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Medication used for anesthesia
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Medication used for anesthesia
1. Local anesthetics:
• Bupivacaine (used most often for spinal (subarachnoid analgesia).
• Ropivacaine (a bupivacaine isomer and is used most often for epidural analgesia).
• Lidocaine.
2. Opioids: these drugs pass through the placenta. Thus, within an hour before birth, such drugs should be given in small doses to avoid toxicity (eg, CNS depression, bradycardia) in newborns. Opioids, used by themselves, do not provide adequate analgesia and therefore are most often used with anesthetics.
Fentanyl - synthetic opioid. Initial dose: 0. 5-1 mcg/kg given IV direct over 1-2 minutes. Maximum initial dose should not exceed 100 micrograms even if the patient’s weight exceeds 100 kg. Wait 5 - 10 minutes for effect. If further doses are needed, give 0. 5-1. 0 mcg/kg q 5-10 min until adequate analgesia or maximum doses are reached. Maximum hourly dose: 2 micrograms/kg.
Sufentanil (R30730, Sufenta)- synthetic opioid analgesic drug. Sufentanil citrate may be administered IV by slow injection or infusion in doses of up to 8 mcg/kg.
Morphine (Astramorph PF, Avinza, Duramorph): Subcutaneous/IM 2-5 mg, or 10 mg (onset, 30-40 minutes), every 4 h as needed. May be administered IV in dose 8 to 15 mg; for very severe pain, additional smaller doses may be given every 3 to 4 h.
Self Test
1. Psychoprophylactic preparation of a healthy pregnant to delivery includes:
A. 3 lessons
B. 5 lessons
C. 10 lessons
2. The III type of smear is:
A. “term of birth”
B. “shortly before birth”
C. “undoubted term of birth”
D. “late term of pregnancy”
3. Cervix is matured when according to the scale of E. H. Bishop it has:
A. 0-2 points
B. 2–4 points
C. 5–8 points
4. A mature cervix is:
A. located according to the pelvic axis;
B. declined towards the axis of pelvis;
C. declined backwards from the axis of pelvis.
5. The length of immature cervix of uterus is:
A. 1cm
B. 0. 5 cm
C. 2 cm and over
6. The pain associated with uterine contractions can usually be relieved by the following regional blocks, except for:
A. pudendal block
B. epidural block
C. spinal block
D. paracervical block
CHAPTER 16. PHYSIOLOGY OF PUERPERAL PERIOD
Puerperal (postpartum) period starts immediately after expulsion of afterbirth. The woman in postpartum period refers to as woman recently confined. Postpartum period on the average proceeds for 6-8 weeks. It can be divided into:
Early postpartum period — first 2 hours after delivery;
Late postpartum period — about 8 weeks after delivery.
In some countries other classification of puerperal periods is used:
• immediate - first 24 hrs
• early - first week
• late - 2nd to 6th week
In early postpartum period, care will be given in a maternity hall under supervision of the doctor and obstetrician, the following 5-7 days — in postpartum department of a maternity home, further — at home, under out-patient supervision of the doctor and obstetrician of maternity welfare clinic.
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Physiological Changes of Puerperium
The internal surface of uterus in puerperal period represents an extensive wound surface accessible to microflora of own organism and environment. Puerperal period is extremely dangerous for woman because there is an opportunity for development of an ascending infection, which quickly spreads in organism and becomes generalized. The features of immune protection connected with pregnancy and manifested in decrease of immune resistance and reactivity, stressful condition after labor, loss of blood in labor facilitate afterbirth infection. Therefore during the first days of postpartum period, the patient requires special care, her stay in maternity ward should be obligatory. The revealing and treatment of puerperal complications are facilitated by woman’s staying in maternity ward.
In puerperal period the changes in the woman’s organism connected with pregnancy and birth partially or completely disappear. In this period the function of mammary glands is manifested by lactation and there is a reorganization of functions of some systems and organs in connection with lactation. The genital organs and mammary glands are exposed to the greatest changes.
Uterus
After delivery the uterus considerably decreases in size due to sharp contraction of musculature, which is the basic mechanism of bleeding arrest after delivery. At normal contraction of uterus during puerperal period for a rather short time interval the muscle of the uterus gets a dense consistence, uterine wall thickens up to 1. 5-2. 5 cm. Spiral arteries of uterus are exposed to pressure and deformation owing to displacement of muscular fibers; blood circulation is sharply disturbed. The bleeding from uterus almost completely stops; small blood discharges usually proceed, however the content of corpuscular blood elements in them is less than in the venous blood. The internal surface of uterus represents a wound with fragments of decidual membrane and small parietal clots of blood, which are the additional factors contributing to hemostasis.
By the end of the first day after delivery the fundus of uterus is at a level of umbilicus, on 5-6th day — on middle between the symphysis pubis and umbilicus, on 10-12th day of postpartum period the uterus falls to the true pelvis and later disappears behind the symphysis. The daily supervision of puerperal patients shows that the length of uterus measured by a centimetric tape from the upper margin of symphysis pubis to the fundus of uterus diminishes by 1-1. 5 centimeters daily, and by the time of discharge from the maternity home it does not exceed 3-4 cm. The excess of muscular tissue of uterus disappears rather quickly. If at the beginning of puerperal period the weight of uterus reaches 1, 000-1, 200 g, in 6-7 weeks it does not exceed 50-70 g. The muscles, vessel walls, nervous structures and connective tissue undergo disintegration and regeneration. Newly occurred proteins and fatty formations are used by organism as initial material for synthesis of milk. The basis of involution processes of the uterus is neurohormonal effect, disturbances of blood circulation. The former is of primary importance for puerperal involution of uterus, while the latter has secondary significance.
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It is necessary to note that uterus in puerperal period is very mobile. The filling of the urinary bladder and lower part of the intestine considerably displaces it upwards. Every 100 ml of urine displace the uterus upwards by 1 cm. Therefore the determining of the uterus height above the level of symphysis pubis should be performed at one and the same time (better in the morning), after urinary bladder emptying and defecation. By the end of the first week the weight of the uterus decreases up to 500-600 g, by the end of the second week — up to 350 g, and third week — to 200g. Uterus in puerperal period keeps a periodic rhythm of contraction during its involution. These reductions considerably amplify at time of breast-feeding of the child, but at second pregnancy they may be accompanied by pain sensations. The delayed involution has got the name “subinvolution of uterus”. If there is significant delay, involution is quite often helped by such means of contractile action as pituitrin, oxytocin, methylergometrin, ergometrin, ergot preparations, etc.
Along with disappearance of significant myometric mass in a mucous layer of uterus the creative processes begin. Scraps of decidual tissue and clots of blood undergo proteolysis in the first days after delivery.
Wound surface of the uterus is hidden. Puerperal discharges from the uterus have received the name lochia. Lochia consist of blood components, blood corpuscles, remnants of disintegrating decidual membrane. The first 2-3 days lochia have a bloody character (1осhia rubra), then sanguineoserous (lochia rubro-serosa); on the 7-9th day after delivery they become serous (lochia serosa). Within 10-12 days, when epithelization of endometrium comes to the end, lochia become completely light, without any impurity of blood (1осhia alba). By the 6th week of afterbirth period the discharge of lochia ends. By this time the regeneration of all mucous layer of uterus, including the placental bed is completely finished. Thus, the character of lochia reflects a degree of reduction of wound surface of the uterus, which becomes covered by cylindrical integument epithelium. After expulsion of afterbirth, the glands, covered by cylindrical epithelium, remain in the basal part of decidual membrane; the growth of epithelium leads to epithelization of wound and its transformation to the typical mucous membrane of the uterus. The surface of uterus cavity outside the placental bed completely epithelizes by the 11–14th day, in the area of placental bed — by the end of the 3rd week. Within the first 7-9 days there is a complete epithelization of small laceration of the cervix of uterus, vagina and perineum.
The muscular tissue of cervix of the uterus is flaccid after delivery. A hand can freely pass through the cervical canal. The vaginal wall is overstretched; folds are almost completely absent, pudendal fissure gapes. There may be abrasions, fissures and wounds of various size in the mucous layer of vagina.
Rehabilitation of muscular tone of cervix of the uterus occurs rather slowly. By the end of the 1st day the cervical canal opens for 3-4 fingers, the edges of the cervix are flabby. The formation of the cervix of uterus takes place from inwards to outwards, primarily the internal os diminishes; therefore the cervical canal of the uterus acquires a funnel-shaped form. Upon the whole by the end of the 3- 4th day the cervix is formed, however its canal remains sufficiently open. A complete closing in the area of internal os occurs only in 10-12 days; by this time the formation of the cervix of uterus is completely finished. But a complete closing of the external os occurs a little later — by the end of the 2-3 week after delivery. If the integrity of uterus is not restored (in case of laceration), the uterus can remain slightly opened for the rest of life, thus being the reason of occurrence of chronic inflammatory processes, glandular-muscular dystrophies and precancerous conditions.
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Fallopian Tubes
During pregnancy and delivery there is hypertrophy and elongation of the fallopian tubes (due to intense blood flow and edema). In puerperal period hyperemia and edema gradually disappear. The fallopian tubes together with the contracted uterus gradually fall into the pelvic cavity and by the end of the 10th day take the normal horizontal position.
Ovaries
In puerperal period the yellow body of ovaries disappears and the hormonal reorganization begins which subsequently results in ripening of follicles. In puerperal period a great amount of prolactin is released, therefore the breast-feeding women have no menstruation, and there is no ripening of follicles and ovulation. Puerperal (luctation) amenorrhea causes the so-called postpartum (physiological) sterility. Lactation amenorrhea can last for the whole period of breast-feeding or a certain period of time (up to 2-6 months after delivery). In non-feeding women the menstrual cycle is restored much earlier — by the 6-8th week after delivery.
As a rule the first two menstrual cycles have an anovulatory character, but in mature follicles there is ovulation, and fertility is restored.
Vagina
A complete involution of vagina does not occur. It remains more capacious, cross rugosity with each birth decreases down to complete disappearance; the pudendal fissure does not close completely.
Muscles of the Pelvic Floor
The muscles and fascias of the pelvic floor undergo a significant stretching in delivery. There are diastases of muscular fascicles, their breaking at some sites of pelvic floor, which lead to decrease of their support function for internal organs. It especially refers the medial crus of the levator muscle, which separates in the distal part, resulting in its expansion giving rise to the gaping of vagina entrance, thus " hernial entrance" of the pelvic floor occurs. The majority of damages do not completely restore. To prevent further prolapse of the vagina wall, uterus and organs of the abdominal cavity, it is necessary to restore gross injuries, i. e. lacerations of perineum, vulva, and vaginal walls in the early postpartum period. In the late puerperal period with this purpose regular gymnastic exercises should be administered aimed at restoration and strengthening of tonus of perineal muscle, muscles of pelvic floor and abdominal wall.
Nevertheless tonus of the muscles of the pelvic floor, as a rule, is restored by the end of the 12-14th day.
The Abdominal Wall
Deep muscles and fascias contract better than superficial ones, and numerous folds appear on the skin.
Striae gravidarum decrease and get a brilliant shade. Gradually pigmentation of the white line of abdomen decreases. For the best contraction of musculature of abdominal wall and best outflow of lymphatic fluid, bandaging of the abdomen is produced by a wide stocking bandage, covering abdomen of the patient from the symphysis pubis to the umbilicus, a bandage is tightly put on the walls of abdomen and fastened by metallic hooks or large pins.
In modern medicine with this purpose a special elastic postpartum bandage is successfully applied.
Mammary Glands
In puerperal period the functioning of mammary gland begins. Since the first weeks of pregnancy in the mammary gland under the action of hypophysial and sexual hormones the growth of glandular epithelium takes place, some lobes of the gland become denser and are clearly marked. It is possible to squeeze out thick whitish liquid from the mammary gland. However a true secret of the mammary gland- milk — appears only after complete elimination of the inhibiting effect of placental sex hormones on prolactin function of hypophysis. Already in 20-30 minutes after delivery the mammary glands contain 8-10 ml of milk.
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In the puerperal period under the influence of prolactin an amplified inflow of blood to the mammary glands takes place; as a result of complex reflex and hormonal influence of the gland, at first the secretion of colostrum, then milk, begins. A large role in the development of lactation of the mammary gland in puerperal period belongs to prolactin — hormone of adenohypophysis. A stimulant action is rendered by the hormones of thyroid and adrenal glands, and also reflex influence — at act of suction.
The secretory cells of the mammary gland secrete milk into glandular tubes, which, like a tree, meet in ducts uniting them. Every large glandular lobe of the mammary gland has a duct with an outlet in the area of nipple. It is a sphincter, impeding a free outflow of milk from the gland.
Colostrum is a thick yellowish liquid having an alkaline reaction.
The color of colostrum depends on coloring fat included in its structure, rich in carotene. Colostrum contains colostric corpuscles, leucocytes, epithelial cells from glandular tubes and mammary ducts. Colostric corpuscles are round cells with pale-colored nucleus and numerous fatty inclusions. It is supposed that colostric corpuscles are leucocytes containing phagocytized drops of emulsified fat. There is a high content of albumin in colostrum (3-6 times higher than in mature milk) in a form of lactalbumin which contains irreplaceable аmino acids (cystine and taurine). After delivery colostrum and colostric milk are rich in mineral salts, vitamins (A, Е, К), the amount of fats is less than in mature milk but they contain polyunsaturated forms of fat which are more easily absorbed in the intestine of the newborn. A high content of sodium and zinc is also of great importance for formation of the immune system of the newborn. Colostrum is secreted from the nipples of the mammary gland on the first days of postpartum period (during 3 days). The transitional breast milk appears on the 3-4th day; during the 2-3 week of postpartum period milk acquires permanent composition and is named mature milk.
The processes of involution occur in other parts of genital system too, e. g. ligamentous apparatus, vascular system, parametrium.
The Clinical Course and Management of Puerperal Period
The important parameters of the normal course of puerperal period are temperature and pulse rate of the mother. However it is necessary to remember that in puerperal period there are two " physiological" elevations of temperature which cannot be referred to development of infection, if other signs of it are absent.
The first of these elevations is observed within the first day of puerperal period, more often during the first 12 hours after delivery, and is explained by overexertion of vegetative part of the central nervous system and some disorders of thermoregulation mechanism of maternal organism. Then it is followed by the second elevation of temperature on the 3-4th day of puerperal period. The temperature rises by 0. 1-0. 3°C, it is observed in 40-60 % of cases and is connected with inflow of milk to the mammary glands. A higher temperature (37. 6-37. 8°) indicates the development of inflammatory process in the uterus (endometritis). The rise of temperature can be also conditioned by delay of lochia from the uterus and absorbtion of products of protein and bacterial disintegration (resorption fever). At delay of lochia drugs of contractile action should be administered, e. g. pituitrin and oxytocin.
For proper diagnostics of possible complications all patients on the 3rd day after physiological birth should undergo speculum examination of cervix of uterus, smears from cervical canal and vagina for microscopic examination should be taken, ultrasound examination of uterus should be performed.
The blood test is made, urine tests should be also performed. The biochemical investigations are made, if indicated.
Ultrasound is an informative method of control of uterus after delivery; it helps to determine its size, condition of the cavity, form and location. Measuring the length of corpus of uterus (distance from the region of internal os to the external surface of fundus), the antero-posterior diameter (distance between the most remote points of anterior and posterior surface of uterus transversely to the longitudinal axis), the width (distance between the most distant points of lateral surfaces of the body of uterus transversely to the longitudinal axis) is most often used.
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The cavity of uterus at normal course of puerperal period is visualized as fissured formation, a little bit extending in the lower third. Sometimes it contains an insignificant amount of homogeneous structures showing the presence of blood clots. At normal puerperal period, within 7 days, the cavity of uterus is usually released from its echostructures or precisely not visualized. Usually the uterus occupies a middle position and slightly rotates around a longitudinal axis to the right. At longitudinal scanning on the 3rd day the uterus is usually of a spherical form, on the 5th day — оvoid and by the end of the 7th day — pyriform.
The spherical form of uterus and the expansion of its cavity containing diverse echostructures (alternation of inclusions of average density with echo-free areas) is characteristic of ultrasonic picture of hemato- and lochiometra. The remained placental tissue at ultrasound examination looks like a formation of moderate echothickness, surrounded by a thin line — “crown”. At endometritis ultrasound reveals subinvolution of the uterus, moderate delay of lochia, sometimes with expansion of the cavity, thickening of the internal layer of uterus (endometrium).
At suspicion on delay of lochia in the uterus, subinvolution, there is a necessity of vaginal examination, dilatation of the cervical canal and internal os.
There is predominance of vagotonia in patients during puerperal period, which is manifested by slowness of the heartbeat — bradycardia. The pulse rate can be reduced up to 60 beats per minute and lower, being full. The pulse rate over 80 beats per minute can point out a pathological loss of blood, the development of infectious process or phenomena of thyrotoxicosis. Bradycardia is a good prognostic sign. In most cases there a slight decrease of arterial blood pressure.
Special attention should be paid to the function of adjacent organs, i. e. gastrointestinal and urinary tract. Within the first 2-3 weeks after delivery tonus of ureters is restored. The function of the urinary bladder within the first days after delivery in most cases is disturbed: there is no vesical tenesmus; in lying position urination does not occur. The overfilling of the urinary bladder can sharply change the position of uterus and disturb the involution processes. The disorders of urination in puerperal period occur due to edema or trauma of tissues in the area of sphincter of the urinary bladder. These phenomena usually disappear in 2-4 days. In the absence of independent urination catheterization of the urinary bladder should be performed. The motor function of intestine in puerperal period is also decreased and causes the absence of independent defecation in most women within the first days after delivery. Defecation occurs only after application of cleansing enema.
Nutrition of patients on the 3-4th day after delivery should be highly caloric and should not contain plenty of cellulose, as the processes of its bacterial disintegration can cause bloating of the stomach. After normal delivery the woman is allowed to be up in 8-12 hours and she is administered a general diet. It is necessary to avoid the consumption of alcohol, onion, garlic and some medicines (quinine), which can easily penetrate into milk and change its taste properties, and get into organism of the child causing undesirable consequences.
For the first time breast-feeding is started in a maternity hall in 20-30 minutes after birth. It promotes colonization of the organism of newborn with microflora of the mother but not of a medical staff. With the first drops of colostrum the newborn receives a lot of immunoglobulin which is the factor of immune protection of organism from received microflora.
After prophylaxis of gonoblennorrhea, cutting and handling of umbilical stump, the newborn rests on mother’s chest, with the head between the mammary glands. A healthy, full-term newborn at once finds a nipple and begins to suck. Some children " have a rest" within 20-30 minutes, then independently find the nipple of the mother. If in 30-40 minutes the child does not start sucking, is necessary to help him.
At breast-feeding just after birth, colostrum is produced during 12-24 hours. Within 30-34 hours, the mammary glands are filled with colostrum of high density. Feeding of the newborn within the first hours of his life requires concentrated food (colostrum), as the immature kidneys are not able to cope with large amount of liquid. Subsequently the newborn is fed " on demand", thus a healthy newborn makes up himself his own individual regimen of breast-feeding. With this purpose in modern maternity homes the principle of joint stay of mother and her child from the first hours after birth is practiced.
Breast-feeding is an important reflex factor influencing the lactation function of the mammary glands. For the newborn it supports the sucking reflex. The amount of received milk is determined by control weighing, which is carried out before and after feeding.
Before each feeding the mother should wash up her hands with soap, wash breast with soap and water, then the nipple with her own milk. After feeding the breast is washed with water and soap, if necessary antiseptic powder or spirit solutions are applied. After birth the patients are recommended to take daily air-baths for the mammary glands after each feeding, to wear brassiere, slightly raising the mammary glands.
A high-calorie diet and physical exercises promote a faster development of lactation and emptying of the mammary glands, thus preventing mastitis.
There is a gradual decrease of flabbiness of abdominal wall muscles, however stria gravidarum and diastasis of direct muscles of the abdomen testify to the previous pregnancy. Therapeutic exercise accelerates restoration of muscular tone and function of intestines. In the early puerperal period it is necessary to take aseptic care of genital organs of the patient. The presence of puerperal wound and lochia discharge is a favorable environment for entry of microorganisms from outside. Some women after delivery have a significant bacterial contamination of the vagina, which promotes a faster migration of microorganisms to the uterus. On delivery and in early puerperal period there is no possibility to influence the penetration of microorganisms from vagina into the uterine cavity, but it is possible to ensure conditions, at which microflora of external genitalia should not get into maternal passages. With this purpose the washing of external genital organs 2-3 times a day should be performed. For washing slightly disinfectant solutions (potassium permanganate 1: 10, 000 solution; solution of formaline — 1 tablespoonful per liter of water) may be used. After emptying the urinary bladder and rectum the patient should be positioned on bedpan and washing of external genitalia should begin. With the help of cotton wool wad the skin of the external genital organs, perineum and upper parts of internal thigh surfaces is cleaned. Washing starts with surfaces distant from the anal orifice, the area of anus is washed last. By means of dry wad of cotton wool the solution from the skin is wiped off, a napkin and oil-cloth which protect bed linen from lochia are changed. The area of external genital organs is laid by a wadding-gauze pad which absorbs the discharged lochia.
One of the most important elements of management of early puerperal period is the organization of a daily regimen of mother, realization of sanitary-educational work and teaching young mothers how to care for the newborn. For this purpose the schools of mothers are organized in maternity homes, where 3-4 classes are conducted by paediatrician, obstetrician and gynaecologist.
Nutrition of suckling mother should completely compensate for the energy loss of organism for milk formation and include animal albumins (not less than 100-150 g), fats (vegetable and animal), carbohydrates and vitamins. However calorie content of the daily diet should not exceed 3, 000-3, 200 Cal. Mother’s milk is a unique source of receiving plastic substances, necessary for the developing child, and compounds rich in energy during the first 3-4 months. Therefore mother’s nutrition should be high-caloric and diverse.
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