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Management of puerperal period
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Management of puerperal period
1. Active management of the 3rd strage of labor
2. Observation and accurate control of blood loss.
3. Improvement of uterine contractility in postpartum period.
4. Accurate control of blood coagulability
Peculiarities of cerasean section in placental abruption
¡ Preceding amniotomy
¡ Operative exploration of uterine walls is obligatory to rule out uteroplacental apoplexy.
¡ In case of uteroplacental apoplexy hysterectomy is obligatory.
If the area of impregnation of the uterine wall with RBC is < 3 cm, the uterus is well contracted – uterus may be remained in abdominal cavity. Ligation of the uterine vessels should be performed, and if ineffective, the ligation of the internal iliac arteries may be performed. In case of presence in the hospital of the department of angiosurgery embolization of vessels should be performed.
If most of the wall of the uterus is impregnated with blood, it is dark purple color, uterus muscle is flabby, does not respond to mechanical and pharmacological irritation (" Couvelaire uterus ", utero-placental apoplexy), the extirpation of the uterus without appendages is indicated. If the area of impregnation is ≥ 3 cm- hysterectomy is indicated.
Self Test
1. The maternal factor encountered most commonly in patients with placental abruption is:
A. hypertension
B. trauma
C. twins
D. cocaine ingestion
E. maternal parity
2. The worst prognosis for the fetus with antepartum bleeding during the 2nd trimester of pregnancy is associated with the following condition:
A. placenta previa
B. placental abruption
C. vasa praevia
D. undetermined cause
3. Which of the following symptoms is not characteristic of placental abruption?
A. increased uterine tone
B. occurring of the retroplacental hematoma
C. hypotonus of the uterus
D. pain in the lower abdomen
E. fetal hypoxia
4. Which is the main etiological factor of premature separation of the placenta?
A. preeclampsia
B. hypovitaminosis in pregnancy
C. diabetes
D. mechanical trauma
E. breech presentation
5. What is the treatment at placental abruption?
A. urgent cesarean section
B. inducing labor pains
C. sedatives and spasmolytics
D. prophylaxis of fetal hypoxia
6. A woman presents with painless vaginal bleeding at 37 weeks’ gestation. The fetal heart rate is stable and makes up 150 beats per minute. Which of the following is the most probable diagnosis?
A. threatened premature labor
B. placenta praevia
C. premature separation of normally implanted placenta
D. cervical laceration
7. The same patient: Which of the following is indicated to make the diagnosis?
A. nonstress test
B. induction of labor
C. ultrasound examination
D. amniotomy
8. A patient who is 36 weeks pregnant has labor and delivery complaints of vaginal bleeding, contractions and a very tender abdomen. Which of the diagnoses is most probable?
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A. premature separation of the placenta
B. placenta praevia
C. threatened premature labor
D. cervical laceration
CHAPTER 29. BLEEDINGS DURING PLACENTAL STAGE OF LABOR AND IN PUERPERAL period
Bleedins During Placental Stage of Labor
Complications in the placental stage of labor are more frequent than during the dilation and expulsive stages. The most frequent and dangerous complication of the placental stage is bleeding.
Hemorrhage is normal for the placental stage of labor and a blood loss of approximately 0. 5% of body weight during the separation and delivery of the placenta is considered physiological. There is a significant contraction of the uterine musculature during the placental stage of labor. This is followed by (a) separation of the placenta and expulsion of the separated placenta (afterbirth) and (b) compression of the bleeding uterine vessels and cessation of the hemorrhage. If contractions of the uterus are weak, the normal separation of the placenta is upset. The placenta fails to separate completely, but until the entire placenta is separated the uterus does not contract and the vessels at the site of the separated placenta continue bleeding. If the placenta has separated from the uterine wall but is retained inside the uterus, bleeding develops as well. The uterus fails to contract adequately until the placenta is expelled from it, and the vessels continue bleeding because of lack of compression.
Therefore, two normal mechanisms of cessation of hemorrhage in the 3rd stage of labor are distinguished: contractions of the uterine muscles and increased coagulability of blood, the latter being characteristic of this term of gestational process.
Hemorrhage in the placental period may also be caused by:
· Failure of the process of placenta separation from the uterine wall and its expulsion;
· Laceration of soft tissues of the reproductive tract: cervix, vagina, and perineum.
Hemorrhages due to Failed Separation and Expulsion of the Placenta (Afterbirth)
Adherent placenta. Total and partial adherences of the placenta are distinguished. The main characteristic sign of the adherent placenta is an underdeveloped spongy layer (Fig. 190, 191) of the decidual membrane. It leads to the partial separation of the placenta, partial contractions of the myometrium fibres, resulting in hemorrhages. Partial adherence of the placenta is the cause of inevitable bleeding in the placental stage. Total adherence of the placenta, as a rule, is not characterized by bleeding. It is characterized by absence of placental separation during 30 minutes and more, which is an indication for the manual removing. And during this removing bleeding happens, as a rule; this bleeding is arrested when the uterus is emptied and contracted.
Fig. 190. Normally developed spongy layer of the decidual membrane
Fig. 191. Placenta adherent: underdeveloped (absent) spongy layer of the decidual membrane
Clinical signs (in case of partial adherence): just after the delivery of the fetus or 10-15 minutes after the delivery the external hemorrhage occurs. The blood is dark, with normal blood clots, no signs of separation of the afterbirth. The uterus is softened.
Treatment: catheterization of the bladder, manual removing of the afterbirth, massage of the uterus “on the fist”.
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Fused placenta (total or partial). It is characterized by absence of spongy layer between the myometrium wall of the uterus and placental villi. It means the growing of the villi into the uterine wall. Three degrees are distinguished: 1) placental villi reach the myometrium (placenta accreta), 2) growing of the placental villi in between the myometrium fibres of the uterus (placenta increta), 3) penetration of the uterine wall with placental villi till the serous coat (placenta percreta). It may be partial and total (complete) too. There is no possibility of normal separation of the placenta. In partial fused placenta there is significant hemorrhage during the third stage of labor, because some placental parts are separated normally, while others — are not separated. The disrupted uterine vessels begin bleeding. The hemorrhage continues until the placenta is expelled from the uterus.
Clinical signs: in total fused placenta there is no hemorrhage during 30 (and more) minutes after the delivery of the fetus, no signs of placental (afterbirth) separation. In partial fused placenta there is bleeding, no signs of separation of the afterbirth. The differentiation between adherent placenta and fused placenta may be made only during manual control of the uterine cavity.
Treatment: In 15 minutes after the delivery of the fetus the intravenous infusion of the isotonic solution should be started, the bladder should be catheterized. Then the operation-hall and surgeons should be prepared. If no separation during the next 15 minutes takes place, a manual control of the uterine cavity should be performed. At fused placenta there is no possibility of its separation from the uterine wall and removing of afterbirth. This is accompanied by strengthening of bleeding and stratification of myometrium fibres. Thus, laparotomy and amputation of the uterus is indicated.
Defect of afterbirth. After the delivery of afterbirth it should be carefully examined. Lobes of the placenta may be left in the uterine cavity. Even a small portion of the placenta that may remain in the uterus after its delivery interferes with a normal contraction of the uterus. The disrupted vessels of the placental site therefore continue bleeding. Parts of the placenta may be retained in the uterus as a result of misconduct of the placental stage of labor and in connection with the adherent placenta. These complications always involve bleeding. The retention of fetal membranes does not present so serious danger, because membranes, as a rule, come out spontaneously. Nevertheless, at retention of more than 2/3 of membranes in the uterine cavity it is necessary to perform a manual revision of the uterus and removing of membranes and blood clots, with the purpose of prophylaxis of the described complications. Hemorrhage due to retention of parts of placenta in the uterine cavity may occur just after the delivery, or in the puerperal period; on the other hand it is one of the most frequent reasons of postpartum endometritis.
Clinical features. Bleeding begins soon after the delivery of the fetus or in a certain lapse of time (30-60 min). Within a short period of time the patient may lose from 500 to 1, 000 ml (and over) of blood. The blood loss is sometimes as high as 1, 500 ml. Hemorrhage is usually external; all blood freely flows out of the birth canal. But the mouth of womb may be closed by a spasm or a lobe of the placenta (or a clot of coagulated blood), and the blood will then accumulate inside the uterus. External bleeding is absent in such cases while the puerperium develops signs of acute anemia, the degree of which depends on the amount of the blood lost and on the health of the woman. Asthenic women and also women who had hypotension before labor develop an especially negative response to the loss of blood.
Developing anemia is characterized by pale skin and visible mucosa, decreased arterial pressure, accelerated pulse, vertigo, ear noise; if the blood loss is significant, the pulse becomes thready, the arterial pressure drops, and dyspnoea develops; the patient may die unless medical aid is given in due time.
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Treatment includes manual separation of part of placenta remained in the uterine cavity. General anesthesia is obligatory for this intervention (given below).
Strangulation and retention of separated afterbirth in the uterine cavity (Fig. 192 ). Afterbirth becoming separated from the uterine wall can stay too long in the uterus at disturbance of its retractive power, at weakness of muscles of prelum abdominale, and also at spasm of internal os. The repletion of urinary bladder also can be the reason of retention of afterbirth in the uterus. The decrease of retractive power of uterus relies on numerous reasons and is the result of initial pathological changes, or is related to complications occurring during labor. At the same time the spasm of internal mouth of womb often occurs due to wrong conduct of placental stage of labor. So, belated administration of methylergometrine at head delivery can result in the spasm of internal os of the uterus. Every interference during a physiological course of placental stage of labor disturbs the separation of placenta, and is accompanied by the spasm of internal pharynx and restriction of afterbirth. Untimely and groundless attempts of expulsion of afterbirth, such as massage of the uterus, pulling by umbilical cord, lead to failure of afterbirth separation and expulsion and increase of hemorrhage. Placenta separated from the uterine wall and lying in the cavity of uterus becomes a foreign body that hinders in contraction of uterus and thrombosis of spiral vessels and leads to increase of blood loss.
Fig. 192. Strangulation and retention of separated afterbirth in the uterine cavity
Clinical features. The signs of separation of placenta are positive, bleeding of different intensity takes place, there is no spontaneous expulsion of afterbirth.
Medical treatment. Catheterization of the urinary bladder is necessary, if it was not performed at once after delivery of the fetus. The use of external methods of expulsion of afterbirth separated from the uterine wall (Abuladze’s, Henter’s or Crede’s methods) should be attempted. To increase the uterine contraction it is necessary to perform local hypothermia of uterus (ice bag on the lower abdomen). If external methods of delivery of afterbirth are ineffective, it is necessary to give anesthesia, and perform the operation of manual removing of afterbirth, which is separated from the uterine wall.
Lacerations of the soft tissues of the birth canal
Lacerations of the cervix and deep lacerations of the vagina, perineum and external genitalia may be the cause of bleeding in the placental stage of labor and puerperium.
Bleeding starts immediately after delivery of the fetus or in a certain lapse of time; hemorrhage that begins during the placental stage sometimes persists in the puerperium. The amount of blood lost may be as high as 1, 000 ml and over; acute anemia develops (the skin and mucosa become pallid, the pulse accelerates, the arterial pressure drops, vertigo develops, etc. )
Clinical features. Bleeding is continuous, with scarlet blood, begins at once after delivery of the fetus.
Treatment. It includes speculum examination of the birth canal, wound closure.
Basic Principles of Bleeding Arrest in the Third Period of Birth
The uterus may be contracted and bleeding stopped only after the uterus has been emptied. The placenta shall therefore be quickly removed from the uterus. If the placenta has separated, it can be extruded by external manipulations. If the placenta remains attached, the external manipulations may prove ineffective, and manual removal of the placenta is therefore recommended.
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When bleeding starts, it is necessary to check immediately if the placenta is separated. If the signs of placental separation are positive, the placenta shall be removed by the Abuladze or Crede manoeuvre. In the absence of these signs an attempt should be made to extrude the placenta by the Crede manoeuvre (with anaesthesia). It sometimes fails because of the spasm of the internal cervix os; anesthesia removes the spasm and the placenta can thus be removed. If the Crede manoeuvre (with anaesthesia) proves ineffective, a recourse of manual separation of the placenta should be made.
If the signs of placental separation are negative, manual removing of the afterbirth is indicated at first.
Manual Separation of the Placenta (or Removing of the Afterbirth)
The invasion of the uterus by the obstetrical hand for separation and removal of the placenta (or its separate parts that may be retained in the uterus) is always fraught with danger of infection. The microflora of the vulva and the vagina inevitably contaminates the obstetrical hand. The microbes carried into the uterus by the hand penetrate the disrupted blood and lymph vessels of the uterus. Septic diseases often develop in puerperas after manual invasion of the uterus and this operation should therefore be done only for special indications and with strict observation of the asepsis rules.
Indications for manual separation and removal of the placenta are as follows:
· bleeding in the puerperium due to retention of separated placenta (or parts of placenta and amniotic membranes) in the uterine cavity;
· absence of spontaneous placental separation for more than 30 minutes. If the placenta is retained for more than half an hour, it should be removed manually even if the blood loss is inconsiderable;
· bleeding in the puerperium depending on the uterine hypotony or atony.
· Indications for manual intrauterine examination after the delivery of the placenta are:
· retention of parts of the placenta,
· if any suspicion arises concerning intactness of the delivered placenta.
Operative technique. The patient is placed on a transverse bed and her bladder is evacuated. The external genitalia are treated as for an obstetrical operation. The operator’s hands are washed thoroughly, disinfected, as for abdominal operation. The operation is performed on an anaesthetized patient, except as rare cases when the operation is performed by an unassisted obstetrician. (Fig. 193).
The pudendal cleft is separated by the left hand and a conically shaped right “obstetrician hand” is introduced into the vagina and further into the uterus. The invading hand should be directed with its palm toward the symphysis. The left hand should then be placed on the bottom of the uterus.
Fig. 193. Manual removing of the afterbirth.
In order not to mistake edematous margin of the os for the placental margin, the right hand should follow the umbilical cord as it is introduced into the uterus. As soon as the right hand, guided by the umbilical cord, reaches the placenta, its margin should be examined for the degree of separation. The hand should be inserted in space between the placenta and the uterine wall; while the right hand acts like a saw to separate the placenta, the left hand should press gently on the uterine bottom to aid the internal hand. As soon as the entire placenta has thus been separated, it should be pulled by the umbilical cord toward the lower uterine segment and extracted from the uterus by the left hand. The internal (right) hand remains in the uterus to examine it for complete removal of the placenta. When the entire placenta has been removed, the uterine walls become smooth except the placental site, which is slightly rough. Remnants of the decidual membrane may remain on the placental site
After the uterine cavity has been examined thoroughly, the hand should be removed from the uterus, and 1 ml of methylergometrine should be given intravenously; an ice bag should be placed on the lower abdomen and blood (plasma, or blood substitute) transfused in case of anemia. If bleeding persists, extirpation of the uterus should be performed.
In the presence of complications (before the manual separation and removal of the placenta) predisposing to puerperal infection (prolonged labor, long “dry” period, signs of endometritis, etc. ), antibiotics should be given during the course of two or three days: ceftriaxon 250 mg intramuscularly plus doxycycline 100 mg orally twice a day.
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The separation of the placenta or its retained parts usually does not present any difficulty. In placenta accreta (fused placenta) the placenta fails to be separated, and attempts to separate it manually will cause uterine perforation and death of the patient. The uterus should therefore be extirpated.
Prophylaxis of blood loss in the placental stage consists in accurate adherence to the rules of conducting labor. The condition of the patient, the amount of the blood lost, and the urinary function should be carefully observed; stimulation of the uterus or traction by the umbilical cord is not recommended. Ergot and its preparations which cause spasm of the uterine muscles are prohibited. If profuse bleeding is anticipated (polyhydramnios, twin pregnancy, etc. ), 1 ml of methylergometrine may be given during the delivery of the fetal head. Pituitrin and oxytocin are also recommended.
Bleedings During Postpartum Period
Early Postpartum Hemorrhages
Bleeding after the delivery of the placenta is a frequent obstetrical pathology. Bleeding in the early hours of the puerperium depends on the following:
· Retention of parts of the placenta in the uterus.
· Uterine hypotony or atony.
· Rupture of the uterus (incomplete form).
· Coagulation defects.
· Water embolism.
Hypotony and atony of the uterus. Uterine hypotony is insufficiency of retractive capability of myometrium, alternated decline and renewal of its tone. By atony it is accepted to consider a complete absence of contractions of uterus, which is more often a prolonged severe form of uterine hypotony. In most cases bleeding starts as hypotonic and then atony of uterus develops. A complete atony of the uterus occurs on relatively rare occasions. Hypotony is more frequent in the early hours of the puerperium.
The causes of hypotonic bleeding after the delivery of the placenta are the same as of hemorrhage in the placental stage of labor, i. e., infantilism, multiple pregnancy, fatigue after tumultuous labor, changes in the uterine wall after previous inflammatory diseases, etc.
Apart from these reasons hypotonic bleeding may occur due to failure of processes of separation and expulsion of the afterbirth, placenta praevia, premature separation of normally located placenta, water embolism.
Clinical features. Usually bleeding begins in a placental stage of labor or in early postpartum period. Two clinical variants of hypotonic (or atonic) bleeding are known.
The first variant: bleeding from the very onset assumes a profuse character, the uterus remains flabby, not responding adequately to administration of uterotonic drugs, external massage. Hypovolemia developes quickly, hemorrhagic shock and disseminated intravascular coagulation syndrome (DIC) also develop. The condition of the patient can quickly pass into an irreversible phase. The second variant: bleeding has an undulating character. The initial hemorrhage is slight, the uterus is periodically weakened, the blood loss increases gradually.
Alternation of repeated hemorrhage with temporal renewal of uterus tone in reply to conservative medical treatment takes place (external massage of uterus, administration of uterotonic agents). Blood is lost by small portions of 150-300 ml. A comparatively small volume of repeated bleeding provides temporal adaptation of the patient to developing hypovolemia. Blood pressure can remain within the limits of norm; pulse rate reveals insignificant tachycardia; severe paleness of skin occurs.
Treatment. The basic tasks facing the obstetrician in case of hypotonic bleeding are a maximally rapid arrest of bleeding, prevention of development of massive blood loss, renewal of the circulating blood volume deficiency, stabilization of hemodynamics. Measures should be executed quickly, simultaneously, that determines their efficacy.
Hypotonic and atonic hemorrhage is controlled in the following way:
The first step:
· The bladder is evacuated. The uterus is massaged through the abdominal wall: the hand is placed on the uterine bottom and rubs it by slight circular movements (energetic movements fail to give the desired effect). The massage stimulates contraction of the uterus and it becomes firm. An ice bag should be placed on the lower abdomen.
· Manual removing of blood clots from the uterus and manual revision of the uterine cavity. Simultaneously, 0. 5-1 ml of a 0. 02 % methylergometrine solution is given intravenously. Oxytocin (5 units with 500 ml of a 5 % glucose solution) should be injected intravenously.
· Revision of soft tissue of the labor canal must be done to repair lacerations, if any, and to arrest bleeding.
· Infusion of frozen plasma, albumin, protein, transfusion of blood, infusion of saline solutions should be done to compensate the blood loss and to treat hypovolemia.
If the uterine hypotony is not marked, these measures will be enough.
The second step
If the bleeding persists and the volume of hemorrhage is 0. 8-1. 0% of body weight, a conservative treatment may be used to arrest bleeding.
Compression of the abdominal aorta. If hypotony (atony) is marked, the aorta should be compressed to decrease blood supply of the uterus. The obstetrician should assume her position by the patient’s side and, using the back surface of the main phalanges, press the abdominal aorta to the spinal column through the abdominal wall. If the hand becomes tired, it should be assisted by the other hand which should grasp the wrist of the pressing hand. The aorta can also be pressed against the spinal column by the fingers of both hands (Biryukov’s method), or by a soft roll which should be pulled tightly to the abdomen by bandaging.
Ten units of oxytocin with 400 ml of isotonic solution of sodium chloride should be injected intravenously droppingly. 1 ml of prostaglandin should be injected into the cervical muscles. 10-20 ml of essenciale forte intravenously, prednizolone 30 mg, dicinon (etamzilat natrium) 2-4 ml of 2. 5% solution should be introduced intravenously. Transfusion of blood is recommended.
The main rule is not to lose time for any ineffective conservative methods of arresting bleeding if it continues. Urgent operation is the best.
The third step is laparotomy and extirpation of the uterus.
Features of this operation are the following: after the opening of the abdominal cavity a temporary hemostasis should be done by clamping of the uterine and ovarian arteries. During the next 10-15 minutes (an operating pause) the resuscitation of the patient should be done (infusions of blood, plasma, saline solutions for stabilizing blood pressure, etc. ). Extirpation of the uterus may be perfomed after an operating pause.
However, arrest of bleeding is not the only component of successful medical treatment, because more often the direct reason of death of patients is multiple organ insufficiency developing in the postreanimation period, i. e. after the stop of bleeding. Death is caused by disturbances of micro- and macrocirculations. Prophylaxis and medical treatment of these complications should start during the 1st step, i. e. the step of diagnostics and arresting of bleeding.
The basic principles of infusion-and-transfusion therapy of hemorrhagic complications in modern obstetrics are the following:
· Renewal of hemodynamic system by introduction of solutions of a high molecular mass — Refortan (6% solution), pentastarch (infucol) — a 6–10% solution in doses of 10-20 ml/kg/body weight, voluven (6% solution), volekam — from 500 to 1000 ml;
· For suppression of excessive fibrinolysis and prevention of DIC it is recommended to use protease inhibitors (gordocs, trasilol) in doses not less than 10 ml/kg /hour;
· An early and rapid administration of fresh frozen plasma (FFP). If blood loss is less than 1, 000 ml it is recommended to inject 2 doses (1 dose is 300 ml), if blood loss is more than 1, 000 ml — 4-5 doses of FFP should be administered (1, 200-1, 500 ml). On occurrence of tissue diathesis a rapid, almost stream introduction of 7 doses of FFP is needed. The primary purpose of FFP application is not compensation of circulated blood volume, but renewal of hemostatic potential of blood, as it is the substance, saving in an active balanced state all factors participating in bleeding arrest;
· Stimulation of thrombocyte link of hemostasis (ditsinon 2-4 ml of a 2. 5% solution intravenously, adenosine triphosphate (ATP) 1. 0 ml intramuscularly);
· Transfusion of blood or red cell mass (better washed red cells);
· At unstable hemodynamics glucocorticoids should be administered (prednisolone in a dose of 10 mg/kg/hour or hydrocortisone — not less 100 mg/kg/hour).
Coagulation defects are rare causes of intrapartum and postpartum hemorrhage. In cases of hypofibrinogenemia, afibrinogenemia the ability of blood to clot sharply decreases or is lost completely, which becomes the cause of persistent bleeding regardless of massage of the uterus or drugs stimulating its contractions, etc. Coagulation defects may develop in cases of longstanding fetal death in the uterus, amniotic fluid embolism, and in profuse (hypotonic or atonic) bleeding.
The prophylaxis of coagulation defects consists in a correct management of the placental stage of labor, careful inspection of the delivered placenta, and prevention of lacerations of the soft tissues of the reproductive tract. The obstetrician must be ready for possible hypotonic hemorrhage (infantilism, hydramnion, multiple pregnancy, fibromyoma, etc. ). She must prepare beforehand all articles that might be necessary to stop bleeding and control anemia.
Late Postpartum Hemorrhages
Bleeding is considered late if it develops 24 hours (and later) after the delivery. Sometimes hemorrhage develops in 10-15 days postpartum.
The most common cause of late postpartum hemorrhage is retention of placental remnants in the uterus. The remnant gradually assumes the form of a polyp and becomes the cause of inevitable bleeding. Less frequently late hemorrhage is caused by retention of fetal membranes or due to infection.
If postpartum hemorrhage is due to retention of the placenta or fetal membranes, the treatment consists in their instrumental removal (curettage).
Cure of infection will stop bleeding.
Self Test
The retained particles of placenta should be:
A. removed from the uterus immediately after the delivery of the placenta
B. waited for its spontaneous removing without any treatment
2. The 1st step in case of hypotonic bleeding is:
A. evacuation of the bladder, the massage of the uterus, manual revision of the uterus, infusion therapy, oxytocics, repairing of any lacerations
B. administrations of uterotonics and sedatives, an ice bag on the lower abdomen
3. Which of the following is an indication for the manual intrauterine examination after the delivery of placenta?
A. perineal laceration
B. pain in the lower abdomen
C. the uterus is flaccid, large in size, hemorrhage begins
4. Which of the following is not characteristic of hypotonic uterus?
A. the uterus is softened, large in size, its contractions due to massage are weak
B. there are no clots in blood from the uterus and vagina
C. after massage the uterus relaxes again and bleeding continues
5. In 30 minutes after the delivery of newborn there aren’t any signs of placental separation; hemorrhage is absent. Which is the most probable diagnosis?
A. adherent placenta
B. uterine hypotony
C. separated afterbirth still remains in the uterine cavity
6. What is the management in the case described in question 5?
A. waiting for spontaneous delivery of the afterbirth
B. manual removing of the afterbirth
C. inducing of uterine contractions, external massage of the uterus
CHAPTER 30. ABNORMALITIES OF LABOR PAINS
Abnormal uterine contractions during labor named abnormalities of labor pains are one of the most important complications leading to worsening of the maternal and fetal condition.
Incidence of abnormalities of labor pains is 10-20% among other obstetrical complications in labor.
Classification
I. Abnormalities of uterine contractions before labor.
1. Pathological preliminary period.
II. Abnormalities of uterine contractions during labor.
1. Weak labor pains: a) primary, b) secondary, c) weakness of expulsive pains.
2. Excessive labor pains (precipitate labor).
3. Incoordinated labor pains: a) spastic lower segment, b) constriction ring,
c) cervical dystocia, d) uterine tetanus.
Etiology
A lot of factors may change the uterine activity: nervous stresses, endocrine disorders, infantilism, and metabolic disorders.
Thus, there are 5 groups of clinical factors associated with the development of abnormalities of labor pains.
· Obstetrical factors (premature rupture of membranes, cephalo-pelvic disproportion, alteration of the uterine muscles, overdistension of the uterus due to a big fetus, hydramnios, twins).
· Factors connected with pathology of the reproductive system (infantilism, congenital anomalies of genitalia, advancing age, especially in the first birth, menstrual disorders, neuroendocrine diseases, artificial abortions, myoma of the uterus).
· Extragenital diseases, general infections.
· Fetal factors (hypotrophy of the fetus, intrauterine infections of the fetus, anencephalia, postmaturity).
· Iatrogenic factors (incorrect inducing of the uterine contractions, incorrect anaesthesia during labor, etc. ).
Pathological Preliminary Period
The clinical signs of pathological preliminary period are:
· painful, irregular uterine contractions, various in intensity, duration and intervals, which continue more than 6 hour;
· the dilation of the cervix is absent in spite of the uterine contractions;
· the patient cannot sleep at night due to pains and becomes tired and irritable;
· worsening of the maternal condition;
· worsening of the fetal condition (intrauterine hypoxia of the fetus connected with the duration of this period);
· an increased tonus of the lower segment of the uterus;
· the presenting part is situated above the pelvic inlet and movable.
Treatment
Correction of uterine contractile activity until optimal biological readiness for childbirth with β -adrenomimetics and antagonists calcium, non-steroidal anti-inflammatory drugs:
- infusion of hexoprenaline 10 μ g, terbutaline 0. 5 mg or orciprenaline 0. 5 mg in a 0. 9% solution of sodium chloride;
- infusion of verapamil 5 mg in a 0. 9% solution of sodium chloride;
- ibuprofen 400 mg or naproxen 500 mg orally.
• Normalization of the psychoemotional state of a woman.
• Regulation of the daily rhythm of sleep and rest (medication sleep in the night time of day or when pregnant):
- preparations of benzodiazepine series (diazepam 10 mg 0. 5% solution w / m);
- narcotic analgesics (trimeperidine 20-40 mg 2% solution w / m);
- non-narcotic analgesics (butorphanol 2 mg 0. 2% or tramadol 50-100 mg IM;
- antihistamines (chloropyramine 20-40 mg or promethazine 25-50 mg IM;
- antispasmodics (drotaverin 40 mg or benzyclan 50 mg IM);
• Prevention of intoxication of the fetus (infusion of 500 ml of 5% solution
Dextrose + sodium dimercaptopropanesulfonate 0. 25 g + ascorbic acid-lots of 5% - 2. 0 ml.
• Therapy aimed at " maturation" of the cervix:
- PG-E2 (dinoprostone 0. 5 mg intracervical).
With a pathological preliminar period and optimal biological readiness for childbirth with full-term pregnancy is shown to be medicated stimulation of labor and amniotomy.
Weak Labor Pains (Uterine Inertia, Hypoactivity of the Uterus)
Primary and secondary weakness of labor pains is distinguished. Primary uterine inertia is characterized by weak, non-effective labor pains from the very beginning of labor. Secondary uterine inertia develops after a varied period of effective contractions. Weakness of “bearing down” efforts is characterized by decreased tone of abdominal and diaphragm muscles.
Primary uterine inertia. The contractions are weak and short, the intervals between contractions are long. Usually there are less than 3 contractions per 10 minutes. There is no good cervical dilatation, the presenting part of the fetus does not descend into the pelvic cavity. The uterus becomes relaxed after the contraction: the fetal parts are well palpable, and fetal heart rate remains constant during contractions. The patient feels less pain and discomfort during uterine contractions.
Primary uterine contractions may last to the second stage of labor to become responsible for ineffective abdominal contractions. Labor thus becomes markedly prolonged, the patient gets tired. Complications often develop during labor and postpartum period: fetal asphyxia, hemorrhages in the 3rd stage of labor and in early postpartum period due to uterine hypotonia. If uterine inertia develops against the background of premature (early) discharge of amniotic fluid, endometritis or chorioamnionitis of labor may occur. Puerperal septic diseases often develop connected with the spread of infection during the prolonged labor.
The diagnosis is based on the following:
· interrogation of the patient (one should pay attention to the duration of labor, character of labor pains, etiological factors in the anamnesis of the patient);
· the external examination of the patient (a hand placed over the uterus during uterine contractions reveals hardening of the uterus, duration of the contraction. Relaxation of the uterine muscles between contractions shows the duration of the interval and rate of pains);
· the external or internal hysterography, cardiotocography are usually used for diagnosis of character of labor pains;
· the internal obstetric examination (one should determine the rate of cevical dilation, the rate of descending of the presenting part of the fetus).
Usually the rate of cervical dilation is approximately 0. 35 cm/hour in the latent phase of the 1st stage of labor, 1. 5–2 cm/hour in primigravidae and 2-2. 5 cm/hour in multiparae in active phase, and 1-1. 5 cm/hour in the slowing down phase.
The rate of descending of the presenting part of the fetus is not so significant: it is usually not more than 1 cm/hour after the dilation of the cervical canal by 8–9 cm.
Treatment
A careful evaluation of the case is to be done: 1) to be sure that the patient is in true labor; 2) to exclude a cephalo-pelvic disproportion or malpresentation.
The differentiation should be done between pathological preliminary period and primary weakness of labor pains. The main feature of preliminary period is irregular pain, whereas true labor means regular contractions, even if they are weak.
Measurement of pelvic sizes, fetal expecting mass will help to exclude a cephalo-pelvic disproportion.
Treatment of primary weakness of labor pains should begin as early as possible. It depends on the maternal general condition.
If the patient is not tired, primary uterine inertia should be stimulated with the help of prostaglandins or/and oxytocin.
Prostaglandins are the derivative of prostanoic acid after which they are named and have the property of acting as “local hormones”. Prostaglandins have an oxytocic effect on the pregnant uterus when used in an appropriate dose. Prostaglandins are usually used for treatment of uterine hypoactivity at the 1st stage of labor, whereas oxytocin is more effective at the 2nd stage of labor. Both may be used only with controlled intravenous infusion. A low dose infusion is usually enough to stimulate the uterine contractions. But the dose is individual for every patient. The procedure consists of low rupture of the membranes followed by prostaglandin or oxytocin infusion. 5 units of oxytocin in 500 ml 5% dextrose with starting drop rate 6-8 drops/minute. Every 10 minutes the rate of drops will increase for 6-8 drops, till the uterine contractions become optimal. The rate of drops can not be more than 40 drops/minute, because this rate can lead to the tetanus of the uterus, rupture of the uterus and may be responsible for fetal asphyxia and even death.
Prostaglandins (enzaprost, prostenon, prostin) may be used by the same plan: 5 mg of enzaprost with 500 ml of 5% dextrose intravenously droppingly with the starting dose of 6-8 drops/min. Every 10 minutes the rate of drops will increase for 6-8 drops till good effect, but not more than 40 drops/min.
Combined stimulation is very effective: 2. 5 units of oxytocin, 2. 5 mg of prostaglandin in 500 ml of 5% dextrose intravenously droppingly according to the same plan.
If the patient is tired, it is necessary to give her some rest before the stimulation. Special treatment named obstetrical medicamental sleep may be administered: 2 ml of 1% promedol, 2 ml pipolphen intravenously, natrium hydroxybutyrate 20 ml of a 20% solution intravenously. The patient will sleep during 2-3 hours; this period of time oxygenation should be administered. In 2-3 hours 10 ml of 10% calcium chloridum, 20 ml of 40% glucose intravenously, complex of vitamins may be done for awakening. Then treatment of weakness must be done. In cases of non-effective treatment cesarean section is indicated to prevent fetal and maternal complications.
Secondary uterine inertia (secondary weakness of labor pains). Secondary uterine inertia follows normal or satisfactory uterine activity. The causes are varied. These are all pathological processes and special conditions that may cause primary uterine inertia. Secondary uterine weakness often develops in prolonged labor due to the general fatigue of the parturient. More often it occurs in contracted pelvis, large fetus, malpresentations.
Treatment is very difficult. If there is no obstructed labor (cephalo-pelvic disproportion) the treatment will be the same as at primary weakness. In cases of obstructed pelvis due to a large fetus, or contracted pelvis, cesarean section must be done as soon as possible.
Excessive Labor Pains (Hyperactivity of the Uterus)
Excessive forceful contractions occur less frequently than uterine inertia. Violent and painful uterine contractions at short intervals develop in women with easily excitable nervous system, in patient with some neuroendocrine disorders. Violent contractions may develop in the presence of contracted pelvis, large fetus, malpresentations to the propulsion of the fetus through the birth canal. Under the impact of convulsive contractions the uterus may rupture. In the absence of cephalo-pelvic disproportion the excessively forceful contractions may result in precipitate labor, which lasts only from one to three hours and therefore often occurs out of hospital (at home, on the way to the hospital).
Clinical features are: significant, intensive pains with very short intervals between them. There are 5 contractions per 10 minutes. The uterus can not relax between contractions, the patient cries, is very irritable, intrauterine fetal hypoxia occurs due to the diminished placental circulation.
Complications of excessive labor pains are:
· maternal injuries (rupture of the cervix, vaginal walls, perineum, uterus, etc. )
· hemorrhages in the 2nd and 3rd stages of labor, in early puerperium
· fetal injuries (intracranial injuries), fetal asphyxia.
Treatment
Spasmolytics, adequate analgesia (2 ml of 1% promedol, 5 ml of baralgin intravenously), peridural anaesthesia may be used. Medicamental tocolysis is usually prescribed: partusisten 5 mg in 500 ml of 5% dextrose intravenously droppingly. The starting rate is 6-8 drops/minute. Every 10 minutes the rate of drops must be increased by 6-8 drops till the uterine activity becomes optimal. Due to the cardiac side-effects of these drugs this infusion should be done under careful measurement of pulse rate and arterial blood pressure. Increasing of the pulse rate to 120 beats/min means the availability of side-effect, and in such cases the rate of drops cannot be increased. If there is no effect of treatment cesarean section is indicated to prevent severe maternal and fetal complications.
Uncoordinated Uterine Activity (Uncoordinated Labor Pains)
This variety usually appears in an active stage of labor. Uterine contractions may begin in its lower but not the upper segment. They may begin from any other part of the uterus but not from the upper segment as normally. Sometimes every part of the uterus contracts in its own rate and rhythm. Uncoordinated contractions are very painful and ineffective, the cervix dilates at a slow rate and the progress of the presenting part is delayed.
Spastic lower segment: fundal dominance is lacking and there is reversed polarity. Inadequate relaxation in between contractions is responsible for painful and non-effective labor.
Constriction ring: there are localized spastic contractions of a ring of circular muscle fibres of the uterus. It is usually situated at the junction of the upper and lower segment around a constricted part of the fetus, usually around the neck in cephalic presentation. The patient feels significant pain, the progress of presenting part is absent, intrauterine fetal asphyxia occurs due to the change of placental circulation. The uterus may rupture.
Cervical dystocia: the normal pattern of uterine contraction is maintained but the external os fails to dilate. It may be due to the presence of excessive fibrous tissue or spasm of circular muscle fibres surrounding the os. The cervix becomes very much thinned out and well applied to the head. Initially, the uterine contraction remains good but ultimately becomes ineffective. On occasion, edema of the anterior lip may occur and delivery may be accomplished by avulsion of the anterior lip or by annular detachment of the cervix.
Uterine tetanus: a pronounced retraction occurs involving the whole of the uterus up to the level of the internal os. Thus, there is no physiological differentiation of the active upper segment and the passive lower segment of the uterus. Every part of the uterus contracts in its own rhythm and intensity. There isn’t any possibility for uterine relaxation, so fetal asphyxia may occur very quickly. The rupture of the uterus may also occur; shock due to significant pains may be too.
Treatment. The main principles of treatment of uncoordanated labor pains are: sedative therapy, spasmolytics, anaesthesia of labor (peridural is better), medicamental tocolysis. In cases of ineffective therapy cesarean section must be done.
Self Test
1. Uterine contractions are irregular, painful; there is no dilation of the cervical canal. What is the most probable diagnosis?
A. weak labor pains
B. preliminary period
C. no signs of labor onset
2. The patient does not sleep at night due to irregular, painful uterine contractions, she is anxious and tired. On vaginal examination the cervix is closed, the presenting part of the fetus is above the pelvic inlet. What is the management in this case?
A. an obstetrical medicamental sleep, hormonal-energetic treatment, spasmolytics, prophylaxis of fetal hypoxia
B. stimulation of uterine contractions with oxytocin intravenously, 5 units in drops
C. stimulation of uterine contractions with prostaglandin, prophylaxis of fetal hypoxia and maternal bleeding
3. Weak labor pains mean:
A. less than 3 contractions per 10 minutes
B. 3-5 uterine contractions per 10 minutes
C. more than 5 contractions per 10 minutes
4. Probable complications of excessive labor pains are:
A. prolonged duration of the 1st stage of labor
B. fetal hypoxia, fetal and maternal injuries, bleeding in the 3rd stage of labor
5. Which of the following should be used for treatment of excessive pains?
A. spasmolytics, adrenomimetics, analgetics, sedatives
B. uterotonics, spasmolytics, energetic complex
6. Which of the following solutions should be used for treatment of weak labor pains?
A. 0. 5 units of oxytocin in 100 ml 5% glucose with a starting drop rate of 6-8 drops per minute, 0. 1 ml of oxytocin in 300 ml 5% glucose
B. 5 units of oxytocin in 500 ml 5% dextrose with a starting drop rate of 6-8 drops per minute
7. Which pains are typical of weakness of labor pains?
A. forceful and short
B. forceful and prolonged
C. weak and irregular
D. weak and short
8. Uncoordinated labor activity usually happens
A. in preliminary period
B. in the 1st stage of labor
C. in the 2nd stage of labor
D. in the 3rd stage of labor
9. Which of the following drugs may be used for treatment of uncoordinated labor pains?
A. oxytocin
B. ensaprost
C. prostenon
D. bricanil
10. Which of the following is not uncoordinated labor pains?
A. spastic lower segment
B. constriction ring
C. cervical dystocia
D. fibrillation of the uterus
CHAPTER 31. CONTRACTED PELVIS
Contracted pelvis is one of the most important problems of obstetrical practice. Complications dangerous to the mother and the fetus often develop during labor in women with contracted pelvis.
Anatomically contracted pelvis is defined as pelvis where the essential diameters of one or more planes are shortened by 1. 5 cm.
Incidence. The incidence of anatomically contracted pelvis is from 2. 6 to 12%, and functionally contracted pelvis is about 0. 8% in general population, and 30% in population with anatomically contracted pelvis.
Etiology. A gross degree of contracted pelvis is nowadays a rarity. Severe malnutrition, rickets, osteomalacia and bone tuberculosis affecting grossly the pelvic architecture are not frequently met in practice. Instead, minor variation in size and/or shape in a particular plane of the pelvis is commonly found which is often over-looked until complication arises.
Common causes of narrow pelvis are:
· Nutritional and environmental defects
· Diseases or injuries affecting the pelvis, spine and bones of the legs
· Developmental defects affecting the pelvic bones
· General acceleration affecting the structure of the skeleton in whole.
Classification of Anatomically Contracted Pelves
Anatomically contracted pelvis is usually classified depending on incidence, architecture, and degree of contraction.
Depending on incidence and pelvic architecture the following shapes of narrow pelvis are distinguished:
А. Frequent types
· Justo minor pelvis
§ hypoplastic pelvis
§ juvenile pelvis
§ funnel-shaped pelvis
§ dwarf pelvis (pelvis nana)
· Transverse contracted pelves
§ forms with enlarged anteroposterior diameters
§ forms with unaltered (normal) anterior-posterior diameters
· Flat pelves:
§ simple flat pelvis
§ flat rachitic pelvis
§ flat pelvis with reduction of an anteroposterior diameter of the 2nd plane of the pelvic cavity
§ generally contracted flat pelvis
B. Rare types
· Asymmetrical or obliquely contracted pelves
§ Naegele’s pelvis
§ scoliotic pelvis
§ coxalgic pelvis
§ spondylolisthetic pelvis
· Deformated pelves (due to injuries, tumors, exostosis).
Classification of Contracted Pelvis by Degree of Contraction
The true conjugate is used to judge on degree of flat pelves and justo minor pelvic contracture.
The 1st degree: the true conjugate is shorter than 11 cm but not shorter than 9 cm. Spontaneous pelvic delivery is possible in most cases with this degree of contracture.
The 2nd degree: the true conjugate is from 8. 9 to 7. 5 cm. Spontaneous delivery of a mature fetus is possible but complications and obstacles often arise which indicate to abdominal delivery.
The 3rd degree: the true conjugate is from 7. 4 to 6. 5 cm. Spontaneous delivery of a mature fetus through the natural birth canal is impossible. The fetus can only be extracted through the natural birth canal after a destructive operation on the fetus. A living fetus can be delivered by cesarean section.
The 4th degree: the true conjugate is less than 6. 5 cm. Spontaneous delivery is impossible. Destructive operations on the fetus are also impossible: the pelvis is so contracted that it cannot let through even small parts of a dissected fetus. A cesarean section is the only possible way to deliver. This degree of contracture is also known as an absolutely contracted pelvis.
The degree of contracture in transverse contracted pelvis is usually distinguished depending on size of transverse diameter of the pelvic inlet.
The 1st degree: the transverse diameter of the pelvic inlet is from 12. 4 to 11. 5 cm.
The 2nd degree: the transverse diameter of the pelvic inlet is from 11. 4 to 10. 5 cm.
The 3rd degree: the transverse diameter of the pelvic inlet is less than 10. 4 cm.
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