Clinical guidelines. Childbirth complicated by the pathology of the umbilical cord. Management of the 3rd stage of labor

The last material thread connecting the baby with such a cozy and safe mother's womb is interrupted after childbirth from the moment when the baby took its first breath and announced its birth with a loud cry - and this thread is the umbilical cord. Gradually, the wound at the junction with the mother's body heals, but the trace of it remains for life, as a reminder of the one that gave us life. Where does the mother’s part of this connecting “thread” go, and what is customary to do with it? To answer such questions, it is necessary to have a more accurate idea of \u200b\u200bwhat, in fact, the umbilical cord is.

Natural "pipeline of life"

WITH scientific point vision, the umbilical cord is one of the components of the fetal bladder, in which the child grows and develops before birth. The fetal bladder consists of the membranes, placenta and amniotic fluid- each of these elements plays an important role in the development of the fetus, but the placenta deserves special attention. Speaking figuratively, then:

The fetal bladder is a space suit that reliably protects the child from dangers - germs, loud noise, strong blows, sharp shocks, etc.;
The placenta is a temporary multifunctional organ of the child, which replaces his lungs, kidneys, liver, and intestines. This is a kind of "factory" that produces all the vital substances for humans, including oxygen, food, medicines, etc.;
The umbilical cord is a "pipeline" through which all substances from the "factory" enter the child's body. The waste products of the fetus are excreted in the same way. All metabolic processes are carried out with the help of a vein and 2 arteries passing in the umbilical cord.

1,2,3 - shells gestational sac, 4 - amniotic fluid, 5 - placenta with umbilical cord.

In the process of childbirth, first there is a rupture of the membranes of the fetal egg and the discharge of amniotic fluid, then the expulsion of the fetus from the uterine cavity.

Childbirth ends with the departure of the placenta - the so-called fetal membranes and placenta, along with the umbilical cord.

Between the time of the birth of the child and the release of the placenta, more than 1.5-2 hours can pass, so the umbilical canal is cut without waiting for the end of the process: first, it is clamped in two places, and, after waiting for the pulsation to stop, it is cut. Ideally, the placenta passes through the birth canal immediately after the baby - in this case, there is less chance of postpartum complications for the mother and newborn.

During the eruption of the head, they begin to receive childbirth, which consists in helping the woman in labor. It is necessary because the extending head puts a lot of pressure on the pelvic floor, causing it to overstretch. The voice of the fetus is also subjected to strong compression by the walls of the birth canal. Naturally, at the climax, both the woman in labor and the fetus are at risk of injury: the first is threatened with a rupture of the perineum, the second is a violation of intracranial pressure. Proper manual assistance significantly reduces the possibility of these complications, and in cephalic presentation "protection of the perineum" consists of a series of manipulations performed in a certain sequence. The first point is to prevent premature extension of the head. The deliverer stands to the right of the woman in labor and puts the palm of his left hand on the pubis so that four fingers tightly adjacent to each other cover flat, and, if possible, the entire head located in the genital gap. Thus, the extension of the head is carefully delayed and its rapid advancement through the birth canal is prevented. The second point is the careful removal of the head from the genital gap. This is achieved outside the attempts, and not at their height, when the pressure on the genital gap is very strong. It is carried out as follows. As soon as the attempt is over, the vulvar ring is carefully stretched over the erupting head with the thumb and forefinger of the right hand. With a new attempt, stop stretching and delay the extension of the head, as described above (see the first moment). These manipulations alternate until the head approaches the genital slit with its parietal tubercles. From this time on, the stretching of the perineum and compression of the head rapidly increase, increasing the risk of injury. The third point is the reduction of tension in the perineum. The purpose of the event is to make it more pliable and increase resistance to tearing. The delivery person places the palm of the right hand on the perineum so that four fingers fit snugly against the area of the left labia, and a strongly abducted thumb to the right. The crease between the thumb and forefinger should be located above the navicular fossa. Gently pressing with the ends of all five fingers on the soft tissues located outside and along the labia majora, they are brought down - towards the perineum, thereby reducing the tension of the latter. At the same time, the palm of the same hand supports the perineum, gently pressing it against the erupting head. Thus, the blood circulation in the tissues of the perineum, which was disturbed during its stretching, is restored, and, consequently, the resistance to rupture increases. The fourth point is the regulation of attempts. By the time the head cuts through the genital gap with its parietal tubercles, the risk of perineal rupture and intracranial injury reaches a maximum. Therefore, the task is to skillfully suspend childbirth when they are undesirable, and, conversely, to induce them when necessary. The woman in labor is offered to breathe deeply with her mouth open, and they watch when she stops breathing and begins to push. Then, with both hands, they delay the advancement of the head until the attempt is completely turned off or significantly weakened, the right hand of the child taking delivery squeezes the perineum over the face of the fetus outside the attempt, while the left one slowly lifts the head up and unbends it. A woman in labor is advised to push sensibly - with a force appropriate for the careful removal of the head. Thus, by turning on and off the attempts, the birth of the densest and most voluminous part of the fetus - the head. The fifth moment is the release of the shoulder girdle and torso of the fetus. After the appearance of the head, the woman in labor is again offered to push. At the same time, important turns are made at the moment of childbirth: the inner one - the shoulders and the outer one - the head, it turns to face the right thigh of the woman in labor in the first position or the left thigh in the second position. This is usually followed by the release of the shoulders. If the natural forces of the body "did not work" spontaneously, the head is captured by the palms of the hands so that they lie flat on the right and left temporo-cervical regions of the fetus. In this case, the head is first pulled downwards until the anterior shoulder fits under the pubic joint. Then with the left hand, the palm of which is on the lower (back) cheek of the fetus, they lift the head up, and with the right hand they bring out the back shoulder - carefully (!) So as not to violate the integrity of the fetal collarbones and the perineum of the woman in labor. When the shoulder girdle is released, the index fingers of both hands are inserted into the armpits from the back side and the torso is lifted up. This contributes to its rapid and normal birth.

8. Separation and isolation of the placenta.

The management of the III stage of labor is expectant.

Remember the existence of a catchphrase in practical obstetrics: "Hands off the afterbirth uterus." This, of course, does not mean that the uterus in the afterbirth period cannot be touched. It is possible and necessary to clarify the signs of separation of the placenta. But this must be done carefully, without making erratic pressure on the uterus, so as not to cause untimely contractions in it, which can lead to dangerous bleeding.

The main rule in the management of this period of labor is to carefully observe:

for a woman in labor (general condition, color of the skin, visible mucous membranes, pulse, pressure, inquire about well-being),

for blood loss (a kidney-shaped tray or a boiled vessel is placed under the pelvis of the woman in labor),

behind the separation of the placenta (they observe the shape of the uterus, the height of its bottom)

for the state Bladder(do not allow it to overflow - an overflowing bladder is a reflex, prevents uterine contractions and the birth of an afterbirth)

In a good condition of the woman in labor, if there is no bleeding, it is necessary to wait for an independent detachment and delivery of the placenta within 30 minutes. Active measures to remove it are required for pathological blood loss and deterioration of the woman's condition, as well as for prolonged retention of the placenta in the uterus for more than 30 minutes.

The actions of medical personnel in such cases are determined by the presence or absence of signs of placental separation:

with positive signs of separation of the placenta, the woman is offered to push. If the woman in labor is straining, and the afterbirth is not born, proceed to methods for isolating the separated afterbirth;

in the absence of signs of separation of the placenta, the presence of signs of external, internal bleeding, the operation is performed manually separation of the placenta, allocation of the placenta. If the separated placenta lingers in the vagina, it is removed by external methods, without waiting for the period indicated above.

Signs of separation of the placenta

Schroeder sign. Change in the shape and height of the fundus of the uterus. Immediately after the birth of the fetus, the uterus takes on a rounded shape and is located in the midline. The bottom of the uterus is at the level of the navel. After separation of the placenta, the uterus stretches (becomes narrower), its bottom rises above the navel, often deviates to the right

Sign of Dovzhenko. The mother is asked to breathe deeply. If the umbilical cord does not retract into the vagina during inhalation, then the placenta has separated from the wall of the uterus; if the umbilical cord retracts into the vagina, then the placenta has not separated

Alfeld sign. The separated placenta descends into the lower segment of the uterus or vagina. In this regard, the Kocher clamp applied to the umbilical cord during its ligation falls by 8-10 cm or more.

Klein sign. The woman in labor is offered to push. If the placenta has separated from the wall of the uterus, after the cessation of the attempt, the umbilical cord remains in place. If the placenta has not separated, then the umbilical cord is pulled into the vagina.

Sign of Kyustner-Chukalov. If, when pressing with the edge of the palm on the uterus above the pubic joint, the umbilical cord does not retract into the birth canal, then the placenta has separated; if it retracts, it means that it has not separated

Sign of Mikulich-Radetsky. The separated placenta descends into the vagina, there is (not always) an urge to try.

Strassmann sign. With an unseparated placenta, tingling along the bottom of the uterus is transmitted to the umbilical vein filled with blood. This wave can be felt with the fingers located on the umbilical cord above the clamp. If the placenta has separated from the wall of the uterus, this symptom is absent.

Sign of Hohenbichler. With an unseparated placenta during uterine contraction, the umbilical cord hanging from the genital slit can rotate around its axis due to overflow of the umbilical vein with blood.

Note: the separation of the placenta is judged not by one sign, but by a combination of 2-3 signs. The signs of Schroeder, Alfeld, Kustner-Chukalov are considered the most reliable.

Methods for isolating a separated placenta

With positive signs of separation of the placenta and the absence of independent birth of the placenta, they resort to its isolation manually. For the birth of the placenta, you need to create sufficient intra-abdominal pressure. To do this, they offer the woman in labor to push. If an artificial attempt does not lead to the birth of the placenta, which occurs with overstretched abdominal muscles, the anterior abdominal wall should be captured in a fold (reduce the volume abdominal cavity) according to Abuladze's method. After that, in one or two attempts, the afterbirth is born.

Abuladze method

Emptying the bladder.

Gentle massage of the uterus through the anterior abdominal wall.

Stand to the right, on the side of the woman in labor.

Grab the anterior abdominal wall with both hands in a longitudinal fold.

Invite the woman to push.

Genter's method

Emptying the bladder.

Bringing the uterus to the middle position.

Stand on the side of the woman in labor, facing her feet.

Clench both hands into fists.

Put the back surface of the fists on the bottom of the uterus in the area of the tube corners.

Forbid the woman in labor to push.

Press the fists on the uterus in the direction down to the sacrum.

Crede-Lazarevich method

Emptying the bladder.

Gentle massage of the uterus through the anterior abdominal wall.

Bringing the uterus to the middle position.

Stand to the left of the woman in labor, facing her feet.

Cover the bottom of the uterus with your right hand so that the thumb is on the front wall of the uterus, the palm is on the bottom, and 4 fingers are on the back of the uterus.

Simultaneously pressing on the uterus with the whole brush in two mutually intersecting directions (fingers from front to back and palm down towards the pubis) to achieve the birth of the placenta.

Stop pressure on the uterus and make sure that the membranes come out completely.

At the birth of the placenta, the midwife captures it with her hands, arms and twists the membranes in the form of a cord with rotational movements (Jacobs' method). This simple technique prevents the shells from tearing off.

Jacobs method- take the placenta in your hands, rotate it clockwise so that the membranes curl up into a cord and come out not torn

Genter's method- after the birth of the placenta, the woman in labor, leaning on her feet, raises the pelvis; at the same time, the placenta hangs down and, with its weight, contributes to exfoliation, the release of membranes.

The separation of the membranes from the uterine wall occurs under the influence of the gravity of the placenta and the weight of the blood accumulated in the formed sac during its central separation. With marginal separation and separation of the placenta, the membranes can come off and remain in the uterus; with the central separation, separation of the membranes is a rare occurrence.

The born placenta is subjected to a thorough examination. The afterbirth (especially its placental part) should be examined very carefully. Retention of placental tissue in the uterus can lead to severe complications in the postpartum period. Therefore, at the slightest suspicion of a delay in the placental tissue in the uterus, it is necessary with all attention and caution to check with a large curette (or hand) under general anesthesia. If immediately after childbirth such curettage is safe, then after 2-3 days it cannot be done, since by this time the uterus will be infected and very soft, which creates a great threat of perforation during such an intervention.

Inspection of the placenta.

The placenta is laid out on a smooth tray with the maternal surface up.

Two gauze swabs remove blood clots.

Look at one slice after another. The edges of the placenta are smooth, do not have dangling vessels extending from them.

The membranes are examined - the placenta is turned with the maternal side down, the fruit side up.

The edges of the rupture of the shells are taken with the fingers, straightened them. Pay attention to the integrity of the water and fleecy membranes; find out if there are broken vessels between the membranes extending from the edge of the placenta.

The place of rupture of the membranes is determined - the closer to the edge of the placenta is the place of rupture of the membranes, the lower it was attached to the wall of the uterus.

The umbilical cord is examined: its length is determined, the presence of true, false nodes, attachment of the umbilical cord to the placenta.

After inspection, the placenta is weighed and measured. All data is recorded in the history of childbirth.

The birth of the placenta ends the birth and the woman who has given birth - the puerperal - enters the postpartum period.

After examining the placenta, the external genital organs are treated according to the generally accepted scheme with a warm disinfectant solution, dried with a sterile napkin. They help the puerperal to move to the gurney, put a kidney-shaped tray with the inscription "blood" under the pelvis and send it to the small operating room. In a small operating room, an obstetrician-gynecologist prepares everything necessary for examining and restoring the birth canal. Such a detailed examination of the tissues of the birth canal, including the cervix, is usually performed only in primiparas. In multiparous women, one can limit oneself to examination of the perineum, control of the cervix and vaginal walls - according to indications (bleeding).

Experience shows that perineal rupture can occur in both primiparous and multiparous women. In the latter, it is even more possible due to the presence of cicatricial changes in the tissues of the perineum as a result of ruptures during previous births. Rupture of the cervix is more often found in primiparous.

Restoration of the integrity of the cervix and perineum is mandatory. Also subject to suturing and cracks in the mucous membrane of the entrance to the vagina. If significant cervical tears are left unsutured, the spontaneous healing of the wound may be slow, the wound will easily become infected, which can lead to complications in the postpartum period. In addition, which is especially important, spontaneous healing of cervical ruptures always leads to cervical deformity, eversion of the cervical mucosa and the formation of ectropion. This condition of the neck should be considered as a condition of precancer. Therefore, it requires prevention - suturing of cervical tears immediately after the end of childbirth.

In the presence of old ruptures of the cervix, the scars are subject to excision and suturing. These activities are one of the measures to prevent precancerous conditions of the cervix.

After examining the birth canal, a "cold" is placed on the lower abdomen through the diaper to the puerperal (an ice pack or a cooling bag - for 20 minutes, every 10 minutes for 2 hours), on the bottom of the uterus a "load" (a bag of sand), under the pelvis enclose a kidney-shaped tray with the inscription "blood".

Often shortly after the birth of the child (and sometimes after the end of childbirth), the woman in labor has a chill. Most likely, this feeling is a response of the body to the work done and, apparently, is associated with a large expenditure of energy and heat in childbirth, transferred by emotional unrest. It is possible that an additional cause of chills in parturients and puerperas is the reaction of the body to absorption from a large wound surface of the uterus. If this chill is not associated with the presence of profuse blood loss or infection, then it soon passes and, in addition to sheltering the woman in labor (puerperal) with a warm blanket, does not require any measures.

In the maternity ward, the puerperal is 2 hours under the close supervision of a midwife, which is associated with the possible occurrence of hypotonic bleeding.

If for 2 hours the uterus remains well reduced, then its further relaxation occurs very rarely, and if it occurs, then without formidable bleeding.

The newborn also stays in the maternity ward for 2 hours, due to the possible relaxation of the ligature on the umbilical cord residue, which can lead to life-threatening blood loss. If urgent assistance is needed, the latter in the delivery room can be provided faster than in the postpartum ward and in the nursery.

After 2 hours, the puerperal is transferred to the postpartum ward, and the newborn is transferred to the children's ward, along with carefully drawn up histories of childbirth and the newborn.

Before transfer:

evaluate the general condition of the puerperal;

through the anterior abdominal wall determine the state of the uterus (VDM, configuration, consistency, sensitivity to palpation);

determine the nature of lochia (postpartum discharge);

a vessel is placed under the pelvis of the puerperal and offered to empty the bladder; in the absence of independent urination, bladder catheterization is performed;

after emptying the bladder, the toilet of the external genital organs of the puerperal is carried out;

make appropriate entries in the history of childbirth; the puerperal (on a gurney), the newborn is transferred to the postpartum department.

In conclusion, it should be noted that the management of childbirth requires the medical personnel to create the necessary conditions for protecting the birth canal from the possible ingress of pathogens of the infectious process, because. the act of childbirth is always accompanied by the formation of a large wound surface on the inner surface of the uterus and often in the lower part of the birth canal.

The woman in labor enters the delivery room after the initial sanitization. Removal of pubic hair is a must.

If childbirth does not end in the next few hours after the woman in labor enters the maternity ward, then the toilet of the external genital organs is performed twice a day.

During vaginal examination, the skin of the external genital organs and the inner surface of the upper third of the thighs are thoroughly disinfected.

The hands of an obstetrician conducting a vaginal examination are treated in the same way as for abdominal surgery.

In the process of conducting labor and in the postpartum period, it is necessary to create conditions to prevent the penetration of pathogens of the infectious process from outside into the birth canal. After a vaginal examination, some obstetricians recommend leaving 3-4 tablets of tetracycline or another antibiotic in the upper vagina.

With the slow dissolution of the antibiotic in the vagina, an environment is created that has an antibacterial effect on the microflora, if it was brought by the examiner's hand from the lower part of the vagina to the cervical region. The accumulated material of the vaginal use of antibiotics for prophylactic purposes, after internal studies, indicates that this method almost completely eliminates the possibility of infection of the birth canal, even with multiple studies. This event is even more important in case of premature and early discharge of water.

In case of infection of the birth canal, antibiotics should be used in accordance with the identified sensitivity of the infectious agent to them. Modern methods make it possible to obtain this data in 18-24 hours.

9. Deliver on a phantom anterior occipital presentation

This topic is quite extensive, you can talk for a long time about what and how. I will give only general concepts, so as not to load you for a long time.

We are connected to my mother's and father's family. This connection is extremely important for us and is reflected in all areas of our life: both in general success and in love, family relationships, social and monetary spheres, not to mention damage and family curses. Often a negative trace can be traced from there.

Well, just a few more words about "where the legs grow from" or the birth canals are attached to us. This information is known to experienced psychologists and psychotherapists. They are fixed from the back, approximately - the projection of the kidneys. The left side is my mother's family, the right side is my father's.

I feel this connection with my hand, I see some images that help change the situation in the right direction.

Before work, you should ask the client: are his closest relatives alive or not? masculine: mother and grandmother and, respectively, father and grandfather.

You can, of course, work only with this knowledge and just connect a person, but it is much better and more efficient to tell a person what I see in the process of work, and feedback gives a different, much more powerful result and a new understanding and vision of the situation.

You can work here with a magic wand with the consciousness of a magician, but in me such a wand is built into the machine - 17 lasso, and therefore the work turns out to be quite interesting.

In this regard, I will give you two examples. I had previously worked with my client from Moscow, who was in his early thirties as a psychotherapist, sexologist and psychologist. When we worked with the female (mother's family), there were no particular problems, we strengthened the connection, cleaned the mother and grandmother and the birth canal in general. I usually fix the alignment with a mandala in the color of the manipura chakra.

On the masculine side, oddities began. The first thing that turned out: there is no connection between the guy and the father, as if there was some kind of interruption. I began to look at the situation further, felt my father (he had already died), and then went up to my grandfather.

The latter I saw so golden, important, like a saint. I ask about my grandfather (he is alive): "Who is your grandfather, just like a saint?" He answers: "Yes, no one, an ordinary drunk, I never had contact with him or with my father."

I thought something is not right here. I see how this golden image begins to build a connection. And the thought comes that this is not the grandfather of the client, but the Spirit of the Genus in the male line, and therefore he looked accordingly.

And further, when in a few minutes the connection building and alignment was completed, and we were finishing our work, the following information came out from the client: if the contact and communication with the father was always bad and there was no understanding, then the grandfather did not want the grandson to be born at all. He asked his daughter to have an abortion. So, the situation was really not simple, and we solved it quickly and radically through the Spirit of the Family, building a system, and putting everything in its place.

To be continued…

FIRST PERIOD

The woman in labor spends the first stage of labor in the prenatal ward. An external obstetric examination in the period of disclosure is carried out systematically, noting the state of the uterus during contractions and outside them. Records in the history of childbirth are made every 2 hours. The fetal heartbeat is heard every 15 minutes. Observation of the insertion and advancement of the fetal head through the birth canal is carried out using external methods of palpation, vaginal examination, listening to the fetal heartbeat, ultrasound. A vaginal examination is mandatory upon admission to the maternity hospital and outflow of amniotic fluid, as well as according to indications - in case of deviation from the norm of the course of childbirth. However, to clarify the obstetric situation (maintenance of the partogram, orientation in the insertion and advancement of the head, assessment of the location of sutures and fontanelles) during childbirth, it can be performed more often.

Diagnosis of rupture of amniotic fluid in most cases is not difficult. Detection during vaginal examination of the head or buttocks of the fetus or loops of the umbilical cord indicates the outflow of amniotic fluid. In doubtful cases, fluid is taken from the posterior vaginal fornix for examination, for which a “posterior” mirror is inserted. The content of amniotic fluid in the fluid taken from the posterior fornix is determined by microscopic examination of a dried smear (the so-called fern phenomenon). Amniotic fluid is alkaline and stains the test strip dark blue. The presence of blood or urine in the contents of the posterior fornix of the vagina can cause a false positive test result. Also, the study notes the presence of an admixture of meconium, often observed in fetal hypoxia, although its primary detection is not pathognomonic for this pathology. If “clean” amniotic fluid first leaks, and then meconium appears, then one should think about fetal hypoxia. If the amniotic fluid is stained with blood, then the possibility of placental abruption is excluded. In case of preterm labor and suspected chorioamnionitis, the sowing of the vaginal discharge from the posterior fornix is carried out. In case of premature birth and outflow of amniotic fluid, the degree of maturity of the lungs of the fetus is determined using a foam test (see "Pain relief in childbirth").

With severe pain in contractions, anesthesia is necessary to maintain reciprocity of contraction of the upper and lower segments of the uterus, eliminate spasm of smooth muscle fibers with a circular anatomical orientation, and prevent cervical rupture during childbirth.

In the first stage of labor, strict bed rest is not necessary. It is possible to carry out the most convenient actions for a woman (shower, massage of the sacrum, etc.).

For early diagnosis of intrauterine hypoxia, it is necessary to assess the condition of the fetus, and therefore it is advisable to use periodic auscultation of the fetal heart and continuous CTG. Conducting periodic auscultation of the heart in the fetus in the first stage of labor is carried out every 15 minutes, and in the second period - after each attempt. According to retrospective studies, the use of this diagnostic method reduces the risk of fetal death, severe asphyxia of the newborn and late neurological disorders. In addition, with continuous CTG, a low Apgar score of the newborn is less common than when using only periodic auscultation of the heart to monitor the condition of the fetus. When using only the method of periodic auscultation of the heart, signs of incipient fetal hypoxia may be missed.

SECOND PERIOD OF DELIVERY

During the passage of the fetal head through the pelvic cavity, the most physiological position of the woman in labor is on her side. In this position, there is a decrease in the tone of the uterus, resulting in an increase in the amplitude of contractions. The frequency of contractions does not increase or even slightly decreases, the labor process accelerates, the uteroplacental blood flow and blood supply improve, which is favorable for the fetus.

The grossest mistake in the conduct of childbirth is the artificial stimulation of attempts at the beginning of the 2nd period with the full opening of the uterine os and a high-standing head. Optimally, the lowering of the head to the pelvic floor in the position of the woman in labor on her side, 4–8 labor contractions will be enough for the birth of the fetus. With longer attempts, the uteroplacental circulation worsens, which can affect the condition cervical fetal spine.

You can observe the translational movement of the head: at first, a protrusion of the perineum is noticeable, then stretching, the skin color becomes cyanotic. Anus protrudes and gapes, the genital slit opens and, as a genital slit, reappears at the beginning of the next attempt - embedding the head. After some time, after the end of the attempt, the head ceases to hide - the eruption of the head begins. It coincides with the beginning of the extension of the head (birth to the parietal tubercles). By extension, the head gradually emerges from under the pubic arch, the occipital fossa is located under the pubic articulation, the parietal tubercles are tightly covered by stretched tissues.

Through the genital gap, the forehead is first born, and then the entire face when the perineum slips off them. The born head makes an external turn, then the shoulders and trunk come out along with the outflow of the posterior waters.

The advancement of the fetal head during the period of exile should be continuous and gradual. The fetal head should not remain in the same plane for more than an hour. During the eruption of the head, it is necessary to provide manual assistance. When unbending, the fetal head exerts strong pressure on the pelvic floor, it is stretched, which can lead to rupture of the perineum. The walls of the birth canal squeeze the head of the fetus, there is a threat of circulatory disorders of the brain. Providing manual assistance in cephalic presentation reduces the risk of these complications. The manual cephalic aid aims to prevent perineal tears. It consists of several moments performed in a certain sequence.

● The first point is to prevent premature extension of the head. It is necessary that during eruption the head passes through the genital gap with its smallest circumference (32 cm), corresponding to a small oblique size (9.5 cm) in a state of flexion. The obstetrician, standing to the right of the woman in labor, puts the palm of his left hand on the bosom, placing four fingers on the head of the fetus in such a way as to cover its entire surface protruding from the genital gap. With light pressure, it delays the extension of the head and prevents its rapid advancement through the birth canal.

● The second point is the reduction of tension in the perineum (Fig. 5.). The obstetrician places the right hand on the perineum so that four fingers are firmly pressed against the left side of the pelvic floor in the region of the labia majora, and the thumb is pressed against the right side of the pelvic floor. With all fingers, the obstetrician gently pulls and lowers the soft tissues towards the perineum, reducing the stretch. The palm of the same hand supports the perineum, pressing it against the erupting head. Reducing the tension of the perineum in this way allows you to restore blood circulation and prevent the appearance of tears.

Rice. 5. Reducing tension in the perineum.

● The third point is the removal of the head from the genital gap without attempts (Fig. 6.). At the end of the effort, with the thumb and forefinger of the right hand, the obstetrician carefully stretches the vulvar ring over the erupting head. The head gradually comes out of the genital gap. At the onset of the next attempt, the obstetrician stops stretching the vulvar ring and again prevents the extension of the head. The actions are repeated until the parietal tubercles of the head approach the genital slit. During this period, there is a sharp stretching of the perineum and there is a risk of ruptures.

Rice. 6. Removal of the head from the genital gap outside the attempts.

At this point, the regulation of attempts is extremely important. The greatest stretching of the perineum, the threat of its rupture and injury to the fetal head, occurs if the head is born during an attempt. To avoid injury to the mother and fetus, it is necessary to regulate the attempts - turning off and weakening, or, conversely, lengthening and strengthening.

The regulation is carried out as follows: when the parietal tubercles of the fetal head pass the genital slit, and the suboccipital fossa is under the pubic symphysis, when an attempt occurs, the obstetrician instructs the woman in labor to breathe deeply in order to reduce the force of the attempt, since during deep breathing attempts are impossible. At this time, the obstetrician with both hands delays the advancement of the head until the end of the contraction. Outside of an attempt with the right hand, the obstetrician squeezes the perineum over the face of the fetus in such a way that it slides off the face. With the left hand, the obstetrician slowly raises the head up and unbends it. At this time, the woman is instructed to push, so that the birth of the head occurs with little stress. Thus, the obstetrician with commands to push and not push achieves the optimal tension of the perineal tissues and the safe birth of the densest and largest part of the fetus - the head.

● The fourth moment - the release of the shoulder girdle and the birth of the fetal body (Fig. 7.). After the birth of the head, the woman in labor is instructed to push. In this case, an external rotation of the head and an internal rotation of the shoulders occur (from the first position, the head turns to face the right thigh of the mother, from the second position - to the left thigh). Usually the birth of the shoulders proceeds spontaneously. If the spontaneous birth of the fetal shoulders did not occur, then the obstetrician captures the head in the region of the temporal bones and cheeks with both palms. Easily and carefully pulls the head down and back until the front shoulder fits under the pubic joint.

Then the obstetrician with his left hand, the palm of which is on the lower cheek of the fetus, grabs the head and lifts its top, and with his right hand carefully removes the back shoulder, shifting the perineal tissues from it. Thus, the birth of the shoulder girdle occurs. The obstetrician inserts the index fingers from the back of the fetus into the armpits, and lifts the torso forward (on the mother's stomach).

Rice. 7. Release of the shoulder girdle of the fetus.

Depending on the condition of the perineum and the size of the fetal head, it is not always possible to save the perineum, it ruptures. Since the healing of an incised wound proceeds better than a lacerated one, in cases where a rupture is inevitable, a perineotomy or episiotomy is performed.

THIRD PERIOD

In the afterbirth period, it is impossible to palpate the uterus, so as not to disturb the natural course of the successive contractions and the correct separation of the placenta. The natural separation of the placenta avoids bleeding. During this period, the main attention is paid to the newborn, the general condition of the woman in labor and signs of separation of the placenta.

The follow-up period is carried out expectantly. The doctor monitors the appearance of pallor of the skin, an increase in heart rate of more than 100 beats per minute, a decrease in blood pressure (BP) by more than 15–20 mm Hg. Art. compared to the original. It is necessary to monitor the condition of the bladder, since an overfilled bladder prevents uterine contraction and disrupts the normal course of placental abruption. To establish whether the placenta has separated from the uterus, signs of separation of the placenta are used.

Schroeder's sign: when the placenta separates and descends into the lower part of the uterus, the fundus of the uterus rises above the navel and deviates to the right, which is noticeable on palpation. In this case, the lower segment protrudes above the womb (Fig. 8.).

Rice. 8. Location of the uterus in the succession period. 1 - before separation of the placenta; - after separation of the placenta (Schroeder's sign); 3 - after the birth of the placenta.

Alfeld's sign: if the separation of the placenta has occurred, then the clamp applied to the stump of the umbilical cord at the genital slit will fall by 10 cm or more (Fig. 9.).

Rice. 9. Sign of separation of the placenta according to Alfeld.

Sign of Kyustner-Chukalov: the umbilical cord is retracted into the vagina when the rib of the hand is pressed over the bosom, if the placenta has not separated. If the separation of the placenta has occurred, the umbilical cord is not retracted (Fig. 10.).

Rice. 10. Sign of placental separation according to Kyustner-Chukalov: on the left - the placenta did not separate; on the right, the placenta separated.

Sign of Dovzhenko: the woman in labor is offered to take a deep breath and exhale. If the separation of the placenta has occurred, when inhaling, the umbilical cord is not retracted into the vagina.

Sign of Klein: the woman in labor is offered to push. If placental abruption has occurred, the umbilical cord remains in place; and if the placenta is not separated, the umbilical cord is pulled into the vagina after attempts.

The diagnosis of separation of the placenta is based on the combination of the listed signs. In order for the birth of the placenta to occur, the woman in labor is instructed to push. If the birth of the placenta does not occur, then external methods are used to extract the placenta from the uterus. Attempts to isolate the placenta before separation of the placenta are prohibited.

In order to combat bleeding, it is possible to use light pulling on the umbilical cord to isolate the placenta.

Isolation of the placenta according to the Abuladze method (strengthening the abdominal press): the anterior abdominal wall is grasped with both hands so that the rectus abdominis muscles are tightly grasped by the fingers. There is a decrease in the volume of the abdominal cavity and the elimination of muscle discrepancy. The woman in labor is offered to push, the placenta is separated with its subsequent birth.

Rice. 11. The method of isolating the separated placenta according to Abuladze.

Isolation of the placenta according to the Krede-Lazarevich method (imitation of a contraction) can be traumatic if the basic conditions for performing this manipulation are not observed. The necessary conditions carrying out the allocation of the placenta according to Krede-Lazarovich: preliminary emptying of the bladder, bringing the uterus to the middle position, lightly stroking the uterus in order to stimulate its contractions. The technique of this method: the obstetrician grasps the bottom of the uterus with the right hand. In this case, the palmar surfaces of the four fingers are located on the back wall of the uterus, the palm is on its bottom, and the thumb is on the front wall of the uterus. At the same time, with the whole brush, they press on the uterus towards the pubic joint until the birth of the placenta occurs (Fig. 12.).

Rice. 12. The method of isolating the separated placenta according to Krede-Lazarevich.

Isolation of the placenta according to the Genter method (imitation of generic forces): the hands of both hands, clenched into fists, are placed with their backs on the bottom of the uterus. With a smooth downward pressure, a gradual birth of the placenta occurs.

Rice. 13. The method of isolating the separated placenta according to Genter.

If signs of separation of the placenta are absent within 30 minutes after the birth of the fetus, anesthesia is indicated, followed by manual removal of the placenta and removal of the placenta. The sequence of manipulations: with one hand, the obstetrician holds the bottom of the uterus. The other hand, dressed in a long glove, is inserted into the uterine cavity and carefully separates the placenta from its walls. The obstetrician then removes the placenta and massages the fundus of the uterus through the anterior abdominal wall to reduce bleeding. After this operation, infectious complications occur quite rarely.

The next important task is to examine the placenta and soft birth canals. To do this, the placenta is placed on a flat surface with the maternal side up and the placenta is carefully examined; Normally, the surface of the lobules is smooth and shiny. If there is doubt about the integrity of the placenta or a defect in the placenta, then a manual examination of the uterine cavity and removal of the placenta remains are immediately performed. When examining the shells, their integrity is determined. It is also necessary to establish whether blood vessels pass through the membranes, which is noted when there is an additional placental lobule. If dangling vessels are visible on the membranes, an additional lobule has probably remained in the uterus. In this case, manual separation and removal of the delayed additional lobule is also performed. The detection of torn membranes indicates that their fragments are in the uterus. At the place of rupture of the membranes, it is possible to determine the location of the placental site in relation to the internal pharynx. The closer to the placenta the rupture of the membranes, the lower the placenta was located, and the greater the risk of bleeding in the early postpartum period. Examination of the external genital organs is performed on the maternity bed. Then, in a small operating room, all primiparous and multiparous examine the walls of the vagina and the cervix using vaginal mirrors. The ruptures found are sutured. After the birth of the placenta, the postpartum period begins, the woman in labor is called the puerperal. During the early postpartum period (2 hours after the separation of the placenta), the puerperal is in the maternity ward. Need to keep an eye on her general condition, the state of the uterus, the amount of blood loss. After 2 hours, the puerperal is transferred to the postpartum ward.

The umbilical cord is an important link between mother and baby. Through it, oxygen and other nutrients, and the products of decay and metabolism return back. During pregnancy, doctors carefully monitor the condition in which it is, as in some cases this helps to predict and correct the outcome of childbirth. In particular, if a short umbilical cord is diagnosed, due to which the child may suffocate in the womb. This is a fairly common pathology, about which future mothers should know as much information as possible in order to understand how to behave in the event of such a diagnosis.

This is an ordinary internal organ, which, like all the others, has its own characteristics that are unique to one or another woman (child). If its length does not correspond to normal indicators initially, from the moment of conception, this is an individual parameter that depends on heredity or some kind of genetic predisposition. But sometimes sizes decrease due to a number of factors that the expectant mother should be aware of in advance. Here are the main causes of a short fetal umbilical cord:

around the neck, legs, arms and other parts of the child's body;
the formation of false nodes on the umbilical cord is a consequence of varicose expansion of one of the vessels in one (one node) or several (many nodes) places;
the presence of true knots on the umbilical cord, which are formed due to excessive activity of the baby;
the fetus has taken the wrong position.

So a short umbilical cord during childbirth can be due to both the individual characteristics of the course of pregnancy and the activity of the baby inside the womb. Depending on the causes and sizes, several types of this pathology are distinguished.

Origin of the word. The word "navel" (respectively, the umbilical cord) has ancient Russian roots. In the Proto-Slavic language, it meant "kidney", that is, something convex.

Kinds

Obstetricians and gynecologists distinguish absolutely and relatively short umbilical cords, each of which has its own characteristics and requires an appropriate attitude.

The most common is an absolutely short umbilical cord, the length of which is less than 40 cm. For comparison: normal parameters range from 40 to 70 cm.
Sometimes a relatively short umbilical cord is diagnosed in a child, which normally corresponds to normal values (40-70 cm), but due to some factors (see above reasons) it becomes shorter.

Both types of short umbilical cord are dangerous. But if the relative has a chance to return to its original position and exclude the development of complications by the time of delivery, then with the absolute risk of their occurrence is maximum. Therefore, it is so important to make a diagnosis in time and clarify its type. What signs indicate this pathology?

This is interesting! It turns out that the navel is a very personal, individual indicator of each person, like fingerprints. There are no two alike.

Symptoms

Among young mothers, the question of how to detect a short umbilical cord in advance in order to prepare for childbirth fully armed becomes very relevant. The answer is unlikely to sound encouraging. Doctors say there are no symptoms during pregnancy - at least on the mother's side. Usually, signs of pathology appear only at the most crucial moment - when childbirth has already begun.

Increased duration of labor: in primiparous - more than 20 hours, in multiparous - more than 15 hours.
Acute vaginal bleeding.

If we talk about the symptoms of this pathology during pregnancy, then the only sign is, but it can also indicate other problems associated with the fetus and its bearing. Therefore, this marker is relative, but not absolute, for a short umbilical cord. However, it is he who should alert doctors and future mother about a possible deviation. Hypoxia can be acute and chronic. Signs of exacerbation:

frequent (more than 160 beats per minute), and then slow (less than 120 beats per minute) heartbeat of the child;
an increase in his motor activity, which can be sharply replaced by its decrease;
the appearance of meconium in the amniotic fluid.

Symptoms of a chronic form of intrauterine hypoxia:

slow heartbeat in a child (less than 120 beats per minute);
a gradual decrease in his motor activity.

Only a child can help diagnose a short umbilical cord during pregnancy, so the doctor needs to constantly monitor his heartbeat, and mommy should carefully monitor him. motor activity. Any changes and deviations from the norm should be alarming. Moreover, the diagnosis of this pathology will not dispel doubts too much.

With the world - on a string. Some peoples have very interesting traditions and beliefs associated with the umbilical cord. So, the umbilical cord after childbirth was not thrown away, but hidden. When the child was 6 or 7 years old, he was given it to untie (this was very difficult to do, since it was very dry by that time) or crushed and added to his food. It was believed that this would give him wisdom.

Diagnostics

The problem is that a short umbilical cord in a fetus is poorly diagnosed. The set of studies and methods for monitoring its condition is very narrow. All of them allow the doctor only to assume the presence of a pathology, but not 100% to assert it. Which of them are the most accurate?

Very rarely, an absolutely short umbilical cord is diagnosed for 2 ultrasounds, since its size cannot be established by this diagnostic technique. The doctor can see the formation of nodes (false and true), the entanglement of the baby, abnormal development blood vessels- that is, those factors that can provoke pathology, but not itself. Thus, a short umbilical cord on ultrasound can only be assumed.

Doppler (Doppler) study

This is a more informative diagnostic method, during which the movement of blood through the umbilical vessels is studied. If it is broken, there is a risk of pathology. But again, the doctor will not be able to say the exact diagnosis.

Constant monitoring by a gynecologist

During routine examinations, the gynecologist regularly measures the baby's heart rate, which may indicate a pathology. In addition, a thorough analysis of the obstetric and gynecological history is carried out - the course of the entire pregnancy, previous births, their features, outcomes.

Cardiotocography

This diagnostic method involves a computer synchronous recording of the child's heartbeats, his activity and their comparison with uterine contractions. If they are not related to each other in any way, this is a sign of umbilical cord pathology.

If the fetus has a very short umbilical cord, which is visible to the naked eye even on ultrasound, this is both good and bad. On the one hand, such an accurate diagnosis allows you to immediately begin to prepare the woman in labor for. On the other hand, even before birth, a short umbilical cord can lead to various complications in the development of the child. What measures are taken by doctors to reduce the risk of undesirable consequences?

From the life of celebrities. There are people whose navel is removed due to various diseases (for example, umbilical hernia). This interesting body part is absent from Karolina Kurkova, the famous Czech model, and no less star film director Alfred Hitchcock.

Treatment

What to do if the fetus has a short umbilical cord - at least there is a suspicion of this pathology? Even with the high innovative technologies of medicine, there has not been an effective drug treatment in recent years. The following activities are recommended.

Hospitalization and constant medical supervision up to the very birth with repeated entanglement around the neck.
performed if the umbilical cord is short and this leads to acute oxygen deficiency and fetal hypoxia.
A planned caesarean section is prescribed if, according to diagnostic studies, a short umbilical cord threatens the life of the child.
If a short umbilical cord is found already at the time of natural childbirth, the doctor cuts the perineum to help the baby be born.

A woman should know everything that she can expect during childbirth if there is a risk of a short umbilical cord. Constant medical supervision will allow you to remain calm and prevent complications and unpleasant consequences for the life and health of the woman in labor and her child.

Curious fact. The navel is the center of gravity human body which explains why African athletes win more often than Europeans. Their legs are longer, which is why the navel is 3 centimeters (on average) higher than the rest.

Complications

The dangerous consequences of a short umbilical cord can affect the health of both the mother and the baby. The most common complications include:

difficult process of childbirth;
difficulties in moving the child through the birth canal: for example, too slow;
this can lead to birth trauma for the mother;
violations of cardiac activity in a child;
acute fetal hypoxia;
injuries of varicose vessels;
hemorrhage in the umbilical cord;
her break;
placental abruption due to strong tension of the short umbilical cord.

The consequences for the child are especially dangerous if the umbilical cord is too short. The same hypoxia, even if the birth still ended successfully, may further affect the development of his higher mental functions (memory, attention, perception, thinking, speech), adaptation, behavior. Therefore, it is better to avoid all these complications by discussing the issue of caesarean section with the doctor in advance. And even better - from the very moment of conception, make sure that all this does not happen.

News of modern medicine. In aesthetic medicine, there is such a service as umblicoplasty - navel correction.

Prevention

So that a short umbilical cord at birth does not harm the baby, a woman needs to initially be aware of the existence of such a pathology and take all possible preventive measures. Since the main cause of this trouble is the hyperactivity of the fetus in the womb, it must be controlled. It's up to mom.

During pregnancy, a woman should not be worried and nervous: the baby feels this very well, also begins to worry, spin, the result is twisting of the umbilical cord, which makes it short.
For the same purpose, you need to talk to your child more often, listen to calm (preferably classical) music, read beautiful poems to him.
Sometimes intrauterine activity of the fetus is caused by a lack of oxygen. Therefore, you need to walk more fresh air and drink plenty of clean water.
Classes breathing exercises also reduce the risk of developing a short umbilical cord.

The diagnosis of "short umbilical cord" sounds on recent weeks pregnancy often. This should not scare the woman, but set her in the right mood. Doctors should give her detailed advice on how to behave and what depends on her during childbirth. modern medicine is ready for such difficulties and with honor comes out of such situations, saving the life and health of the mother and baby.