What ends the 1st period of childbirth. First stage of childbirth. Follow-up management

According to the WHO, “Normal labor is labor that begins spontaneously in low-risk women at the onset of labor and remains so throughout labor: the baby is born spontaneously in cephalic presentation at 37 to 42 completed weeks of gestation, and after delivery both mother and baby are in good health. condition."

Childbirth is divided into three periods:

disclosure period;

period of exile;

Follow-up period.

The total duration of childbirth depends on many circumstances: age, readiness of the woman's body for childbirth, features of the bone pelvis and soft tissues of the birth canal, size of the fetus, the nature of the presenting part and the features of its insertion, the intensity of the expelling forces, etc.

The average duration of normal labor in primiparas is 9-12 hours, in multiparous - 7-8 hours. Childbirth is rapid in primiparous lasting 3 hours, in multiparous - 2 hours. Rapid delivery, respectively, 4-6 hours and 2-4 hours.

Duration of childbirth by periods:

I period: 8-11 hours in primiparous; 6-7 hours in a multiparous;

II period: primiparous 45–60 min; multiparous 20–30 min;

III period: 5–15 minutes, maximum 30 minutes.

I stage of childbirth - the period of disclosure. This period of labor begins after a short or long preliminary period, in it the final smoothing of the cervix and the opening of the external pharynx of the cervical canal to a degree sufficient to expel the fetus from the uterine cavity, i.e., by 10 cm or, as noted in the old days, - on 5 cross fingers.

Cervical dilation occurs differently in primiparous and multiparous women. In nulliparous women, the internal os opens first, and then the external one; in multiparous women, the internal and external os open at the same time. In other words, in a primiparous woman, the neck is first shortened and smoothed, and only then the external pharynx opens. In a multiparous woman, there is a shortening, smoothing, and opening of the cervix at the same time.

As already mentioned, the smoothing of the cervix and the opening of the external os occurs due to retractions and distractions. The average rate of cervical opening is from 1 to 2 cm per hour. The opening of the cervix is ​​facilitated by the movement of amniotic fluid towards the lower pole of the fetal bladder. When the head descends and presses against the entrance to the small pelvis, it comes into contact with the region of the lower segment from all sides. The place where the fetal head is covered by the walls of the lower segment of the uterus is called the contact zone, which divides the amniotic fluid into anterior and posterior. Under the pressure of amniotic fluid, the lower pole of the ovum (fetal bladder) exfoliates from the walls of the uterus and is introduced into the internal pharynx of the cervical canal. During contractions, the fetal bladder is filled with water and strains, contributing to the opening of the cervix. Rupture of the fetal bladder occurs at the maximum stretching of the lower pole during contractions. Spontaneous opening of the fetal bladder is considered optimal when the cervix is ​​dilated by 7–8 cm in a nulliparous woman, and in a multiparous woman, a dilatation of 5–6 cm is sufficient.

The movement of the head through the birth canal contributes to a greater tension of the amniotic sac. If the waters do not leave, they are artificially opened, which is called an amniotomy. With the insolvency of the fetal membranes, the water leaves earlier. Premature is the discharge of water before the onset of labor, early - in the first stage of labor, but before optimal disclosure. With a spontaneous or artificial opening of the fetal bladder, the anterior amniotic fluid leaves, and the posterior waters are poured out along with the child.

As the cervix opens (especially after the anterior waters leave), nothing holds the head, and it descends (moves along the birth canal). During the first period of physiological labor, the head performs the first two moments of the biomechanism of labor: flexion and internal rotation; in this case, the head descends into the pelvic cavity or onto the pelvic floor.

As it descends, the head goes through the following stages: over the entrance to the small pelvis, pressed against the entrance to the small pelvis, with a small segment at the entrance to the small pelvis, a large segment at the entrance to the small pelvis, in the cavity of the small pelvis, on the pelvic floor. Promotion of the head is facilitated by regular contractions, the characteristics of which are given.

The expulsion of the fetus is most facilitated by the contractile activity of the body of the uterus. In normal childbirth, the first stage of childbirth proceeds harmoniously in terms of the main indicators: cervical opening, contractions, lowering of the head and discharge of water. The first period begins with regular contractions (lasting at least 25 seconds, with an interval of no more than 10 minutes) and neck opening (whole water and the head pressed against the entrance to the small pelvis are optimal). The first period ends when the cervix is ​​fully open (by 10 cm), contractions - every 3–4 minutes for 50 seconds, and attempts begin, the waters have receded, and by this time the head should sink to the pelvic floor. In the first stage of labor, three phases are distinguished: latent, active and transient.

Latent phase is 50-55% of the duration of the first period, begins with the appearance of regular contractions and the beginning of the opening of the neck, at the end of her contractions should be in 5 minutes for 30-35 seconds, the opening of the neck is 3-4 cm. The head is pressed against the entrance to the small pelvis . The duration of this phase depends on the preparedness of the birth canal and is 4-6 hours.

active phase lasts no more than 30-40% of the total time of the disclosure period, its initial characteristics are the same as at the end of the latent period. By the end of the active phase, the opening is 8 cm, contractions after 3-5 minutes for 45 seconds, the head with a small or even large segment at the entrance to the small pelvis. By the end of this period, the amniotic fluid should depart or an amniotomy is performed.

Transient phase lasts no more than 15% of the time, in multiparous faster. It ends with a full opening of the cervix, contractions by its end should be every 3 minutes for 50-60 seconds, the head descends into the pelvic cavity or even sinks to the pelvic floor.

II stage of labor- the period of exile begins after the full opening of the pharynx and ends with the birth of a child. The waters should recede by this time. The contractions become tight and come on every 3 minutes, lasting almost a minute. All types of contractions reach their maximum: contractile activity, retractions, and distractions. Head in the pelvic cavity or on the pelvic floor. Increases intra-uterine pressure, and then intra-abdominal pressure.
The walls of the uterus become thicker and more closely clasp the fetus. The unfolded lower segment and the smoothed cervix with an open pharynx form, together with the vagina, the birth canal, which corresponds to the size of the head and body of the fetus.

By the beginning of the period of exile, the head is intimately in contact with the lower segment - the inner zone of contact, and together with it closely adjoins the walls of the small pelvis - the outer zone of contact. Attempts are added to the contractions - reflex contractions of the striated abdominal muscles. The woman in labor can control the attempts - to strengthen or weaken.

During attempts, the woman's breathing is delayed, the diaphragm lowers, the abdominal muscles tense up strongly, intrauterine pressure increases. The fetus, under the influence of expelling forces, takes on the shape of an eggplant: the fetal spine unbends, the crossed arms are pressed more tightly against the body, the shoulders rise to the head, and the upper end of the fetus acquires a cylindrical shape, the legs are bent at the hip and knee joints.

The translational movements of the fetus are made along the wire axis of the pelvis (the axis of the pelvis, or the axis of the birth canal, passes through the intersection points of the direct and transverse dimensions of the four classical planes of the pelvis). The axis of the pelvis bends in accordance with the concave shape of the anterior surface of the sacrum, at the exit from the pelvis, it goes anteriorly to the symphysis.

The bone canal is characterized by the unequal size of its walls and dimensions in individual planes. The walls of the small pelvis are uneven. The symphysis is much shorter than the sacrum.

The soft tissues of the birth canal, in addition to the deployed lower segment and the vagina, include the parietal muscles of the pelvis and the pelvic floor. The muscles of the pelvis, lining the bone canal, smooth out the roughness of its inner surface, which creates favorable conditions for the advancement of the head. The muscles and fascia of the pelvic floor and the Boulevard Ring until the last moments of childbirth resist the advancing head, thereby contributing to its rotation around the horizontal axis. Providing resistance, the muscles of the pelvic floor at the same time stretch, mutually displace and form an elongated outlet tube, the diameter of which corresponds to the size of the born head and body of the fetus. This tube, which is a continuation of the bone canal, is not straight, it goes obliquely, bending in the form of an arc. The lower edge of the birth canal is formed by the vulvar ring. The wire line of the birth canal has the shape of a curve (“fishhook”). In the bone canal, it goes down almost straight, and at the bottom of the pelvis it bends and goes anteriorly. In period I childbirth, flexion of the head and its internal rotation are performed, and in II period childbirth - other moments of the biomechanism of childbirth. II stage of labor ends with the birth of a child. Its duration is 30-60 minutes in nulliparous and 20-30 minutes in multiparous. During this period, the woman feels frequent, prolonged, strong and painful contractions, feels strong pressure on the rectum and perineal muscles, which causes her to push. She does very hard physical work and is stressed. In this regard, there may be an increase in heart rate, an increase in blood pressure, due to tension and breath holding, facial flushing, respiratory rhythm disturbance, trembling and muscle cramps are noted. III period - successive period. After the birth of the fetus, the third stage of childbirth begins - the afterbirth.

In the third stage of labor occurs:

1. Separation of the placenta and membranes from the walls of the uterus.

2. Expulsion of the exfoliated placenta from the genital tract.

A few minutes after the birth of the fetus, contractions resume, contributing to the detachment of the placenta and the expulsion of the separated placenta (placenta, membranes, umbilical cord).

After the birth of the fetus, the uterus decreases and becomes rounded, its bottom is located at the level of the navel. During subsequent contractions, the entire musculature of the uterus is reduced, including the area of ​​​​attachment of the placenta - the placental site. The placenta does not contract, and therefore it is displaced from the placental site decreasing in size. The placenta forms folds that protrude into the uterine cavity, and, finally, exfoliate from its wall. The placenta exfoliates in the spongy (spongy) layer, in the area of ​​​​the placental site on the wall of the uterus there will be a basal layer of the mucous membrane and gastric spongy layer.

If the connection between the placenta and the wall of the uterus is broken, the uteroplacental vessels of the placental site break.
Separation of the placenta from the wall of the uterus occurs from the center or from the edges. With the onset of detachment of the placenta from the center, blood accumulates between the placenta and the wall of the uterus, a retroplacental hematoma is formed. The growing hematoma contributes to further detachment of the placenta and its protrusion into the uterine cavity.

The separated placenta during attempts comes out of the genital tract with the fruit surface outward, the membranes are turned inside out (the water membrane is outside), the maternal surface is turned inside the born placenta. This variant of placental abruption, described by Schulze, is more common. If the separation of the placenta begins from the periphery, then the blood from the disturbed vessels does not form a retroplacental hematoma, but flows down between the wall of the uterus and the membranes. After complete separation, the placenta slides down and pulls the membrane along with it.

The placenta is born with the lower edge forward, the maternal surface outward. The shells retain the location in which they were in the uterus (water shell inside). This option is described by Duncan. The birth of the placenta, separated from the walls of the uterus, in addition to contractions, is facilitated by attempts that occur when the placenta moves into the vagina and irritation of the pelvic floor muscles. In the process of allocation of the placenta, the severity of the placenta and retroplacental hematoma are of auxiliary importance. With the horizontal position of the woman in labor, the separation of the placenta located along the anterior wall of the uterus is easier.

In normal childbirth, separation of the placenta from the uterine wall occurs only in the third stage of labor. In the first two periods, separation does not occur, since the site of attachment of the placenta is reduced less than other parts of the uterus, intrauterine pressure prevents the separation of the placenta.

III stage of labor is the shortest. A tired woman in labor lies calmly, breathing is even, tachycardia disappears, blood pressure returns to its original level. Body temperature is usually normal. The skin has a normal color. Subsequent contractions usually do not cause discomfort. Moderately painful contractions are only in multiparous.

The bottom of the uterus after the birth of the fetus is located at the level of the navel. During subsequent contractions, the uterus thickens, becomes narrower, flatter, its bottom rises above the navel and deviates more often to the right side. Sometimes the bottom of the uterus rises to the costal arch. These changes indicate that the placenta, together with a retroplacental hematoma, descended into the lower segment of the uterus, while the body of the uterus has a dense texture, and the lower segment has a soft consistency.

The woman in labor has a desire to push, and the afterbirth is born.
In the postpartum period with normal childbirth, physiological blood loss is 100-300 ml, an average of 250 ml or 0.5% of the body weight of the woman in labor in women weighing up to 80 kg (and 0.3% with a body weight of more than 80 kg). If the placenta separated in the center (the variant described by Schulze), then the blood is released along with the placenta. If the separation of the placenta from the edge (the variant described by Duncan), then part of the blood is released before the birth of the placenta, and often with it. After the birth of the placenta, the uterus shrinks sharply.

Stages of childbirth or how natural childbirth goes in time

In order for a woman to more easily endure the process of giving birth, not to interfere with her actions, but to help medical personnel, she must clearly know what stages of childbirth she will have to go through. Having an idea about the physiological changes taking place in the body, a woman reacts less emotionally to what is happening, is less afraid, and experiences moderate pain. When the first stage of labor has already begun, it is too late to conduct training. Difficulty focusing on new information. We suggest that you familiarize yourself with the three stages of childbirth in advance in order to fully prepare for the upcoming difficult, responsible work.

1. Stage one: preparatory
2. Birth of placenta
3. Duration of labor

The first stage is preparatory

At the end of pregnancy, a woman may experience discomfort in the area of ​​\u200b\u200bthe abdomen, lower back. Is it possible to confuse them with the beginning of real fights? Women who already have children argue that this is almost impossible. The painful sensations of training fights can be weakened and completely stopped if, at the moments of their appearance, you distract yourself with something interesting:

• watching a movie;
• taking a warm shower;
• a cup of fragrant tea.

If this is not a “training”, but the first stage of childbirth, then the body can no longer be deceived by any means. Soreness slowly and gradually increases, the intervals between contractions are even periods of time, which are getting shorter. Stage 1, in turn, is divided into 3 time periods, during which there is a consistent preparation for the expulsion of the fetus. Of all the stages of childbirth, this is the most painful and lengthy period. Attempts to speed it up are fraught with injury to the mother and baby. The cervix does not have time to open properly.

Three phases of the first stage:

• latent (opening of the cervix up to 3-4 cm);
• active (opening up to 8 cm);
• transient (full disclosure up to 10 cm).

By the second phase, water usually departs. If this does not happen, the doctor who controls the stages of labor activity pierces the fetal bladder, due to which the cervix opens faster.

By the end of the second phase, the woman enters the maternity hospital. She already has quite intense contractions, going at intervals of less than 5 minutes. The third phase takes place under the supervision of doctors. Every 3 minutes there are undulating contractions lasting up to 60 seconds. Sometimes a woman does not have time to rest between them, because they roll one after another. At this stage of labor activity, the fetal head descends into the pelvic cavity (on the pelvic floor). A woman may experience fear, even panic. She needs specialist support. Sometimes there is a desire to push, and here the help of obstetricians is indispensable. They will tell you when it is time or should be patient until the neck opens to the desired size.

In the early stages of labor, close women in labor can play a huge role. It is important to talk to her, calm her down, do a light massage of the lower back, hold hands, help to take those positions in which a woman can easily endure pain:

• be on all fours;
• while moving vertically;
• stand on your hands.

The first of the three stages of labor is the period when the fetal head moves downward under the pressure of the uterine muscles. The head is oval, the birth canal is round. On the head there are places where there is no bone tissue - fontanelles. Due to this, the fetus has the opportunity to adapt and pass through the narrow birth canal. - this is a slow opening of the cervix, smoothing the birth canal and the formation of a kind of "corridor", wide enough to let the baby through. When everything is prepared, the second stage of childbirth begins - pushing.

The second stage: the panting period and the birth of a child

If we consider everything 3 stages of childbirth, then the straining one is the happiest for a newly-made mother, who can finally forget about the suffering she has endured and for the first time press her little blood to her chest.

At the beginning of this stage, if a natural birth is planned (without a caesarean section), the woman is asked to sit on the birth chair. The most important and responsible work begins. By this time, the woman in labor is already very exhausted by prolonged pain, her main task is to focus on the commands of the medical staff and follow them exactly. The child turns several times during the passage of the birth canal and, finally, approaches the exit. The head is shown first (it may hide back several times). In order not to harm the child, it is necessary to push strictly on the command of the doctors. The head of the child with force presses on the rectum - and along with the next fight, there is a desire to push.

After the birth of the head, the doctor helps her to free herself from the perineum. The shoulders are born, and then (very quickly) the whole body. The newborn is applied to the breast. A woman at this moment has a powerful release of the hormone oxytocin, she experiences a state of euphoria. There is some time for rest. The work is not finished yet - you need to wait for the birth of the placenta.

Birth of placenta

When describing the 3 stages of childbirth, this last period is given a minimum of attention. But it is extremely important for a woman's health. It is necessary that the "children's place" be separated on time and completely. The third stage begins with rather weak (compared to everything that the woman in labor has already experienced) contractions. Normally, there will be very few of them, you still need to push and help the uterus expel the placenta. If the placenta does not separate on its own, doctors resort to surgical intervention. The uterus must be cleansed. Otherwise, an inflammatory process occurs, prolonged bleeding. The last stage is completed, the young mother and child are left under observation for a while. Then they are sent to the room.

Duration of labor

Stages of childbirth are different in time. The duration of each of them is different in those giving birth for the first time and again. Let's see how the birth goes on in primiparas and in those who have already passed (more than once) this path.

Table 1. Duration of 3 stages of labor

Those who give birth to the second and subsequent children, the first two periods pass much faster. Therefore, it is very important for multiparous women to call an ambulance in time so that the birth is not caught at home or on the way to the hospital.

What to do if a woman in labor feels: the baby's head is about to appear, and there is no time to get to the hospital in time? In this case, others will have to take delivery at the pre-hospital stage.

Such situations are possible in case of premature pregnancy, in multiparous, when walking, with rapid delivery. It is necessary to prepare warm water, sterile gloves, napkins, diapers. The person assisting the woman in labor should carefully support the perineum when the fetal head comes in to prevent tears. Only when the suboccipital fossa of the child is under the pubic joint of the mother, you can carefully help the child to get out into the light. After delivery, the mother and newborn should be taken to the hospital as soon as possible for examination.

Childbirth is a process that women have always treated with understandable fear. But if you are prepared for each stage, you will be able to manage childbirth, that is, from a passively suffering patient, turn into an active participant in difficult but joyful work. All fears will be immediately forgotten as soon as your small copy appears at the chest. For the sake of the birth of the most beloved creature in the world, it is worth suffering!

Childbirth is a rather complex and unpredictable physiological process. Nevertheless, the body of a healthy woman is endowed with all the necessary resources for a successful childbearing. In order to be less anxious and know what to expect, the mother-to-be should know basic information about the periods of labor and their duration. This will allow a woman to mentally prepare for the upcoming difficult events, which will end in a real miracle - the appearance of a long-awaited baby.

How should normal labor begin?

Natural childbirth in a pregnant woman should begin spontaneously, spontaneously, for a period of 38 to 42 weeks. The waters may break immediately or later. Throughout the process, with a successful, normal birth, the body of the expectant mother does not need any intervention, everything happens as it was intended by nature. Medical help is needed if something goes wrong.

It's important to know! The minimum gestational age at which a baby can be born completely healthy and adapted to life outside the womb is 28 weeks, while the weight of the fetus should be at least 1 kg. Childbirth is considered natural from 38 to 42 weeks.

Such a baby is considered premature and will be in intensive care under close supervision for the first time, but he has every chance of survival.

A couple of days before the onset of labor, the expectant mother may feel strong pressure in the lower abdomen. Usually, a lot of mucus begins to stand out from the vagina (the mucous plug that closes the uterine canal leaves), the pelvic joints may begin to ache. The activity of the fetus is markedly reduced, which is the norm.

The main periods of childbirth

The birth process begins with contractions and the moment the cervix opens, and ends after the placenta is expelled. It is impossible to determine exactly how long this whole difficult act of the birth of a new life will last. Everything is individual: in primiparous it can last longer - up to 1 day; in multiparous, everything happens faster - within 5-8 hours. It is extremely rare that everything happens in a fairly short period of time - 2-3 hours.

The course of childbirth is divided into 3 periods:

1. The first one is preliminary (disclosure period). It begins with the departure of amniotic fluid (they leave later), and the first, still weak contractions, ends with the full opening of the cervix.
2. The second is the expulsion of the fetus. It is fixed at the moment of full disclosure of the birth canal and ends when the fetus is born.
3. The third is sequential. It is fixed after the fetus has already been expelled, and ends with the release of the placenta (afterbirth).

If the pregnant woman is at home, then with the beginning of the first stage, she must be immediately taken to the hospital.

In the clinic, delivery by periods can be carried out by different doctors. Immediately before the birth itself, the patient is monitored by nurses, the obstetrician-gynecologist only periodically examines the woman in labor. At this stage, before giving birth, the patient is given a cleansing enema to completely empty the intestines.

With the transition to the second stage, the woman is transported from the prenatal ward to the sterile delivery room, and now obstetricians will be with her until the process is completed.

Let us consider in more detail each stage of childbirth.

First stage of labor - disclosure

The initial, preliminary period of childbirth is fixed from the moment the uterus opens. Usually a woman with dilation feels the first contractions. They are not so painful yet and last only a few seconds. Unpleasant sensations begin from the lower back and only then spread to the pelvic area. The intervals between contractions can be 20-25 minutes. In rare cases, the opening of the cervix begins without contractions, the woman only feels sipping in the back and lower abdomen.

The organism during the 1st period contributes to the softening of the tissues of the uterine pharynx, its smoothing. The stomach at this moment can become very hard, tense.

In multiparous and giving birth for the first time, the stages of disclosure occur in different ways. At the first birth, first there is a shortening of the uterine muscles and smoothing of the neck, and only then the opening of the external pharynx. With repeated childbirth, these actions of the body often occur simultaneously.

On average, the uterus expands the pharynx at a rate of 1-2 cm per hour. Disclosure is considered sufficient when the birth canal has dissolved by 8-12 cm (depending on the mass and physique of the woman in labor). The obstetrician periodically examines the vagina and monitors the course of this process.

The fetus in this stage gradually approaches the head to the pelvic floor. Under such pressure, the fetal bladder (if it has not burst earlier) bursts and the amniotic fluid comes out. Bubble rupture does not always occur spontaneously. If the cervix has already opened up to 6-8 cm, and the water has not yet broken, the doctor pierces the bladder wall so that the baby can move on freely. For the patient, this action (puncture) is almost imperceptible, you should not be afraid of it.

The first stage of childbirth for the expectant mother is painful. In addition to contractions, a woman may feel nausea, dizziness, profuse sweating, chills or fever, frequent urge to empty. The intensity of pain and associated symptoms are individual and depend on the neuropsychological characteristics of each woman. For some, everything goes quite easily and quickly, for others the torment seems barely tolerable.

In medicine, the preliminary period is divided into 3 phases:

• Phase I is latent. Its beginning occurs from the first contraction and continues until the uterus opens up to 4-5 cm. Intervals of contractions in this period are usually 10-15 minutes, the rate of cervical dilatation is up to 1 cm per hour. In time, the phase can last from 2-3 to 6-7 hours.
• Phase II - active. Contractions noticeably become more frequent (occur every 3-5 minutes) and become longer, more painful. The speed of the opening of the pharynx increases (1.5-2.5 cm per hour). The phase ends when the uterus dilates to 8 cm.
• III phase - slow. After the active and most difficult phase, there is a slight slowdown in the process, painful contractions gradually turn into strong pressure, which the woman begins to feel in the pelvic floor. At this stage, the uterus is fully opened and the body is ready for childbirth.

Important! Throughout the preliminary period, the woman in labor should not push and strain. The main task for the expectant mother at this time is to breathe deeply in order to saturate her body and the blood of the baby with oxygen. The subsequent periods of childbirth largely depend on how these three phases proceed.

Ideally, everything should happen in this order, but there are cases when the sequence of stages is violated or pathological situations arise. In such situations, doctors decide on the spot what to do to successfully resolve the birth. Sometimes you have to urgently do a caesarean to save the life of the child.

When everything ends well in the first stage, the main part follows.

Second stage of labor - expulsion of the fetus

The hardest and most painful stage is over. Now the contractions almost stop and turn into pushing. Feelings are unpleasant, but not so painful. This act cannot be controlled. The attempts are reflexive, the muscles of the diaphragm, abdominals, and pelvic floor are actively contracting.

The head of the fetus intensively begins to move along the birth canal. The body of a little man gradually straightens, the arms straighten along the body, the shoulders rise to the head. Nature itself guides the process.

In the second stage of labor, the patient is transferred to the delivery room, on a special couch, and the time comes when you have to push. The doctor tells the woman what to do, how to breathe and at what point to strain. The baby's head is shown in the crotch. With each push, the baby gradually moves outward. At this stage, some patients experience a rupture of the soft tissues of the perineum. There is no particular danger to this, later the doctors will sew up the perineum and in a couple of months there will be no trace left on it. The woman giving birth herself, against the background of strong attempts, no longer feels the breaks.

The duration of labor depends on the following factors:

• Physique of a woman.
• The physical and psychological state of the woman in labor.
• The position and activity of the fetus, its size.

On average, the exile time lasts from 20 minutes to 2 hours. While the baby's head is moving through the birth canal, it is very important to monitor the baby's pulse. If his face lingers in the pelvic area longer than necessary, hypoxia (lack of oxygen) may begin. This happens if suddenly, for some unknown reason, the attempts fade away. Doctors take action to expel the fetal head as quickly as possible.

When the little man's head is completely out, the obstetrician removes mucus from his face to clear the airways and completely removes the body from the womb. The baby is connected to the placenta, which is still inside, by the umbilical cord. It is cut and bandaged on the child's body. The umbilical cord has no nerve endings, so neither the mother nor the newborn feel any pain.

If the course of childbirth went well, the baby began to breathe and screamed, it is placed on the mother's chest for a few minutes. Such an action began to be practiced not so long ago. According to psychologists, this allows the woman to recover faster, and the baby to calm down, feeling the familiar beating of the mother's heart in a new, frightening environment. Later, the child is taken away and taken to a special department so that the baby can also rest after such severe stress. The mother is still on the couch.

On this, the 2nd stage of labor is considered completed.

The third stage of childbirth - postpartum (postpartum)

After some time (15-30 minutes), the woman who gave birth again feels soreness and attempts. This is completely normal and necessary. The placenta (children's place) remained inside, and it should come out spontaneously.

As soon as the woman again felt contractions in the abdomen and pressure, the third stage of labor began. Everything is happening much faster and not so painful. If the placenta does not come out within half an hour after the completion of the second stage, doctors do a "squeezing" or manual cleaning under anesthesia.

At the end of the third period, the obstetrician sews up the perineum (if there were tears), disinfects the birth canal. The woman may assume a more comfortable position, but must still remain in her position, lying on her back. Within an hour, sometimes two after childbirth, doctors observe the patient with a frequency of 15-20 minutes. If no complications and pathologies are observed, she is transported to the postpartum ward. Now a woman in labor is considered a puerperal.

It's important to know! For the first couple of days, a new mother may have a fever (within 38º C). This is a normal reaction, the temperature will gradually return to normal.
At the end of the third period, a woman is recommended to lie on her back for several more hours.

The duration of childbirth significantly exhausts the body and an accomplished mother usually experiences severe weakness after everything. Along with fatigue, there may be a feeling of thirst or hunger, chills, drowsiness, fever. There is bloody discharge from the vagina. These are all perfectly normal reactions. Linen is put on the puerperal, a gauze swab is laid in the perineum, which will need to be changed periodically. It is impossible to use ordinary sanitary pads after childbirth, they do not allow air to pass through, promoting the growth of bacteria, and can lead to suppuration of the tissues.

Gradually, the state of a happy mother returns to normal.

On a note! If the birth was successful, and there were no gaps, the woman can stand up on her own after 3-4 hours.

These are the main three stages of childbirth that any woman who gives birth naturally goes through. Our body is perfect and has sufficient resources to safely withstand such a serious and difficult act of the birth of a new life. Today, there are various preparatory courses for pregnant women that teach proper behavior and breathing during childbirth. The more confident and calm a woman is, the easier and faster the whole process will go. A positive mental attitude also has a huge positive impact on childbirth.

Come to the end of 9 months of pregnancy. The expectant mother lives in anticipation of the birth. Generic activity takes place in three periods. The first period of labor is the beginning of labor, which is the longest and most painful in time.

Signs of the onset of labor

In the period between 259 and 294 days - the child is ready for birth. At any moment of this period of time, hormones are produced by the mother's body to start the birth process.

By 35–36 weeks, the fetus is grouped into a pose, namely, the torso is bent, the chin is pressed to the sternum, the legs are bent, pressed to the stomach, and the arms are crossed, lying on the chest. In this position, he is until delivery. In the first stage of labor, the fetus moves along the birth canal while maintaining this body position.

A couple of days before the onset of labor, certain signs appear - this is a pulling pain in the lower back and lower abdomen, a frequent desire to urinate, insomnia, prolapse of the uterus and a decrease in body weight. The closer the day of birth, the softer the uterus becomes. As a result, a yellowish plug with blood splashes is pushed out of its channel. But the process sometimes begins without precursors. The first stage of labor in primiparas begins with the occurrence of periodic, constant contractions with a gradual increase. This also applies to repeaters.

Two signs of the onset of labor:

1. frequent contractions;
2. bubble burst.

Contractions are measured contractions of the muscles of the uterus. They can occur a few weeks before childbirth. True labor pains resume after 20 minutes, and the time between them gradually decreases. In the maternity hospital, the lady needs to gather when the period between contractions reaches 10 minutes, and they become permanent.

Bubble burst. Sometimes amniotic fluid leaks before contractions or there is a sudden rupture of the amniotic membrane. This process is not accompanied by pain. Labor activity begins to develop after 5-6 hours. A woman needs to remember the time when the outflow of water occurred and immediately come to the hospital even in the absence of contractions.

In some women in labor, the period when contractions do not become more frequent is delayed for several days. During this time, she is exhausted and loses a lot of strength. Her psyche is starting to fail. So that the expectant mother does not exhaust herself mentally and physically, you need to visit a gynecologist. The specialist will examine it and make the right decision about further actions. Often it is enough for a lady to sleep a few hours under the influence of drugs in order to fully recover and prepare for childbirth.

Phases

The birth process begins with the onset of the first contraction. It can reach several days, although this is undesirable and lasts until the uterus is fully prepared for childbirth.

How long is the first period? This period is the longest in time and painful in sensations. The duration of the first stage of labor in primiparous reaches 11 hours, in multiparous it proceeds faster and is about 7 hours.

The course of 1 period of labor is divided into 3 phases:

1. latent;
2. active;
3. slowdown.

latent phase. Contractions in a pregnant woman are observed after 20-30 minutes. Their duration is 20 seconds. The latent phase of the first stage of labor is characterized by moderate contractions. The woman in labor tolerates pain mostly calmly, although this depends on the individual characteristics of the lady. At the end of the phase, the cervix opens up to 4 cm.

active phase. The duration of the period reaches 3 hours. During this period, the time between contractions sharply decreases, it reaches two contractions in 10 minutes, the duration increases and reaches a minute. The neck opens up to 8 cm.

deceleration phase. Contractions begin to gradually weaken. The opening of the neck ends and reaches 10–12 cm. Attempts begin to appear. At this stage, the management of labor in young primiparas is important, since the woman in labor cannot be allowed to start pushing. This is prohibited, as it will lead to swelling of the cervix of the uterus and, as a result, childbirth will be delayed. The duration of the phase is from 15 minutes to 2 hours.

The essence of the principles of the introduction of the first stage of labor is to support and control labor. It is also required to take into account that this is a painful period of childbirth, so it is allowed to use painkillers.

Anesthesia

The tactics of managing the first period in some cases involves the use of anesthesia, since not all women in labor are able to withstand the pain symptom. But this does not mean only the use of medications.

There are ways to relieve pain without medication. Their plus is that there is no effect of drugs on the fetus, they do not cause an allergic reaction. The drug method of pain relief is intravenous or intramuscular injections, which include narcotic or non-narcotic substances.

Narcotic anesthesia is used only for serious complications. The management of childbirth in adult primiparas sometimes requires just such an injection. But do not be afraid of this, because the dose of the drug is strictly calculated and cannot harm either the woman in labor or the child.

The use of any pain medication can cause drug-induced depression in the fetus. This is due to the effect of drugs on his weak nervous system.

In maternity hospitals, epidural anesthesia is often used. This method, in which an analgesic is injected into the spinal canal. As a result, pain impulses do not pass through the nerves of the spine and the brain simply does not receive them. So the woman does not feel pain. The dose of the drug is calculated taking into account that at the beginning of the second stage of labor it does not work. During the back procedure, the patient's brain is not affected.

Deviations

Not always labor activity goes according to the rules, often deviations from the norm are observed in women in labor. This is influenced by: age, the presence of pathologies in a woman, multiple pregnancy, low water or polyhydramnios, previous abortions, fetal size, endocrine diseases.

Deviations from the norm in labor activity:

• weak;
• excessive;
• discoordinated.

Weak labor activity. The duration of labor in primiparas reaches 12 hours. But sometimes the process is delayed, and this time can reach several days. The woman in labor has rare and short contractions. As a result, the cervix and the movement of the fetus to the exit is delayed. This birthing scenario proceeds in two ways.

The first way is a weak generic activity that manifests itself initially. The second way is when the process is running normally, but at some point it slows down. Any of the two paths will lead to a long, traumatic birth. Which will provoke bleeding and hypoxia in the baby. Gynecologists with this course of pregnancy use stimulation of labor, if the treatment does not give positive results, then only surgery remains: a caesarean section.

Excessive labor activity. These labors are characterized by frequent, violent, and painful contractions. If a woman in labor has contractions of this nature, then the process of resolving the burden proceeds rapidly. The danger is that a woman will get ruptures of the cervix, vagina and even the uterus. The fetus at this time experiences oxygen starvation. Specialists use drugs that weaken childbirth or use medical sleep.

Discoordinated labor activity. This course is characterized by a mosaic of contractions, that is, they do not increase in strength, but different ones come: weak and painless or strong and frequent. The lower part of the uterus is in good shape, which prevents the baby from moving through the birth canal. The cause of such pathological births are: deviations in the development of the uterus, surgery or cauterization of cervical erosion, as well as the banal fatigue of the woman in labor. Gynecologists with this course of the first period use drug sleep and anesthesia. If this does not improve, then a caesarean section is performed.

Proper management of the 1st stage of labor is an important point. The further development of the whole process depends on how it goes. The main thing is that the expectant mother should not be afraid and be prepared for childbirth psychologically and physically.

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.

For the onset of labor and contraction of the muscles of the uterus, it is important 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, an important role belongs to 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, the endocrine system and the fetoplacental complex are united in the concept of "patrimonial 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);

Decreased motor activity of the fetus;

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

Isolation of thick viscous mucus from the genital tract - a mucous plug (the secretion of a 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 of the fetal egg 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. Hemostasis is promoted by the narrowing of the terminal sections of the arteries, the spiral structure of which ensures their contraction and displacement into the 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. The front of the 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 the large dimensions of the 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 of the 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 it advances, 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;

Increased 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 the contraction, deep breaths are recommended 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, the last moment of the birth mechanism takes place - the internal rotation of the shoulders and the 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 the primary treatment of a newborn, a sterile individual kit is used, which includes a sterile individual kit for processing the umbilical cord with brackets.

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 breastfeeding and breastfeeding contribute to the more rapid establishment of normal intestinal microflora, an increase in the nonspecific defense of the newborn's body, the establishment 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 vital systems, primarily the cardiovascular and respiratory systems: 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, impulses are transmitted along the posterior roots of the 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. Given the negative impact of pain on the birth process, anesthesia is indicated.

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, drugs and inhalation anesthetics are used.

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 severe 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 complete blockage or movement is limited to the ankle joint is not adequate during labor as it contributes to labour.

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.