, smoothing of the cervix and the opening of the external pharynx (distraction).
During contractions, the part of the uterine body adjacent to the isthmus is stretched and drawn into the lower segment, which is much thinner than the so-called upper segment of the uterus. The border between the lower segment and the upper segment of the uterus has the form of a groove and is called contraction ring. It is determined after the rupture of amniotic fluid; the height of its standing above the womb in centimeters shows the degree of dilation of the cervical pharynx.
The lower segment of the uterus tightly covers the presenting head, forms internal belt of fit or contact. The latter divides the amniotic fluid into " front waters", located below the contact belt and " back waters" - above the contact belt. When the head, tightly enclosed by the lower segment, is pressed against the walls of the pelvis along its entire circumference, a outer belt fit. Therefore, if the integrity of the amniotic sac is broken and the amniotic fluid is released, the posterior waters do not flow out.
Cervical dilatation and effacement occur differently in first- and multiparous women. Before birth, in first-time mothers, the external and internal os are closed. The opening begins from the internal pharynx, the cervical canal and the cervix are somewhat shortened, then the cervical canal is stretched more and more, the cervix is correspondingly shortened and completely smoothed out. Only the outer pharynx remains closed (" obstetric pharynx"). Then the external pharynx begins to open. When fully dilated, it is defined as a narrow border in the birth canal. In multiparous women, at the end of pregnancy, the cervical canal is passable for one finger due to its stretching by previous births. The opening and smoothing of the cervix occurs simultaneously.
Amniotic sac during physiological childbirth, it ruptures with complete or almost complete dilatation of the uterine pharynx - timely opening of the amniotic sac. Rupture of the membranes before birth or with incomplete dilatation of the cervix (up to 6 cm of dilatation) is called premature opening of the membranes(respectively - prenatal, early). Sometimes, due to the density of the membranes, the fetal bladder does not open when the cervix is fully dilated - this delayed opening of the membranes.
Childbirth is divided into three periods: the first is the period of disclosure, the second is the period of expulsion, the third is the successive period.
Disclosure period refers to the time from the onset of regular contractions until the cervix is fully dilated. Currently, the average duration of the first stage of labor for a primipara is 11-12 hours, and for multiparous women it is 7-8 hours.
The period of exile refers to the time from the moment of complete dilation of the cervix until the birth of the fetus. During the period of expulsion, contractions of the abdominal wall, diaphragm and pelvic floor muscles join contractions and develop attempts expelling the fetus from the uterus. The expulsion period for primiparous women lasts up to 1 hour, for multiparous women - from 10 to 30 minutes.
Along with the birth of the fetus, the posterior waters flow out.
Succession period called the time from the birth of the fetus to the birth of the placenta. The placenta is the placenta, membranes, and umbilical cord.
After the birth of the fetus, the uterus is at rest for several minutes. Its bottom is at the level of the navel. Then rhythmic contractions of the uterus begin - afterbirth contractions, and the separation of the placenta from the wall of the uterus begins, which occurs in two ways: from the center or from the periphery.
The placenta exfoliates from the center, the uteroplacental vessels rupture, and the gushing blood forms a retroplacental hematoma, which contributes to further placental abruption. The separated placenta with its membranes falls down and, when pushing, is born, blood flows out with it. More often, the placenta is separated from the periphery, so with each subsequent contraction, part of the placenta separates and a portion of blood flows out. After complete detachment of the placenta from the wall of the uterus, it also descends into the lower parts of the uterus and, with pushing, is born. The succession period lasts from 7 to 30 minutes. The average blood loss after childbirth ranges from 150 to 250 ml. Physiological blood loss is considered to be equal to 0.5% of the mother’s body weight.
After the birth of the placenta, the postpartum period begins, and the woman in labor is called postpartum woman. The first 2 hours are designated as the early postpartum period.
CLINICAL COURSE OF LABOR
During the opening period
Contractions are characterized by duration, pauses, strength and pain. At the beginning of labor, contractions are repeated every 15-20 minutes for 10-15 seconds, weak in strength, painless or slightly painful. Gradually, the pauses between contractions shorten, the duration of contractions lengthens, the strength of contractions increases, and they become more painful. During contractions, the round ligaments become tense and the fundus of the uterus moves closer to the anterior abdominal wall. Contraction ring becomes more and more pronounced and rises above the pubic arch. By the end of the dilation period, the uterine fundus rises to the hypochondrium, and the contraction ring rises 5 transverse fingers above the pubic arch. The effectiveness of contractions is judged by the degree of dilatation of the cervix, determined during vaginal examination. During the process of dilatation, violations (shallow) of the integrity of the mucous membrane and muscle fibers of the cervix occur. The amniotic sac tenses during each contraction and, with almost complete dilatation of the uterine pharynx, opens, pouring out about 100-200 ml of light water. The amniotic sac usually ruptures within the cervical os.
Maintaining the disclosure period
A woman in labor enters the maternity hospital with a pregnant woman’s exchange card, which is filled out in the antenatal clinic, where there is information about the course of pregnancy and the state of the pregnant woman’s health. In the emergency department, the woman in labor is examined: an anamnesis is collected, a general and special obstetric examination is performed (measuring the external dimensions of the pelvis, the height of the uterine fundus, abdominal circumference, listening to the fetal heartbeat, etc.), and a vaginal examination.
In the prenatal ward, the woman in labor spends the first stage of labor. External obstetric examination during the dilatation period is carried out systematically, paying attention to the state of the uterus during and outside of contractions, and determining all four properties of contractions. Entries are made in the birth history every 3 hours. Listen to the fetal heartbeat every 15 minutes. The pattern of insertion and advancement of the fetal head along the birth canal is observed. This can be determined by external palpation techniques, vaginal examination, listening to the fetal heartbeat, and ultrasound examination.
Vaginal examination performed upon admission to the maternity hospital, when amniotic fluid ruptures and when a pathological course of labor occurs.
The general condition of the woman in labor is assessed and recorded in the birth history: color of the skin and visible mucous membranes, pulse, blood pressure, bladder and bowel function. When amniotic fluid is released, its quantity, color, transparency, and smell are determined.
To assess the progress of labor, it is advisable to keep a partogram (see figure).
During childbirth there are latent and active phases(E.A. Chernukha). Latent phase- this is the period of time from the beginning of regular contractions until the appearance of structural changes in the cervix, and this is - smoothing and dilation of the cervix up to 3-4 cm. The duration of the latent phase is 6.4 hours in primiparous women and 4.8 hours in multiparous women.
After the latent phase comes active phase. The speed of cervical dilatation in the active phase in primiparous women is 1.5-2 cm per hour, in multiparous women - 2-2.5 cm per hour. When the uterine os is fully dilated and the expulsion period begins, the woman in labor is transferred to the delivery room.
The course of labor during the period of exile
During the period of expulsion of contractions - after 2-3-4 minutes, 50-60 seconds each, and each contraction is reflexively accompanied by a contraction (voluntary) of the abdominal press. This process is called pushing. Under the influence of pushing, the fetus is gradually born through the birth canal, the presenting part - the head - comes in front. The pelvic floor muscles contract reflexively, especially when the head descends to the pelvic floor, and pain occurs from the pressure of the head on the nerves of the sacral plexus. At this moment there is a desire to expel the head from the birth canal.
The forward movement of the head can soon be seen: the perineum protrudes, then it stretches, the skin color becomes bluish. The anus protrudes and gapes, the genital fissure opens and, finally, the lower pole of the fetal head appears. At the end of the attempt, the head disappears behind the genital slit. And so several times the head appears and then disappears. It is called cutting in the head. After some time, the head does not hide after the end of the attempt - it begins eruption of the head, which coincides with the beginning of the third moment of the biomechanism of childbirth - extension of the head (birth to the parietal tuberosities). By extension, the head gradually emerges from under the pubic arch, the occipital fossa is located under the pubic symphysis, the parietal tubercles are tightly covered by stretched tissues. The forehead and face are born through the genital slit when the perineum slides off them. The head is born, makes an external turn, then the shoulders and torso are born, along with the pouring posterior waters.
The fetal head changes its shape, adapting to the shape of the birth canal, the bones of the skull overlap each other - this is called fetal head configuration. In addition, a birth tumor- swelling of the skin of the subcutaneous tissue located below the internal contact zone. At this point, the vessels suddenly fill with blood, and fluid and formed elements of blood flow into the tissue surrounding the vessels. A birth tumor occurs only after the rupture of water and only in a living fetus. In occipital presentation, the birth tumor is located in the area of the small fontanelle, or rather on one of the parietal bones adjacent to it. The birth tumor does not have clear contours, is soft in consistency, can pass through sutures and fontanelles, and is located between the skin and the periosteum. The tumor resolves on its own a few days after birth.
The birth tumor must be differentiated from cephalohematoma(head blood tumor), which occurs during pathological childbirth and is a hemorrhage under the periosteum.
Managing the period of exile
During the period of expulsion, constant monitoring of the general condition of the woman in labor, the fetus and the birth canal is carried out. After each attempt, be sure to listen to the fetal heartbeat, since during this period acute fetal hypoxia often occurs and intrauterine fetal death may occur.
The advancement of the fetal head during the expulsion period should occur gradually, constantly, and it should not stand in the same plane in a large segment for more than an hour. During the eruption of the head, they begin to provide manual assistance. When extending, the fetal head puts strong pressure on the pelvic floor, and it is greatly stretched, and a rupture of the perineum may occur. On the other hand, the fetal head is subjected to strong compression from the walls of the birth canal, the fetus is exposed to the threat of injury - impaired blood circulation to the brain. Providing manual assistance during cephalic presentation reduces the possibility of these complications.
Manual aid for cephalic presentation aimed at protecting the perineum. It consists of several moments performed in a certain sequence.
First moment - preventing premature extension of the head. The head, erupting through the genital slit, should pass its smallest circumference (32 cm), drawn along a small oblique dimension (9.5 cm) in a state of flexion.
The person delivering the baby stands to the right of the woman in labor, places the palm of his left hand on the pubis, and places the palmar surfaces of four fingers on the head, covering its entire surface emerging from the genital slit. Light pressure delays the extension of the head and prevents its rapid movement along the birth canal.
Second point - reduction of perineal tension. To do this, the right hand is placed on the perineum so that four fingers are pressed tightly to the left side of the pelvic floor in the area of the labia majora, and the thumb is pressed to the right side. The soft tissues are carefully pulled with all fingers and moved towards the perineum, thereby reducing the tension of the perineum. The palm of the same hand is used to support the perineum, pressing it against the erupting head. The excess soft tissue reduces perineal tension, restores blood circulation and prevents rupture.
Third point - removing the head from the genital slit without pushing. At the end of the attempt, use the thumb and forefinger of the right hand to carefully stretch the vulvar ring over the erupting head. The head is gradually removed from the genital slit. At the beginning of the next attempt, the stretching of the vulvar ring is stopped and the extension of the head is again prevented. This is repeated until the head approaches the genital slit with its parietal tubercles. During this period, the perineum sharply stretches, and there is a danger of its rupture.
Fourth point - regulation of pushing. The greatest stretching and the threat of rupture of the perineum occurs when the head in the genital fissure is located by the parietal tubercles. At the same moment, the head experiences maximum compression, creating a threat of intracranial injury. To avoid injury to the mother and fetus, it is necessary to regulate pushing, i.e. turning them off and weakening or, conversely, lengthening and strengthening them. This is done as follows: when the fetal head is positioned by the parietal tubercles in the genital fissure, and the suboccipital fossa is located under the pubic symphysis, when pushing occurs, the woman in labor is forced to breathe deeply in order to reduce the force of pushing, since pushing is impossible during deep breathing. At this time, both hands delay the advancement of the head until the contraction ends. Outside the attempt, with the right hand they squeeze the perineum above the fetal face in such a way that it slides off the face, with the left hand they slowly lift the head up and straighten it. At this time, the woman is asked to push so that the birth of the head occurs with low tension. Thus, the person leading the labor with the commands “push” and “don’t push” achieves optimal tension of the perineal tissues and the successful birth of the densest and largest part of the fetus - the head.
Fifth point - release of the shoulder girdle and birth of the fetal torso. After the birth of the head, the woman in labor must push. In this case, an external rotation of the head occurs, an internal rotation of the shoulders (in the first position, the head turns towards the opposite position - towards the mother’s right thigh, in the second position - towards the left thigh). Usually the birth of the shoulders occurs spontaneously. If this does not happen, then the head is grabbed with the palms in the area of the right and left temporal bones and cheeks. The head is easily and carefully pulled downwards and backwards until the anterior shoulder fits under the symphysis pubis. Then with the left hand, the palm of which is on the lower cheek, they grab the head and lift its top, and with the right hand they carefully remove the back shoulder, moving the perineal tissue from it. The shoulder girdle was born. The midwife inserts the index fingers from the back of the fetus into the armpits, and the torso is lifted anteriorly (up onto the mother's stomach). The child was born.
Depending on the condition of the perineum and the size of the fetal head, it is not always possible to preserve the perineum and it ruptures. Considering that an incised wound heals better than a lacerated one, in cases where a rupture is imminent, a perineotomy or episiotomy is performed.
The course of labor in the afterbirth period
After the birth of the fetus, the third stage of labor begins. The woman in labor is tired. The skin is of normal color, the pulse is leveled out, and blood pressure is normal.
The fundus of the uterus is at the level of the navel. The uterus is at rest for several minutes, and contractions that occur are painless. During contractions, the uterus becomes dense. There is little or no bleeding from the uterus. After the placenta is completely separated from the placental platform, the fundus of the uterus rises above the navel and deviates to the right. The contours of the uterus change somewhat, it takes on the shape of an hourglass, since in its lower part there is a separated baby's place. When an attempt appears, the placenta is born. Blood loss with the placenta does not exceed 150-250 ml (0.5% of the mother's body weight). After the birth of the placenta, the uterus becomes dense, round, located in the middle, its bottom is located between the navel and the womb.
Management of the afterbirth period
During the afterbirth period, you cannot palpate the uterus so as not to disrupt the natural course of afterbirth contractions and the correct separation of the placenta, and thereby avoid bleeding. During this period, attention is paid to the newborn, the general condition of the woman in labor and signs of placental separation.
The mucus from the upper respiratory tract is sucked out for the newborn baby. The child screams and actively moves his limbs. The doctor assesses his condition in the first minute and at the fifth minute after birth using the Apgar scale. Produce primary toilet of a newborn And primary treatment of the umbilical cord: it is wiped with a sterile swab soaked in 96 alcohol, and at a distance of 10-15 cm from the umbilical ring, it is crossed between two clamps. The end of the newborn's umbilical cord together with the clamp is wrapped in a sterile napkin. The eyelids are wiped with sterile swabs. Blenorrhea is prevented: the lower eyelid of each eye is pulled back and 1-2 drops of a 30% solution of albucid or a freshly prepared 2% solution of silver nitrate are instilled onto the everted eyelids with a sterile pipette. Bracelets are placed on both arms of the child, on which the date of birth, the gender of the child, the mother’s surname and initials, the birth history number, and the date and time of birth are written in permanent paint.
Then the baby, wrapped in a sterile diaper, is transferred to the nursery on a changing table. On this table, the midwife performs the first toilet of the newborn and secondary processing of umbilical cord remnant. The umbilical cord stump between the clamp and the umbilical ring is wiped with 96 alcohol and tied with a thick silk ligature at a distance of 1.5-2 cm from the umbilical ring, if it is very thick or is necessary for further treatment of the newborn. The umbilical cord is cut 2 cm above the ligation site with scissors. The cut surface is wiped with a sterile gauze swab and treated with a 10% iodine solution or a 5% potassium permanganate solution. For healthy children, instead of a ligature, a Rogovin bracket or a plastic clamp is placed on the umbilical cord. Before applying a bracket or clamp, the umbilical cord cut site is also wiped with 96 alcohol, Wharton's jelly is squeezed out with two fingers and a bracket is applied, retreating 0.5 cm from the umbilical ring. The umbilical cord is cut off above the bracket, wiped with a dry gauze swab and treated with a 5% solution of potassium permanganate. In the future, care of the umbilical cord is carried out using the open method.
Areas of skin densely covered with cheese-like lubricant are treated with a cotton swab soaked in sterile petroleum jelly or sunflower oil.
After the initial toilet, the height, circumference of the head, chest, and abdomen of the newborn are measured with a centimeter tape and weighed, determining the weight of the fetus. He is then wrapped in warm, sterile linen and left on a heated changing table for 2 hours. After 2 hours they are transferred to the neonatal department. Premature newborns with suspected trauma are transferred to the neonatal department immediately after the primary toilet for special treatment measures.
The succession period is expectant. The doctor observes the woman in labor: the skin should not be pale, the pulse should not exceed 100 beats per minute, blood pressure should not decrease by more than 15-20 mm Hg. Art. compared to the original one. Monitor the condition of the bladder; it must be emptied, because... an overfilled bladder prevents uterine contraction and disrupts the normal course of placental abruption.
To diagnose whether the placenta has separated from the uterus, use signs of placenta separation. The placenta has separated and descended into the lower part of the uterus, the fundus of the uterus rises above the navel, deviates to the right, the lower segment protrudes above the womb (sign Schroeder). A ligature placed on the umbilical cord stump at the genital slit, when the placenta is separated, drops 10 cm or more (a sign Alfeld). When pressing with the edge of the hand above the womb, the uterus rises up, the umbilical cord does not retract into the vagina if the placenta has separated, the umbilical cord is retracted into the vagina if the placenta has not separated (sign Kustner-Chukalov). The woman in labor takes a deep breath and exhales, if when inhaling the umbilical cord does not retract into the vagina, therefore, the placenta has separated (a sign Dovzhenko). The woman in labor is asked to push: with a detached placenta, the umbilical cord remains in place; and if the placenta has not separated, the umbilical cord is retracted into the vagina after pushing (a sign Klein). The correct diagnosis of placental separation is made based on the combination of these signs. The woman in labor is asked to push, and the placenta is born. If this does not happen, then use external methods of releasing placenta from the uterus.
Way Abuladze(strengthening the abdominals). The anterior abdominal wall is grasped with both hands in a fold so that the rectus abdominis muscles are tightly grasped with the fingers, the discrepancy of the abdominal muscles is eliminated, and the volume of the abdominal cavity is reduced. The woman in labor is asked to push. The separated afterbirth is born.
Way Gentera(imitation of generic forces). The hands of both hands, clenched into fists, are placed with the back surfaces on the fundus of the uterus. Gradually, with downward pressure, the placenta is slowly born.
Way Crede-Lazarevich(imitation of a contraction) may be less gentle if the basic conditions for performing this manipulation are not met. The conditions are as follows: emptying the bladder, bringing the uterus to the midline position, lightly stroking the uterus in order to contract it. Technique of the method: the fundus of the uterus is grasped with the right hand, the palmar surfaces of four fingers are located on the back wall of the uterus, the palm is on the bottom of it, and the thumb is on the front wall of the uterus; at the same time, use the whole hand to press the uterus towards the pubic symphysis until the placenta is born.
The next responsible task of the doctor is examination of the placenta and soft birth canal. To do this, place the placenta on a smooth surface with the mother side up and carefully examine the placenta; the surface of the lobules is smooth and shiny. If there is any doubt about the integrity of the placenta or a defect in the placenta is detected, then a manual examination of the uterine cavity is immediately performed and the remnants of the placenta are removed.
When examining the membranes, their integrity is determined, whether blood vessels pass through the membranes, as happens with an additional lobe of the placenta. If there are vessels on the membranes, they break off, therefore, the additional lobule remains in the uterus. In this case, manual separation and removal of the retained additional lobe are also performed. If torn membranes are found, it means that their fragments lingered in the uterus. In the absence of bleeding, the membranes are not artificially removed. After a few days they will come out on their own.
Based on the location of the rupture of the membranes, the location of the placental site in relation to the internal os can be determined. The closer to the placenta the rupture of the membranes, the lower the placenta was attached, the greater the risk of bleeding in the early postpartum period. The doctor who examined the placenta signs the birth history.
Women in labor in the afterbirth period are not transportable.
Blood loss during childbirth is determined by measuring the blood mass in graduated vessels and weighing wet wipes.
Examination of the external genitalia is carried out on the delivery bed. Then, in a small operating room, all primiparous and multiparous women are examined using vaginal speculums, the vaginal walls and cervix. Detected tears are sutured.
After the birth of the placenta, the postpartum period begins, and the woman in labor is called mother in labor. For 2-4 hours (early postpartum period), the postpartum woman is in the maternity ward, where her general condition, the condition of the uterus, and the amount of blood loss are monitored. After 2-4 hours, the postpartum woman is transferred to the postpartum ward.
TOPIC No. 7
PAIN RELIEF FOR CHILDREN
Students are reminded about changes in the body during pregnancy. The rapid growth of the pregnant uterus is accompanied by a high standing of the diaphragm and liver, which, in turn, leads to a displacement of the heart, pushing the lungs upward and limiting their excursion. The main changes in hemodynamics associated with increasing gestational age are an increase to 150% of the initial volume of blood volume, a moderate increase in peripheral resistance, the occurrence of uteroplacental circulation, an increase in pulmonary blood flow with a tendency to hypertension, and partial occlusion in the inferior vena cava system.
Inferior vena cava syndrome (postural hypotensive syndrome) is expressed in rapidly occurring hypotension (sometimes in combination with bradycardia, nausea, vomiting, shortness of breath) when the woman in labor is placed on her back. It is based on partial compression of the inferior vena cava by the pregnant uterus with a sharp drop in venous flow to the heart. Restoration of the initial blood pressure occurs after the woman in labor turns on her side (preferably on the left).
Pain management during labor is the basis of obstetric anesthesiology. Unlike surgical operations, during childbirth it is not necessary to achieve deep stages III 1-2, but the stage of analgesia (I 3) is sufficient while the mother in labor maintains consciousness, contact with the doctor, and, if necessary, active participation in childbirth.
The immediate causes of labor pain are:
dilation of the cervix, which has highly sensitive pain receptors;
contraction of the uterus and tension of the round uterine ligaments, parietal peritoneum, which is a particularly sensitive reflexogenic zone;
irritation of the periosteum of the inner surface of the sacrum due to tension of the uterosacral ligaments and mechanical compression of this area during the passage of the fetus;
excessive contraction of the uterus as a hollow organ in the presence of relative obstacles to its emptying, resistance of the pelvic floor muscles, especially with anatomical narrowing of the pelvic inlet;
compression and stretching during contractions of the uterus of blood vessels, which represent an extensive arterial and venous network and have highly sensitive baromechanoreceptors;
changes in tissue chemistry - accumulation during prolonged contractions of the uterus of under-oxidized products of tissue metabolism (lactate, pyruvate), temporarily creating uterine ischemia due to periodically recurring contractions.
NON-PHARMACOLOGICAL METHODS OF ANALGESIA
Fertility preparation, hypnosis, acupuncture and transcutaneous electrical nerve stimulation (TENS) are methods of influencing the psychophysiological aspect of pain. A patient's individual perception of pain depends on a number of interdependent and complicating circumstances, such as physical condition, expectation, depression, motivation and upbringing. Pain during childbirth is intensified by such factors as fear of the unknown, danger, fears, and previous negative experiences. On the other hand, pain is reduced or better tolerated if the patient has confidence, understanding of the birth process, if expectations are realistic; breathing exercises, developed reflexes, emotional support and other distraction techniques are used. The patient's own choice is important for the success of all physiological techniques. Factors associated with the success of these methods include genuine commitment from the birthing mother and the instructing or attending staff, higher socioeconomic and educational levels, positive prior experiences, and a normal birth.
PREPARATION FOR CHILDREN
Preparing for childbirth consists of a series of conversations, the participation of the future father is highly desirable. Parents are taught the essence of the processes accompanying pregnancy and childbirth in the form of lectures, audiovisual classes, and group discussions. The mother must be taught proper relaxation, exercises that strengthen the abdominal and back muscles, increase overall tone, and relax the joints (mainly the hip). She should also be taught how to use different breathing techniques during uterine contractions in the first and second stages of labor, as well as directly at the moment of birth of the fetal head. Although preparation for childbirth reduces pain response, the need for other pain management methods remains approximately the same as in the control group. However, the need for pain relief in trained women during childbirth still occurs later. It is advisable to discuss a possible method of pain relief during prenatal discussions and avoid the use of medications unless seriously necessary or that could cause harm to the fetus. If this is not done, the result may be a significant reduction (sometimes complete absence) of the effect of drug pain relief, if the need arises. It should be made clear that the use of epidurals or other necessary pain management techniques, when performed correctly, is harmless to the child.
It should be noted that the psychoprophylactic preparation of pregnant women for childbirth, developed and introduced into widespread practice for the first time in Russia (in Europe this method is called the Lamaze method, or “Russian method”), consists of using individual exercises to increase the threshold of excitability of the cortex brain and create a so-called positive generic dominant in the cerebral cortex. Psychoprophylactic training is not an independent method, but is carried out in conjunction with physical training of pregnant women. It should begin with the first pregnancy consultation and be completed 7-10 days before birth. The doctor conducts the first lesson individually, the following lessons are conducted by a specially trained midwife in a group method. There are only 5 classes. Psychoprophylactic preparation of pregnant women for childbirth consists of using separate classes to increase the threshold of excitability of the cerebral cortex and create the so-called positive generic dominant in the cerebral cortex. Psychoprophylactic training is not an independent method, but is carried out in conjunction with physical training of pregnant women. It should begin with the first pregnancy consultation and be completed 7-10 days before birth. The doctor conducts the first lesson individually, the subsequent sessions are conducted by a specially trained midwife in a group method. There are only 5 lessons. Analyze the purpose of each of them.
The examination allows us to determine whether the pregnant woman’s appearance matches her age. At the same time, attention is paid to the woman’s height, physique, condition of the skin, subcutaneous tissue, mammary glands and nipples. Particular attention is paid to the size and shape of the abdomen, the presence of pregnancy scars (striae gravidarum), and skin elasticity.
Pelvic examination
During examination, attention is paid to the entire pelvic area, but particular importance is attached to the lumbosacral rhombus (Michaelis rhombus). The Michaelis rhombus is a shape in the sacral area that has the contours of a diamond-shaped area. The upper corner of the rhombus corresponds to the spinous process of the V lumbar vertebra, the lower – to the apex of the sacrum (the origin of the gluteus maximus muscles), the lateral corners – to the superoposterior spine of the iliac bones. Based on the shape and size of the rhombus, you can evaluate the structure of the bony pelvis and detect its narrowing or deformation, which is of great importance in the management of childbirth. With a normal pelvis, the rhombus corresponds to the shape of a square. Its dimensions: the horizontal diagonal of the rhombus is 10-11 cm, the vertical - 11 cm. With various narrowings of the pelvis, the horizontal and vertical diagonals will be of different sizes, as a result of which the shape of the rhombus will be changed.
Measurements are made with a centimeter tape (circumference of the wrist joint, dimensions of the Michaelis rhombus, abdominal circumference and height of the uterine fundus above the womb) and an obstetric compass (pelvis gauge) in order to determine the size of the pelvis and its shape.
Using a centimeter tape, measure the largest circumference of the abdomen at the level of the navel (at the end of pregnancy it is 90-100 cm) and the height of the uterine fundus - the distance between the upper edge of the pubic symphysis and the fundus of the uterus. At the end of pregnancy, the height of the uterine fundus is 32-34 cm. Measuring the abdomen and the height of the uterine fundus above the womb allows the obstetrician to determine the duration of pregnancy, the expected weight of the fetus, and identify disorders of fat metabolism, polyhydramnios, and multiple births.
By the external dimensions of the large pelvis one can judge the size and shape of the small pelvis. The pelvis is measured using a pelvic meter.
Usually four sizes of the pelvis are measured - three transverse and one straight. The subject is in a supine position, the obstetrician sits to the side of her and faces her.
Distantia spinarum - the distance between the most distant points of the anterior superior iliac spines (spina iliaca anterior superior) - is 25-26 cm.
Distantia cristarum - the distance between the most distant points of the iliac crests (crista ossis ilei) is 28-29 cm.
Distantia trochanterica - the distance between the greater trochanters of the femurs (trochanter major) is 31-32 cm.
Conjugata externa (external conjugate) - the distance between the spinous process of the V lumbar vertebra and the upper edge of the pubic symphysis - is 20-21 cm.
To measure the external conjugate, the subject turns on her side, bends the underlying leg at the hip and knee joints, and extends the overlying leg. The pelvic meter button is placed between the spinous process of the V lumbar and I sacral vertebrae (suprasacral fossa) at the back and in the middle of the upper edge of the symphysis pubis at the front. By the size of the outer conjugate one can judge the size of the true conjugate. The difference between the external and true conjugate depends on the thickness of the sacrum, symphysis and soft tissues. The thickness of bones and soft tissues in women is different, so the difference between the size of the external and true conjugate does not always exactly correspond to 9 cm. To characterize the thickness of the bones, they use the measurement of the circumference of the wrist joint and the Solovyov index (1/10 of the circumference of the wrist joint). Bones are considered thin if the circumference of the wrist joint is up to 14 cm and thick if the circumference of the wrist joint is more than 14 cm. Depending on the thickness of the bones, with the same external dimensions of the pelvis, its internal dimensions may be different. For example, with an external conjugate of 20 cm and a Solovyov circumference of 12 cm (Soloviev index - 1.2), we need to subtract 8 cm from 20 cm and get the value of the true conjugate - 12 cm. With a Solovyov circumference of 14 cm, we need to subtract 9 cm from 20 cm, and at 16 cm, subtract 10 cm - the true conjugate will be equal to 9 and 10 cm, respectively.
The size of the true conjugate can be judged by the vertical size of the sacral rhombus and the Frank size. The true conjugate can be more accurately determined by the diagonal conjugate.
Diagonal conjugate (conjugata diagonalis)
The distance from the lower edge of the symphysis to the most prominent point of the sacral promontory is called (13 cm). The diagonal conjugate is determined during a vaginal examination of a woman, which is performed with one hand.
Straight pelvic outlet size
- this is the distance between the middle of the lower edge of the symphysis pubis and the tip of the coccyx. During the examination, the pregnant woman lies on her back with her legs apart and half-bent at the hip and knee joints. The measurement is carried out with a pelvis meter. This size, equal to 11 cm, is 1.5 cm larger than the true one due to the thickness of the soft tissues. Therefore, it is necessary to subtract 1.5 cm from the resulting figure of 11 cm, and we obtain the direct size of the exit from the pelvic cavity, which is equal to 9.5 cm.
Transverse size of the pelvic outlet
- this is the distance between the inner surfaces of the ischial tuberosities. The measurement is carried out with a special pelvis or measuring tape, which is applied not directly to the ischial tuberosities, but to the tissues covering them; therefore, to the resulting dimensions of 9-9.5 cm, it is necessary to add 1.5-2 cm (thickness of soft tissues). Normally, the transverse size is 11 cm. It is determined in the position of the pregnant woman on her back, with her legs pressed as close as possible to her stomach.
The oblique dimensions of the pelvis have to be measured with oblique pelvises. To identify pelvic asymmetry, the following oblique dimensions are measured: the distance from the anterosuperior spine of one side to the posterosuperior spine of the other side (21 cm); from the middle of the upper edge of the symphysis to the right and left posterosuperior spines (17.5 cm) and from the supracruciate fossa to the right and left anterosuperior spines (18 cm). The oblique dimensions of one side are compared with the corresponding oblique dimensions of the other. With a normal pelvic structure, the paired oblique dimensions are the same. A difference greater than 1 cm indicates pelvic asymmetry.
Lateral dimensions of the pelvis
– the distance between the anterosuperior and posterosuperior iliac spines of the same side (14 cm), measured with a pelvis. The lateral dimensions must be symmetrical and at least 14 cm. With a lateral conjugate of 12.5 cm, childbirth is impossible.
The pelvic inclination angle is the angle between the plane of the entrance to the pelvis and the horizontal plane. In the standing position of a pregnant woman, it is 45-50°. Determined using a special device - a pelvis angle meter.
In the second half of pregnancy and during childbirth, the head, back and small parts (limbs) of the fetus are determined by palpation. The longer the pregnancy, the clearer the palpation of parts of the fetus.
Techniques of external obstetric examination (Leopold-Levitsky)
- This is a sequential palpation of the uterus, consisting of a number of specific techniques. The subject is in a supine position. The doctor sits to her right, facing her.
First appointment of external obstetric examination.
The first step is to determine the height of the uterine fundus, its shape and the part of the fetus located in the uterine fundus. To do this, the obstetrician places the palmar surfaces of both hands on the uterus so that they cover its bottom.
Second appointment of external obstetric examination.
The second step determines the position of the fetus in the uterus, the position and type of the fetus. The obstetrician gradually lowers his hands from the bottom of the uterus to its right and left sides and, carefully pressing with his palms and fingers on the lateral surfaces of the uterus, determines the back of the fetus along its wide surface on one side, and the small parts of the fetus (arms, legs) on the other. This technique allows you to determine the tone of the uterus and its excitability, palpate the round ligaments of the uterus, their thickness, pain and location.
Third appointment of external obstetric examination.
The third technique is used to determine the presenting part of the fetus. The third technique can determine the mobility of the head. To do this, cover the presenting part with one hand and determine whether it is the head or the pelvic end, a symptom of voting of the fetal head.
Fourth appointment of external obstetric examination.
This technique, which is a complement and continuation of the third, makes it possible to determine not only the nature of the presenting part, but also the location of the head in relation to the entrance to the pelvis. To perform this technique, the obstetrician stands facing the legs of the examinee, places his hands on both sides of the lower part of the uterus so that the fingers of both hands seem to converge with each other above the plane of the entrance to the pelvis, and palpates the presenting part. When examined at the end of pregnancy and during childbirth, this technique determines the relationship of the presenting part to the planes of the pelvis. During childbirth, it is important to find out in which plane of the pelvis the head is located with its largest circumference or major segment.
Fetal heart sounds are listened to with a stethoscope, starting from the second half of pregnancy, in the form of rhythmic, clear beats repeated 120-160 times per minute.
- With cephalic presentations, the heartbeat is best heard below the navel.
- with breech presentation - above the navel.
- with occipital presentation - near the head below the navel on the side where the back is facing, with posterior views - on the side of the abdomen along the anterior axillary line,
- in case of facial presentation - below the navel on the side where the breast is located (in the first position - on the right, in the second - on the left),
- in a transverse position - near the navel, closer to the head,
- when presented with the pelvic end - above the navel, near the head, on the side where the back of the fetus is facing.
The dynamics of the fetal heartbeat is studied using monitoring and ultrasound.
Techniques for external obstetric examination. Leopold-Levitsky techniques.
Target: determining the position of the fetus in the uterine cavity
Indications: are used for objective examination of pregnant women in the second half of pregnancy and for examination of women in labor (childbirth).
Contraindications: threat of miscarriage
Manipulation technique:
1) Explain the purpose and how this manipulation is carried out (sequence of the upcoming procedure)
2) Relieve emotional and mental stress
3) Place the pregnant woman (mother in labor) on a couch covered with a clean sheet
4) The examiner’s hands are treated with disinfectant. solution
5) The examiner stands to the right of the pregnant woman (mother in labor).
6) When palpating the abdomen, four Leopold-Levitsky techniques are used sequentially:
First reception of Leopold Levitsky: allows you to determine the height of the uterine fundus and the part of the fetus that is located in the uterine fundus. For this purpose, the palms of both hands are placed on the fundus of the uterus, the fingers are brought together and, with gentle downward pressure, they palpate and determine the level of the fundus of the uterus, and also determine the part of the fetus located in the fundus of the uterus.
Second appointment. Serves to determine the position of the fetus and its type. Both hands are placed on the lateral surfaces of the uterus. Palpation of parts of the fetus is performed alternately, first with one hand, then with the other. Thus, in the second step, the position of the fetus is determined. In a longitudinal position, the back is determined on one side, and small parts on the other. The second step is to determine the position and type of the fetus based on the position of the back.
Third reception. Used to determine the presenting part of the fetus. To do this, the open palm of the right hand is located above the symphysis and it covers the presenting part of the fetus located above the entrance to the pelvis. With a cephalic presentation, the head is defined as a dense round part. With the head standing movably above the entrance to the pelvis, its movement is clearly felt. This part of the fetus is born first. With breech presentation, a wide part without clear contours is determined
Fourth reception. Complements the third and clarifies the level of standing of the presenting part. The subject stands facing the lower limbs of the pregnant woman. The palms of both hands are placed on the lower segment of the uterus on the right and left, the ends of the fingers determine the relationship of the presenting part to the entrance to the small pelvis and the standing height of this presenting part in relation to the pelvic cavity: above the entrance to the pelvis, at the entrance to the small pelvis, in the cavity of the small pelvis
7) Assessment of achieved results: The height of the uterine fundus, position, position, appearance, presentation were determined
8) Possible complications: Inferior vena cava compression syndrome. Prevention of this complication is not to leave the pregnant woman (mother in labor) on her back for a long time.
The student establishes the breech presentation of the fetus with the first, second, third and fourth methods of external examination: pure breech, mixed breech, leg presentation
The student determines the transverse position of the fetus based on the shape of the uterus and the absence of the presenting part above the entrance to the pelvis
The position of the fetus is determined by the position of the head: head on the left - I position, on the right - II position
The back of the fetus can be located both in front and behind, both above and below
Notes:
Breech presentations are longitudinal, but the course of labor and outcome are unfavorable for the mother and fetus. The question of delivery is decided by the doctor individually for each woman.
If the full-term fetus is in transverse position, a caesarean section is always performed.
Table of contents of the topic "Fetal articulation (habitus).":1. Articulation of the fetus (habitus). Fetal position (situs). Longitudinal position. Transverse position. Oblique position.
2. Fetal position (positio). Type of position (visus). First position of the fetus. Second position of the fetus. Front view. Back view.
3. Presentation of the fetus (praesentatio). Head presentation. Breech presentation. Presenting part.
4. External techniques for obstetric examination (Leopold's techniques). Leopold's first move. Purpose and methodology of the study (reception).
5. Second appointment of external obstetric examination. Leopold's second move. Purpose and methodology of the study (reception).
6. Third appointment of external obstetric examination. Leopold's third move. Purpose and methodology of the study (reception).
7. Fourth appointment of external obstetric examination. Leopold's fourth move. Symptom of running. Purpose and methodology of the study (reception).
8. The degree of insertion of the fetal head into the pelvis. Determination of the degree of insertion of the fetal head.
9. Auscultation of the fetus. Listening to the abdomen of a pregnant woman and woman in labor. Fetal heart sounds. Places of best listening to fetal heart sounds.
10. Determination of gestational age. Time of the first fetal movement. Day of the last menstruation.
External techniques for obstetric examination (Leopold's techniques). Leopold's first move. Purpose and methodology of the study (reception).
When palpating the abdomen, they use the so-called external obstetric examination techniques (Leopold's techniques). Leopold(1891) introduced palpation of the abdomen into the system and proposed typical palpation techniques that received universal recognition
Rice. 4.17. First appointment of external obstetric examination.First appointment external obstetric examination(Fig. 4 17) Target it is to determine the height of the uterine fundus and the part of the fetus located in its fundus.
Research methodology. The palmar surfaces of both hands are placed on the uterus in such a way that they tightly cover its bottom with the adjacent areas of the corners of the uterus, and the fingers are facing each other with their nail phalanges. Most often, at the end of pregnancy (in % of cases), the buttocks are identified in the fundus of the uterus. Usually it is not difficult to distinguish them from the head by their less pronounced roundness and sphericity, lower density and less flattened surface.
First external obstetric examination makes it possible to judge the duration of pregnancy (by the height of the fundus of the uterus), the position of the fetus (if one of its large parts is in the fundus of the uterus, it means there is a longitudinal position) and the presentation (if the buttocks are in the fundus of the uterus, then the presenting part is the head) .
