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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 ………………………………….. ………………………………………………………. 4 9 12 23 30 44 50 56 62 71 80 86 88 94 101 108 111 118 128 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. - - - - 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. - - - - - - 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. - - - - - - - - - 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 - - - - - - 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 - 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 25С. 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.