Obstetrics and Gynecology - A.M. Gromova 2000

Physiology of Childbirth
Management of Labor

A woman in labor is typically admitted to the maternity ward at the end of Pregnancy or at the onset of The First stage of labor, carrying her pregnancy record (prenatal card). Upon admission, healthcare providers measure her body Temperature, examine her Skin and mucous membranes, take an epidemiological history, and review her pregnancy record. Based on this assessment, a decision is made to admit her either to the physiological or observation department. In the admission ward, the medical history is taken, a general somatic and external obstetric examination is performed, an enema is administered, and hygienic Processing is carried out, after which the woman is transferred to the pre-labor ward.

In the pre-labor ward, the laboring woman undergoes a more thorough examination and continuous dynamic monitoring. This includes an external physical examination and assessment every 2 hours (measuring Blood pressure, determining fetal Heart rate and characteristics, tracking the descent of the fetal HEAD through the birth canal, and evaluating The Nature of contractions). Ideally, contractions and fetal condition should be monitored using a cardiotocograph (cardiac monitor).

The degree of cervical dilation is determined through a vaginal examination. An internal (vaginal) obstetric examination allows the physician to assess the condition of the birth canal, monitor the dynamics of cervical dilation during labor, track The Mechanism of engagement and movement of the fetal presenting part, check the state of the amniotic sac, and measure the diagonal conjugate.

A vaginal examination during labor must be performed upon the woman's admission to the hospital and immediately after the rupture of membranes. Furthermore, to monitor the progression of the first stage of labor, a vaginal examination is repeated every 6 hours. If there are any deviations from the normal course of labor, vaginal examinations are performed as clinically indicated.

External obstetric examinations during the dilation stage must be performed repeatedly and systematically. Entries in the labor record (partograph/history) must be made at least every 2 hours. During an external obstetric examination, attention should be paid to the shape and consistency of the Uterus both during and between contractions, the height of the uterine fundus, and the condition of the contraction ring. It is also necessary to determine the lie, position, presentation, and attitude of the fetus, as well as The Relationship of the presenting part to the pelvic inlet. Additionally, one must verify whether There is a clinical match between the size of the fetal head and the mother's pelvis (Vasten's sign).

The intensity and duration of contractions can be assessed by placing a hand over the area of the uterine fundus. The uterus should relax thoroughly between contractions.

Auscultation of fetal heart tones is most effective over the area of the fetal anterior shoulder. The heartbeat of an intrauterine fetus has 3 main auscultatory characteristics: rate, rhythm, and clarity. The normal heart rate ranges from 120 to 160 beats per minute. The heartbeat must be rhythmic and clear. When the amniotic sac is intact, the fetal heart rate is auscultated every 15–20 minutes, and after the rupture of membranes—every 5–10 minutes.

The progress of fetal descent can be monitored using:

1) external Methods of obstetric examination;

2) vaginal examination;

3) Piskacek's and Genter's maneuvers.

If the amniotic membranes are intact, the woman is allowed to walk around the ward. It is preferable for her to lie on her side corresponding to the fetal position—that is, on her left side for the 1st position, and on her right side for the 2nd position.

When the membranes rupture, a vaginal examination is mandatory to determine the amount and color of the Amniotic Fluid, the fetal presenting part, and its station. If the cervix is fully dilated and the membranes are still intact, an Amniotomy is performed. Upon completion of the dilation stage, the woman changes into clean clothes and is transferred to the delivery room. The external genitalia are cleansed with a potassium permanganate solution (1:6000), followed by Treatment with a 3–5% iodine solution or other disinfectants (as a surgical field). During the second (expulsion) stage of labor, continuous Supervision of the woman's general condition is maintained, along with monitoring of the fetal heart rate (after every push) and the descent of the fetus through the birth canal.

Following the crowning of the fetal head, obstetric assistance is provided to protect the Perineum and safely deliver the fetus (Fig. 21–22). It consists of the following steps:

1) regulation of expulsive efforts (pushing);

2) Prevention of premature extension of the head;

3) simultaneous reduction of perineal tissue tension by borrowing Tissues;

4) delivery of the fetal head between contractions;

5) assistance in the delivery of the fetal shoulders and trunk.

Expulsive efforts are regulated as follows: during a contraction, the parturient woman should either enhance or weaken her pushing. To enhance pushing, she braces her feet, grips the handles, pulls her head toward her chest, and takes a deep breath. Conversely, when the contraction wave subsides, she can weaken the pushing by placing her hands on her chest, lowering the head of the bed, and distracting the woman—for example, by asking her to count.

Furthermore, it is necessary to prevent premature extension of the head before the fixation point is formed. The palm of the left hand is placed on the Pubic Symphysis, while the 4 fingers of this hand are positioned on the fetal head to prevent its extension during contractions and its rapid descent through the birth canal.

Reducing perineal tension makes the tissues more pliable for the passage of the crowning head by borrowing tissue from neighboring areas (the Labia Majora). Tissue recruitment is performed downward toward the perineum, sliding the tissues off the fetal head. However, performing this maneuver during active pushing is strictly prohibited.

Delivery of the fetal head between contractions is carried out once the fetal occiput has appeared and the suboccipital region rests against the symphysis. At this point, the woman must not push; she should breathe through her Mouth with her hands placed on her chest.

After the delivery of the head, the woman is encouraged to push if the shoulders do not deliver spontaneously. The head is grasped with both hands, avoiding any pressure on the face, and deflected downward until the anterior shoulder approaches the pubic arch. Then, the head is lifted upward, the right hand slides the perineum away from the posterior shoulder, and it is gently guided out of the vulvar cleft. Index fingers of both hands are inserted into the armpit on the side of the fetal back, and the body is lifted forward and upward to facilitate prompt delivery. The initial newborn care is performed (see Chapter 13). The woman's general condition is monitored, blood loss is estimated, and the expulsion of the Placenta is supervised.

In the placental (third) stage of labor, two phases are distinguished: the phase of placental Separation from the uterine wall and the phase of expulsion (delivery) of the placental complex (placenta, fetal membranes, and umbilical cord).

The Third Stage of labor should be managed expectantly, with careful observation of the parturient woman, beginning with bladder evacuation. If the woman’s general condition is satisfactory and there are no signs of internal or external Hemorrhage, one may wait for spontaneous placental separation and expulsion of the secundines within 30 minutes.

In certain cases, a delay in the expulsion of an already separated placenta may occur. Therefore, it is essential to recognize the clinical signs indicating that the placenta has separated and has descended into the lower uterine segment, the cervix, or the Vagina.

Signs of placental separation:

- Schroeder's sign — A change in the shape and height of the uterine fundus. Immediately after the birth of the fetus, the uterus assumes a rounded shape and lies in the midline. The uterine fundus is at the level of the umbilicus. Following placental separation, the uterus elongates, deviates to the right, and its fundus rises to the right hypochondrium (Fig. 23);

- Ahlfeld's sign — descent of the ligature placed on the umbilical cord near the vulva by 10–12 cm;

- Chukalov-Kustner's sign — pressing with the edge of the hand just above the pubic bone causes the umbilical cord to retract if the placenta is not yet separated, whereas no retraction occurs if the placenta has separated from the uterine walls (Fig. 24);

- Dovzhenko's sign — retraction and descent of the umbilical cord during deep breathing indicates that the placenta has not separated; conversely, the absence of cord retraction during inspiration indicates placental separation;

- Klein's sign — analogous to Dovzhenko's sign, but observed during forced bearing down;

- Strassmann's sign — when tapping on the uterus, the fluid wave is transmitted along the umbilical cord only when the placenta is not yet detached. To confirm placental separation, it is sufficient to elicit 2–3 of these signs.

Once the placenta has separated, its delivery should be initiated immediately. The parturient woman is asked to bear down; under the pressure of the Abdominal Muscles, the detached placenta is usually delivered with ease. If this method proves unsuccessful, external techniques for delivering the secundines are employed.

Methods for delivering the secundines:

- Abuladze method — gentle uterine massage to stimulate contractions. Both hands then grasp the anterior abdominal wall into a longitudinal fold, and the woman is asked to bear down. Due to a significant increase in intra-abdominal pressure, the secundines are expelled (Fig. 25);

- Genscher method — the uterine fundus is brought to the midline of the abdomen, followed by gentle massage. The dorsal surfaces of the proximal Phalanges of the fingers are placed on the uterine fundus in the area of its cornua and pressure is gradually applied downwards and inwards. During this method of secundine delivery, the parturient woman should not bear down (Fig. 26);

- Credé-Lazarevich method — the uterus is brought to the midline with light massage to stimulate contraction. The uterine fundus is then grasped such that the thumb rests on the anterior uterine wall, the palm on the fundus, and the four fingers on the posterior uterine wall. The placenta is then expressed by pressing the uterine fundus downwards and forwards along the pelvic axis while simultaneously compressing the uterus in the anteroposterior direction (Fig. 27).

The third stage of labor concludes with the delivery of the secundines. The delivered placenta must be carefully inspected for the integrity of the placental cotyledons and the presence of all membranes. To accomplish this, it is placed on a smooth tray with the maternal surface facing upward, and the placenta is examined first, followed by the membranes, to verify their completeness. Attention is paid to the distance between the edge of the placental rupture of membranes and the placental margin; the closer this area is to the placental edge, the lower the placenta was implanted in the uterine cavity. The course of the Blood Vessels on the fetal surface of the placenta is traced. A vessel extending from the placenta onto the membranes may indicate the presence of additional placental lobes (succenturiate lobes) and velamentous cord insertion. Furthermore, placental fragments are frequently retained in the uterus. The site of umbilical cord insertion is inspected, its length is measured, and any anomalies (such as true or false knots) are noted. After inspection, the placenta is weighed, and the dimensions of the maternal surface are measured using a tape measure.

Following the delivery of the secundines, a thorough inspection of the birth canal is performed in all postpartum women. The cervix and vaginal walls are examined using specula. All identified tears of the soft Tissues of the birth canal (perineum, vagina, cervix) are repaired under aseptic conditions with local or general anesthesia.

To inspect the birth canal, the postpartum woman is placed on a delivery table (Rakhmanov bed). Special leg Supports are used to secure the lower extremities. The external genitalia and the inner thighs are treated with an antiseptic solution. A vaginal speculum and retractor are inserted into the vagina to expose the cervix. The cervix is grasped with fenestrated ring forceps and examined along its entire circumference by repositioning the forceps stepwise. Following inspection of the cervix, the vaginal walls, as well as the posterior and anterior vaginal fornices, are examined. If tears or deep fissures are identified, they are sutured.

Following the completion of labor, the postpartum woman must remain in the delivery room for 2 hours.

Review Questions

1. What is labor (childbirth)?

2. What are the prodromal signs of labor?

3. Name the signs indicating the onset of labor.

4. WHAT IS A woman called during labor?

5. Name the stages of labor.

6. Name the Components of the expulsive forces.

7. Signs of the onset of the first stage of labor and its duration.

8. Duration of the stages of labor.

9. How are forewaters and hindwaters formed?

10. Signs of the onset of the second (expulsion) stage.

11. What is the biomechanism of labor?

12. Name the cardinal Movements of the biomechanism of labor in the anterior occipital presentation.

13. Features of the biomechanism of labor in the posterior occipital presentation.

14. A.Ya. Krasovsky's theory of the biomechanism of labor.

15. Examination of the parturient woman upon admission to the maternity hospital.

16. Monitoring the parturient woman in the pre-labor ward.

17. Protection of the perineum.

18. Name the signs of placental separation.

19. Methods for delivering the separated placenta.

20. What steps does the postpartum examination of the placenta include?