In obstetric practice, in addition to poll and the standard clinical methods of a research, apply the following special methods: outside and internal and internal (vulval) researches; survey by means of mirrors; palpation of a fruit; size discrimination and forms of a basin; measurement of size of a pre-natal fruit, etc.
Bacteriological, biochemical, electrophysiologic, histologic, cytologic, endocrinological methods of a research are widely used hematologic, immunological (serological, etc.). In the presence of the corresponding indications apply X-ray diffraction techniques, researches ultrasound and other diagnostic methods.
Poll of the pregnant woman and woman in labor is held according to a certain plan. Find out a surname, a name, a middle name, age, the place of work and a profession, the residence; at what age there were first periods and through what time term they were established; type of periods (3-or a 4 weeks cycle, duration, amount of the lost blood, existence of pains, etc.); whether periods after the beginning of sex life, the former childbirth and abortions changed; when there were the last periods. Find out whether there are no allocations from a genital tract. Pathological allocations (plentiful, purulent, mucous or watery with impurity of pus etc.) indicate usually existence of gynecologic diseases. During the collecting the obstetric anamnesis find out: edges on the account the real pregnancy; the course of the previous pregnancies (whether was toxicoses, diseases of cardiovascular system, a liver and other bodies); as the previous pregnancies (childbirth or abortions) ended; nature of the previous childbirth (urgent or premature, their current); whether earlier puerperal diseases were observed. Pathological childbirth in the past (the burdened obstetric anamnesis) causes to anticipate emergence of complications at the real pregnancy and childbirth.
Collect the family anamnesis, ask about health of the husband (whether has alcoholism), find out existence of the hereditary diseases and diseases threatening with infection of the pregnant woman and to future child (gonorrhea, tuberculosis, etc.). Specify a working condition and life in respect of impact on a fruit.
Survey of the pregnant woman and woman in labor. Pay attention to growth, a constitution, deformation of a backbone and the lower extremities (ankiloza of joints and other deviations in bone system indicate a possibility of change of a form of a basin and its narrowing), color and a condition of integuments and visible mucous membranes, pigmentation of the person, the white line of a stomach, nipples and peripapillary circles, hems of pregnancy, fatness, a condition of mammary glands, size and a shape of a stomach.
Survey of a stomach in the second half of pregnancy sometimes allows to find out deviations from the normal course of pregnancy. At normal pregnancy and the correct provision of a fruit the stomach has the ovoidny (ovoid) form; at the cross (wrong) provision of a fruit the stomach is distributed in sides, at a hydramnion it spherical, increases very sharply, not respectively to duration of gestation. The shape of a stomach can change also at a narrow basin.
It is necessary to examine a lumbosacral rhombus, the form to-rogo in total with other data allows to judge a structure of a basin.
After survey make a research of cardiovascular system, lungs, a nervous system, digestive organs according to the practical standard (auscultation, percussion, a palpation).
At pregnant women without fail measure arterial pressure, investigate urine and blood (a morphological picture, ROE), define a blood group, a Rhesus factor accessory, conduct serological and other researches for clarification of latent infections (syphilis, toxoplasmosis, etc.); establish body weight. In the second half of pregnancy measurement of arterial pressure, weighing, a blood analysis and urine make systematically. If necessary apply radiological, electrophysiologic and other methods of a research.
Special obstetric researches are divided into the main and auxiliary methods. To the main methods A. and. belong: vaginal examonation, survey of a neck of uterus by means of mirrors, measurement of a basin, a palpation of a stomach of the pregnant woman and auscultation of cordial tones of a fruit, etc.
At a palpation of a stomach define parts of a fruit, its size, situation, a position, presentation, the relation of the prelying part of a fruit to a basin of mother (it is high over an entrance to a basin, it is pressed to an entrance, a small segment in an entrance etc.), feel the movements of a fruit, and also gain an impression about amount of amniotic waters and a condition of a uterus. At palpation the condition of an abdominal wall is defined (an excess adiposity, a remuscle strain, discrepancy of direct muscles and so forth). The palpation of a stomach of the pregnant woman is made according to a certain plan, consistently use four methods of an outside research (Leopold's receptions).
Pregnant (woman in labor) lies on spin, legs are bent in hip and knee joints. The doctor costs to the right of it facing her face. It is necessary that before a research the bladder and intestines were emptied.
The first reception (fig. 1, 1) — both hands turned to each other by the ends of fingers have on an uterine fundus, fingers of hands pull together; down determine by careful pressing the level of standing of an uterine fundus, on Krom judge duration of gestation. Define the part of a fruit which is located at an uterine fundus by this reception (the pelvic end of a fruit is more often).
The back and small parts of a fruit is defined by the second reception (fig. 1, 2); under the provision of a back judge a position and a type of a fruit. Both hands from an uterine fundus move from top to bottom on each side a stomach and are located on side surfaces of a uterus. The palpation of parts of a fruit is run gradually right and left hand. At the longitudinal provision of a fruit on the one hand the back, from opposite — an extremity, small parts of a fruit — in the form of the small ledges which are often changing situation is probed; sometimes it is possible to feel the bystry tolchkoobrazny movements of extremities.
The second reception of an outside research allows to define a tone of a uterus and its excitability (reductions in response to the irritation caused by a palpation), to probe round ligaments of a uterus, their thickness and an arrangement. On an arrangement of round sheaves judge the place of an implantation of placenta. If round sheaves disperse from top to bottom, the placenta is located on a front wall if meet — on back.
The third reception (fig. 1, 3) serves for definition of the prelying part of a fruit. One hand (usually right) is put a little above a pubic symphysis so that the thumb was on one party, and by four others — on other party of the lower segment of a uterus. The slow and careful movement fingers immerse deep into and clasp the prelying part. The head is probed in the form of the dense roundish part having clear contours. At pelvic presentation the voluminous, softish part which does not have rounded shape is probed. At cross and slanting provisions the prelying part is not probed.
At pelvic presentation it is probed voluminous, myagkovatayachast, not having rounded shape. At cross and slanting provisions the prelying part is not probed.
It is possible to determine by the third reception mobility (balloting) of the prelying part that is especially well expressed at repeated and pregnant women.
The fourth reception (fig. 1, 4) allows to define not only character of the prelying part, but also level of its standing. Palms of both hands have on the lower segment of a uterus on the right and at the left, the ends of fingers reach a symphysis. Carefully determine by the extended fingers the prelying part (a head, the pelvic end) and height of its standing. This reception allows to reveal whether there is a head over an entrance to a small pelvis, passed through the plane of an entrance to a basin a small or big segment; if the head considerably fell to a pelvic cavity, then only its basis is probed. Also successfully height of standing of the prelying pelvic end of a fruit is defined. By means of the fourth reception on the prelying head it is possible to define a nape and a chin, and also size of a head, density of her bones and gradual lowering of a head in a basin at the time of delivery.
Auscultation is made by an obstetric stethoscope for the purpose of listening of cordial tones of a fruit which are a reliable sign of pregnancy. By listening of cordial tones find out a condition of a pre-natal fruit which are a reliable sign to a bermennost. By listening of cordial tones find out a condition of a pre-natal fruit.
Cordial tones of a fruit are listened since the beginning of the second half of pregnancy (more rare from 18 — 20 weeks), it is better from that side of a stomach where the back of a fruit is turned, is closer to a head. Only at front presentations heartbeat of a fruit is more distinct from a thorax of a fruit.
At occipital presentation heartbeat is well listened below a navel, at the left — at the first position, on the right — at the second position. At pelvic presentations heartbeat of a fruit clearly is listened above a navel on that party where the back is turned.
At a front look head and pelvic presentation heartbeat is better listened closer to the centerline of a stomach, at back — is farther from the centerline, sideways a stomach. At cross situation heartbeat is listened at the level of a navel, is closer to a head. At polycarpous pregnancy heartbeat of fruits is usually listened clearly in different departments of a uterus. At the time of delivery during the lowering of a head of a fruit in a pelvic cavity and its birth heartbeat is better listened closer to a symphysis, almost on the centerline of a stomach.
Cordial tones of a fruit are listened in the form of the rhythmical double blows repeating on average 130 — 140 times in 1 min. During attempts there is a physiological delay of cordial tones of a fruit depending on temporary squeezing of vessels of the reduced uterus or on squeezing of a head of a fruit and irritation of a vagus nerve. Between attempts the usual rhythm of heartbeat is recovered. The resistant urezheniye or increase of heartbeat indicates the begun asphyxia. Special devices (by means of ultrasound) possible to hear heartbeat of a fruit with 9 — the 10th week of pregnancy. Apply an electrocardiography, a phonocardiography to more exact assessment of a condition of a fruit, amnioskopiya (see), amniocentesis (see). Besides, during the listening of a stomach cordial tones of a fruit and deaf, spasmodic, its tolchkoobrazny movements are defined. It is also possible to catch various sounds, coming from mothers of internals: the beating of a ventral aorta matching pulse of the woman; the blowing uterine noise arising in the large blood vessels passing in sidewalls of a uterus (match pulse of the woman); spasmodic intestinal noise.
The research of a basin is made by survey, palpation and measurement of its sizes. According to indications apply a rentgeno-pelvimetriya (see. Pelvimetriya ).
At survey pay attention to a structure of all basin, but attach special significance to a lumbosacral rhombus. The upper corner of a rhombus makes deepening between an acantha of the V lumbar vertebra and the beginning of a median sacral crest, side corners correspond to posterosuperior awns of ileal bones, lower — a top of a sacrum. At correctly put women the rhombus approaches a square, at anomalies of a basin it is expressed insufficiently clearly, and its form changes.
From all methods of a research of a basin measurement of a basin most is important. The majority of internal dimensions of a basin is unavailable to direct measurement. Therefore usually establish the outside sizes of a basin and on them judge the size and a shape of a small pelvis. Measurement of a basin is performed a tazomer. Usually measure four sizes of a basin: three cross (fig. 2) and one straight line. The following sizes belong to cross.
1. Distantia cristarum — distance between the most remote points of crests of ileal bones (28 — 29 cm).
2. Distantia spinarum — distance between anterosuperior awns of ileal bones. Buttons a tazo-measure press to the outer edges of anterosuperior awns. This size usually equals 25 — 26 cm
3. Distantia trochanterica — distance between big spits of femurs (30 — 31 cm).
Conjugata externa (an outside conjugate) — the direct size of a basin, distance between the upper outer edge of a symphysis and the suprasacral pole which is located between an acantha of the V lumbar vertebra and the beginning of a median sacral crest (top of a lumbosacral rhombus). The outside conjugate is normal equal to 20 cm (fig. 3),
For definition of a true conjugate subtract 8 — 9 cm from length of an outside conjugate. The true conjugate can be determined by a diagonal conjugate more precisely.
Conjugata diagonalis (a diagonal conjugate) — distance from bottom edge of a symphysis to the most outstanding point of the cape of a sacrum (fig. 4). It is defined at vaginal examonation of the woman. If the cape is achievable, then the tip of a long finger is fixed on its top, and the edge of a palm is rested against bottom edge of a symphysis. After that note the place of contact of the investigating hand with bottom edge of a symphysis and measure distance from a top of a long finger to the point of contact with bottom edge of a symphysis. The size of a diagonal conjugate at a basin of the correct structure equals on average 12,5 — 13 cm.
For definition of a true conjugate subtract 1,5 — 2 cm from the size of a diagonal conjugate.
If at inspection of the woman there is a suspicion of reduction of area of the sizes of an exit of a basin, then make determination of these sizes (fig. 5 and 6). For measurement of the direct size one button of a tazomer is pressed to bottom edge of a symphysis, another — to a top of a tailbone. This size is normal equal to 11 cm.
Cross sectional dimension of an exit is measured by a centimetric tape or a tazomer with the crossing branches. Probe inner surfaces of sciatic hillocks and measure distance between them. This distance normal is equal to 9,5 cm. To the received size it is necessary to add 1 — 1,5 cm, considering thickness of the soft tissues which are between buttons of a tazomer and sciatic hillocks.
The known clinical value has definition of a form of a corner of a pubic symphysis. At the correct structure of a basin the pubic corner is equal 90 — 110 °, reduction or increase in a pubic corner indicates any aberrations in a structure of a basin (fig. 7).
The slanting sizes of a basin establish at kososuzhenny Tazy. For detection of asymmetry of a basin the following slanting sizes are measured: 1) distance from an anterosuperior awn of one party to a posterosuperior awn of other party and vice versa; 2) distance from the upper edge of a symphysis to the right and left posterosuperior awn; 3) distance from a suprasacral pole to the right and left anterosuperior awn.
The slanting sizes of one party are compared to the corresponding slanting sizes of other party. At a normal structure of a basin the size of the pair slanting sizes is identical. The difference exceeding 1 cm indicates asymmetry of a basin.
If necessary to obtain additional data on the sizes of a basin, compliance of its size to a head of a fruit, deformations of bones and joints make X-ray inspection of a basin.
For judgment of thickness of pelvic bones the known value has measurement by a centimetric tape of a circle of a radiocarpal joint of the pregnant woman (Solovyov's index). The average size of this circle is 14 cm. If the index is more, then it is possible to assume that massive and the sizes of a pelvic cavity it is less pelvic bones, than it would be possible to expect according to its measurement (see. Solovyova index ),
Measurement of a stomach. Measurement of height of standing of an uterine fundus over a pubis is performed a centimetric tape or a tazomer. Measure distance between the upper edge of a symphysis and the most outstanding point of an uterine fundus. Measurements by means of a tazomer give considerably smaller figures, than measurement by a centimetric tape.
In the second half of pregnancy perform an abdominometry; the centimetric tape is imposed in front at the level of a navel, behind — on the middle of lumbar area.
Measurement of length of a pre-natal fruit is performed by means of an ordinary tazomer. Having felt through an abdominal wall of a part of a fruit, one button of a tazomer is established on the lower pole of a head, another — on an uterine fundus where there are buttocks of a fruit (fig. 8) more often. The size received at measurement of distance from the lower pole of a head to buttocks is multiplied on 2. Subtract 2 or 3 cm depending on thickness of abdominal walls from the received number.
Vaginal examonation in the first half of pregnancy is made for determination of its term (fig. 9); in the second half of pregnancy and at the end of it — at those women who were in consultation initially in late durations of gestation, and also if necessary to specify a condition of patrimonial ways (a vagina, a neck of uterus, an inner surface of pelvic bones, etc.), the size of a diagonal conjugate, degree of a maturity of a neck of uterus. At women in labor vaginal examonation (fig. 10) is made at receipt in obstetrical establishment. Further vaginal examonation is made according to indications.
In the first half of pregnancy its, especially considerable in the field of an isthmus (Gorvits's sign — Hegara), change of a consistence (consolidation) define increase in a pregnant uterus, a softening at a palpation (Snegirev's sign), asymmetry, dome-shaped protrusion of the right or left corner of a uterus (Piskachek's sign). Determine width of a gleam and distensibility of walls of a vagina; reveal whether there are no hems, tumors, partitions and other pathological educations; find a neck of uterus and define its form, size, a consistence; at a research of women in labor define extent of smoothing of a neck and passability of the cervical channel; investigate a condition of an outside opening of the channel of a neck of uterus (a form round or slit-like, it is closed or open); at women in labor define a condition of edges of an outside pharynx of a neck of uterus (soft or rigid, thick or thin) and extent of its opening. Find out a condition of a bag of waters (its integrity, rate of strain); define the prelying part (where it is); on a head define seams and fontanels, on the pelvic end — a sacrum, an anus, generative organs, etc.; on their arrangement judge the mechanism of the forthcoming childbirth. Then make palpation of an inner surface of a sacrum, symphysis and sidewalls of a basin.
At a rectal research it is possible to gain an impression about extent of smoothing of a neck and opening of a pharynx, a condition of a bag of waters, the prelying part of a fruit, and also about the relation of a head (buttocks) to this or that plane of a basin.
The research is made in gloves. The index finger greased with vaseline is entered into a rectum and feel a neck of uterus, the prelying part of a fruit, its identification points, pelvic bones.
However data of a rectal research considerably are inferior to the data obtained at a research through a vagina. Besides, during the leading of a wall of a vagina to a neck of uterus there can be implementation of the flora which is in a vagina, in an open pharynx.
At a research by means of mirrors cyanosis of a mucous membrane of a vagina and neck of uterus, a condition of an outside pharynx and accumulation in it transparent slime comes to light.
Treat auxiliary methods of a research: amnioskopiya, amniocentesis, electrocardiography, phonography, X-ray analysis, etc. Apply to survey of the lower pole of fetal membranes amnioskopiya (see), for definition of a condition of a fruit — amniocentesis (see).
The electrocardiography allows to register biopotentials of heart of a fruit since 13 — the 14th week of pregnancy when at auscultation heartbeat of a fruit is not listened yet. This method is used for diagnosis of precursory symptoms of disturbance of cordial activity of a fruit (asphyxia, fetopathies), presentation, recognitions of polycarpous pregnancy, etc.
Fonokardiografiya — registration of the sound phenomena caused by cordial activity allows to reveal low frequencies of fluctuations which are not caught at auscultation. The phonocardiogram reflects the mode of cordial activity — norm, increase, an urezheniye, arrhythmia, etc. (see. Fruit ).
X-ray inspection. It is possible to determine by method of a X-ray analysis situation and a chlenoraspolozheniye of a fruit (fig. 11), existence of a multiple pregnancy, feature of a structure of a basin and its sizes.
The X-ray analysis is made in situation on spin and on one side that allows to judge a form of a sacrum, pubic and other bones; measure by a special ruler the cross and direct sectional dimensions of a basin. Measure also a head and on this basis judge compliance of its size to the sizes of a basin.
However resort to a X-ray analysis only in exceptional cases when at usual methods of a research (a palpation, auscultation, vaginal examonation, etc.) do not obtain the convincing data necessary for the exact diagnosis. It is connected with high sensitivity of a fruit to ionizing radiation, especially at early stages of development.
Bibliography: Bodyazhina V. I. and Zhmakin K. N. Akusherstvo, M., 1970; Gubarev A. P. Obstetric research (outside and internal), M., 1922; Zhmakin K. N. and Syrovatko F. A. Obstetric seminar, M., 1960; I. F. Uchebnik's Zhordania of obstetrics, M., 1964; Petchenko A. I. of Akusherstvo, page 137, Kiev, 1963.
V. I. Bodyazhina.