Download (module I «Physiological obstetrics») / укладачі: В. І. Бойко, М. Л

Ministry of Education and Science of Ukraine
Sumy State University
Medical Institute
3915 Methodical instructions
for practical work on obstetrics
(module I «Physiological obstetrics»)
for foreign students
of the specialty 7.110101 “Medical Care”
of the full-time course of study
Sumy
Sumy State University
2015
Methodical Instructions for practical work on obstetrics (module I
«Physiological obstetrics») / укладачі: В. І. Бойко,
М. Л. Кузьоменська, С. А. Сміян, І. М. Нікітіна,
Н. А. Іконописцева. – Суми : Сумський державний університет,
Contents
Lesson 1.
Lesson 2.
Lesson 3.
Lesson 4.
Lesson 5.
Lesson 6.
Lesson 7.
Lesson 8.
Lesson 9.
Lesson 10.
Lesson 11.
Lesson 12.
Lesson 13.
Lesson 14.
Lesson 15.
Lesson 16.
Lesson 17.
Lesson 18.
TEST……
Female pelvis …………………………………..……
Fetus as the object of labor. Segments of fetal head ..
Physiological pregnancy. Assessment of fetal wellbeing ………………………………………………..
Methods of examination of pregnant women.
Obstetrics terminology ……………………………...
Normal labor. Biomechanism of labor in cephalic
presentation …………………………………………
Anaesthesia in labour ……………………………….
Physiological puerperium …………………………...
Newborn’s physiological period ……………………
Pregnancy and labor in breech presentation ………...
Pregnancy and labor in pelvic malformations.
Macrosomia’s problem in obstertrics. Pregnancy of
large babies and labor……………………………….
Abnormal development of zygote. Multiple
gestations ……………………………………………
Disorder of implantation ……………………………
Antenatal method of examination. Placental
insufficiency ………………………………………...
Fetal distress syndrome. Retardation, hypotrophy of
fetus………………………………………………….
Isoantigen conflict between mother blood and fetus.
Pathology in newborn period. Asphyxia in
newborn……………………………………………...
Toxico-septic disease of newborn. Method of
intensive therapy and reanimation…………………...
Case history (pregnant women) ……………………..
History of delivery …………………………………..
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LESSON 1
FEMALE PELVIS
Aim: to learn measuring of the pelvis sizes, to estimate pelvis
from the point of view of the obstetrics, to learn the structure of the
pelvic floor, sizes of fetus head.
Basic level:
1. Structure of pelvis.
2. Main anatomic landmarks for measuring pelvis.
3. Shape and sizes of pelvic planes.
4. External sizes of pelvis.
5. Structure of pelvic floor.
6. Structure and sizes of fetus head at term.
STUDENTS' INDEPENDENT STUDY PROGRAM
I. Objectives for Students' Independent Studies
You should prepare for the practical class, using the existing
textbooks and lectures. Special attention should be paid to the
following:
1. What bones does the pelvis consist of?
2. Differences between female and male pelvis.
3. The main landmarks of the female pelvis.
4. Planes of pelvis and their sizes.
5. Main and additional external pelvis sizes.
6. Methods of estimation of true conjugate.
7. Soloov's index. Its significance for estimation of internal
pelvic sizes.
8. Mikhaelis' rhomb. Its significance for estimation of result
of labor.
9. Structure of pelvic floor.
10. Structure and sizes of fetal head.
11. Body sizes of fetus.
12. Sutures and fontanels and their significance for
diagnosing the situation of fetal head.
13. Definition of «large segment» of fetal head.
14. Relationship of fetal head to pelvic planes.
Key words and phrases: Bony pelvis, pelvic inlet, greatest
diameter, midplane, pelvic outlet, anterior and posterior fontanels,
occipitofrontal dimension, subocccipitobregmatic diameter, occipitomenlal dimention; biparietal and bitemporal distance; sagittal,
frontal, lambdoid suture.
SUMMARY
Planes and Diameters of the Pelvis
The pelvis has four imaginary planes:
1) plane of the pelvic inlet;
2) pelvic plane of greatest dimensions;
3) the plane of the midpelvis (least pelvic dimensions);
4) the plane of the pelvic outlet.
Pelvic inlet is bounded posteriorly by the promontory,
laterally by the finea terminal is and anteriorly by the horizontal rami
of the pubic bones and the top of the symphysis pubis. Four
diameters of pelvic inlet are described: the anterioposterior (11 cm),
the transverse (13 cm), and two obliques (12 cm from left or right
sacroiliac synchondroses to the iliopectineal eminence on the
opposite side of the pelvis).
The pelvic plane of greatest dimension extends from the
middle of the posterior surface of the symphysis pubis through the
ischial bones over the middle of the acetabulum to the junction of the
second and third sacral vertebrae. Its anteroposterior and transverse
diameters are 12.5 cm. The midpelvis at the level of the ischial
spines is particularly important following engagement of the fetus
head in obstructed labor. The transverse diameter (interspinous) is
10.5 cm and anteroposterior is 11 cm.
Pelvic outlet has two diameters: anteroposterior extends from
the lower margin of the symphysis pubis to the tip of the coccyx
(9.5cm) and transverse diameter between the inner edges of the
ischial tuberosities (11.5 cm).
The main external pelvic sizes:
D. Spinarun − distance between anterior superior iliac spines
from both sides. It is 25−26 cm.
D. Cristarum − distance between iliac crista from both sides.
It is 28−29 cm.
D. Trochanterica − distance between trochanter majors from
both sides. It is 31−32 cm.
C. Externa − distance between midpoint of superior surface
of the symphysis pubis and suprasacralis fossa.
Michael's rhomb. It has 4 angles The upper angle is located in
the suprasacralis fossa. The lower angle is situated in the apex of
coccyx, and laterally angles are situated in the posterior superior iliac
spines. In the women with normal pelvis, rhomb has regular form. Its
vertical size is 11 cm, and horizontal size is 10 cm.
Soloiov's index. It is estimated by the circumference of
radiocarpal joint. It is 14−16 cm and indicates pelvic bones'
thickness.
The additional external pelvic sizes:
Lateral conjugate is a distance between the anterior superior
iliac spine and posterior superior iliac spine of the same iliac bone. It
is 14.5−16 cm.
Oblique conjugate is a distance between the right anterior
superior iliac spine to the left posterior superior iliac spine. It is
14.5−16 cm.
Anteroposterior diameter of the pelvic outlet is a distance
between the lower part of symphysis pubis and apex of the coccyx. It
is 9.5 cm.
Transverse diameter of the pelvic outlet is a distance between
the posterior portions of the ischial tuberosities. It is 11.5 cm.
The main internal pelvic sizes:
The widest anteroposterior diameter of the pelvic inlet is
called obstetric conjugate. It runs from the upper midpoint of the
pubic symphysis to the promontorium. It is 11 cm long. It is one of
the most important pelvic dimensions.
Indirect ways to estimate true conjugate:
1. An estimate of the obstetric conjugate is made by
determining the diagonal conjugate. During a vaginal examination,
the physician attempts to reach the sacral promontory with the
middle finger of the examining hand. The index finger of the free
hand marks the point where the lower border of the pubic symphysis
impinges on the examining hand proximal to the
metacarpophalangeal joint of the index finger. The diagonal
conjugate usually exceeds the obstetric conjugate by 1.5 − 2 cm.
2. External conjugate exceeds the obstetric conjugate by 9 cm.
3. Vertical dimension of Michael's rhomb equals obstetric conjugate.
II. Tests and Assignments for Self-Testing
Multiple Choice
Choose the correct answer / statement.
l. The innominate bones are composed of:
A – Ilium;
B – Tibia;
C – Ischium;
D – Pubis;
E – A, B, and C;
F – A, C, and D.
2. The false pelvis and true pelvis are separated by the:
A – Acetabulum;
B – Sacrospinous ligament;
C – Linea terminalis;
D – Obturator membrane;
E – Obturator foramen.
3. The false pelvis is separated from the true pelvis by:
A – Pelvic inlet;
B – Greatest diameter;
C – Least diameter;
D – Pelvic outlet.
Real - life situations to be solved:
4. During examination of female pelvis, it was revealed that
distantia of spinarum − 26 cm, distantia cristiarum − 29 cm, distantia
trochanterica −30 cm, conjugata externa − 21 cm. Soloviov's index is
15 cm. Define the size of true conjugate.
III. Answers to Self-Testing
1. F; 2. C; 3. A; 4. Size of true conjugate is 12 cm. Pelvis has
normal sizes.
Visual aids and material tools:
Chart №__
Equipment:
Students must know:
1. Structure of female pelvis.
2. Planes of true pelvis and their sizes.
3. Main and additional sizes of pelvis.
Student should be able:
1. To measure pelvic sizes.
2. To measure diagonal conjugate.
3. To measure true corrugate.
4. To measure Soloviov's index and to apply it for estimation
of internal sizes of pelvis.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 50−58, 68−70, 130−132, 181.
2. Danforth's Obstetrics and Gynecology − Seventh edition − 1994
−P. 108−112.
3. Gant N. F. Basic Gynecology and Obstetrics / Norman F. Gant,
F. Gary Cunningham. − 1993. − P. 299−303.
LESSON 2
FETUS AS THE OBJECT OF LABOR.
SEGMENTS OF FETAL HEAD
I. Fetal Head The fetal head, from the obstetrical viepoint, is
the most important part, since an essential feature of labor is an
adaptation between the fetal head and the maternal bone pelvis. Only
a comparatively small part of the head of the fetus at term is
represented by the face; the rest is composed of the firm skull, which
is made up of two frontal, two parietal, and two temporal bones
along with the upper portion of the occipital bone and the wings of
the sphenoid. These bones are not united rigidly but are separated by
membranous spaces, the sutures. The most important sutures are
sagittal between the two parietal bones, frontal between the two
frontal bones, the two coronal between the frontal and parietal bones,
and the two lambdoid between the posterior margin of the parietal
bones and upper margin of the occipital bone.
Where several sutures meet an irregular space forms, which is
enclosed by a membrane and designated by a fontanel. The greater or
anterior fontanel is a lozenge-shaped space situated at the junction of
the sagittal and coronal sutures. The lesser or posterior fontanel is
represented by a small triangular area at the intersection of the
sagittal and lambdoid sutures. Both may be felt readily during labor,
and their recognition gives important information concerning the
presentation and position of the fetus.
The circumferences and average fetal head diameters are:
suboccipitobregmatic 32 cm (9.5 cm); suboccipitofrontal 33 cm
(10cm); occipitomental 38 cm (13 cm); occipitofrontal 34 cm (12
cm); sublinguobregmatic 32 cm (9.5 cm), biparietal (9.5 cm);
bitemporal (8 cm). Circumference of shoulders is 34 cm (12 cm),
circumference of pelvic part is 28 cm (9.5 cm).
II. Tests and Assignments for Self- Testing
multiple hoice
I. Relationship of fetal head to pelvic inlet plane.
l. The sagittal suture fetal head is:
A – Oblique diameter;
B – Anteroposterior diameter;
C – Transverse diameter;
D – Oblique or transverse diameter;
2. The posterior fontanel is:
A – Anterior;
B – Posterior;
C – Center.
III. Answers to the Self-Testing
1. D; 2 C.
Visual aids and material tools:
Chart №__
Equipment:
Students must know:
1. Structure of interm letus head.
2. Definition of large segment.
3. Relationship of fetus head to pelvic planes.
Student should be able to determine:
1. Structure and sizes of fetal head.
2. Body sizes of fetus alt term.
3. Sutures and fontanels and their significance for diagnosing
the situation of fetal head.
4. Definition of «large segment» of fetal head.
5. Relationship of fetal head to pelvic planes.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 50−58, 68−70, 130−132, 181.
2. Danforth's Obstetrics and Gynecology. − Seventh edition. − 1994
− P. 108−112.
3. Gant N. F. Basic Gynecology and Obstetrics / Norman F. Gant,
F. Gary Cunningham.− 1993. − P. 299−303.
LESSON 3
PHYSIOLOGICAL PREGNANCY.
ASSESSMENT OF FETAL WELL- BEING
Pregnancy is associated with normal physiological changes
that assist fetal survival as well as preparation for labor. It is
important to know what 'normal' parameters of changes are
appropriate to diagnose and manage common medical problems of
pregnancy, such as hypertension, gestational diabetes, anaemia and
hyperthyroidism.
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Endocrine system (non-reproductive)
Pituitary disorders
FSH/LH fall to low levels.
ACTH and melanocyte-stimulating hormone increase.
Prolactin increases.
Thyroid and parathyroid disorders
Thyroxine binding globulin (TBG) concentrations rise due to
increased oestrogen levels.
T4 and T3 increase over first half of pregnancy, but there is a
normal to slightly decreased amount of free hormone due to
increased TBG level.
TSH production is stimulated, although in healthy individuals
this is not usually significant. A large rise in TSH is likely to
indicate iodine deficiency or subclinical hypothyroidism.
Serum calcium levels decrease in pregnancy which stimulates
an increase in parathyroid hormone (PTH).
Colecalciferol (vitamin D3) is converted to its active
metabolite, 1.25-dihydroxycolecalciferol, by placental 1αhydroxylase.
Adrenal gland and pancreas disorders
Cortisol levels increase in pregnancy, which favours
lipogenesis and fat storage.
Insulin response also increases, so blood sugar should remain
normal or low.
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Peripheral insulin resistance may also develop over the course
of pregnancy and gestational diabetes is thought to reflect a
pronounced insulin resistance of this sort.
Cardiovascular system
Progesterone reduces systemic vascular resistance by about
20% in early pregnancy. Postural hypotension may result.
Diastolic and systolic blood pressure tend to fall during midpregnancy and then return to normal by week 36.
Venous return in the inferior vena cava can be compromised in
late pregnancy if a woman lies flat on her back. This is relieved
by lying in the left lateral position.
Increased circulating angiotensin II encourages water and
sodium retention leading to an increased plasma volume (to
50% by 30 weeks) and predisposing to oedema. This enables
increased uterine blood flow to meet growing nutritional and
oxygenation needs of the fetus. It also enables blood loss
(average 500 ml) at delivery to be met without physiological
decompensation.
Advise women not to take up unaccustomed, vigorous exercise
in pregnancy as there is a risk of diversion of uterine blood
flow to the skeletal muscles.
Blood flow to kidneys, skin and mucosa increases.
Cardiac output increases by 30−50 % with 15 % increase in
heart rate and 25−30 % increased stroke volume. Much of this
adjustment occurs prior to 12 weeks' gestation and so impaired
cardiac function is likely to present problematically in early
pregnancy or with the sudden increase in pre-load in the third
stage of labor.
Cardiac examination in pregnancy
Many women have the a third heart sound after mid-pregnancy.
Diastolic murmurs should be considered potentially
pathological.
Systolic flow murmurs are common.
ECG-symptom − left axis deviation is common; sagging of ST
segments and inversion or flattening of the T-wave in lead III
may also occur.
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Respiratory system
Tidal volume increases by about 200 ml, increasing vital
capacity and decreasing residual volume. In later stages of
pregnancy, splinting of the diaphragm may occur with some
decrease in tidal volume. Respiratory rate does not alter
significantly.
Oxygen consumption increases by approximately 20 %.
State of compensated respiratory alkalosis − arterial PCO2
drops, arterial PO2-remains unchanged, and decrease in
bicarbonate prevents pH change. Lower maternal PCO2
facilitates oxygen/carbon-dioxide transfer to/from fetus.
Many women complain of feeling short of breath in pregnancy
without explanatory pathology. The mechanism of this is not
fully understood.
Alimentary system
Appetite is usually increased, sometimes with specific cravings.
Progesterone causes relaxation of the lower oesophageal
sphincter and increased reflux, making many women prone to
heartburn.
GI motility is reduced and transit time is consequently longer.
This allows increased nutrient absorption. Constipation is
common.
The gallbladder may dilate and empty less completely.
Pregnancy also predisposes to the precipitation of cholesterol
gallstones.
Gums become spongy, friable and prone to bleeding. Good
dental care is important.
Urinary tract
Glomerular filtration rate (GFR) increases by 50 % early in
pregnancy, increasing creatinine clearance. Serum creatinine
and urea will fall by about 25 %.
Increased GFR also increases filtered sodium. Aldosterone
levels rise by 2-3 times to reabsorb the filtered sodium.
Increased GFR and impaired tubular reabsorption of glucose
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produce glucosuria in approximately 15 % of normal
pregnancies.
Proteinuria is abnormal in pregnancy.
The smooth muscle of the renal pelvis and ureter become
relaxed and dilated; kidneys increase in length and ureters
become longer, more curved and with an increase in residual
urine volume. Bladder smooth muscle also relaxes, increasing
capacity and risk of UTI. Approximately 5 % of pregnant
women have bacteriuria, often asymptomatic, and there is a
greater risk of developing pyelonephritis in pregnancy.
Haematological
Dilutional anaemia is caused by the rise in plasma volume.
Elevated erythropoietin levels increase the total red cell mass
by the end of the second trimester, but haemoglobin
concentrations never reach pre-pregnancy levels.
A modest leukocytosis is observed.
A normal pregnancy creates a demand for about 1000 mg of
additional iron. This equates to 60 mg elemental iron or 300 mg
ferrous sulphate per day.
Serum iron falls during pregnancy whilst transferrin and total
iron binding capacity rises.
Levels of some clotting factors (VII, VIII, IX and X) and
fibrinogen increase whilst fibrinolytic activity decreases. These
changes protect from haemorrhage at delivery but also make
pregnancy a hypercoagulable state with increased risk of
thromboembolism.
Protein C and Protein S activities gradually reduce during
pregnancy. Interpretation of thrombophilia screens is difficult
during pregnancy, and testing following a thromboembolic
event should wait until after the puerperium.
Serum alkaline phosphatase increases during pregnancy due to
placental production.
Serum albumin decreases.
Metabolic
Changes in energy requirements in pregnancy remain
controversial − healthy levels of fat deposition and variation in
women's physical activity levels cause uncertainty as to the
recommendations we should make for this time.
- The basal metabolic rate increases slowly over the course of
pregnancy by 15-20 %.
- In women with normal BMIs, energy requirement does not
increase significantly during the first trimester, increases by
about 350 Kcal/day in the second trimester and 500 Kcal/day in
the third.
- Active energy expenditure tends to fall over pregnancy.
- Normal weight gain is approximately 12.5 kg (usually at a rate
of 0.5 kg per week for the last 20 weeks). 5 kg is the fetus,
placenta, membranes and amniotic fluid and the rest is maternal
stores of fat and protein and increased intra- and extra-vascular
volume.
Skin
- Hyperpigmentation of the umbilicus, nipples, abdominal
midline (linea nigra) and face (chloasma) are common due to
the hormonal changes of pregnancy.
- Hyperdynamic circulation and high levels of oestrogen may
cause spider naevi and palmar erythema.
- Striae gravidarum ("stretch marks") are common.
Musculoskeletal
- Increased ligamental laxity caused by increased levels of
relaxin contribute to back pain and pubic symphysis
dysfunction.
- Shift in posture with exaggerated lumbar lordosis leading to the
typical gait of late pregnancy.
Assessment of Fetal Well-Being
Aim: to be able to prescribe and assess modern methods of
diagnostics of fetal well-being in obstetrics for timely detection of
pathological changes in pregnant woman's organism and fetal status;
to prescribe an adequate treatment to the pregnant woman in case of
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fetal hypoxia.
Professional motivation, appropriate interpretation of fetal
well-being tests in light of the natural course of any antenatal mental
health problem, provides a firm base on which decisions are made.
Basic level:
1. Conceptus development.
2. Obstetric ultrasound examination and its assessment.
3. Fetal heart rate monitoring by auscultation.
4. To prescribe an adequate therapy in the impairment of fetal
well-being.
STUDENTS INDEPENDENT STUDY PROGRAM
I. Objectives for Students' Independent Studies
You should prepare for the practical class using the existing
textbooks and lectures. Special attention should be paid to the
following:
1. Obstetric ultrasound examination.
2. Investigation of discharge from breast glands on the
gestational age of pregnancy.
3. Electronic fetal monitoring.
4. Biophysical profile of the fetus.
5. Test for revealing amniotic fluid.
6. Functional diagnostic tests.
7. Invasive methods for assessment of fetal status,
cordocentesis, phetoscopy, amnioscopy, amniocentesis.
Key words and phrases: assessment of fetal well-being, fetal
hypoxia, biophysical profile.
SUMMARY
Assessment of fetal well-being includes maternal perception
of fetal activity and several tests using electronic fetal monitors and
ultrasonography.
Tests of fetal well-being have a wide range of uses, including
the assessment of fetal status at a particular time and the prediction
of fetal status for varying time intervals, depending on the test and
the clinical situation.
An active fetus is generally a healthy fetus, so that
quantification of fetal activity is a common test of fetal well-being.
If, for example, the mother detects more than four fetal movements
while lying comfortably and focusing on fetal activity for 1 hour, the
fetus is considered to be healthy.
Techniques using electronic fetal monitoring and
ultrasonography are most costly, but also provide more specific
information. The most common tests used are the nonstress test, the
contraction stress test (called the oxytocin challenge test if oxytocin
is used), and the biophysical profile.
The nonstress test (NST) measures the response of the fetal
heart rate to fetal movement. Interpretation of the nonstress test
depends on whether the fetal heart rate accelerates in response to
fetal movement. A normal, or reactive, NST occurs when the fetal
heart rate increases by at least 15 bpm over a period of 15 seconds
following a fetal movement. Two such accelerations in a 20-minute
time span are considered reactive or normal. The absence of these
accelerations in response to fetal movement is a nonreactive NST. A
reactive NST is generally reassuring in the absence of other
indicators of fetal stress. Depending on the clinical situation, the test
is repeated every 3 to 4 days or weekly. A nonreactive NST must be
immediately followed with further assessment of fetal well-being.
Whereas the nonstress test evaluates the fetal heart rate
response to fetal activity, the contraction stress test (CST) measures
the response of the fetal heart rate to the stress of uterine contraction.
With uterine contraction, uteroplacental blood flow is temporary
reduced. A healthy fetus is able to compensate for this intermittent
decreased blood flow, whereas a fetus who is compromised is unable
to do so, demonstrating abnormalities such as fetal heart rate
decelerations. If contractions are occurring spontaneously, the test is
known as a contraction stress test; if oxytocin infusion is required to
elicit contractions, the test is called an oxytocin challenge test (OCT).
The normal fetal heart rate response to contractions is for the
baseline fetal heart rate to remain unchanged and for there to be no
fetal heart rate decelerations.
The biophysical profile is a series of five assessments of fetal
well-being, each of which is given a score of 0 or 2. The parameters
include a reactive nonstress test, the presence of fetal movement of
the body or limbs, the findings of fetal tone (flexed extremities as
opposed to a flaccid posture), and an adequate amount of amniotic
fluid volume. Perinatal outcome can be correlated with the score
derived from these five parameters.
A score of 8 to 10 is considered normal, a score of 6 is
equivocal, requiring further evaluation, and a score of 4 or less is
abnormal, usually requiring immediate intervention.
Table 1. Biophysical profile
Biophysical
Variable
Fetal breathing
movements (FBM)
Score
Normal = 2
Abnormal = 0
Gross body
movement
Normal = 2
Abnormal = 0
Fetal tone
Normal = 2
Abnormal = 0
Reactive fetal heart
rate
Explanation
At least 1 FBM of at least 30 seconds
duration in 30 minutes
No FBM of at least 30 seconds
duration in 30 minutes
At least 3 discrete body /limb
movements in 30 minutes
2 or less discrete body /limb
movements in 30 minutes
At least 1 episode of active extension
with return to flexion of fetal
limbs/trunk or opening/closing of
hand
Either slow extension with return to
partial flexion or movement of limb in
full extension or no fetal movement
Normal = 2
Reactive NST
Abnormal = 0
Nonreactive NST
Qualitative amniotic
Normal = 2
fluid volume
Abnormal = 0
At least 1 pocket of amniotic fluid at
least 1 cm in two perpendicular planes
No amniotic fluid or no pockets of
fluid greater than 1 cm in two
perpendicular planes
II. Tests and Assignments for Self-Testing
Multiple Choice.
Choose the correct answer / statement:
1. A reactive nonstress test (NST) is characterized by a fetal heart
rate increase of how many beats per minute:
A – 15;
B – 25;
C – 50;
D – 5;
E– 55.
2. Which of the following statements correctly describes an
abnormal contraction stress test (CST)?
A – Fetal heart rate increases in response to fetal movement;
B – Fetal heart rate decreases in response to fetal movement;
C – Maternal heart rate increases in response to uterine
contraction;
D – Maternal heart rate decreases in response to uterine
contraction;
E – All of the above.
3. A biophysical profile in which there is one or more episodes of
fetal breathing in 30 minutes, three or more discrete movements in
30 minutes, opening/closing of the fetal hand, a nonreactive
nonstress test (NST), and no pockets of amniotic fluid greater than 1
cm would have a total score of:
A – 2;
B – 4;
C – 6;
D – 8;
E – 10.
4. The normal fetal heart rate at term is:
A – 50−75 beats per minute (bpm);
B – 80−100 bpm;
C – 200 bpm;
D – 175−190 bpm;
E – 120−160 bpm.
Real-life situations to be solved:
5. A 27-year-old woman at 37 weeks calls saying her baby is
moving mucrfless than it did a few days ago. On review of her
antepartum record, you note no medical problems, normal fetal
growth, and a normal obstetric ultrasound examination at 18 weeks.
Your most appropriate action(s) is/are:
A – Because she has an unremarkable antepartum record,
reassure the patient that she is just inexperienced and
that everything is good;
B – Suggest to the patient the coming to the hospital for labor
induction;
C – Suggest to the patient the coming to the hospital for an
NST;
D – Suggest to the patient the coming to the hospital for an
OCT;
6. The patient comes to the hospital and receives an NST. It is
nonreactive. Your most appropriate action is to suggest which of the
following?
A – A biophysical profile;
B – A repeat NST in 1 week;
C – An induction of labor;
D – Nutrition consult to avoid hypoglycemia associated with
deceased fetal movement;
E – Cordocentesis for fetal blood sampling.
III. Answers to Self-Testing
l. A; 2. C; 3. C; 4.E.
5. Answer A will only raise the patient's concerns and does
not address the problem to proper evaluation of decreased fetal
movement. An NST is the least invasive and most cost-effective test.
An OCT is also a good test of fetal well-being, but it is more invasive
and costly than the NST, and it is not warranted in a patient with no
risk factors. Labor induction is not indicated.
6. Cordocentesis is risky and not indicated, nor is induction.
A biophysical profile is the least invasive and most cost-effective test
of fetal well-being as follow-up to a nonreactive NST. An OCT
would also serve as a test of fetal well-being, but it does not measure
amniotic fluid volume.
Visual aids and material tools:
Charts №
Equipment:
Students must know:
1. The main methods of assessment of fetal well-being in
obstetrics.
Students should be able:
1. To perform fetal heart tone auscultation.
2. To prescribe an adequate treatment of fetal hypoxia.
3. To do ultrasonography assessment.
4. To evaluate fetal heart tones during electronic fetal
monitoring.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 50−58, 68−70, 130−132, 181.
2. Danforth's Obstetrics and Gynecology − Seventh edition. − 1994.
− P. 108−112.
3. Obstetrics and Gynecology. − Third Edition. − Williams &
Wilkins Waverly Company. − 1998. − P. 118−130.
4. Gant Norman F. Basic Gynecology and Obstetrics / Gant Norman
F., F. Gary Cunningham. −1993. − P. 328−397.
5. Obstetrics and Gynecology / Pamela S. Miles, J. Christopher
Carey William F. Rayburn. − Springer-Verlag New York. −1994. −
P. 30-34.
LESSON 4
OBSTETRICS TERMINOLOGY. METHODS OF
EXAMINATION OF PREGNANT WOMEN
Aim: to know obstetrics terminology, the methods of external
and internal examination of pregnant women.
Professional motivation: learning the methods of obstetrics
examination of pregnant women is necessary to diagnose and to
estimate the given information.
Basic level:
Student must know:
1. Anatomic terminology in English and Latin.
2. Methods of physical examination of a patient.
3. The structure of fetal head ( anatomy of the skull ).
STUDENTS' INDEPENDENT STUDY PROGRAM
I. Objectives for Students' Independent Studies
You should prepare for the practical class, using the existing
textbooks and lectures. Special attention should be paid to the
following:
1. Definition of the obstetrics terms: attitude (habitus), lie,
presentation, position, variety (visus, fase).
2. Definition of the terms: axis of fetus, axis of uterus, axis
of pelvis.
3. Engagement (synclitic and asynclitic).
4. Auscultation of fetal heart sounds.
5. Vaginal examination.
6. Speculum examination.
7. Abdominal examination of ( Leopold's maneuvers).
8. Ultrasonic assessment of the fetus.
Key words and phrases: habitus (attitude), lie, presentation,
position, variety, axis of fetus, axis of uterus, axis of pelvis,
synclitism and asynclitism, engagement; Leopold's maneuvers,
speculum and vaginal examination.
SUMMARY
Attitude is the relationship of the fetal body parts to each
other (fetal head is flexed on fetal chest, thighs are flexed on fetal
abdomen).
Lie of the fetus is the relationship of the long axis of the fetus
to the long axis of the uterus and is either longitudinal or transverse.
In longitudinal lie, the long axis of the fetus is parallel to the long
axis of the uterus . When long axis of the fetus and long axis of the
uterus cross at a 45- degree angle, an oblique lie is formed. At
transverse lie, they cross at a 90 degree angle. Longitudinal lies are
present in over 99 % of labor at term.
Presentation indicates the part of the fetus that directly
overlies pelvic inlet. Presenting part is that of the fetus that comes
down first through the birth canal (foremost wilhin the birth canal).
When the lie is longitudinal, the presenting part is either the head
(cephalic) or fetal butt (breech). The occiput, chin, and sacrum are
respectively the determining points in vertex, face and breech
presentation.
Position refers to the relationship of definite parts of the fetus
to the right or left side of the maternal pelvis. With each presentation,
there may be two positions: right or left.
Variety (visus face) − the relation of the given portion of the
presenting part to the anterior and or posterior portion of the mother's
pelvis. Since there are two positions, there must be six varieties for
each presentation. Any presentation may be either the left and right
occipital ( LO, RO), or the left and right mental (LM, RM), or the
left and right sacral ( LS, RS). The presenting part in each of the two
positions may be directed anteriorly or posteriorly.
Engagement exists when the biparietal diameter of the fetal
head have passed through the plane of the pelvic inlet. If at the time
of engagement the sagittal suture is midway between the pubic
symphysis and the promontory of the sacrum in a transverse position,
the head is said to be synclitic. If the sagittal suture is parallel to the
transverse diameter of pelvis but anterior or posterior to it, the fetal
head engages with some degree of asynclitism (anterior asynclitism,
posterior asynclitism).
Abdominal palpation: Leopold's maneuvers
In the first maneuver, the examiner palpates uterine fundus
and distinguishes which part of the fetus occupies the fundus.
Important is estimation of gestational age of the pregnancy and fetal
lie.
The second maneuver is accomplished when hands are placed
on either side of the abdomen to determine on which side lies the
fetal back. Important is estimation of fetal lie, position, variety,
amount of amniotic fluid, fetal movement.
In the third maneuver, a single examining hand is placed just
above the symphysis. Important is determination of presentation and
a presenting part. The presented part is grasped between the thumb
and the third finger.
The fourth maneuver is done with the examiner facing the
patient's feet and placing both hands on either side of the lower
abdomen just above the inlet. Important is determination of fetal
head station (relation of presenting part to the pelvic inlet).
Vaginal examination. In vaginal examination a doctor
should examine vaginal walls; dilation, effacement, consistency and
position of the cervix; presence of amniotic fluid; fetal presentation
and position, pelvis.
To determine presentation and position by vaginal
examination, it is advisable to pursue a definite routine that consists
of three maneuvers as:
Two gloved fingers are introduced into vagina and carried up
to the presenting part. Differentiation of vertex, face and breech
presentation is then readily accomplished.
If the vertex is a presenting part, the examiner's fingers are
introduced in the posterior aspect of the vagina. The fingers are then
swept over the fetal head toward the maternal symphysis. The
examiner's finger must cross the sagittal suture, and its course is
outlined with small and large fontanels at the opposite ends.
The positions of the two fontanels then are ascertained, i.e.
anterior and posterior.
Auscultation. In cephalic presentation, the point of maximal
intensity of fetal heart sounds is usually midway between the
maternal umbilicus and the anterior-superior spine of her ilium.
Employing ultrasonography, the fetal head and body can be
located usually without difficulty.
Ultrasonic dating of pregnancy and an ultrasonic fetal survey
to detect gross abnormalities have been recommended in some
clinics as a routine part of early prenatal care. Routine
ultrasonography is most cost -effective in patients in whom the date
of the last menstrual period is uncertain and in patients with a family
history of congenital anomalies. Considerable individualization
should be exercised in making the decision to order this evaluation.
If ultrasonography is performed, it is most informative between 1820 weeks.
Structural defects that have been diagnosed with this
technique include craniospinal abnormalities (e. g. anencephaly,
hydrocephaly, spina bifida, microcephaly), gastrointestinal anomalies
(e. g. omphalocele, gastroschisis), excretory system anomalies (e. g.
renal agenesis, renal dysplasia, urinary obstruction), skeletal
dysplasia and congenital heart defects.
Erdovaginal ultrasonography is used primarily in the first
trimester to establish fetal viability.
II. Tests and Assignments for Self-Testing
Multiple Choice.
Choose the correct answer / statement:
1. The most common fetal lie found during early labor is:
A – Oblique.
B – Transverse.
C – Vertex.
D – Longitudinal.
2. The most common fetal presentation found during early labor
is:
A – Oblique.
B – Transverse.
C – Vertex.
D – Longitudinal.
3. What is presentation?
A – Relationship of the fetal presenting part to the right and
left side of the maternal pelvis.
B – Relationship of the long axis of the fetus with the uterine
long axis.
C – Portion of the fetus lowest in the birth canal.
D – Part of the fetus that is most easily palpable on abdominal
examination.
4. Leopold's maneuvers are used to establish all of the following
except:
A – Fetal gender.
B – Fetal lie.
C – Fetal presentation.
D – Fetal position.
E – Fetal movement.
5. What do we identify carrying out the third Leopold's
maneuver?
A – Part of the fetus which occupies the fundus of the uterus.
B – Fetal back.
C – The lie of the fetus.
D – The presenting part.
E – The position of the fetus.
Real-life situations to be solved:
6. While perfoming the first Leopold's maneuver, a physician
palpates in fundal area an irregular and soft part; carrying out the
third maneuver, determines a round, firm and ballotable part. What is
the presentation of the fetus?
7. While examining the abdomen of a pregnant woman, a
physician identifies the longitudinal lie of the fetus, head
presentation, left position and anterior variety. Where is the best
place for auscultation of the fetal heart beats? What is the normal
fetal heart rate?
III. Answers to Self-Testing.
1. D; 2. C; 3. C; 4. A; 5. D; 6. Cephalic presentation.
7. Auscultation should be performed on the abdominal left
side and lower the umbilicus. The normal heart rate of fetus is 120 –
140 beats per minute.
Visual Aids and Material Tools:
Charts №
Equipment:
Students must know:
1. Obstetrics terminology.
2. Examination of the abdomen ( Leopold's maneuvers).
3. Pelvic examination.
4. The landmarks of fetal skull, segments of fetus heard.
Students should be able:
1. To take history.
2. To perform objective examination of pregnant woman.
3. To perform Leopold's maneuver.
4. To identify the lie, position and presentation of the fetus.
5. To perform the auscultation, vaginal examination done by a
vaginal speculum.
6. To estimate the given information.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C.80 − 91.
2. Danforth's Obstetrics and Gynecology. − Seventh edition. − 1994.
− P. 113 − 115.
3. Obstetrics and Gynecology. − Third Edition. − Williams &
Wilkins Waverly Company. − 1998. − P. 86 − 91.
4. Gant Norman F. Basic Gynecology and Obstetrics / Gant Norman
F., F. Gary Cunningham. − 1993. − P. 304 − 307.
5. Obstetrics and Gynecology / Pamela S. Miles, J. Christopher
Carey, William F. Rayburn. − Springer-Verlag New York. −1994. −
17 – 20.
LESSON 5
NORMAL LABOR. BIOMECHANISM OF LABOR IN
CEPHALIC PRESENTATION
Part I
Aim: to learn clinical duration of the first, second and third
stages of labor principles of pain relief. Primary care of a newborn.
Professional motivation: careful diagnosis and management
of each stage of labor are important for preventing complication in
the puerperium and preventing maternal and perinatal mortality.
Basic level:
1. Mechanism of muscle contractions.
2. Estimation of gestational age.
3. Structure of conceptus at the end of pregnancy.
STUDENTS' INDEPENDENT STUDY PROGRAM
I. Objectives for Students' Independent Studies
You should prepare for the practical class, using the existing
textbooks and lectures. Special attention should be paid to the
following:
1. What is labor?
2. Stages of labor.
3. Labor's expulsive forces.
4. Mechanism of cervical dilatation in primapara and
multipara.
5. What is lower uterine segment, contractile ring?
6. Management of the first stage of labor.
7. Role of vaginal examination in diagnosis of labor stages.
8. Management of the second stage of labor.
9. Perineal protective maneuvers.
10. Signs of placental separation.
11. Manual removal of placenta.
12. Structure of afterbirth.
13. Blood loss during labor and its estimation.
14. Definition of physiological blood loss.
Key words and phrases: normal labor, delivery, cervical
effacement and dilatation, expulsion of fetus, separation and
expulsion of placenta, manual removal of placenta.
SUMMARY
Labor is a physiologic process that permits a series of
extensive physiological changes in the mother to allow for the
delivery of her fetus through the birth canal.
It is defined as progressive cervical effacement, dilatation, or
both, resulting from regular uterine contractions that occur at least
every 5 minutes and last 30 – 60 seconds.
Labor forces:
1. Uterine contractions is a regular contractions of uterine
musculature. Typically, contractions occur every 5 to 10 minutes and
last for 20−25 seconds in the onset of labor. As labor proceeds, the
contractions become more frequent, more intense, and last longer. In
the end of labor the contractions occur every 2−3 minutes and last for
50 to 60 seconds. They are characterized by strength, duration, and
frequency which are important in generating a normal labor pattern.
2. Bearing-down efforts (or pushing) is the periodic
contractions of diaphragm, pelvic floor muscles, and prelum
abdominale, which are added to the force of uterine contractions. It is
voluntary expulsive force.
There are three stages of labor, each of which is considered
separately.
The first stage (cervical) is from the onset of true labor to
complete dilatation of the cervix.
The second stage (pelvic) starts from complete dilatation of
the cervix to the delivery of the baby.
The third stage (placental) lasts from the birth of the baby to
delivery of the placenta. It is divided into two phases: placental
separation and its expulsion.
During the first stage of the labor cervical effacement and
dilatation occur.
Labor begins with cervical effacement. Cervical effacement is
the thinning of the cervix.
Although cervical softening and early effacement may occur
before labor, during the first stage of labor the entire cervical length
is retracted into lower uterine segment as a result of myometrial
contractile forces and pressure exerted by either presenting part of
fetal membranes.
The length of the first stage may vary in relation to parity;
primiparous patients generally experience a longer first stage than do
multiparous patients. The minimal dilatation during the first stage is
l−l.2 cm/hour for primiparous and 1.2−1.5 cm/hour for multiparous
women. If the progress is slower than this, evaluation for uterine
dysfunction, fetal malposition, or cephalopelvic disproportion should
be undertaken.
During the first stage, the progress of labor may be measured
in terms of cervical effacement, cervical dilatation and descent of the
fetal head. Uterine contractions should be monitored every 30
minutes by palpation for their frequency, duration, and intensity. For
high-risk pregnancies, uterine contractions should be monitored
continuously along with the fetal heart rate.
Vaginal examination should be done sparingly to decrease
the risk of an intrauterine infection. Cervical effacement and
dilatation, the station and position of the presenting part, the presence
of molding or caput in vertex presentation should be recorded.
Additional examinations may be performed if the patient reports the
urge to push (to determine if the full dilatation has occurred), or if a
significant fetal heart rate deceleration occurs (to examine for a
prolapsed umbilical cord).
The fetal heart rate should be evaluated by either
auscultation with a stethoscope or by external monitoring with
Doppler equipment. In patients with no significant obstetric risk
factors, the fetal heart rate should be auscultated at least every 30
minutes in the first stage of labor and after each uterine contraction
in the second stage of the labor.
At the beginning of the second stage, the mother usually has a
desire to bear down with each contraction. This abdominal pressure,
together with uterine contractile force, combines to expel the fetus.
In cephalic presentation, the shape of the fetal head may be altered
during labor, making the assessment of fetal head descent more
difficult. Molding is the alteration of the relationship of the fetal
cranial bones to each other as the result of the compressive forces
exerted by the bony maternal pelvis.
The second stage generally takes from 30 minutes to 2 hours
in primigravid women and from 10−50 minutes in multigravid
women. The median duration of labor 50 is minutes in a primipara
and slightly under 20 minutes in a multipara.
Clinical management of the second stage of labor. When
delivery is imminent, the patient is usually placed in the lithotomy
position.
With each contraction, the mother should be encouraged to
hold her breath and bear down with expulsive efforts. As the
perineum becomes flattened by the crowning head, an episiotomy
may be performed to prevent perineal lacerations.
As the fetal head crowns (i. e., distends the vaginal opening),
we examine every 15 minutes the following: pulse, aterial preassure,
fundus of uterus, hemorrhage and general condition of the woman.
The delivery of the placenta occurs during the third stage of
labor. Separation of the placenta generally occurs within 2 - 10
minutes at the end of the second stage of labor. Squeezing of the
fundus to hasten placental separation is not recommended because it
may increase the likelihood of passage of fetal cells into the maternal
circulation Signs of placental separation are as follows: a fresh show
of the blood from the vagina, the umbilical cord lengthens outside
the vagina, the fundus of the uterus rises up, the uterus becomes firm
and globular. Only when these signs have appeared, the attempt to
remove off the separated placenta should be perform. The placenta
should be examined to ensure its complete removal and to detect
placental abnormalities. If the patient is at risk of postpaitum
hemorrhage (e. g., because of anemia, prolonged oxytocin
augmentation of labor, multiple gestation or hydroamnion), manual
removal of the placenta, manual exploration of the uterus, or both
may be necessary. After the placental delivery, the cervix and vagina
should be thoroughly inspected for lacerations and surgical repair
should be performed if necessary.
II. Tests and Assignments for Self-Testing
Multiple Choice.
Choose the correct answer / statement:
1. Cervical effacement relates to:
A – How far the cervix is opened.
B – The degree of cervical thinning.
C – The relation of the presenting part to the cervix.
D – The softness of the cervix.
2. During second stage of labor, the absence of electronic fetal
monitoring, fetal heart rate auscultation should be performed after:
A – Each uterine contraction.
B – Every other uterine contraction.
C – Every third uterine contraction.
D – Every contraction generating pressure more than 15 − 20
mm Hg.
3. How many minutes approximately is it customary to wait for
spontaneous extrusion of the placenta?
A – 10.
B – 20.
C – 30.
D – 40.
E – 50.
4. All of the following are necessary for the diagnosis of true
labor EXCEPT:
A – Rhythmic contractions.
B – Cervical dilatation.
C – Cervical effacement.
D – Bloody show.
5. The second stage of labor consists of the time:
A – From compete dilatation of the cervix to delivery of the
infant.
B – From divery of infant to delivery of the placenta.
C – From onset of labor to full cervical dilatation.
D – During the period extending up to 2 hours after delivery
of the placenta.
Real-life situations to be solved:
6. A woman with in-time pregnancy bears down during 40−45
seconds with intervals for 1−2 minutes. The rupture of the membrane
has occurred 10 minutes ago. Vaginal examination has occured, fetus
head is on the pelvic floor. Saggital suture is in anterior-posterior
diameter of pelvic outlet. Arnniotic sac is absent. What the stage of
labor?
7. The bleeding began after childbirth. The blood loss is 300 ml.
There aren't the signs of the placental abruption. What is the
diagnosis? What do you have to do?
III. Answers to Self-Testing
1. B; 2. A; 3. C; 4. D; 5. A; 6. Second pelvic stage of labor;
7. Placenta accreta. Manual removal of the placenta.
Visual Aids and Material Tools:
Charts №
Equipment:
Students must know:
1. Stages of labor.
2. Clinical picture of the first stage of labor.
3. Significance of vaginal examination for estimation of the
patient's progress of labor.
4. Management of the first stage of labor.
5. Clinical picture and management of the second stage of
labor. Perineal protective maneuvers.
6. Primary newborn care.
7. Clinical picture and management of the third stage of labor.
8. Methods of placental removal, which is separated.
9. Estimation of blood lost during labor.
10. Manual removal of placenta.
11. Manual revision of uterine cavity.
Students should be able:
1. To diagnose true labor.
2. To estimate the character of uterine contractions.
3. To estimate fetal station.
4. To estimate of fetal well-being.
5. To choose the analgesic and anesthetic agents.
6. To perform perineal protective maneuvers.
7. To perform primary newborn care.
8. To estimate the maternal vital signs.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 110 − 149.
2. Danforth's Obstetrics and Gynecology. − Seventh edition. − 1994.
− P. 117 − 128.
3. Obstetrics and Gynecology. − Third Edition. − Williams &
Wilkins Waverly Company. − 1998. − P. 91 − 100.
4. Obstetrics and Gynecology. / Pamela S. Miles, J. Christopher
Carey, William F. Rayburn. − Springer-Verlag New York. − 1994. −
P. 27 – 30.
BIOMECHANISM OF LABOR IN CEPHALIC
PRESENTATION
Part II
Aim: to learn the biomechanism of labor in cephalic
presentation, recognise anterior and posterior positions.
Professional motivation: occiput presentations occur in
about 95% of all labors. It is very important to know biomechanism
of labor in cephalic presentation for management of labor. Students
have to know the normal and abnormal positions of fetal head and
complications caused by pathological labor.
Basic level:
1. Anatomy, structure of the fetal head. The sutures and
fontanels of the fetal head. Diameters of the fetal head at term.
2. Anatomy and topography of the uterus, pelvis and pelvic
floor.
3. External and internal examinations of pregnant women.
4. The main marks on the fetal head.
STUDENTS' INDEPENDENT STUDY PROGRAM
I. Objectives for Students' Independent Studies
You should prepare for the practical class, using the existing
textbooks and lectures. Special attention should be paid to the
following:
1. Give the definition of such obstetric terms as: "leading
point", "fixative point".
2. Graphic documentation of the fetal head station in the true
pelvis in different types of cephalic presentation.
3. Theories of the cardinal movemehts of labor.
4. Cardinal movemehts of labor in the vertex (occiput)
anterior presentation.
5. Cardinal moments of labor in the vertex (occiput)
posterior
1. presentation.
6. Importance of perineal protection maneuvers.
7. Techniques of perineal protection maneuvers (five
moments).
Key words and phrases: occiput presentation,
biomechanism of labor, flexion, internal rotation, extension, external
rotation, synclitism, asynclitism.
SUMMARY
Occiput presentations occur in about 95% of all labors.
Because of the irregular shape of the pelvic canal and the relatively
large dimensions of the mature fetal head, it is evident that not all
diameters of the head can necessarily pass through all diameters of
the pelvis. It follows that adaptation or accommodation of suitable
portions of the fetal head to the various segments of pelvis is
required for completion of childbirth. These positional changes of the
presenting part constitute the mechanism of labor.
There are 2 kinds of the occiput presentations − anterior and
posterior. The cardinal movements of labor in anterior occiput
presentation are:
- flexion;
- internal rotation;
- extension;
- internal rotation of the fetal head and external rotation of the
fetal body.
The various movements are often described as though they
have occurred separately and independently. In reality, the
mechanism of labor consists of a combination of movements that are
going on the same time. For example, as a part of the engagement
process, there are both flexion and descent of the head. It is
manifestly impossible for movements to be completed, unless the
presenting part descends simultaneously. The uterine contractions
effect important modifications in the attitude, or habitus of the fetus
especially after the head has descended into the pelvis. These
changes consist principally in a straightening of the fetus, with loss
of its dorsal convexity and closer application of the extremities and
small parts of the body. As a result, the fetal ovoid is transformed
into a cylinder with the smallest possible cross section normally,
passing through the birth canal.
Synclitism and asynclitism. Synclitism is a position when
the sagittal suture is in the transverse pelvic diameter. The sagittal
suture lies exactly midway between the symphysis and promontory.
If the sagittal suture approaches the sacral promontory, more
of the anterior parietal bone presents itself to the examining fingers
and that condition is called anterior asynclitism. If the sagittal suture
lies close to the symphysis, more of the posterior parietal bone
presents itself and the condition is called posterior asynclitism.
The cardinal movements of labor in anterior occiput
presentation are:
1. Flexion. As soon as descending head meets resistance,
whether from the cervix, the walls of the pelvis, or the pelvic floor,
flexion of the head normally results. In this movement, the chin is
brought into more intimate contact with the fetal thorax, and the
shorter suboccipitobregmatic diameter (9 cm) is substituted for the
longer occipitofrontal diameter.
2. Internal rotation. This is movement of the fetal head in
such manner that the occiput gradually moves from its original
position anteriorly towards the symphysis pubis. The rotation begins
when the fetal head descends from the plane of the greatest pelvic
dimensions to the least pelvic dimensions (midpelvis). The rotation is
complete when the head reaches the pelvic floor; the sagittal suture is
in the anteroposterior diameter of the pelvic outlet, and the small
fontanel is under the symphysis.
3. Extension. After internal rotation, the sharply flexed head
reaches the pelvic floor and two forces come into play. The first,
exerted by the uterus, acts more posteriorly, and the second, supplied
by the resistant pelvic floor, acts more anteriorly. The resultant force
is the direction of the vulvar opening, thereby causing extension.
Extension begins when the fixing point (fossa suboccipitalis) is under
the inferior margin of the symphysis pubis. With increasing
distension of the perineum and vaginal opening, an increasingly large
portion of the occiput gradually appears. The head is born by further
extension as the occiput, bregma, forehead, nose, mouse.
4. Internal rotation of the fetal head and external rotation of
the fetal body. During the head extension, the fetal body is in the
pelvic cavity. The biacromial diameter turns from the oblique to the
anterioposterior diameter of the pelvic outlet. Thus one shoulder is
anterior behind the symphysis and the other is posterior. This
movement is brought about apparently by the same pelvic factors
that effect internal rotation of the head. The anterior shoulder comes
under the symphysis pubis, the fetal body flexes and the posterior
shoulder is delivered first. Then the anterior shoulder is delivered.
Fetal head rotates as a result of the body rotation. In the I position,
fetal face turns towards the right, in the II position, towards the left.
After delivery of the shoulers, the rest of the body of the child is
quickly extruded.
The cardinal movements of labor in posterior occiput
presentation are:
1. Flexion. The fetal head flexes and presents the
suboccipitofrontal (10 cm) diameter in the oblique diameter of the
pelvic inlet. The leader point is a middle part of the sagittal suture.
2. Internal rotation. The fetal head passes through the pelvic
cavity and in the narrow plane it begins to rotate. In the outlet plane
of the pelvis (pelvic floor), the sagittal suture is the (anterioposterior)
diameter of the pelvic outlet and the small fontanel is under the os
sacrum.
3. Additional flexion. After internal rotation, the head reaches
the pelvic floor. Fetal head fixes with the area of the border of the
hair part of the head (the first fixing point) under symphysis pubis
and flexes. This process leads to delivery of the vertex.
4. Extension. Extension begins when the second fixing point
(fossa suboccipitalis) is under the tip of the sacrum. The head is born
by further extension.
5. Internal rotation of the fetal head and external rotation of
the fetal body. Shoulders enter the inlet of small pelvis in oblique
size and, in pelvic cavity, perform the internal rotation to 45°; in the
pelvic floor, they stand in the direct (anterioposterior) size. The
anterior shoulder comes under the margin of symphysis pubis, the
fetal body flexes. The posterior shoulder is born first and then the
anterior shoulder is born. The head rotation realizes as in anterior
occiput presentation.
III. Tests and Assignments for Self-Testing
Multiple choice.
Choose the correct answer / statement:
1. The fetal presentation with the estimated incidence of its
occurrence in anterior occiput presentation is:
A – 95 .
B – 1 %.
C – 4 %.
D – 20 %.
2. The fetal presentation with the estimated incidence of its
occurrence in posterior occiput presentation is:
A – 95 %.
B – 1 %.
C – 3,5 %.
D – 15 %.
3. The first movement of the labor mechanism in the anterior
occiput presentation is:
A – Flexion.
B – Rotation.
C – Extension.
D – Additional flexion.
4. What is the fixing point in the anterior occiput presentation:
A – Occiput.
B – Sinciput.
C – Fossa suboccipitalis.
D – The area of the border of the hair part.
5. What is the first fixing point in the posterior occiput
presentation:
A – Occiput.
B – The root of the nose.
C – Fossa suboccipitalis.
D – The area of the border of the hair part.
6. What is the leading point in the anterior occiput presentation:
A – Anterior fontanel.
B – Posterior fontanel.
C – Fossa suboccipitalis.
D – The area of the border of the hair part.
Real - life situations to be solved:
7. M., 28 years old, para 2. Full term of pregnancy. Initiation of
labor was 8 hours ago. The membranes ruptured 20 minutes ago.
Pelvic sizes: 25, 28, 31, 20. Fetal heart rate is 132 beats per minute
with satisfactory characteristics.
A vaginal exam tolls that the cervix is completely dilated.
The amniotic sac is absent. Fetal head is in outlet plane of the pelvis.
Sagittal suture is in the anterioposterior diameter of the pelvic outlet.
Small fontanel is in the anterior side.
What is the diagnosis? What moment of labor biomechanism
is st?
8. Primipara N., 25 years old. Delivery at term. Initiation of labor
was 8 hours ago. The amniotic sac is ruptured. Pelvic sizes: 25, 28,
31, 20. Fetal heart rate is 140 beats per minute with satisfactory
characteristics. Uterine contractions are occurring every 8 minutes
and judged to be mild in intensity.
Per vaginum, the uterine cervix dilatation is 6 cm. The
amniotic sac is absent. Fetal head is fixed in the inlet of the pelvis.
Sagittal suture is in the right oblique pibvic drameter size. Small
fontanel is in the left anterior side.
What is the diagnosis? What moment of labor biomechanizm
it is?
III. Answers to Self-Testing
1. A; 2. B; 3. A; 4. C; 5. D; 6. B; 7. Labor 2, at term, 2 stage
of labor. Anterior occiput presentation. Third moment of the labor
biomechanism, extension of the fetal head. Management: normal
vaginal delivery; 8. Labor preterm. First stage of labor. Anterior
occiput presentation. First moment of the labor biomechanism.
Management: normal vaginal delivery.
Visual Aids and Material Tools:
Charts №
Equipment:
Students must know:
1. The cardinal movements of labor in anterior occiput
presentation.
2. The cardinal movements of labor in posterior occiput
presentation.
3. The definition of synclitism and asynclitism.
4. The mechanism of head flexion, rotation, extension,
internal body rotation and external head rotation.
5. The definition of the leading point and the fixing point.
Students should be able:
1. To make the external obstetric physical examination.
2. To make the internal obstetric physical examination.
3. To show the cardinal movements of labor in anterior and
posterior occiput presentation on dummy.
4. To determine the suture and fontanels on the fetal head.
5. To determine the movements of the labor.
6. To determine normal and abnormal labor.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 121 − 124.
2. Danforth's Obstetrics and Gynecology. − Seventh edition. − 1994.
− P. 115 − 117.
3. Obstetrics and Gynecology. − Third Edition. − Williams &
Wilkins Waverly Company. − 1998. − P. 91 − 93.
4. Gant Norman F. Basic Gynecology and Obstetrics / Gant Norman
F., Gary Cunningham. − 1993. − P. 308 − 310.
LESSON 6
ANAESTHESIA IN LABOR
Aim: to learn the main methods of analgesia and anesthesia
in the first and second stages of labor.
Professional motivation: labor is a painful process that, for
the nullipara, may be the most painful event that she has ever
experienced. Fortunately, it often proves to be the most rewarding.
The relief of the pain in labor presents special problems, which may
be best solved by administration of special medicines and
procedures.
Basic level:
1. Anatomy and physiology of female sex organs; diagnosis
of the first and second stages of labor.
2. Methods of anesthesia (infiltrative, conductive, columnal).
Anatomic sites for pudendal anesthesia.
3. Peculiarities of medicines for general and local anesthesia
with their prescriptions in a correct dose.
STUDENTS' INDEPENDENT STUDY PROGRAM
I. Objectives for Students' Independent Studies
You should prepare for the practical class, using the existing
textbooks and lectures. Special attention should be paid to the
following:
1. Anatomical substrate of pain in labor.
2. Importance of cortex, conditioned reflex in the
development of pain in labor.
3. Psychoprophylactic painless labor.
4. Methods of analgesia and anesthesia during labor and
indications for them:
1) combination of sedation, spasmolytic and analgetic
medicines;
2) superficial anesthesia;
3) inhalation anesthesia;
4) acupuncture;
5) epidural anesthesia.
5. Structure and prescription of apparatus for anesthesia.
6. The main analgesic and anesthetic used in obstetrics:
1) gas anesthetics;
2) intravenous anesthetics;
3) psychotropic medicines.
7. The anesthetic technique that provides pain relief during
first stage of labor.
8. The anesthetic technique that provides pain relief during
second stage of labor.
9. Indications for pudendal block.
Key words and phrases: Psychoprophylaxis for pain relief
in labor, analgesia and anesthesia in obstetrics.
SUMMARY
The intensity of pain with labor is related to a large degree of
emotional tensions. Psychoprophylaxis for pain relief with pregnant
women begins at the 35 − 36 gestational age and is composed of four
lessons. Themes of the lessons are: 1st lesson − anatomy and
physiology of female sex organs, labor and its stages; 2nd lesson −
training in breathing, counting of labor pains, compression of
anterior superior iliac spine, muscle relaxation be instituted well in
advance of labor; 3d lesson − women have to be well informed about
the various hospital procedures to which they would be subjected
during labor and delivery; 4th lesson − regimen of puerperal period,
preparing breasts to lactation, care of infant.
Women, who attempt psychoprophylaxis but find the
discomforts of labor to be too great, should not be refused a relief
provided by appropriate analgesics and nerve block anesthesia for
delivery.
Any analgesic or anesthetic technique used during labor and
delivery process should take into account those sensory pathways
involved and the points at which they may be affected. During the
first stage of labor, pain results from contraction of the uterus and
dilation of the cervix. This pain travels along the visceral afferents,
which accompany sympathetic nerves, entering the spinal cord at
T10, T1l, T12, and LI. As the head descends, there is also distension
of the lower birth canal and perineum. This pain is transmitted along
somatic afferents that comprise portions of the pudendal nerves that
enter the spinal cord at S2, S3, and S4.
Spinal anesthesia − introduction of a local anesthetic into the
subarachnoid space can be used for vaginal or abdominal delivery
also, but it is typically given just before delivery. Complications with
spinal anesthesia: maternal hypotension, total spinal blockage,
anxiety and discomfort, spinal headaches, arachnoiditis.
The anesthetic technique that provides pain relief during labor
is the epidural (peridural) block (a block from T10 to S5) The
advantage of this tecnique is its ability to provide analgesia during
labor as well as excellent anesthesia for delivery, yet maintains the
patients' sense of touch, facilitating participation in the birth process.
A pudendal block with local anesthesia can be administrated
easily at the time of delivery to provide perineal anesthesia for a
vaginal delivery. Indications for pudendal block: preterm labor, labor
in breach presentations.
A local block (i.e., local injection of anesthetic) may be used
at the area of an episiotomy or tear.
General anesthesia is reserved only for cesarean section in
selected cases. During this anesthesia, gas, volatile and intravenous
anesthetics should be administrated. Two anesthetics gases, nitrous
oxide and cyclopropane, are used currently in obstetrics. The gas is
highly explosive and must always be given in a closed system.
Volatile anesthetics, ether, halothane, methoxyflurane, enflurane
cross the placenta readily and are capable of producing narcosis in
the fetus. Intravenous anesthetics in obstetrics, such as thiopental,
cetamin, phentanil offer the advantages of ease and extreme rapidly
induction, ample oxygenation, ready controllability, minimal
postpartum bleeding, and promptness of recovery without vomiting.
II. Tests and Assignments for Self-Testing
Multiple Choice.
Choose the correct answer / statement:
1. Pudendal anesthesia or block:
A – Provides perineal anesthesia for vaginal delivery.
B – Anesthesia for the active phase of labor and delivery.
C – Short-term anesthesia for vaginal or abdominal delivery.
D – Anesthesia for latent phase of labor.
E – All of the above.
2. Which of the following is an associated maternal risk when
spinal anesthesia is used?
A – Hypotension.
B – Loss of desire to push.
C – Headache.
D – All of the above.
3. Maternal aspiration syndrome is a particularly high risk of
general anesthesia in obstetric cases because of:
A – High alkaline content of the maternal gut during
pregnancy.
B – Decreased gastrointestinal function during labor.
C – Pica-like eating habits of women just before labor.
D – Most general anesthetics causing reflex spasm of the
stomach.
E – All of the above.
Real-life situations to be solved.
4. A 22-year-old woman at term comes to labor unit complaining
of increasingly severe, painfulness and frequent uterine contractions.
Contractile ring is placed 2 fingers above pubis, cephalic
presentation. Fetal heart rate − 140 bpm. Which method of anesthesia
and analgesia should be administrated?
5. A 22-year-old woman in 35 – 36 week of gestational age is
present in the labor unit in the second stage of the first pre-term labor
in cephalic presentation. Which method of anesthesia should be
administrated?
6. Which method of anesthesia may be used in the area of episiotomy?
III. Answers to Self-Testing
1. A; 2. D; 3. B; 4. Intramuscular administration of
spasmolytics and analgesics; 5. Pudendal block; 6. Episiotomy
shouldn't use anesthesia because it is performed during active
pushing at labor, when the sensory pathways are compressed by
descended fetal head.
Visual Aids and Material Tools:
Charts №
Equipment:
Students must know:
1. Anatomical substrate of pain in labor.
2. Methods of analgesia and anesthesia during the first and
second stages of labor.
3. Structure and prescription of apparatus for anesthesia.
4. The main analgesic and anesthetic agents used in
obstetrics.
Students should be able:
1. To diagnose the first and second stages of labor.
2. To determine the importance of administration of
anesthesia during labor.
3. To give the prescriptions of analgesia and anesthetic agents
in correct doses.
4. To determine the sites for pudendal block.
5. To organize a psychoprophylactic lesson with pregnant
women.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 45 − 65.
2. Obstetrics and Gynecology. Williams & Wilkins Waverly
Company. − Third Edition. − 1998. − P. 118 − 130.
3. Basic Gynecology and Obstetrics / Norman F. Gant, F. Gary
Cunningham. − 1993. − P. 347 − 353.
4. Obstetrics and Gynecology. − Pamela S. Miles, William F.
Rayburn, J. Christopher Carey. − Springer-Verlag New York. −
1994. − P. 35 − 36.
LESSON 7
PHYSIOLOGICAL PUERPERIUM
Aim: to study the normal puerperium, to diagnose the
complications of the puerperium and methods of their prevention.
Basic level:
1. Anatomy and physiology of female reproductive system.
2. Changes in the female reproductive organs and in the
whole organism of the woman during pregnancy, labor and
puerperium.
3. The structure and function of breasts.
4. Laboratory tests during the puerperium.
STUDENTS' INDEPENDENT STUDY PROGRAM
І. Objectives for Students' Independent Studies
You should prepare for the practical class, using the existing
textbooks and lectures. Special attention should be paid to the
following:
1. The definition of the puerperium.
2. The definition of the early and late puerperium.
3. The main processes in the puerperium.
4. Involution of the uterus.
5. What is lochia? The role of the lochia.
6. Changing of the lochia during the puerperium.
7. Hygiene of the female reproductive organs in puerperants.
8. Care of the puerperants after episiotomy.
9. Function of breasts in puerperium.
10. Fissures of the nipples. Their treatment and prevention.
11. The rules of breast feeding.
12. Management of the puerperium.
13. Ultrasonic estimation of uterine involution.
14. Medicines stimulating myometrial contraction.
15. Hospital discharge of maternity patients.
Key words and phrases: puerperium, involution, uterus,
cervix.
SUMMARY
The pueperium (also known as postpartum) consists of the
6-week period following delivery of the baby and placenta. Early (2
hours after delivery) and late postpartum are distinguished. During
the puerperium, the reproductive organs and maternal physiology
return toward the pregnancy state, although menses may not return
for much longer.
Involution of the uterus. Immediately after delivery, the
fundus of the uterus is easily palpable on the level of the umbilicus.
The immediate reduction in uterine size is the result of the delivery
of the fetus, placenta and amniotic fluid as well as the loss of
hormonal stimulation. Further uterine involution is caused by
autolysis of intracellular myometrial protein, resulting in a decrease
in cell size but not cell number. Through these changes, the uterus
returns to its normal size.
As the myometrial fibers contract, the blood clots from the
uterus are expelled and thrombi in the large vessels of the placental
bed undergo organization. Within the first 3 days, the remaining
decidua differentiates into a superficial layer, which becomes
necrotic and sloughs, and a basal layer-adjacent to the myometrium,
which contains the fundi of the endometrial glands and is the source
of the new endometrium.
Immediately after the delivery of the placenta, the uterus is
palpated bimanually to ascertain that it is firm.
This discharge is fairly heavy at first and rapidly decreases in
amount over the first 2 – 3 days postpartum, although it may last for
several weeks. For the first few days after delivery, the uterine
discharge appears red (lochia rubra) due to the presence of
erythrocytes. After 3 – 4 days, the lochia becomes paler (lochia
serosa), and by the tenth day, it turns a white or yellow-white color
(lochia alba). By the end of the third week postpartum, the
endometrium is reestablished in most patients.
Cervix. Within several hours of delivery, the cervix has
reformed, and by 1 week, it usually admits only one finger (i. e., it is
approximately 1 cm in diameter). The round shape of the nulliparous
cervix is usually permanently replaced by a transverse, fish-mouth
shaped external os, the result of laceration during delivery. Vulvar
and vaginal tissues return to normal over the first several days, in
spite of the vaginal mucosa that reflects a hypoestrogenic state of the
woman breastfeeding, because ovarian function is suppressed during
breastfeeding.
Abdominal wall. Return of the elastic fibers of the stretched
rectus muscles to normal configuration occurs slowly and is aided by
physical exercise.
At time of delivery, the drop of estrogen and other placental
hormones is also a major factor in removing the inhibition of the
prolactin action, suckling by the infant stimulates release of oxytocin
from the neurohypophysis. On approximately the second day after
delivery, colostrum is secreted. After about 3 – 6 days, the colostrum
is replaced by mature milk.
Nipple care is also important during breastfeeding. The
nipples should be washed with water and exposed to the air for 15 to
20 minutes after each feeding. A water-based cream, such as lanolin,
or vitamin A and D ointment may be applied if the nipples are
tender.
Mastitis is an uncommon complication of breastfeeding and
usually develops 2 – 4 weeks after beginning breastfeeding. The first
symptoms are usually slight fever and chills. These are followed by
redness of a segment of the breast, which becomes indurated and
painful. The etiologic agent is usually Staphylococcus aureus, which
originates from the infant's oral pharynx. Milk should be obtained
from the breast for the culture and sensitivity test, and mother should
start on a regimen of antibiotics, immediately. Because the majority
of staphylococcal organisms are penicillinase-producing, a
penicillinase-resistant antibiotic, such as dicloxacillin, should be
used. Breastfeeding should be discontinued, and an appropriate
antibiotic should be continued for 7 – 10 days. If a breast abscess
occurs, it should be surgically drained. A breast pump can be used to
maintain lactation until the infection has cleared up, but the milk
should be discarded. The infant, along with other family members,
should be evaluated for staphylococcal infections that may be source
of reinfection if breastfeeding is resumed.
II. Tests and Assignments for Self-Testing
Multiple Choice.
Choose the correct answer / statement:
1. The puerperium is the period of time following birth during
which the reproductive tract returns to its normal, nonpregnant state.
How many weeks does this last approximately?
A – 4.
B – 6.
C – 8.
D – 10.
E – 12.
2. How many weeks does it take for the uterus to return to its
pregnancy position in the true pelvis?
A – 1.
B – 2.
C – 3.
D – 4.
E – 5.
3. On approximately what postpartum day does milk production
begin?
A – First.
B – Third.
C – Fifth.
D – Seventh.
E – Ninth.
4. When after delivery is the endometrium reestablished in most
patients?
A – First week.
B – Second week.
C – Third week.
D – Fourth week.
E – Fifth week.
5. Breastfeeding in the postpartum period:
A – Markedly diminishes blood loss.
B – Slightly diminishes blood loss.
C – Does not affect the amount of blood loss.
D – Slightly increases blood loss.
E – Markedly increases blood loss.
Real-life situations to be solved:
6. A 23-year-old woman delivers a healthy full-term boy by
normal vaginal delivery after an unremarkable anterpartum course
and spontaneous labor. She decides to breastfeed, which she has
started satisfactorily during her stay in the hospital. She and her
newborn son are well at the time of discharge. Ten days later, she
calls complaining of the slight fever and pain in her left breast. You
learn that the segment in the left side of her left breast has redness,
which is indurated and painful and feels especially warm to the
touch. Her temperature is 38°C, and she feels generally bad. What is
the most likely diagnosis?
III. Answers to Self-Testing
1. B; 2. B; 3. B; 4. C; 5. C; 6. Mastitis.
Visual Aids and Material Tools:
Charts №
Equipment:
Students must know:
1. Regimen of the Postpartum Unit.
2. Preventive methods of postpartum complication of genital
infection.
3. Physiologic changes of the postpartum period.
4. Management of physiologic changes of the pueperium
period.
5. Principles of breastfeeding.
Students should be able:
1. To perform the palpation of postpartum uterus for its
consistency determination.
2. To examine the external reproductive organs, to estimate
the character of lochia.
3. To estimate the breast and nipple care, to diagnose crafted
nipples.
4. To perform breast pumping, to study how to pump breast.
5. To care the perineum, perineal lacerations.
6. To remove the sutures from perineal tears.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 150 − 158.
2. Danforth's Obstetrics and Gynecology − Seventh edition. − 1994.
− P. 163 − 174.
3. Obstetrics and Gynecology. − Third Edition. − Williams &
Wilkins Waverly Company. − 1998. − P. 136 − 146.
4. Gant Norman F. Basic Gynecology and Obstetrics / Gant Norman
F., F. Gary Cunningham. − 1993. − P. 317 − 320.
5. Obstetrics and Gynecology / Pamela S. Miles, J. Christopher
Carey, William F. Rayburn. − Springer-Verlag New York. − 1994. −
P. 47 – 50.
LESSON 8
NENBORN’S PHYSIOLOGICAL PERIOD
Urgent terms. Modern principles of prenatal care are based on
the concept of physiological care of the child with restriction to
medical interventions without indications. To attend physiological
adaptation of the newborn and further development of the child, it is
necessary to know correctly how to look after the newborn.
Aim: to be able to estimate the condition of the newborn in
the delivery room and to provide correct care of the child. To keep
the physiological condition of this period.
To be able:
Specific goals:
1. To define functioning features of
bodies and systems in prenatal
development of the child and the
changes after the birth (department
of pediatrics and anatomy)
2. To define clinical and laboratory
indicators of a healthy matured
child (Department of Pediatrics)
3. To be able to define what occurs
in the newborn at various time
4.To define conditions which are
necessary for adaptation of the
newborn after delivery
(Department of Pediatrics)
5. To define hemolytic condition
of the newborn (Department of
Physiology).
Target level:
1. To carry out primary estimation of
the in the maternity room
2. To organize conditions for thermal
condition maintenance
3. To carry out suction of slime from
upper respiratory system
4. To provide comfortable condition
of the mother and the child
5. To put the child to the mothers
breast correctly
6. To carry out vaccination of the
newborn
7. To carry out screening inspection
of the newborn
8. To normalize conditions of
rooming-in and the discharge of the
newborn from the hospital
1. Sequence of medical actions for the care of the newborn
in the maternity home.
1.1. Right after birth, the midwife lays the child on the
mothers stomach, cleans the head and body of the child with a dry
warm towel, dresses up the child with cap and socks, and covers with
warm blanket.
1.2. Simultaneously, the doctor carries out primary estimation
of the newborn.
Estimation of the condition of the newborn
Diagnosis
Medical
recommendations
Breathing
Normal
Irregular
absent
Body
weight/
term of
pregnancy
palpitation
>2500;
Congenital
defect/birt
h trauma
Normal
Normal
>< 2500;
< 2500;
><2500;
>37 wk
><37 wk
><37 wk
><37 wk
If the child
breathes
or
shouts, has the
normal
muscular tone,
time is not
measured
<100 beats/
min
>100
beats/min
>100
beats/min
No
No
No
Available
Asphyxia
Low birth Congenital
weight
defect/birth
trauma
Medical care
of a newborn
with asphyxia
Medical care
of a newborn
with low
birth weight
Healthy
newborn
Medical care of
healthy
newborn
or
Medical
care of a
newborn
with
congenital
disorders
and birth
trauma
Estimation
of
newborn
condition
and
medical
recommendations:
1.1 To provide warm temperature after birth.
1.2 To estimate the condition of the newborn.
1.3 After the termination of umbilical cord pulsation but not
later than 1 minute after birth, to press and cut the umbilical cord to
separate from the mother.
1.4. The midwife observes the condition of the newborn all the
time in maternity home.
1.5 At the starting of sucking reflex, the midwife helps to put
the child to the breast of the mother.
1.6 In 30 minutes after birth, the midwife measures the body
temperature of the newborn with electronic thermometer.
1.7 In an hour after birth, the midwife carries out prophylactic
ophthalmia with 0.5 % of erythromycin or 1 % tetracycline
ointments.
1.8 Skin to skin contact should be provided at least 2 hours a
day at the maternity home under satisfactory conditions of the
mother and the child.
1.9 In 2 hours after the birth, measurements of the length and
weight of the child are carried out, and the umbilical cord is cut.
1.10 The doctor estimates the condition of the child, and the
midwife dress the child.
1.11 The child together with the mother is transfered to the
Department of Postnatal Care.
2. Warming condition:
Temperature in the delivery room should not be lower than
25С.
Ten steps of warming condition are:
1) Warm maternity home (operational).
2) Immediately dry the child.
3) Contact “skin to skin”.
4) Breast feeding.
5) Postpone weighing and bathing.
6) Correctly dress the child.
7) Stay together with the mother round-the-clock.
8) Transfer to warm conditions.
9) Resuscitation in warm conditions.
10) Increase level of consciousness.
3. Indications of adaptation which are necessary to define
before primary check-up
Table 2
Signs
Palpitation frequency
Breathing frequency
Colour of skin
Movements
Muscular tone
Temperature of the newborn
Normal values
100−160 / min
30−60 / min
Pink, absence of central
cyanosis
Active
Satisfactory
36.5−37.5°С
4. Vaccination
4.1 Vaccination of the newborn against hepatitis B within 12
hours after birth.
4.2 Vaccination of the newborn against tuberculosis within 3
– 5 days of life.
4.3 The discharge of the newborn from the maternity hospital
is carried out in 3 days under the following conditions:
1) The umbilical cord ruminants or wound is dry, clean, and
without inflammation signs.
2) The body temperature of the newborn is within the limits
of 36.5−37.5°С.
3) The child has good sucking reflex.
4) Vaccination, screening for phenylketonuria, congenital
hypothyroidism are carried out in the newborn.
5) The newborn is in a satisfactory condition.
6) The mother and the members of the family have sufficient
skills for care of the newborn.
Tasks for self-preparation:
1. A woman is admitted to the Hospital Department of Obstetrics
with gestation period of 37 weeks. Tell if it is a matured pregnancy
or not.
Possible answers:
А – yes;
В – no.
2. The child was born with weight 2400 g and length 43 cm. Is the
child matured?
Possible answers:
А – yes;
В – no.
3. What signs say about fetus maturity?
Possible answers:
А – colour of skin;
В – length of the baby's hip;
С – finding of umbilical cord;
D – vagina in girls and scrotum in boys;
Е – chest diameter.
4. In premature pregnancy can the child be matured?
Possible answers:
А – yes;
В – no.
Answers to the task:
1. А; 2. В; 3. А, С, D; 4. А.
Topic theoretical questions:
1. The sequence of actions of medical inspection for a healthy
newborn in the maternity home.
2. Organisation routine of heat maintenance.
3. What medical actions are carried out before newborn's
check-up.
4. Medical supervision of the newborn.
5. Adaptation indications of the newborn before primary
check-up.
6. Scheme of the first check-up of the newborn.
7. Keeping the mother and the child, together.
8. Absolute contra-indications for keeping the mothers and the
child together.
9. Care of the child which was born by a cesarean section.
10. Rules for mother breastfeeding.
11. Care of umbilical ruminants and umbilical wound.
12. Vaccination.
13. Discharge of the newborn from the hospital.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 150 − 158.
2. Danforth's Obstetrics and Gynecology − Seventh edition. − 1994.
− P. 163 − 174.
3. Obstetrics and Gynecology. − Third Edition. − Williams &
Wilkins Waverly Company. − 1998. − P. 136 − 146.
4. Gant Norman F. Basic Gynecology and Obstetrics / Gant Norman
F., F. Gary Cunningham. − 1993. − P. 317 − 320.
5. Obstetrics and Gynecology / Pamela S. Miles, J. Christopher
Carey, William F. Rayburn. − Springer-Verlag New York. − 1994. −
P. 47 – 50.
LESSON 9
PREGNANCY AND LABOR IN BREECH PRESENTATION
Aim: to learn the biomechanism of labor in breech
presentation, recognise the breech presentation and be able to render
manual assistance in labor in different types of breech presentation.
Professional motivation: the breech presentations occur in
about 3−4% of all labors. With breech presentation, compared to
cephalic presentation, both the mother and the fetus are at greater
risk. The prognosis for the fetus in a breech presentation is
considerably worse than for the fetus in a vertex presentation. The
operative delivery rate is higher and may be higher maternal
morbidity and mortality. It is very important to know the
biomechanism of labor in breech presentation and the correct
management of labor. Students have to be able to render the manual
aid to avoid the complication coursed by pathological labor.
Basic level:
1. Anatomy of the fetal head.
2. Anatomy and topography of the uterus, pelvis and pelvic
floor.
3. External and internal examination of the pregnant woman.
4. The structure of the fetal head.
5. Diameters of the fetal body at term.
6. The stages of labor.
STUDENTS' INDEPENDENT STUDY PROGRAM
I. Objectives for Students' Independent Studies
You should prepare for the practical class, using the existing
textbooks and lectures. Special attention should be paid to the
following:
1. Classification of breech presentations.
2. Diagnosis of breech presentations.
3. Biomechanism of labor in breech presentations.
4. The cardinal movements of labor in breech presentations.
5. The manual aid by Tsovyanov I in labor in the frank
breech presentation.
6. The conventional manual aid in labor in the complete and
incomplete breech presentations.
7. The manual aid by Tsovyanov II in labor in the footling
presentation.
8. The operative delivery in the breech presentation.
9. The complications to the delivery in the breech
presentation.
Key words and phrases: biomechanism, breech
presentation, frank breech presentation, complete and incomplete
breech presentation, descent, flexion, rotation, extension, manual
assistance by Tsovyanov I and Tsovyanov II, conventional manual
assistance.
SUMMARY
There is a fundamental difference between delivery in
cephalic and breech presentations. With a cephalic presentation, once
the head is delivered, typically the rest of the body follows without
difficulty. With a breech, successively larger or, in case of the head,
much less compressible parts of the fetus are born after the smaller
and compressible legs and pelvis.
Spontaneous complete expulsion of the fetus that presents as
a breech, as described below, is seldom successfully accomplished.
As a rule, either cesarean section or vaginal delivery that requires
skilled participation of the obstetrician is essential for a favorable
outcome.
Etiology. Breeches are much more common at the end of the
second trimester of pregnancy than at or near term. Factors other
than prematurity that appear to predispose to breech presentation
include uterine relaxation associated with high parity, multiple
fetuses, hydramnion, hydrocephalus, anencephalus, previous breech
delivery, uterine anomalies, and tumors.
Classification. The varying relations between the lower
extremities and buttocks of the fetus in breech presentation form the
categories of frank breech, complete breech, incomplete breech
presentation, footling and kneeling presentations.
In frank breech presentation, the lower extremities are flexed
at the hips and extended at the knees, and thus the feet lie in close
proximity to the head.
In complete breech presentation, the lower extremities are
flexed at the hips and at the knees.
In incomplete breech presentation, the lower extremities are
flexed at the hips and at the knees, and the one or both feet lie below
the breech.
In footling presentation, the feet lies lower than the breech.
The kneeling presentation is a special form of the breech,
when the fetal knees are lower than the breech.
Diagnosis. The diagnosis of the breech presentation may be
made with the help of external and internal obstetrics' investigation.
By the first maneuver of the external examination, we identify that
the hard, round, ballottable fetal head occupies the fundus of the
uterus. The second maneuver indicates the back to be on one side of
the abdomen and the small parts in other. On the third maneuver, the
breech is movable above the pelvic inlet. The heart sounds of the
fetus are usually heard the loudest slightly above the umbilicus.
Vaginal examination. In frank breech presentation, only
buttocks and its components (both ischial tuberosities, the sacrum,
the anus, the external genitalia) are usually palpable. In incomplete
breech presentation, the buttocks and the feet may be palpated. In
footling, the fetal feet are lower than buttocks.
Biomechanism of labor in breech presentation:
I moment − the internal breech rotation. The breech rotates
and the fetal intertrochanteric diameter from one of the oblique
diameters of the pelvic inlet to anteroposterior diameter of the pelvic
outlet.
II moment − the lateral flexion of the body. The anterior hip
is stemmed against the pubic arc. By lateral flexion of the fetal body,
the posterior hip is forced over the anterior margin of the perineum.
Then the anterior hip is born.
III moment − the internal shoulders' rotation. After the birth
of the breech, there is the slight external rotation as a result of the
descends and rotations of the shoulders. The shoulders rotate on the
pelvic floor and diameter biacromialis occupies anteroposterior
diameter of the pelvic outlet.
IV moment − the lateral flexion of the body in the thoracobrachial part. The shoulders are born.
V moment − the internal rotation of the head. The rotation
begins when the fetal head descends from the plane of the greatest
pelvic dimension to the least pelvic dimension (midpelvis). The
rotation is complete when the head reaches the pelvic floor, the
sagittal suture is in the anteroposterior diameter of the pelvic outlet
and the small fontanel is under the symphysis.
VI moment − the flexion of the fetal head. The head fixes
with its fossa suboccipitalis to the inferior margin of symphysis pubis
and flexes. The face, forehead, vertex, and occiput are born.
The manual aids in breech presentations
The manual aid by Tsovyanov I in frank breech
presentations
The aim of the manual aid: to prepare the maternal ways to
the delivery of the head and shoulders and to keep the normal
attitude of the fetus.
In the frank breech presentation, the fetus extremities are
flexed at the hips and extended at the knees, and thus the feet lie in
close proximity to the head. The circumference of the thorax with
arms and legs crossed over the thorax is larger than the
circumference of the head, therefore the after-coming head delivery
will be casy.
The technique. The aid begins after the delivery of the
buttocks. The obstetrician's hands are applied over the buttocks, the
thumbs placed on the fetus sacrum and other fingers on the legs. The
doctor gently supports the legs to avoid its flexion. If the fetus is in
the normal attitude, the head delivery will be easier.
The classic manual aid on the labor in complete and
incomplete breech presentation
The aim of the classic manual aid: to help the delivery of the
shoulders and the head.
The classic manual aid begins when the lower angular of the
anterior scapula became visible. There are 4 moments of the classic
manual aid.
I moment − the delivery of the posterior arm. The posterior
shoulder must be delivered first. The feet are grasped in one hand
and drawn upward over the groin of the mother toward which the
ventral surface of the fetus is directed; in this manner, leverage is
exerted upon the posterior shoulder, which slides out over the
perineal margin, usually followed by the arm and hand.
II and III moments − the external trunk rotation and removal
of the posterior arm. The aim of this moment is the reverse of the
anterior shoulder to the sacrum and the delivery of the second arm.
The obstetrician applies his hand on the lateral sides of the fetus
trunk and rotates it. The direction of the movement must be in this
way: the occiput must go under the symphysis pubis. When the
posterior shoulder and arm appear at the vulva, the doctor puts two
fingers into the vagina, the fingers pass along the humerus until the
elbow is reached. The fingers are now used to splint the arm, which
is swept downward and delivered through the vulva.
IV moment − delivery of the head. After the shoulders are
born, the head usually occupies an oblique diameter of the pelvic
with the occiput directed anteriorly. The fetal head may then be
extracted by the method of Mauriceau-Levret. Employing the
Mauriceau-Levre maneuver the doctor helps to flex the head with
middle finger of one hand applied into the fetal mouth, while the
fetal body rests upon the palm of the hand and forearm with
straddled legs. Two fingers of the operator's other hand are then
hooked over the fetal neck and, grasping the shoulders, downward
traction is applied until the suboccipital region appears under the
symphysis. The body of the fetus is then elevated toward the
mother's abdomen, and the mouth, nose, brow and the occiput
emerge over the perineum. Gentle traction should be exerted by the
fingers over the shoulders.
The manual aid by Tsovyanov II in footling presentations
The aim of the manual aid: to perform the footling
presentation to the incomplete breech and to prepare the maternal
ways to the delivery of the head and shoulders.
The doctor covers the area of the vulva with the sterile napkin
and puts up resistance to the delivery of the feet. The feet are flexing
and the footling presentation becomes incomplete breech
presentation. Than the delivery is managed as an incomplete breech
presentation.
The management of the breech delivery
To minimize infant mortality and morbidity, a cesarean
section is now commonly used. The indications to the cesarean
section are:
1. Breech presentation and a large fetus (the weight of the
fetus 3500 g and more).
2. Breech presentation and any degree of contraction or
unfavorable shape of the pelvis.
3. Breech presentation and deflexed head.
4. Breech presentation and uterine dysfunction.
5. Breech presentation and previous perinatal death of
children suffering from birth trauma.
6. Breech presentation and fetal hypoxia.
II. Tests and Assignments for Self-Testing
Multiple Choice.
Choose the correct answer / statement:
1. What type of presentation is it if the buttocks and feet are
palpable:
A – Frank breech presentation.
B – Complete breech.
C – Incomplete breech presentation.
D – Footling presentation.
E – Kneeling presentation.
2. What type of presentation is it if the feet are palpable lower
than the buttocks:
A – Frank breech presentation.
B – Complete breech.
C – Incomplete breech presentation.
D – Footling.
E – Kneeling presentation.
3. What the estimated weight of the fetus may be the indication to
the cesarean section?
A – 2500 g.
B – 3000 g.
C – 3600 g.
D – 4000 g.
4. What type of the manual aid does the patient with a footling
presentation need?
A – Manual aid by Tsovyanov I.
B – Manual aid by Tsovyanov II.
C – Classic manual aid.
D – Breech extraction.
5. What type of the manual aid does the patient with a frank
breech presentation need?
A – Manual aid by Tsovyanov I.
B – Manual aid by Tsovyanov II.
C – Classic manual aid.
D – Breech extraction.
Real-life situations to be solved:
6. N., 21 -year-old, primipara. Full term of pregnancy. The labor
started 8 hours ago. The membranes ruptured 15 minutes later. Pelvic
sizes: 25, 28, 31, 20 cm. Fetal heart rate is 140 beats per minute with
satisfactory characteristics. Per vagina: the cervix is completely
dilated. The amniotic sac is absent. Fetal buttocks are palpated in
outlet plane of pelvis. Bitrochanteric diameter is in the direct size of
pelvic outlet.
Diagnosis? What type of the manual aid does the patient
need?
7. Primipara F., 20-year-old. Pregnancy at term. The labor started
6 hours later. The membranes ruptured 1 hour ago. Pelvic sizes: 23,
25, 29, 18 cm. Fetal heart rate is 140 beats per minute with
satisfactory characteristics. Uterine contractions are occurring every
7-8 minutes. Per vagina: the uterine cervix dilatation is 5 cm. The
amniotic sac is absent. One fetal foot is palpated in the vagina.
Buttocks are in the pelvic inlet.
Diagnosis? How the delivery must be managed?
III. Answers to Self-Testing
1. C; 2. D; 3. C; 4. B; 5. A; 6. First at term labor. Second
stage of labor. The frank breech presentation. Management: vaginal
delivery. The manual aid by Tsovyanov I; 7. First at term labor I,
first stage of labor. Footling presentation. Contracted pelvis I-II
degree. Cesarean section should be performed.
Visual Aids and Material Tools:
Charts №
Equipment:
Students must know:
1. Classification of breech presentations.
2. Diagnosis of breech presentations.
3. The biomechanism of the labor in breech presentations.
4. The cardinal movements of labor in breech presentations.
5. The classification of the manual aids to breech
presentations, the indications to cesarean section.
Students should be able:
1. To show the cardinal movements of labor in breech
presentation of fetus.
2. To determine the movements of the labor.
3. To determine the complications in the labor.
4. To show the technique of the manual aids in breech
presentation of fetus.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 194 − 199.
2. Danforth's Obstetrics and Gynecology − Seventh edition. − 1994.
− P. 113 − 114, 501−528.
3. Obstetrics and Gynecology. − Third Edition. − Williams &
Wilkins Waverly Company. − 1998. − P. 112 − 113.
LESSON 10
PREGNANCY AND LABOR OF PELVIS WITH
MALFORMATIONS. MACROSOMIA PROBLEM IN
OBSTERTRICS. PREGNANCY WITH LARGE BABIES AND
LABOR.
Aim: be able to diagnose anatomically contracted pelvis, to
make a plan of labor management in different types of contracted
pelvis.
Professional motivation: to learn the mother's types and
peculiarities of labor of contracted pelvis; it gives the possibility to
prevent the mother's obstetric complications and perinatal and
maternal death.
Basic level:
1. Etiology and pathogenesis of abnormal development of
pelvis.
2. Sizes of the pelvis.
3. Principles of dispensary of the pregnant women with
contracted pelvis.
4. Methods of pregnant and puerpera investigatioin.
5. Estimation of external and internal pelvic sizes.
6. Clinic and management of physiologic pregnancy and
labor.
7. Cardinal moments of labor in flexed and deflexed vertex
presentations.
STUDENTS’ INDEPENDENT STUDY PROGRAM
I. Objectives for Students Independent Studies
You should prepare for the practical class using the existing
textbooks and lectures. A special attention should be paid to the
following:
1. Pelvic classification according to term of contractions.
2. Anatomically and clinically contracted pelvis.
3. Diagnosis of contracted pelvis.
4. Pelvic classification according to degree of contraction.
5. Often required contracted pelvis, generally contracted
pelvis, flat pelvis, simple flat pelvis, flat rachitic pelvis, generally
contracted flat pelvis.
6. Principles of pregnancy management in the case of
contracted pelvis.
7. Principles of labor management in the case of contracted
pelvis.
8. Cardinal moments of labor in different types of contracted
pelvis.
9. Vasten's and Zangemeister's sign.
Key words and phrases: contracted pelvis, classification,
management of labor.
SUMMARY
Anatomically contracted pelvis is characterized by
shortening of all or one diameters of the true pelvis into 1,5 − 2 cm
and more.
Clinically or functionally contracted pelvis is usually
defined as pelvis with normal dimensions, but vaginally delivery is
impossible due to "fetopelvic disproportion".
The mother's causes of "cephalopelvic disproportion" are fetal
macrosomia,
postdate
pregnancy,
uterine
inertia,
fetal
malpresentation, especially fetal head extension − sinciput vertex,
brow, face anterior position.
Clinic signs of clinically contracted pelvis:
1. Head is suspended in the pelvic inlet (absence of fetal
descending in complete cervical dilation and normal uterine
contractions).
2. Uterine contractions abnormality.
3. Positive Vasten' sign (if disproportion between fetal head
and symphysitis pubis is obvious − Vasten' sign is positive; if
disproportion between fetal head and symphysitis pubis is absent −
Vasten' sign is negative).
4. Signs of urinary bladder compression.
5. Edema of the cervix, and vaginal walls, productions of
fistulas. When the presenting part is firmly wedged into the pelvic
inlet but does not advance for a considerable time, portions of the
birth canal lying between them and the pelvic wall may be subjected
to excessive pressure. As a circulation is impaired, the resulting
necrosis may occur in several days after delivery by the appearance
of vesicovaginal, vesicocervical, or rectovaginal fistulas.
6. Danger of uterine rupture.
When the disproportion between the head and the pelvis is so
that engagement and descent do not occur, the lower uterine segment
becomes increasingly stretched, and the danger of its rupture
becomes imminent. In such cases, a pathologic contractile ring may
develop and can be felt as a transverse or oblique ridge extending
across the uterus somewhere between the symphysis and the
umbilicus. It this condition is noted, the immediate cesarean delivery
must be made to terminate labor and prevent rupture of the uterus.
7. Pushing occurs if fetal head is situated in the plane of inlet.
The way out in the case of clinically contracted pelvis is only
cesarean section.
Pelvic classification according to form of contractions:
1. Often occurred
• Generally contracted pelvis;
• Flat pelvis: simple flat pelvis, flat rachitic pelvis, generally
contracted flat pelvis.
Generally contracted pelvis is characterized by diminution
of all true pelvic diameters (anteroposterior, transverse, and oblique)
into 1 – 2 cm. Subpubic arch is narrow. Average sizes of the pelvis
are: D. spinarum − 23 cm., D. cristarum − 26 cm., D. trochanterica −
29 cm., C. externa − 18 cm., C. diagonalis − 11 cm., C. vera − 9 cm.
Course of labor:
• Prolongation of labor;
• Considerable fetal head flexion owing to which it is
elongated in the occipitofrontal diameter (dolichocephaly);
• Posterior fontanel is situated into the axis of pelvis;
• Considerable molding of the fetal head. Caput succedaneum
is formed in the area of posterior fontanel;
• With increasing narrowing of the pubic arch, the occiput
cannot emerge directly beneath the symphysis pubis but is forced
increasingly farther down upon the ishiopubic rami. It may play an
important role in the production of perineal tears.
Management of labor. Vaginally delivery is possible.
Flat pelvis − is usually defined as diminution of
anteroposterior diameters of true pelvis, transverse and oblique
diameters are normal.
Simple flat pelvis is defined as shortening of anteroposterior
diameters at all levels of true pelvis, as a result of this, sacrum is
inclined anteriorly to pubis.
Average sizes of the pelvis are: D. spinarum − 26 cm, D.
cristarum − 29 cm, D. trochanterica − 31 cm, C. externa – 18 cm, C.
diagonalis – 11 cm, C. vera – 9 cm.
Course of labor:
• Prolongation of labor;
• Sagittal suture of the fetal head suspending in the transverse
diameter of the plane of inlet;
• Fetal head extension until bitemporal fetal head diameter
would be situated in the anteroposterior diameter of the plane of
inlet;
• Anterior fontanel is the leading point of the fetal head
(lowermost situated);
• Asynclitism should be presented (anterior or posterior);
• Considerable molding of the fetal head. Caput succedaneum
is formed in the area of anterior fontanel.
Management of labor. In the case of posterior asynclitism
vaginal delivery is impossible owing to engagement of posterior
shoulder into the plane of inlet. Cesarean section should be
performed.
Flat rachitic pelvis − is characterized by some peculiarities:
1. True conjugate is shortened;
2. Sidewalls tend to converge, as the result of this D.
spinarum and D. cristarum are equal;
3. Additional promontorium may be presented between 1 and
2 vertebrae of sacrum;
4. Subpubic arch is shallow and wide;
5. Top of the sacrum is situated posteriorly that's why
dimensions of the pelvic outlet are normal or even increased.
Average sizes of the pelvis are: D. spinarum − 26 cm., D.
cristarum − 26 cm., D. trochanterica − 31 cm., C. externa − 17 cm.,
C. diagonalis − 10 cm., C. vera − 8 cm.
Course of labor is the same as in the simple flat pelvis. But
owing to normal or even increased anteroposterior size of pelvic
outlet perineal tears as a result of quick second stage labor may be
presented.
Management of labor. Vaginal delivery is possible.
Generally contracted flat pelvis is characterized by
combination of the signs of generally contracted and flat pelvis.
Average sizes of the pelvis are: D. spinarum − 24 cm, D.
cristarum − 25 cm, D. trochanterica − 28 cm, C. externa − 16 cm, C.
diagonalis − 9 cm, C. vera − 7 cm.
Course of labor depends on predominance of kind of pelvis
contraction.
Management of labor. Cesarean section is the way out of
situation.
2. Rare occurred contracted pelvis: obliquely contracted
pelvis, obliquely dislocated pelvis, transverse contracted pelvis,
osteomalacic pelvis, funnel-shaped pelvis, contracted pelvis because
of spondylolisthesis, contracted pelvis as a result of exostosis and
bone tumors.
Management of labor. Cesarean section should be
performed at all these types of pelvis.
Pelvic classification according to the degree of
contraction:
Four degrees of pelvic contractions should be distinguished:
I degree − True conjugate is 11 − 9 cm. Vaginal delivery is
possible.
II degree − True conjugate is 9 − 7.5 cm. Vaginal delivery is
possible.
III degree − True conjugate is 7.5 − 5.5 cm. Cesarean section
is performed.
IV degree − True conjugate is 5.5 cm. Cesarean section is
performed.
Fetal macrosomia. The definition of fetal macrosomia in the
literature varies, but the most commonly accepted definition is birth
weight greater than 4000 g. Infants with weight more than 5000 g are
called "giant".
Macrosomic infants have a mortality rate to to five times
greater than controls. These infants have an increased risk for
shoulder dystocia, meconium aspiration, asphyxia, brachial plexus
injury, placenta previa, traumatic midforceps, and fetopelvic
disproportion. The macrosomic fetal head is somewhat larger than
average, and it is harder, with less potential for molding. Size of fetal
trunk may also cause dystocia and mechanical problems at delivery,
labor abnormalities including a protractile active phase with a
prolonged deceleration phase and protracted descent.
Risk factors for fetal macrosomia include multiparity,
maternal obesity, heavy birth weight in the mother or father,
advanced maternal age, excessive gain of weight during pregnancy, a
previous macrosomic infant, and prolonged gestation.
Prognosis. Since macrosomic infants are more commonly
often born by multiparous mothers and by women with diabetes, both
the maternal and fetal risks are increased.
II. Tests And assignments for Self-Testing
Multiple Choice.
Choose the correct answer / statement:
1. Third degree oi pelvic contraction is associated with :
A – True conjugate is 11 − 9 cm.
B – True conjugate is 9 − 5.5 cm.
C – True conjugate is 7.5 − 5.5 cm.
D – True conjugate is 5 − 6 cm.
E – True conjugate is 12 cm.
2. Which statement is true about simple flat pelvis?
A – Shortening of anteroposterior diameters at all levels of
true pelvis.
B – Shortening of anteroposterior diameters of the pelvic
inlet.
C – Shortening of anteroposterior diameters of the pelvic
outlet.
D – Diminution of all true pelvic diameters (anteroposterior,
transverse, and oblique).
E – Diminution of all transverse pelvic diameters.
3.The indications for cesarean section in contracted pelvis are:
A – First degree of pelvic contraction.
B – Clinically contracted pelvis.
C – Third degree of pelvic contraction.
D – Obliquely contracted pelvis.
E – Spondylolisthetic pelvis.
Real-life situations to be solved:
4. A 24-year-old woman in labor had bech pushing efforts for 1
hour. Pelvic sizes: 26, 28, 30, 20 cm. Fetal head is fixated at the
pelvic inlet (− 2 station). Probable fetal weight is 4900 grams, fetal
heart rate is 130 beats per minute. Positive Vasten's sign. Vaginal
examination reveals full dilation of the cervix, absence of the
amniotic sac, and edema of the fetal scalp (caput succedaneum).
Sagittal suture is located in transverse position of the pelvic inlet.
What diagnosis would be the most probable? What
management should be done?
5. A 25-year-old woman presents with a history of 8 weeks of
pregnancy to the female dispensary. Her pelvic sizes are 22, 24, 27,
16 cm. Diagonal conjugate is 8 cm.
What diagnosis would be the most probable? Which
recommendations should be given for woman in pregnancy?
6. A 27-year-old pregnant woman has average sizes of the pelvis:
D spinarum − 26 cm, D. cristarum − 29 cm, D. trochanterica − 31
cm, C. externa − 18 cm. In vaginal examination C. diagonal was − 11
cm, anteposterior diameter of the pelvic outlet was 8 cm. Which type
of the contracted pelvis is the most probable?
III. Answers to Self-Testing.
1. C; 2. A; 3. B, C, D, E; 4. First interm labor, second stage of
labor, cephalic presentation. Clinically contracted pelvis. Cesarean
section should be performed; 5. 16 weeks of pregnancy. Generally
contracted pelvis of II degree of contraction. A patient should be
hospitalized in the pathological pregnancy department at 38 weeks of
gestation to make a plan of labor management;
6. Simple flat pelvis.
Visual Aids and Material Tools:
Charts №
Equipment:
Students must know:
1. Classification of the contracted pelvis.
2. Cardinal moments of labor in contracted pelvis.
3. Management of the pregnancy and labor in the case of
contracted pelvis.
Students should be able:
1. To take the female history, to measure the external and
internal pelvic sizes.
2. To evaluate the results of additional methods of pelvic
measurement.
3. To make a diagnosis.
4. To make different diagnosis between different types of
contracted pelvis.
5. To make a plan of investigation and management of
pregnancy and labor at different types of contracted pelvis.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 80 − 91.
2. Danforth's Obstetrics and Gynecology − Seventh edition. − 1994.
− P. 111−112, 523 − 525.
3. Obstetrics and Gynecology. − Third Edition. − Williams &
Wilkins Waverly Company. − 1998. − P. 34 − 37.
4. Gant Norman F. Basic Gynecology and Obstetrics / Gant Norman
F., F. Gary Cunningham . − 1993. − P. 371 − 372.
5. Obstetrics and Gynecology / Pamela S. Miles, J. Christopher
Carey, William F. Rayburn. − Springer-Verlag New York. − 1994. −
P. 226.
LESSON 11
ABNORMAL DEVELOPMENT OF ZYGOTE.
MULTIPLE GESTATIONS.
Aim: to learn the peculiarities of pregnancy duration in
polyhydramnios, multifetal pregnancy, to diagnose the main
complications in labor at polyhydramnios, multifetal gestation, and
in the case of macrosomic fetus.
Professional motivation. In fact, pregnancies with multiple
fetuses pose significant medical risks for both the mother and her
offspring. The special care is necessary to achieve an optimal
outcome. In general, all potential complications with twin
pregnancies are somewhat more frequent and more serious as the
number of fetuses has increased.
Basic level:
1. Methods of examination in Obstetrics.
2. Uterine sizes in different terms of pregnancy.
3. Sizes of conceptus at the end of pregnancy.
4. Biophysical sizes of the fetus at the end of pregnancy.
5. Clinical duration of normal labor.
STUDENTS’ INDEPENDENT STUDY PROGRAM
I. Objectives for Students Independent Studies
You should prepare for the practical class using the existing
textbooks and lectures. Special attention should be paid to the
following:
1. The volume of the amniotic fluid at the end of pregnancy.
2. Fetal weight and height at interm pregnancy.
3. Signs of multifetal pregnancy.
4. Peculiarities of pregnancy duration in multiple gestation.
5. Peculiarities of labor duration in multiple gestation.
6. Management of labor in multiple gestation.
7. Differential diagnosis of monochorionic and dichorionic
twins.
8. Etiology of polyhydramnios.
9. Diagnosis of polyhydramnios.
10. Peculiarities of duration of pregnancy in the case of
polyhydramnios.
11. Peculiarities of labor duration and its management in
polyhydramnios.
12. Which fetuses are called "large" and "giant"?
13. Diagnosis of pregnancy in the case of macrosomic fetus.
14. Etiology of fetal macrosomia.
15. Complications in labor with macrosomic fetus.
16. Peculiarities of labor management in macrosomic fetus.
Key words and phrases: Polyhydramnios, multifetal
pregnancy, macrosomic fetus.
SUMMARY
Polyhydramnios is excessive amnionic fluid. Normally, the
volume of amnionic fluid increases to about 1 l − 1.5 l more by 36
weeks but decreases thereafter. Somewhat, more than 2000 ml of
amniotic fluid is considered excessive, or hydramnios. In acute
hydramnios, the volume increases very suddenly and the uterus may
become markedly distended within a few days. In chronic
hydramnios, the increase of amniotic fluid is gradual.
Etiology. Hydramnios is frequently associated with fetal
malformations, especially in the central nervous system and
gastrointestinal tract, its incidence is increased in pregnancies
complicated by diabetes and immune and nonimmune hydrops.
Infective disorders can provoke hydramnios also.
Diagnosis. Uterine enlargement in association with difficulty
in palpating fetal small parts and in hearing of heart tones. In severe
cases, the uterine wall may be so tense that it is impossible to palpate
any part of the fetus. Such findings call for prompt ultrasonic
examination to quantify better amnionic fluid and to identify multiple
fetuses or fetal abnormalities.
Treatment. Minor degree of hydramnios rarely require
treatment. In the case of infective etiology of polyhydramnios −
antibacterial treatment is recommended.
Management of labor. Early amniotomy is recommended to
prevent uterine contractions abnormalities. In the third stage of labor
contractile drugs for prevention of early postpartum hemorrhage are
used.
Multiple pregnancy. Dizygotic twins occur when two
separate ova are spermatized by two separate sperms, and in fact,
represent two siblings who happen to be born at approximately the
same time. Monozygotic twins represent division of the spermatized
ovum at different time after conception.
Diagnosis. Twin pregnancy is usually suspected when the
uterine size is excessively large for the supposed gestational age. The
diagnosis is made by obstetric ultrasonography.
Pregnancy complications are associated with multiple fetuses:
abortion, perinatal death, low birth weight, fetal malformations,
pregnancy induced hypertension, maternal anemia, placental
misadventure, uterine atony, cord misadventure, uterine atony,
hydramnios, abnormal fetal presentations, complicated labor.
II. Tests and Assignments for Self-Testing
Multiple Choice.
Choose the correct answer / statement:
1. Which infant is called to be giant?
A – Birth weight greater than 4000 g.
B – Birth weight greater than 3500 g.
C – Birth weight greater than 5000 g.
D – Birth weight greater than 3600 g.
E – Birth weight greater than 3900 g.
2. What of the following should be included into the differential
diagnosis when uterine size is excessively large compared with the
calculated gestational age?
A – Twins.
B – Polyhydramnios.
C – Uterine fibroids.
D – Hydatidiform mole.
E – All of the above.
3. All of the following are more commonly associated with
multiple pregnancy EXCEPT:
A – Megaloblastic anemia.
B – Fetal macrosomia.
C – Vasa previa.
D – Congenital anomaly.
E – Polyhydramnios.
4. Twin pregnancy in which one twin is characterized by
impaired growth, anemia, and hypovolemia and the other twin by
hypervolemia, hypertension, polycythemia, and congestive heart
failure is suffering from:
A – Conjoined twin syndrome.
B – Twin-twin syndrome.
C – Single umbilical artery syndrome.
D – Congenital rubella syndrome.
E – Isoimmunization.
Real-life situations to be solved:
5. At 32 weeks of pregnancy, a 35-year-old woman with known
twins is noted to have a fundal height not commensurating with
gestational age. Her weight gain and blood pressure are as normal as
her antenatal laboratory studies. She says the babies are moving
normally and she feels well, although "rather large". Which of the
following interventions, if any, are indicated?
A – Oxytocin challenge test.
B – Ultrasound.
C – Induction of labor if cephalic/cephalic presentation.
D – Cesarean birth.
6. During ultrasound her twins were noted to be
monochorionic/diamniotic, both moving actively in normal amounts
of amniotic fluid. Comparison of twin A to twin B shows 25 %
difference in weights, with twin B being larger. An NST is reactive
for both twins so that the biophysical profile is 10/10 for each twin.
Which recommendations can you give?
III. Answers to Self-Testing.
1. C; 2. E; 3. B; 4. B; 5. B. Intrauterine growth restriction and
discordant growth are both common in the case of twin pregnancies.
Measurement of each fetus for comparison may reveal abnormal
development; 6. Biweekly NSTs and weekly biophysical profiles and
evaluation of fetal growth.
Visual Aids and Material Tools:
Charts №
Equipment
Students must know:
1. Signs of multiple gestation.
2. Peculiarities of pregnancy duration in multiple gestation.
3. Management of labor in multiple gestation.
4. Differential diagnosis of monochorionic and dichorionic
twins.
5. Diagnosis of polyhydramnios.
6. Peculiarities of pregnancy and labor duration in
polyhydramnios.
7. Which fetuses are called as "large" and "giant"'.
8. Diagnosis of pregnancy with macrosomic fetus.
9. Complications in labor with macrosomic fetus.
10. Management of labor with macrosomic fetus.
Students should be able:
1. To diagnose polyhydramnios, to prescribe treatment and to
make a plan of labor in polyhydramnios.
2. To differentiate monochorionic and dichorionic twins.
3. To diagnose multifetal pregnancy, to make a plan of labor.
4. To determine the probable fetal weight and to diagnose
"large" fetus.
5. To make a plan of labor in the case of "large" fetus.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 178−180, 201−204.
2. Obstetrics and Gynecology. − Third Edition. − Williams &
Wilkins Waverly Company. − 1998. − P. 247 − 252.
3. Gant Norman F. Basic Gynecology and Obstetrics / Gant Norman
F., F. Gary Cunningham. − 1993. − P. 404 − 405, 421 − 425.
LESSON 12
DISORDER OF IMPLANTATION
Ectopic pregnancy is implantation of spermatized ovum
outside the uterine cavity.
Risk factors: prior salpingititis, old maternal age, failed
sterilization, prior acyesis.
Types of ectopic pregnancy: 1) tubal – in the case of tubal
rupture or tubal abortion; 2) abdominal (primary and secondary);
3) ovarian; 4) cervical; 5) bowel. Cervical pregnancy − ovum is
implanted into the cervical mucosa below the level of the histologic
cervical internal os. It presents as an incomplete or threatened
abortion, with uncontrollable hemorrhage as a removal of the
pregnancy tissue was attempted. Hysterectomy is often needed to
control the bleeding.
Evaluation:
1. Menstrual history.
2. Clinical symptoms − abdominal pain, abnormal uterine
bleeding, amenorrhea, pregnancy symptoms, dizziness, syncope,
nausea, urge to defecate.
3. Physical examination − abdominal tenderness, peritoneal
signs, adnexal tenderness, cervical motion tenderness, adnexal mass,
uterus normal size or enlarged.
4. Ultrasound − to localize pregnancy, to find adnexal
complex, to see blood in cul-de-sac.
5. Pregnancy test − positive for ectopic pregnancy.
6. Culdocentesis − to use the spinal needle to enter cul-de-sac
for posterior vaginal fornix to retrieve fluid (non-clotting blood
indicates intraperitoneal bleeding).
7. Laparoscopy − to diagnose.
Management of ectopic (tubal) pregnancy:
1. Surgery: a) Surgical removal of the tube − salpingectomy;
b) Conservative surgical techniques − linear salpingostomy,
segmental resection.
2. Nonsurgical − if it is small and unruptured, one must
make, intramuscular, as well as direct injection into ectopic
gestational sac of methotrexate and then serum bhCG.
II. Tests and Assignments for Self-Testing
Multiple Choice.
Choose the correct answer / statement:
1. Ectopic pregnancy should be suspected in the women who
present with all the following complaints EXCEPT:
A – Acute pelvic pain.
B – Lower abdominal pain.
C – Vaginal bleeding.
D – Acute nausea and vomiting.
E – Amenorrhea.
III. Answers to Self-Testing.
1. D.
Visual aids and material tools:
Charts №
Equipment
Students must know:
1. Etiology and pathogenesis of ectopic pregnancy.
2. Classification of ectopic pregnancy.
3. Algorithm of management for ectopic pregnancy.
LESSON 13
ANTENATAL METHOD OF EXAMINATION.
PLACENTAL INSUFFICIENCY
Aim: to be able to perform physical examination of the
patients with uterine haemorrhage in the third trimester of pregnancy,
first and second stages of labor. Learn the main causes, clinical signs
and symptoms, methods of treatment in the patients with placenta
previa and abruptio placenta.
Professional motivation: third trimester bleeding is the main
cause of maternal mortality. Placenta previa occurs in 0.14−0.18 %
and abruptio placenta in 0.3−0.4 % out of the labours. Many
maternal and fetal complications may develop as a result of these
states. Management of an immediate diagnostics and care in these
patients is one of the important tasks to prevent these complications.
Basic level:
1. Hazards of the patients with uterine bleeding, first and
second stages of labor.
2. Physical examination of pregnant woman assessment.
3. Assessment of vaginal examination of pregnant woman.
STUDENTS’ INDEPENDENT STUDY PROGRAM
I. Objectives for Students Independent Studies
You should prepare for the practical class using the existing
textbooks and lectures. Special attention should be paid to the
following:
1. Predisposing factors of placenta previa.
2. Classification of placenta previa.
3. Maternal signs and symptoms of placenta previa.
4. Diagnosis of placenta previa.
5. Differential diagnosis of placenta previa with the
pathology of childbirth canal, cervical lesions, rupture ot the varicose
veins of the vagina, vaginal lesions.
6. Treatment of the placenta previa during pregnancy.
7. Therapy of women in labor with placenta previa.
8. Predisposing factors of the abruptio placenta.
9. Clinical signs and symptoms of abruptio placenta.
10. Diagnosis of abruptio placenta.
11. Differential diagnosis of abruptio placenta with placenta
previa, uterine rupture.
12. Definition of the term "Couvelaire uterus".
13. Management of the patients with the abruptio placenta
during pregnancy.
14. Complications in women with placenta previa and
abruptio placenta.
Key words and phrases: third trimester of pregnancy,
haemorrhage, placenta previa, abruptio placenta, "Couvelaire uterus".
SUMMARY
Placenta previa – is low lying placenta which is covering the
internal cervical os. Predisposing factors of placenta previa include
multiparity, increasing maternal age, prior placenta previa, multiple
gestation. Placenta previa is classified according to the relationship
of the placenta to the internal cervical os.
Placenta previa classification
Type of placenta
previa
Complete (total)
placenta previa
Partial placenta
previa
Method of delivery
Maternal signs and
in the case of in term
symptoms
pregnancy
Placenta totally
Intermittent
covers the
bleeding; may
By cesarean section
cervical
become profuse
os
and painless
Placenta
partially covers
Intermittent
-IIthe internal
bleeding
cervical os
Definition
Continuation of table
Edge of the
placenta is
Marginal placenta extended to the
previa
margin of the
internal cervical
os
-II-
Amniocentesis,
vaginal delivery
usually
accomplished,
although it should be
done in a wellcontrolled manner
and sitting
Placenta is
implanted in the
lower uterine
segment
-II-
-//-
Low-lying
placenta
With the preterm pregnancy, the goal is obtaining the fetal
maturation without compromising the mother's health. You prescribe
drugs which increase fetal maturity, tocolysis is exhibited with
magnesium sulfatis. Autologous blood donation is indicated if the
patient is a candidate, or blood may be donated by a family member.
Abruptio placenta − is a premature separation of the
normally implanted placenta. Risk factors for abruptio placenta
include maternal hypertension, hydramnios, after delivery of the first
of multiple fetuses, premature rupture of membranes, short umbilical
cord, tobacco and cocaine used by the mother, trauma, folate
deficiency Clinically, the diagnosis of placental abruption is
accepted if the patient has with painful vaginal bleeding in
association with uterine tenderness, hyperactivity, and increased
tones. The most common is revealed of vaginal bleeding (blood is
effused downward toward the cervix), which is noted in 80 % of
cases. In 20 % of cases bleeding will be concealed (blood is spreaded
upward toward the fundus), and so there will be no external evidence
of hemorrhage.
Maternal-fetal risks of abruptio placenta include significant
risk of hypoxia and, ultimately, death of the fetus. 15 % of live-born
infants have significant neurologic impairment. Maternal
complications include disseminated intravascular coagulopathy
(DIG), hypovolemic shock and acute renal failure due to massive
hemorrhage, Couvelaire uterus. Couvelaire uterus − blood infiltrate
the myometrium, causing a blue discoloration of the uterus.
Management − hysterectomy.
Management. Cesarean delivery should be reserved for
obstetric indications only in the case of abruptio placenta.
II. Tests and Assignments for Self-Testing
Multiple Choice.
Choose the correct answer/statement:
1. All of the following is associated with massive placental
abruption EXCEPT:
A – Painless vaginal bleeding.
B – Uterine rigidity.
C – Uterine pain.
D – Maternal cardiovascular collapse.
E – Absent fetal heart sound.
2. Vasa previa diagnosed in early labor is best treated with:
A – Voorhees bag.
B – Forceps delivery.
C – Spontaneous delivery.
D – Cesarean section.
E – Willett clamp.
3. Which form of therapy is often most effective for patients with
"Couvelaire uterus''?
A – Bedrest.
B – Cervical cerclage.
C – Total abdominal hysterectomy.
D – Intravenous ampicillin.
E – Cesarean section.
Real-life situations to be solved.
4. An 18 year-old primigravida at term, not in labor, has sudden
onset of the severe continuous lower abdominal pain with a rapid
pulse, low blood pressure, fetal bradycardia, and tender abdomen.
Which diagnosis is the most likely?
5. A primigravida at term has profuse vaginal bleeding. Fetal
heart tones are normal. The cervix is 2−3 cm dilated with the edge of
placenta palpable. Which treatment is the most appropriate?
6. A 26-year-old G6 P5 is presented for her normal antepartum
visit 18 weeks gestational age. She is distressed because at her
ultrasound visit the day before, she was told by the specialist that her
placenta was partly over the opening of her womb. What would you
tell the patient?
III. Answers to Self−Testing.
1. A; 2. D; 3. C,D; 4. abruptio placenta; 5. Cesarean section;
6. She has placenta previa and is definitely required cesarean section.
The ultrasound is consistent with a partial placenta previa. Because
the growth of the upper and the lower uterine segments may results
in the placenta "moving away'' from the cervical os, it is too early to
be sure that cesarean section will be required.
Visual Aids and Material Tools:
Charts №
Equipment
Students must know:
1. Etiology of placenta previa.
2. Classification of placenta previa.
3. Diagnosis of placenta previa.
4. General principles of the management of labor in women
with placenta previa according to its types.
5. Causes of the placental abruptio.
6. Clinical signs and symptoms of the placental abruptio.
7. Management of the patients with placental abruptio.
8. Definition of the "Couvelaire uterus" term.
Students should be able:
1. To take history.
2. To reveal the main symptoms of placenta previa and
abruptio placenta.
3. To make plan of initial examination of the patients with
uterine bleeding.
4. To evaluate data received during physical examination of
the pregnant woman.
5. To confirm the diagnosis.
6. To prescribe adequate therapy.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 283 − 295.
2. Danforth's Obstetrics and Gynecology − Seventh edition. − 1994.
− P. 489 − 500.
3. Obstetrics and Gynecology. − Third Edition. − Williams &
Wilkins Waverly Company. − 1998. − P. 260 − 268.
4. Gant Norman F. Basic Gynecology and Obstetrics / Gant Norman
F., F. Gary Cunningham. −1993. − P. 432 − 437.
LESSON 14
FETAL DISTRESS SYNDROME RETARDATION,
HYPOTROPHY OF FETUS
Aim: to study the main methods of diagnostics, treatment and
prevention of fetal hypoxia and asphyxia of the infant.
Professional motivation: evidence suggesting nonreassuring
fetal status occuring in 5 % to 10 % of pregnancies, when there is a
concern that the function of the maternal-fetal physiologic unit is so
altered that fetal death or serious injury may occur.
Basic level:
1. Methods of fetal surveillance.
2. The main principles of immediate care (resuscitation) of
the infant.
3. Emergency ventilation of the newborn infant and external
cardiac massage.
STUDENTS’ INDEPENDENT STUDY PROGRAM
I. Objectives for Students Independent Studies
You should prepare for the practical class using the existing
textbooks and lectures. Special attention should be paid to the
following:
1. Give the definitions of such term as: "fetal hypoxia",
"asphyxia of the infant", "viable infant", "dead infant".
2. Etiology and pathogenesis of fetal hypoxia and asphyxia
of the infant.
3. Classification of fetal hypoxia.
4. Methods of fetal heart rate evaluation.
5. Assessment of the fetal hypoxia stages of severity.
6. Principles of treatment of fetal hypoxia.
7. Classification of asphyxia of the infant.
8. Evaluation of asphyxia severity.
9. ABC-steps of infant's resuscitation.
10. Treatment of newborn infant in postresuscitation period.
11. Prevention of fetal hypoxia and asphyxia of the infant.
Key words and phrases: fetal hypoxia, asphyxia of the
infant, resuscitation of the infant.
SUMMARY
Fetal hypoxia is a result of dysfunction of maternal-fetal
physiologic unit alteration. The term fetal distress or nonreassuring
fetal status is also often used for this situation. Causes of
nonreassuring fetal status: 1) uteroplacental insufficiency − placental
edema, maternal diabetes, hydrops fetalis, Rh-isoimmunization,
placental "accidents" (abruptio placenta, placenta previa),
postdatism, intrauterine growth restriction, uterine hyperstimulation;
2) umbilical cord compression – umbilical cord accidents, umbilical
cord knot, umbilical cord prolapse or entanglement; 3) fetal
anomalies or conditions – sepsis, fetal congenital anomalies,
intrauterine
growth
restriction,
prematurity,
postdatism.
Classification of fetal hypoxia according to etiology factors: 1)
hypoxic decreased amount of oxygen in erythrocytes; 2) hemic as a
result of decreased amount of erythrocytes during maternal anemia or
during hydrops fetalis; 3) circulatory as a result of placental or
umbilical cord disturbances; 4) tissue on the cellular level. According
to duration hypoxia may be acute and chronic.
Methods of fetal heart rate evaluation include:
1) Assessment of fetal well-being includes maternal
perception of fetal activity − the fetus is considered to be healthy
when mother detects more than five fetal movements while lying
comfortably and focusing on fetal activity for 30 minutes;
2) Intermittent auscultation of the fetal heart rate (FHR) after
contractions;
3) Electronic fetal monitoring (EFM). Fetal heart rates EFM
is described by pattern of variability. The baseline FHR ("normal
FHR") at term is defined as 120 to 160 beats per minute (bpm).
Baseline fetal tachycardia is defined as > 160 bpm for 10 or more
minutes, being classified mild if the baseline is between 161 and 180
bpm, and severe if more than 182 bpm. Baseline fetal bradycardia is
defined as less than 120 bpm for 10 or more minutes, and is
classified as moderate between 80 and 100 bpm and severe at less
than 80 bpm. A sinusoidal heart rate pattern is when the rate is 120
to 160 bpm, but there is a smooth, undulating pattern of 5 to 10 bpm
in amplitude and shortened short-term variability.
Fetal heart rate variability is the most reliable single EFM
indicator of fetal status. The presence of good variability is highly
suggestive of adequate fetal central nervous system oxygenation.
Two types of variability are described: short-term and long-term
variability.
Acceleration of the FHR is defined as the increase in the FHR
above the baseline of at least 15 bpm, usually of 15 to 20 second
duration, and is associated with an intact fetal mechanism unstressed
by hypoxia and acidemia. It is reassurance and usually indication of
fetal well-being.
Early deceleration is slowing of the FHR that starts as uterine
contraction begins, reaches their nadir at the peak of the uterine
contraction, and returns to the baseline FHR with the end of the
uterine contraction. Early FHR deceleration is considered to be
physiologic and is not the cause of concern. Variable FHR
deceleration is slowings of the FHR that may start before, during, or
after when uterine contraction begins. It is also reflexed as mediated,
usually associated with umbilical cord compression. Late FHR
deceleration is slowings of the FHR that begins after the uterine
contraction, reaches its nadir after the peak of uterine contraction,
and resolves to baseline after the uterine contraction is over. It is
sometimes associated with uteroplacental insufficiency and
progressive fetal hypoxia and acidemia. The most common tests that
can be used are the nonstress test, the contraction stress test (called
the oxytocin challenge test if oxytocin is used), and the biophysical
profile;
4) Ultrasonography.
The diagnosis of neonatal asphyxia applying is characterized
by significant newborn depression associated with severe hypoxia
and mixed respiratory and metabolic acidosis. The American College
of Obstetricians and Gynecologists has suggested that the diagnosis
of neonatal asphyxia is extremely unlikely unless four criteria are
met: 1) Apgar scores are less than 4 at 5 minutes of life; 2) umbilical
artery pH is less than 7.00; 3) neuromuscular signs and symptoms
soon after birth (including seizures, coma, hypotonia); 4) multiorgan
system failure.
Neonatal asphyxia is classified as moderate (Apgar score at
1'− 4−6, 5'−8−10) and severe (Apgar score at the 1'−0−3, 5'−7).
II. Tests and Assignments for Self-Testing
Multiple Choice.
Choose the correct answer / statement:
1. All of the following are criteria for the diagnosis of fetal
asphyxia EXCEPT:
A – Metabolic acidemia.
B – Mixed acidemia.
C – Persistent Apgar scores of 3 or below.
D – Evidence of neonatal neurologic sequelae.
E – Heart rate accelerations.
2. Which of the following statements describe late fetal heart rate
deceleration?
A – Deceleration starts after uterine contraction begins,
reaches nadir after the peak of uterine contraction,
resolves to baseline when uterine contraction is over.
B – Deceleration begins with uterine contraction, reaches
nadir at the peak of uterine contraction, returns to baseline
at the end of uterine contraction.
C – Deceleration may start before or after the beginning of
the uterine contraction;
D – All of the above.
3. Which of the following statements regarding the Apgar score
is an accurate reflection of its proper use?
A – It is used to define birth asphyxia.
B – It indicates the cause of the newborn's depression.
C – The 1-minute Apgar score identifies newborns requiring
special attention.
D – The 5-minute Apgar score predicts neurologic injury.
E – All of the above.
Real-life situations to be solved:
4. A term infant is born by spontaneous vaginal delivery almost
immediately on arrival at the labor unit. The infant is covered with
meconium fluid, is limp, has heart rate of 100, and has some body
tone and a grimace. Your management of the newborn will include:
A – Oxygen by face mask.
B – Intubation.
C – Warming.
D – External cardiac massage.
E – Blood gas sampling.
F – Stimulation.
5. A term newborn is evaluated and found to have heart rate of
110, irregular respirations, some flexion of its extremities, no
reflexes, and pale color. The newborn's Apgar score is:
A – 2.
B – 4.
C – 6.
D – 8.
E – 10.
6. Neonatal resuscitative efforts are provided in this infant. At the
5-minute assessment, the heart rate is now 120, respirations are
strong, and the baby is crying loudly. There is active motion of all
extremities. The newborn is pink, with only bluishness of the
extremities. It is sneezing and coughing. What is its 5-minute Apgar
score?
A – 6.
B – 7.
C – 8.
D – 9.
E – 10.
III. Answers to Self-Testing
1. D; 2. A; 3. C; 4. B, C, F. Intubation and removal of any
meconium in the nasopharynx and below the cords is important to
avoid meconium aspiration syndrome. Stimulation, warming, and
oxygen in the interval immediately after birth as it is needed after
aspiration of meconium are the first appropriate steps; 5. B. In
assessing of a newborn, the Apgar score is given for each of the five
criteria. In this case, because the heart rate is greater than 100, 2
points are given. Slow, irregular respirations and some flexion of the
extremities provide 1 point each. A lack of reflexes and a pale color
provide no points, for a total of 4; 6. D. All of the parameters suggest
2 points for each category except color. In this case, 1 point is taken
away for cyanotic extremities. The Apgar score is 9 at 5 minutes.
Visual Aids and Material Tools:
Charts №
Equipment:
Students must know:
1. Etiology and pathogenesis of fetal hypoxia and asphyxia of
the infant.
2. Stages of fetal hypoxia and asphyxia of the infant severity.
3. Principles of the treatment of fetal hypoxia and infant's
asphyxia.
Students should be able:
1. To take medical history, make general and obstetric
examination.
2. To evaluate the results of electronic monitoring of the
fetus, ultrasonography, colpocytological and investigations of
hormones.
3. To make previous diagnosis.
4. To make plan of treatment of pregnant women and
puerperants with fetal hypoxia.
5. To perform the resuscitative measures of the newborn
infant.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 93 − 99.
2. Danforth's Obstetrics and Gynecology − Seventh edition. − 1994.
− P. 269 − 288.
3. Obstetrics and Gynecology. − Third Edition. − Williams &
Wilkins Waverly Company. − 1998. − P. 118 − 130.
4. Gant Norman F. Basic Gynecology and Obstetrics / Gant Norman
F., F. Gary Cunningham. − 1993. − P. 328 − 339.
5. Obstetrics and Gynecology / Pamela S. Miles, J. Christopher
Carey, William F. Rayburn. − Springer-Verlag New York. − 1994. −
P. 69 − 73.
LESSON 15
ISOANTIGEN CONFLICT BETWEEN MOTHER BLOOD
AND FETUS. PATHOLOGY IN NEWBORN PRIOD.
ASPHYXIA IN NEWBORN
Aim: to be able to diagnose the Rh and other
isoimmunization in the obstetrics; prescribe the adequate treatment to
the pregnant women; to be able to diagnose the hemolytic disease of
the infant and to prescribe the treatment of this pathology. Master the
principles of performing the reactions for determination of Rh, titer
of antibodies.
Professional motivation: abilities to diagnose Rh and other
isoimmunization, hemolytic disease in obstetrics practice allows to
prescribe adequate therapy to pregnant women, therefore decrease
the amount of perinatal diseases and lethality.
Basic level:
Physiology Course, lesson-blood types.
1. Principles of the reactions which determine blood type. Rhfactor, antibodies titer.
2. Diagnosis of the hemolytic disease of the newborn.
3. Physical examination assessment of the newborns.
STUDENTS’ INDEPENDENT STUDY PROGRAM
I. Objectives for Students Independent Studies
You should prepare for the practical class using the existing
textbooks and lectures. Special attention should be paid to the
following:
1. The main principles of blood transfusion.
2. Diagnosis of hemolytic disease of the infant.
3. Evaluation of the laboratory methods of investigation.
4. Etiology and pathogenesis of isoimmunization.
5. Diagnosis of isoimmunization during pregnancy.
6. Peculiarities of the management isoimmunisation during
pregnancy in the case if pregnant woman has or doesn’t have Rh
isoantibodies.
7. Peculiarities of the management of delivery in the pregnant
women with isoimmunisation.
8. Pathogenesis of hemolytic disease of the newborn.
9. Clinical forms of hemolytic disease.
10. Treatment of the hemolytic disease. Indications to fetal
blood transfusion.
11. Prevention of hemolytic disease of the newborn.
Key words and phrases: isoimmumzation, hemolytic disease
of the newborn, pregnancy.
SUMMARY
Rhesus (Rh) isoimmunization is an immunologic disorder that
occurs in a pregnant, Rh-negative patient is carrying an Rh-positive
fetus. The immunologic system in the mother is stimulated to
produce antibodies to the Rh antigen, which then crosses the placenta
and destroys red blood cells.
Risk of Rh Sensitivization: mismatched blood transfusion
(90 − 95 %), full-term delivery, ABO-compatible or incompatible
(14 − 17 %), induced abortion (5 − 6 %), spontaneous abortion (3 − 4
%), amniocentesis (1 − 3 %), full-term pregnancy (1 − 2 %), ectopic
pregnancy (< 1%).
Pathophysiology. The "Rh disease" results from the Rh
negative mother becoming isoimmunized to an Rh antibody from the
red cells of her first child.
1) The first Rh positive pregnancy will almost never be
affected unless the mother has a previous blood transfusion with Rh
positive blood;
2) Once immunized, the mother's immune system responds
by manufacturing anti Rh isoantibodies with the second pregnancy;
3) If the second pregnancy is one in which the fetus Rh is
positive, the mother's anti Rh isoantibodies are transferred to the
fetus across the placenta.
Stages of hemolytic disease of infant severity:
Clinical symptom
I stage
II stage
Anemia, hemoglobin
level in umbilical cord
150
150−100
(g/L)
Jaundice, bilirubin level
in umbilical cord
85.5
85.6−136.8
(mkmol/L)
Edema of
Subcutaneous
Edema
subcutaneous fat
edema
and ascites
III stage
100
136.9
Hydrops
fetalis
Indications to exchange blood transfusion in infants:
Laboratory
In term fetus
Preterm fetus
symptom
Repea
Repeat
I day
5 day I day
5 day
ted
ed
Indirect bilirubin.
> 68.42
300.7 59.9
273.6
mkmoll/L
Indirect bilirubin
6.8
6.8
5.1
5.1
per hour, mkmoll/L
Hemoglobin, g/L
< 150
< 150
Hematocrit
<0.4
<0.4
Critical indirect bihrubin level which damage the nervous
ganglia and provoke kernicterus in in term fetus 307.8 − 342
mkmol/L in preterm fetus 153−205 mkmol/L.
Diagnosis of isoimmunization: basis of history − previous
pregnancies abortions, ectopic pregnancy.
Laboratory evaluation:
• Determination of the father's Rh status;
• Maternal blood is tested for presence of variety of
antibodies that may cause significant disturbances in fetus −
"antibody screening test" "indirect" and "direct Coomb's tests". Mild
isoimmunization − antibody titer below 1:16. Rarely produced fetal
hydrops do not usually cause any intervention in the pregnancy. The
newborn may be anemic and hyperbilirubinemia may develop.
Severe isoimmunization − titer of over 1:16 or greater is generally
considered to be the critical point at which there is a sufficient risk of
fetal jeopardy to warrant additional evaluation. The amniocentesis or
percutaneous umbilical blood sampling (PUBS) should be done;
• Amniocentesis denotes the amount of blood destruction by
estimating the amount of bilirubin pigments in the amniotic fluid;
• Percutaneous umbilical blood sampling (PUBS) under
ultrasound guidance − fetal blood can be taken for hematocrit,
hemoglobin, blood gases, pH, bilirubin levels;
• Amniotic fluid spectrophotometry − there is an excellent
correlation between the amount of biliary pigment in the amniotic
fluid and the fetal hematocrit beginning at 27 weeks gestation. Liley
chart can be used – it is a spectrophotometric graph based on the
correlation of cord blood hemoglobin concentrations at birth and the
amniotic fluid change in optical density at 450nr;
• Ultrasonic detection − both the placenta and the fetal liver
are enlarged with hydrops. Fetal hydrops is easily diagnosed by the
characteristic appearance of one or more of the following: ascites,
pleural effusion, pericardial effusion, skin edema. Appearance of
these factors during ultrasonic examination eliminates the need for
diagnostic amniocentesis and necessitates the the rapeutic
intervention based on fetal gestational age;
• New techniques for evaluating fetal Rh Status 1)
determination of fetal Rhd blood type by DNA amplification using a
single fetal nucleated erythrocyte isolated from maternal blood, 2)
determination of fetal RhD genotype from amniotic fluid or
chorionic villus cells using DNA amplification;
Administration of Rh Immune Globulin (RhoGAM) prevents
an active antibody response by the mother in most cases. Standard
300-mg dose of Rh immune globulin effectively neutralizes 15 ml of
fetal red blood cells.
Indications of RhoGAM administration man unsensitized
Rh-negative patient (unless the father of the infant is known to be
Rh-).
• At approximately 28 weeks pregnancy – the risk of
sensitization is reduced to 0.2 %;
• Within 3 days ( 72 hours of delivery) days of delivery of an
Rh-positive infant − the risk of subsequent sensitization decreases
from approximately 15 % to 2 %;
• At the time of amniocentesis;
• After positive Kleihauer-Betke test − it allows to identify
fetal cells in maternal circulation in cases of trauma or bleeding
during pregnancy because of which feto-maternal hemorrhage has
occurred;
• After ectopic pregnancy, spontaneous or induced abortion −
50 mg of RhoGAM can be used to prevent sensitization.
II. Tests and assignments for Self-Testing.
Multiple Choice.
Choose the correct answer / statement:
1. The major factor allowing fetal erythrocytes to enter the
maternal circulation is:
A – Labor and delivery.
B – Normal placental circulation.
C – Spontaneous abortion.
D – Premature rupture of membranes.
E – Low level placental abruption.
2. Pregnancies with severely affected Rh-immunised fetuses may
be complicated by:
A – Polyhydramnios.
B – Fetal hydrops.
C – Fetal cardiac failure.
D – Fetal anemia.
E – All of the above.
3. Human Rh immune globulin (RhoGAM):
A – Prevents the transfer of incompatible fetal cells to the
mother.
B – Attaches to the fetal Rh+ cells in the maternal circulation
and obscures the antigen sites.
C – Prevents antibody production in the maternal
hematopoietic system.
D – All of the above.
Real-life situations to be solved:
4. A 22-year-old Gl P0 is presented for prenatal care at 28 weeks
by dates and size. Her medical and family history are negative, and
her physical examination is normal and consistent with her stated
gestational term. Reviewing her initial laboratory work you note that
her blood type is 0−. You ask her about the father's blood type, but
he has left town and she does not know it. What your management
should be?
5. The patient's health is declined because she does not want to
take medication unless she knows it is necessary. When she is 38
weeks, she finds out that the father of the child blood type is 0+. She
asks if her baby would be damaged in the result.
6. In which cases and which dose of RhoGAM should you
administrate to an Rh-patient?
III. Answers to Self-Testing.
l. A; 2. E; 3. B; 4. Offer RhoGAM on the possibility that the
father is Rh- because of the risk of isoimrnunization and low risk of
administration of RhoGAM, it should be offered and given;
5. Probably not, because it is the second or subsequent pregnancies
that are usually affected. You may reasonably reassure her and test
for antibody to ascertain if any sensitization has occurred; 6. It is
now standard practice for Rh- patients who deliver Rh+ infants to
receive an intramuscular dose of 300 h of Rh immune globulin
(RhoGAM) within 72 hours of delivery, at 28 weeks of gestation (to
reduce the risk of sensitization to approximately 0.2 %), at the time
of amniocentesis.
Visual Aids and Material Tools:
Charts №
Equipment:
Students must know:
1. Etyology and pathogenesis of Rh and other
isoimmunization.
2. Principles of treatment and management of women with
Rh-isoimmunization.
3. Clinical picture, diagnosis and therapy of hemolytic disease
of the newborn.
Students should be able:
1. To evaluate the state of the fetus during Rh and other
isoimmunization by the ultrasound examination.
2. Principles of organization of the fetal department in the
case of isoimmunization.
3. Laboratory establishment of the antibodies and their titer.
4. To prescribe the laboratory methods of examination.
5. To determine previous diagnosis of the disease.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 346 − 348.
2. Danforth's Obstetrics and Gynecology − Seventh edition. − 1994.
− P. 393 − 426.
3. Obstetrics and Gynecology. − Third Edition. − Williams &
Wilkins Waverly Company. − 1998. − P. 147 − 153.
4. Gant Norman F. Basic Gynecology and Obstetrics / Gant Norman
F., F. Gary Cunningham. − 1993. − P. 415 − 416.
5. Obstetrics and Gynecology / Pamela S. Miles, J. Christopher
Carey, William F. Rayburn. − Springer-Verlag New York. − 1994. −
P. 80 − 83.
LESSON 16
TOXICO-SEPTIC DISEASE OF NEWBORN. METHOD AND
INTENSIVE THERAPY AND REANIMATION
Physiologically, this can be defined as failure of the circulation
to meet the metabolic needs of tissues. Clinically, it may be
manifested as hypotension, usually tachycardia and pallor, and
sometimes by cyanosis, sweating, oliguria, cold extremities,
restlessness and an abnormal state of consciousness.
Progressive hypovolaemia is the primary problem in most
children with shock; "cardiogenic" shock is much less common;
combinations of mechanisms may occur; for example in sepsis,
decreased peripheral resistance, myocardial depression and
hypovolaemia may coexist. Remember that "hidden" fluid losses (for
example intraperitoneal in peritonitis, blood loss around major closed
fractures) are usually underestimated. Abrupt changes in peripheral
resistance or blood flow redistribution can lead to sudden shock with
no external fluid losses (for example, in meningococcal septicaemia).
ABC-steps of infant's resuscitation:
A − suction of the airways. Once the newborn has been
delivered, it is transported to the warning unit, which is equipped
with a radiant heat source. The neonate is dried well to minimize
evaporative loss of core temperature. The nose and pharynx are
suctioned once again as the infant placed in the supine position with
the head lowered, turned to one side. The newborn is expected to
breathe and cry within the first 30 seconds of the life.
B − breath stimulation: suctioning, rubbing the back, slapping
the feet.
C − normalization of circulatory disturbances by intravenous
prescription of albumin in a dose of 10 ml per kg in a case of
hypovolemia, sodium bicarbonate in a dose of 4 ml per kg in a case
of metabolic acidosis, adrenalin − 0.1 ml per kg if the FHR is absent
or after 15−30 minutes of ventilation and external cardiac massage
FHR remains less 80 bpm.
Table 1. Apgar Scoring System
Sign
Score
0
1
2
Heart rate
Absent
<100
> 100
Muscle tone
Limp
Some flexion of
Active motion
extremities
Respiratory effort
Absent
Slow, irregular
Good cry
Reflex activity
No response
Grimace
Cough, sneeze, or
response to
crying
stimulation
Color
Blue or pale Body pink and Completely pink
extremities blue
Students must know:
1. Etyology and pathogenesis of toxico-septic disease of a
newborn.
2. Principles of treatment and management of a newborn
whith toxico-septic disease.
3. Clinical picture, diagnosis and therapy of a newborn whith
toxico-septic disease.
Students should he able:
1. To evaluate the state of the newborn whith toxico-septic
disease.
2. Principles of organization of the newborn intensive therapy
and reanimation.
3. Laboratory establishment of the antibodies and their titer.
4. To prescribe the laboratory methods of examination.
5. To determine previous diagnosis of the disease.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − C. 346 − 348.
2. Danforth's Obstetrics and Gynecology − Seventh edition. − 1994.
− P. 393 − 426.
3. Obstetrics and Gynecology. − Third Edition. − Williams &
Wilkins Waverly Company. − 1998. − P. 147 − 153.
4. Gant Norman F. Basic Gynecology and Obstetrics / Gant Norman
F., F. Gary Cunningham. − 1993. − P. 415 − 416.
5. Obstetrics and Gynecology / Pamela S. Miles, J. Christopher
Carey, William F. Rayburn. − Springer-Verlag New York. − 1994. −
P. 80 − 83.
LESSON 17
HISTORY OF PREGNANCY
Aim: to acquainted the students with the moments of history
of pregnancy, labor and postpartum period writing.
Professional motivation it is very important in obstetrics to
know the mam's aspects while writing the history of pregnancy, labor
and postpartum period.
Basic level:
1. Methods of examination of the pregnants, women in labor
and puerperants.
2. Physiological clinical duration of pregnancy, labor and
postpartum period.
3. Management of the physiologic pregnancy, labor and
postpartum period.
STUDENTS’ INDEPENDENT STUDY PROGRAM
A student writes a history of pregnancy, labor and postpartum
period according to such scheme:
Head of the Obstetrics and Gynecology Chair
____________________________________
Teacher of the group____________________
HISTORY OF PREGNANCY,
LABOR AND POSTPARTUM PERIOD
Name, and surname of puerperant____________________________
DIAGNOSIS:
• Gestational term of the fetus_________________________
• Presentation of the fetus____________________________
• Obstetric pathology________________________________
• Extragenital pathology ____________________________
Complications in labor____________________________________
Interventions in labor______________________________________
Name, and surname of the student_______________
Course_______________
Group_______________
Mark of the history_______________
I. HISTORY
I. Time and day of hospitalization_________________
Main complaints on the period of admission to the hospital:
_________________________________________________
• Indicate the time of occurring uterine contractions________
• Their characteristics_______________________________
• The present gush of the fluid. Its characteristics_________
Gestational age determination:
1. Add 280 days to first of last menstrual period (LMP)_____
2. Naegele's rule − LMP minus 3 months plus 1 week______
3. Ovulation rule − LMP minus 3 months plus 2 weeks_____
4. By data of Womens Health Organization − LMP minus 3
months_________________________________________________
5. By the first ultrasonography________________________
6. By the first attendance to the doctor_________________
7. If known with certainty its most reliable clinical estimator
of gestational age_________________________________
II. Menstrual history
• Age of menarche__________________________________
• Last menstrual period______________________________
• Cycle interval____________________________________
• Duration and amount of flow________________________
• Associated cyclic symptoms_________________________
III. Sexual history
• Age of tne first intercourse__________________________
• Number of sexual partners__________________________
• How long is married_______________________________
• Usage of contraceptives (all prior contraceptives methods
and any complications should be discussed)______________
• Current problems in sexual function and any history of
sexual abuse_____________________________________________
IV. Obstetric history
• Gravida − number of total pregnancies_________________
• Para − number of term deliveries, followed by:
1. Number of preterm deliveries_______________________
2. Number of abortions / miscarriages___________________
3. Then number of living children _____________________
• Outcome of each delivery___________________________
• Mode of delivery _________________________________
• Any complications in labor__________________________
• Postpartum period_______________(should be recordered)
V. Duration of the present pregnancy
• Management in the female dispancery________________
• Return visits_____________________________________
• Give the results of all necessary analysis and
investigation_______________________________________
_________________________________________________
_________________________________________________
• Complications during pregnancy _____________________
• Their treatment ___________________________________
• In which term of gestation they took place______________
VI. Secretory function
• Presence of discharge______________________________
• Their characteristics_______________________________
• Do they provoke irritation of external geni?
(yes\no)________________________________________________
VII. Social history
• Growing in childhood______________________________
• Ability to function at work, at home___________________
• Medications, allergies_____________________________
• Other medical diagnosis___________________________
• Past, non gynecologic surgeries______________________
• Personal habits___________________________________
VIII. Family History
• Gynecologic or breast diseases______________________
• Genetics________________________________________
IX. General review of systems
Other symptoms besides those ones related to the pelvis and
reproductive organs should be elicited by organ system review.
There may be overlap between the past medical history and the
review of systems.
II. PHYSICAL EXAMINATION
1. General state of the patient_________________________
2. Temperature________ Arterial blood pressure__________
Weight__________________ Height___________________
3. Blood type______________________________________
4. Consciousness ___________________________________
Structure of the body________________________________
State of the skin and subcutaneous fat___________________
Presence of edema__________________________________
Muscle and joints development________________________
5. Breast:
• Inspection
Alterations in the appearance of the breast such as changes in
shape__________________________________________________
Contour____________________ Symmetry___________________
Coloration__________________ Skin retractions or edema___
_______________________________________________________
• Palpation
Examine the axilla and the entire area of the breast tissue with
the flat part of the fingers. Any felt mass should be documented in
location, consistency, size, shape, and mobility. Gentle pressure on
the areola is used to check for any
discharge________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
6. Thyroid gland and peripheral lymph nodes____________
7. Cardio-pulmonary system__________________________
8. Stomach and intestinal function_____________________
9. Urinary system__________________________________
10. Nervous impairment_____________________________
OBSTETRIC EXAMINATION
A Pelvic sizes:
Main_____________________________________________
_________________________________________________
Additional_________________________________________
________________________________________________
Mychaelis Rhomb__________________________________
Solovyov's index___________________________________
Abdomen: inspection for shape _______________________
scars___________, striae____________, hair pattern______
Uterine fundal height_______________________________
Abdominal circumference determination________________
C. External obstetric examination:
Leopold’s maneuvers
I. _______________________________________________
________________________________________________
II. ______________________________________________
_________________________________________________
III. ______________________________________________
_________________________________________________
_________________________________________________
D. Fetal heart rate auscultation______________________
E. Probable fetal weight by Volskov___________________
by Yakubova____________________________________
F. Characteristics of labor activity: uterine contractions or
pushing________________________________________________,
their strength________________, duration____________________,
interval_________________________________________________
VAGINAL EXAMINATION
Day ___________, hour ___________, № ____________
A. External genitalia:
Inspection of mons pubis_____________________________
labia majora______________, labia minora______________
perineum and pineal area __________________________,
urethral meatus______________; clitoris________________
Skein's gland _________________________________ and
Bartholin's gland areas__________________________(will
be visible for inspection as palpation is begun).
B. Vagina________________________________________
C. Uterine cervix status_____________________________
Bishop score of 9 to 13 points is associated with the highest
likelihood successful labor duration.
The Bishop Score for cervical status
0
1
2
3
Closed
12 cm
3 – 4 cm
5 cm
Dilation
0−30 %
40−50 %
60−70 %
80%
Effacement
−3
−2, −1
0
+1,+2
Station
Firm
Medium
Soft
Consistency
Posterior
Mid
Anterior
Position
D. Amniotic sac state (its presence or absence, its
characteristics)___________________________________________
E. Presented part and its station (−3, −2, −1, 0, +1, +2, +3 ).
Zero station is the level of the spines (example 1 cm above is −1,
2 cm below is +2).
Situation of sutures_________________________________
Fontanels on the fetal head___________________________
Graphical documentation:
F. Evaluation of the pelvis ___________________________
DIAGNOSIS:
• Gestational age of the labor_________________________
• Lie __________ Position _____________ Visus_________
• Presentation of the fetus____________________________
• Stage of labor____________________________________
• Obstetric pathology________________________________
• Extragenital pathology_____________________________
• Complications during labor__________________________
LESSON 18
HISTORY OF DELIVERY
III. MANAGEMENT OF LABOR
_________________________________________________
_________________________________________________
_________________________________________________
IV. CLINICAL DURATION OF LABOR
The notes in the first stage of labor are being written every
2 hours, starting from the moment of escalation of the first stage
of labor. Every note should contain information about:
Day and time______________________________________
General state of the woman___________________________
Complaints________________________________________
Characteristics of uterine forces (contractions or pushing
efforts) frequency_______ Intensity_______ Strength____________
Presented part and its station__________________________
Fetal heart rate_____________________________________
Amniotic fluid_____________________________________
Signature of the doctor
Day and time______________________________________
General state of the woman___________________________
Complaints________________________________________
Characteristics of uterine forces (contractions or pushing
efforts) frequency_______ intensity_______, strength____________
Presented part and its station__________________________
Fetal heart rate_____________________________________
Amniotic fluid_____________________________________
Signature of the doctor
Day and time______________________________________
General state of the woman___________________________
Complaints________________________________________
Characteristics of uterine forces (contractions or pushing
efforts) frequency_______ intensity_______, strength____________
Presented part and its station__________________________
Fetal heart rate_____________________________________
Amniotic fluid_____________________________________
Signature of the doctor
Day and time______________________________________
General state of the woman___________________________
Complaints________________________________________
Characteristics of uterine forces (contractions or pushing
efforts) frequency_______ intensity_______, strength____________
Presented part and its station__________________________
Fetal heart rate_____________________________________
Amniotic fluid_____________________________________
VAGINAL EXAMINATION
Day _________ Hour ________ № ___________________
A. External genitalia:
Inspection of mons pubis____________________________
Labia majora_____________ Labia minora______________
Perineum and pineal area __________________________
Urethral meatus_____________________ Clitoris________
Skein's gland _____________________________________
Bartholin's gland areas (will be visible for inspection as
palpation is begun)_________________________________
B. Vagina________________________________________
C. Uterine cervix status_____________________________
D. Amniotic sac state_______________________________
E. Presented part and its station ______________________
F. Evaluation of the pelvis __________________________
DIAGNOSIS:
• Gestational term of the fetus_________________________
• Lie __________ Position _____________ Visus_________
• Presentation of the fetus____________________________
• Stage of labor____________________________________
• Obstetric pathology________________________________
• Extragenital pathology_____________________________
• Complications during labor__________________________
• Stage of labor____________________________________
• Obstetric pathology________________________________
• Extragenital pathology_____________________________
• Complications during labor__________________________
MANAGEMENT OF LABOR
_______________________________________________________
_______________________________________________________
_______________________________________________________
CONFIRMATION OF THE ONSET OF THE SECOND
STAGE OF LABOR:
1 _______________________________________________
2 _______________________________________________
3 _______________________________________________
4 _______________________________________________
5 _______________________________________________
The notes in the second stage of labor are being written
every 15 minutes starting from the moment of estimation of the
second stage of labor every note should contain information about:
Day and time______________________________________
General state of the woman___________________________
Complaints________________________________________
Characteristics of uterine forces (contractions or pushing
efforts) frequency_______ intensity_______, strength____________
Presented part and its station__________________________
Fetal heart rate_____________________________________
Amniotic fluid_____________________________________
Signature of the doctor
Day and time______________________________________
General state of the woman___________________________
Complaints________________________________________
Characteristics of uterine forces (contractions or pushing
efforts) frequency_______ intensity_______, strength____________
Presented part and its station__________________________
Fetal heart rate_____________________________________
Amniotic fluid_____________________________________
Signature of the doctor
Day and time______________________________________
General state of the woman___________________________
Complaints________________________________________
Characteristics of uterine forces (contractions or pushing
efforts) frequency_______ intensity_______, strength____________
Presented part and its station__________________________
Fetal heart rate_____________________________________
Amniotic fluid_____________________________________
When the fetal leading point passes over the mother's
perineum, perineal protective maneuvers should be started. You
should describe them (5 moments).
1 ______________________________________________
2 ______________________________________________
3 ______________________________________________
4 ______________________________________________
5 ______________________________________________
The cardinal moments of labor with graphical evaluation
should be described also:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Day and the time of the delivery _______________________
Newborn evaluation: Alive ___________________________
Presence or absence of asphyxiya _____________________
Apgar Score evaluation on the first __________ and fifth
minutes ________________________________________________
Characteristics of the in term infant: Weight____________\
Height ___________________ Infant maturity_________________
Newborn sex _____________________________________
In the case ot asphyxia you should give information about
newborn infant resuscitation__________________________
Care of the eyes ___________________________________
STAGE OF LABOR
Day, time of occurring placental separation signs _________
Delivery of placenta ________________________________
Inspection of placenta: Size___________________________
Presence of all cotyledons__________________________________
Cord length____________________________________________
Evaluation of the blood loss during delivery:
• Before delivery of the placenta______________________
• With delivery of the placenta _______________________
• In two hours after labor ____________________________
Inspection of the birth canal for laceration
Speculum inspection of the: Cervix__________________________
Vagina ________________________________________________
Perineum (you should pay attention to the degrees of
lacerations, their treatment and anesthesia).
_______________________________________________________
_______________________________________________________
SUMMARY OF THE LABOR
You should give answers to such questions:
• Which type of delivery is it? (Preterm, in term, or post
term)_______________________________________________
• Day and time of onset each period of labor and their
duration ________________________________________________
• Day and time of the rupture of the amniotic membranes
_______________________________________________________
• Duration of the period without amniotic fluid___________
• Day and the time of infant delivery___________________
Visus _____________________ Position _____________________
Presentation_____________________________________________
• Do any complications take place in labor? ____________
• What is an adequate management? ___________________
V. POSTPARTUM AND THE NEWBORN INFANT
PERIOD
The notes in the postpartum period should contain
information about:
First day of the postpartum period______________________
General state of the woman___________________________
Temperature ____________ Arterial blood pressure _______
Heart beats rate____________________________________
Evaluation of the breasts _____________________________
Lactation_________________________________________
Uterine involution _________________________________
Lochia character___________________________________
Perineal region should be inspected in the case of perineal
lacerations presence ______________________________________
Prescribed medications this day________________________
_________________________________________________
Analysis of blood___________________________________
Analysis of urine___________________________________
Signature of the doctor
The notes about attendance of the newborn infant should
contain information about:
Day of attendance__________________________________
General state of the newborn infant_____________________
Activity ________________ Temperature_______________
Color of the skin ___________________________________
Physiologic states__________________________________
Changes of the weight_____________________ State of the
umbilical cord place______________________________________
Signature of the doctor
Third day of the postpartum period_____________________
General state of the woman___________________________
Temperature ____________ Arterial blood pressure _______
Heart beats rate____________________________________
Evaluation of the breasts _____________________________
Lactation_________________________________________
Uterine involution _________________________________
Lochia character___________________________________
Perineal region should be inspected in the case of perineal
lacerations presence ______________________________________
Prescribed medications this day_____________________
_________________________________________________
Analysis of blood___________________________________
Analysis of urine___________________________________
Smear____________________________________________
Signature of the doctor
The notes about attendance of the newborn infant should
contain information about:
Day of attendance__________________________________
General state of the newborn infant_____________________
Activity ________________ Temperature_______________
Color of the skin ___________________________________
Physiologic states__________________________________
Changes of the weight_____________________ State of the
umbilical cord place______________________________________
Signature of the doctor
Third day of the postpartum period_____________________
General state of the woman___________________________
Temperature ____________ Arterial blood pressure _______
Heart beats rate____________________________________
Evaluation of the breasts _____________________________
Lactation_________________________________________
Uterine involution _________________________________
Lochia character___________________________________
Perineal region should be inspected in the case of perineal
lacerations presence ______________________________________
Prescribed medications this day_____________________
_________________________________________________
Analysis of blood___________________________________
Analysis of urine___________________________________
Smear____________________________________________
Ultrasonography___________________________________
Chest X-ray examination____________________________
Signature of the doctor
The notes about attendance of the newborn infant should
contain information about:
Day of attendance__________________________________
General state of the newborn infant_____________________
Activity ________________ Temperature_______________
Color of the skin ___________________________________
Physiologic states__________________________________
Changes of the weight_____________________ State of the
umbilical cord place______________________________________
Signature of the doctor
EPICRISIS
Name and surname of the woman_____________________
_______________________________________________________
Age______________________________________________
Days of hospital stay________________________________
Diagnosis_________________________________________
_______________________________________________________
Newborn infant evaluation in the moment of delivery and
discharge _______________________________________________
State of the puerpera in the moment of discharge
_______________________________________________________
Recommendations__________________________________
_______________________________________________________
P. S!
Patient's temperature and uterine involution graphical
documentation according to the postpartum day should be given
obligatory.
A note of student's attendance with signature of the doctor
should be given also.
Notes of the attendance
Obstetrics and Gynecology Chair №1
Note of the attendance of the puerpera and newborn infant
By a student_______________________________________
IV-year studing__________ Group № __________________
Surname of the puerpera
_______________________________________________________
Day of the attendance
Signature of the doctor
Visual Aids and Material Tools:
Charts №
Equipment:
Students must know:
1. Management of the pregnants in the female dispensary.
2 Management of the labor and postpartum period.
Students should be able:
1. To perform interrogation of the pregnants, women in labor
and puerperants.
2. To evaluate the results of additional methods examination
of the pregnants, women in labor and puerperants.
3. To make a correct diagnosis.
4. To make a plan of examination and treatment of the
pregnants, women in labor and puerperants.
References:
1. Хміль С. В. Акушерство / С. В. Хміль. − Тернопіль :
Укрмедкнига. − 1998. − 378 с.
2. Danforth's Obstetrics and Gynecology − Seventh edition. − 1994.
− 1121 p.
3. Obstetrics and Gynecology. Williams & Wilkins Waverly
Company − Third Edition. − 1998. − 822 p.
4. Obstetrics and Gynecology / Pamela S. Miles, J. Christopher
Carey, William F. Rayburn. − Springer-Verlag New York. − 1994. −
225 p.
TEST 1
1.
The main units of Obstetric and Gynecological center:
female dispensary, obstetric hospital, gynecological departments.
2.
Structure and principles of working of female dispensary.
3.
Medical documents of female dispensary.
4.
Examination of pregnant in the female dispensary.
5.
Structure of the Obstetric hospital.
6.
Principles of Sanitary inspection room working, its main
rules.
7.
Pregnants who undergo hospitalization to the second
obstetric department.
8.
Sanitary-hygienic regimen of maternity home working.
9.
Structure of the Obstetric suite.
10. Sanitary-hygienic regimen of obstetric suite working.
11. Principles of postnatal wards working.
12. Peculiarities of the second obstetric department working.
13. Peculiarities of sanitary-hygienic rules at infants
department.
14. Sanitary-hygienic demands to the medical stuff of the
obstetric hospital.
15. Mothers’ and infants’ staying together: indications,
predominance, rules of the working of medical stuff in these wards.
16. Working of pathologic pregnancy department.
17. Prevention of intrahospital infection.
18. The main forms of medical documents of maternity home.
19. The structure of external female reproductive organs.
20. What is vaginal vestibule?
21. Where does the urethral meatus open?
22. Where do the meatuses of the Bartholin's glands open?
23. Structure of vagina, peculiarities of vaginal epithelium.
24. Self-cleaning of vagina.
25. Structure of uterus and its parts.
26. Structure of uterine cervix, shape of its vaginal part.
27. What is isthmus of uterus?
28. Definition of lower uterine segment.
29. What is contractile ring?
30. Pelvic peritoneum.
31. Pelvic cellular spaces.
32. Suspensive apparatus of the uterus.
33. Fixative apparatus of the uterus.
34. Supportive apparatus of the uterus.
35. Structure and function of ovaries.
36. Structure and function of fallopian tubes.
37. Blood supply of female generative organs.
38. Nerve supply of female generative organs.
39. Egg fertilization. Stages of embryonic development.
Embryonic formation and fetal development in different periods of
pregnancy.
40. Implantation.
41. Placentation types.
42. Placenta structure.
43. Amniotic fluid.
44. The critical periods of embryo development and its
alteration by toxic substances.
45. Ovum structure in the end of pregnancy.
46. The signs of the fetal maturity and gestation.
47. Fetal sizes in different periods of its development.
48. Physiological peculiarities of the fetus in different stages of
its development.
49. Give the definitions of such terms as "viable fetus", "fetus
in term", "fetus preterm", "deep preterm fetus".
50. Principles of medical-genetic counseling organization.
51. Tasks of medical-genetic counseling.
52. Structure of the medical-genetic counseling.
53. The causes of the ovum abnormalities occurring.
54. Patients which should be examinated in medical-genetic
counseling.
55. Methods of medical-genetic counseling.
56. The essence of genetic method.
57. Determination of sex-chromatin.
58. Ultrasonography importance in prenatal diagnostics of fetal
abnormalities.
59. Immunogenetical method of investigation.
60. Biochemical methods of investigation.
61. Clinical and laboratory characteristics of the diseases which
have been occurred as a result of chromosomes rearrangements and
point mutations.
62. What bones does the pelvis consist of?
63. Differences between female and male pelvis.
64. The main landmarks of the female pelvis.
65. Planes of pelvis and their sizes.
66. Main and additional external pelvis sizes.
67. Methods of estimation of true conjugate.
68. Solovyov's index. Its significance for estimation of internal
pelvic sizes.
69. Mikhaelis's rhomb. Its significance for estimation of result
of labor.
70. Structure of pelvic floor.
71. Structure and sizes of fetal head.
72. Body sizes of in term fetus.
73. Sutures and fontanels and their significance for diagnosing
the situation of fetal head.
74. Definition of «large segment» of fetal head.
75. Relationship of fetal head to pelvic planes.
76. Definition of the obstetrics terms: attitude (habitus), lie,
presentation, position, variety (visus).
77. Definition of the terms: axis of fetus, axis of uterus, axis of
pelvis.
78. Engagement (synclitic and asynclitic).
79. Auscultation of fetus heat sounds.
80. Vaginal examination.
81. Speculum examination.
82. Examination of abdomen ( Leopold maneuvers).
83. Ultrasonic assessment of the fetus.
84. Methods of pregnancy diagnosis.
85. Presumptive signs of pregnancy.
86. Probable signs of pregnancy.
87. Positive signs of pregnancy.
88. Signs of pregnancy: Hegar's, Piskachek's, Henter's,
Snegirov's.
89. Biological tests for pregnancy.
90. Tests with chorionic gonadotropin in determination of
pregnancy.
91. Modern tests for pregnancy.
92. Diagnosis of late terms of pregnancy.
93. Sizes of uterus in different terms of pregnancy.
94. Evaluation methods of gestational age.
95. Examination of the pregnant in third trimester of
pregnancy.
96. Obstetric ultrasound examination.
97. Investigation of discharge from breast glands on the
gestational age of pregnancy.
98. Electronic fetal monitoring.
99. Biophysical profile of the fetus.
100. Test for revealing of amniotic fluid.
101. Functional diagnostic tests.
102. Invasive methods of assessment of fetal status:
cordocentesis, fetoscopy, amnioscopy, amniocentesis.
TEST 2
1.
Give the definition of such term as "biomechanism" of
labor.
2.
Give the definition of such obstetric terms as: "leading
point", "fixative point".
3.
Graphic documentation of the fetal head station in the true
pelvis in different types of cephalic presentation.
4.
Theories of the cardinal moments of labor.
5.
Cardinal moments of labor in the vertex (occiput) anterior
presentation.
6.
Cardinal moments of labor in the vertex (occiput) posterior
presentation.
7.
Importance of perineal protective maneuvers.
8.
Technique of perineal protective maneuvers (five
moments).
9.
What is labor?
10. Stages of labor.
11. Labor expulsive forces.
12. Mechanism of cervical dilatation in primapara and
multipara.
13. What is lower uterine segment, contractile ring?
14. Management of the first stage of labor.
15. Role of vaginal examination in diagnosing the stages of
labor.
16. Management of the second stage of labor.
17. Perineal protective maneuvers.
18. Signs of placental separation.
19. Manual removal of placenta.
20. Structure of afterbirth.
21. Blood loss during labor and its estimation.
22. Definition of physiological blood loss.
23. The definition of the puerperium.
24. The definition of the early and late puerperium.
25. The main processes in the nuerperium.
26. Involution of the uterus.
27. What is lochia? The role of the lochia.
28. Changes of the lochia during puerperium.
29. Hygiene of the female reproductive organs in pueperants.
30. Care of the pueperants after episiotomy.
31. Function of breasts in puerperium.
32. Fissures of the nipples. Their treatment and prevention.
33. The rules of breast feeding.
34. The management of the puerperium.
35. Ultrasonic estimation of uterine involution.
36. Medicines stimulants of myometrial contractions.
37. Patients discharge from the hospital after delivery.
38. Anatomical substrate of pain in labor.
39. Importance of cortex, conditioned reflex in the development
of pain in labor.
40. Psychoprophylactic painless labor.
41. Methods of analgesia and anesthesia during labor and
indications for its usage.
42. Structure and prescription ot apparatus for anesthesia.
43. The main analgesic and anesthetic used in obstetrics.
44. The anesthetic technique that provides pain relief during
first stage of labor.
45. The anesthetic technique that provides pain relief during
second stage of labor.
46. Indications for pudendal block.
47. Classification of uterine contractions abnormalities.
48. Factors that provide normal uterine contractions.
49. Definition of primary and secondary uterine inertia.
50. Incoordmative uterine activity.
51. Excessive uterine activity.
52. Medicines for correction of uterine contractions.
53. Methods of treatment of uterine inertia in the first and
second stages of labor.
54. Prevention of uterine contractions abnormalities.
55. Diagnosis of multifetal gestation.
56. Peculiarities of pregnancy duration in multifetal gestation.
57. Peculiarities of labor duration in multifetal gestation.
58. Management of labor in multifetal gestation.
59. Etiology of polyhydramnios.
60. Peculiarities of pregnancy duration in polyhydramnios.
61. Peculiarities of labor duration and management of labor in
polyhydramnios.
62. Which fetus is called "macrosomic" (large and giant )?
63. Diagnosis of pregnancy with macrosomic fetus.
64. What are the main causes of macrosomic fetuses?
65. Complications of labor with macrosomic fetus.
66. Peculiarities of labor management with macrosomic fetus.
67. Classification of breech presentations.
68. What are circumferences of buttocks, shoulders and head
according to type of breech presentation?
69. Etiology of breech presentations.
70. Management of the pregnants with breech presentation in
the female dispensary.
71. Methods of correction of breech presentation during
pregnancy.
72. Biomechanism of labor in breech presentation.
73. Management of the cervical stage of labor in breech
presentation.
74. Management of the cervical stage of labor in breech
presentation.
75. Manual aid by Tsovyanov in frank breech presentation.
76. Classic manual aid in complete breech presentation.
77. Management of delivery by Tsovyanov in incomplete
breech presentation.
78. Which complications are possible during pregnancy and
delivery in breech presentation?
79. Prevention of breech presentation.
80. Give the definition of obstetric term "total breech
extraction".
81. Indications to breech extraction.
82. Prerequisites for breech extraction.
83. Types of breech extraction.
84. Stages of breech extraction beginning from.
85. Stages of breech extraction beginning from foot or feet.
86. Complications of breech extraction.
87. Give the definition of obstetric term "incorrect fetal lie".
88. Types of incorrect fetal lie.
89. Etiology of incorrect fetal lie.
90. Diagnosis of incorrect fetal lie.
91. Give the definition of term "obstetric version".
92. Types of obstetric versions.
93. Types of external obstetric version.
94. Indications and contraindications for external obstetric
version.
95. Prerequisites and technique of external obstetric version.
96. Complications during labor in transverse and oblique fetal
lie.
97. Indications, contraindications for internal podalic version.
98. Prerequisites and technique of internal podalic version.
99. What does persistent transverse lie mean?
100. Management of labor in persistent transverse lie.
101. Complications in external obstetric version and internal
podalic version.