Physiological childbirth

Physiological (normal) childbirth

Europe

Reasons for the onset of labor

Principles of conducting normal childbirth

Diagnosis and confirmation of childbirth

PERIODS OF BIRTH

Duration of childbirth

Diagnosis of periods and phases of childbirth:

The sequence of actions in the case of a normal course of childbirth

The sequence of actions in the case of a normal course of childbirth

first stage of labor

Observation and assistance to a woman in labor in the first stage of labor

Partogram Rules

Components of a partogram

Observation and assistance to a woman in labor in the second stage of labor

Position of a woman at birth

Management of the III stage of labor

Management of the III stage of labor

Assessing the condition of the newborn and monitoring a healthy newborn

APGAR SCALE

Thermal chain

postpartum period

Pain relief for childbirth

SYSTEM OF FPPP PREGNANT WOMEN FOR BIRTH

Prenatal FPPP of pregnant women

MEDICAMENTAL ANESTHESIA OF CHILDHOOD

MEDICAMENTAL ANESTHESIA OF CHILDHOOD

Other METHODS OF PAIN RELIEF FOR BIRTH

Physiological childbirth are final stage pregnancy, ending with the birth of a child for a period of 37 to 42 weeks. The physiology of childbirth depends on such aspects as the age of the woman, the readiness of her body for childbirth, the size of the fetus, the features of the birth canal and bone pelvis, the strength of contractions and much more.

Childbirth takes place in 3 periods: disclosure, exile and afterbirth. On average, labor activity in nulliparous women lasts from 9 to 12 hours, in multiparous women - about 7 hours. They can tell you that the body is preparing for childbirth.

Harbingers of childbirth

Normally, they appear in every woman, but the nature and degree of their manifestation can be individual. Harbingers are a signal of the body about its preparation for labor. The female body begins preparing for childbirth a few months before their onset.

The appearance of precursors is due to the following reasons:

• change hormonal background;
• change in the position of the fetus;
• preparation of the cervix and birth canal for childbirth.

We list the main precursors.

Prolapse of the abdomen

Closer to the crucial moment, the fetus begins to take a more favorable position for itself, lowering its head into the small pelvis. At this time, the expectant mother may notice that her shortness of breath has disappeared, and her stomach has dropped down a little. At the same time, the pressure on the bladder increased. In primiparas, this harbinger appears at about 35 weeks of gestation, in multiparous ones much later - a couple of days before childbirth or only with their onset.

Removal of the mucous plug

The mucous plug throughout pregnancy closes the entrance to the cervix, protecting the fetus from negative impact external factors. Shortly before childbirth, the cork begins to depart in parts or in full. Visually, it resembles light pink or brownish mucus with streaks of blood. The mucous plug can go away a few weeks before the birth - starting from the 36th week of pregnancy, less often - a day before the birth of the baby at 39-41 weeks.

Weight loss

Most women gradually gain from 12 to 16 kg during pregnancy, and this is normal. A couple of days before the birth, the expectant mother may notice a stop in weight gain and even weight loss - up to 2 kg. Body weight decreases against the background of a decrease in the volume of amniotic fluid and.

Training bouts

Digestive disorder

Abdominal pain, nausea, vomiting and diarrhea can occur in the expectant mother a few days before the birth. This is due to changes in the hormonal background, which also affect the functioning of the digestive organs.

nesting syndrome

And another harbinger of childbirth, often occurring in expectant mothers in the last weeks of pregnancy. The desire to wash the whole apartment, sort out cupboards, cook a lot of healthy and tasty food - every woman has a nesting syndrome in her own way.

Periods of childbirth

Physiological childbirth is divided into 3 periods:

1. disclosure. Against the background of intense and regular contractions, the cervix opens.
2. Expulsion of the fetus. Attempts begin, thanks to which the fetus moves through the birth canal.
3. Follow-up period. The shell of the fetus is also born.

Consider the periods of childbirth in more detail.

Cervical dilatation period

It begins with the appearance of regular contractions and / or discharge of amniotic fluid. Contractions are regular involuntary contractions of the muscular layer of the uterus, their task is to shorten and open its neck as much as possible. For the birth of a child, it is necessary that the neck shorten by 5 cm and open up to 10 cm.

The first stage of labor is the longest. At the beginning of labor, contractions last a few seconds with an interval of 15-20 minutes. Gradually they become longer and more intense, the intervals are shortened. During the cervical dilation period, it is important to move more, be in an upright position, if necessary, perform breathing exercises, massage the lower back and take a warm shower. All this helps to reduce the intensity of pain from contractions.

Fetal expulsion period

At the end of the first stage of labor, the strength and frequency of contractions reaches its peak, for many women this process becomes a difficult test. By this time, the woman is already tired of pain and physical stress, pain relief often ceases to work, while the cervix should open up to 10 cm. If this happens, the doctor suggests the woman to push a little, but usually attempts already appear by this moment, complementing contractions.

The second period runs much faster than the first - from 10 minutes to 2 hours. All that is required of a woman in labor is to push, listening to the requirements of doctors. Specialists at this moment carefully monitor the well-being of the mother and fetus. Inadequate behavior of a woman in childbirth can harm the baby.

For a successful pushing period, a woman in labor is recommended to inhale full lungs of air before each attempt, hold her breath for a while and push down with all her might. Shouting, talking and straining your cheeks and face should not be done, since such an attempt will bring little effect. In the intervals between attempts, it is recommended to relax as much as possible, to rest.

At these moments, the child moves through the birth canal. At a certain moment, the baby's head begins to erupt from the woman's genital slit, hiding in between attempts. After several effective attempts, the child is born into the world.

If everything is in order with him, he is immediately placed on the mother's stomach. After that, the midwife cuts the umbilical cord and takes the newborn for the necessary hygiene procedures, as well as weighing and examination by a pediatrician. After 10 minutes, the baby will be returned to the mother and placed on the breast for the first time.

succession period

This is the shortest period in childbirth. The birth of the placenta and fetal membranes, on average, occurs 10 minutes after the birth of the baby. For this to happen, the woman will need to push slightly. If the placenta does not leave the uterine cavity within half an hour, specialists begin to apply emergency measures.

After delivery, the placenta is evaluated by the doctor for integrity. If everything is normal, the woman's genital tract is examined for an object and incisions. If they are, they are sewn up. Then, a heating pad with ice is placed on the young mother's lower abdomen and left in the delivery room for 2 hours for observation. This is important, since the first 2 hours after childbirth are the most dangerous - a woman may begin hypotonic postpartum hemorrhage, which often has to be stopped urgently.

Childbirth is a complex multi-link unconditional reflex act aimed at expelling the fetus with the afterbirth (placenta, fetal membranes, umbilical cord) from the uterine cavity after the fetus has reached viability.

Physiological childbirth is childbirth with one fetus, which began spontaneously, proceeded without complications, without the use of benefits and medications, in which a mature full-term baby was born in the occipital presentation. After childbirth, the mother and the newborn are in a satisfactory condition.

Normal delivery is a birth with one fetus at 37-41 weeks of gestation, which began spontaneously, had low risk to the beginning, passed without complications, in which the child was born in the occipital presentation. In childbirth, the use of amniotomy, the use of antispasmodics, and analgesia are possible. After childbirth, the mother and the newborn are in a satisfactory condition.

FROM clinical point of view, childbirth is divided into three periods: opening of the uterine os, expulsion of the fetus and the afterbirth period.

Along with the opening of the uterine os and the birth of the placenta, it has great importance the mechanism of childbirth is a complex of movements performed by the fetus during childbirth under the action of multidirectional forces.

Childbirth mechanism
Knowledge of the mechanism of childbirth is the foundation on which the art of childbirth is based. To initiate labor, interaction is required at least two mutually opposing forces. In the vertical position of the woman in labor, the forces developed by the uterus and the abdominal press (expelling force directed from top to bottom) and the resistance exerted by the presenting part of the fetus by the hard and soft tissues of the birth canal (from bottom to top) interact. Without an expelling force, there is no forward movement of the fetus through the birth canal. Without opposition from the bone pelvis and muscles pelvic floor there are no rotations of the fetal head, which determine the mechanism of childbirth. It is generally accepted that the force developed by the uterus and the abdominal press presses on the buttocks located in the bottom of the uterus (with the head presentation of the fetus) and through the spine acts on the head of the fetus.

However, the pressure of the uterine fundus acting on the fetal head is not the only source of force causing the fetus to move through the birth canal. For the development of the mechanism of childbirth, the action of the walls of the uterus, tightly clasping the fetus from all sides, is no less important. This helps to straighten the fetal spine and increase its length. Resistance from the bottom of the uterus forces the presenting part to move forward along the birth canal. Without the participation of the diaphragm and the abdominal wall in this process, only the musculature of the uterine fundus would not be able to develop a force sufficient to overcome the opposition from the small pelvis with the head. The reasons that affect the mechanism of childbirth can be divided into 2 groups:
- mechanical order ( anatomical features birth canal and fetus);
- biological (the tone of the body of the fetus, the active role of the muscles of the uterus, pelvis, etc.).

The movements made by the fetus during childbirth are determined, on the one hand, by the total effect of contractions and attempts (contractions of the uterus, abdominal wall, diaphragm, pelvic floor muscles).

On the other hand, the counteracting force of the resistance of the birth canal with an uneven distribution of obstacles in different planes of the pelvis. Along with the indicated reasons, there are other, additional factors that affect the mechanism of childbirth. These include the angle of inclination of the pelvis, the condition of the fontanels and sutures on the head of the fetus, the condition of the joints of the pelvis of the woman in labor.

Depending on the obstetric school, from 4 to 7 moments of the birth mechanism are distinguished. In this publication, intended for obstetrician-gynecologists, we consider the mechanism of childbirth as a set of translational movements performed by the fetus when passing through the mother's birth canal and highlight 4 points in it:
- flexion of the head with lowering
- inner turn heads;
- extension of the head;
- internal rotation of the body, external rotation of the head.

In occipital presentation, the head is installed with an arrow-shaped suture in the transverse or one of the oblique dimensions of the plane of entry into the small pelvis.
1st moment - flexion and lowering of the head, due to the pressure of the contracting uterus on the fetus. In this case, the small fontanel is set lower, becoming a wire point. In front view occiput presentation the head passes into the pelvis with a small oblique size (9.5 cm). At this moment, the formation of a temporary insignificant, often anterior, (physiological) asynclitism is possible.
2nd moment - the internal rotation of the head occurs at the transition from the wide part of the pelvic cavity to the narrow one. The movement has the character of translational-rotational. In this case, the swept suture from the transverse or oblique size passes at the oblique, and then into a straight line on the pelvic floor.
3rd moment - extension of the head. On the pelvic floor, the head rests with the region of the suboccipital fossa (point of fixation) against the lower edge of the symphysis (point of rotation) around which the head is extended during which it is born.
4th moment - internal rotation of the body and external rotation of the head.

The shoulder girdle of the fetus enters the small pelvis in the transverse or one of the oblique dimensions of the entry plane. Then it descends into the pelvis and at the same time turns, passing with its intershoulder size, first into an oblique, and then a straight size of the pelvis. On the pelvic floor, the interhumeral size of the fetus is in the direct size of the pelvic exit plane. The internal rotation of the shoulders is accompanied by the external rotation of the head. First, the upper third of the front shoulder is born. Around this point, the lateral flexion of the body occurs, the back shoulder and the entire back handle are born. Then the birth of the fetus occurs without difficulty. In the posterior view of the occipital presentation, the head is rotated with the occiput posteriorly. This leads to the fact that the head passes through the pelvic cavity not with a small, but with an average oblique size (10.5 cm). The wire point in the posterior view of the occipital presentation is the middle of the distance between the small and large fontanel. When the rotation of the head ends, then under the lower edge of the symphysis is the border of hair growth on the forehead. Additional flexion of the head is required, during which the region of the suboccipital fossa approaches the coccyx. The region of the suboccipital fossa abuts against the coccyx around which the extension of the head occurs during which it is born. The internal rotation of the body and the external rotation of the head are performed in the same way as in the anterior view of the occipital presentation. Changes in the body of a pregnant woman on the eve of childbirth

The completion of the intrauterine stage of development of the human fetus occurs at the 38-40th week of pregnancy. There is an intensive synchronous preparation of the organisms of the mother and fetus for the process of childbirth. This process is characterized by changes in the functioning of the nervous and endocrine systems, activation of the vascular-platelet and procoagulative link of hemostasis, increased production of a number of pro-inflammatory cytokines, prostaglandins, accumulation of energy substrates and increased synthesis of contractile proteins, changes in the permeability of myocyte cell membranes, which is accompanied by structural changes in the tissues of the neck. uterus, its lower segment. The course of childbirth largely depends on the readiness of the woman's body. The first signs of preparation usually appear 10-15 days before delivery.

Harbingers of labor are symptoms that usually appear one to two weeks before delivery. The harbingers of childbirth include: moving the center of gravity of the body of the pregnant woman forward, deviating the head and shoulders back while walking (“proud tread”), pressing the presenting part of the fetus to the entrance to the small pelvis, as a result of which the bottom of the uterus sinks (in nulliparous this occurs a month before childbirth) and a decrease in the volume of amniotic fluid. It is known that the largest amount of amniotic fluid (1200 ml) was noted at the 38th week of pregnancy. After this period, the amount of water decreases every week by 200 ml. The presenting part of the fetus is tightly fixed in the pelvic inlet due to the shortening of the supravaginal part of the cervix involved in the deployment of the lower uterine segment. The cervix acquires softness, elasticity and extensibility, which reflects the synchronous readiness of the mother-placenta-fetus system for the birth process. From the vagina protrude mucosaic discharge (the secret of the glands of the cervix). The walls of the vagina become swollen, juicy, moist, cyanotic, which indicates a high estrogen saturation. There is an increase in the excitability of the uterus: on palpation, there is a compaction of the myometrium. There are contractions-harbingers ("false contractions") - separate coordinated contractions, as a result of which there is a gradual shortening of the cervix. The internal cervical os smoothly passes into the lower segment of the uterus. Preparatory contractions occur most often at night, at rest. There is a detachment of the membranes of the lower pole of the fetal bladder, which causes an intensive synthesis of prostaglandins. In the central nervous system (CNS), a "birth dominant" appears - a stagnant focus of excitation that regulates the process of childbirth and preparation for it. There are signs of "maturity" of the cervix - it softens, shortens, the position changes to the central one relative to the wire axis of the pelvis. "Maturity" of the cervix - the main clinical criterion childbirth readiness.

There are several methods for assessing the "maturity" of the cervix. All methods take into account the following parameters:
- the consistency of the cervix;
- the length of the vaginal part and the cervical canal of the uterus;
- the degree of patency of the cervical canal;
- the location and direction of the axis of the cervix in the pelvic cavity.

The most common and recognized by most of the world's obstetric schools is the E.H. Bishop as modified by the Royal College of Obstetricians and Gynecologists. Immature neck up to 5 points inclusive. Not mature enough 6-7 points. Mature cervix 8 points or more.

First stage of labor
The onset of labor is characterized by the appearance of regular uterine contractions - contractions with an interval of at least 1-2 per 10 minutes, which lead to the smoothing of the cervix and the opening of the uterine os.

There are three types of regulation of the contractile activity of the uterus:
- endocrine (hormonal);
- neurogenic;
- myogenic.

Endocrine regulation: normal labor activity proceeds against the background of an optimal estrogen content. Estrogens are not considered to be direct factors in the onset of contractions, but they have important functions in the formation of receptors that respond to the action of contracting substances.

In the regulation of the motor function of the uterus, along with hormonal factors serotonin, kinins and enzymes are involved. The hormone of the posterior pituitary gland (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, produced by the placenta, maintains a dynamic balance of oxytocin in the blood plasma. Prostaglandins are the most powerful stimulants of uterine contraction, for the most part acting locally at the site of formation. The main site of prostaglandin synthesis is the fetal, chorionic, and decidua membranes. In the amnion and chorion, prostaglandin E2 (of the fetus) is formed, and in the decidua and myometrium, both prostaglandin E2 and F2a (maternal prostaglandins) are synthesized.

The release of fetal cortisol, fetal hypoxia, infection, changes in the osmolarity of amniotic fluid, rupture of membranes, mechanical irritation of the cervix, detachment of the lower pole of the fetal bladder and other factors that cause cascade synthesis and release of prostaglandins can lead to increased prostaglandin synthesis and the onset of labor activity.

Neurogenic regulation. From the physiological balance of the sympathetic and parasympathetic nervous system and the localization of the pacemaker in the myometrium, the coordination of contractions of the longitudinal muscle bundles depends on the active relaxation of the circular and spirally located muscle fibers. In turn, the function of the autonomic nervous system is to a certain extent subject to regulation by the cerebral cortex and structures of the limbic complex, which performs the most subtle regulation of childbirth.

Myogenic regulation. By the onset of childbirth, different parts of the uterus have unequal functional contractile activity. Conventionally, two main functional layers of the myometrium are distinguished in the uterus:
- external - active, powerful in the area of ​​the uterine fundus, gradually thinning in the distal cervix;
- internal - expressed in the neck and in the isthmus, thinner in the bottom and body of the uterus.

During childbirth, the outer layer is sensitive to oxytocin, prostaglandins and substances that have a tonomotor effect. The inner layer has a weak contractile activity. Features of the contractile activity of the uterus during childbirth are determined by the functional difference in its muscle layers. The outer layer actively contracts and moves upward, while the inner layer relaxes, ensuring the opening of the cervix.

In childbirth, unidirectional peristaltic contractions of the fundus, body and lower segment of the uterus occur, ensuring the expulsion of the fetus and placenta. The strongest and longest uterine contractions occur in the fundus of the uterus. Each cell excitation is a source of excitation impulses of neighboring cells. Alternate excitation of the sympathetic and parasympathetic nervous system causes a contraction of the longitudinally located muscle bundles of the uterus simultaneously with active relaxation of the circular and spiral muscle bundles, which leads to a gradual opening of the uterine os and the advancement of the fetus through the birth canal.

The labor pain differs from the preparatory frequency (at least 12 contractions in 10 minutes), as well as the strength of the contraction of the uterus (the amplitude of the contraction increases). Labor pains cause smoothing and opening of the cervix. During each contraction in the muscular wall of the uterus, there is a simultaneous contraction of all muscle fibers and layers - contraction, as well as their displacement relative to each other - retraction. During a pause, contraction is completely absent, and retraction is partially absent. As a result of contraction and retraction of the myometrium, the muscles move from the isthmus to the body of the uterus (distraction), as well as the formation of the lower segment of the uterus, smoothing of the cervix and opening of the cervical canal.

During each contraction, there is an increase in intrauterine pressure up to 100 mm Hg. The pressure acts on the fetal egg; thanks to the amniotic fluid, it takes the same shape as the cavity of the uterine giving birth. The amniotic fluid flows down to the presenting part of the membranes, while the pressure irritates the endings of the nerve receptors in the walls of the cervix, which contributes to increased contractions.

The muscles of the body of the uterus and the lower segment of the uterus, when contracted, stretch the walls of the cervical canal to the sides and up. The contractions of the muscle fibers of the body of the uterus are directed tangentially to the circular muscles of the cervix, this allows the opening of the cervix to occur in the absence of the amniotic sac and even the presenting part.

Thus, with the contraction of the muscles of the body of the uterus (contraction and retraction), the muscle fibers of the body and cervix lead to the opening of the internal os, the smoothing of the cervix and the opening of the external os (distraction). During contractions, there is a stretching of the part of the body of the uterus adjacent to the isthmus and involvement in the lower segment of the uterus, which is much thinner than the upper one. The border between the segments of the uterus is called the contraction ring and looks like a furrow. The contraction ring is determined after the outflow of amniotic fluid, the height of the ring above the womb, expressed in centimeters, shows the degree of opening of the cervix of the cervix. At the same time, the lower segment of the uterus tightly covers the presenting head and makes up the internal zone of contact.

Amniotic fluid is conditionally divided into anterior, located below the level of contact, and posterior - above this level. Pressing the fetal head, covered by the lower segment of the uterus, along the entire circumference of the pelvis to its walls, forms an external fit belt. It prevents the outflow of posterior water in case of violation of the integrity of the fetal bladder and the outflow of amniotic fluid.

Shortening and smoothing of the cervix in women giving birth and nulliparous occurs in different ways. In primiparas before childbirth, the external and internal os of the cervix is ​​\u200b\u200bclosed. There is an opening of the internal pharynx, shortening of the cervical canal and cervix, and then a gradual stretching of the cervical canal, shortening and smoothing of the cervix. The previously closed external ("obstetric") pharynx begins to open. When fully opened, it looks like a narrow border in the birth canal. In multiparous 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. Timely rupture of the fetal bladder occurs with complete or almost complete disclosure of the uterine os.

The rupture of the fetal bladder before childbirth is called premature, and with incomplete opening of the cervix (up to 6 cm) - early. Sometimes, due to the density of the membranes, the rupture of the fetal bladder does not occur even with the full opening of the cervix (late autopsy).

The effectiveness of the contractile activity of the uterus is assessed by the rate of opening of the uterine os and lowering of the presenting part into the pelvic cavity. Due to the uneven process of opening the cervix and moving the fetus through the birth canal, there are several phases of the first stage of labor:
I latent phase: begins with the establishment of a regular rhythm of contractions (at least 1-2 in 10 minutes) and ends with complete smoothing of the cervix and opening of the uterine os by 3-4 cm. The duration of the latent phase in most women in labor is on average 4-8 hours. In primiparas, the latent phase is always longer than in multiparas. During this period, contractions are usually painless; drug therapy is not required or limited to the appointment of antispasmodic drugs.
II active phase: begins after the opening of the uterine pharynx by 4 cm. It is characterized by intensive labor activity and rapid opening of the uterine pharynx from 4 to 8 cm. The duration of this phase is almost the same in primiparous and multiparous women, and in the majority it averages 3-4 hours. The frequency of contractions in the active phase of the first stage of labor is 3-5 per 10 minutes. The rate of opening of the uterine os in primiparas averages 1.5-2 cm/h, in multiparous 2-2.5 cm/h. Contractions often become painful. In this regard, medical and regional anesthesia is used in combination with antispasmodic drugs. The fetal bladder should open on its own at the height of one of the contractions when the cervix opens more than 5-6 cm. At the same time, about 150250 ml of light and transparent amniotic fluid is poured out. Preservation of the fetal bladder after the opening of the cervix more than 8 cm is impractical. An excessive density of the membranes or an insufficient increase in intra-amniotic pressure can prevent the spontaneous outflow of water in the active phase of labor. If there was no spontaneous outflow of amniotic fluid, then when the uterine os is opened 6-8 cm, the doctor should open the fetal bladder by amniotomy. Other indications for amniotomy are a flat fetal bladder, the appearance of bloody discharge from the genital tract, and weakening of labor. Simultaneously with the opening of the cervix, the advancement of the fetal head through the birth canal begins. Determination of the standing height of the presenting part of the fetus by external methods should be done 1 time in 2 hours.
Phase III deceleration: begins at 8 cm and continues until the cervix is ​​fully dilated. This phase in primiparous lasts up to 2 hours, and in multiparous may be absent altogether. The allocation of the deceleration phase is necessary in order to avoid the unreasonable appointment of rhodostimulation, if during the period of cervical dilatation from 8 to 10 cm there is an impression that labor activity has weakened.

Second stage of labor
The period of expulsion of the fetus begins from the moment of full disclosure of the cervix and ends with the birth of a child. During the second stage of labor, the main part of the labor mechanism takes place, during which the head passes through all the planes of the pelvis. The duration of the second period of physiological labor in nulliparous women is on average 1-2 hours, in multiparous women from 30 minutes to 1 hour.

Usually in the second stage of labor, the frequency of contractions is at least 4-5 per 10 minutes. When the fetal head is lowered to the pelvic floor (less often with the head located in the narrow part of the pelvic cavity), attempts are added to the contractions due to irritation of the receptors of the pelvic nerve plexus. Attempts strengthen and accelerate the advancement of the fetal head. Usually, no more than 5-10 attempts are required for the birth of the fetus. In the second period, the shape of the fetal head changes - the bones of the fetal skull are configured to pass through the birth canal. In addition, a birth tumor occurs on the head - swelling of the skin of the subcutaneous tissue located below the inner contact zone. In this place, there is a sharp filling of the vessels, fluid enters the surrounding fiber and shaped elements blood. The occurrence of a birth tumor occurs after the outflow of water and only in a living fetus. With occipital insertion, a birth tumor occurs in the region of the small fontanel, on one of the parietal bones adjacent to it. The birth tumor does not have clear contours and soft consistency, it can pass through the seams and fontanels, it is located between the skin and the periosteum. The tumor resolves on its own within a few days after delivery. In this regard, a generic tumor must be differentiated from a cephalohematoma that occurs when pathological childbirth and representing a hemorrhage under the periosteum.

The total duration of the first and second stages of labor at present in primiparous is on average 10-12 hours (up to 18 hours), in multiparous - 6-8 hours (up to 12-14). Differences in the duration of labor in primiparous and multiparous are noted mainly in the latent phase of the first stage of labor, while there are no significant differences in the active phase.

third stage of labor

After the birth of the fetus, there is a sharp decrease in the volume of the uterus. For several minutes, the uterus is at rest, the resulting contractions are painless. There is little or no bleeding from the uterus. The bottom of the uterus is located at the level of the navel. 5-7 minutes after the birth of the fetus, during 23 postpartum contractions, the placenta separates and the placenta is expelled. After complete separation of the placenta from the placental site, the bottom of the uterus rises above the navel and deviates to the right. The contours of the uterus take shape hourglass, since in its lower section there is a separated placenta. With the appearance of an attempt, the birth of the placenta occurs. Blood loss during separation of the placenta should not exceed 500 ml and is usually about 250 ml (up to 0.5% of the body weight of the woman in labor). After the birth of the placenta, the uterus acquires density, becomes round, is located symmetrically, its bottom is located between the navel and the womb. The birth of the placenta marks the end of childbirth.

Childbirth lasting less than 6 hours is called fast, and 4 hours or less is called rapid or assault. If the duration exceeds 18 hours, labor is considered protracted. Rapid, rapid and protracted labor are pathological, as they are often associated with the risk of injury to the fetus, birth canal, bleeding in the afterbirth and early postpartum periods, and other complications.

Examination of the woman in labor at the address in admission department
When a woman in labor goes to the admission department, it is necessary to assess the general condition, complaints, take thermometry and examine skin, measure blood pressure, listen to the fetal heartbeat. Examine the data of the exchange or outpatient card. In the absence of signs infectious diseases, do the following:
Registration of a woman in labor in the maternity ward: passport data, institution of the history of childbirth, registration in the history of the received informed consent for the necessary medical manipulations held in a medical facility.
Complaints and history taking:
- complaints;
- allergic history;
- epidemiological history: contact with infectious patients, stay in countries with an unfavorable epidemiological situation over the past 3 years;
- blood type, Rh factor;
- family history, heredity (tuberculosis, syphilis, mental, oncological diseases, diabetes, multiple pregnancies, diseases of the cardiovascular system - stroke, heart attack, thrombosis);
- information about the husband (age, health status, bad habits, blood type, Rh factor);
- working and living conditions ( occupational hazards, sanitary and hygienic conditions at work and at home, food, rest);
- information about the use of narcotic drugs;
- past illnesses, including hepatitis A, B, C;
- surgical interventions: their course, methods and terms of treatment, complications, blood transfusions;
- injury;
- menstrual function(time of appearance and establishment, the nature of the menstrual cycle, the first day of the last menstruation);
- transferred gynecological diseases (time of occurrence, duration of the disease, treatment, outcome);
- sexual function, contraception (methods, duration of use), the onset of sexual activity;
- childbearing function: parity, course and outcome of previous pregnancies in chronological order, the nature of previous births, weight and height of newborns, the course of the post-abortion and postpartum periods;

Definition real pregnancy by trimesters:
- I term (up to 13 weeks) - common diseases, complications of pregnancy, the date of the first visit to the antenatal clinic and the gestational age established at the first visit, test results, medication;
- II trimester (13-28 weeks) - general diseases and complications during pregnancy, weight gain, blood pressure numbers, test results, date of the first fetal movement, medication;
- III trimester (29-40 weeks) - total weight gain during pregnancy, blood pressure figures, test results, diseases and complications during pregnancy, medication;
- results ultrasound(date, term, features);
- calculation of the expected date of birth
- by the date of the last menstruation;
- date of conception or ovulation (with a short or long cycle);
- ultrasound data in the period from 8 to 24 weeks of pregnancy (most accurately 11-14 weeks).

Inspection.
- assessment of the general condition;
- skin;
- general thermometry;
- body type;
- measurement of body weight;
- growth measurement;
- study of pulse and blood pressure in peripheral arteries;
- auscultation of heart sounds;
- auscultation of the lungs;
- examination of the mammary glands;
- palpation of the abdomen, determining the size of the liver;
- tapping test (Pasternatsky).

External obstetric examination.
- measuring the size of the uterus: the height of the fundus of the uterus and the circumference of the abdomen;
- measuring the size of the pelvis (d. spinarum, d. cristarum, d. trochanterica, c. externa);
- fetal palpation: position, position, presentation, relation of the head to the planes of the pelvis;
- auscultation of the fetus with an obstetric stethoscope or dopton.

Vaginal examination: the state of the external genitals and perineum, vagina, cervix, fetal bladder, determination of the standing height of the presenting part of the fetus, features of the pelvic planes, determination of the diagonal and true conjugates, assessment of the nature of amniotic fluid and vaginal discharge.
Ultrasound examination of the fetus (if possible, if the previous ultrasound examination was performed 10 days ago or more): position, position, type, estimated weight of the fetus, the presence of entanglement of the umbilical cord; volume of amniotic fluid, localization of the placenta, the state of the lower segment of the uterus.
Determination of the estimated fetal weight (based on ultrasound data, formulas Zhordania, Yakubova).

Taking blood from a peripheral vein:
- determination of HbsAg (hepatitis B virus);
- determination of class M, G antibodies (IgM, IgG) to hepatitis C2 virus;
- determination of class M, G antibodies (IgM, IgG) to HIV1, HIV23;
- blood test for syphilis4;
- if the woman in labor has not been previously examined:
- determination of blood group and Rh factor;
- clinical blood test;
- other blood tests (definition total protein, urea, creatinine, total and direct bilirubin, alkaline phosphatase, glucose, serum iron; hemostasiogram and coagulation hemostasis (platelet count, clotting time, bleeding time, platelet aggregation, fibrinogen, determination of prothrombin (thromboplastin) time) are carried out according to indications.

Childbirth is recommended to be carried out in an obstetric hospital under direct medical supervision and control.
If possible, delivery is recommended to be carried out in an individual delivery room.
Childbirth is conducted by a doctor, the midwife fulfills the doctor's orders, monitors the condition of the woman and the fetus, under the supervision of a doctor, provides manual assistance at the birth of the fetus; takes care of the newborn.
For each woman in labor, a individual plan childbirth, the woman in labor is introduced to the plan of childbirth, her consent is obtained for the alleged manipulations and operations in childbirth.
Participation in childbirth of a husband or a close relative (mother, sister) is welcome - family childbirth. During the entire first stage of childbirth, the state of the mother and her fetus is constantly monitored (Table 10.2). Records in the history of childbirth are made every 2 hours. They monitor the condition of the woman in labor (complaints, discharge from the genital tract, pulse rate, respiration, blood pressure - every hour, body temperature - every 4 hours, frequency and volume of urination - every 4 hours), intensity and labor efficiency.

An external obstetric examination in the period of disclosure is carried out systematically, noting the state of the uterus during contractions and outside them. The insertion and advancement of the fetal head through the birth canal is monitored using external palpation techniques, vaginal examination, and ultrasound. Conducting a vaginal examination is mandatory upon admission to the maternity hospital and outflow of amniotic fluid, before anesthesia, and also, according to indications, in case of deviation from the norm of the course of childbirth. However, to clarify the obstetric situation (maintenance of the partogram, orientation in the insertion and advancement of the head, assessment of the location of the sutures and fontanelles) during childbirth, it can be performed more often.

An important indicator of the course of labor is the rate of cervical dilatation. The rate of opening of the cervix in the latent phase averages 0.35 cm/h, in the active phase 1.5-2 cm/h in nulliparous and 2-2.5 cm/h in multiparous. The lower limit of the normal rate of opening of the uterine os in primiparous is 1.2 cm/hour, in multiparous 1.5 cm/hour. The opening of the uterine os in the deceleration phase is 1-1.5 cm / hour. Another important clinical indicator of the course of labor is the dynamics of lowering the fetal head. To determine the level of location of the fetal head, the fourth reception of an external obstetric examination and / or data from a vaginal examination is used.

Maintaining a partogram during childbirth. Latest revision of randomized results clinical research presented in the Cochrane review showed no difference in frequency caesarean section, vaginal delivery operations, assessment of the newborn on the Apgar scale, depending on whether or not partogram filling was used during childbirth. In this regard, the authors did not recommend the introduction of the partograph as a routine component. standard protocol childbirth. It is advisable to leave partogram maintenance only in those institutions where there is already evidence of the effectiveness of its use.

Assessment of the functional state of the fetus during childbirth. In the normal course of childbirth, the main method for assessing the functional state of the fetus is to control the nature of its cardiac activity. The most reliable is the use of cardiotocography for this purpose. If it is impossible to use a cardiotocograph, listening to the fetal heartbeat with a stethoscope is performed after a contraction for 30-60 seconds every 15-30 minutes. Be sure to determine the frequency, rhythm and sonority of heart tones. Cardiotocography with normal delivery can be used intermittently (upon admission within 40 min-1 h, after the outflow of amniotic fluid, after labor anesthesia, with the opening of the uterine os more than 8 cm). Diagnostic value method depends on the thoroughness of comparison of cardiotocography data with the obstetric situation.

The outpouring of light clear water indicates a rupture of the membranes and its diagnosis usually does not cause difficulties. Detection at vaginal examination of the head or buttocks of the fetus or loops of the umbilical cord confirms the rupture of the membranes. In doubtful cases, a diagnostic test system is used to clarify the diagnosis. The presence of meconium-stained amniotic fluid or the appearance of its impurities in the initially pure waters indicates a violation of the fetal condition that occurred before or developed during childbirth. If the amniotic fluid is stained with blood, then it is necessary to exclude premature detachment of the placenta, as well as rupture of the vessels of the umbilical cord.

The position of the mother in the first stage of labor. The results of a Cochrane systematic review showed that in women in labor using the standing position, the duration of the first stage of labor is on average 1 hour and 22 minutes shorter than in women in the prone position. They also have lower rates of caesarean section and epidural analgesia.

In the first stage of labor, a woman in labor can choose any position convenient for herself. Can sit, walk for a short time, stand. You can get up and walk both with whole and outflowing waters, but on condition that the presenting part of the fetus is tightly fixed in the pelvic inlet.

In bed, the position of the woman in labor is optimal on the side where the back of the fetus is located. In this position, the frequency and intensity of contractions do not decrease, the basal tone of the uterus remains normal. Water and food intake during childbirth. Restricting the intake of liquids and food during labor is a common practice in modern obstetrics. It is assumed that these restrictions not only cause discomfort, but can also worsen the condition of the woman in labor and the prognosis of childbirth, especially with a long course of childbirth. M. Singata et al published the results of a systematic Cochrane review in which they showed that the tactics of restricting the intake of fluids and water in labor is not accompanied by an increase in the frequency of operative delivery, a low Apgar score. However, the authors concluded that it is unreasonable to prohibit fluid and food intake during labor in low-risk women.

Based on results this study and expert opinion, a low-risk woman should be allowed to drink water during normal/normal labor. However, a small amount of light food (biscuits, chocolate, light broth) can only be allowed at the beginning of the latent phase 1 of the period of labor.

Starting from the active phase of the first stage of labor, it is undesirable to feed a woman in labor, since sometimes it may be necessary to perform surgical interventions under anesthesia, during which there may be a danger of aspiration of gastric contents and acute respiratory failure. The occurrence of this syndrome is facilitated by relaxation of the esophageal-gastric sphincter due to the action of progesterone, high standing of the diaphragm, increased intra-abdominal pressure, and a decrease in the cough reflex.

Prevention of this complication is the use of antacids before surgery (antacid, ranitidine, cimetidine) and the mandatory emptying of the stomach before anesthesia, if the meal was less than 5-6 hours before surgery. drug therapy in childbirth. The appointment of medications (antispasmodics, painkillers, uterotonic drugs) in the normal course of childbirth should not be carried out routinely, but it is possible as indications appear. When a woman enters the maternity ward in childbirth, it is advisable to establish a permanent intravenous catheter of sufficient diameter to exclude repeated venipuncture and provide urgent intravenous infusion in the event of an emergency.

Management of the second stage of labor
In the second stage of labor, close monitoring of the condition of the mother and fetus is necessary (Table 10.4). Before the start of attempts, preparations should be made for the reception of the child (opening the birth kit, warming the changing table, baby clothes, etc.). With the onset of attempts to give birth, a neonatologist is called.

Listening to the fetal heartbeat with a stethoscope should be carried out at the beginning of the second stage of labor every 15 minutes, then after each attempt. If possible, it is advisable to conduct continuous registration of cardiotocography. The basal heart rate is 110 to 170 per minute. With a head located in a narrow part of the pelvic cavity, early or uncomplicated variable decelerations can be observed on the cardiotocogram during an attempt, with fast recovery normal heart rate without pushing. The appearance of late or complicated variable decelerations, bradycardia, especially with a decrease in basal rate variability, should be considered as a deviation from the norm.

In the II period of physiological labor, the fetal head does not linger in any plane of the small pelvis for more than 30-40 minutes in primiparas and 20-30 minutes in multiparous ones. The presence of the head in the same plane for 60 minutes or more requires a reassessment of the clinical situation. Determination of the height of the fetal head is carried out by external methods or vaginal examination. Regulation of attempts. The results of systematic reviews show no clear benefit of immediate or delayed onset of labor at the end of the second stage of labor. So, with their immediate start using the Valsalva maneuver, the duration of the second period is reduced without affecting the frequency of operative delivery and outcomes for the newborn. However, the frequency of violation of urodynamics in the postpartum period increases. According to a meta-analysis, with a delayed onset of pushing, the second stage of labor is lengthened, but the duration of active pushing is shortened.

If, with the fetal head located in a narrow part of the cavity or the exit of the pelvis, a woman has effective attempts (the translational movement of the fetal head during normal condition women and the absence of signs of suffering of the fetus) there is no need to regulate the attempts. Regulation of attempts is advisable in the absence of effective exertion. At the same time, it is necessary to pay attention to women to ensure correct breathing, coordination of contractions and attempts, the correct distribution of efforts aimed at advancing the fetal head:
- at the beginning of the attempt, the woman in labor should take the deepest possible breath, and then hold her breath. The entire volume of air should press on the diaphragm, and through it on the bottom of the uterus, as if pushing the fetus out;
- when there is a feeling of lack of air, the woman in labor should smoothly exhale the air and immediately take the deepest possible breath;
- for one attempt, the cycle "inhale-exhale" repeat three times. Between attempts, they switch to slow, smooth breathing.

Artificial stimulation of attempts at the beginning of the 2nd period with a high-standing head is a mistake in labor management. Choosing a position in the second stage of labor. The question of choosing the optimal position for the birth of a child has been a subject of controversy for centuries. At the same time, vertical births (sitting, on the birth chair, squatting or kneeling) are most often compared with the prone position. The latest Cochrane systematic review showed that obstetrical assistance, episiotomy, are less common in vertical births, but second-degree perineal tears and pathological blood loss are more common.

With a satisfactory condition of the mother and fetus in the second stage of labor, an independent choice of the position of the woman in labor is acceptable. You can offer her a position on her left side, squatting, standing using a support. From the moment the head is lowered to the pelvic floor, the woman in labor is transferred to a special bed (transformer bed).

The midwife takes the child in the position of the woman in labor half-sitting with legs bent at the hips and knee joints and divorced to the sides, which allows the woman in labor to fully use the strength of her arms and legs during attempts; and the midwife should monitor the condition of the perineum, prevent its ruptures, carefully take the fetal head.

The advancement of the fetal head during the period of exile should be gradual. After lowering the head to the pelvic floor, one can observe the translational movement of the head: at first, protrusion of the perineum is noticeable, then stretching. The anus protrudes and gapes, the genital slit opens and the lower pole of the fetal head appears. Several times after the end of the attempt, the head hides behind the genital slit, again showing up at the beginning of the next attempt - cutting the head. After some time, after the end of the attempt, the head ceases to hide - the eruption of the head begins. It coincides with the beginning of the extension of the head (birth to the parietal tubercles). By extension, the head gradually emerges from under the pubic arch, the occipital fossa is located under the pubic articulation, the parietal tubercles are tightly covered by stretched tissues.

Through the genital gap, the forehead is first born, and then the entire face when the perineum slips from them. The born head makes an external turn, then the shoulders and trunk come out along with the outflow of the posterior waters.

During the eruption of the heads provide manual assistance. When extended, the fetal head exerts strong pressure on the pelvic floor, it is stretched, which can lead to rupture of the perineum. The walls of the birth canal squeeze the head of the fetus, there is a threat of circulatory disorders of the brain. The provision of manual assistance in cephalic presentation reduces the risk of these complications. Manual assistance in childbirth. A manual manual consists of several moments performed in a certain sequence.
The first point is to prevent premature extension of the head. It is necessary that during eruption the head passes through the genital gap with its smallest circumference (32 cm), corresponding to a small oblique size (9.5 cm) in a state of flexion. The obstetrician, standing to the right of the woman in labor, puts the palm of his left hand on the bosom, placing four fingers on the head of the fetus in such a way as to cover its entire surface protruding from the genital gap. With light pressure, it delays the extension of the head and prevents its rapid advancement through the birth canal.
The second point is the reduction of tension in the perineum. The obstetrician places the right hand on the perineum so that four fingers are firmly pressed against the left side of the pelvic floor in the region of the labia majora, and the thumb is pressed against the right side of the pelvic floor. With all fingers, the obstetrician gently pulls and lowers the soft tissues towards the perineum, reducing the stretch. The palm of the same hand supports the perineum, pressing it against the erupting head. Reducing the tension of the perineum in this way allows you to restore blood circulation and prevent the appearance of tears.
The third point is the removal of the head from the genital gap outside the attempts. At the end of the effort, with the thumb and forefinger of the right hand, the obstetrician carefully stretches the vulvar ring over the erupting head. The head gradually comes out of the genital gap. At the onset of the next attempt, the obstetrician stops stretching the vulvar ring and again prevents the extension of the head. The actions are repeated until the parietal tubercles of the head approach the genital slit. During this period, there is a sharp stretching of the perineum and there is a risk of ruptures. At this point, the regulation of attempts is extremely important. The greatest stretching of the perineum, the threat of its rupture and injury to the fetal head, occurs if the head is born during an attempt. In order to avoid injury to the mother and fetus, it is necessary to regulate the attempts - turning off and weakening, or, conversely, lengthening and strengthening. The regulation is carried out as follows: when the parietal tubercles of the fetal head pass the genital slit, and the suboccipital fossa is under the pubic symphysis, when an attempt occurs, the obstetrician instructs the woman in labor to breathe deeply in order to reduce the force of the attempt, since during deep breathing attempts are impossible. At this time, the obstetrician with both hands delays the advancement of the head until the end of the contraction. Outside of an attempt with the right hand, the obstetrician squeezes the perineum over the face of the fetus in such a way that it slides off the face. With the left hand, the obstetrician slowly raises the head up and unbends it. At this time, the woman is instructed to push, so that the birth of the head occurs with little stress. Thus, the obstetrician with commands to push and not push achieves the optimal tension of the perineal tissues and the safe birth of the densest and largest part of the fetus - the head.
The fourth moment is the release of the shoulder girdle and the birth of the fetal body. After the birth of the head, the woman in labor is instructed to push. In this case, an external rotation of the head and an internal rotation of the shoulders occur (from the first position, the head turns to face the right thigh of the mother, from the second position - to the left thigh). Usually the birth of the shoulders proceeds spontaneously. If the spontaneous birth of the fetal shoulders did not occur, then the obstetrician captures the head in the region of the temporal bones and cheeks with both palms. Easily and gently pulls the head downwards and backwards until the front shoulder fits under the pubic joint. Then the obstetrician with his left hand, the palm of which is on the lower cheek of the fetus, grabs the head and lifts its top, and with his right hand carefully removes the back shoulder, shifting the perineal tissues from it. Thus, the birth of the shoulder girdle occurs. The obstetrician inserts the index fingers from the back of the fetus into armpits, and lifts the body anteriorly (on the mother's stomach).

Dissection of the perineum during childbirth is not performed routinely, but is performed according to indications: in case of a threat of rupture, in order to reduce the straining period in case of violation of the fetal condition, or according to indications from the mother. From the moment the head is inserted, everything should be ready for delivery. Usually the birth of a child occurs in 5-10 attempts.

In physiological childbirth and a satisfactory condition of the newborn, the umbilical cord should be crossed after the cessation of vascular pulsation or one minute after the birth of the child. At the same time, until the umbilical cord is crossed, the newborn cannot be raised above the mother's body, otherwise there is a reverse outflow of blood from the newborn to the placenta. Immediately after the birth of the child, if the umbilical cord is not clamped, and it is located below the level of the mother, then there is a reverse "infusion" of 60-80 ml of blood from the placenta to the fetus. In order to prevent bleeding at the time of birth of the anterior shoulder of the fetus, 10 IU of oxytocin is administered intramuscularly or 5 IU intravenously slowly.

It is also possible at the end of the second stage of labor to introduce a solution of oxytocin 5 IU per 50 ml of saline using an infusion pump, starting from 1.8 ml / hour. After eruption of the anterior shoulder of the fetus, the infusion rate is increased to 15.2 ml/h.

After the birth of a child, the third stage of childbirth begins - afterbirth.

third stage of labor
The third (afterbirth) period of childbirth begins from the moment the child is born and ends with the separation of the placenta and the release of the placenta. Duration 5 - 20 min.

After the birth of the fetus, there is a sharp decrease in the volume of the uterus. For several minutes, the uterus is at rest, the resulting contractions are painless. There is little or no bleeding from the uterus. The bottom of the uterus is located at the level of the navel. 5-7 minutes after the birth of the fetus, during 2-3 postpartum contractions, the placenta separates and the placenta is expelled. After complete separation of the placenta from the placental site, the bottom of the uterus rises above the navel and deviates to the right. The contours of the uterus take the form of an hourglass, since in its lower section there is a separated placenta. With the appearance of an attempt, the birth of the placenta occurs. Blood loss during separation of the placenta should not exceed 500 ml and is usually about 250 ml (up to 0.5% of the body weight of the woman in labor). After the birth of the placenta, the uterus acquires density, becomes rounded, is located symmetrically, its bottom is located between the navel and the womb.

Management of the third stage of labor
AT consecutive period it is impossible to palpate the uterus, so as not to disturb the natural course of contractions and the correct separation of the placenta. The natural separation of the placenta avoids bleeding. During this period, the main attention is paid to complaints, the general condition of the woman in labor and signs of separation of the placenta. There are two tactics for managing the afterbirth period: expectant (physiological) and active. With expectant management, separation of the placenta and the birth of the afterbirth occurs without any medication or manual assistance, due to the natural contractile activity of the uterus. With active tactics, a uterotonic drug is used to accelerate and intensify uterine contraction, the umbilical cord is crossed until the pulsation stops, and the birth of the placenta is promoted by external methods.

The results of numerous randomized clinical trials and a Cochrane systematic review have convincingly shown the benefits of active tactics: reduction in the frequency of blood loss of more than 500 ml (RR 0.38; CI 95% 0.32-0.46); reduction in blood loss; reduction in the duration of the 3rd stage of labor. For some time, active labor tactics were associated mainly with the WHO-recommended "tactics of active traction for the umbilical cord." Research carried out in recent times showed that umbilical cord traction does not reduce the likelihood and magnitude of pathological blood loss, and the main effective component of active tactics is the use of an uterotonic. As mentioned earlier, the optimal is the introduction of oxytocin at the time of eruption of the anterior shoulder of the fetus.

After the birth of a child, the doctor assesses the condition of the woman in labor (the appearance of pallor of the skin, an increase in heart rate of more than 100 beats per minute, a decrease in blood pressure by more than 15-20 mm Hg compared with the original, indicates the likelihood of pathological blood loss), and the midwife performs emptying the bladder of a woman in labor with a catheter.

During this period, it is necessary to monitor the nature and amount of blood discharge from the uterus, signs of separation of the placenta, when they appear, it is recommended that the woman push for the birth of the separated placenta or proceed to its isolation by external methods. It is impossible to allow the separated placenta to be in the uterine cavity, as this increases the volume of blood loss and the risk of bleeding. Signs of separation of the placenta. Schroeder's sign: when the placenta separates and descends into the lower part of the uterus, the fundus of the uterus rises above the navel and deviates to the right, which is noticeable on palpation. In this case, the lower segment protrudes above the bosom.

Alfeld's sign: if the separation of the placenta has occurred, then the clamp applied to the stump of the umbilical cord at the genital slit will drop by 10 cm or more.

Sign of Kyustner-Chukalov: the umbilical cord is retracted into the vagina when the rib of the hand is pressed over the bosom, if the placenta has not separated. If separation of the placenta has occurred, the umbilical cord is not retracted.

Sign of Dovzhenko: the woman in labor is offered to take a deep breath and exhale. If the separation of the placenta has occurred, when inhaling, the umbilical cord is not retracted into the vagina.

Sign of Klein: the woman in labor is offered to push. If placental abruption has occurred, the umbilical cord remains in place; and if the placenta is not separated, the umbilical cord is pulled into the vagina after attempts.

The diagnosis of separation of the placenta is based on the combination of the listed signs. If the independent birth of the placenta does not occur, then it is recommended that the woman push herself arbitrarily; if there is no effect, external techniques are used that contribute to the birth of the placenta. You can not try to isolate the placenta before separation of the placenta.

The use of external techniques for isolating the separated placenta. Isolation of the placenta according to the method of Abuladze (strengthening abdominals): the anterior abdominal wall is grasped with both hands so that the rectus abdominis muscles are tightly grasped by the fingers. There is a decrease in the volume of the abdominal cavity and the elimination of muscle divergence. The woman in labor is offered to push, the placenta is separated with its subsequent birth.

Isolation of the placenta according to the Krede-Lazarevich method (imitation of a contraction) can be traumatic if the basic conditions for performing this manipulation are not observed. Necessary conditions for the allocation of the placenta according to Krede-Lazarevich: preliminary emptying of the bladder, bringing the uterus to the middle position, light stroking of the uterus in order to stimulate its contractions. Technique this method: the obstetrician grasps the bottom of the uterus with the right hand. In this case, the palmar surfaces of the four fingers are located on back wall uterus, the palm is at its bottom, and the thumb is on the front wall of the uterus. At the same time, with the whole brush, they press on the uterus towards the pubic co-Isolation of the placenta according to Genter's method (imitation of generic forces): the hands of both hands, clenched into fists, are placed with their backs on the bottom of the uterus. With a smooth downward pressure, a gradual birth of the placenta occurs.

If there are no signs of separation of the placenta within 20 minutes after the birth of the fetus, then this may be due to infringement of the placenta. In such a situation, anesthesia is indicated, followed by the allocation of the placenta by the Crede method. If the selection by manual methods is unsuccessful, they proceed to the manual separation of the placenta and the allocation of the placenta.

After the birth of the placenta, an external massage of the uterus should be performed and make sure there is no bleeding. After that, they proceed to inspect the placenta to make sure that it is intact. To do this, the placenta, facing the maternal surface upwards, is placed on a smooth tray or obstetrician's hands and first the placenta and then the membranes are examined. The surface of the lobules of the maternal part of the placenta is smooth, shiny. Defective tissue of the placenta indicates retention of a lobule or part of a lobule. In the membranes, blood vessels are identified in order to detect an additional lobule of the placenta. If there are vessels in the membranes, and there are no lobules of the placenta in their path, then it lingered in the uterine cavity. In this case, produce manual separation and removal of the retained placenta. The detection of torn membranes indicates that their fragments are in the uterus. By the place of rupture of the membranes, one can determine the location of the placental site in relation to the internal pharynx. The closer to the placenta the rupture of the membranes, the lower the placenta was located, and the greater the risk of bleeding in the early postpartum period.

Holding surgical intervention(manual examination of the uterus) is necessary if:
- there is a deterioration in the condition of the puerperal;
- no signs of separation of the placenta and the presence of bleeding from the genital tract;
- bleeding in the afterbirth period (the volume of blood loss exceeds 500 ml or 0.5% of body weight);
- doubt about the integrity and defect of the placenta;
- if the follow-up period lasts more than 20 minutes, even if the woman in labor is in a satisfactory condition and there is no bleeding.

After making sure that the placenta is intact, the external genitalia and soft tissues of the birth canal are examined. Examine the walls of the vagina and the cervix with the help of vaginal mirrors. The ruptures found are sutured. After the birth of the placenta, the postpartum period begins, the woman in labor is called the puerperal. During the early postpartum period (2 hours after the separation of the placenta), the puerperal is in the maternity ward. It is necessary to monitor its general condition, the condition of the uterus, the amount of blood loss.

After examining the birth canal and restoring their integrity, the puerperal, under the supervision of a neonatologist and a midwife, breastfeeds the baby. After 2 hours after birth, the puerperal is transferred to the postpartum department. Before the transfer, the general condition of the puerperal is assessed (complaints, skin coloration, the presence of dizziness, headache, visual disturbances, and others, body temperature is measured, the pulse and blood pressure in the peripheral arteries are examined, the condition of the uterus, the nature and volume of discharge from the genital tract. If epidural analgesia was performed - an anesthesiologist is called to remove the catheter from the epidural space.If the puerperal did not urinate on her own, empty the bladder with urinary catheter. Write a diary in the history of childbirth.

Childbirth ( partus) - the process of expulsion of the fetus from the uterus after the fetus has reached viability.

In the Russian Federation, since 2005, childbirth is considered the birth of a child weighing 1000 g or more at 28 weeks of gestation or more. According to WHO recommendations, childbirth is considered the birth of a fetus, starting at 22 weeks of gestation (weight 500 g or more). In our country, termination of pregnancy between 22 and 28 weeks is considered an abortion. All the necessary medical and resuscitation measures are carried out for those born alive during these gestation periods. If the child is going through the perinatal period (168 hours), then a medical birth certificate is issued and the newborn is registered in the registry office, and the mother receives a disability certificate for pregnancy and childbirth.

In addition to spontaneous, there are induced and programmed births. Induced labor refers to artificial labor induction according to indications from the mother or fetus.

Programmed childbirth - artificial labor induction at a convenient time for the doctor.

CAUSES OF DELIVERY

The reasons for the onset of childbirth have not yet been established. Childbirth is a complex multi-link process that arises and ends as a result of the interaction of the nervous, humoral and fetoplacental systems, which affect the contraction of the muscles of the uterus. Contractions of the muscles of the uterus do not differ from the contraction of smooth muscle muscles in other organs and are regulated by the nervous and humoral systems.

By the end of pregnancy, as a result of fetal maturity and genetically determined processes against this background, both in the mother's body and in the feto-placental complex, relationships are formed aimed at strengthening the mechanisms that activate uterine muscle contraction.

The activating mechanisms include, first of all, the strengthening of nerve stimuli arising in the ganglia of the peripheral nervous system, the connection of which with the central nervous system is carried out through the sympathetic and parasympathetic nerves. Adrenergic receptors a and b are located in the body of the uterus, and m-cholinergic - in the circular fibers of the uterus and the lower segment, where serotonin and histamine receptors are located simultaneously. The excitability of the peripheral parts of the nervous system and, after that, the subcortical structures (almond-shaped nuclei of the limbic part of the hypothalamus, pituitary gland, epiphysis) increases against the background of inhibition in the cerebral cortex (in the temporal lobes of the cerebral hemispheres). Such relationships contribute to automatic reflex contraction of the uterus.

The second variant of mechanisms that activate uterine contractions, closely related to the first, is humoral. Before childbirth, the content of compounds leading to an increase in the activity of myocytes increases in the blood of a pregnant woman: estriol, melatonin, prostaglandins, oxytocin, serotonin, norepinephrine, acetylcholine.

The main hormone responsible for preparing the uterus for childbirth is estriol. A special role in increasing its level is played by cortisol and melatonin, which are synthesized in the body of the fetus. Cortisol serves as a precursor and stimulator for the synthesis of estriol in the placenta. Estrogens help prepare the uterus and the mother's body as a whole for labor. In this case, the following processes occur in the myometrium:

Increased blood flow, actin and myosin synthesis, energy compounds (ATP, glycogen);

Intensification of redox processes;

Increasing the permeability of cell membranes for potassium, sodium, especially calcium ions, which leads to a decrease in membrane potential and, consequently, acceleration of the conduction of nerve impulses;

Suppression of oxytocinase activity and preservation of endogenous oxytocin, which reduces cholinesterase activity, which contributes to the accumulation of free acetylcholine;

An increase in the activity of phospholipases and the rate of the "arachidon cascade" with an increase in the synthesis of PGE in the amniotic and PGF2a in the decidua.

Estrogens increase the energy potential of the uterus, preparing it for a long contraction. At the same time, estrogens, causing structural changes in the cervix, contribute to its maturation.

Before childbirth, the uterus becomes estrogen-dominant with a predominance of a-adrenergic receptor activity and a decrease in b-adrenergic receptors.

An important place in the initiation of labor activity belongs to melatonin, the concentration of which increases in the fetus, and decreases in the mother. A decrease in the level of melatonin in the mother's blood promotes the expression of foli- and lutropin, leading to the activation of estrogen synthesis. Melatonin not only increases estrogen function, but also activates immune responses by suppressing the synthesis of the immunosuppressants prolactin and hCG. This, in turn, enhances transplant immunity and stimulates rejection of the fetus as an allograft.

To start labor and contract the muscles of the uterus importance have PGE and PGF 2a - direct labor activators. The first of them to a large extent contributes to the maturation of the cervix and uterine contraction in the latent phase, and PGF2a - in the latent and active phase of the first stage of labor.

An increase in the synthesis of prostaglandins is due to the activation of the "arachidon cascade" before childbirth as a result of dystrophic changes in the decidua, fetal membranes, placenta, as well as the release of fetal cortisol and an increase in estriol.

Prostaglandins are responsible for:

Formation on the muscle membrane of a-adrenergic receptors and receptors for oxytocin, acetylcholine, serotonin;

An increase in the level of oxytocin in the blood due to inhibition of the production of oxytocinase;

Stimulation of the production of catecholamines (adrenaline and norepinephrine);

Ensuring automatic contraction of the muscles of the uterus;

Deposition of calcium in the sarcoplasmic reticulum, which contributes to prolonged contraction of the uterus during childbirth.

One of the important regulators of the contractile activity of the uterus is oxytocin, secreted in the hypothalamus and secreted before birth by the pituitary gland of both the mother and the fetus.

The sensitivity of the uterus to oxytocin increases in the last weeks of pregnancy and reaches a maximum in the active phase of the first period, in the second and third stages of labor. By increasing the tone of the uterus, oxytocin stimulates the frequency and amplitude of contractions by:

Excitation of a-adrenergic receptors;

Reducing the resting potential of the cell membrane and thus the threshold of irritability, which increases the excitability of the muscle cell;

Synergistic action on acetylcholine, which increases the rate of its binding by myometrial receptors and release from the bound state;

Inhibition of cholinesterase activity, and, consequently, the accumulation of acetylcholine.

Along with the main uterotonic compounds in the process of preparing for childbirth important role belongs serotonin, which also inhibits cholinesterase activity and enhances the action of acetylcholine, facilitating the transfer of excitation from the motor nerve to the muscle fiber.

The change in the ratio of hormones and biologically active substances that affect the excitability and contractile activity of the uterus before childbirth takes place in several stages: the first stage is the maturity of the hormonal regulation of the fetus (cortisol, melatonin); the second stage is the expression of estrogens and metabolic changes in the uterus; third stage -

synthesis of uterotonic compounds, primarily prostaglandins, oxytocin, serotonin, which ensure the development of labor activity. The processes occurring before childbirth in the central and peripheral nervous system, endocrine system and fetoplacental complex, united in the concept of "generic dominant".

During childbirth, alternating excitation of the centers of sympathetic and parasympathetic innervation develops. Due to the excitation of the sympathetic nervous system (norepinephrine and adrenaline) and the release of mediators, there is a contraction of longitudinally located muscle bundles in the body of the uterus with simultaneous active relaxation of the circularly (transversely) located bundles in the lower segment. In response to the maximum excitation of the center of the sympathetic nervous system and the release of a large amount of norepinephrine, the center of the parasympathetic nervous system is excited, under the action of mediators of which (acetylcholine) the circular muscles contract while relaxing the longitudinal ones; after reaching the maximum contraction of the circular muscles, the maximum relaxation of the longitudinal muscles occurs. After each contraction of the uterus, its complete relaxation occurs (a pause between contractions), when the synthesis of myometrial contractile proteins is restored.

harbingers of childbirth

At the end of pregnancy, changes occur that indicate the readiness of the body for childbirth - "harbingers of childbirth." These include:

"lowering" of the pregnant woman's abdomen as a result of stretching the lower segment and inserting the head into the entrance to the small pelvis, deviation of the uterine fundus anteriorly due to some decrease in the tone of the abdominal press (observed 2-3 weeks before delivery);

Moving the center of gravity of the body of a pregnant woman forward; shoulders and head are laid back ("proud tread");

protrusion of the navel;

Decreased body weight of a pregnant woman by 1-2 kg (2-3 days before delivery);

Increased excitability or, conversely, a state of apathy, which is explained by changes in the central and autonomic nervous system before childbirth (observed a few days before childbirth);

decline motor activity fetus;

The appearance in the region of the sacrum and lower abdomen of irregular, first pulling, then cramping sensations (preliminary pain);

Discharge from the genital tract thick stringy mucus- mucous plug (discharge of the mucous plug is often accompanied by slight bloody discharge due to shallow tears of the edges of the pharynx);

maturation of the cervix. The degree of cervical maturity is determined in points (Table 9.1) using a modified Bishop scale.

Table 9.1. Cervical maturity scale

Unlike the Bishop scale, this table does not take into account the ratio of the head to the planes of the pelvis.

When assessing 0-2 points - the neck is considered "immature", 3-4 points - "not mature enough", 5-8 points - "mature".

"Maturation" of the cervix before childbirth is due to morphological changes in collagen and elastin, an increase in their hydrophilicity and extensibility. As a result, softening and shortening of the neck occur, opening first the internal and then the external pharynx.

The "maturity" of the cervix, determined by vaginal examination and a modified Bishop scale, is the main sign of the body's readiness for childbirth.

PERIODS OF BIRTH. CHANGES IN THE UTERUS DURING BIRTH

The onset of labor is characterized by regular contractions every 15-20 minutes. There are three periods of childbirth: the first period - the opening of the cervix; the second period - the expulsion of the fetus; the third period is successive.

At present, with the widespread use of anesthesia, more active tactics of conducting labor, their duration has decreased and is 12-16 hours in primiparas, 8-10 hours in multiparous. 10-12 hours in multiparous.

The first stage of labor is the opening of the cervix. It begins with the appearance of regular contractions, which contribute to the shortening, smoothing and opening of the cervix. The first stage of labor ends with full dilatation of the cervix.

The duration of the first stage of labor in primiparous is 10-12 hours, in multiparous - 7-9 hours.

Disclosure of the cervix is ​​facilitated by: a) peculiar, characteristic only for the uterus, muscle contractions (contraction, retraction, distraction); b) pressure on the neck from the inside by the fetal bladder, and after the outflow of amniotic fluid - by the presenting part of the fetus due to increased intrauterine pressure.

Features of uterine contraction are determined by its structure and the location of muscle fibers.

From obstetric positions, the uterus is divided into the body and the lower segment, which begins to form in the middle of pregnancy from the cervix and isthmus. Muscle fibers located longitudinally or obliquely predominate in the body of the uterus. In the lower segment, they are located circulatory (Fig. 9.1).

The muscles of the body of the uterus, contracting, contribute to the opening of the cervix and the expulsion of the fetus and afterbirth. The mechanism of contractile activity of the uterus is very complex and not completely clear. The theory of contraction, which was proposed by Caldeyro-Barcia and Poseiro in 1960, is generally accepted. The researchers introduced elastic microballoons at different levels into the wall of the uterus of a woman in labor, responding to muscle contraction, and into the uterine cavity - a catheter that responds to intrauterine pressure, and recorded the features of muscle contraction in its various departments. The scheme of uterine contraction according to Caldeyro-Barcia is shown in the figure. (see figure 9.2).

As a result of the research, the law of the triple downward gradient was formulated, the essence of which is that the wave of uterine contraction has a certain direction from top to bottom (1st gradient); decrease in duration (2nd gradient) and intensity (3rd gradient) of uterine muscle contraction from top to bottom. Consequently, the upper sections of the uterus in relation to the lower ones contract longer and more intensely, forming the dominant of the uterine fundus.

Excitation and contraction of the uterus begins in one of the uterine angles (see Fig. 9.2), in the area of ​​​​the pacemaker ("pacemaker"). The pacemaker appears only in childbirth and is a group of smooth muscle cells capable of generating and summing up high charges of cell membranes, initiating a muscle contraction wave that moves to the opposite uterine angle, then passes to the body and lower segment with decreasing duration and strength. The pacemaker is often formed in the uterine angle, opposite to the location of the placenta. The speed of propagation of the contraction wave from top to bottom is 2-3 cm/s. As a result, after 15-20 seconds, the contraction covers the entire uterus. With normal coordinated labor activity, the peak of contraction of all layers and levels of the uterus falls at the same time (Fig. 9.2). The total effect of muscle contraction realizes the activity of the uterus and significantly increases intra-amniotic pressure.

The amplitude of the contraction, decreasing as it spreads from the bottom to the lower segment, creates a pressure of 50-120 mm Hg in the body of the uterus. Art., and in the lower segment only 25-60 mm Hg. Art., i.e. the upper sections of the uterus contract 2-3 times more intensely than the lower ones. Due to this, retraction is possible in the uterus - the displacement of muscle fibers upwards. During contractions, longitudinally located muscle fibers, stretched in length, contract, intertwine with each other, shorten and shift relative to each other. During a pause, the fibers do not return to their original position. As a result, a significant part of the musculature is shifted from the lower sections of the uterus to the upper ones. As a result, the wall of the uterine body progressively thickens, contracting more and more intensively. The retraction regrouping of muscles is closely related to the parallel process of cervical distraction - stretching of the circular muscles of the cervix. The longitudinally located muscle fibers of the body of the uterus at the time of contraction and retraction pull and entail the circularly located muscle fibers of the cervix, contributing to its opening.

When the uterus contracts, the relationship (reciprocity) of its various departments (body, lower segment) is important. The contraction of the longitudinal muscles should be accompanied by stretching of the transverse muscles of the lower segment and the neck, which contributes to its opening.

The second mechanism of opening the cervix is ​​associated with the formation of a fetal bladder, since during contractions, as a result of uniform pressure of the walls of the uterus, amniotic fluid rushes to the internal pharynx in the direction of least pressure (Fig. 9.3, a), where there is no resistance of the walls of the uterus. Under the pressure of amniotic fluid, the lower pole gestational sac exfoliates from the walls of the uterus and is introduced into the internal pharynx of the cervical canal (Fig. 9.3, b, c). This part of the amniotic fluid of the shell of the lower pole of the egg is called fetal bladder, dilates the cervix from the inside.

As labor progresses, thinning and final formation of the lower segment from the isthmus and cervix occur. The border between the lower segment and the body of the uterus is called the contraction ring. The height of the contraction ring above the pubic joint corresponds to the opening of the cervix: the more the cervix opens, the higher the contraction ring is located above the pubic joint.

The opening of the cervix occurs differently in primiparous and multiparous. In primiparous, the internal pharynx first opens, the neck becomes thin (smoothed), and then the external pharynx opens (Fig. 9.4.1). In multiparous, the external os opens almost simultaneously with the internal one, and at this time the cervix shortens (Fig. 9.4.2). The opening of the cervix is ​​considered complete when the pharynx opens up to 10-12 cm. Simultaneously with the opening of the cervix in the first period, as a rule, the advancement of the presenting part of the fetus through the birth canal begins. The fetal head begins to descend into the pelvic cavity with the onset of contractions, being by the time the cervix is ​​fully opened, most often as a large segment at the entrance to the small pelvis or in the cavity of the small pelvis.

With cephalic presentation, as the fetal head advances, separation of amniotic fluid on the anterior and posterior, as the head presses the wall of the lower segment of the uterus against the bone base of the birth canal. The place where the head is covered by the walls of the lower segment is called internal belt of contact(adjacency), which divides the amniotic fluid into the anterior ones, located below the contact zone, and the posterior ones, above the contact belt (Fig. 9.5).

By the time the cervix is ​​fully dilated, the fetal bladder loses its physiological function and must open. Depending on the time of outflow of amniotic fluid, there are:

Timely discharge, which occurs with full (10 cm) or almost complete (8 cm) opening of the cervix;

Premature or prenatal effusion - effusion of water before the onset of labor;

Early outflow - outflow of water after the onset of labor, but before the cervix is ​​fully dilated;

Late outflow of amniotic fluid, when, due to the excessive density of the membranes, the bladder ruptures later than the full opening of the cervix (if, with a belated rupture of the fetal bladder, an amniotomy is not performed - opening the membranes of the membranes of the membranes, then the fetus can be born in the amniotic membrane - "shirt");

A high rupture of the fetal bladder is a rupture of the membranes above the external os of the cervix (if the head is pressed against the entrance to the small pelvis, then the rupture is plugged and a straining fetal bladder is determined during vaginal examination).

With a whole fetal bladder, the pressure on the head is uniform. After the outflow of amniotic fluid, the intrauterine pressure becomes higher than the external (atmospheric) pressure, which leads to a violation of the venous outflow from the soft tissues of the head below the contact zone. As a result of this, a generic tumor is formed on the head in the region of the leading point (Fig. 9.6).

The full opening of the cervix ends the first stage of labor and the period of exile begins.

The second period - the period of exile lasts from the moment of full disclosure of the cervix until the expulsion of the fetus. Its duration in primiparas ranges from 1 to 2 hours, in multiparous - from 20-30 minutes to 1 hour.

In the second period develop attempts, which are contractions of the muscles of the uterus, abdominal wall (abdominal pressure), diaphragm and pelvic floor.

Attempts are an involuntary reflex act and occur due to the pressure of the presenting part of the fetus on the nerve pelvic plexus, nerve endings of the cervix and perineal muscles. As a result, the Forgust reflex is formed, i.e. irresistible desire to push. A woman in labor, holding her breath, contracts the diaphragm and muscles of the abdominal wall. As a result of attempts, intrauterine and intra-abdominal pressure increases significantly. The uterus is fixed to the walls of the pelvis by a ligamentous apparatus (wide, round, sacro-uterine ligaments), therefore, intrauterine and intra-abdominal pressure is completely aimed at expelling the fetus, which, making a series of complex movements, moves in the direction of least resistance along the birth canal, respectively, the wire axis of the pelvis. Sinking to the pelvic floor, the presenting part stretches the genital slit and is born, the whole body is born behind it.

Along with the birth of the fetus, the posterior amniotic fluid is poured out. The birth of a child ends the second stage of labor.

Third period - consecutive begins after the birth of the child and ends with the birth of the placenta. During this period, placental abruption and membranes from the underlying uterine wall and the birth of the placenta (placenta with membranes and umbilical cord) occur. The follow-up period lasts from 5 to 30 minutes.

Separation of the placenta is facilitated by:

A significant decrease in the uterine cavity after the expulsion of the fetus;

Cramping contractions of the uterus, called succession;

The location of the placenta in the functional layer of the uterine mucosa, which is easily separated from the basal layer;

The placenta lacks the ability to contract.

The uterine cavity decreases due to the contraction of the muscular wall, the placenta rises above the placental site in the form of a roller facing the uterine cavity, which leads to rupture of the uteroplacental vessels and disruption of the connection between the placenta and the uterine wall. The blood pouring out at the same time between the placenta and the wall of the uterus accumulates and forms a retroplacental hematoma. The hematoma contributes to further detachment of the placenta, which protrudes more and more towards the uterine cavity. Contraction of the uterus and an increase in retroplacental hematoma, together with the force of gravity of the placenta pulling it down, leads to the final detachment of the placenta from the uterine wall. The placenta, together with the membranes, descends and, with an attempt, is born from the birth canal, turned outward with its fruit surface, covered with a water membrane. This variant of detachment is most common and is called the Schultze placenta isolation variant (Fig. 9.7, a).

When the placenta is separated according to Duncan, its detachment from the uterus does not begin from the center, but from the edge (Fig. 9.7, b). Blood from ruptured vessels freely flows down, peeling off the membranes on its way (there is no retroplacental hematoma). Until the placenta is completely separated from the uterus, with each new successive contraction, detachment of more and more of its new sections occurs. The separation of the afterbirth is facilitated by the own mass of the placenta, the edge of which hangs down into the uterine cavity. The placenta exfoliated according to Duncan descends and, with an attempt, is born from the birth canal in a cigar-shaped folded form with the maternal surface facing outward.

The subsequent period is accompanied by bleeding from the uterus, from the placental site. Physiological blood loss is considered to be no more than 0.5% of body weight (300-500 ml).

The stoppage of bleeding in the afterbirth period is due to the contraction of the muscles of the uterus, the peculiarities of the structure of the uterine vessels (spiral structure); increased local hemostasis.

After the birth of the placenta, the muscles of the uterus, intensively contracting, lead to deformation, twisting, kinks and displacement of the uterine vessels, which is an important factor in stopping bleeding. Promotes hemostasis terminal departments arteries, the spiral structure of which ensures their contraction and displacement into deeper muscle layers, where they are subjected to additional compressive action of the contracting muscles of the uterus.

The activation of local hemostasis in the vessels of the uterus is largely determined by the high thromboplastic activity of the chorion tissue. Thrombus formation, together with mechanical clamping of the vessels, leads to a stop of bleeding.

After the birth of the placenta, the woman is called the puerperal.

MECHANISM OF DELIVERY

The mechanism of childbirth is a set of movements performed by the fetus when passing through the birth canal. As a result of these movements, the head tends to pass through the large dimensions of the pelvis with its smallest dimensions.

The mechanism of childbirth begins when the head, as it moves, encounters an obstacle that prevents its further movement.

The movement of the fetus under the influence of expelling forces takes place along the birth canal (Fig. 9.8) in the direction of the wire axis of the pelvis, which is a line connecting the midpoints of all direct dimensions of the pelvis. The wire axis resembles the shape of a fishhook, due to the curvature of the sacrum and the presence of a powerful layer of pelvic floor muscles.

The soft tissues of the birth canal - the lower segment of the uterus, the vagina, the fascia and the muscles lining the inner surface of the small pelvis, the perineum - stretch as the fetus passes, resisting the fetus being born.

The bone base of the birth canal has unequal dimensions in different planes. The advancement of the fetus is usually attributed to the following planes of the small pelvis:

Entrance to the pelvis;

The wide part of the pelvic cavity;

The narrow part of the pelvic cavity;

Pelvic exit.

For the mechanism of childbirth, not only the size of the pelvis, but also the head, as well as its ability to change shape, i.e. to the configuration. The configuration of the head is provided by sutures and fontanelles and a certain plasticity of the bones of the skull. Under the influence of the resistance of soft tissues and the bone base of the birth canal, the bones of the skull are displaced relative to each other and overlap one another, adapting to the shape and size of the birth canal.

The presenting part of the fetus, which first follows the wire axis of the birth canal and is the first to be shown from the genital gap, is called the wire point. A generic tumor is formed in the area of ​​the wire point. According to the configuration of the head and the location of the birth tumor after childbirth, it is possible to determine the presentation variant.

Before childbirth in nulliparous women, as a result of preparatory contractions, pressure of the diaphragm and the abdominal wall on the fetus, its head in a slightly bent state is installed at the entrance to the pelvis with an arrow-shaped suture in one of the oblique (12 cm) or transverse (13 cm) sizes.

When inserting the head into the plane of the entrance to the pelvis, the swept seam in relation to the pubic joint and the promontory can be located synclitically and asynclitically.

With synclitic insertion, the head is perpendicular to the plane of the entrance to the small pelvis, the sagittal suture is located at the same distance from the pubic joint and the promontory (Fig. 9.9).

With asynclitic insertion, the vertical axis of the fetal head is not strictly perpendicular to the plane of entry into the pelvis, and the sagittal suture is located closer to the promontory - anterior asynclitism (Fig. 9.10, a) or to the bosom - posterior asynclitism (Fig. 9.10, b).

With anterior asynclitism, the parietal bone facing anteriorly is inserted first, with the posterior - the parietal bone facing backwards. In normal labor, either synclitic insertion of the head or slight anterior asynclitism is observed.

The mechanism of childbirth in the anterior view of the occipital presentation. The mechanism of childbirth begins at the moment when the head encounters an obstacle for its further advancement: during the period of opening when the head enters the plane of entry into the small pelvis or during the period of expulsion when the head moves from the wide to the narrow part of the small pelvic cavity.

There are four main points of the mechanism of childbirth.

First moment - head flexion. As the cervix opens and intrauterine pressure increases, transmitted along the spine (Fig. 9.11, a), the head flexes in the cervical region. Bending of the head occurs taking into account the rule of uneven leverage. The manifestation of this law is possible because the junction of the spine with the base of the skull is not in the center of the skull, but closer to the back of the head than to the chin. In this regard, most of the expelling forces are concentrated on the short arm of the lever - on the back of the head. At the end of the long lever is the face of the fetus with its most convex and voluminous part - the forehead. front part head meets resistance from the innominate line of the pelvis. As a result, intrauterine pressure presses from above on the nape of the fetus, which falls lower, and the chin is pressed against the chest. The small fontanel approaches the wire axis of the pelvis, setting below the large one. Normally, the head is bent as much as it is necessary for it to pass along the planes of the pelvis to the narrow part. When bending, the size of the head decreases, with which it must pass through the planes of the pelvis. In this case, the head passes in a circle located along a small oblique dimension (9.5 cm) or close to it. Depending on the degree of flexion of the head, the wire point is located either in the region of the small fontanelle, or next to it on one of the parietal bones, taking into account the type of asynclitism.

second moment - internal head rotation(Fig. 9.11, b, c). As it moves from the wide to the narrow part, the head, simultaneously with flexion, performs an internal rotation, being established by an arrow-shaped seam in the direct size of the pelvis. The back of the head approaches the pubic joint, the front part is located in the sacral cavity. In the exit cavity, the sagittal suture is in direct size, and the suboccipital fossa is under the pubic joint.

4 Extension of the head (third moment) .5. Internal rotation of the body and external rotation of the head (fourth moment) A - birth of the upper third of the humerus, facing anteriorly; B - the birth of the shoulder, facing backwards

To turn the head, different resistance of the anterior and posterior walls of the pelvic bones matters. The short anterior wall (pubic bone) offers less resistance than the posterior (sacrum). As a result, during translational movement, the head, tightly covered by the walls of the pelvis, slides along their surfaces, adapting its smallest dimensions to large sizes pelvis, of which at the entrance to the pelvis is transverse, in the wide part of the pelvis - oblique, narrow and at the exit from the pelvis - straight. The muscles of the perineum, contracting, also contribute to the rotation of the head.

The third moment is the extension of the head begins after the head, located as a large segment in the exit cavity, rests with the suboccipital fossa on the lower edge of the pubic articulation, forming a fixation point (hypomachlion). The head, rotating around the point of fixation, unbends and is born. As a result of attempts, the parietal region, forehead, face and chin appear from the genital slit (Fig. 9.11, d).

The head passes through the vulvar ring with a circle formed around a small oblique size.

Fourth moment - internal rotation of the trunk and external rotation of the head(Fig. 9.11, e). The shoulders of the fetus are inserted in the transverse size of the entrance to the pelvis. As the fetus advances, the shoulders change from transverse to oblique in the narrow part of the pelvic cavity and then to a straight size in the exit plane. The shoulder, facing the front, turns to the pubic joint, the back - to the sacrum. The rotation of the shoulders in a straight size is transmitted to the born head, while the nape of the fetus turns to the left (in the first position) or right (in the second position) thigh of the mother. The baby is born in the following sequence: upper third of the upper arm facing forward &Symbol (OTF) Regular_F0AE; Lateral Spinal Flexion &Symbol (OTF) Regular_F0AE; posterior shoulder &Symbol (OTF) Regular_F0AE; fetal body.

All of the above moments of the mechanism of labor of the trunk and head are performed synchronously and are associated with the forward movement of the fetus (Fig. 9.12).

Each moment of the mechanism of childbirth can be detected during a vaginal examination by the location of the swept suture, small and large fontanelles, and identification points of the pelvic cavities.

Before the internal rotation of the head, when it is located in the plane of the entrance or in the wide part of the cavity of the small pelvis, the sagittal suture is located in one of the oblique dimensions (Fig. 9.11, b). Small fontanel on the left (at the first position) or on the right (at the second position) in front, below the large fontanel, which is respectively on the right or left, behind and above. The ratio of small and large fontanelles is determined by the degree of flexion of the head. To the narrow part, the small fontanel is somewhat lower than the large one. In the narrow part of the cavity of the small pelvis, the swept suture approaches the direct size, and in the exit plane - in the direct size (Fig. 9.10, c).

The shape of the head after birth is elongated towards the back of the head - dolichocephalic due to the configuration and formation of a birth tumor (Fig. 9.13, a, b).

The mechanism of childbirth in the posterior view of the occipital presentation. At the end of the first stage of labor, in about 35% of cases, the fetus is in the occiput posterior view and only in 1% is it born in the posterior view. In the rest, the fetus makes a turn of 135 ° and is born in the anterior view: in the initially posterior view of the first position, the head rotates counterclockwise; the swept seam successively passes from the left oblique to the transverse, then to the right oblique and, finally, to the straight size. If there is a second position, when the fetal head is rotated clockwise, the sagittal suture moves from the right oblique to the transverse, and then to the left oblique and straight.

If the head does not turn the back of the head anteriorly, then the fetus is born in the posterior view. The mechanism of childbirth in this case consists of the following points.

The first moment - bending the head in the plane of the entrance or in the wide part of the small pelvis. At the same time, the head is inserted into the entrance to the pelvis more often in the right oblique size. The wire point is a small fontanel (Fig. 9.14, a).

The second point is the internal rotation of the head during the transition from the wide to the narrow part of the pelvic cavity. The sagittal suture passes from an oblique to a straight size, the back of the head is turned backwards. The area between the small and large fontanel becomes a wire point (Fig. 9.14, b).

The third moment is the maximum additional flexion of the head after turning the head, when the front edge of the large fontanelle approaches the lower edge of the pubic joint, forming the first fixation point. Around this point of fixation, additional flexion of the head and birth of the occiput are carried out. After that, the suboccipital fossa rests against the coccyx, forming a second fixation point, around which extension of the head (fourth moment) and her birth (see Fig. 9.14, c).

Fifth moment - internal rotation of the body and external rotation of the head occur similarly to the anterior view of the occipital presentation.

The birth of the head occurs in a circle (33 cm), located around the average oblique size. The shape of the head after birth approaches dolichocephalic. The birth tumor is located on the parietal bone closer to the large fontanel.

With the rear view of the occipital presentation, the first period proceeds without features. The second stage of labor is longer due to the need for additional maximum flexion of the head.

If labor activity is good, and the head is moving slowly, then with normal sizes pelvis and fetus, a posterior occiput presentation can be assumed.

In the posterior view of the occipital presentation, errors in determining the location of the head are not ruled out. When the head is located backwards, an erroneous idea is created about its lower standing in relation to the planes of the pelvis. For example, when the head is located in a small or large segment at the entrance to the small pelvis, it may seem that it is located in the pelvic cavity. A thorough vaginal examination with the determination of the identification points of the head and small pelvis and a comparison of the data obtained with an external examination help to correctly determine its location.

A long second stage of labor and increased pressure of the birth canal, which the head experiences at maximum flexion, can lead to fetal hypoxia, impaired cerebral circulation, and cerebral lesions.

CLINICAL COURSE OF DELIVERY

During childbirth, the entire body of the woman in labor carries out serious physical work, which especially affects the cardiovascular, respiratory system and metabolism.

During childbirth, tachycardia is noted, especially in the second period (100-110 per minute), and an increase in blood pressure by 5-15 mm Hg. Art.

At the same time, the respiratory rate changes: during contractions, the lung excursion decreases and is restored in the pauses between contractions. With attempts, breathing is delayed, and then becomes more frequent by 8-10 respiratory movements per minute.

As a result of the activation of the activity of the cardiovascular and respiratory systems, an adequate metabolism is formed that satisfies the needs of the woman in labor. In the first and second stages of labor, compensated metabolic acidosis is determined due to the formation of underoxidized metabolic products. The accumulation of lactic acid in the tissues due to intense muscular work causes chills in parturient women after childbirth.

The course of childbirth in the period of disclosure (the first stage of childbirth). The period of disclosure begins with the appearance of regular contractions after 15-20 minutes and ends after the full disclosure of the cervix.

In the first stage of labor, a latent, active phase and a deceleration phase are distinguished.

Latent phase begins with the onset of labor and ends with the opening of the cervix by 3-4 cm. The rate of opening of the cervix in the latent phase is 0.35 cm / h.

Contractions in the latent phase with a whole fetal bladder in most parturient women are moderately painful and do not require anesthesia. In women with a weak type of higher nervous activity, contractions, even in the latent phase, can be sharply painful.

The duration of the latent phase is determined by the initial state of the cervix. Often, before the development of labor, due to preliminary contractions of the uterus, the cervix shortens, and sometimes evens out.

In total, the duration of the latent phase in primiparous is 4-8 hours, in multiparous - 4-6 hours. The opening of the cervix in the latent phase occurs gradually, which is reflected in the partogram (Fig. 9.15).

active phase childbirth begins with the opening of the cervix by 3-4 cm and continues until the opening of the cervix by 8 cm.

In the active phase of labor, the cervix dilates rapidly. Its speed is 1.5-2 cm/h in nulliparous and 2-2.5 cm/h in multiparous.

As labor activity progresses, the intensity and duration of contractions increase, and the pauses between them decrease.

By the end of the active phase of labor, contractions, as a rule, alternate after 2-4 minutes, the fetal bladder tenses not only during contractions, but also between them, and at the height of one of them it opens on its own. At the same time, 100-300 ml of light water is poured out.

The posterior amniotic fluid moves upward, into the space between the fundus of the uterus and the buttocks of the fetus, and therefore it is not always possible to determine their color.

The deployment rate in the active phase is displayed on the partograph (see Figure 9.15).

After the outflow of amniotic fluid and the opening of the cervix by 8 cm, a deceleration phase begins, associated both with the entry of the cervix behind the head, and with the fact that the uterus adapts to the new volume, tightly clasping the fetus. In this phase, the energy potential of the uterus can be restored, which is necessary for intensive contraction during the expulsion of the fetus. The deceleration phase in clinical practice is very often interpreted as a secondary weakness of labor activity. The rate of opening of the cervix in the deceleration phase is 1.0-1.5 cm/h.

In rare cases, the membranes do not rupture, and the head is born covered with part of the membranes of the ovum.

After the full disclosure of the cervix and the timely outflow of amniotic fluid, a period of exile begins.

The course of childbirth in the period of exile (the second period of childbirth). After the full opening of the cervix and the outflow of amniotic fluid, labor activity intensifies. At the top of each contraction, attempts are added to the contractions of the uterus. The force of the attempts is aimed at expelling the fetus from the uterus. Under their influence, the head, and behind it the torso, descend along the birth canal with a leading point along the wire axis of the pelvis. As you advance, the head presses on the nerve sacral plexuses, causing an irresistible desire to push and push the head out of the birth canal.

Normally, the speed of the head moving through the birth canal in primiparas is 1 cm / h, in multiparous - 2 cm / h.

When advancing the head and placing it on the pelvic floor, the perineum is stretched first during attempts, and then during a pause. With the pressure of the head on the rectum, the expansion and gaping of the anus are associated. As the head advances, the genital slit opens, and during one of the attempts, the lower part of the head is shown in it, which is hidden in the pauses between contractions (Fig. 9.16). This moment of birth is called head cutting. During plunging, the internal rotation of the head ends. With further advancement, the head protrudes more and more and, finally, does not go back behind the genital gap during a pause. it head eruption(Fig. 9.16, a, b).

After eruption, the back of the head is born first, and then the parietal tubercles. At the same time, the perineum is maximally stretched, tissue ruptures are possible. Following the birth of the parietal tubercles, the forehead emerges from the genital slit as a result of extension of the head, and then the entire face (Fig. 9.16, c).

After birth, the face of the fetus is turned backwards. After the next attempt, the fetus turns with its shoulder line in the direct size of the exit plane: one shoulder (anterior) is facing the pubic joint, the other is facing backwards, towards the sacrum. When the shoulders are turned, the face in the first position turns to the right thigh (Fig. 9.16, d), in the second - to the left. With the next attempt, the first shoulder is born, facing anteriorly, and then - facing backwards (Fig. 9.16. e, f). Following the shoulder girdle, the torso and legs of the fetus are born, while the back waters are poured out.

The fetus after birth is called a newborn. He takes his first breath and lets out a scream.

The course of childbirth in the afterbirth period (the third stage of childbirth). The succession period begins after the expulsion of the fetus. After great emotional and physical stress during attempts, the woman in labor calms down. Respiratory rate and pulse are restored. Due to the accumulation of incompletely oxidized metabolic products in the tissues during attempts, a short chill appears in the afterbirth period.

After the expulsion of the fetus, the uterus is located at the level of the navel. Weak subsequent contractions appear.

After separation and movement of the placenta to the lower sections, the body of the uterus deviates to the right (Fig. 9.17). When the placenta descends along with a retroplacental hematoma into the lower part of the uterus, its contours change. In its lower part, slightly above the pubis, a shallow constriction is formed, giving the uterus an hourglass shape. The lower part of the uterus is defined as a soft formation.

When lowering, the placenta begins to put pressure on the nerve sacral plexuses, causing subsequent attempts, after one of which it is born. Simultaneously with the afterbirth, 200-500 ml of blood is released.

With the separation of the placenta according to Duncan (from the edges), blood loss is greater than at the beginning of the separation from the central sections (according to Schultze). With the separation of the placenta according to Duncan, bleeding may appear some time after the birth of the fetus, with the onset of separation of the placenta.

After separation of the placenta, the uterus is located in the median position in a state of maximum contraction. Its height is 10-12 cm above the womb.

LABOR MANAGEMENT

In a maternity hospital or in the maternity ward of a city or central district hospital, a midwife conducts childbirth under the guidance of an obstetrician.

In Russia, home births are not legalized, but are sometimes performed. In some European countries, it is considered possible to give birth at home. This requires the absence of extragenital pathology and complications of pregnancy and the ability to quickly transport a woman in labor to a hospital in the event of complications, the presence of a midwife or doctor.

In a hospital where there is a maternity ward, the sanitary and anti-epidemic regime is very important, the observance of which begins in the emergency department, where the patient undergoes sanitation. At the same time, they determine in which department the birth will be conducted. To do this, they necessarily measure body temperature, examine the skin, identify extragenital pathology, study documents, primarily an exchange card.

A woman in labor with a contagious infectious disease (tuberculosis, AIDS, syphilis, influenza, etc.) is isolated in an observational department or transferred to a specialized medical institution.

Women in labor without infectious diseases after sanitization are transferred to the maternity ward. With a boxed maternity ward, a woman in labor is placed in a box where childbirth takes place. If desired, the husband is allowed to be present during childbirth. If the department has only prenatal and labor chambers, in the first stage of labor, the woman in labor is in the prenatal room. In the second period, she is transferred to the delivery room, where there are special beds for childbirth. In Russia, in most medical institutions, women give birth lying on the table. So-called vertical births are possible, when in the second period the patient is located vertically on a special table.

Conducting childbirth during the opening of the cervix. In the first stage of labor, if epidural anesthesia or anesthesia by another method is not performed and planned, the woman in labor can walk or lie down, preferably on her side, depending on the position of the fetus (in the first position - on the left side, in the second - on the right) for prevention syndrome of compression of the inferior vena cava, which occurs when positioned on the back.

The issue of feeding a woman in labor is decided individually. If anesthesia is not planned, tea, chocolate are allowed.

During childbirth, the external genitalia are regularly treated or the woman in labor takes a shower. Control the function of the bladder and intestines. A woman in labor should urinate every 2-3 hours, since bladder distension can contribute to weakness in labor. When the bladder is overfilled and it is impossible to urinate on its own, a bladder catheterization is performed.

During childbirth, the general condition of the woman in labor, the condition of the uterus and birth canal, labor activity, and the condition of the fetus are monitored.

General state assessed by general well-being, pulse, blood pressure, color of the skin, visible mucous membranes.

When conducting childbirth, determine condition of the uterus and birth canal.

During external obstetric examination and palpation of the uterus, attention is paid to its consistency, local pain, the condition of the round uterine ligaments, the lower segment, the location of the contraction ring above the pubic joint. As the cervix opens, the contraction ring gradually rises above the pubic symphysis as a result of stretching of the lower segment. The opening of the cervix corresponds to the location of the contraction ring above the womb: when the cervix is ​​opened by 2 cm, the contraction ring rises by 2 cm, etc. When the cervix is ​​fully opened, the contraction ring is located 8-10 cm above the pubic symphysis.

Vaginal examination is important for assessing labor activity. It is produced with:

The first examination of the woman in labor;

Outflow of amniotic fluid;

Deviation of labor activity from the norm;

Before the start of rhodoactivation and every 2 hours of its implementation;

Indications for emergency delivery by the mother or fetus.

In a vaginal examination, evaluate:

The condition of the tissues of the vagina;

The degree of cervical dilatation;

The presence or absence of a fetal bladder;

The nature and advancement of the presenting part on the basis of determining its relationship to the planes of the small pelvis.

Examining the tissues of the vagina and external genitalia, pay attention to varicose veins, scars after old ruptures or perineo- and episiotomies, the height of the perineum, the condition of the pelvic floor muscles (elastic, flabby), the capacity of the vagina, the partitions in it.

The cervix can be saved, shortened, smoothed. Cervical dilatation is measured in centimeters. The edges of the neck can be thick, thin, soft, stretchable or rigid.

After assessing the condition of the cervix, the presence or absence of a fetal bladder is determined. If it is intact, its tension should be determined during the contraction and pause. Excessive tension of the bladder, even in the intervals between contractions, indicates polyhydramnios. Flattening of the fetal bladder indicates oligohydramnios. With a pronounced oligohydramnios, it gives the impression of being stretched over the head. A flat amniotic sac can delay labor. When amniotic fluid is discharged, attention is paid to their color and quantity. Normally, amniotic fluid is light or slightly cloudy due to the presence of cheese-like lubricant, vellus hair and the epidermis of the fetus. The admixture of meconium in the amniotic fluid indicates fetal hypoxia, blood indicates placental abruption, ruptures of the vessels of the umbilical cord, the edges of the cervix, etc.

Following the characteristics of the fetal bladder, the presenting part of the fetus is determined by determining the identification points on it.

With cephalic presentation, sutures and fontanelles are palpated. According to the location of the sagittal suture, large and small fontanelles, the position, type of position, insertion (synclitic, axinclitic), moment of the labor mechanism (flexion, extension) are revealed.

Vaginal examination determines the location of the head in the small pelvis. Determining the location of the head is one of the main tasks in the management of childbirth.

The location of the head is judged by the ratio of its dimensions to the planes of the small pelvis.

When conducting childbirth, the following location of the head is distinguished:

Movable above the entrance to the small pelvis;

Pressed to the entrance to the small pelvis;

Small segment at the entrance to the small pelvis;

Large segment at the entrance to the small pelvis;

In the wide part of the small pelvis;

In the narrow part of the small pelvis;

At the outlet of the small pelvis.

The location of the head and the landmarks determined in this case are given in table. 9.1 and in fig. 9.18.

Table 9.1. Head location and obstetric examination

The American school determines the relationship of the presenting part of the fetus to the planes of the small pelvis during its progress through the birth canal, using the concept of "level of the small pelvis". There are the following levels:

The plane passing through the ischial spines - level 0;

Planes passing 1, 2 and 3 cm above level 0 are designated respectively as levels -1, -2, -3;

Planes located 1, 2 and 3 cm below level 0 are designated respectively as levels +1, +2, +3. At level +3, the presenting part is located on the perineum.

contractility of the uterus reflect the tone of the uterus, the intensity of contractions, their duration and frequency.

For a more objective determination of the contractile activity of the uterus, it is better to carry out a graphic recording of contractions - tocography. It is possible to simultaneously record contractions and the fetal heartbeat - cardiotocography (Fig. 9.19), which allows you to evaluate the reaction of the fetus to the contraction.

The following international nomenclature is used to evaluate abbreviations.

Tone uterus (in millimeters of mercury) - the lowest pressure inside the uterus, recorded between two contractions. In the first stage of labor, it does not exceed 10-12 mm Hg. Art.

Intensity- the maximum intrauterine pressure during contractions. In the first stage of labor increases from 25 to 50 mm Hg. Art.

Frequency contractions - the number of contractions in 10 minutes, in the active phase of labor is about 4.

Activity uterus - the intensity, multiplied by the frequency of contraction, in the active phase of labor is 200-240 IU (Montevideo units).

For an objective assessment of labor activity in childbirth, it is advisable to maintain a partogram. Given its standard values ​​(see Fig. 9.15), deviations from normal labor activity are established.

The condition of the fetus can be determined by auscultation and cardiotocography. Auscultation with an obstetric stethoscope during the period of disclosure with an undisturbed fetal bladder is performed every 15-20 minutes, and after the outflow of amniotic fluid - after 5-10 minutes. It is also necessary to count the fetal heart rate. During auscultation, attention is paid to the frequency, rhythm and sonority of heart tones. Normally, when listening to the heart rate, it is 140 ± 10 per minute.

The method of monitoring the cardiac activity of the fetus during childbirth has become widespread (see Chapter 6 "Examination methods in obstetrics and perinatology").

After examination and research, a diagnosis is made, which reflects in sequential order:

Gestational age;

Presentation of the fetus;

Position, position type;

The period of childbirth;

Complications of childbirth and pregnancy;

Complications in the fetus;

Extragenital diseases.

Conducting childbirth during exile. The second stage of childbirth is the most responsible for the mother and fetus. In the mother, complications may be due to the tension of the cardiovascular and respiratory systems, the possibility of their decompensation, especially during attempts.

The fetus may experience complications as a result of:

Compression of the head by the pelvic bones;

Promotions intracranial pressure;

Violations of the uteroplacental circulation during uterine contraction during attempts.

In the second stage of labor should be monitored for:

The condition of the woman in labor and the fetus;

Strength, frequency, duration of attempts;

Promotion of the fetus through the birth canal;

condition of the uterus.

At women in labor count pulse and respiratory rate, measure blood pressure. If necessary, monitor the function of the cardiovascular system.

At fetus listen or constantly record heart rate, determine indicators of acid-base state (CBS) and oxygen tension (pO2) in the blood of the presenting part (Zaling method - see Chapter 6 "Examination methods in obstetrics and perinatology").

During cardiac monitoring during exile in cephalic presentation, the basal heart rate is 110-170 per minute. The heart rate remains correct.

With the passage of the head through the narrow part of the pelvic cavity and an increase in intracranial pressure after contractions, decelerations are possible. During attempts, early decelerations or

U-shaped up to 80 per minute or V-shaped - up to 75-85 per minute (Fig. 9.20). Short-term accelerations up to 180 per minute are possible.

Evaluation of the contractile activity of the uterus and the effectiveness of attempts. An objective assessment of contractions of the muscles of the uterus can be obtained with tocography. The tone of the uterus in the second stage of labor increases and is 16-25 mm Hg. Art. Uterine contractions are enhanced as a result of contraction of the striated muscles and amount to 90-110 mm Hg. Art.

The duration of the attempts is about 90-100 s, the interval between them is 2-3 minutes.

Provide head advance control along the birth canal, depending on the intensity of the attempts and the correspondence of the size of the head to the size of the pelvis.

The progress and location of the head is judged by determining its landmarks during external obstetric and vaginal examination (see Table 9.1). The Piskachek method is also used: with the fingers of the right hand, they press on the tissues in the region of the lateral edge of the labia majora until they “meet” the fetal head. Piskacek's symptom is positive if the lower pole of the head reaches the narrow part of the pelvic cavity. With a large birth tumor, a false positive result can be obtained.

If in the second stage of labor the head is in the same plane for a long time, then compression of the soft tissues of the birth canal, bladder, rectum is possible, as a result of which vaginal-vesical, vaginal-rectal fistulas are not excluded in the future. Standing the head in the same plane for 2 hours or more is an indication for delivery.

Mandatory in the second period control of the uterus, in particular its lower segment, round uterine ligaments, external genitalia, vaginal discharge.

During examination and palpation of the uterus, its tension is determined during attempts, thinning or soreness of the lower uterine segment. Segment overextension is judged by the location of the contraction ring. The height of the contraction ring above the womb corresponds to the degree of dilatation of the cervix. Overstretching of the lower uterine segment and constant tension of the round ligaments are signs of a clinically narrow pelvis, or threatened uterine rupture.

A possible obstruction to the passage of the head is also evidenced by swelling of the external genital organs, indicating compression of the soft tissues of the birth canal.

A serious symptom in childbirth is bleeding, which can indicate both damage to the cervix when it opens, ruptures of the vagina, vulva, and premature detachment of a normally and low-lying placenta, ruptures of the umbilical cord vessels, especially when it is attached to the shell.

In the second period, when the fetus passes through the vulvar ring, manual allowance for the prevention of perineal rupture and trauma to the fetal head. The benefit lies in the regulation of attempts and protection of the perineum. Attempts in a woman in labor appear, as a rule, when the head occupies the sacral cavity. During this time, the patient should be supervised. During a fight, it is recommended deep breaths so that the head advances on its own. An offer to push before this time can lead to an increase in the birth tumor and an increase in intracranial pressure in the fetus. Attempts are resolved when the head crashes. In primiparas, the insertion lasts up to 20 minutes, in multiparous - up to 10 minutes.

Obstetric care should be started during the eruption of the head.

In most maternity hospitals, a woman gives birth lying on her back on a special table. The woman in labor holds on to the edges of the bed or special devices. The legs, bent at the knees and hip joints, rest against the devices. During the contraction of the uterus, the woman in labor usually has time to push three times. She should take a deep breath and tighten her abdominals.

The obstetric allowance consists of four points.

First moment- prevention of premature extension of the head (Fig. 9.21, a).

The head should pass through the vulvar ring in a bent position in a circle around a small oblique size (32 cm). With premature extension, it passes in a larger circle.

To prevent premature extension of the head, the midwife puts her left hand on the pubic joint and the erupting head, carefully delaying its extension and rapid advancement through the birth canal.

second moment(Fig. 9.21, b) - a decrease in the tension of the tissues of the perineum. Simultaneously with the delay in premature extension of the head, it is necessary to reduce the force of the circulatory pressing on it of the soft tissues of the pelvic floor and make them more pliable as a result of "borrowing" from the labia area. The palm of the right hand is placed on the perineum so that four fingers fit snugly against the area of ​​the left, and the most abducted finger - to the area of ​​the right labia. The fold between the thumb and forefinger is located above the navicular fossa of the perineum. Gently pressing with the ends of all fingers on the soft tissues along the labia majora, they are brought down to the perineum, while reducing its tension. At the same time, the palm of the right hand gently presses the perineal tissue against the erupting head, supporting them. Thanks to these manipulations, the tension of the perineal tissues is reduced; they maintain normal blood circulation, which increases resistance to tearing.

Third moment- removal of the head. At this point, the regulation of attempts is important. The danger of rupture of the perineum and excessive compression of the head are greatly increased when it is inserted into the vulvar ring by the parietal tubercles. The woman in labor experiences at this time an irresistible desire to push. However, the rapid advancement of the head can lead to perineal tissue ruptures and head injury. It is no less dangerous if the advancement of the head is delayed or suspended due to the cessation of attempts, as a result of which the head is subjected to compression by stretched perineal tissues for a long time.

After the head has been established by the parietal tubercles in the genital slit, and the suboccipital fossa has come under the pubic articulation, it is desirable to carry out the removal of the head without attempts. For this, a woman in labor during attempts is offered to breathe deeply and often with an open mouth. In such a state, it is impossible to push. At the same time, with both hands, the advancement of the head is delayed until the end of the attempt. After the end of the attempt with the right hand, the tissues are removed from the face of the fetus with sliding movements. With the left hand at this time, slowly raise the head anteriorly, unbending it. If necessary, the woman in labor is offered to arbitrarily push with a force sufficient to completely remove the head from the genital slit.

Fourth moment(Fig. 9.21, c, d) - the release of the shoulder girdle and the birth of the fetal body. After the birth of the head, last moment the mechanism of childbirth - internal rotation of the shoulders and external rotation of the head. For this, the woman in labor is offered to push. During the push, the head is turned to face the right hip in the first position or to the left hip in the second position. In this case, independent birth of shoulders is possible. If this does not happen, then with the palms they grab the head by the temporo-buccal regions and carry out traction backwards until a third of the anteriorly facing shoulder fits under the pubic joint. After the shoulder is brought under the bosom, the head is grabbed with the left hand, lifting it up, and the perineal tissues are shifted from the shoulder facing backwards with the right hand, bringing it out (Fig. 9.21). After the birth of the shoulder girdle, the index fingers of both hands are inserted into the armpits from the back side, and the torso is lifted forward, corresponding to the wire axis of the pelvis. This contributes to the rapid birth of the fetus. The shoulder girdle must be released very carefully, without overstretching the fetal cervical spine, as this may cause injury to this region. It is also impossible to first remove the front handle from under the pubic joint, since a fracture of the handle or collarbone is possible.

If there is a threat of perineal rupture, it is dissected along the midline of the perineum - perineotomy (Fig. 9.22) or more often median episiotomy (see Fig. 9.22), since a cut wound with smooth edges heals better than a lacerated wound with crushed edges. Perineotomy can also be performed in the interests of the fetus - to prevent intracranial injury with an unyielding perineum.

Table 9.2. Assessment of the state of the newborn on the Apgar scale

If, after the birth of the head, a loop of the umbilical cord is visible around the neck of the fetus, then it should be removed through the head. If this is not possible, especially if the umbilical cord becomes taut and restricts the movement of the fetus, it is cut between two clamps and the torso is quickly removed. The condition of the child is assessed on the Apgar scale 1 and 5 minutes after birth. A score of 8-10 points indicates a satisfactory condition of the fetus. After the baby is born, the mother's bladder is emptied with a catheter.

PRIMARY TREATMENT OF A NEWBORN

In the primary toilet of a newborn in an obstetric hospital, intrauterine infections are prevented.

Before handling the newborn, the midwife washes and treats her hands, puts on a sterile mask and gloves. For primary processing The newborn is given a sterile individual kit, which includes a sterile individual umbilical cord treatment kit with staples.

The child is placed on a sterile, warmed and covered with a sterile diaper tray between the mother's bent and divorced legs at the same level with her. The child is wiped with sterile wipes.

After birth, for the prevention of gonorrhea, wipe the eyelids from the outer corner to the inner with a dry cotton swab. Then lift the upper and lower eyelids, slightly pulling the upper one up, and the lower one -

down, drip on the mucous membrane of the lower transitional fold 1 drop of a 30% solution of sodium sulfacyl (albucid). Eye solutions are changed daily. Such prophylaxis is carried out both during the primary toilet of the newborn, and again, after 2 hours.

The umbilical cord is treated with a 0.5% solution of chlorhexidine gluconate in 70% ethanol. After the termination of the pulsation, stepping back 10 cm from the umbilical ring, a clamp is applied to it. The second clamp is applied, retreating 2 cm from the first. The area between the clamps is re-treated, after which the umbilical cord is crossed. The child is placed in sterile diapers on a changing table, heated from above by a special lamp, where he is examined by a neonatologist.

Before processing the umbilical cord, the midwife carefully processes, washes, wipes her hands with alcohol, puts on sterile gloves and a sterile mask. The rest of the umbilical cord on the child's side is wiped with a sterile swab dipped in a 0.5% solution of chlorhexidine gluconate in 70% ethanol, then the umbilical cord is squeezed between the thumb and forefinger. A sterile metal bracket of Rogovin is inserted into special sterile forceps and placed on the umbilical cord, stepping back 0.5 cm from the skin edge of the umbilical ring. Forceps with a bracket are closed until they are pinched. The rest of the umbilical cord is cut off 0.5-0.7 cm above the edge of the bracket. The umbilical wound is treated with a solution of 5% potassium permanganate or a 0.5% solution of chlorhexidine gluconate in 70% ethanol. After applying the bracket to the umbilical cord, film-forming preparations can be placed.

The umbilical cord is cut off with sterile scissors 2-2.5 cm from the ligature. The stump of the umbilical cord is tied with a sterile gauze.

The skin of the newborn is treated with a sterile cotton swab or a disposable paper towel moistened with sterile vegetable or vaseline oil from a single-use bottle. Remove cheese-like grease, blood residue.

After the initial treatment, the height of the child, the size of the head and shoulders, and body weight are measured. Bracelets are put on the handles, on which the surname, name and patronymic of the mother, the number of the history of childbirth, the sex of the child, and the date of birth are written. Then the child is wrapped in sterile diapers and a blanket.

In the delivery room, within the first half hour after birth, in the absence of contraindications associated with complications of childbirth (asphyxia, large fetus, etc.), it is advisable to apply the newborn to the mother's breast. Early attachment to the breast and breast-feeding contribute to faster growth normal microflora intestines, increasing the nonspecific defense of the newborn's body, the development of lactation and uterine contraction in the mother. Then the child is transferred under the supervision of a neonatologist.

SUBSEQUENT MANAGEMENT

At present, the expectant management of the third period has been adopted, since untimely interventions, uterine palpation can disrupt the processes of separation of the placenta and the formation of a retroplacental hematoma.

Controlled:

- general condition: skin color, orientation and reaction to the environment;

- hemodynamic parameters: pulse, blood pressure within the physiological norm;

- amount of blood released- blood loss of 300-500 ml (0.5% of body weight) is considered physiological;

- signs of separation of the placenta.

Most often in practice, the following signs of separation of the placenta from the uterine wall are used.

Schroeder sign. If the placenta has separated and descended into the lower segment or into the vagina, the fundus of the uterus rises up and is located above and to the right of the navel; the uterus takes the form of an hourglass.

Sign of Chukalov-Kyustner. When pressing the edge of the hand on the suprapubic region with the separated placenta, the uterus rises up, the umbilical cord does not retract into the vagina, but, on the contrary, goes out even more (Fig. 9.23).

Alfeld sign. The ligature applied to the umbilical cord at the genital slit of the woman in labor, with the separated placenta, falls 8-10 cm below the vulvar ring.

In the absence of bleeding, the signs of placental separation begin 15-20 minutes after the birth of the child.

Having established signs of separation of the placenta, they contribute to the birth of the separated placenta external extraction methods.

The methods of external allocation of the placenta include the following.

Abuladze method. After emptying the bladder, the anterior abdominal wall is grasped with both hands in a fold (Fig. 9.24). After that, the woman in labor is offered to push. The separated placenta is born as a result of an increase in intra-abdominal pressure.

Crede-Lazarevich method(Fig. 9.25):

Empty the bladder with a catheter;

Bring the bottom of the uterus to the middle position;

Produce light stroking (not massage!) The uterus in order to reduce it;

They cover the bottom of the uterus with the hand of the hand that the obstetrician is better at, so that the palmar surfaces of her four fingers are located on the back wall of the uterus, the palm is on the very bottom of the uterus, and the thumb is on its front wall;

At the same time, they press on the uterus with the whole brush in two intersecting directions (fingers - from front to back, palm - from top to bottom) towards the pubis until the afterbirth is born.

The Krede-Lazarevich method is used without anesthesia. Anesthesia is necessary only when it is assumed that the separated placenta is retained in the uterus due to spastic contraction of the uterine os.

In the absence of signs of separation of the placenta, manual separation of the placenta and separation of the placenta are used (see Chapter 26. "Pathology of the afterbirth period. Bleeding in the early postpartum period"). A similar operation is also performed when the postpartum period lasts more than 30 minutes, even in the absence of bleeding.

If, after the birth of the placenta, the membranes linger in the uterus, then to remove them, the born placenta is picked up and, slowly rotating, the membranes are twisted into the cord (Fig. 9.26). As a result of this, the membranes are carefully separated from the walls of the uterus and are released after the placenta. The membranes can also be removed by the following method: after the birth of the placenta, the woman in labor is offered to lift the pelvis up, leaning on her feet. The placenta, by gravity, will pull the membranes behind it, which will detach from the uterus and stand out (Fig. 9.26).

After removal of the placenta, a thorough examination of the placenta and membranes, the place of attachment of the umbilical cord is necessary (Fig. 9.27). Pay attention to the defect of additional lobules, as evidenced by additional vessels between the membranes. With a defect in the placenta or membranes, a manual examination of the uterus is performed.

After separation of the placenta and treatment of the external genital organs under anesthesia, they begin to examine the cervix, vagina, and vulva to identify gaps that are sutured.

In the postpartum period, a woman is not transportable.

After the birth of the placenta, the woman is called the puerperal. For 2 hours, she is in the delivery room, where they control blood pressure, pulse, the condition of the uterus, the amount of blood released.

Blood loss is measured by the gravimetric method: blood is collected in graduated dishes, diapers are weighed.

After 2 hours, the puerperal is transferred to the postpartum ward.

ANESTHESIS OF CHILDHOOD

Childbirth is usually accompanied by pain.

A pronounced pain reaction during childbirth causes excitement, a state of anxiety in a woman in labor. The release of endogenous catecholamines at the same time changes the function of the vital important systems, primarily cardiovascular and respiratory: tachycardia appears, cardiac output increases, arterial and venous pressure increases, and total peripheral resistance increases. At the same time with changes in the cardiovascular system disrupt breathing, resulting in tachypnea, a decrease in tidal volume and an increase in minute respiratory volume, which leads to hyperventilation. These changes can lead to hypocapnia and impaired uteroplacental circulation with the possible development of fetal hypoxia.

Inadequate perception of pain during childbirth can cause both weakness of labor activity and its discoordination. Inadequate behavior and muscle activity of the patient is accompanied by increased oxygen consumption, the development of acidosis in the fetus.

Pain during childbirth is due to:

In period I:

opening of the cervix;

Myometrial ischemia during uterine contraction;

Tension of the ligaments of the uterus;

Stretching of the tissues of the lower uterine segment.

In period II:

The pressure of the presenting part of the fetus on the soft tissues and the bone ring of the small pelvis;

Overstretching of the muscles of the perineum.

During childbirth, biochemical and mechanical changes in the uterus, its ligamentous apparatus with the accumulation of potassium, serotonin, bradykinin, prostaglandins, leukotrienes in the tissues are transformed into electrical activity at the endings of sensory nerves. Subsequently, the impulses are transmitted through back roots spinal nerves T 11 -S 4 to the spinal cord, to the brain stem, reticular formation and thalamus, the cerebral cortex to the area of ​​the thalamo-cortical projection, where the final subjective emotional sensation is created, perceived as pain. Taking into account negative influence pain in the process of childbirth shows pain relief.

The following requirements are imposed on the anesthesia of childbirth: the safety of the method of anesthesia for the mother and fetus; the absence of the inhibitory effect of painkillers on labor; preservation of the consciousness of the woman in labor and her ability to actively participate in the birth act. The simplicity and accessibility of labor pain relief methods for obstetric institutions of any type is important.

To anesthetize childbirth in modern obstetrics, the following are used:

Psychoprophylactic preparation during pregnancy;

Acupuncture;

Homeopathic preparations;

Hydrotherapy;

Systemic drugs and analgesics;

inhalation anesthesia;

regional anesthesia.

Psychoprophylactic training during pregnancy is carried out in the antenatal clinic. In the classroom, a pregnant woman receives knowledge about childbirth and the necessary behavior during it. Women in labor who have undergone psychoprophylactic training require a lower dose of drugs during childbirth.

Anesthesia methods using acupuncture, hypnosis, homeopathic medicines require a specialist trained in this field, so they are not widely used.

For application hydrotherapy in the delivery room, special baths are required. If they are, then the woman in labor can be in it up to her chest in water in the first stage of labor. In water, childbirth is easier, less painful. The warmth of the water reduces the secretion of adrenaline and relaxes the muscles. Water can also promote L-waves in the brain, creating a state of relaxation of the nervous system, which promotes rapid cervical dilation.

From medical methods sedatives, antispasmodics and narcotic analgesics are used.

When prescribing drugs, one should be aware of the possible inhibitory effect of some of them on the fetal respiratory center. In the presence of these properties, their introduction stops 2-3 hours before the expected delivery.

In the normal course of childbirth, the whole fetal bladder in the latent phase of childbirth, as a rule, contractions are not painful. Easily excitable patients are prescribed sedatives to relieve fear.

In the active phase of labor, when contractions become painful, use medications and inhaled anesthetics.

At the first stage, pain relief begins with the use of antispasmodics (Buscopan, no-shpa, papaverine).

In the absence of effect, analgesics are used (moradol, fentanyl, promedol). The following combinations with sedatives and antispasmodics are possible:

20 mg promedol + 10 mg of seduxen + 40 mg of no-shpy;

2 mg of moradol + 10 mg of seduxen + 40 mg of no-shpy.

The use of these drugs provides pain relief within 1.0-1.5 hours.

At inhalation The most common method of pain relief is nitrous oxide combined with oxygen. Apply a mixture containing 50% nitrous oxide and 50% oxygen during the fight. On the eve of the upcoming contraction, the woman in labor begins to breathe the indicated mixture with the help of a mask, pressing it tightly to her face. Nitrous oxide is quickly eliminated from the body without being komulirovaniya.

The most effective method of labor pain relief is regional (epidural) anesthesia, which allows you to vary the degree of pain relief and can be used throughout all childbirth with minimal impact on the condition of the fetus and the woman in labor.

It is preferable to perform a regional block in the active phase of labor with established labor activity with contractions of force

50-70 mmHg st, lasting 1 minute, after 3 minutes. However, with a pronounced pain syndrome regional analgesia can also be started in the passive phase when the cervix is ​​2-3 cm open.

For anesthesia of childbirth, fractional administration or continuous infusion of drugs into the epidural space is used.

Taking into account the innervation of the uterus and perineal tissues, labor pain relief requires the creation of a regional block with a length from S5 to T10.

The puncture of the epidural space is performed in the lateral or sitting position, depending on the situation and preference of the anesthesiologists.

It is preferable to puncture and insert the catheter into the following intervals: L2 - L3, L3 - L4.

For regional anesthesia, lidocaine 1-2% 8-10 ml, bupivacaine 0.125-0.1% 10-15 ml, ropivacaine 0.2% 10-15 ml are used.

One of the consequences of regional anesthesia is motor block, when the patient cannot actively take up an upright position and move around. The Bromage scale is used to assess motor blockade. Bromage 0-1 blockade is desirable for labor pain relief, when the patient can raise both the straight and bent leg. Bromage 2-3 when there is a full block or moves are only saved in ankle joint, not adequate during childbirth, because it contributes to the weakness of labor.

The effectiveness of pain relief is assessed using the Visual Analogue Scale (VAS). The VAS is a 100mm ruler with 0 for no pain and 100mm for the most pain possible. The patient is asked to rate her feelings within these limits. Anesthesia corresponding to 0-30 mm is considered adequate.

With the correct technical implementation of regional anesthesia, its effect on labor activity in the first stage of labor is minimal.

In the second stage of labor, a weakening of the tone of the skeletal muscles can cause a lengthening of labor due to weakening of the attempts, the inability of the woman in labor to stand by the bed, and a decrease in the tone of the muscles of the pelvic floor. In addition, the internal rotation of the fetal head is difficult, which can lead to childbirth in the posterior occipital presentation. The lengthening of the second stage of labor occurs during regional analgesia and, to certain limits, does not lead to a deterioration in the condition of the fetus and newborn. In this regard, the allowable duration of the second stage of labor with the use of regional analgesia can be increased to 3 hours in nulliparous and up to 2 hours in multiparous. Regional anesthesia does not adversely affect the fetus.

Pregnancy is called one of the happiest periods in a woman's life. It usually ends with the process of childbirth. The birth of a baby is long-awaited and at the same time frightening. Most of all, a woman is worried about childbirth itself.

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The first signs of the onset of labor in a woman

The expectant mother has already noticed that her stomach has slumped down a little, because the child has taken comfortable position preparing for childbirth. It stopped tormenting, it became easier to sit and walk. It is during this period that pregnant women begin to be especially nervous, expecting the appearance of a baby at any moment.

1. Before the onset of childbirth passage of the cork from the cervix. She can depart 3 weeks before the birth itself or already in the process. Cork is a thick, dark-colored mucus that may contain blood streaks. It is impossible to confuse the discharge of the mucous plug before childbirth with other secretions due to the large amount of mucus.
2. Another indispensable condition for the onset of labor is contractions. The first ones are like menstrual pain, they are accompanied by a pulling feeling in the lower abdomen, pulling pain in the lower back is possible. Real contractions cannot be relieved with a pill or a warm bath. Unlike false contractions, real contractions are regular. the rest periods between contractions gradually decrease, and the strength of the contractions increases.
3. The onset of labor is characterized by a combination of three main features. Third on this list is discharge of water. The waters may break before contractions or already during them. In some cases, doctors have to open the amniotic sac to free it from water. Physiological childbirth is impossible without the fulfillment of these basic conditions.

Changes are also noted in the mental and emotional state of a woman just before childbirth. Her depression disappears, everything disappears intrusive thoughts, tearfulness. She again feels full of strength and energy, which she wants to direct to decorate the house, take care of the family.

Childbirth mechanism

Normal childbirth is usually divided into three main stages:

1. Opening of the uterine os. It starts at the same time as labor pains. In the process, the cervix is ​​smoothed. With full disclosure of the uterine pharynx, its diameter is 10-12 cm. By this time, the vagina and the uterine cavity become one, representing the birth canal. During this period, the outflow of amniotic fluid must necessarily occur. At the peak of the contraction, there is strong pressure on the amniotic sac, which leads to its rupture. How does the cervix dilate before childbirth 2. Exile. After the outflow of amniotic fluid, contractions noticeably become more frequent, they become longer and stronger. This is designed to force the fetus to quickly descend into the pelvic cavity and stimulate the muscles of the pregnant woman to start pushing. With attempts, the head of the fetus begins to erupt. It appears and disappears in order to move further along the birth canal next time. This happens before the appearance of the fetal head. After a short pause, a new attempt allows the shoulders and the whole body of the child to be born. When a pregnant woman is exhausted by prolonged contractions, she may not have enough strength for this last attempt. Doctors who help the baby to be born at this stage use pressure, pushing the fetus to birth.

3. Postpartum period. Physiological childbirth ends with the discharge of the placenta. After the expulsion of the fetus, postpartum contractions begin, which ensure the discharge of the umbilical cord, placenta and amniotic membrane. Attempts in this process are also involved. In the normal course of childbirth, the discharge of the placenta causes the uterus to contract strongly in order to ensure the occlusion of the uterine vessels to stop the bleeding. This completes the birth, mom and baby can rest.

Periods of childbirth and their duration:

Anesthesia during childbirth: pros and cons

Epidural (spinal) anesthesia during childbirth Childbirth is accompanied by pain. For some pregnant women, the expectation of pain turns into an obsession, they begin to experience such strong fear that during childbirth they are unable to behave adequately, discoordinating labor activity.

In some cases, there is also an individual intolerance to labor pain, which prevents normal labor activity. In such cases, specialists make a decision on anesthesia. Its purpose is to reduce pain, but not to relax the muscles of the woman in labor, not to provoke a loss of sensitivity.

Recourse to anesthesia is essential for maternal and fetal safety at the time of delivery if a woman:

• suffers from hypertension or has high blood pressure as a result of childbirth,
• is sick with severe diseases of the heart, cardiovascular system, endocrine system,
• is pregnant with a very large fetus or the fetus is breech presentation,
• gives birth at a very young age.

Anesthesia, especially medication, leaves an imprint on the condition of the newborn. Any drug penetrates the placenta to the fetus, which later results in the child's unwillingness to breastfeed, drowsiness, general weakness, and problems in spontaneous breathing. The action of drugs occurs simultaneously with their excretion from the body of the child.

The greatest fear in pregnant women is caused by a popular method of pain relief - epidural anesthesia. She really has unpleasant consequences, about which in propaganda posters hung in medical institutions, prefer to remain silent:

• the epidural opening for the catheter does not disappear simultaneously with the completion of labor. Through it, fluid flows out, which provokes headache, who does not leave the young mother alone for several weeks,
• the first days after childbirth are overshadowed by the impossibility of self-emptying of the bladder,
• a young mother may suddenly have a fever,
• lower back pain haunt a woman for months.

The consequences of anesthesia should completely recede within 6 months from the moment of birth, but there is another danger in this. A woman may not seek advice from her attending physician due to unpleasant symptoms, attributing them to the effects of anesthesia. Only after six months, she is forced to undergo an examination and begin treatment.

Green water during childbirth: causes and consequences

Experts believe that during the normal course of pregnancy, with the outflow of amniotic fluid, they should be transparent. However, often the waters are green or dark in color. There are several reasons for this phenomenon:

The discharge of green waters is actually not a sign of a disease of the fetus, a danger to it, or a harbinger difficult childbirth. This is just a warning to the doctor to be more careful.

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