CHILDBIRTH (partus) — physiological process of an expulsion of the fetus, placenta with fetal membranes and amniotic waters from a uterus in patrimonial ways after achievement by a fruit of viability. Viable fruit (see), as a rule, becomes after 28 weeks of pregnancy when its weight (weight) makes not less than 1000, and height of 35 cm. The expulsion of the fetus is carried out due to regular reductions of a uterus.
Rubles can be timely (partus maturus normalis) at duration of gestation of 38 — 42 weeks, premature (partus praematurus) at duration of gestation from 28 to 38 weeks (see. Premature births ), overdue (partus seretinus) at duration of gestation over 42 weeks (see. Perenashivany pregnancies ). During R. it is accepted to call the woman the woman in labor (parturieris); primapara — primipara, multipara — multipara.
- 1 CHANGES IN the ORGANISM of the PREGNANT WOMAN BEFORE CHILDBIRTH
- 2 The REASONS of APPROACH of CHILDBIRTH
- 3 The CLINICAL COURSE of NORMAL CHILDBIRTH
- 4 The MECHANISM of CHILDBIRTH
- 5 CONDUCTING NORMAL CHILDBIRTH
- 6 CHILDBIRTH AT EXTENSIVE PRESENTATIONS OF THE HEAD
- 7 CHILDBIRTH AT CROSS AND SLANTING PROVISIONS of the FRUIT
- 8 CHILDBIRTH AT LOSS of the LOOP of the UMBILICAL CORD AND SMALL PARTS of the FRUIT
- 9 CHILDBIRTH AT the LARGE (HUGE) FRUIT AND ANOMALIES of FETATION
- 10 CHILDBIRTH AT UNTIMELY IZLITIYA of AMNIOTIC WATERS, the HYDRAMNION AND the OLIGOAMNIOS
- 11 CHILDBIRTH AT PATHOLOGICAL CHANGES of GENERATIVE ORGANS
- 12 CHILDBIRTH AT ANOMALIES of SOKRATITELNY ACTIVITY of the UTERUS
- 13 CHILDBIRTH AT SOME EXTRAGENITAL DISEASES of MOTHER AND COMPLICATIONS of PREGNANCY
- 13.1 Rhoda at heart diseases
- 13.2 Childbirth at infectious hepatitis
- 13.3 Childbirth at diseases of lungs
- 13.4 Childbirth at pyelonephritis
- 13.5 Childbirth at an idiopathic hypertensia
- 13.6 Childbirth at arterial hypotension
- 13.7 Childbirth at anemia
- 13.8 Childbirth at a diabetes mellitus
- 13.9 Childbirth at late toxicoses of pregnant women
- 13.10 Childbirth at a hydrops gravidarum
- 13.11 Childbirth at a nephropathy
- 13.12 Childbirth at a preeclampsia and an eclampsia
- 14 SHOCK AND the EMBOLISM IN LABOUR
- 15 BLEEDING IN LABOUR
- 16 PATRIMONIAL TRAUMATISM
- 17 DIAGNOSIS of the FORMER CHILDBIRTH IN the MEDICOLEGAL RELATION
CHANGES IN the ORGANISM of the PREGNANT WOMAN BEFORE CHILDBIRTH
at the end pregnancies (see) there is a peculiar reorganization of functions (and partly and structures) bodies and systems of the woman connected with formation of biological readiness of an organism for R. that provides timely approach and the correct current of a childbed.
Changes of content of hormones before R. are defined generally by function of a so-called fetoplacental complex, and also functional activity gipotalamo - pituitary and gonadal system of mother and partly a fruit.
The important role in preparation of an organism of the pregnant woman for a childbed belongs to oestrogenic hormones. The strengthened education estrogen (cm.) promotes synthesis of sokratitelny protein of actomyosin, increases sensitivity of a myometrium to effect of biologically active agents — to oxytocin (see), to acetylcholine (see), to serotonin (see), etc. Besides, estrogen promotes a softening of a neck of uterus. In two weeks prior to R. there is a change in the ratio of fractions of estrogen: concentration estriol (see) increases while estrone (see) and oestradiol (see) decreases. Contents progesterone (see) in blood progressively accrues with development of pregnancy. Also allocation with urine of the main metabolite of progesterone — pregnandiol increases. However one week prior to R. the content of progesterone and its metabolites in blood and urine falls therefore sensitivity of a myometrium to oxytocin increases. The ratio in urine of pregnandiol and an estrpol by the end of pregnancy makes 1:1 (at the beginning of pregnancy 1:100) that also has a certain value in approach of childbirth. In amniotic waters concentration of progesterone by the end of pregnancy decreases and makes only 1/6 of its concentration in a blood plasma.
The general maintenance of 17 corticosteroids in blood is much higher than srednefiziologichesky norm and only after R. their sharp recession is observed. Level 17 ketosteroids (see) in urine during pregnancy significantly does not change. The general maintenance of 11 oxycorticosteroids in a blood plasma doubles, and generally due to sharp increase of maintenance of the proteinaceous and connected forms; at the same time also the connecting ability of transcortinum increases. Excretion of glucocorticoids (see. Glucocorticoid hormones ) in recent months pregnancy up to R.'s approach decreases a little. A ratio between fractions of glucocorticoids (cortisol, a cortisone, 11 - zoksikortizola) and their tetragidro-derivatives in urine and amniotic waters before R. above, than at the time of delivery. Contents Aldosteronum (see), biosynthesis to-rogo is stimulated by estrogen, to 39 — 40 weeks of pregnancy increases that is one of the factors promoting development of a physiological hypervolemia (see. Blood circulation ).
Observed hyperfunction cortical and marrow of adrenal glands has great biological value as promotes maintenance of a high level of readiness of mechanisms of adaptation to the various stressorny influences arising during childbirth.
In the last days before R. there is a decrease in content of serotonin and its metabolite (5-oxyindolacetum to - you) in blood, and also melatonin (see) in urine. Possibly, it is connected with accumulation of serotonin in myometriums and a placenta that promotes the beginning of patrimonial activity. Products of melatonin a pinus decrease that, perhaps, promotes emission of oxytocin and, besides, reduce the braking influence of melatonin on motor function of a uterus.
Before R. level sharply increases in blood relaksina (see), to-ry disappears a day before development of patrimonial activity. At the same time concentration increases prostaglandins (see), in particular F20t, to-ry is synthesized in a decidua and is the main stimulator of the beginning of patrimonial activity. Level of placental lactogenic hormone in blood (see. Prolaktin ) increases in process of development of pregnancy and stimulates development of mammary glands. Before R. there is a decrease in level chorionic gonadotrophin (see).
In to a placenta (see) by the end of pregnancy the content of many biologically active agents, microelements, vitamins, the enzymes providing a high level of power and plastic processes increases. Just before R. the level of the substances sensibilizing and increasing sokratitelny ability of a uterus (oxytocin, acetylcholine, a histamine) due to decrease in fermental activity of the placenta suppressing effect of the oksitotichesky substances stated above increases. In blood activity increases cholinesterases (see), allocation adrenaline (see) decreases several, and noradrenaline (see) and serotonin increases. All these substances also promote maintenance of a tone of a uterus in labor.
Thus, by the end of pregnancy there occur changes in ratios of the steroid and other hormones exerting the expressed impact on excitability and sokratitelny activity of a uterus.
Changes of reproductive system. By the end of pregnancy the sizes of a uterus considerably increase and average 30X 25 X 20 cm. The volume of a cavity of the uterus increases more than by 500 times (to 4 l), the area of its inner surface makes apprx. 1000 cm2, a circle — 50 cm. The weight of a uterus increases during pregnancy from 30 — 100 g till 1000 — 2000 at the expense of a hypertrophy and a hyperplasia of muscle fibers, and also growth of connecting fabric, circulatory and absorbent vessels of a uterus. Walls of a uterus by the end of pregnancy stretch and become thinner (their thickness to 0,5 cm and less), the cross diameter of an uterine fundus increases, and the shape of a uterus approaches pear-shaped. The uterus during pregnancy is considerably softened and easily displaced, at the end of pregnancy it turns slightly to the right (dextrarotatio), its turn is occasionally observed (sinistrarotatio) to the left. By 40th week of pregnancy contents in myometriums of proteins of a sarcoplasm increases up to 45%, the amount of connective tissue proteins at the same time decreases (by 40%); the ratio between muscular and connecting tissue of a uterus towards sharp dominance of muscular tissue changes.
By the end of pregnancy in myometriums the maintenance of a glycogen, and also the phosphoric connections (ATP, creatine phosphate, a fosfokrea-tinin, etc.) playing an essential role in power processes of muscular tissue increases. At the same time in myometriums ion concentration of calcium considerably increases. By the end of pregnancy the content of actomyosin increases by 25% in comparison with its contents before pregnancy, and in a body of the womb the level of actomyosin is higher, than in its isthmus and a neck. Almost in Z,5 of time oxygen consumption in myometriums increases.
Nervous elements of a uterus expand and hypertrophy, the number of her receptors sharply increases that does a uterus more sensitive to an impulsation of a fruit. However after 30 — the 34th week of pregnancy part of them is exposed to involution. It reduces painful information from a uterus at preservation of myoneural ways of regulation of its sokratitelny activity.
The vascular system of a uterus during pregnancy also undergoes considerable changes. Diameter, length and tortuosity of uterine and ovarian arteries increases, veins extend, on the party of a placenta big venous sine are formed. The total amount of a uterine blood-groove considerably increases and by the end of pregnancy reaches about 700 ml/min.
Before R. the neck of uterus becomes «mature», i.e. is softened throughout, including area of the internal pharynx (which is softened usually the last), its vulval part is shortened (to 1,5 — 2 cm and less), the channel of a neck of uterus becomes straight, smoothly passing it into the area of an internal pharynx, diameter makes 2 — 2,5 cm; through the arches it is possible to palpate seams, fontanels or other episemes of the prelying part of a fruit; the neck is located strictly on a wire axis of a basin, the outside pharynx is defined at the level of ischiums. Degree of a maturity of a neck of uterus is connected generally with reorganization at molecular level of its collagenic fibers and the main substance (concentration of hydroxyproline increases in protein fraction from 17,2 conditional units in 16 weeks of pregnancy to 58,8 in 40 weeks of pregnancy). If by the end of pregnancy the neck of uterus remains insufficiently mature, then it is not necessary to expect the spontaneous beginning of childbirth in the nearest future. During «maturing» of a neck of uterus at the end of pregnancy there is a change of function of glands of its channel that is shown by increase in amount of the separated slime, increase of its transparency, emergence of a symptom of crystallization, increase in contents in it crude protein.
At the beginning of the period of disclosure of a neck of uterus from it the mucous secret (a mucous stopper) is forced out that is followed by insignificant bloody allocations because of superficial anguishes of edges of a pharynx. In an epithelium of a neck of uterus hyperreactivity basal and proliferation of reserve cells is observed. Similar processes are observed in a mucous membrane of the channel of a neck of uterus.
Vagina (see). By the end of pregnancy rather well vaskulyari-zirovano, elastic fabric it expands thanks to what it becomes very extensible. The cytology of a vulval smear before R. is characterized by existence of the intermediate cells lying separately and emergence of superficial.
The uterus during pregnancy stretches and breaks off elastic fibers in deep layers of skin that leads to formation of so-called strips of pregnant (striae gravidarum). The divarication of recti is sometimes formed. The navel by the end of pregnancy becomes level with skin, «smoothes out», and on the 10th month of pregnancy acts over it.
Changes in other systems and bodies. Before R. the amount of extracellular liquid increases up to 5 l, at the same time a part passes it into vessels. It is explained by increase (at the end of pregnancy) concentration of estrogen in blood and the increased accumulation of liquid at the expense of a depolymerization of polysaccharides of the main substance of interstitial fabric that causes «loosening» of fabrics of patrimonial ways and promotes advance of a fruit. By the end of pregnancy increase in volume of plasma and quantity of erythrocytes reaches a maximum. Physiological expediency of this hypervolemia is defined by need of filling of sharply increased vascular system of a uterus and promotes the prevention of possible adverse influences on mother and a fruit at disturbance of venous return and reduction of cordial emission. Besides, it compensates the subsequent blood loss in the River. The maximum increase in volume of blood by the beginning of childbirth makes 35 — 40% (more than 1 l), and the volume of plasma increases for 30 — 50%, and erythrocyte volume — on average for 15 — 20% from initial (up to pregnancy). Gematokritny number (see) decreases on average to 36,5% due to increase in volume of plasma. Concentration of erythrocytes decreases (to 4 — 3,5 million in 1 mkl) shch but the lump of the circulating erythrocytes increases for 20 — 30%. It leads to exhaustion of reserves of iron (to 70 — 60 mkg on 100 ml of blood serum) at mother and to the strengthened products of cells of marrow. Concentration of hemoglobin falls, but total quantity of hemoglobin increases. The quantity of leukocytes in blood before R. makes apprx. 8 — 10 thousand in 1 m of C.
Concentration of albumine of blood serum by the end of pregnancy decreases, alpha globulin and gamma-globulin remains without changes, and beta globulin increases. The volume of heart increases by 10%, cordial emission increases by the end of pregnancy for 30 — 50%, on an ECG left axis deviation is noted (due to change in position of heart or a hypertrophy of a left ventricle). Peripheric resistance of a vascular bed before R. increases. The ABP usually does not exceed datum level. By the end of pregnancy the phenomena of venous stagnation amplify, varicose veins are overflowed, especially standing, in generative organs and in an anus. Sometimes in position of the pregnant woman lying on spin there is hypotension, the cut is a proximate cause a prelum of an aorta and the lower vena cava a pregnant uterus. For its warning and treatment to the woman recommend to lie on one side. Pulse rate by the end of pregnancy usually increases.
At the end of pregnancy becomes more active coagulant system of blood (see) due to strengthening of a number of coagulative factors. The maintenance of factors of VII, VIII, IX, X and XII increases, also the level of a factor of I (fibrinogen) and II (prothrombin) increases, i.e. the condition of the increased coagulability is observed. The maintenance of a factor of V does not change, and XI and XIII — decreases. Prothrombin time (see) fibrinolitic activity decreases slightly, as well as. Immunol. reactivity of an organism by the end of pregnancy decreases, causing the lowered resistance of pregnant women to an infection.
At the end of pregnancy the diaphragm is pushed aside by a pregnant uterus up. Sensitization of a respiratory center of the pregnant woman to carbon dioxide leads to the expressed hyperventilation and a hypocapny; according to V. A. Lopatin, the minute volume of breath increases by 1,5 times. Increase in minute volume of breath is reached due to increase in respiratory volume (the average size of respiratory volume at pregnant women makes 689 ±34мл) that promotes more effective alveolar ventilation. Functional residual capacity of lungs (see. Vital capacity of lungs) by the end of pregnancy decreases by 17 — 25% (at the expense of the reserve volume of an exhalation and residual lung volume). Elasticity of lungs does not change, but pulmonary resistance decreases, and conductivity of air ways increases. Emergence of an asthma is possible (see), edges it is connected with a hyperventilation.
By the end of pregnancy the most expressed expansion of ureters (due to increase in level of progesterone), increase in their bends near a uterus (at the expense of a prelum a uterus or an ovarian vein), and also expansion of one or both renal pelvis is observed that contributes to development pyelonephritis (see). Speeded up urination (see) explain with pressure upon a bladder of the prelying part of a fruit and the accompanying hyperemia of a mucous membrane of a bladder. Speed of glomerular filtering of N a renal blood stream increase by 30 — 50%, and the content of creatinine of plasma and an urea nitrogen decreases (to 0,5 and 9 mg / 100 ml respectively). The clearance of creatinine increases from 100 to 150 ml! min. Reabsorbtspya of various ions, especially sodium, increases.
R.'s harbingers — a number of the clinical signs preceding R.'s beginning and appearing for several days or hours before childbirth. Treat them: «omission of a stomach» of the pregnant woman due to insertion of a head in an entrance of a small pelvis and a deviation of an uterine fundus of a kpereda due to nek-ry decrease in a tone of a prelum abdominale (it is observed for 2 — 3 weeks before childbirth); pregnancies of feeling of the woman, unusual to the last months — increase in excitability or, on the contrary, a condition of apathy, «inflows» to the head that is explained by changes in central and the autonomic nervous system before R. (are observed some days before R.); decline of body weight of the pregnant woman by 1 — 2 kg (in 2 — 3 days prior to childbirth); increase in excitability of uterine muscles; decrease in a physical activity of a fruit; allocation from a genital tract of dense viscous slime (a so-called mucous stopper).
The REASONS of APPROACH of CHILDBIRTH
For an explanation of origins of R. a large number of theories, the majority from was offered to-rykh are of only historical interest. Also others concern them such as theory of «foreign body», immunoanaphylactic.
Now the childbed is considered as difficult mnogozvenyevy the process arising and which is coming to the end as a result of interaction of many systems of an organism. The most essential role in R.'s emergence belongs to it-rogumoralnoy and hormonal to systems of an organism of mother, and also a fetoplacental complex. By R.'s beginning at the woman dominance of brake processes in a cerebral cortex, increase in excitability of subcrustal structures and a spinal cord is observed. It leads to strengthening of spinal reflexes, to increase in reflex and muscular irritability of a uterus. Studying of a condition of nerve centers and their reaction to various intero-and eksterotseitiviy irritants throughout pregnancy and before R. by means of an electroencephalography (see) shows that by the end of pregnancy interoceptive influences from bodies of the sexual sphere on bioelectric activity of a cerebral cortex amplify; there is a braking of exteroceptive irritations (e.g., light, sound). On this background the interoceptive influences proceeding from a fruit become superthreshold and reflex can promote the beginning and development of a childbed.
Relationship of estrogen and progesterone are of great importance for R.'s approach. While in an organism of the pregnant woman exists and physiological balance between them is maintained, sokratitelny activity of a uterus is not observed. By the end of normal duration of gestation this balance is broken due to sharp growth of one of fractions of estrogen (estriol) that leads to increase in excitability of a uterus, the termination of its free stretching, increase in intrauterine pressure and tension of a wall of a uterus.
The big role in development of patrimonial activity belongs to oxytocin (see), in a large number collecting in an organism before River.
The essential part in preparation for R. is assigned to a functional condition of a fetoplacental complex. Turnbull and Chard (A. Turnbull, T. Chard) point to a role in hormonal regulation of R. of pituitary and adrenal system of a fruit. Chard showed that vasopressin (see), allocated by a fruit, works as corticotropic hormone and carries out communication between hypothalamic neurohumoral system and system a hypophysis — adrenal glands of a fruit. According to its data, allocation vazopress Ina is followed by release a hypophysis of a fruit of oxytocin, action to-rogo similarly oxytocin of mother. The last excites alpha adrenoceptors of a uterus, increases excitability of cellular membranes, suppresses activity of cholinesterase, promoting accumulation of acetylcholine rendering, in turn, powerful action on reductions of a uterus and their regulation. Acetylcholine and Pituitrinum (see) mutually exponentiate action of each other. In an experiment on animals it is proved that these two substances taken in biologically inactive concentration at simultaneous introduction find exclusively powerful action on a uterus, and acetylcholine has bigger activity.
Along with oxytocin and acetylcholine the great value in sokratitelny activity of a uterus is attached to serotonin, a histamine, kinin system, prostaglandins (E of E2, Fla, F2a). F2a prostaglandin is the highly specific connection causing strengthening of reduction of a myometrium and stimulating release of oxytocin with a back share of a hypophysis. Serotonin provides permeability of cellular membranes for Sa2+, to-ry activates fermental systems that is necessary for reduction of a muscle cell. Estrogen, serotonin and catecholamines change a ratio of the adrenergic components strengthening function and - receptors of nervous structures, and facilitate release of progesterone from communication with protein of cells of a uterus. It promotes increase in excitability and contractility of muscular elements of a uterus.
Under the influence of neurohumoral changes before R. in a uterus activity and - adrenore-tseptorov, sensitive to acetylcholine, serotonin and a histamine prevails. Essential changes happen also in muscle cells of a myometrium: membrane potential of cells decreases, their excitability increases, spontaneous activity amplifies, sensitivity to kontraktilny substances increases. In myometriums the power substances providing sokratitelny activity of a uterus collect: glycogen, phosphocreatinine, glutathione. At decrease in membrane potential all cells of a myometrium can generate excitement. However, according to most of researchers, in a uterus there is a group of cells, in to-rykh initially there is an excitement extending in the subsequent to all uterus; believe that this so-called pacemaker is located in an uterine fundus, is closer to the right corner. All complex of the neurohumoral and endocrine changes happening in an organism of the pregnant woman and also in a uterus before R., makes a so-called patrimonial dominant. In the conditions of a patrimonial dominant the big role in approach of patrimonial activity belongs to an afferent impulsation from a fruit through receptors of a uterus on hypogastric and to pelvic nerves in projective zones of a cerebral cortex. Rubles proceed at the joint function of the highest nerve centers and executive bodies. When excitability of a uterus and power of irritations reach a certain limit, there is a patrimonial activity. In total many reasons defining R.'s approach, the leading role belongs to reflex acts. All complex processes defining approach and the correct current of R. are regulated by a nervous system. The neurohumoral factors defining R.'s emergence promote their correct current. E.g., each reduction of a uterus is followed by irritation of its nervous elements, nerve terminations at the same time allocate acetylcholine and sympathies, to-rye promote new reduction of a uterus. Similarly there is a rhythmic increase of content in blood of oxytocin. The oxytocin (just as acetylcholine and sympathies) which came to blood and caused reduction of a uterus quickly collapses enzymes (an oxytocinase, a pitocinase). However new portions of oxytocin and acetylcholine, defiant new reductions of a uterus come to blood. Similar processes happen until the end of childbirth. In the course of R. frequency of uterine reductions to a great extent is defined by frequency of allocation of oxytocin and acetylcholine.
The CLINICAL COURSE of NORMAL CHILDBIRTH
R.'s Duration at primapara makes 15 — 20 hours, at multipara — 10 — 12 hour. In a wedge, normal R.' current allocate three periods: The I period — disclosure of a neck of uterus (at primapara 13 — 18 hours, at multipara — 10 — 11 hours proceed); The II period — an expulsion of the fetus (1 — 2 hour and of 30 min. till 1 o'clock respectively); The III period — afterbirth (as a rule, up to 30 min. at that and others).
Period of disclosure of a neck of uterus begins with emergence of regular uterine reductions (pains) and comes to an end with full disclosure of an outside pharynx of a neck of uterus. Pains at first happen short, weak and rare (in 15 — 20 min.). In the subsequent their duration, force and frequency increases.
During the pains intrauterine pressure increases to 80 — 250 mm of mercury. Pains usually cause pain in the bottom of a stomach and in a sacrum, and degree of morbidity is individual.
During the pains there is a reduction of muscle fibers of a uterus (counteraction), shift of muscle fibers relatively each other (retraction), stretching of muscle fibers (distraction). In a body of the womb to the located muscle fibers prevailing longwise generally there is a counteraction; in the lower segment of a uterus (a neck and an isthmus) where the most part of fibers is located tsirkulyatorno — distraction. Despite dominance of processes of stretching in the lower segment of a uterus, its reduction also is a necessary condition of River. Thanks to retraction muscle fibers after the fight do not revert to the original state therefore the reduced body of the womb stretches and tightens muscles of a neck aside and up. Registration of reductions of various departments of a uterus by means of a multichannel gisterograf (see) showed that the wave of reductions of a uterus extends from top to down, from one horn to another, then passes to a body, and further takes the lower segment with the decreasing duration and intensity. This phenomenon received the name of the triple descending gradient. Reductions of a uterus at the same time begin not at the same time, but the maximum reduction of uterine muscles happens at normal patrimonial activity at the same time in different departments of a uterus. It is confirmed by the fact that tops of all gisterogramm and records of intraamnionalny pressure match. Thanks to retraction the body of the womb becomes shorter, its walls are thickened, intrauterine pressure increases. To each fight there is a shortening and expansion of the channel of a neck of uterus (disclosure of a neck). Disclosure of a neck of uterus is promoted also by a bag of waters (see. Fetal membranes). During the fight pressure of amniotic waters increases and the lower pole of a bag of waters is displaced towards an internal pharynx where he meets a smaller obstacle and thanks to it stretches a neck of uterus. As a result the neck of uterus smoothes out, its channel together with an outside pharynx turns into the stretched tube, through to-ruyu perhaps passing of a head and a trunk of a fruit.
Thus, in the mechanism of disclosure of a neck of uterus action of two forces directed opposite matters: an inclination from below up due to reduction and retraction of longitudinal muscles of a body of the womb and down pressure at the expense of a bag of waters. The basic at the same time is action of uterine muscles. In process of disclosure of a neck of uterus the border between a body of the womb and its isthmus (the contraction, or boundary, a ring) rises up. Height of standing of the contraction ring over a pubic joint (a pubic symphysis) correlates with extent of disclosure of a neck of uterus: the more the neck of uterus reveals, the contraction ring over a pubic joint is located above (see below Conducting childbirth).
Disclosure of a neck of uterus happens unequally at primapara and multipara. At primapara the internal pharynx reveals in the beginning, the neck becomes thin (smoothes out), and then the outside pharynx (fig. 1) reveals. At multipara the outside pharynx reveals almost along with internal and at this time there is a shortening of a neck of uterus (fig. 2). Disclosure of a neck of uterus is considered full when the pharynx extends on And — 12 cm. Along with disclosure of a neck of uterus in the first period advance of the prelying part of a fruit through a parturient canal, as a rule, begins. The head of a fruit begins to fall to a pelvic cavity from the beginning of pains, being by the time of full disclosure most often either in wide, or in a narrow part of a cavity of a small pelvis.
At head presentation in process of advance of a head of a fruit there is a division of amniotic waters (see) on two parts since the head presses a wall of the lower segment of a uterus to a bone basis of a parturient canal. The place of coverage of a head walls of the lower segment is called an internal belt of a prileganiye, or contact (fig. 3), to-ry divides amniotic waters on the lobbies which are below a belt of contact and back — belts of contact are higher. The bag of waters loses the physiological function by the time of full disclosure of a neck of uterus. Distinguish a flat bubble when it does not form camber, and fetal membranes cover a head of a fruit; cylindrical when he considerably acts from a neck of uterus; pear-shaped, acting in a vagina at incomplete disclosure of a neck of uterus. Flat and pear-shaped bags of waters can detain the course of childbirth.
After full or almost full disclosure of a neck of uterus the cover of a bag of waters under the influence of the increased intrauterine pressure is broken off and front waters stream (timely izlity amniotic waters). If the rupture of fetal membranes occurs prior to patrimonial activity, then tell about premature, or prenatal, izlitiya of amniotic waters (see. Premature bursting of waters ); if waters stream after R.'s beginning, but before full opening of a neck of uterus — izlity waters early. At the excessive density of covers the bag of waters is broken off after approach of full disclosure of a neck of uterus (an overdue rupture of a bag of waters). Occasionally covers of a bag of waters are not broken off and the fruit is born covered with fetal membranes (the birth «in a shirt»). The «double» rupture of fetal membranes is sometimes observed: the bubble is torn not on the lower pole, about an outside pharynx, and above («a high gap»). In such cases at the entered and moving ahead head the opening in a bag of waters is closed and in a further current of R. at vaginal examonation find the straining bag of waters. After an izlitiya of amniotic waters of a fight on a nek-swarm time stop or weaken, and then again become strong.
Period of exile. During this period there is an expulsion of the fetus from a uterus at the expense of attempts — simultaneous rhythmical reduction of muscles of a uterus and a prelum abdominale.
Intensity of reduction of a uterus in I and in the II period of R. is not identical. In the II period of childbirth decrease in intensity of reductions of a uterus is observed a nek-swarm, but the joining reductions of a prelum abdominale promote continuation of River. During attempts the breath is held, the diaphragm falls, muscles of a stomach strain, intra belly pressure increases. Attempts arise reflex, at the expense of irritation presakralyyugo neuroplex the prelying part of a fruit.
Under the influence of attempts the fruit moves ahead but to a parturient canal according to the direction it an axis, making the rotary, flexion and extensive motions and overcoming resistance of the reduced muscles of a pelvic bottom and vulvar ring. From the moment of approach of a head of a fruit to an exit in a basin the crotch of the woman in labor begins to be stuck out, only during attempts in the beginning, and afterwards and in pauses between them. Protrusion of a crotch is followed by expansion and a gaping of an anal orifice. At further progress of a head of a fruit the sexual crack begins to reveal. During an attempt from the revealing sexual crack the small site of a head is shown, edges out of attempts disappears again, the sexual crack is closed. There are vrezyvany heads (fig. 4, a). With further development of potuzhny activity vrezyvayushchayasya the head acts more and more forward and any more does not disappear after the termination of an attempt, the sexual crack is not closed, and widely gapes. If the head does not disappear after the termination of attempts, speak about disengagement (fig. 4, b).
At occipital presentation the occipital area of a head of a fruit is cut through in the beginning, further from a sexual crack parietal hillocks are shown, tension of a crotch reaches the highest limit at this time. After the birth of a nape and a darkness at strong attempts from patrimonial ways the forehead and a face of a fruit are released.
The been born head is turned by a face of a kzada (fig. 4, c); the face becomes blue, from a nose and a mouth slime is emitted. At the attempts which renewed after the birth of a head there is a turn of a trunk of a fruit, as a result to-rogo one plechiko another addresses a pubic joint — a sacrum. The turn of a trunk of a fruit causes rotation of the been born head; at the first position the face yovorachivatsya to the right hip of mother (fig. 4, d), at the second — to left.
The birth of a coat hanger occurs as follows: front plechiko (plechiko, turned to a pubic joint) is late under a pubic joint and then is born (fig. 4, e), over a crotch it is rolled out back plechiko — plechiko, turned to a crotch (fig. 4, e), and then all shoulder girdle is born. After the birth of a head and a shoulder girdle without difficulties the trunk and legs of a fruit are born. Rather turbid back waters containing particles of syrovidny lubricant of a fruit, sometimes impurity of blood from small ruptures of soft tissues of patrimonial ways follow.
Afterbirth period begins after the birth of a fruit. At the same time there is separation of a placenta from a uterus and the birth of an afterbirth as a result of pains and attempts (see. Afterbirth period ).
The MECHANISM of CHILDBIRTH
in the course of R. during the passing via the bone channel (small pelvis) and soft tissues of patrimonial ways of the woman in labor a fruit makes set of movements, to-rye are called the mechanism of childbirth. The movements of a fruit in the course of R. are defined by a form of a parturient canal; sizes and form of a fruit, mobility of his backbone; patrimonial activity — the expelling forces.
The parturient canal is formed by bones of a small pelvis and soft tissues. The bone basis of a parturient canal in the course of R. does not change space relationship whereas soft tissues (the developed lower segment of a uterus and a vagina, and also a fascia and the muscles covering an inner surface of a small pelvis, muscle of a pelvic bottom, crotches) stretch, show resistance to the born fruit and take active part in the mechanism P. The bone basis of a parturient canal thanks to a sacral hollow has not an identical configuration in various departments (see. Taz ).
The natural movements of a fruit are made always strictly in the direction of a wire axis of a basin. At extraction of a fruit the doctor shall follow the same direction. A wire axis of a basin — the line connecting the middle of all direct sizes of a basin (fig. 5). Due to the curvature of a sacrum and availability of powerful layer of muscles of a pelvic bottom and a crotch the wire axis of a basin reminds a form of a fishing hook (according to A. P. Gubarev) or a parabola (according to M. S. Malinovsky).
In addition to a wire axis of a basin, distinguish an axis of a pelvic strait — the straight line which is conditionally carried out through the middle of an entrance to a basin perpendicularly to its plane. Continued caudally, it shall cross a tailbone, and kranialno — to reach a navel. The wire axis of a basin only to the middle of a pelvic cavity matches the direction of an axis of a pelvic strait. If to imagine a pelvic cavity as the cylinder which slantwise is cut off from top to bottom and kpered, then a head of a fruit the greatest circle shall pass through a number of its planes, to-rye H. L. Hodge called the parallel planes. Such planes four (fig. 6). The plane passing through the terminal line call terminal; passing through bottom edge of a pubic joint — main, or nizhnelonny; passing through sciatic hillocks — spinal and through a tailbone — day off.
The fruit also takes part in the mechanism P. Under the influence of patrimonial forces there is a peculiar formation of a fruit: the backbone is unbent, the crossed handles nestle on a trunk more densely, a coat hanger rises to a head and an upper part of a fruit gets a cylindrical form that promotes its exile from a cavity of the uterus. During the passing of a parturient canal (at the longitudinal provision of a fruit) the sizes of a head of a fruit have the greatest value. Bones of a skull of a fruit are connected by seams and fontanels that allows bones to be displaced from each other and to change a configuration of a head. Such plasticity allows a head of a fruit to adapt to a form and the sizes of a parturient canal. In the course of R. mobility of a backbone of a fruit matters. Its cervical department is easily bent kpered, hardly to the right and to the left. The chest department, as well as lumbar, is more bent in the parties less forward and back.
The mechanism P. is defined by option of presentation. At head presentation distinguish flexion type (a front and rear view of occipital presentation) and extensive type (perednegolovny, frontal, front presentation). The look predle-zhanpya is defined by the largest size of a head (a big segment), the Crimea the head passes all planes of a basin. The wire point is on the prelying part, edges of the first falls to an entrance of a basin, is ahead during internal version, follows strictly in the direction of a wire axis of a parturient canal and is shown to the first from a sexual crack.
Each movement of a fruit can be referred to the following planes of a basin: entrance to a basin, wide and narrow part of a cavity of a small pelvis, exit of a basin.
In literature there are numerous theories explaining flexion and rotary motions of a fruit in the course of R. to-rye are of only historical interest. Now consider that in the mechanism P. are of great importance as physical (space relationship of a fruit and parturient canal), and biological factors: force of intrauterine pressure and muscular resistance of separate parts of a fruit. The considerable role in the mechanism P. belongs to muscles of a pelvic bottom. As a result of interaction of all specified factors the separate moments of the mechanism P. can be explained as follows. The head which is slightly bent prior to the beginning of the II period of R. is bent under the influence of the expelling forces under the law of the uneven dvuplechny lever. The turn is promoted by a variety of reasons: adaptation of a head to the largest sizes of the different planes of a basin, a structure of a pelvic bottom and reduction of his muscles, turn of a trunk a back of a kpereda, reflex movements of a fruit. Extension of a head is made under the influence of two opposite forces — the expelling patrimonial forces and counteraction of muscles of a crotch, reductions to-rykh direct a head of a kpereda. The internal version of a trunk (coat hanger) occurring under the influence of the expelling forces promotes external version of a head.
Options of flexion type of the mechanism of childbirth
Occipital presentation (a front and rear view) is characteristic of normal childbirth.
The mechanism of childbirth at a front type of occipital presentation. The head is established in the plane of an entrance to a basin so that the arrow-shaped seam is located in cross, in one of slanting or in slightly slanting size. On the relation of an arrow-shaped seam to a pubic joint and the cape (promontorium) distinguish axial (sinklitichesky) and off-axis (asynclitic) insertions of a head. At einklitichesky insertion the vertical axis of a head costs perpendicularly to the plane of an entrance to a small pelvis, and the arrow-shaped seam is located at identical distance from a pubic joint to the cape. At asynclitic insertion the vertical axis of a head of a fruit costs to the plane of an entrance to a basin not strictly perpendicularly, and the arrow-shaped seam is located closer to the cape — a front asynclitism (the parietal bone turned kpered is implanted) or is closer to a pubic joint — a back asynclitism (the parietal bone turned kzad is implanted). At normal R. either sinkli-tichesky insertion of a head, or small front asinkli-tpzm is observed.
Distinguish four moments of the mechanism P. The first moment — bending of a head (flexio capitis), i.e. its rotation around a lateral (frontal) axis. The arrow-shaped seam is located in a cross or slightly slanting size of a basin. Under the influence of intrauterine and intra belly pressure the nape of a fruit falls, the chin approaches a thorax, the small fontanel is located below big and is a wire point (fig. 7, a).
The second moment — internal version of a head (rotatio capitis interna). The head of a fruit makes progress forward (falls) and at the same time turns around a longitudinal axis. In a pelvic cavity the arrow-shaped seam passes into one of the slanting sizes, and in an exit of a basin — in a straight line. On it the turn of a head comes to an end, the small fontanel is turned to a pubic joint (fig. 7, b).
The third moment — extension of a head (extensio, deflexio capitis) occurs after the head area of a suboccipital pole approaches under a pubic arch (fig. 7, c). A point of support, around a cut at eruption there is a rotation of a head, call a point of fixing (punctum fixum) or gipomokhliony. For a front type of occipital presentation such point is the area of a suboccipital pole. In the course of extension of a head from a sexual crack consistently there are a parietal area, a forehead, the person and a chin, i.e. all head is born.
The fourth moment — internal version of a trunk and external version of a head (rotatio trunci interna seu rotatio capitis externa). The head after the birth turns to right (fig. 7, d) or to the left hip of mother. A coat hanger the cross sectional dimension enters the cross slightly slanting size of a basin of a pla, in a pelvic cavity their turn begins and they pass into the slanting size, and in an exit of a basin are established in a direct size — one plechiko — to a pubic joint, another — to a sacrum. Then the shoulder girdle in the following sequence is born: at first top
a ny third of the plechik turned kpered, and then due to side bending of a backbone — plechiko, turned kzad. Further all trunk of a fruit is born. All moments of the mechanism P. are made at progress of a head of a fruit and strict differentiation between them is not present.
The mechanism of childbirth at a rear view of occipital presentation. The first moment — bending of a head. In an entrance to a basin a wire point — a small fontanel. In a pelvic cavity the area between a small and big fontanel (fig. 8, a) becomes a wire point. The second moment — internal version of a head, to-ry can doubly occur. Or the small fontanel turns kzad, to a sacrum, a big fontanel — to a pubic joint (fig. 8, b); or the head makes turn on 135 ° and the small fontanel passes kpered and thus the rear view of occipital presentation passes into the mechanism P. front further does not differ from that at a front type of occipital presentation. The third moment — during eruption occurs additional bending of a head. The border of a pilar part of a forehead rests against a pubic arch and around it (the first point of fixing), the head is strongly bent (fig. 8, c); during this additional bending of a head parietal hillocks and an occipital hillock are cut through. The fourth moment — extension of a head (fig. 8, d): the head rests area of a suboccipital pole (the second point of fixing) against a sacrococcygeal joint and makes extension, in time to-rogo from under a pubic arch the forehead, a face, a chin are released. The fifth moment (external version of a head and internal version of a coat hanger) occurs the same as at a front type of occipital presentation.
Childbirth at a rear view of occipital presentation longer, than at a front look.
Options of extensive type of the mechanism of childbirth
concern To them anomaly of insertion of a head: perednegolovny, frontal and front. Are the reasons of extensive head presentations: decrease in a tone and in-coordinate reductions of a uterus, narrow basin (especially flat), decrease in a tone of muscles of a pelvic bottom, small or, on the contrary, excessively big sizes of a fruit, weak prelum abdominale, laterposition of a uterus and seldom head, inborn tumor of a thyroid gland of a fruit, rigidity of an atlantozatylochny joint of cervical department of a backbone of a fruit.
The mechanism of childbirth at perednegolovny presentation. First moment: in an entrance to a basin the head is unbent and established in cross sectional dimension of a basin a little, a wire point is the big fontanel. The second moment — internal version of a head comes upon transition from a wide part of a pelvic cavity in narrow, at the same time the small fontanel addresses kzad, the arrow-shaped seam is established in a direct size. The third moment — bending of a head: at a vrezyvaniye of a head of the first of a sexual crack the area of a big fontanel is shown. After a vykhozh-deniye from under a pubic arch of a forehead and frontal hillocks the head is fixed by area of a bridge of the nose, bent and over a crotch parietal hillocks are born. The fourth moment — extension of a head. The nape is fixed in a crotch (the second point of fixing), at the same time the face and a chin are born. The fifth moment — internal version of a coat hanger, external version of a head and the birth of a trunk of a fruit occur as well as at a front type of occipital presentation.
The mechanism of childbirth at frontal presentation. Frontal presentation usually is transitional from perednegolovny to front. Very seldom, having fallen by a pelvic bottom, the head is cut through in frontal presentation. The head in an entrance to a basin is unbent, being located with a frontal seam in a cross or slightly slanting size (the first moment of childbirth). Falling to a pelvic cavity, the head at a pelvic bottom turns (the second moment of childbirth) a face of a kpereda, a nape — kzad. At a vrezyvaniye in a sexual crack the forehead, a root of a nose and a part of a darkness (fig. 9) are shown. Then two points of fixing are formed: the first — area of an upper jaw, at the same time a head is slightly bent and over a crotch the nape (the third moment of childbirth) is born; the second point of fixing — area of a nape is fixed over a crotch, at the same time there is an easy extension of a head and from under a pubic arch the bottom of the face and a chin (the fourth moment of childbirth) are born. Internal version of a coat hanger and external version of a head (the fifth moment of childbirth) occur as well as at a front type of occipital presentation.
The mechanism of childbirth at front presentation. The head of a fruit at front presentation is in a condition of the maximum extension (extensio, deflexio) and the nape is pressed kzad. The concept about a position and a look at front presentation is considered by obstetricians differently. V. S. Gruzdev, H. N. Fenomenov, M. S. Malinovsky, V. I. Bodyazhina and R.H. Zhmakin the type of presentation is determined by a chin: if it is turned kpered, it is a front look if kzad — back. G. G. Genter, I. F. Zhordaniya determine a position of a fruit by a back: at the first position the back of a fruit is turned to the left side of a uterus, at the second — to right.
The head enters an entrance to a basin the front line — the line going from a frontal seam on the ridge of the nose to a chin (fig. 10, a) which is in cross or slightly slanting size and thus reaches to the bottom a basin, on Krom there is a turn her chin of a kpereda (a wire point). At eruption through a vulvar ring there is a bending of a head. A point of fixing is the area of a hypoglossal bone (fig. 10, b). At the same time from a sexual crack the forehead, a cinciput, a nape are born. Internal version of a coat hanger and external version of a head occur as well as at a front type of occipital presentation. If in the course of R. the nape turns kpered (to a pubic joint) (fig. 11), then R. are impossible.
At extensive head presentations also other anomalies of insertion of a head are possible: high direct standing, low (deep) cross standing of a head, asynclitic insertions (the mechanism P. at the listed anomalies — see. Narrow basin).
Each of the listed versions of the mechanism of childbirth (flexion and extensive types) is followed by a typical configuration of a head — change of its form at the expense of the shift of bones of a calvaria. Change of a form of a head is promoted also by a patrimonial tumor (see Caput succedaneum). The dolichocephalic form of a head extended in the direction of a nape is characteristic of occipital presentation (fig. 12, a). At perednegolovny presentation the head has the brachycephalic form, is extended towards a darkness (fig. 12, b). At frontal presentation the head is extended towards a forehead where also the patrimonial tumor is located (fig. 12. в). At front presentation the expressed puffiness of lips, cheeks, a nose is observed. At a narrow basin formation of a cephalhematoma is possible (see).
The mechanism of breech labors — see. Pelvic presentations .
CONDUCTING NORMAL CHILDBIRTH
In the USSR the wide network of obstetrical institutions is created (see. Obstetric aid ). At receipt in a hospital the woman in labor passes through the filter then it is directed in normal or observation (the II obstetric) department. The basis for the placement of the woman in labor to observation department is detection of symptoms of an infectious or venereal disease, temperature increase, identification of a dead fruit. At nek-ry infectious diseases (scarlet fever, an ugly face, a viral hepatitis) the woman in labor is sent to the relevant department of infectious diseases hospital where for R.'s carrying out direct the midwife and in case of need — the doctor of the obstetrician-gynecologist.
From the filter the woman in labor passes into the viewing room where conduct an obstetric research (see), a research of urine to protein, and if necessary — an integrated analysis of urine and blood. After a cleansing enema the woman in labor passes cleansing (sbriva-ny a hair from external genitals, washing by their disinfecting solution, a shower), changes clothes in pure, sterile linen is desirable. All data of the anamnesis and research of the woman in labor bring in history of childbirth. Then it is transferred in prenatal (during the I period of R.) or to patrimonial chamber (during the II period of R.). The established diagnosis is stated in the following order: duration of gestation (see); option of presentation, position, look; R.'s period; complications of pregnancy, childbirth; ekstragenigalny diseases (if they are available). After establishment of the diagnosis the plan of maintaining R. taking into account option of presentation, a position of a fruit etc. is drawn up.
The provision of a head in relation to the planes of a basin can be determined by way of outside and vulval researches (see. Obstetric research). Distinguish the following provisions of a head: over an entrance to a basin, a small or big segment in an entrance to a basin. in a wide or narrow part of a cavity of a small pelvis, in an exit of a basin. The head which is located over an entrance to a basin is mobile (fig. 13, a), freely moves at pushes (ballots) or is pressed to an entrance to a small pelvis. At vaginal examonation the head costs highly, it does not interfere with palpation of anonymous lines of a basin, the cape (if it is achievable), an inner surface of a sacrum and a pubic joint.
The head in an entrance to a small pelvis a small segment (fig. 13, b) is not mobile, its most part is over an entrance to a basin, a small segment of a head — the planes of an entrance to a basin are lower. At use of the fourth reception of an outside obstetric research the ends of fingers meet, and the bases of palms disperse (see. Obstetric research). At vaginal examonation the sacral hollow is free, it is possible to approach the cape the bent finger (if the cape is achievable). The inner surface of a pubic joint is available to a research.
The head a big segment in an entrance to a basin (fig. 13, c) means that the plane passing through a big segment of a head matches the plane of an entrance to a basin. At the outside obstetric research conducted by the fourth reception, palms are located or in parallel, or the ends of fingers disperse. At vaginal examonation it is found out that the head covers an upper third of a pubic joint and a sacrum, the cape is unattainable, sciatic hillocks are easily probed.
If the head is located in a wide part of a cavity of a small pelvis (fig. 13, d), then the plane passing through a big segment of a head matches the plane of a wide part of a basin. At an outside obstetric research (the third reception) over an entrance to a basin it is possible to probe a small part of a head. At vaginal examonation define that the head the greatest circle is in the plane of a wide part of a pelvic cavity, two thirds of an inner surface of a pubic joint and an upper half of a sacral hollow are busy with a head. IV and V sacral vertebrae and sciatic hillocks are freely probed.
If the head is located in a narrow part of a small pelvis (fig. 13, e), then the plane of a big segment of a head matches the plane of a narrow part of a basin. The head over an entrance is not probed. At vaginal examonation it is found out that two upper thirds of a sacral hollow and all inner surface of a pubic joint are blocked by a head of a fruit; sciatic hillocks are reached hardly.
The head in an exit of a basin (fig. 13, e) — the plane of a big segment of a head of a fruit is in an exit of a basin. The sacral hollow is completely filled with a head, sciatic hillocks are not defined.
For control of progress of a head during exile use method of Pnskache; the fingers of the right hand wrapped by a gauze press on fabric in the field of lateral edge of big vulvar lips prior to «meeting» with a head of a fruit. It is possible if the head of a fruit is in a cavity of a small pelvis. At a normal current of R. consecutive advance of a head in patrimonial ways is observed, it is not necessary is long in one plane of a basin. Long standing of a head indicates emergence of some obstacles to an expulsion of the fetus or weakening of patrimonial activity. Long standing of a head in one plane leads to a prelum of soft tissues of patrimonial ways and a bladder with disturbance in them of blood circulation and possible subsequent formation of fistulas.
Conducting childbirth in the I period
the Woman in labor is located in prenatal chamber. At the whole bag of waters, not really strong contractions or at the head of a fruit fixed to an entrance to a basin to the woman in labor allow to stand and go around a bed. It is better to lie on one side that prevents development of a syndrome of «a prelum of the lower vena cava». For R.'s acceleration to the woman in labor recommend to lie on that side where the nape of a fruit is defined. If the woman in labor lies on spin, then it is reasonable to give it the situation close to semi-sedentary since at the same time longitudinal axes of a fruit and a uterus match that favors to insertion of a head of a fruit in a small pelvis.
During disclosure of a neck of uterus careful overseeing by a condition of the woman in labor is necessary. Find out its health (degree of pain, fatigue, existence of dizziness, headache, visual disturbances, etc.), listen to cordial tones of the woman in labor, systematically investigate pulse and measure the ABP. Measurement of body temperature is performed 2 — 3 times a day (in case of need — more often). Food of the woman in labor shall be regular, easily assimilable, easy: tea, milk, liquid porridges, the wiped soups, kissels. Care of the woman in labor in the I period of R. consists in washing of external genitals in each 6 hours and, besides, after the act of defecation and before vaginal examonation. For this purpose apply or solution of potassium permanganate (1:8000) in boiled water, or solution of Furacilin. Before vaginal examonation external genitals are processed also 5% by spirit solution of iodine or it is better than Iodonatum. The woman in labor shall have the individual vessel which after each use is carefully disinfected.
In the first period of R. watch the nature of patrimonial activity, a condition of a uterus, disclosure of a neck of uterus, advance of a head and a condition of a fruit. Sokratitelny activity of a uterus (duration, force of pains, their frequency) can be defined palpatorno — the hand is put on a stomach of the woman in labor. It is possible to judge character of pains more objectively, registering sokratitelny activity of a uterus by means of an outside and internal gisterografiya, an elektrogisterogra-fiya, a reografiya (see) or radio telemetry (see Telemetry).
The multichannel outside gisterografiya allows to obtain information on sokratitelny activity of a uterus in its different departments. For more precision quantitative measurement of force of reductions of a uterus use an internal gisterografiya (topography) — determination of pressure in a cavity of the uterus by means of the strain gages entered into it. Intrauterine pressure indirectly, but rather precisely allows to estimate as intensity (or force) reductions of a uterus during the fight, and extent of relaxation of uterine muscles between pains.
For assessment of sokratitelny ability of a uterus use also methods of definition of its electric activity, in particular radio telemetry. For this purpose enter the tiny transistor transmitter into a cavity of the uterus, of 1,5 cm3, to-ry during 72 hours (operating time of a battery) it is capable to give continuous information on intrauterine pressure. Within three periods of childbirth these signals can be caught, transformed and registered in the form of curves on the recorder.
At all types of registration of sokratitelny activity of a uterus in I and in the II periods of R. on a curve the waves of a certain amplitude and duration corresponding to reductions of a uterus are registered; disturbances of sokratitelny activity of a uterus (weakness, excessive force, a diskoordination) are reflected in the registered curve.
The condition of a uterus in the course of R. is defined on the basis of its palpation (the uterus out of a fight shall be weakened and painless in all departments). Round ligaments of a uterus at physiological R. strain evenly on both sides. The contraction ring at physiological R. is defined in the form of poorly expressed cross going groove. On height of standing of the contraction ring over a pubic joint it is possible to judge approximately extent of disclosure of a neck of uterus (Schatz's sign — Unterberger). In process of disclosure of a neck of uterus the contraction ring is displaced above and above over a pubic joint: during the standing of a ring is two fingers higher than a pubic joint — the pharynx is open on 4 cm, during the standing on three fingers — the pharynx is open approximately on 6 cm; height of standing on four-nyat fingers over a pubic joint corresponds to full disclosure of a uterine pharynx. By outside methods of a research as it was stated above, it is possible to control the provision of a head of a fruit in relation to a parturient canal, i.e. to monitor its advance. R. given an outside research in the I period allow to suspect the wrong insertion of a head (frontal, front) and to establish the wrong provision of a fruit.
The rupture of a bag of waters and izli-ty amniotic waters — the responsible moment of R. also requires special attention. Impurity of meconium to amniotic waters usually indicates the beginning hypoxia of a fruit (see), impurity of blood — a rupture of edges of a pharynx, peeling of a placenta and others patol. processes.
Overseeing by heartbeat of a fruit during disclosure at nenaru-shennokhm a bag of waters is made every 15 — 20 min., and after an izlitiya of amniotic waters in 5 — 10 min. It is necessary to carry out not only auscultation, but also calculation of number of cordial reductions of a fruit. At auscultation pay attention to frequency, a rhythm and sonority of cordial tones. In the place of the best listening of heartbeat of a fruit it is possible to assume a position, presentation, polycarpous pregnancy (see), and also to suspect extensive option of presentation of a head of a fruit.
More and more the method of monitor observation is widely adopted (see) behind cordial activity of a fruit in the course of R. V the I period of R. at head presentation the cardiac rhythm of a fruit varies from 125 to 160 blows in 1 min., a rhythm correct with an amplitude of instant fluctuations from 5 to 10 blows of 1 min. Reaction of cordial activity of a fruit to a fight either is absent, or is shown by early urezheniye, to-rye begin from the beginning of a fight and on time match its duration.
At women in labor of group of the increased risk concerning development of a hypoxia of a fruit (the complicated course of pregnancy and childbirth) for assessment of its state use the Za-lpnga method: after disclosure of a neck of uterus on 4 cm and more and an izlitiya of amniotic waters from the prelying part of a fruit take blood for the research pH. pH higher than 7,25 is considered normal. At pH 7,25 — 7,20 the condition is estimated as the subkompensirovan-ny acidosis (see) demanding a repeated research; at pH lower than 7,20 — the decompensated acidosis testimonial of a hypoxia of a fruit.
Vaginal examonation in the I period of R. is made at the first inspection of the woman in labor, after an izlitiya of amniotic waters, at emergence of complications from mother or a fruit.
Before vaginal examonation examine external genitals (varicose nodes, hems, etc.) and crotches (height, old gaps, etc.). At vaginal examonation find out a condition of muscles of a pelvic bottom (elastic, flabby), vaginas (wide, narrow, existence of hems, partitions), necks of uterus. Note extent of smoothing of a neck it (is shortened, maleficiated) whether disclosure of a pharynx and extent of disclosure (in centimeters), a condition of edges of a pharynx (thick, thin, soft or rigid began), existence in limits of a pharynx of the site of placental fabric, a loop of an umbilical cord, small part of a fruit. At the whole bag of waters define degree of its tension during the fight and a pause. Its excessive tension even during a pause specifies on hydramnion (see), flattening — on oligoamnios (see), flabbiness — on weakness of patrimonial activity. Define the prelying part of a fruit and identification points on it. At head presentation define seams and fontanels and on their relation to the planes and the sizes of a basin judge a position (see the Fruit), insertion (sinklitichesky or asynclitic) whether there was a bending (the small fontanel is lower than big) or presentation extensive (perednegolovny, frontal, front). If recognition of identification points on the prelying part is complicated (a big patrimonial tumor, a strong configuration of a head, malformations) or presentation is not clear, make a research «semi-hand» (four fingers) or all hand greased with sterile vaseline.
At vaginal examonation, in addition to detection of identification points of a head, find out features of a bone basis of patrimonial ways.
Overflow of a bladder and rectum interferes with a normal current of the period of disclosure and exile, allocation of an afterbirth. Overflow of a bladder can arise in connection with its atony and lack of desires to an urination, and also in connection with pressing of an urethra to a pubic joint a head of a fruit. To avoid it, to the woman in labor each 2 — 3 hours suggest to urinate independently; if the independent urination is impossible, resort to catheterization. In those cases. when the period of disclosure of a neck of uterus proceeds more than 12 — 15 hours, give an enema cleansing. In the period of disclosure of a neck of uterus anesthesia is carried out (see. Labour pain relief ).
Conducting childbirth in the II period
the Second period of R. demands the big tension of physical forces of the woman in labor. The fruit suffers more often during this period of R. since there is a prelum of a head, intracranial pressure increases, at strong and long attempts uteroplacental blood circulation is broken. In this regard especially careful overseeing by the woman in labor and a fruit is required. Also careful overseeing by the nature of patrimonial activity (force, duration, frequency of attempts) and a condition of a uterus is necessary. At a palpation of a stomach define extent of reduction of a uterus and its relaxation out of pains, tension of round sheaves, height of standing of the contraction ring. Pay attention to a condition of the lower segment of a uterus — whether there is no its thinning and morbidity. On a parturient canal make repeated outside obstetric researches for clarification of advance of the prelying part of a fruit. Determine by the third and fourth reception of an outside obstetric research the relation of a head of a fruit to various planes of a small pelvis. At vaginal examonation specify the provision of a head of a fruit.
Pay attention to frequency, a rhythm and sonority of cordial tones of a fruit. In the II period of R. it is necessary to listen and consider cordial tones of a fruit after each attempt and at least each 10 — 15 min. The obtained data fix in the history of childbirth. Basal heart rate of a fruit (average heart rate in 10 min.) in the II period of R., according to objective observation, fluctuates from 110 to 170 (on average 110 — 130 blows in 1 min.). After attempts early urezheniye (to 80 blows in 1 min.) or short-term increase of heartbeat of a fruit, as a rule, are registered. Deviations of cordial reductions of a fruit from norm in all respects (basal heart rate, monotony of a rhythm, change of reaction to reduction of a uterus) testify to a hypoxia of a fruit (see Asphyxia of a fruit and the newborn).
During exile monitor advance of a head of a fruit, using the third and fourth receptions of an outside obstetric research, and also Piskachek's way — Gentera: at position of the woman in labor on spin fingers in gloves or wrapped by a sterile gauze aim through tissues of a crotch outside from the right big vulvar lips to reach the lower pole of a head. If the head is in a wide part of a cavity of a small pelvis or below, then it is achievable for a finger. It is necessary to consider that at a big patrimonial tumor the way does not yield reliable result.
Overseeing by a condition of external genitals and the nature of allocations from a vagina is of great importance. Emergence of hypostasis of external genitals indicates a prelum of soft tissues of patrimonial ways. Blood allocations can testify to the beginning placental detachment or to damage (a gap, a graze) of soft tissues of patrimonial ways. Impurity of meconium in amniotic waters at head presentation is a symptom of a hypoxia of a fruit.
Obstetrical institutions usually use the maternity bed designed by A. N. Rakhmanov. It differs from usual in what consists of two displaced half. Its foot end can be moved under head, at the same time the basin of the woman in labor is located on the edge of a bed (a so-called cross bed). It is also possible to change height of a bed-head of Rakhmanov. The mattress of a maternity bed consists too of two half of pillows-pol-sterov), sheathed by an oilcloth. At normal R.' maintaining a polster since the foot end of a bed delete. By the end of the period of exile the woman in labor lies on spin, legs are bent in hip and knee joints. The head end of a bed is raised, sublime position of an upper part of a trunk facilitates attempts and promotes easier passing of the prelying part of a fruit through a parturient canal. If R. are conducted not on a maternity bed, then under the head and shoulders of the woman in labor enclose an additional pillow. During attempts the woman in labor of a stupnyama (legs are bent in knee and hip joints) rests against a bed, hands holds special handles or edges of a bed or the beds of a towel tied to the foot end, to-rye pulls on herself during attempts. At strong attempts their use is not allowed.
External genitals and inner surfaces of hips wash disinfecting solution, drain and grease with solution of Iodonatum. The area of an anus is covered with a sterile diaper.
From the moment of a vrezyvaniye of a head of a fruit everything shall be ready to reception of River. During a vrezyvaniye of a head are limited to overseeing by a condition of the woman in labor, patrimonial activity and advance of a head. Explain to the woman in labor how she needs to behave during the rendering a grant, it is necessary to teach her to breathe, regulate correctly attempts by a doctor's advice (midwife), to lean legs, etc. At primapara the vrezyvaniye of a head proceeds 10 — 20 min.; at multipara — comes quicker. During disengagement start an obstetric grant — reception of River. The help is necessary since at eruption the head of a fruit puts the strong pressure upon a pelvic bottom and pererastyagivat it. At the same time the head of a fruit is exposed to a prelum from walls of a parturient canal. Can be a consequence of it at the woman in labor a gap crotches (see) and disturbance of cerebral circulation at a fruit. Therefore at the time of removal of a head the woman in labor shall not make an effort. It is possible to weaken attempts, having suggested the woman in labor to put hands on a breast both it is at the same time frequent and to breathe deeply.
The obstetric grant shall promote the natural course of River. For this purpose the accepting R. with observance of all rules of an asepsis from the moment of disengagement of a fruit the right hand carries out protection of a crotch, and left (at occipital presentation) premature extension of a head detains (fig. 14, a), the head at the same time passes a vulvar ring the smallest size.
In pauses between attempts fingers of the left hand of the doctor lie on a head of a fruit, and eliminate with the right hand stretching of fabrics in posterolateral departments of a vulvar ring, make a so-called «loan of fabrics». For this purpose the clitoris and small vulvar lips «lower» from the born nape: less stretched fabrics of front department of a vulvar ring reduce whenever possible kzad, towards a crotch, than eliminate its excess stretching. From the moment of the birth of a nape (the area of a suboccipital pole rests against bottom edge of a pubic joint) and until removal of all head to the woman in labor prohibit to make an effort, once again explaining sense of prohibition of attempts and need of implementation of all other recommendations. If there is a threat of a rupture of a crotch (blanching of skin, emergence of cracks), make a perineotomy or an epiziotomiya (see. Perineotomy ).
The been born head shall turn a face to the right or left hip of mother (depending on a position). If external version of a head is late, to the woman in labor suggest to be extinguished; during an attempt there is internal version of a coat hanger and external version of a head, a coat hanger rises in the direct size of a basin and is probed through a vulvar ring. At first promote the birth of an upper third of the plechik turned kpered (fig. 14, b), and then back (fig. 14, c). For this purpose carefully «cramp» a crotch from a back plechik. If independent eruption of a shoulder girdle is late, the head is taken both hands so that palms laid down on area of auricles (the ends of fingers shall not touch a neck of a fruit because of danger of squeezing of vessels and nerves). It is possible to remove back plechiko also the following reception: the head of a fruit is taken the left hand and taken away up, the right hand lowered from a plechik of tissue of crotch. If these receptions did not possible to remove a coat hanger, enter an index finger from a back into an axillary hollow of a front plechik, to the woman in labor suggest to make an effort and at this time sip for plechiko until it does not approach under a pubic arch. After that release back plechiko.
After the birth of a shoulder girdle carefully clasp with both hands a thorax of a fruit and direct a trunk up, at the same time the birth of the bottom of a trunk occurs without difficulties. If after the birth of a head around a neck of a fruit the loop of an umbilical cord is visible (see), it should be removed through a head; at impossibility to make it, especially if the umbilical cord stretches and constrains the movement of a fruit, it needs to be cut between two clips and to quickly take a trunk.
A. I. Petchenko and M. I. Gosteva recommend the following method of protection of a crotch: from the beginning of a vrezyvaniye of a head have the right hand with the bent fingers (the thumb is not taken away) on a crotch, previously having put on it sterile laying; the head of the child the left hand is not bent, and interfere with its bystry extension by the right hand, holding a parietofrontal part. Nek-ry obstetricians persistently recommend to carry out R. without protection of a crotch and without bending of a head. It, in their opinion, reduces traumatism of mother and especially a fruit. It is necessary to believe that at correctly carried out protection of a crotch during exile and timely, according to indications, the perineotomy of traumatizing a head shall not be.
Conducting childbirth in the III period — see. Afterbirth period .
CHILDBIRTH AT EXTENSIVE PRESENTATIONS OF THE HEAD
Childbirth at perednegolovny presentation. In an etiology of perednegolovny presentation the crucial role is played by a forkhma and the size of a basin, a condition of a pelvic bottom, and also size and a form of a head. Especially often this type of presentation is observed at the small sizes of a fruit and at a dead fruit. The contributing moments are the hydramnion, encirclement of an umbilical cord around a neck, presentation of the handle at a narrow basin. The diagnosis is based on data of vaginal examonation: fontanels are at one level or big below small. For diagnosis with success it is possible to use X-ray inspection. Childbirth happens in natural patrimonial ways, maintaining their waiting. If there are indications (a hypoxia of a fruit, rigidity of fabrics of a parturient canal) and a condition, then an operative measure — an application of forceps is admissible (see. Obstetric nippers) or use of a vacuum extractor (see Vacuum extraction). Protection of a crotch is conducted by the standard rules (see above). The indication to Cesarean section (see) is disproportion of the sizes of a basin of the woman in labor and a head of a fruit (see. Narrow basin).
Childbirth at frontal presentation. Frontal presentation meets as a transient state to front presentation more often. Emergence of frontal presentation is promoted by a narrow basin, inferiority of uterine muscles at many giving birth. Recognition of frontal presentation is based on data of vaginal examonation. Heartbeat of a fruit is better listened from a breast, on the one hand probe an acute ledge (chin), with another — define a corner between a back of a fruit and a nape. Rubles in frontal presentation are possible only at the small sizes of a fruit.
In other cases at establishment of frontal presentation if it in the next 2 hours does not pass in front or flexion, it is necessary to make Cesarean section.
Childbirth at front presentation. During R. a narrow basin, tumors of a neck of a fruit, repeated encirclement of an umbilical cord around a neck can be the reasons of the maximum extension of a head. Approximately it is possible to assume existence of front presentation at an outside obstetric research: the sizes of a head it is more, than at zaty-lochnokhm presentation. During the carrying out vaginal examonation and existence of a considerable face edema of a fruit there is a danger of establishment of the wrong diagnosis of buttock presentation. Differential diagnosis is based preferential on definition of bone fetations. At front presentation probe a chin, superciliary arches, an upper part of an eye-socket, at buttock — a tailbone, an aitcbone, sciatic hillocks. The research should be made very carefully not to damage an eyeglobe, a mucous membrane of an oral cavity.
If at vaginal examonation it is established that the chin is turned kzad, then spontaneous R. are impossible. At a live fruit it is necessary to make Cesarean section, and at the dead — perforation of a head (see the Craniotomy). If at front presentation the chin is turned kpered, childbirth proceeds independently.
Childbirth at high direct and low (deep) cross standings of a head, asynclitic insertions of a head — see. Narrow basin .
CHILDBIRTH AT CROSS AND SLANTING PROVISIONS of the FRUIT
At slanting situation the longitudinal axis of a fruit is crossed with a longitudinal axis of a uterus at an acute angle and one of large parts of a fruit is below a crest of an ileal bone. The cross provision of a fruit is characterized by the crossing of longitudinal axes of a fruit and a uterus at an angle coming to 90 °, at the same time large parts of a fruit are located above a crest of an ileal bone.
The cross or slanting provision of a fruit arises at a narrow basin, placental presentation, tumors of a uterus and ovaries, a hyperinflate abdominal wall, inferiority of uterine muscles, a hydramnion. The position of a fruit at cross situation is determined by its head. If the head of a fruit is at the left, it is the first position if on the right — the second; the look is determined by a back (if it is turned kpered — a front look, kzad — a rear view).
If at vaginal examonation the shovel is located in front, and a clavicle — behind, then it is a front look. To Varnekroza (To. Warnefcrose) selects two more provisions — verkhnespinny cross (the back is located to an uterine fundus), nizhnespinny — the back is turned to a pubic joint.
Recognition of cross and slanting provision of a fruit is based on data of survey of a stomach of the woman in labor, a palpation, vaginal examonation. The stomach at the same time has the unusual, stretched in transverse direction form. The prelying part of a fruit at cross situation is not defined, at slanting — the head of a fruit is palpated at the left or to the right of the centerline. At vaginal examonation, a cut at the whole bag of waters make very carefully, do not define a large part of a fruit over an entrance to a small pelvis, sometimes it is possible to palpate small parts of a fruit. In case of loss from a genital tract after an izlitiya of amniotic waters of the handle of a fruit, the diagnosis does not raise doubts.
After an izlitiya of amniotic waters at vaginal examonation it is possible to probe fallen to an entrance of a basin plechiko a fruit. If in patrimonial ways the handle or a leg is found, and in an entrance to a basin the head or buttocks of a fruit are not defined, it authentically indicates its cross situation. The handle lying in a parturient canal can be distinguished from a leg on the bigger length of fingers and on lack of a calcaneal hillock. The brush is connected to a forearm in a straight line. Fingers are divorced, the thumb is taken especially away. Foot is connected to a shin at an angle, usually pressed to a front surface of a shin, and the calcaneal hillock acts. Over a calcaneal hillock thick condyles are defined on each side. If the handle already dropped out of a sexual crack, then to establish, right or left, with it it is necessary «to greet» or turn palm up (if the thumb is turned to the right hip of mother, then it is the right handle). Characteristic signs of a shoulder, unlike buttocks, are the axillary hollow, edges, a clavicle and a shovel.
The slanting provision of a fruit from the beginning of patrimonial activity sometimes passes into longitudinal. At the slanting provision of a fruit it is possible to try to correct it outside reception or having laid the woman in labor on that side. aside to-rogo an underlying large part of a fruit is rejected.
If the cross or slanting provision of a fruit remains, R. (in the absence of medical aid) are followed by a row very life-threatening the woman in labor and a fruit of oyelozhneniye (untimely izlity amniotic waters, loss of small parts of a fruit, loops of an umbilical cord, the handle) and development of the started cross provision of a fruit — states, at Krom the fruit loses mobility because of full an izlitiya of amniotic waters owing to lack of a belt of a prileganiye and dense coverage of a fruit muscles of a uterus (the uterus sometimes repeats a form of a fruit). Quite often at the started cross provision of a fruit plechiko it is driven in an entrance to a basin and to a vagina the handle (fig. 15) drops out, edges quickly becomes cyanotic, edematous. At the expense of strong contractions the fruit moves to the area of the lower segment of a uterus, to-ry having outgrown-givayetsya, and there is a threat of its gap, and in the absence of the help and a hysterorrhesis. The hypoxia of a fruit is sometimes noted or the fruit perishes. Infection of a uterus is possible.
R. at cross and slanting provisions of a fruit is spontaneous come to an end extremely seldom though sometimes at the small sizes of a fruit and a hydramnion are possible self-turn, samoizvorot and the birth the trunk folded double, at the same time the head end (more often than pelvic) falls to an entrance to a basin.
Now at the cross provision of a fruit regardless of time an izlitiya of amniotic waters indications to Cesarean section are expanded. At a combination of cross situation with placental presentation, the narrow basin and other complications interfering extraction of a fruit, Cesarean section is obligatory. The river is admissible to begin expectantly only at multipara at the small sizes of a fruit and the whole amniotic waters. For the purpose of preservation of amniotic waters before full disclosure of a neck of uterus it is possible to enter into a vagina a kolpeyrinter (see. Colpeurysis ).
At a dead fruit and incomplete disclosure of a neck the turn according to Braxton Giks is possible (I eat. Obstetric turn ). Necessary conditions are mobility of a fruit and its small sizes. In case of the started cross provision of a fruit if the fruit is live and viable, make Cesarean section if it is dead or impractical — fetaldestructive operations (see).
CHILDBIRTH AT LOSS of the LOOP of the UMBILICAL CORD AND SMALL PARTS of the FRUIT
Childbirth at loss of a loop of an umbilical cord. The arrangement of a loop of an umbilical cord is lower than the prelying part of a fruit at the whole bag of waters is called presentation, after opening of a bag of waters — loss. Loss of a loop of an umbilical cord at head presentation because of a possibility of its pressing to walls of a basin (fig. 16) is the most dangerous.
The diagnosis is established at vaginal examonation. Suspicion on loss of a loop of an umbilical cord arises in case of permanent change of heartbeat of a fruit right after an izlitiya of amniotic waters. At head presentation of R. in these cases are followed by a hypoxia of a fruit and a still birth, at pelvic presentation danger of these complications decreases.
Having found a presentation of the cord, the woman in labor is given kolennoloktevy situation or situation with the raised basin that sometimes prevents further pressing of an umbilical cord. If loss of a loop of an umbilical cord at head presentation is found, nek-ry obstetricians recommend to try to fill it for a head with the subsequent fixing of a head to an entrance to a small pelvis by means of craniodermal nippers (see). If it is not possible to fill a loop of an umbilical cord and there are no conditions for immediate delivery in natural patrimonial ways, make Cesarean section.
At pelvic presentation and loss of a loop of an umbilical cord if there are no other complications, R. is allowed to be carried out in natural patrimonial ways.
Childbirth at loss of the handle. Presentation of the handle (at the whole bag of waters) and its loss (after disturbance of an integrity of covers of a bag of waters) is most dangerous at head presentation. The diagnosis is established at vaginal examonation.
Loss of the handle complicates insertion of a head of a fruit in an entrance to a small pelvis, and sometimes makes it impossible. It is necessary to fill carefully dropped-out handle for a head. At failure of this intervention of R. quite often it is necessary to finish by means of Cesarean section.
Childbirth at presentation and loss of a leg. Are observed extremely seldom at head presentation, at premature and matserirovan-number a fruit, and also at twins. There is a sharp bending of a trunk of a fruit at the unbent leg. In these cases the mistake can be made — this complication is accepted to incomplete foot presentation. The extraction of a fruit undertaken in connection with this mistake can end with accident. At the correct diagnosis it is possible to try to set a leg carefully; in case of failure at a viable fruit Cesarean section is shown.
CHILDBIRTH AT the LARGE (HUGE) FRUIT AND ANOMALIES of FETATION
Childbirth at a large fruit. The fruit is powerful (weighing) from 4000 to 5000 g the large, 5000 g and more — huge are considered. Often it occurs at a diabetes mellitus and other endocrine diseases at mother, at an edematous form of a hemolitic disease of a fruit. The diagnosis is based on data of measurement of the sizes of a stomach of the woman in labor (a circle over 100 cm, height of standing of an uterine fundus is higher than 38 cm), heads of a fruit; for calculation of estimated weight of a fruit, it is reasonable to use A. A. Rudakov's formula, A. V. Lankovitsa, etc. The large sizes of a fruit manage to be diagnosed also by means of an ultrasonic method of a research (see. Ultrasonic diagnosis, in obstetrics and gynecology).
Rubles at a large fruit can proceed normally and in most cases reach a limit spontaneously, however complications arise rather often. Treat them primary and secondary weakness of patrimonial activity, premature and early izlity amniotic waters, the big duration of River. In the course of R. discrepancy of the sizes of a basin of the woman in labor and a head of a fruit can come to light. In these cases of R. proceed, as at a narrow basin (see). After the birth of a head quite often there are difficulties at removal of a shoulder girdle of a large fruit. The fruit is larger, the complications, especially in the II period of childbirth are more often. Rubles a large fruit are characterized by the big frequency of an injury of mother and a fruit. In afterbirth and early puerperal the periods it is possible to expect developing of hypotonic uterine bleeding (see. Hypotonic bleedings). At R.'s maintaining by a large fruit prevention of weakness of patrimonial activity consists in creation of an estrogenoglyukozovitaminny background, treatment — in holding the actions directed to strengthening of reduction of a uterus (see below weakness of patrimonial activity); in the absence of effect Cesarean section is shown. At identification of signs of discrepancy of the sizes of a basin and a head of a fruit it is necessary to stop stimulation of pains and to make Cesarean section. In the II period of R. if there is a threat of a rupture of a crotch, it is reasonable to carry out its section. At the time of the birth of the child (a vrezyvaniye, disengagement) of mother enter intravenously 1 ml of ergometrine or 1 ml of oxytocin together with glucose for prevention of bleeding.
At the large sizes of a fruit and pelvic presentation it is necessary to expand indications to Cesarean section.
Childbirth at hydrocephaly. Hydrocephaly — dropsy of a head, is characterized by excessive increase in the sizes of a head owing to excess fluid accumulation in a head cavity (see Hydrocephaly). Bones of a skull of a fruit at the same time become thinner, seams and fontanels become very wide. At this pathology of a fruit of R. quite often are complicated by weakness of patrimonial activity and restretching of the lower segment of a uterus because of disproportion of the sizes of a basin and a head. The diagnosis is based on identification of the big sizes of a head of a fruit, edges is not inserted into an entrance to a small pelvis at good patrimonial activity. At vaginal examonation thinning of bones of a skull (during the pressing on a bone the sound reminding a crunch of parchment is felt as a finger), their mobility, existence of wide seams and fontanels is found. The diagnosis can be specified at ultrasonic investigation. At pelvic presentation (see. Pelvic presentations) it is difficult to make the diagnosis till the birth of a trunk. It is possible to specify it at ultrasonic investigation. After the birth of a trunk the diagnosis is established on the same signs, as at head presentation. If the doctor is sure that there is expressed hydrocephaly of a fruit and delivery is impossible, it is necessary to make a puncture of a skull of a fruit for rescue of the woman and to produce liquid (at head presentation and disclosure of a uterine pharynx not less than on 3 — 5 cm). If restretching of the lower segment of a uterus is observed, perforation of a head is more reasonable (see the Craniotomy). In further R. occurs in the natural way. In afterbirth and early puerperal the periods holding actions for the purpose of the prevention of possible uterine bleeding is necessary.
Childbirth at an anencephalia and a hemianencephalia proceeds usually without special difficulties and is more often in front presentation. There can sometimes be a delay of the birth of a trunk since it is preceded by the birth of a head of small volume. Noprinek-rom waiting also the trunk is born.
Childbirth at accrete twins— see. Polycarpous pregnancy .
Childbirth at other anomalies of fetation. Anomalies of a fruit — the polycystic dysplasia of kidneys, various tumors of internals, and also the big sizes of a trunk (owing to a diabetes mellitus at mother, at the general edema of a fruit at a Rhesus factor sensitization) can result in weakness of patrimonial activity and complications. The choice of a method of delivery is defined individually. At the excessive difficulties connected with removal of a coat hanger it is admissible cleidotomy (see).
CHILDBIRTH AT UNTIMELY IZLITIYA of AMNIOTIC WATERS, the HYDRAMNION AND the OLIGOAMNIOS
Childbirth at premature or early izlitiya of amniotic waters. At premature izlitiya of amniotic waters R.'s current depends on readiness of an organism for R. to a large extent, and at early izlitiya of amniotic waters — at most patrimonial activity and an arrangement of the prelying part (see. Premature bursting of waters). If the organism of the pregnant woman is ready to R., premature izlity amniotic waters can not interfere with a normal current of R. Obychno in such cases patrimonial activity develops in 5 — 6 hours after a rupture of fetal membranes. The uncomplicated current of R. is possible also at early izlitiya of amniotic waters at women in labor with good patrimonial activity and the prelying part of a fruit inserted into an entrance to a small pelvis. However quite often premature and early izlity amniotic waters leads to serious complications: weaknesses of patrimonial activity, to a long current of R., gipoksip and an intracranial injury of a fruit (see. A birth trauma), to a ho-rioamnionit and an endometritis in labor (see. Metroendometritis ). Besides, izlity amniotic waters in the absence of a belt of contact can cause a prolapse of the umbilical cord and small parts of a fruit that substantially complicates R.'s current and their outcome for a fruit.
Tactics of the doctor at premature izlitiya of waters is defined by duration of gestation, and at a mature fruit depends on degree of readiness for childbirth.
Childbirth at an overdue rupture of fetal membranes. At this pathology the integrity of fetal membranes is kept, despite full disclosure of a uterine pharynx. The overdue rupture of fetal membranes can be caused by their excessive density or elasticity, and also trace amount of front amniotic waters (at a flat bag of waters).
R.'s current at an overdue rupture of fetal membranes is characterized by the long period of exile, painful reductions of a uterus which is slowed down by advance of the prelying part, emergence of blood allocations from a genital tract. There is a danger of placental detachment and a hypoxia of a fruit. At excessive elasticity of fetal membranes the bag of waters is stuck out outside. The diagnosis is based on data of vaginal examonation. If existence of a flat bubble causes difficulties in definition of an integrity of covers, it is necessary to examine by means of mirrors. Timely detection of not opened bag of waters is prevention of asphyxia of a fruit (see Asphyxia of a fruit and the newborn).
Tactics of maintaining R. provides artificial opening of a bag of waters. If the head of a fruit was not fixed in an entrance to a small pelvis, amniotic waters it is necessary to release slowly in order to avoid loss of a loop of an umbilical cord or small parts of a fruit. The artificial rupture of a bag of waters is carried out by a branch of bullet nippers.
Childbirth at a hydramnion. Childbirth at a hydramnion (see) often is complicated by weakness of patrimonial activity in I, II and III periods because of reraces-tyazheniya of a uterus. At bystry izlitiya of amniotic waters are possible loss of loops of an umbilical cord, small parts of a fruit, premature placental detachment (see). At a hydramnion the hypoxia of a fruit or anomaly of its development are quite often noted. R.'s maintaining waiting. In the I period of R. it is recommended to open an intense bag of waters at incomplete (on 3 — 4 cm) disclosure of a uterine pharynx. In order to avoid bystry the izlitiya of amniotic waters is better to open a bag of waters not in the center, and sideways, above an isthmus of a uterus. Waters need to be produced slowly, without removing a hand from a vagina to warn a prolapse of the umbilical cord or handles. At weakness of patrimonial activity appoint the means increasing sokratitelny ability of a uterus (see below weakness of patrimonial activity), hold events for prevention of a hypoxia of a fruit and bleeding in the afterbirth period (see).
Childbirth at an oligoamnios. The course of childbirth long since pains are usually ineffective and very painful. The pre-natal hypoxia of a fruit, pathological blood loss (see) in afterbirth and early puerperal the periods are often observed. At R.'s maintaining for their acceleration and reduction of morbidity open a bag of waters, appoint the stimulating and anesthetizing therapy, carry out prevention and treatment of a hypoxia of a fruit.
CHILDBIRTH AT PATHOLOGICAL CHANGES of GENERATIVE ORGANS
Rhoda at the expressed varicosity of external genitals, cicatricial changes of a crotch (e.g., as a result of secondary healing after a rupture of a crotch of the III degree) leads to complications at eruption of the prelying part of a fruit. In all such cases of R. it is necessary to make Cesarean section.
Childbirth at partitions of a vagina. Partitions of a vagina can be inborn or acquired (cicatricial changes after diphtheria, a corrosive burn). During R. they sometimes are an obstacle to advance of the prelying part. It is usually enough to cut a partition to liquidate an obstacle. If there is a sharp colpostenosis, Cesarean section is shown.
Childbirth at rigidity of a neck of uterus. This pathology can be result of anatomic changes, in particular cicatricial, or a consequence of disturbances of the neuromuscular device of a neck of uterus. Believe that the spasm is caused by a diskoordination of an innervation between a body and a neck of uterus (see below a diskoordination of patrimonial activity). Clinically rigidity of a neck of uterus is followed by either weakness of patrimonial activity, or frequent, painful, inefficient contractions. The diagnosis is specified at vaginal examonation: the neck of uterus is dense, not extensible; after opening to 4 — 6 cm inflexibility of its edges comes to light. The neck of uterus densely covers a head of a fruit and interferes with its advance that brings antispasmodics to a long current of R. Primenyayut, at their inefficiency manual expansion of a neck of uterus is shown. Violent expansion of a neck of uterus should be made only after smoothing of a neck since there can be its gap and bleeding. The trachelotomy (hysterostomatotomia) is possible, a cut it is applied seldom. The pharynx is cut in four places slantwise in front and behind on 2 — 2,5 cm, according to figures 2,5, 8 and 10 on the hour dial. Now at the expressed rigidity of a neck of uterus expand indications to Cesarean section.
Childbirth during the pasting of an outside pharynx of a uterus with a bag of waters. At this pathology, despite a smoothness of a neck of uterus and existence of patrimonial activity, disclosure of an outside uterine pharynx is not observed. The diagnosis is established at vaginal examonation; it is necessary to remember that the hyperinflate neck of uterus can be taken for a bag of waters. Carry out manual expansion of a neck of uterus and otslaivat a bag of waters. If the finger does not manage to be carried out, then manipulation is carried out by the uterine probe.
Childbirth at a hysteromyoma. Rubles at a hysteromyoma proceed without complications if nodes small and them it is a little. At larger nodes located in a body of the womb during R. weakness of patrimonial activity, disturbance of process of placental detachment, hypotonic bleeding, subinvolution of a uterus are possible premature izlity amniotic waters. The indication to Cesarean section is the low arrangement of nodes, a multiple hysteromyoma, a submucosal arrangement of a node, disturbance of food in one of nodes. In the course of operation after extraction of a fruit small nodes leave, subserous on the thin basis delete; at a multiple hysteromyoma, disturbance of food in one of nodes supravaginal amputation of a uterus is made (see).
Childbirth at a double uterus. At a double uterus of R. usually proceed without essential complications and do not demand special events.
Childbirth at tumors and tumorous formations of ovaries proceeds without features more often. However in the course of R. and after their termination twisting of a leg of a tumor is possible that demands an operative measure. Slow-moving, the considerable sizes the tumor in a small basin complicates advance of a fruit. In cases of infringement of a tumor in a small basin during R. resort to Cesarean section, a cut is followed by an oncotomy.
CHILDBIRTH AT ANOMALIES of SOKRATITELNY ACTIVITY of the UTERUS
Regulation of sokratitelny activity of a uterus is under direct control of a cerebral cortex (see). As the proof of it serves development of patrimonial activity or its termination under the influence of various sudden psychological «stresses» (sensation of fear, death of relatives, etc.). The physiological current of R. requires preservation of the correct reciprocal relations between various departments of a uterus. In recent years nek-ry obstetricians explain development of anomalies of patrimonial activity with localization of a placenta in the field of an uterine fundus.
The main indicators of a functional condition of the «giving birth» uterus are its tone and excitability. The tonic tension of a uterus is able fiziol. rest characterizes readiness of a uterus for vigorous activity. Distinguish a normal tone of a uterus — 8 — 10 mm of mercury.; the hypotone — is lower than 7 mm of mercury. and a hyper tone (weak — 12 — 20 mm of mercury.; average — 21 — 30 mm of mercury.; high — is higher than 30 mm of mercury.). Excitability of a uterus reflects ability of smooth muscles to pass into a condition of excitement under the influence of biologically active agents (adrenaline, acetylcholine, oxytocin, prostaglandin), potassium ions, calcium, etc., and also under the influence of other irritants, napr, mechanical, electric.
At the characteristic of patrimonial activity usually estimate the following indicators: tone of a uterus, intensity (force) of a fight, its duration, interval between pains, rhythm, frequency. Anomalies of sokratitelny activity of a uterus can be shown in easing or excessive strengthening, disturbance of frequency (rhythm) of reductions, and also in disturbance of their coordination, uniformity and symmetry of reductions of a myometrium in various departments of a uterus. L. S. Persianinov, etc. offered the following classification of anomalies of sokratitelny activity of a uterus — weakness of patrimonial activity (hypoactivity or inertness of a uterus): primary, secondary, weakness of attempts; excessively strong patrimonial activity (hyperactivity of a uterus); dis-coordinate patrimonial activity: diskoordination (first and second degree), hyper tone of the lower segment of a uterus (return gradient), convulsive pains or tetany of a uterus.
Weakness of patrimonial activity (a hypouterine activity or inertness of a uterus — dolores debiles). Frequency of weakness of patrimonial activity makes from 2 to 10% of total number of River. At weakness of patrimonial activity intensity, duration and frequency of pains are insufficient; processes of smoothing of a neck of uterus, disclosure of the channel of a neck of uterus and advance of a fruit (at its compliance with sizes of a basin) are slowed down. Weakness of attempts is characterized by their inefficiency owing to weakness of muscles of a prelum abdominale or exhaustion.
Primary weakness of patrimonial activity (dolores debiles primariae) arises from the very beginning of R. and proceeds during the period of disclosure or before the end of childbirth.
Develops at primapara more often 30 years at disturbances of a menstrual cycle and the postponed inflammatory diseases of generative organs are more senior, at a large fruit, a multiple pregnancy, a hydramnion, early to an izlntiya of amniotic waters, a hysteromyoma, postmature pregnancy, at the women with a gross obesity, infantility who transferred abortions and a large number of childbirth.
The reasons of primary weakness of patrimonial activity are diverse. Most often it disturbances of the mechanisms regulating a childbed (changes of function of c. N of page as a result of psychological tension, adverse trace reactions, disorders of endocrine functions, disturbances of exchange, etc.). Quite often it is caused patol. changes of a uterus (malformations, inflammatory changes, restretching of a uterus). It is noted that at weakness of patrimonial activity in myometriums activity of a lactate dehydrogenase considerably increases (see), it leads to increase in concentration milk to - you in muscle cells and, therefore, to weakening of sokratitelny activity of a uterus. R.'s current at primary weakness of patrimonial activity is various. Pains can be rather frequent, but weak and short, rare, but satisfactory force. The last are more favorable since long pauses promote rest of muscles of a uterus.
The diagnosis of weakness of patrimonial activity is reasonable if there is a low intensity of reductions or their small frequency (less than 2 reductions in 10 min.). The tone of a uterus is usually lower, than at normal Rubles. The diagnosis of weakness of patrimonial activity is established at dynamic overseeing by the woman in labor during 5 — 6 hours, at the same time conduct repeated vaginal examonations for control of efficiency of pains in the absence of rigidity of a pharynx or its spasm. At monitor observation the diagnosis can be established in 2 — 3 hours.
At primary weakness of patrimonial activity the prelying part of a fruit it is long remains mobile or pressed to an entrance to a small pelvis. R.'s duration sharply increases, they can accept long character. It is quite often observed early izlity amniotic waters that extends an anhydrous time term and promotes infection of a genital tract of the woman in labor and a hypoxia of a fruit.
In an afterbirth and early puerperal period hypotonic or atonic bleedings owing to the lowered sokratitelny ability of a uterus are possible, and also at a delay in a uterus of a placenta or its parts.
The differential diagnosis of weakness of patrimonial activity needs to be carried out with the pathological preliminary (preparatory) period, rigidity of a neck of uterus, and also the dicoordinated patrimonial activity, a hyper tone of the lower segment of a uterus, clinical discrepancy between the sizes of a basin of the woman in labor and a head of a fruit (see appropriate sections in the text of article).
The pathological preliminary period is characterized by the painful, alternating on force and feelings pains arising against the background of the raised tone of a uterus. Pains often have regular character, but do not lead to disclosure of a neck of uterus, tire the pregnant woman, break a day-night rhythm of a dream and wakefulness. Duration of the pathological preliminary period quite often makes more 10th hour. The multichannel outside gisterografiya facilitates differential diagnosis of the pathological preliminary period and weakness of patrimonial activity. Weakness of patrimonial activity at a pathological preliminary perird is observed, according to V. V. Abramchenko, in 31% of cases of River.
Secondary weakness of patrimonial activity (dolores debiles secundariae) is more often observed at the end of the period of disclosure and in the period of exile. Meets considerably less than primary. All morbid conditions of an organism of the woman in labor, expressiveness to-rykh it is insufficient to lead to development of primary weakness of patrimonial activity (see above), at the end of the period of disclosure of a neck of uterus and in the period of exile can cause emergence of secondary weakness. Besides, the exhaustion of the woman in labor as a result of long and painful contractions can be the cause of this complication that is observed at anatomic and clinical discrepancy between the sizes of a head of a fruit and a basin of the woman in labor, the wrong provisions of a fruit, unprepared fabrics of patrimonial ways (immaturity and rigidity of a neck of uterus, its cicatricial changes, stenoses of a vagina, a tumor in a small basin, etc.) expressed to morbidity of pains and attempts, an untimely rupture of a bag of waters, an endometritis, inept and chaotic use of the medicamentous means (stimulating, anesthetizing, spasmolytic, etc.).
The wedge, picture of secondary weakness of patrimonial activity is characterized by lengthening of River. Intensive, long and rhythmical pains gradually weaken and are shortened, pauses between them increase, sometimes pains absolutely stop. Advance of a fruit on a parturient canal sharply is slowed down or stops. Prolonged R. can lead to a horioamnionit and an endometritis in labor and a hypoxia of a fruit. Soft patrimonial ways and the next bodies — a bladder, an urethra, a rectum, sometimes ureters — can be restrained between a head of a fruit and pelvic bones of mother that promotes formation of urinogenital and enterosexual fistulas. The head of a fruit is also exposed to an adverse effect from patrimonial ways that leads to disturbance of cerebral circulation of ii to the hematencephalon which is followed not only by asphyxia, but also paresis, paralyzes and even death of a fruit. In the afterbirth and puerperal periods at women with secondary weakness of patrimonial activity can be observed hypo - and atonic bleedings, puerperal infectious diseases.
The diagnosis is based on a clinical picture. Big help is given by objective methods of registration of patrimonial activity in dynamics.
Weakness of attempts happens primary and secondary. Nek-ry researchers refer weakness of attempts to secondary weakness of patrimonial activity. It is observed at weakness of muscles of a prelum abdominale, at the multigiving birth women with excessively stretched and relaxed belly muscles, at infantility (see), obesity (see), and also at defects of an abdominal wall (an epigastrocele, umbilical and inguinal hernias). Weakness of attempts can arise also at defeats of c. N of page (poliomyelitis, brain injuries and a backbone, etc.), it is reflex (at severe pains), at insufficiency of reflex reactions of muscles of a pelvic bottom and the general fatigue of the woman in labor, during the calling of premature artificial attempts for acceleration of childbirth. The braking impact on development of attempts is exerted overflow of a bladder, intestines and stomach. Negative emotions, fear of R. in the period of exile at women in labor quite often is followed by weakness of attempts.
The wedge, a picture is characterized by lengthening of the period of exile. Attempts become short, weak l rare. Advance of the prelying part is late or stops. Lengthening of the period of exile is followed by hypostasis of a neck of uterus and external genitals, signs of a prelum of the next bodies and development of a horioamnionit and an endometritis in labor appear. The fruit is threatened by asphyxia and death. On a gisterogramma the low amplitude of reductions of cross-striped muscles is noted. The diagnosis establish on the basis a wedge, yielded and results of a gisterografiya.
Conducting childbirth at weakness of patrimonial activity provides first of all where it is possible, elimination of the reason of a complication: at a hydramnion or an oligoamnios and existence of a maturity of a neck of uterus, and also at disclosure of a uterine pharynx on 4 — 6 cm open a bag of waters; at exhaustion if there are no urgent indications to delivery, provide to the woman in labor rest — an obstetric anesthesia (see below), a medical electroanalgesia (see the Electroanesthesia). The woman in labor needs to provide regular and good nutrition (a strong beef-infusion broth, sweet tea, honey, fruit), administration of vitamins (redoxon — 300 mg, Thiamini bromidum — 50 — 100 mg), 50 mg of cocarboxylase intravenously in 50 ml of 40% of solution of glucose, Galascorbinum (1 g in), introduction of 10 ml of 10% of solution of a gluconate of calcium. If operational delivery under anesthetic is supposed, it is necessary to refrain from meal.
In the I period of childbirth in the absence of contraindications the behavior of the woman in labor shall be active, to it allow to rise, go, the warm shower, bowel emptying (enemas) are shown. For sensitization of a uterus to oksito-tichesky substances, and especially at an unripe neck of uterus, use oestrogenic drugs: 0,1% solution of folliculin in oil (20 — 30 thousand. Piece), 0,1% solution of platforms a yole and Dipropionas in oil (20 — 30 thousand. Piece) or 2% solution of hexestrol in oil (10 — 20 mg) intramusculary or in a back lip of a neck of uterus in 2 — 3 hours two-three times. For acceleration of absorption oestrogenic hormones dissolve in 0,5 ml of ether.
At prolonged childbirth, and especially at secondary weakness of patrimonial activity, for elimination of acidosis introduction of 100 — 250 ml of 5% of solution of hydrosodium carbonate is reasonable.
Apply an electroanalgesia with use of impulse currents during 1 1/2 to providing rest (dream) — 2 and more hours, against the background of preliminary intramuscular introduction of 1 ml of 2% of solution of Promedolum and 2 ml 2,5%r-r of Pipolphenum.
For a medical obstetric anesthesia intravenously use solutions of sodium of hydroxybutyrate (GOMK) in a dose of 50 — 65 mg on 1 kg of body weight (on average 4 g of nonvolatile solid) or steroid drug — viadril «G» in the form of 2,5% of solution in a dose of 10 mg on 1 kg of body weight (on average 1 g of nonvolatile solid). For premedication enter intramusculary or intravenously solutions of Promedolum and Pipolphenum. During sleep pains continue and are usually normalized. Duration of a dream averages 2 hours at use of viadril «G» and 2 x / 2 hour — at GOMK. The anesthesiologist shall carry out a medical obstetric anesthesia.
If after the held events patrimonial activity was not normalized, medicamentous stimulation is shown. At the same time it is necessary to consider contraindications: discrepancy between the sizes of a fruit and a basin of the woman in labor, existence of a hem on a uterus after the undergone operations, exhaustion of the woman in labor, threat of a hysterorrhesis, the wrong provisions and presentations, the central (full) placental presentation, existence of a stenosis of a vagina, hems after the begun to live rupture of a crotch of the III degree and other changes of soft patrimonial ways, allergic intolerance of oksitotichesky substances.
For the purpose of stimulation of patrimonial activity the set of various medicinal schemes is recommended. For intravenous administration of 1 ml of oxytocin (5 PIECES) dissolve in 500 ml 5% of solution of glucose or isotonic solution of sodium chloride. Solution is entered kapelno, since 6 — 8 drops in 1 min., gradually increasing quantity of drops each 5 — 10 min. by 5 drops before obtaining effect (but no more than 40 drops in 1 min.). Instead of intravenous administration of oxytocin perhaps the trance-bukkalnoye use of dezamino-oxytocin (ODA-914), tablet is entered for a cheek, since 25 bucketed PIECES 30 min. It is possible to increase a dose to 100 PIECES. At emergence of rough patrimonial activity the tablet is deleted, the mouth is rinsed by 5% solution of hydrosodium carbonate or water.
Apply to stimulation of patrimonial activity also prostaglandins of a series E and F. For intravenous administration of 5 mg of F2a prostaglandin or Enzaprostum of F2a and 1 mg of a prostin of E2 or a prostenon of E2 dissolve in 500 ml 5% of solution of glucose or isotonic solution of sodium chloride and enter with a speed from 10 to 40 thaws of 1 min. depending on the gained effect.
The good effect of use of the tableted prostin of E2 is gained. Initial dose of a prostin of E2 — 0,5 mg (one tablet), to-ruyu repeat each hour. At an insufficient uterine activity it is possible to increase a dose to 1 mg each hour. At purpose of prostaglandins it is not necessary to apply at the same time their inhibitors (indometacin, aspirin, Butadionum). It is established that prostaglandins exponentiate action of oxytocin and therefore the combined their introduction is the most effective. 2,5 PIECES of oxytocin and 2,5 mg of F2a prostaglandin part in 500 ml of isotonic solution of sodium chloride or 5% of solution of glucose and enter with a speed from 6 — 8 to 40 thaws of 1 min. Administration of drugs is continued during the entire period of R. and for the purpose of prevention of bleeding within 10 — 15 min. in an early puerperal period. The overdose of prostaglandin, and especially oxytocin, leads to a hyper tone of a uterus, its convulsive reductions, and it in turn — to disturbance of matochnoplatsentarny blood circulation. If at introduction of oxytocin, prostaglandin or their combined use during 2 hours dynamics in disclosure of a neck of uterus is not observed, further administration of drugs is inexpedient and it is necessary to resolve an issue in favor of operational delivery depending on an obstetric situation.
In practical obstetrics it is earlier wide, and various schemes of stimulation of patrimonial activity are less often applied now. Kurdinovsky's scheme — Matte: in an hour after intake of 60 ml of castor oil appoint quinine a hydrochloride on 0,2 — 0,25 g to reception, only 4 — 6 times at an interval of 30 min. In 30 min. after the first reception of quinine make injections of Pituitrinum on 0,2 — 0,3 ml, only 3 — 4 injections at an interval of 20 — 30 min. before emergence of regular contractions.
A. P. Nikolaev's scheme: castor oil of 60 ml, in 2 hours a cleansing enema, for an hour to a cleansing enema of quinine a hydrochloride inside on 0,2 g of 5 times at an interval of 30 min., 50 ml of 40% of solution of glucose intravenously, 10 ml of 10% of solution of calcium chloride (a gluconate of calcium) intravenously, 60 — 100 mg of 6% of solution of Thiamini bromidum intravenously.
V. N. Hmelevsky's scheme: in the I period of R. mix from 50 g of glucose, 2 g of calcium chloride and 8 — 10 drops divorced salt to - you on the I glass of hot water is given. The specified mix can be given repeatedly every two hours 2 — 3 times. In the II period of R. along with reception of the above-stated mix enter intravenously 30 — 40 ml of 40% of solution of glucose, 10 ml of 10% of solution of calcium chloride, 5 — 6 ml of 5% of solution ascorbic to - you and intramusculary — 30 mg of 6% of solution of Thiamini bromidum.
After establishment of regular patrimonial activity and opening of a uterine pharynx on 3 — 4 cm administration of anesthetics (e.g., 1 ml of 2% of solution of Promedolum) and antispasmodics is shown (1 ml of 1% of solution of aprophene, 2 ml of 2,5% of solution of a spazmaverin, 2 — 3 ml of a palerol, 2,5 ml of a buskopan, 2 ml of 2% of solution of Nospanum, 1 ml of an efazin, 2 ml of 2% of solution of Estocinum, etc.). It is reasonable to use an electroanalgesia impulse currents during 2 — 3 hours, especially at the women having a medicinal allergy. Repeated introduction of antispasmodics can be carried out in 3 — 4 hours. Patrimonial activity amplifies at position of the woman in labor on one side, of the same name with a position of a fruit, and it should be considered during the carrying out stimulation. It is recommended to carry out prevention of a pre-natal hypoxia of a fruit: a triad over Nikolaev (see. Asphyxia of a fruit and newborn ), 2 ml of 1% of solution of Sygethinum intravenously.
Cesarean section at weakness of patrimonial activity shall be applied only when conservative therapy is unsuccessful also R.'s forecast for mother and a fruit it develops adversely, especially at a combination of weakness of patrimonial activity to other pathology (pelvic presentation, the burdened obstetric anamnesis, advanced age of the woman in labor, etc.).
At secondary weakness of the patrimonial activity which is not giving in to medicamentous stimulation operational delivery is shown. Depending on an obstetric situation imposing of obstetric nippers, vacuum extraction, extraction of a fruit the pelvic end, etc. is applied. A vacuum stimulator, craniodermal nippers according to Ivanov (see. Craniodermal nippers) owing to the high injury are applied (to a fruit) now seldom as well as operation of a met-reyriz, in view of insufficient efficiency, injury for a fruit and danger of development of an infection.
In cases of rigidity of a uterine pharynx and unsuccessfulness of use of antispasmodics stretching or a section of a uterine pharynx is shown. In the presence of symptoms of the developing infection, and also at an anhydrous interval more than 12 hours if the termination P. in the next 1 — 2 hour is not expected, antibiotics appoint.
At weakness of attempts usually abstain from an obstetric anesthesia and use the means stimulating a uterus. At insolvency of muscles of a prelum abdominale resort to use of bandage of Verbov (see Verbov bandage). In case of unsuccessfulness of actions and existence of indications apply imposing of obstetric nippers or a vacuum extractor, an episiotomy to delivery (the prolonged period of exile, a hypoxia of a fruit, an endometritis).
For the purpose of prevention of bleeding in an afterbirth and early puerperal period at the time of a vrezyvaniye and disengagement of a fruit kapelno intravenously enter solution of methylergometrine (0,02% — 1 ml on 500 ml of isotonic solution of sodium chloride) or oxytocin (5 PIECES).
Excessively strong patrimonial activity (hyperactivity of a uterus). This anomaly of patrimonial activity is shown by extremely strong contractions or bystry alternations of pains (more than 5 in 10 min.). Intervals between pains decrease due to shortening of a phase of slow relaxation, the tone of a uterus raises (more than 12 mm of mercury.). Rubles in similar cases reach a limit within 1 — 3 hours and earlier, and call them prompt (partus praecipitatus).
The etiology of excessively strong patrimonial activity is studied insufficiently. More often it is observed at women in labor with the increased general excitability (a neurasthenia, hysteria, a thyrotoxicosis, etc.). Believe that at the same time there are disturbances of corticovisceral regulation and the impulses coming from a uterus to subcrustal educations are insufficiently controlled by a cerebral cortex. The increased formation of such substances as oxytocin, adrenaline, acetylcholine, prostaglandins is observed, to-rye make powerful impact on sokratitelny function of uterine muscles.
The wedge, a picture is characterized by the sudden and rough beginning of R. Ochen strong contractions follow one by one through short pauses and quickly lead to full disclosure of a uterine pharynx. The woman in labor at suddenly and violently begun R. proceeding with intensive and almost continuous pains is sometimes excited. After an izlitiya of amniotic waters rough and prompt attempts immediately begin, and sometimes the fruit, and after it and an afterbirth is born in 1 — 2 attempts. Prompt R., to-rye at the multigiving birth women can End even in several minutes, find the woman quite often in an adversity, is frequent out of a maternity home — so-called street childbirth.
At excessively strong patrimonial activity uteroplacental blood circulation is broken and gas exchange at a fruit is as a result broken, there is a deficit of time necessary for recovery of power processes in a uterus.
The similar current of R. threatens the woman with danger of placental detachment, is followed by deep ruptures of a neck of uterus, vagina, cavernous bodies of the clitoris, crotches and can cause the menacing bleeding. Bystry delivery can lead to hypotonia or an atony of a uterus. Due to the injuries at prompt R. diseases in a puerperal period are often observed.
At bystry advance of a head of a fruit in patrimonial ways it does not manage to be configured and is exposed to a bystry and strong prelum that quite often leads to a birth trauma and intracraneal hemorrhages at a fruit owing to what also early child mortality increases mertvorozhden-nost (see) (see).
The diagnosis is easily established on the basis of described above a wedge, pictures and data of a gisterografiya.
Conducting childbirth is directed to decrease in patrimonial activity: the woman in labor is stacked sideways, opposite by positions of a fruit, and give an anesthesia (radio, ftorotanovy). Use of nitrous oxide is inexpedient since it does not reduce a tone of a uterus. In recent years to regulation and removal of patrimonial activity with success apply (the 3-mime-ticheskiye drugs — Partusistenum (0,5 mg) or Ritodrinum (10 mg) on 250 — 400 m of of isotonic solution of sodium chloride, etc. The drug is administered a cap-lno intravenously, gradually increasing number of drops before effect, to-ry it is observed, as a rule, in 5 — 10 min. R. accept in position of the woman on one side, opposite to a position of a fruit. After R. careful survey of a crotch for the purpose of identification of its gaps is necessary.
If there was «street» childbirth, then after arrival of the woman in obstetrical establishment carefully disinfects external genitals and enters antitetanic serum to the woman in childbirth and the newborn. In the presence hospitalization before the term of River is shown in the anamnesis at the pregnant woman of rapid childbirth.
The dicoordinated patrimonial activity. Understand a lack of coordination of reductions of various departments of a uterus as the dicoordinated patrimonial activity — the right and left its half, between top and bottom segments or between all departments of a uterus (fibrillation, a tetanus of a uterus). Frequency of this pathology fluctuates, by data I. I. Yakovleva (1957), N. V. Onopriyenko (1966), R. I. Kalganova (1972), JI. S. Persianinova (1975), etc., from 0,47 to 18% of all
of R. Prichina of the dicoordinated reductions of a uterus can be defects of its development (a two-horned, saddle uterus, etc.), disturbance of an innervation, and also defeat of limited sites of a uterus owing to inflammatory, dystrophic and tumoral processes. On the changed sites ability of the neuromuscular device of a uterus to perception of irritation is reduced or the changed muscles are not capable to answer the received impulses with normal reductions. Development of diskoordiniro-bathing patrimonial activity is promoted by immaturity of a neck of uterus, localization of a placenta in the field of an uterine fundus, hems on a uterus after operative measures, untimely izlity amniotic waters, the excessive density of fetal membranes, age of primapara more than 30 years, etc.
Diskoordination of sokratitelny activity of a uterus. There are several classifications of a diskoordination of sokratitelny activity of a uterus. R. Caldeyro-Barcia distinguishes two of its degrees. The first degree of a diskoordination is caused by a lack of coordination between two «pacemakers» of a uterus. At registration of intrauterine pressure big and small waves of reduction are fixed, and at multichannel record it is visible that various departments of a uterus are reduced asynchronously. R.'s current is slowed down. At the second degree of a diskoordination, or uterine fibrillation, the uterus is functionally divided into a set of zones, to-rye control a set of «pacemakers». On multichannel record it is visible that various departments of a uterus are reduced asynchronously. At registration of intrauterine pressure the high tone and small irregular reductions of a uterus of big frequency are noted (fibrillation, a hyper tone with a hyposystole). At this form of anomaly patrimonial activity does not progress.
Are typical for a diskoordination of sokratitelny activity of a uterus painful, irregular, times frequent pains, morbidity in a waist. At a palpation the uterus is unevenly condensed. Immaturity of a neck of uterus, the slowed-down its disclosure, sometimes lack of its disclosure are often noted untimely izlity amniotic waters. The prelying part of a fruit it is long remains the mobile pla pressed to an entrance to a small pelvis. The spontaneous urination, despite the lack of symptoms of a prelum of an urethra is often broken. Further pains can stop. R.'s process is slowed down at the first degree of a diskoordination and stops at the second. In the afterbirth period anomaly of placental detachment and a delay of its parts in a cavity of the uterus can be observed that leads to bleeding. Uteroplacental blood circulation what development of a hypoxia of a fruit is result of is sharply broken.
Character of a curve at registration of intrauterine pressure is changed that testifies to different intensity, duration and change of a tone. On the basis of record only of intrauterine pressure it is also possible to judge a diskoordination of reductions of a uterus, but without reductions of various departments of a uterus. The Tonografichesky curve at the same time takes irregular shape in building-up period of pressure or its sshikeniye or throughout all fight. Jump of a tone, intensity of pains, longer rise and the shortened recession, sudden increase in duration of a fight at low figures of the general intrauterine pressure consider as manifestation of a diskoordination of patrimonial activity.
The diagnosis is established on the basis a wedge, by pictures of long childbirth, inefficiencies of pains, delays of disclosure of a neck of uterus and progress of the prelying part of a fruit. Registration of sokratitelny activity of a uterus by means of a multichannel gisterografiya or record of intrauterine pressure is more objective.
Patrimonial activity should differentiate Diskoordination first of all from its weakness since wrong stimulation of patrimonial activity can lead to terrible complications for mother and a fruit.
For treatment recommend psychotherapy (see. Psychoprophylactic training of pregnant women), paracervical novocainic anesthesia, use analgetic, sedative, spasmolytic, beta meticheskikh means and obstetric anesthesia. The good effect gives carrying out an electroanalgesia or the combined electroanalgesia, to-rye normalize patrimonial activity and accelerate disclosure of a neck of uterus.
Hyper tone of the lower segment of a uterus (the return gradient) — patol. the state, at Krom the lower segment of a uterus is reduced stronger than a body and an uterine fundus and a wave of reduction, beginning in the lower uterine segment, extends up with the decreasing force and duration. At the same time the dominating role of the lower segment of a uterus over a body and a bottom is noted. Such reductions of a uterus, despite their intensity, are not effective for disclosure of a neck of uterus. Actually these reductions are directed to closing of a neck, especially at the beginning of patrimonial activity when in disclosure of a neck of uterus the lower segment of a uterus takes part in the basic. Most of researchers consider that disturbance of the mechanism of the reciprocal (interfaced) relations between a body and a neck of uterus is the main reason for a hyper tone of the lower segment of a uterus. As it is established, similar anomaly of patrimonial activity is often observed at a «unripe» and rigid neck of uterus.
The wedge, picture is characterized by quite expressed patrimonial activity, but pains are more painful, than normal, there is no disclosure of a neck of uterus or dynamics of disclosure is badly expressed, the prelying part of a fruit does not move ahead, during the fight the prelying part of a fruit does not press on a neck of uterus. Pains are especially expressed in lower parts of a uterus and in a waist. It is often observed untimely izlity amniotic waters. Further secondary weakness of patrimonial activity can develop. The hypoxia of a fruit is quite often noted.
Diagnosis is facilitated by multichannel registration of sokratitelny activity of a uterus from its various departments. Registration of intrauterine pressure is not informative.
For recovery of the triple descending gradient of a uterus recommend psychotherapy, use analgetic, sedative, antispasmodics, paracervical novocainic blockade, an electroanalgesia, an obstetric anesthesia. The good effect renders opening of a bag of waters. Purpose of oxytocic means, attempts of manual expansion of a neck of uterus and other interventions in patrimonial ways without anesthesia are wrong.
At an unripe neck of uterus it is necessary to carry out the treatment directed to its maturing (see above conducting childbirth at weakness of patrimonial activity).
Convulsive pains or tetany of a uterus (tetania uteri) — a rare form of pathology of sokratitelny activity of a uterus, is characterized by long reduction of muscles of all uterus. Reductions follow quickly one another without pauses. Before approach of a tetany of a uterus the frequency of pains increases (more than 5 pains in 10 min.), their intensity progressively decreases, and the hyper tone because of incomplete relaxation quickly grows. The hyper tone of a uterus remains a long time, pains at the same time are practically not defined. Then the tone of a uterus slowly decreases and gradually reaches datum level. Intensity of pains increases in process of decrease in a tone of a uterus. And repeatedly conducted researches, repeated attempts of obstetric turn, imposing of obstetric nippers, extraction of a fruit the pelvic end and other interventions which are carried out without anesthesia and also overdose of pharmaceuticals (drugs of quinine a hydrochloride, Pituitrinum, oxytocin, prostaglandins) can be the reason of emergence of convulsive reductions of uterine muscles roughly.
In addition to a tetany of a uterus, the spasm of an internal pharynx at rough extraction of a fruit the pelvic end, incomplete opening and insufficient anesthesia can be observed. Persistent attempts to take a fruit increase a spasm. The spasm in an internal pharynx is usually observed at the end of the period of disclosure or during exile. During vaginal examonation at the same time the continuous muscular ring in the field of the lower segment of a uterus is defined, a cut remains also in pauses between pains.
At convulsive reductions of a uterus painful contractions, the woman in labor feels pains in sacrolumbar area, and at a tetany of a uterus — a continuous «arching» abdominal pain. Tenesmus from a bladder and a rectum are possible. At a palpation a uterus of stony density, painful. Heartbeat of a fruit usually is not listened or listened hardly. The fruit suffers from the progressing hypoxia and often perishes. Rubles stop, quite often develop horioamnionit, an endometritis and a septic state (see Sepsis, in obstetrics and gynecology).
The diagnosis is established on the basis a wedge, pictures. Treatment of convulsive pains or a tetany of a uterus depends on the reasons which caused them. So, at overdose of oxytocic means immediately stop their introduction and if necessary give to the woman in labor a deep anesthesia, to-ry normalizes patrimonial activity. If patrimonial ways are prepared, then under anesthetic take a fruit by means of obstetric nippers (at head presentation) or for a leg (at pelvic presentation). At a dead fruit make fetaldestructive operation. After extraction of a fruit manual department of a placenta, allocation of an afterbirth and inspection of a cavity of the uterus for an exception of gaps is shown.
Prevention of anomalies of patrimonial activity shall begin long before River. Implementation of actions for hygiene of the girls of children's and school age (the rational mode, food, physical culture) providing harmonious development of a female body is important. During pregnancy implementation of hygienic measures, full-fledged food, vitamin-rich and microelements, and also a rational exercise stress are necessary. Moderate physical work without heavy lifting is recommended, to LFK, daily stay in the fresh air from 2 to 4 hours. From the second half of pregnancy for the prevention of hyperdystension of a prelum abdominale the woman shall carry a bandage (see). Physio-psychoprophylactic preparation for River has beneficial effect. Preventive use of Galascorbinum shortens R.'s duration, reduces the frequency of weakness of patrimonial activity and the birth of children in asphyxia.
Are necessary early detection of pregnant women with endocrinopathies and extragenital diseases and their preparation for River. The pregnant women belonging to group of «the increased risk» concerning possible development of anomalies of patrimonial activity should appoint widely Galascorbinum, vitamins A, With and groups B, an electroanalgesia (7 — 10 sessions 45 minutes).
CHILDBIRTH AT SOME EXTRAGENITAL DISEASES of MOTHER AND COMPLICATIONS of PREGNANCY
Rhoda at heart diseases
For patients with heart disease of R. can pose a direct threat for life, especially at wrong tactics of maintaining R. Mneniye that delivery by means of Cesarean section guarantees against a lethal outcome at heavy heart disease, was not confirmed. Under the authority of spontaneous R. at patients with heart disease, except the obstetrician, shall participate the therapist and the anesthesiologist. By the beginning of patrimonial activity it is necessary to have clear ideas of a form of heart disease, extent of disturbance of blood circulation, at defect of a rheumatic origin (see the Heart diseases acquired) of activity of rheumatic process, and also associated diseases. In labor constant objective control behind function of the blood circulatory systems and breath is necessary. From R.'s beginning effective anesthesia shall be carried out. At the compensated and subcompensated heart diseases use of protoxidic and oxygen mix is admissible (in the ratio 1:1 and 1:2). The combined methods of an analgesia can be applied (see the Labour pain relief).
Control and maintenance of the main functions of an organism (first of all blood circulation and breath) along with management of patrimonial activity have first-priority value. Shortening even of normally proceeding R. at women in labor with heart disease, especially dekompensirovanny, promotes decrease in load of cardiovascular system. Use in R. of redoxons and Vkh, cocarboxylase, and also Prednisolonum (on pokazaniyakhm). stabilizes a hemodynamics and at the same time promotes development of good patrimonial activity. From the same position it is rational to combine an anesthesia with antispasmodics that promotes acceleration of disclosure of a uterine pharynx. At women in labor with the expressed tachycardia it is necessary to avoid purpose of such spasmolytic drugs as atropine and aprophene. Use of the active means reducing a uterus (oxytocin, Pituitrinum, etc.), is admissible, but repeated introductions of oxytocin at these patients in connection with its possible antidiuretic action should be avoided.
Recently there were messages on expediency of delivery of patients with heavy heart diseases and limited functionality in a pressure chamber (see an iper the baric oxygenation) that prevents increase of an anoxemia and a hypoxia.
The end of II and the beginning of the III period of River are most responsible and dangerous at women in labor with diseases of cardiovascular system. Load of heart excessively increases in the second period, arterial pressure considerably increases during attempts and sharply falls in pauses between them. Directly after the birth of the child in an abdominal cavity of the woman in childbirth pressure sharply falls, blood vessels are quickly overflowed with blood that can lead to a relative hypovolemia and a lowering of arterial pressure.
Most of researchers recommends at patients with the phenomena of a decompensation of blood circulation to switch off attempts by means of obstetric nippers. The vacuum extractor at women in labor with heart disease is applied extremely seldom (only in the absence of conditions for imposing of obstetric nippers), only for the purpose of shortening of the second period of R., but not to switching off of attempts as its use without combination to attempts is inadmissible.
According to L. V. Vanina (1970), indications to use of Cesarean section for patients with diseases of cardiovascular system are: returnable rheumatic carditis and subacute septic endocarditis; the heart diseases proceeding with preferential dominance of a left ventricular failure (mitral insufficiency, aortal heart diseases); sharply expressed mitral stenosis in the absence of effect of active, long medicamentous therapy; combination of heart disease to obstetric pathology.
Contraindications to Cesarean section are the heart diseases which are followed by sharply expressed hypertensia of a small circle of blood circulation (see); pressure in a pulmonary trunk exceeds 60 mm of mercury. At heavy pulmonary hypertensia in the postoperative period acute respiratory insufficiency often develops (see). However flexible tactics of management of the main functions of an organism in R., the corresponding selection of means of anesthesia provide more chances of preservation of life of mother and a fruit, than Cesarean section.
At patients with heart disease it is necessary to aim at the least traumatic maintaining the afterbirth period and to abstain whenever possible from use of ways of squeezing of an afterbirth across Kreda — to Lazarevich (see. Afterbirth period) without good anesthesia since there is a high risk of emergence of a metastasis ad nervos of a heart rhythm. Considering that at women in labor with heart disease hypotonic bleeding in afterbirth or early puerperal the periods is sometimes observed, it is necessary to carry out its prevention (at the time of disengagement intravenously enter 1 ml of a metilergo-metrin into 10 — 20 ml of 40% of solution of glucose). For a stop of bleeding it is possible to combine introduction of oxytocin and methylergometrine. It is intravenously kapelno better to enter oxytocin (3 — 5 PIECES) to extend the term of its action and to avoid sharp reduction of a uterus.
At women in labor with a mitral stenosis and developments of stagnation in lungs weight on a stomach after the birth of the child should not be applied as moving of blood to vessels of an abdominal cavity promotes unloading of a small circle of blood circulation. On the contrary, at the women in labor suffering from insufficiency of the mitral valve, the phenomena of stagnation in a big circle of blood circulation, this action warns an overload of a left ventricle.
Pathological blood loss in R. at patients with heart disease shall be filled adequately on volume. The circulatory unefficiency cannot serve as a contraindication to a transfusion. Blood shall be the minimum shelf-life, on each 250 ml of a citrated blood enter 5 ml of 10% of solution of a gluconate of calcium. Compensation of massive blood loss should be begun with introduction of Polyglucinum (200 — 400 ml) together with 30 — 100 mg of Prednisolonum. The last is necessary for the prevention of glucocorticoid insufficiency. Massive infusions of blood shall be followed by inhalation of oxygen (see. Oxygen therapy).
A frequent and terrible complication in R. at patients with heart disease is the fluid lungs (see). It develops at the beginning of patrimonial activity more often, but can arise both in II, and in the III periods of River. Emergence of a fluid lungs at patients with heart disease in R. is promoted: anemia in connection with big blood loss; increase in permeability of pulmonary vessels as a result of a rheumatic vasculitis; build-up of pressure in a pulmonary trunk and the expressed disproteinemia. Signs of a fluid lungs are the progressing asthma passing into suffocation, cough, plentiful wet rattles, pallor and cyanosis of lips, frequent small pulse, emergence foamy pink (with impurity of blood) phlegms.
Tactics of the obstetrician is various depending on in what period of R. the fluid lungs developed. In the I period it is reasonable to suspend and not to force R., to concentrate efforts on fight against an acute heart failure (see). Only after removal of the patient from a condition of a fluid lungs it is possible to raise a question of the most careful way of delivery depending on an obstetric situation. In the II period of R. obstetric tactics other: it is necessary to finish as soon as possible childbirth, it is more preferable (in the presence of conditions) by imposing of obstetric nippers, at the same time carrying out an intensive care (see). In the III period of R. all efforts are bent on fight against a fluid lungs. In cases of inefficiency of medicamentous therapy urgent heart operation — a mitral commissurotomy according to vital indications is admissible (see the Heart diseases acquired).
Considering the lowered resilience of women in labor with cardiovascular diseases and a possibility of development in them of a septic infection, it is recommended with the preventive purpose to appoint by it antibiotics or sulfanamide drugs with a complex of vitamins.
Childbirth at infectious hepatitis
Rhoda at infectious hepatitis carry out in the conditions of the boxed department of infectious diseases hospital. The most frequent complication of R. is bleeding in the III period of R. and an early puerperal period in connection with hypotonia and disturbance of system of a hemostasis.
Childbirth at diseases of lungs
At a pulmonary tuberculosis (see Tuberculosis of a respiratory organs) R. proceeds without essential complications, at pneumonia the hypoxia of a fruit is possible. Childbirth conducts expectantly. According to indications cardial therapy, an oxygenotherapy is carried out, imposing of band nippers is possible (better under local anesthesia).
Childbirth at pyelonephritis
Rhoda at pregnant women with acute pyelonephritis (see) proceeds spontaneously. In labor broad use of antispasmodics is shown. Delivery Caesarian should be carried out by section according to strict indications (extra-peritoneal Cesarean section is more preferable). During R. continue the antibacterial therapy begun during pregnancy. At hron. pyelonephritis owing to frequent development of late toxicosis of pregnant women (see) the issue of early delivery (in the absence of effect of the carried-out therapy), especially is more often resolved if duration of gestation exceeds 35 — 36 weeks. In the absence of indications (taking into account other obstetric pathology) childbirth leads to the emergency termination of pregnancy expectantly. In labor prevention of a hypoxia of a fruit, and also bleedings in afterbirth and early puerperal the periods is carried out.
Childbirth at an idiopathic hypertensia
Rhoda at an idiopathic hypertensia can be followed by development of late toxicosis of pregnant women. Bleeding in afterbirth and early puerperal the periods is possible. During R. at women with an idiopathic hypertensia (see) creation of the medical and guarding mode, purpose of the means reducing arterial pressure is necessary (Dibazolum on 20 mg of 1 — 2 time a day, an Euphyllinum on 0,1 — 0,2 g 3 times a day, Reserpinum on 0,1 — 0,25 mg 2 — 3 times a day). Adequate anesthesia of River is important. At increase in arterial pressure in the II period of R. and deterioration in the general condition of the woman in labor it is necessary to accelerate R. by imposing of obstetric nippers on a head of a fruit of a pla of extraction of a fruit the pelvic end. In cases of disturbance of cerebral circulation (see) abdominal Cesarean section is shown. At the end of the period of exile and the III period of R. events for prevention of bleeding are held (see below bleedings in the afterbirth period).
Childbirth at arterial hypotension
carries a condition of pregnant women when systolic arterial pressure does not exceed 105 mm of mercury To hypotension., diastolic — 60 mm of mercury. R.'s current at women in labor with arterial hypotension (see Hypotension arterial) quite often is followed by development of weakness of patrimonial forces and a hypoxia of a fruit therefore timely diagnosis and therapy of weakness of patrimonial forces (see above weakness of patrimonial activity) and hypoxias of a fruit is necessary (see Asphyxia of a fruit and the newborn). At the end of the II period and in the III period of R. it is necessary to hold events for prevention of bleeding (see below bleeding in labor). At blood loss over 400 ml it is necessary to begin to enter plasma substitutes. Pathological blood loss shall be completely recovered.
Childbirth at anemia
the Pathogeny and clinic of anemia of pregnant women — see Anemia. Rubles at women with anemia can be followed by a hypoxia of a fruit and bleeding in afterbirth and early puerperal the periods. Conducting childbirth waiting. It is necessary to carry out prevention and treatment of a hypoxia of a fruit (see Asphyxia of a fruit and the newborn). At the end of the second and in the third R.'s periods prevention of possible bleeding is carried out. At blood loss over 400 ml are necessary early and its adequate completion (a packed red cells, plasma substitutes, a whole blood).
Childbirth at a diabetes mellitus
Rhoda at a diabetes mellitus quite often causes ahead of schedule (see. diabetes mellitus, pregnancy and disturbance of sexual function ). Features of a current of R. depend on the sizes of a fruit (the large fruit is more often), often found accompanying complications (a hydramnion, a nephropathy), degree of a pre-natal chronic hypoxia. At the large sizes of a fruit, a hydramnion it is possible to expect development of primary and secondary weakness of patrimonial forces. In the course of R. the hypoxia of a fruit is often shown, especially at additional complications of pregnancy. Rubles, as a rule, can pass through natural patrimonial ways; Cesarean section is made generally according to obstetric indications. During R. it is necessary to continue treatment of the woman in labor by insulin under control of a sugar content in blood and urine. Timely diagnosis and therapy of weakness of patrimonial forces are important (see above weakness of patrimonial activity). In the course of R. hold events for prevention and treatment of a hypoxia of a fruit. During the period of exile it is necessary to be ready to the complicated removal of a coat hanger. At the end of II and in the III period P, perform prevention of bleeding (see below bleedings in the afterbirth period).
Childbirth at late toxicoses of pregnant women
in case of lack of effect of the carried-out complex treatment of late toxicosis of pregnant women early delivery, especially is shown if it is possible to expect the birth of a viable fruit. The choice of a method of delivery (Cesarean section or in natural patrimonial ways) depends on severity of toxicosis, a condition of a fruit and the accompanying obstetric pathology. In the absence of indications to operational delivery (it is applied according to strict indications) resort to initiation of patrimonial activity (see above). Prevention of a hypoxia of a fruit, bleedings in afterbirth and early puerperal the periods is carried out. In labor widely apply anesthetics and antispasmodics. At rodorazreshayushchy operations (an application of forceps, extraction of a fruit in natural patrimonial ways) anesthesia by means of an anesthesia is reasonable.
Childbirth at a hydrops gravidarum
Rhoda at a hydrops gravidarum (see) proceeds usually without special complications, however it is necessary to watch the arterial pressure of the woman in labor carefully. In case of increase it the events directed to decrease in the ABP and prevention of bleeding are held (see below bleeding in labor).
Childbirth at a nephropathy
At a nephropathy quite often arises complications: a hypoxia of a fruit, premature amotio of normally located placenta, transition of a nephropathy to a preeclampsia and an eclampsia. Such R.' maintaining consists in careful overseeing by the woman in labor, effective anesthesia of R., carrying out measures of prevention and treatment of a hypoxia of a fruit; if necessary — switching off of attempts.
The first period of R. at a nephropathy of pregnant women (see) it has to be carried out in the special darkened chamber isolated from noise. Carry out hypotensive therapy (an Euphyllinum intravenously, Dibazolum, a papaverine intramusculary or intravenously, rausedyl intramusculary, Reserpinum inside), during a cut careful overseeing of the patient is necessary. At disclosure of a neck of uterus on 5 — 6 cm early opening of a bag of waters with tselyo decrease in intrauterine pressure is shown.
The high arterial pressure which is not decreasing under the influence of the carried-out therapy, and threat of transition of a nephropathy to a preeclampsia and an eclampsia are the indication to carrying out the managed hypotonia (see Hypotonia artificial). For this purpose apply arfonad, Pentaminum, petrolhexonium and other ganglioblokiruyushchy means (see). At the same time reduce systolic arterial pressure to 140 — 120 mm of mercury. The managed hypotonia is shown in II and III periods of childbirth. At a severe form of a nephropathy in case of impossibility to apply this method switching off of attempts (extraction of a fruit the pelvic end at pelvic presentation and by means of obstetric nippers — is necessary at head).
In the third period of childbirth hold events for prevention of hypotonic bleeding. Blood loss at the women suffering from a nephropathy quickly becomes dekompensirovanny and quite often is followed by a vascular collapse (see). Pathological blood loss shall be compensated on volume completely by blood and blood-substituting liquids.
Childbirth at a preeclampsia and an eclampsia
Rhoda at a preeclampsia and an eclampsia can be followed by the same complications, as at a nephropathy, but they arise much more often. The preeclampsia and an eclampsia (see) during R. constitute serious health hazard of the woman in labor (a possibility of a hematencephalon, amotio of a retina, etc.)*. R.'s maintaining is admissible only in the special darkened chamber isolated from noise in the presence of a separate post of the midwife. In the course of childbirth carry out hypotensive therapy by alkaloids of group of Rauwolfia (serpasil, Reserpinum). Widely use spasmolytic drugs (Nospanum, a papaverine, Dibazolum, repeatedly enter an Euphyllinum). Intravenous administration of glucose (30 — 50 ml of 40% of solution from 0,2 g of ascorbic acid 2 — 3 times a day) promotes cerebral decompression, increase in a diuresis, improvement of food of a muscle of heart.
All manipulations (measurement of arterial pressure, vaginal examonation, injections) carry out against the background of a protoxidic acid-native analgesia. Also use of a radio and oxygen and ftorotanovy anesthesia (see), and also use of trichloroethylene (Trilenum) with oxygen is admissible. Psychosedation is reached by intravenous administration of 2 — 3 ml of Droperidolum in combination with one of antihistaminic drugs (Dimedrol, Suprastinum, Pipolphenum) or all-sedative (diazepam — 5 — 10 mg). At disclosure of a neck of uterus on 4 — 5 cm of R. conduct under anesthetic (viadril) by fractional administration of drug (on 0,5 — 0,6 g). The general dose can be brought to 2 g. The anesthesia is supported before the termination P., and also in an early puerperal period.
Infusional therapy (see) during R. at these states shall be extremely reduced and is carried out against the background of sedative and hypotensive therapy. The indication to infusional therapy are symptoms of wet brain, and also an anury. The volume of the entered liquid shall not be big, it is in strict accordance with the size of a diuresis and indicators of a hemodynamics. Infusional therapy promotes recovery of microcirculation and elimination of a hypovolemia.
At an eclampsia it is necessary to aim at acceleration of delivery by careful methods. The precocious rupture of a bag of waters (is reasonable at disclosure of a neck of uterus on 3 — 4 cm). According to indications apply obstetric nippers and extraction of a fruit for the pelvic end. Resort to Cesarean section according to the following indications: inefficiency of therapy within a day, the proceeding attacks of an eclampsia, long coma, hemorrhage in an eyeground, a retinitis, amotio of a retina, an anury and the expressed oliguria (with a cylindruria and a proteinuria), premature placental detachment and other complications in the absence of conditions for delivery in natural patrimonial ways. In the third period of R. hold the events directed to prevention of possible hypotonic bleeding. Pathological blood loss shall be filled adequately.
SHOCK AND the EMBOLISM IN LABOUR
Shock — rather rare complication, its frequency considerably decreased in connection with timely recognition of the morbid conditions contributing to its development and rational maintaining River. The acute decompensation of blood circulation observed at shock in labor is shown by a symptom complex: concern, black-out, pale cyanochroic or marble coloring of skin, to the touch it cold and wet, tachycardia, lowering of arterial pressure and its small amplitude, dispnoe, oliguria. In the course of R. various clinical forms of shock can develop: hemorrhagic, or hypovolemic shock (see), cardiogenic shock (see), septic shock (see Sepsis), an acute anaphylaxis (see). Earlier existing opinion on existence of so-called patrimonial shock with not clear genesis at spontaneous R. is rejected now.
Hemorrhagic (hypovolemic) shock arises at the massive blood loss in labor (25 — 30% of volume of the circulating blood and more) caused by pathology of an implantation of placenta, a hysterorrhesis, hypotonia and an atony of a uterus in the III period of R., disturbances in system of a hemostasis (e.g., at pre-natal death of a fruit), spontaneous or artificial (violent) injuries of soft tissues of a genital tract. The combination of the specified reasons, especially with disturbances in system of a hemostasis is sometimes observed. At massive obstetric bleedings the syndrome of the disseminated intravascular coagulation, as a rule, develops (see. Hemorrhagic diathesis) with the subsequent hypocoagulation.
Obstetric bleedings at the specified forms of pathology happen preferential outside, is more rare — internal (e.g., at a hysterorrhesis); arise suddenly more often and quickly progress. At a hysterorrhesis bleeding in R. is combined with sharply expressed pain syndrome that extremely quickly exhausts kompensatornozashchitny mechanisms and leads to development of shock even at the blood loss which is not exceeding 15 — 20% of volume of the circulating blood.
Cardiogenic shock in R. connected with reduction of minute volume of heart owing to disturbances of its functional activity is observed rather seldom. He is possible at the women in labor having myocarditis, heavy heart diseases and disturbances of a cordial rhythm.
Septic shock (bacterial, endotoxic shock) is considered as the state caused by inadequate perfusion of fabrics as a result of defeat of a peripheral vascular bed endotoxins of gram-negative or (more rare) exotoxins of gram-positive bacteria. In a pathogeny of septic shock in R. an essential role is played disturbance of exchange of biogenic amines, neuro vaskulyatornykh reactions, by secondary changes in oxidizing metabolism, endocrine function, the expressed changes in system of a hemostasis (possibility of a syndrome of the disseminated intravascular coagulation). Can be a proximate cause of septic shock in R. horioamnionit, acute purulent pyelonephritis, purulent defeats of other bodies.
Septic shock develops against the background of the symptoms characteristic of the heavy progressing bacterial infection. Its important signs — discrepancy between the expressed arterial hypotension and rather small size (or total absence) blood losses, an oliguria, thrombocytopenia.
The acute anaphylaxis in R. meets less often in comparison with other clinical forms of shock. Main reasons for shock: irrational use of antibiotics, especially benzilpenitsil-lin and semi-synthetic penicillin (ampicillin, Oxacillinum, Methicillinum), and also incompatible blood transfusion. It use of other pharmaceuticals (novocaine, pyramidon, etc.) without their portability can be the cause.
Shock in labor needs to be differentiated from other forms of shock, and also from a myocardial infarction (see), pancreatitis (see), premature amotio of normally located placenta, an eclampsia, an embolism amniotic waters (see below).
The general principles of treatment of all a wedge, forms of shock in R. come down to elimination of pain (adequate anesthesia), a hypovolemia under control of the central venous pressure, correction of metabolic disturbances, pharmacotherapy (appoint slmpatomimetichesky, positive and inotropic drugs, corticosteroids, heparin, Streptokinasa, diuretics), oxygen therapy (see). At the same time treatment of shock shall be differentiated and be defined by its clinical form. At hemorrhagic shock and need of massive transfusions it is necessary to use whenever possible fresh donor, previously warmed up blood. At the cardiogenic shock and disturbances of a heart rhythm which arose as the reason or the investigation of shock apply the means normalizing a rhythm. At septic shock in R. antibacterial therapy with use of antibiotics of a broad spectrum of activity is shown. At an acute anaphylaxis the desensibilizing therapy (antihistaminic drugs, corticosteroids) amplifies, antispasmodics are more widely used.
An essential role in the prevention of shock is played by active therapy of obstetric pathology, against the background of a cut shock, and rational obstetric tactics developed, including also necessary operative measures (e.g., at a hysterorrhesis — sewing up of a gap, a hysterectomy; at a horioamnionita — the most bystry delivery according to a specific obstetric situation).
Irreversible changes in bodies and fabrics at septic shock occur much quicker, than at hypovolemic shock. The lethal outcome most quickly can come at an acute anaphylaxis in R. (owing to sudden release of mediator substances).
An embolism in labor
Distinguish a thromboembolism (see), an embolism amniotic waters and an air embolism (see).
The thromboembolism meets seldom, usually in a puerperal period, especially at emergence inf. complications. The pregnancies of fibrinferments transferred to time and thrombophlebitis of vessels of the lower extremities and a small pelvis significantly increase risk of a thromboembolism in the course of a childbed. The thromboembolism can arise after the massive blood losses which are especially connected with disturbance of blood coagulation after Cesarean section and at insufficient compensation of blood loss.
The embolism amniotic waters meets seldom — about 1 case on 20 Ltd companies of childbirth, is more often at multipara, after 30 years, at the end of the first period of R., after a rupture of fetal membranes (spontaneous or artificial), at bystry R. with excessively strong patrimonial activity, at pre-natal death of a fruit, at operation of Cesarean section. The pathogeny is caused by receipt in a blood stream of mother of amniotic waters and vorsin chorion through the gaping vessels of a body of the womb, the matochnoplatsentarny platform (at a hysterorrhesis, premature amotio of normally located placenta, at Cesarean section, etc.) and their drift in system of pulmonary arteries. Accumulation in arterioles of the smallest elekhment which are contained in amniotic waters (scales of an epithelium, meconium, slime) leads to development of shock as anaphylactic (see above) with possible massive bleeding in the subsequent as a result of hypo - or afibrinogenemiya (see).
The clinical picture is characterized by sudden development of cyanosis, dispnoe, heavy hypotonia, a fluid lungs, a relaxation of a uterus and profuse uterine bleeding in afterbirth and early puerperal the periods and is followed, as a rule, by disturbance of system of a hemostasis.
In cases of a lethal outcome during R. or soon after their end the diagnosis is confirmed by detection at a morphological research of elements of amniotic waters in uterine and pulmonary vessels. At a happy end when the diagnosis remains unconfirmed, there are all bases to think of other reasons which caused the described clinical picture. Treatment of an embolism amniotic waters shall be immediate and vigorous. It is necessary to transfer the patient to the managed breath urgently (see. An artificial respiration), hold events for fight against a fluid lungs (see), a massive hemotransfusion (direct hemotransfusion is desirable), intravenous administration of fibrinogen. For stopping patol. a fibrinolysis (see) use inhibitors of proteolysis (Trasylolum, Contrykal, Gordoxum). For the purpose of elimination of a bleeding point the hysterectomy is shown (see).
The air embolism represents the most rare kind of an embolism in the River. It is caused by hit of air in the gaping vessels of a uterus during R. or in an early puerperal period. Existence of negative pressure in an abdominal cavity, a bystry postural change of a body of the woman in labor, manual interventions in cavities of the uterus and in a vagina (operations, grants), low arterial pressure are the factors promoting development of an air embolism. Air from uterine veins through venous vessels of a basin gets to the lower vena cava, further to the right half of heart and to a pulmonary trunk. The air embolism is clinically shown by sudden blanching of skin, feeling of constraint in a breast, frequent low arrhythmic pulse, expansion of pupils, fading of reflexes, quite bystry termination of cordial activity. The same medical actions, as at an embolism amniotic waters.
Prevention of shock and embolism in R. comes down to the prevention and elimination of those factors, to-rye promote their development (late toxicoses of pregnant women, anemia, an allergy, existence of a bacterial infection, unreasonable use of antibiotics, irrational maintaining R., the wrong performance of obstetric grants and operations, etc.).
Horioamnionit. Recently it is shown that at infection of a uterus first of all the inflammation of chorial and amniotic covers develops (horioamnionit) and only in the subsequent it can extend to an endometria (see the Metroendometritis). Infection of a uterus and its contents is promoted by a long anhydrous time term, long R., a low arrangement of a placenta, frequent vaginal examonations, pustulous diseases at the woman in labor. The general condition of the woman in labor can remain satisfactory. Are observed fervescence to 38 ° above, frequent pulse (110 — 120 blows in 1 min.), a fever, a leukocytosis, putreform with off-flavor of allocation from a genital tract. Horioamnionit provokes and aggravates weakness of patrimonial activity. Usually after the birth of a fruit and an afterbirth temperature decreases, the general state improves and the puerperal period proceeds normally. But at heavy pathological R. and their irrational maintaining horioamnionit in labor it is transformed to this or that puerperal infectious disease (see. Puerperal diseases). Horioamnionit in labor increases percent of mortinatality and a neomortality. Treatment consists in appointment in the earliest terms of antibiotics — semi-eintetichesky penicillin (Oxacillinum). Taking into account an obstetric situation aim at acceleration of childbirth: in the I period — medicamentous stimulation of patrimonial activity, in II — extraction of a fruit (imposing of obstetric nippers, vacuum extraction). At a dead fruit and existence of conditions perforation of a head is shown.
BLEEDING IN LABOUR
Bleeding in R. is possible in I, in II, in the III periods of R., and also in an early puerperal period. Having arisen in the I period of R., it can amplify in the III period and immediately after R. Krovotecheniye, begun in the afterbirth period, often proceeds in an early puerperal period. Blood loss in afterbirth or early puerperal the periods, exceeding in size of 0,5% in relation to body weight, is considered as pathological. Distinguish the acute bleeding arising in R., and bleedings, to-rye can repeat several times during pregnancy and amplify during R. Vydelyayut three phases of reaction of an organism to blood loss: compensations, decompensations, final bradycardia with the subsequent cardiac standstill.
Bleeding in I and II periods of childbirth. The possible reasons of bleeding in I and in the II periods of R. are: to the predlezhayena of a placenta or its low arrangement; premature amotio of normally located placenta, traumatic injury of a vagina and neck of uterus, a rupture of varicose veins of a vagina, an erosion, polyps and cancer of a neck of uterus. Pathology of soft patrimonial tissues is excluded at survey of external genitals, vaginas and necks of uterus by means of mirrors.
Predlezhanne of a placenta (placenta praevia) is the most frequent reason of bleeding in the I period of R. and is connected with disturbance of an integrity of intervillous sine. At this pathology there can be insignificant bleeding during pregnancy and repeat several times; from the beginning of patrimonial activity bleeding, as a rule, amplifies. An etiology and a pathogeny, clinic and diagnosis — see Placental presentation.
Conducting childbirth depends not only on a type of placental presentation, but also on intensity of bleeding and reaction of an organism to blood loss. In the I period of R., when there is no conditions for bystry delivery in natural patrimonial ways, irrespective of a type of presentation at plentiful bleeding Cesarean section is shown. At the full (central) placental presentation diagnosed during pregnancy or at the beginning of R. even at small bleeding also make Cesarean section. At incomplete placental presentation, good patrimonial activity, occipital presentation and disclosure of a neck of uterus not less than on 2 — 3 cm open with a branch of bullet nippers a bag of waters that warns further placental detachment. The falling head presses the exfoliated part of a placenta to the placental platform, and bleeding stops. In further R. proceed usually physiologically.
If after opening of a bag of waters the head of a fruit does not fall quickly enough to a small pelvis and bleeding proceeds, impose craniodermal nippers according to Ivanov with a load weighing 300 — 400 g (see. Craniodermal nippers ). The fixed head presses down fabrics of the lower segment of a uterus and reflex strengthens patrimonial activity. The tool can remain on a head within 3 — 4 hour. It should be removed to this term if good patrimonial activity developed, the head fell to a pelvic cavity and bleeding stopped.
At pelvic presentation and the mobile prelying part (leg) it is possible to try to make (carefully) bringing down of a leg and suspension of a load to it in 200 g. Extraction of a fruit at incomplete disclosure of a neck of uterus is contraindicated as it conducts to a rupture of a neck of uterus with possible transition it on the lower segment and to profuse bleeding.
Now at partial placental presentation and the mobile prelying part in a case an izli-tiya of amniotic waters make Cesarean section.
At side or regional placental presentation and incomplete disclosure of a neck of uterus (on 4 — 5 cm) if the fruit is dead or impractical owing to deep prematurity, nek-ry obstetricians recommended to make version on a leg according to Braxton Giks (see. Obstetric turn ). Now this operation is almost not applied.
In all cases when in attempts of delivery in the vulval way it is not possible to cope with bleeding, urgent performing Cesarean section is shown.
After the birth of a fruit for the purpose of prevention of possible bleeding in the afterbirth period intravenously kapelno enter 1 ml of an oksn-totsin or 1 ml of methylergometrine together with solution of glucose. If within 30 — 40 min. the afterbirth was not born or bleeding amplified, under anesthetic start manual department of a placenta and allocation of an afterbirth with simultaneous audit of walls of a cavity of the uterus. Manual inspection of a uterus (see. The afterbirth period) make also at the spontaneous birth of an afterbirth and doubt in its integrity. In all cases of placental presentation necks of uterus by means of mirrors after the delivery examine (see. Gynecologic research).
Owing to a hypotonic condition of an isthmus of a uterus in an early puerperal period perhaps hypotonic bleeding, for a stop to-rogo is carried out the corresponding therapy.
Premature amotio of normally located placenta. An etiology, a pathogeny and clinic — see. Premature otsly placentae.
Make inspection of the woman in labor in the following order for diagnosis of a source and a form of bleeding: collecting the anamnesis, assessment of the general state (including indicators of hemoglobin and a hematocrit), a palpation of a uterus, survey of external genitals and definition of nature of blood allocations, vaginal examonation. First of all it is necessary to exclude a possibility of premature amotio of normally attached placenta. Existence in the anamnesis of late toxicosis of pregnant women, idiopathic hypertensia and other vascular pathology, injuries of a stomach, identification at a palpation of a local painful swelling, constant tension of a uterus allow to suspect this pathology. Small outside bleeding at the expressed change of the general condition of the woman in labor (weakness, tachycardia, pallor of skin and mucous membranes, decrease in the ABP) and falling of hemoglobin is characteristic of it that indicates internal bleeding. At placental presentation, on the contrary, expressiveness of anemia corresponds to the size of outside blood loss.
Further estimate a condition of soft patrimonial ways, generally at survey by means of mirrors. And only after that make vaginal examonation to exclude placental presentation. The diagnosis is confirmed at ultrasonic investigation.
Tactics of conducting childbirth at this pathology depends on a clinical picture and an obstetric situation. At disclosure of a neck of uterus on 3 — 4 cm and good patrimonial activity in case of the small and completely compensated blood loss further amotio can be suspended by opening of a bag of waters that is especially effective at its flatness. If symptoms of premature placental detachment remain, Cesarean section is shown. At the phenomena of the accruing decompensation of blood circulation and unpreparedness of patrimonial ways to Cesarean section resort even at a dead fruit. If during a chrevosecheniye find multiple extensive hemorrhages in a wall of a uterus (Kuveler's uterus), make its extirpation (see the Hysterectomy).
In the II period of R. tactics consists in bystry and careful delivery. If the head of a fruit is over an entrance to a basin and mobility of a fruit (e.g., the second fruit is kept at twin), classical version and its extraction is shown. In case of pre-natal death of a fruit its head is perforated. At the prelying part of a fruit inserted into an entrance to a basin acceleration of emptying of a uterus can be carried out by means of a vacuum extractor, imposing of obstetric nippers (a head in a pelvic cavity or in escaping it), extraction of a fruit the pelvic end, and at a dead fruit — - craniotomies (see) with the subsequent cranioclasia (see. Fetaldestructive operations). In case of hemorrhagic shock even at full disclosure of a neck of uterus make Cesarean section.
After delivery in natural patrimonial ways at all women in labor under anesthetic make manual department of a placenta with simultaneous audit of walls of a uterus to exclude disturbance of an integrity them. For the purpose of the prevention of hypotonic bleeding intravenously enter the means reducing a uterus (see above).
Bleeding in afterbirth and early puerperal the periods. Bleeding (see) in afterbirth and early puerperal the periods is possible at the women in labor who transferred the frequent and especially complicated abortions, inflammatory diseases of generative organs and also at women in labor with infantility, a hydramnion, a multiple pregnancy, toxicosis of the second half of pregnancy, anomaly of patrimonial activity, postmature pregnancy.
Bleedings in the afterbirth period can be connected with an injury of soft tissues of patrimonial ways, disturbance of separation of a placenta from walls of a uterus and its allocation from a uterus (a delay in a uterus of the separated placenta, hypotonia of a uterus, infringement of a placenta in a uterus, a dense attachment or an increment of a placenta).
Bleedings in an early puerperal period can be caused: a delay of parts of a placenta in a cavity of the uterus (see. Puerperal period, pathology); hypotonia or an atony of a uterus (see. Hypotonic bleedings); a hypofibrinogenemia and an afibrinogenemiya (see); rupture of soft tissues of patrimonial ways.
Bleeding at a rupture of soft tissues of patrimonial ways arises right after the birth of a fruit; despite bleeding, the uterus dense, well reduced, does not stop introduction of the means reducing a uterus and does not reduce krovo-ioteryu. Diagnosis is facilitated by survey of external genitals, a research by means of mirrors of a neck of uterus and walls of a vagina.
The stop of bleeding in the afterbirth period is possible only after department and allocation of an afterbirth. Events are held in the following sequence: bladder emptying by means of a catheter; intramuscular or intravenous administration of the means reducing a uterus (oxytocin, metilergomet-rin, etc.); allocation afterbirth (see) Abuladze or Krede's receptions — Lazarevich (see. Afterbirth period); manual department and allocation of an afterbirth. At plentiful bleeding quite often it is necessary to start manual department of an afterbirth at once (see. Afterbirth period). At suspicion on a true increment of a placenta (see) it is necessary to stop attempts to separate a placenta and to make a chrevosecheniye with the subsequent supravaginal amputation or a hysterectomy depending on an arrangement of a placenta.
For the prevention of bleeding in afterbirth and early puerperal the periods it is recommended: introduction of the means reducing a uterus (intravenously methylergometrine or oxytocin) at the time of disengagement or a front plechik, bladder emptying by means of a catheter, weight on a stomach at a hydramnion, a multiple pregnancy, a large fruit; in an early puerperal period — ice on area of a projection of a uterus.
At the same time with means of fight against bleeding it is necessary to hold events for compensation of blood loss and fight against air hunger. Timely and adequate therapy of anemia of pregnant, late toxicoses of pregnant women is necessary for the prevention of bleeding in afterbirth and early puerperal the periods, for thrombocytopenia and a trombotsitopatiya.
To birth trauma is referred by ruptures of a crotch, vulva, vagina; hematomas of a vulva and vagina; ruptures of a neck of uterus; hysterorrhesis, traumatic necrosis of a neck of uterus; ectropion of a uterus; injuries of pelvic bones (most often — discrepancy or symphysiolyses), injuries of a bladder (see) and a rectum (see the Rectum), puerperal fistulas (see. Urinogenital fistulas).
Ruptures of a crotch — injuries of a crotch in the course of a childbed. Distinguish spontaneous (not connected from a kashsh-lib by intervention) and violent (depending on obstetric interventions) gaps. The factors promoting a rupture of a crotch are: the high or rigid crotch, its cicatricial changes, narrowness of a pubic arch of a basin, a small inclination of a basin, nek-ry types of its anomaly (ploskorakhitichesky, funneled, infantile), at to-rykh occur either rapid childbirth, or the prelying part of a fruit meets obstacles in the way (a narrow pubic corner) that causes supertension on a crotch, and also the wrong rendering a manual grant at pelvic or head presentation, disengagement big, than usually, the size at extensive predlezhaniy (perednegolovny, frontal, front), a big circle of a head, its increased density and a bad configuration, operative measures in labor (an application of forceps, extraction of a fruit), etc. More detailed ruptures of a crotch, their treatment and prevention — see. Crotch .
Ruptures of a vulva and vagina. Quite often along with a rupture of a crotch there are gaps in small lips (continuous, fenestrated, plane cracks), gaps in an urethra and strongly bleeding gaps in a clitoris. All of them (except insignificant plane cracks) are subject to mending, and the bleeding vessels — to an obkalyvaniye and bandaging; anesthesia is obligatory. During the mending of damages near an urethra in - it enter a metal catheter in order to avoid its bandaging. At gaps in a clitoris stitches should be put superficially since the puncture of cavernous bodies leads to plentiful bleeding.
Colporrheses on localization divide into gaps in an upper, average and lower third of a vagina (see), on a pathogeny — on spontaneous (not connected with any obstetric intervention) and violent (at various obstetric interventions). Colporrheses in its upper third most often represent separations of a uterus from the arches and on a clinical picture are close to hysterorrheses. Sometimes they deeply get into a parametrium (e.g., at rough introduction of spoons of nippers), strongly bleed and even after mending quite often heal second intention. The isolated gaps in an average third of a vagina meet seldom, also are violent and are very dangerous concerning infection (extensive suppuration, a necrosis of a wall, etc.). More often they are continuation of gaps in the lower third of a vagina. Each colporrhesis shall be taken in, the bleeding vessels are tied up.
Prevention of colporrheses and a vulva comes down to the correct conducting childbirth, especially at a vrezyvaniye and eruption of the prelying part of a fruit, a cut consists in slow removal of a head the smallest size (so-called protection of a crotch); to careful performance of obstetric interventions with observance of all necessary rules according to the mechanism of childbirth. For the purpose of relaxation of muscles of a pelvic bottom (for protection of a crotch against a gap) recommend to carry out pudendalny anesthesia (see Anesthesia local) or introduction of muscle relaxants of the central action (mefedol, mioka-in, etc.), and also introduction of a lidaza to a crotch (at rigidity of its fabrics). At threat of a gap make a perineotomy for protection of a crotch (see) or an epiziotomiya. Decrease in traumatism of soft tissues of patrimonial ways is promoted by fi-ziopsikhoprofilaktichesky training of pregnant women for childbirth.
Hematomas of a vulva and vagina. Hemorrhages in hypodermic cellulose of vulvar lips or in a paravaginal fat are result of the injuries got during pregnancy (from bruises, blows, etc.) or childbirth (at bystry childbirth, the prolonged period of exile, imposing of obstetric nippers, etc.). Most often at the same time varicose nodes or vessels of deep fabrics are damaged, and the mucous membrane of a vagina and skin of a vulva remain unimpaired. The size of a hematoma depends not only on number or caliber of the damaged vessels, but also on coagulability of blood. Sometimes hematomas of a vulva and a vagina can extend on cellulose up to gluteuses.
Clinically a hematoma (see) it is shown by emergence and rapid growth of a tumor in the field of vulvar lips, a vagina or a crotch, pressure sense or a raspiraniye, sharp morbidity in the field of the right or left vulvar lips. Hematomas of a vagina are diagnosed most often at vaginal examonation, sometimes they are stuck out from a sexual crack. The hematoma of a vulva is defined in the form of tugoelastichny formation of crimson color in the field of vulvar lips, a thicket left. Treatment, as a rule, conservative. Small hematomas resolve spontaneously. At big hematomas appoint a bed rest, a compressing bandage, a hard tamponade of a vagina, locally cold, inside a gluconate of calcium, ascorbic to - that and citrin, at considerable blood losses — antianemic means.
Only the huge, quickly accruing hematomas demand opening with an obkalyvaniye of the bleeding vessels and open maintaining a wound or its mending with the subsequent drainage (see). Also it is necessary to arrive if over a hematoma there are sites of a necrosis, to-rye serve as entrance gate for an infection. The suppuration of a hematoma which is followed by rise in temperature, increase of pulse, etc. demands iyemedlenny opening it.
Prevention of hematomas consists in carrying a special bandage by pregnant women at varicose nodes of a vulva, the correct conducting childbirth, careful carrying out obstetric interventions and operations, timely treatment of disturbances of system of a hemostasis and vascular diseases.
Ruptures of a neck of uterus. Ruptures of a neck of uterus can be spontaneous and violent. Spontaneous gaps meet at bystry childbirth, a large fruit, anomalies of insertion of a head more often (extensive, asynclitic), the long childbirth which is followed by long squeezing of soft tissues of an outside pharynx, rigidity of a neck and its inflammatory changes, operative measures on a neck of uterus in the past (a diatermoekstsiziya, plastic surgeries, etc.). Processes of smoothing and disclosure of a neck of uterus are connected with stretching and thinning of its fabrics, especially in an outside pharynx. Therefore small ruptures or anguishes of a neck of uterus in an outside pharynx are almost inevitable, but they often remain not distinguished even at survey of a neck by means of mirrors right after childbirth and seldom cause noticeable bleedings. At pathological childbirth, especially at use of obstetric interventions, ruptures of a neck of uterus meet considerably more often, quite often are followed by considerable bleedings and other complications. I. F. Zhordaniya suggested to distinguish 3 degrees of gaps: 1 degree — a gap up to 2 cm long, the II degree — a gap more than 2 cm long, but not reaching a vault of the vagina, the III degree — the gap reaching a vault of the vagina or passing to the arch. Ruptures of a neck of uterus of all three degrees are followed by outside bleeding, a cut is especially expressed at ruptures of the III degree, at the same time parametralny hematomas in connection with internal bleeding are formed. Ruptures of a neck of uterus of the III degree sometimes pass into ruptures of an isthmus of a uterus.
Clinically small ruptures of a neck of uterus proceed asymptomatically, big and deep gaps are shown by bleedings in afterbirth and early puerperal the periods. Till the birth of an afterbirth the bleeding point from a genital tract is, as a rule, not clear. If after the birth of an afterbirth the uterus was well reduced, and bleeding proceeds, then it is necessary to think of bleeding from ruptures of soft patrimonial ways (a neck or a vagina). The diagnosis is established after survey of a neck of uterus and a vagina by means of a mirror. For convenience of survey of a neck of uterus impose bullet or fenestrated nippers on edges of a pharynx, and then, gradually moving them, consistently examine all «border» of a uterine pharynx.
Survey of a neck of uterus in mirrors is obligatory after the delivery. Even small ruptures of a neck at their detection shall be taken in since they are gate for a puerperal infection and a source of various gynecologic diseases (erosion, ectropions, chronic inflammatory diseases of a neck of uterus including precancerous). Tactics of maintaining women in labor with the ruptures of a neck of uterus of the III degree passing into ruptures of an isthmus of a uterus shall be same, as well as at hysterorrheses (need of a laparotomy, control of degree of a gap, bandaging of vessels and sewing up of a gap).
Prevention of ruptures of a neck of uterus comes down to the correct conducting childbirth and careful carrying out obstetric interventions.
Hysterorrhesis — disturbance of its integrity during pregnancy or in labor. Hysterorrheses oiiyea-nyeshche in 16 century of J. Guillemeau. J. L. Beaudeloque for the first time proved that hysterorrheses are a consequence of mechanical obstacles to delivery, and G. A. Michaelis and Bandl (L. Bandl, 1878) studied the mechanism of typical hysterorrheses in detail. In details the clinic of hysterorrheses was described by L. S. Persianinov (1954).
Hysterorrheses are promoted: the mechanical obstacles in labor connected most often with discrepancy of the sizes of the prelying part of a fruit and a basin of mother; the pathological changes in a wall of a uterus creating inferiority of its muscular layer; combination of the first and second reasons. In the mechanical theory of a hysterorrhesis offered by Bandl, the main role is assigned to mechanical obstacles in labor that is more often observed at the big sizes of a head of a fruit (a huge fruit, hydrocephaly), at a narrow basin, the wrong presentations (frontal, a rear view of front) or insertions of a head (asynclitism), at cross or slanting provisions of a fruit. In the presence of mechanical obstacles to advance of a fruit excessively strong patrimonial activity develops. At the same time the lower segment of a uterus fixed by sheaves to walls of a basin and which does not have an opportunity to follow actively reduced and retracting hollow muscle of a uterus, and also due to the lack of forward advance of a fruit stretches and becomes thinner much more, than usually. The contraction ring (border between a body and the lower segment of a uterus) gradually rises above and above, up to the level of a navel, clearly demonstrating degree of stretching of the lower segment of a uterus and signaling about threat of a hysterorrhesis. At last, degree of stretching and thinning of the lower segment of a uterus, in to-ry as if is born the fruit expelled by a hollow muscle of a uterus, exceeds greatest possible for this muscle. Then there is a hysterorrhesis in the field of the lower segment. In Ya. F. Verbov and N.'s theory 3. Ivanova is emphasized value patol. changes in a wall of a uterus (e.g., existence of a hem, inflammatory changes, congenital anomalies it. the item) when the gap it can occur also in the absence of mechanical obstacles for advance of a fruit, only owing to inferiority of a myometrium. At such mechanism of a gap defective hems of a uterus have the greatest value (see) after Cesarean section, caused by the wrong technology of mending, small term from time of operation before this childbirth, healing of an operational wound second intention, a hyalinosis of a hem and its thinning, and also an arrangement of a placenta in the field of a hem. An essential role in emergence of inferiority of a myometrium is played by puerperal and postabortion septic diseases. The combination patol is especially dangerous. changes in a muscle of a uterus with existence even of small mechanical obstacles for advance of a fruit. Hysterorrheses meet more often at multipara in the period of exile. However at patol. changes in a wall of a uterus the gap it can come in the period of disclosure of a neck of uterus and even at pregnancy.
Hysterorrheses on the classification offered by L. S. Persianinov divide: on time of emergence (during pregnancy, at the time of delivery); on an etiology and a pathogeny (spontaneous, violent, mixed); on localization (in an uterine fundus, in a body of the womb, in the lower segment of a uterus, a separation of a uterus from vaults of the vagina); on the nature of damage (a complete separation, an incomplete gap, a crack); on a clinical current (the menacing, beginning, made gap).
Spontaneous gaps call such, to-rye occur without any intervention in a childbed from the outside; violent — those, to-rye are called by obstetric intervention (e.g., at version on a leg, imposing of obstetric nippers, etc.); the threat of a spontaneous gap is mixed — such, at to-rykh, and then it is forced by obstetric intervention. The complete separation of a uterus takes all its layers, incomplete — only a mucous membrane and a muscular layer. The crack of a uterus in essence is an incomplete gap, usually smaller on the extent and depth. Complete separations occur most often in a body, a bottom, partly the lower segment of a uterus i.e. where the peritoneum closely adjoins to a wall of a uterus. Incomplete gaps occur in those places of a uterus where the peritoneum rykhlo is connected to a muscular layer, usually in side departments of the lower segment of a uterus. Complete separations of a uterus meet by 9 — 10 times more often than incomplete. Most often hysterorrheses in the lower segment, on front or its side surface meet. Gaps in a body and an uterine fundus, as a rule, occur in the field of an old hem after earlier postponed operative measure (Cesarean section, enucleation of fibromatous nodes, sewing up of a perforation opening, etc.).
The menacing hysterorrhesis on a hem during pregnancy is characterized by pains in an anticardium, nausea, vomiting. Then pains develop in the bottom of a stomach. The beginning of a disease quite often imitates a picture of an acute appendicitis (see). During R. weakness of patrimonial forces or their diskoordination join these symptoms. The begun hysterorrhesis on a hem at the time of delivery is characterized by nausea, vomiting, dizziness, constant tension of a uterus owing to formation of a hematoma in the field of a hem, symptoms of a hypoxia of a fruit. There can be bloody allocations from a genital tract.
Typical signs of the menacing hysterorrhesis caused by a mechanical obstacle are stretching of the lower segment of a uterus and its sharp morbidity against the background of excessively strong, sharply painful patrimonial activity sometimes gaining character convulsive, tension and morbidities of round ligaments of uterus, hypostasis of edges of a uterine pharynx, a vagina and a vulva at the expense of their prelum, the complicated urination connected with a prelum of a bladder and urethra, attempt to make an effort at highly in an entrance to a basin the standing head. At survey high standing of the contraction ring is noted (at the level of a navel), at the same time the uterus gets a form of hourglasses.
The begun hysterorrhesis is characterized by accession to the above-stated signs of sensation of fear, extreme concern and excitement of the woman in labor, emergence of sanious or bloody allocations from a genital tract, impurity of blood in urine, an aggravation of symptoms of a fruit (change of frequency of heartbeat and a physical activity). There are painful attempts in the absence of advance of a fruit, highly standing head and full opening of a uterine pharynx.
The doctor shall be guarded especially weakness of patrimonial activity after an izlitiya of amniotic waters and change of nature of heartbeat of a fruit at multipara, in the anamnesis at to-rykh there were complicated or long childbirth, operative measures, septic diseases in the puerperal or postabortion periods, etc.
The made hysterorrhesis regardless of a pathogeny is characterized by a sharp abdominal pain and complete cessation of patrimonial activity (sudden «calm» after «storm»); symptoms of shock and internal bleeding (pallor of skin, low and frequent pulse, falling of the ABP, dizziness, sometimes — a loss of consciousness); emergence of symptoms of irritation of a peritoneum (see Shchetkin — Blyumberg a symptom); death of a fruit and full or its partial vykhozhdeniye in an abdominal cavity (the termination of heartbeat, clear palpation through an abdominal wall of parts of a fruit and the prelying part of a fruit which became mobile, and near it — the small, dense, reduced uterus); outside bleeding, usually insignificant. At an incomplete gap the hematoma in friable cellulose of a basin, usually between leaves of a wide sheaf or under a peritoneal cover of a uterus is formed. Formation of a hematoma is followed by severe pains in the bottom of a stomach, sometimes with irradiation in a sacrum and in a leg; in a lower part of a stomach quickly growing painful unilateral education is defined; during the developing of a hematoma in a wide sheaf the uterus deviates to the opposite side.
At incomplete hysterorrheses of the phenomenon of shock can be expressed «poorly or at all not be shown, and symptoms of internal bleeding prevail. At gradual «creeping» patholologically of the changed tissue of a uterus the sudden acute pain characteristic of a hysterorrhesis can be absent, pains stop not at once, and gradually, and the fruit can even sometimes be born in natural patrimonial ways.
The diagnosis is made on the basis of set of the listed above clinical signs. Diagnostic difficulties arise at hysterorrheses on a hem, especially in the lower segment of a uterus. Such «atypical» gaps can not be followed by the expressed symptoms and sometimes there are even not di-agnostirovannymi. In these cases, in addition to the symptoms of irritation of a peritoneum and internal bleeding which is often poorly expressed increase of a meteorism and diffuse morbidity of all area of a stomach shall draw attention of the doctor. Quite often also incomplete hysterorrheses present diagnostic difficulties. The leading symptom at the same time are symptoms of internal bleeding, however they also not always clearly are expressed since blood streams not in an abdominal cavity, and in an okolom - exact or paravesical cellulose, otslaivy a peritoneum. Formation of such subperitoneal quickly accruing hematoma near a uterus and quite often subperitoneal: the emphysema defined palpator-but in ileal area (a symptom of «a crunch of snow»), are the signs allowing to suspect an incomplete hysterorrhesis. The diagnosis is finalized as a result of manual inspection of a cavity of the uterus after extraction of a fruit or at a laparotomy.
Differential diagnosis of the made hysterorrhesis is carried out with quickly progressing full amotio of normally located placenta, edges can be followed by shock and internal bleeding. However at placental detachment the configuration of a uterus sharply does not change, protrusion of a wall of a uterus in the place of amotio is only sometimes formed, local moderate morbidity in the place of amotio is noted, parts of a fruit are not defined by an abdominal wall, symptoms of irritation of a peritoneum, as a rule, are absent.
At the menacing gap it is necessary to stop urgently patrimonial activity and to finish childbirth in the operational way. For the bystry termination of patrimonial activity give a deep anesthesia, usually endotracheal radio and oxygen with muscle relaxants (see) also make operational delivery. At a live fruit and lack of symptoms of an infection do operation of Cesarean section (see). At a dead fruit make fetaldestructive operations (see) — craniotomy (see); at the cross provision of a fruit and its small sizes — decapitation (see) or embryotomy (see); at the big sizes of a fruit Cesarean section is more preferable. Such operations as podalic version with the subsequent extraction of a fruit or imposing of obstetric nippers since at the menacing hysterorrhesis the specified operations, as a rule, lead to formation of a gap are categorically contraindicated. The begun and made hysterorrhesis is demanded by a chrevosecheniya (see. Laparotomy ). Before operation it is necessary to hold immediately a complex of antishock and antianemic events (see. Shock , Blood loss ). Antishock and antianemic actions continue in time and after operation. After opening of an abdominal cavity delete a fruit and an afterbirth. If a hysterorrhesis small, linear (or its torn edges can be easily excised) and also if the gap occurred recently and danger of infection is small, sewing up of a gap is admissible. At extensive gaps, especially with crush of fabric and existence of an infection, it is made, as a rule, hysterectomy (see).
The forecast even at the current state of obstetric aid at a complete separation of a uterus remains adverse for a fruit, death to-rogo occurs at the phenomena of the asphyxia connected with placental detachment. The outcome for mother is defined by the volume of blood loss and weight of a depressed case.
Prevention of a hysterorrhesis is generally connected with the organizational events held in clinic for women (see). The pregnant women threatened on a hysterorrhesis are allocated on the basis of data of carefully collected anamnesis and objective inspection in special group of the increased risk. Carry the pregnant women with a narrow basin, a large fruit, the wrong provision of a fruit who were multigiving birth with the lowered tone of an abdominal wall and a uterus, pregnant women with the burdened obstetric anamnesis to it (postabortion and puerperal inflammatory diseases, long childbirth, weakness of patrimonial activity and other types of pathology in labor), and also undergone uterus operations, especially Cesarean section. Behind the specified group establish careful observation, if necessary hospitalize the woman in the second half of pregnancy and, as a rule, send to a maternity hospital in 2 — 3 weeks prior to childbirth. In the presence of the expressed cicatricial changes on a uterus and at detection of inferiority of a hem on a uterus owing to the previous operations hospitalization is performed for 6 — 8 weeks before childbirth. In a hospital draw up the plan of conducting childbirth, establish need of Cesarean section even prior to patrimonial activity. If operational delivery is not shown, develop the plan of careful conducting childbirth, plan methods of delivery and tactics of the doctor at emergence of these or those complications. Carry a balanced diet of pregnant women to measures of prevention (not to allow development of a large fruit). It is not recommended to resort to korporalny Cesarean section, later to-rogo especially often there are hysterorrheses at the subsequent childbirth.
Traumatic necrosis of a neck of uterus — the rare complication connected with a long prelum of a neck of uterus in the course of childbirth between a head of a fruit and walls of a bone basin. Necroses from pressure arise most often in labor at anatomically or clinically narrow basin, weakness of patrimonial activity, the long anhydrous period, rigidity and cicatricial changes of a neck of uterus. Most often the necrosis is formed on a front wall of a neck of uterus, is more rare — on back. The necrotic site usually does not pass into a gap and is localized in the place of infringement of a neck. After the delivery the nekrotizirovanny site of a neck is torn away and fistula is, as a rule, formed. Quite seldom at traumatic necroses of a neck spontaneous amputation of its vulval part or one of her lips is observed (front or back). It at primapara is more senior than 30 years with a rigid neck of uterus and prolonged childbirth by a large fruit.
Treatment of the formed fistulas operational and similar to treatment of puerperal fistulas (see below).
Ectropion of a uterus (puerperal) — the rare complication of a puerperal period, at Krom a uterus is as if turned «inside out» at the same time by its outside layer there is a mucous membrane, and internal — a serous cover. Are the reason of an ectropion sharp weakening of a tone of muscles of a uterus, at Krom of reduction of a prelum abdominale, on an uterine fundus or a pandiculation for an umbilical cord cave-in of an uterine fundus or the placental platform (see) often with yet not separated afterbirth, and then and its ectropion can cause pressing (see the Ectropion of a uterus).
Stretching and symphysiolysis. Discrepancy of pubic bones is observed as a result of stretching or disturbance of an integrity of the copular device of a pubic joint (a pubic symphysis). During pregnancy there is a serous treatment of all pelvic joints and sheaves that results in hypermotility of joints of a basin and to their discrepancy under pressure of the prelying part of a fruit which is moving ahead on a parturient canal. At the same time there can be hyperdystension and a rupture of joint bags and sheaves. Most often this process is observed in a pubic joint since here the head of a fruit encounters the largest resistance from a bone basin, especially at the narrowed basin and the big sizes of a head. More rare discrepancies and gaps are observed in a sacroiliac joint. Gaps can be spontaneous or violent. Cases of so sharply expressed changes in area of a pubic joint at pregnancy are described that ruptures of the last occur very easily. Symphysiolyses should be distinguished from stretchings of the copular device in the field of a bosom, at to-rykh there is a discrepancy of pubic bones without damage of the copular device. Physiological changes of the copular device of a basin during pregnancy usually lead to discrepancy of pelvic bones in joints no more than on 5 mm. However cases of much bigger discrepancies are observed. Radiographic distinguish three rates of divergence of pubic bones: The I degree — discrepancy of pubic bones on 5 — 9 mm, the II degree — on 10 — 20 mm, the III degree — more than on 20 mm. However about weight of damage it is necessary to judge not by rate of divergence of pelvic bones, and by expressiveness of all clinical picture (see. Pubic symphysis ). So, identical rates of divergence of bones in the field of a bosom can be both at a symphysiolysis and without it.
The clinical picture at a gap is expressed much stronger and is shown by heavy disorders of function of the lower extremities. At discrepancy of pubic bones after a rupture of the copular device injuries of a bladder, an urethra, a sacroiliac joint are frequent. The diagnosis of a gap is confirmed radiological. Prevention and treatment of stretching and a symphysiolysis — see. Pubic symphysis.
Puerperal fistulas are a consequence of long pressing by a head of a fruit of tissues of vagina or neck of uterus to a bone basin. In rare instances fistulas can be a consequence of obstetric interventions (so-called violent fistulas). Depending on localization fistulas can be cervical and vulval, vesicocervical, ureteric and cervical, vaginovesical and rectovaginal. Clinically they are shown after rejection of nekrotizirovan-ny sites usually on 3 — the 8th day after the delivery, spontaneous department of urine or a calla through a genital tract. It is possible to expect formation of fistulas in the course of childbirth at their long current, a long anhydrous interval and standing of a head over 3 — 4 hours in the same plane of a basin. At the same time puffiness of a vagina, vulva, an ischuria, emergence of blood in urine and bloody allocations from a vagina is sometimes observed. For the prevention of such complications it is not necessary to allow standings of a head without progress at the departed waters more than 2 — 3 hours, and it is necessary to pass to active actions up to an operative measure.
Survey of a vagina by means of mirrors easily reveals existence of fistulas. Occasionally it is necessary to resort to administration of contrast mediums in a bladder for a fistulogra-fiya (see) or to a tsistoskopiya (see). Treatment of fistulas operational (see. Urinogenital fistulas). Spontaneous treatment is occasionally observed. An operative measure can be made not by what in 4 — 6 months after the delivery ra-earlier. Before shall carry out by the patient with fistulas an obligatory daily toilet of a vulva, oil it either liquid, or emulsions with streptocides, or 5 — 10% metatsilinovy ointment. Prevention of fistulas comes down to the correct conducting childbirth.
DIAGNOSIS of the FORMER CHILDBIRTH IN the MEDICOLEGAL RELATION
Forensic medical examination of the former childbirth and their prescription is appointed at investigation of infanticides (see), tossings and kidnappings of newborn children, simulations of pregnancy (see) and childbirth. Diagnosis of childbirth, especially later considerable time, is very difficult as the signs used for this purpose (increase in the sizes of a uterus, increase and secreting of mammary glands, definition of the hormones characteristic of pregnancy, etc.) remain very short time — 6 — 8 weeks. The exception is made by so-called strips of pregnant (striae gravidarum), however they are not specific (are possible, for example, at obesity) and do not allow to speak about prescription of childbirth. In most cases expertize is carried out in 2 — 4 months after the delivery, is frequent when the woman does not feed the child. Therefore at a provodeniya of examination, in addition to survey (see), apply a number of laboratory methods of a research. Survey is carried out jointly by the forensic scientist and the obstetrician-gynecologist. At the same time they get acquainted with evidences, reveal the obstetric anamnesis of the woman (as long fed children after the delivery, when last time and as milk was emitted whether was diseases of mammary glands), note existence of pigmentation of the white line of a stomach and peripapillary circles, the sizes of a uterus, a form of a vulval part of her neck, a form and the sizes of an outside pharynx, traces of gaps in a pharynx and a crotch, color of a mucous membrane of a vagina and character its separated (quantity, color, a smell). Surely investigate a condition of mammary glands — the sizes, density, allocation of a secret (struyno or drops, its consistence, color). Very informatively in aspect of the resolved issues the research of secretory activity of mammary glands in dynamics, a cut is conducted by additional surveys of the woman up to the moment of establishment of stable data, at least throughout 1 — 1kh/2 months every 10 days. The gradual zatikhaniye of secretory activity of glands (reduction of quantity of a secret and its cells), especially in the first 1,5-2 months after the delivery is characteristic of a puerperal period. In addition to lacteal balls (see Colostrum), it contains deskvamirovanny small (pro-current) and average (alveolar) epithelial cells (their ratio makes 3:1), free kernels, their parts and cytoplasm (after disintegration of cells). Within 2 — 3 months after the delivery the quantity of small cells decreases, and averages increases, reaching the return ratio (1:3). From 4th month there are only average epithelial cells.
The cytologic research of the separated vagina allows to establish features of hormonal changes in an organism in connection with childbirth (see). In the 1st week after the delivery in separated erythrocytes, leukocytes, parabasal, basal and intermediate cells come to light. By the end of the 2nd week the ground mass of a smear is made by intermediate cells; basal and parabasal cells are presented in a small amount. By the same time the quantity of erythrocytes and leukocytes considerably decreases. By 3 — 4 weeks the number of superficial cells so in a smear intermediate and superficial cells are present at equal quantity increases. To 5 — the 6th week intermediate cells, superficial, single prevail. If the woman does not feed, then the picture of a vulval smear in general is similar described, but superficial cells can appear earlier, there come at such women also the periods earlier.
For diagnosis of a puerperal period determine the content of chorionic gonadotropic hormone (see. Chorionic gonadotrophin) by means of domestic immunological system — a gravidadiagnos-tikum (State Duma). After normal births in time the chorionic gonadotrophin in urine and lokhiya of women in childbirth is allocated within 2,5 days. It is steady against external influences, in particular at a temperature of 30 ° in spots of blood and urine not less than 1 year keep immunological activity, and it is frequent up to 3 years, in spots of vaginal separated — up to 3 months, in pieces of the dried bodies and fabrics — up to 4 weeks; maintains heating to t ° 100 ° for 7 days. Definition of a chorionic gonadotrophin is possible also in the spots formed by amniotic waters at a research of extracts from them. From spots of urine and vulval allocations they can be otdifferentsirovat on fenolsulfoftaleinovy reaction by means of special indicator paper. Identification of a chorionic gonadotrophin in extracts from spots of milk indicates an origin them from recently given rise woman. Spots of women's milk (see. Breast milk ) differentiate from milk of domestic animals (cows, goats, mares, sheep) on thioseven-carbaheat of reaction in D. Ya. Shabelnik's modification (1975).
The analysis elektroforegramm blood serum or extracts of spots of blood for the purpose of detection of leytsinamino-peptidase and an oxytocinase helps to determine the fact and approximately prescription of the former childbirth. So, on 8 — the 10th week of pregnancy in blood serum there is an additional fraction of leucineaminopeptidase, intensity a cut increases in process of increase in duration of gestation; the greatest she is in the last days of pregnancy and at the time of delivery. After the delivery the additional fraction is defined within 3 weeks, then its intensity sharply decreases. In spots of blood this enzyme comes to light from the moment of their education up to 50 days. In the course of pregnancy the range of free amino acids of blood serum changes. This change remains and registered for the first 2 months after the delivery, also helping to determine their fact and prescription.
Thus, forensic medical examination of the former childbirth and their prescription is based on complex assessment of results of clinical inspection of the woman and laboratory methods of a research taking into account investigative data.
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G. M. Savelyeva; V. I. Alipov (patrimonial traumatism), B. L. Gurtova (shock and an embolism), I. G. Myaenikov (childbirth at heart diseases, bleeding in labor), Yu. I. Novikov (change in an organism of the pregnant woman before childbirth), K. I. Hizhnyakova (court.), E. A. Chernukh (anomaly of patrimonial activity).