simone - 3b scientific · 2020. 1. 15. · 3 vaginal-operative delivery methods 17 3.1 forceps 18...
TRANSCRIPT
…close to reality
Obstetrical medicine background
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SIMone™
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Illustrations Holger Vanselow 2008
1 Thephysiologicalcourseofbirth 5
1.1 Thebirthmechanismintheoccipito-anteriorposition 6
1.2 Levelofthefetus’headinthematernalpelvis 10
2 Documentingandmonitoringbirth 12
2.1 Documentingthecourseofbirth 12
2.1.1 Cardiotocography(CTG) 13
2.1.2 Fetalscalpbloodanalysis(FSBA) 16
3 Vaginal-operativedeliverymethods 17
3.1 Forceps 18
3.2 Forcepsdelivery 19
3.2.1 Techniqueofforcepsdelivery,i.e:transverseforcepsdelivery 19
3.3 Vacuumextractor 24
3.4 Vacuumextractiondelivery 24
3.4.1 Techniqueforvacuumextraction 25
4 Amniotomy 28
5 Episiotomy 29
6 Caesareansection 30
7 Contractionstimulationforinefficientcontractions 31
8 Inhibitionofcontractions(tocolysis) 32
9 Analgesiaandanesthesiaduringdelivery 33
10 Assessmentofthenewborn 35
11 Literature 36
TableofContents
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5
Anormally-progressingbirthproceedsspontaneouslyandissubjecttoacomplex
interplayofactions.
Thephysiologicalcourseofbirthcanbeclassifiedinthreestages:
1. Dilatativestage
2. Expulsivestage
3. Placentalstage
Dilatativestage
Thedilatativestagecommenceswiththefirstlaborcontractionsandconcludes
withcompletedilationoftheosuteri.Itisdividedintoalatentphaseandan
activephase.Thelatentphasecomprisesthetimeofthecontinuousshortening
ofthecervixduringtheabsenceof,oronlyminimal,openingoftheosuteri.
Theactivephasecomprisesthecompleteopeningoftheosuteri,withincreasing
contractileactivity.
Expulsive stage
Theexpulsivestagecommenceswithcompleteopeningoftheosuteri
(approx.10cm)andconcludeswiththebirthoftheinfant.Itisdividedintoan
earlyexpulsivestageandapushingstage.
Placental stage
Theplacentalstagecomprisesthedetachmentandexpulsionoftheplacenta
1 Thephysiologicalcourseofbirth
6
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Thebirthmechanismintheoccipito-anteriorpositioniscomprisedofthefol-
lowingphases:
• Commencementmechanism
• Progressionmechanism
• Expulsionmechanism
• Externalrotation
Duringthebirth,thefetalheadgoesthrougharangeofmotions
(presentationandpositionalchanges):
• 1.Turning=Flexion
• 2.Turning=Rotation
• 3.Turning=Deflexion
• 4.Turning=Rotation
Asthebodypartofthefetusproceedstoincreasinglylowerpartsofthebirth
canal,itmustadapttothevariableanatomyofthefemalepelvis.
Forthisreason,duringthecommencementmechanism,aheadthatislocatedin
theoccipito-anteriorpositionwithflexionmustmovetoatransversepresentation
inthetransverseovalpelvicentrance:withthesagittalplaneproceedingtrans-
verselyorinasomewhatslanteddirection(Ill.1a–c).
Duringtheprogressionmechanism,theheadmovesdeeper(progression)intothe
pelviccavity.Inordertoadapttotheroundtransverseovalpelvicinlet,thehead
bends.Thusthe1stturn(=flexion)iscompleted.Inthisphase,thesmallfonta-
nelisatthedeepestpointoftheanteriorportion,theso-calledcentralpresenta-
tion(Ill.1d–f).
Whentheheadreachesthepelvicfloor,the2ndturn(=rotation)follows:the
headturns90°andtheanteriorocciputturnsforward(towardsthesymphysis).
Nowthesagittalplaneisinastraightdiameter(Ill.1g–i).
1.1 Thebirthmechanismintheoccipito-anteriorposition
7
Subsequently,duringtheexpulsivemechanismtheheadmustmoveinanarc
aroundthesymphysis.The3rdturn(=deflexion)follows;thatis,theheadmakes
anextendingmovement,thuschangingitspresentation.Theinfant’sfaceis
facingthedeliverytable(Ill.1j–l).
Immediatelyafteritsexpulsionfromthepelvis,theheadmakesanother90°turn,
theso-called4thturn(=rotation),sothatthesagittalplaneisonceagaintrans-
verse,meaningthattheinfant’sfaceisfacingtheupperthighofthemother
(Ill.1m–r).
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Ill. 1a – r
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9
Ill.1
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.
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Thelevelofthefetalheadwithinthematernalpelvisisdeterminedbymeansof
external(LeopoldandZangemeistermaneuver)andinternal(vaginal)examination.
Uponinternalexamination,thesagittalplaneandthefontanelarepalpated.The
centralpresentationisassessedbydeterminingcentimeters(-4to+4cmaccording
toDeLee)above(+)orbelow(-)theinterspinalline(thevirtuallinebetweenthe
IschialSpines).Inaddition,theinterspinalplateau,accordingtoDeLee,alsode-
monstratesthe0-station(=0cm).Iftheanteriorocciputhasenteredthepelvis
duringanterior-occipitaladjustment,theheadisinthecentreofthepelvis,mea-
ningthatthebonycentralpresentationcanbepalpatedbetween0and+3cm.The
infant’sheadisonthefloorofthepelviswhenthecentralpresentationispalpable
at+4cm.Theplaneofpassageisthenattheleveloftheinterspinalplane(0cm).
Inaddition,thelevelcanbedeterminedbasedontheparallelplanesystemaccor-
dingtoHodge.Theindividualparallelplanesare4cmapart,whicharedefinedas
follows,fromcranialtocaudal:
•Theupperuterinesagittalplane,whichrunsfrom
theupperedgeofthesymphisistothesacralpromontory.
•Theloweruterinesagittalplane,whichrunsfrom
theloweredgeofthesymphisistothesacrum.
•Theinterspinalplane,theorientationpoints
ofwhichareindicatedbytheIschialSpines.
•Thepelvicfloorplane.
TheAmericanCollegeofObstetriciansandGynecologistshaspublishedaclassifi-
cationofthelevels,thusdefiningtheinterspinalplaneat0cmandrunningfrom5
to+5cm.Thismeansthatat+5cm,thefetalheadisvisibleinthevaginalintroitus.
1.2 Levelofthefetalheadinthematernalpelvis
11
Ill. 2 Levels according to DeLee and Hodge
Upper uterine sagittal plane
-4 cm, lower uterine sagittal plane
0 cm, interspinal plane
+4 cm, pelvic floor plane
-3 cm -2 cm -1 cm
+1 cm +2 cm +3 cm
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2 Documentationandmonitoringofthebirth
Itisoftheutmostimportancethatthebirthbemeticulouslydocumented,not
onlyonforensicgrounds.Thismeansthatanexpertthirdpartycanbeadequately
informedbythedocumentationaboutthecasehistory,thepregnancyandthe
courseofthebirthsothathe/sheisabletoassessthemeasurestakenduringthe
birth,retrospectively.
2.1 Documentingthecourseofbirth
Thepartogramisusedtodocumentthecourseofbirthanddeterminewhether
ornotitwasnormal.Thepartograminvolvesagraphicrepresentationinwhich,
accordingtotheFriedmannmethod(1954),thewidthoftheosuteriandthe
levelofthecentralfetalpresentation(ordinates)versusthetime(abscissa)are
delineated(s.Ill.3).
Thepatient’shistory,detailsofthepresentpregnancy,theCTGand,ifrelevant,
theORreportscompletethepartogram,yieldingasounddocumentationofthe
courseanddevelopmentofthebirth.
Ill. 3 Partogram modified according to Friedmann
13
2.1.1 Cardiotocography(CTG)
Thecardiotocographycomprisesacontinuousrecordofthefetalheartrateand
thepatternofcontractions.Patternsoffetalheartratearedocumentedtoreflect
bothnormalanddeliteriouschangestothefetalenvironmentinutero.The
tocogramdeterminesthefrequency,duration,formandregularityofthecontrac-
tions.
InordertobeabletointerprettheCTGcorrectly,thedeliveryassistantmustpos-
sessacomprehensiveknowledgeofthesubject.RepeatedCTGtrainingisrequired
inordertoreinforcethisknowledge
Fetal heart rate
•Basicrate(basalrate,baseline)inbeatsperminute[Bpm]:
Thisshowsthemeanvalueofthefetalheartrateduringanextendedperiod.
•Floatingline:Thisshowsthelong-termmeanoscillationtrend.
•Normocardia:Normalbasicrate.
•Tachycardia:Riseinbasicrate>10minutes>150Bpm1
•Bradycardia:Dropinbasicrate>3minutes<100Bpm1
•Oscillation(variability):Showsthefluctuationsinthecurveofthefetalheart
rateinrelationtothebasicrate.
•Oscillationamplitude(bandwidth/variability)[Bpm]:Thisspecifiesthe
differencesinthefetalheartratebetweenmaximumandminimumfluctuations.
•Oscillationrate:Thisistherateoffluctuationaroundthefloatingline.
•Accelerations:Riseinfetalheartrate.
•Deceleration:Dropinfetalheartrate.
- Earlydecelerations(DIPI):Adropinfetalheartratebeginswhenacon-
tractioncommencesandthefetalheartratereachesitslowestpointatthe
peakofthecontraction.Attheendofacontraction,thefetalheartrate
returnstoitsbasiclevel.
- Latedecelerations(DIPII):Thedropinfetalheartratedoesnotoccuruntil
1 Because the reference values vary internationally, applicable guidelines and recommendations should always be followed.
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afterthepeakofthecontractionandthefetalheartratereturnstoits
basiclevelaftertheendofacontraction.
- Variabledecelerations:Theseappearinavarietyofforms,duration,levels
andrelationshiptocontractionsintermsoftime.
- Atypicalvariabledecelerations:Variabledecelerationsthatdemonstrate
thefollowingcharacteristics:
Aftertheendofacontraction,thereturntobasicrateisgradual.
Afteracontraction,thebasicratelastsforanextendedperiod.
Nooscillationsaredemonstratedduringdeceleration.
Thebasicrateremainslow.
Thereisnoprimaryorsecondaryriseinfetalheartrate.
Biphasicdeceleration.
- Sinusoidalpattern:Thebasicratedemonstratesafluctuationoveran
extendedperiod,intheformofsinuswaves
15
Ill. 4 Acceleration in the fetal heart rate
Ill. 5 Variable deceleration in the fetal heart rate
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2.1.2 Fetalscalpbloodanalysis(FSBA)
Thefetalscalpbloodanalysis,whichisalsoreferredtoasamicro-bloodevaluation
(MBU)isusedtomonitorthefetus.Afterdisinfectionoftheexternalgenitalia,depen-
dinguponthestageofbirth,afewdropsofbloodaretakenfromtheemerging
partofthefetus,eitheramnioscopicallyorelsewiththeaidofaspeculum.Itis
requiredthatthereisabrokenoropenamnioticsacandanosuterithatisopen
atleast2to3cm.InadditiontothepHvalue,thepCO2,thepO
2,bicarbonateand
thebaseexcesscanalsobedetermined.
IndicationsforcarryingoutanFSBAarethefollowing:
• ContinuedsuspiciousorpathologicalCTGpattern
• ExtremelyprotractedcourseofbirthwithsuspiciousCTGpattern
• GreenamnioticfluidwithsuspiciousorpathologicalCTG
ContraindicationsforcarryingoutanFSBAarethefollowing:
• Aclosedoronlyslightly-openosuteri
• ApathologicalCTGonthesecondtwin
• Prematurity<34WOP
• Terminalbradycardia
• MaternalinfectionssuchasHIV,HBV,HCV,HGVandHSV
• Thefirstappearingpartoftheinfantisonthepelvicfloor
• Fetalcoagulationdisturbances
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3 Vaginal-operativedeliverymethods
Vaginal-operativedeliverymethodsincludevacuumextractionandforceps
extraction.
Thefollowingconditionsmustbefulfilledforavaginal-operativedelivery:
• Completeopeningoftheosuteri
• Exactdeterminationofthelevelofthefetalhead
(inthecentreofthepelvis/onthepelvicfloor)
• Exactdeterminationofthepositionanddirectionofthefetalhead
• Brokenoropenamnioticsac
• Desirableproportionsbetweenthefetalheadandthematernalpelvis
• Theinfantmustbealive
• Themothermustbeawareofthesituation
• Thebirthassistantmustbeanexpertinthetechnique
• Sufficientanalgesiaandanesthesia
Inordertobeabletocarryoutavaginal-operativedelivery,theabove-listed
conditionsmustbemetandthefollowingaretypicalindications:
• Fetalemergencysituation(hypoxia,asphyxia)=pathologicalCTG
• Maternalemergency,suchas,forexample,eclampsia,epilepticattack
• Exhaustionofthemother
• Weakcontractions
• Suspensionofthebirthingprogressduringthepushingperiod
• Cardiopulmonaryorcerebrovascularillnessinthemother
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3.1 Forceps
Therearevarioustypesofobstetricforceps.Allconsistoftwobranchesthatmeet
eithertransverselyorparalleltothehub
Eachbranchoftheforcepsconsistsofforcepsblades,aforcepsshankandafor-
cepshandle.Theforcepsbladesconsistoftworibsandapoint.Thebladesofthe
forcepsdemonstratesthecurvatureoftheheadandpelvis.Theclosureisatthe
shankoftheforceps.Theforcepsdeliveryistheclassicmethodforrapidlyconclu-
dingadelivery.
Ill. 7a – e a Shute forceps, b Bamberger forceps, c Laufe forceps, d Naegele forceps, e Kielland forceps
a
b
c
d
e
19
Onceoneoftheabove-mentionedconditionsisfulfilled,thefollowingprepara-
tionsmustbemade:
• Themothermustbepositioned(dorsosacralposition)
• Contractionsmaybestimulatedusingmedication
• Theurinarybladdermustbeemptied
• Thesurgeon’shandsandthevulvamustbedisinfected
• Vaginalexamination:osuteriwidth,positionandpresentationof
thefetalhead
• Analgesia,forexampleepiduralanesthesiaorpudendalblock
• Episiotomyifnecessary
3.2.1 Techniqueofforcepsdelivery,i.e:transverseforcepsdelivery
• Assemblyoftheforceps
• Holdtheclosedforcepsinthecorrectpositioninfrontofthevulvaasthe
headoftheinfantistobegrasped(Ill.6a).
• Withthelefthand,introducetheleftforcepsbranchintotheleftsideofthe
mother(Ill.6b):
- Placetwotofourfingersoftherighthandintothespacebetweenthe
vaginalwallandthefetalheadtoprotectthematernalsofttissue.The
thumbremainsoutside.
- Theleftforcepsbranch,heldwiththelefthand,isheldhangingperpendi-
cularlyinfrontofthevulva.
- Placetheextendedthumboftherighthandonthebackriboftheleft
forcepsblade.
3.2 Forcepsdelivery
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- Withthelefthand,allowtheleftforcepsspoontocomebetweenthefetal
headandtheprotectingrighthandovertherightsideofthemotherand
slideitgentlyintothevaginabyallowingthehandletodropdownward.
• Now,usetherighthandtointroducetherightforcepsbranchintotheright
sideofthemother(Ill.6d):
- Toprotectthematernalsofttissue,introducetwotofourfingersofthe
lefthandbetweenthevaginalwallandthefetalhead.Thethumbremains
outside.
- Holdtherightforcepsbranch,heldwiththerighthand,perpendicularlyin
frontofthevulva.
- Theextendedthumbofthelefthandliesonthebackriboftheright
forcepsspoon.
- Withtherighthand,allowtherightforcepsbladetocomebetweenthe
fetalheadandtheprotectinglefthandovertheleftsideofthemother
andslideitgentlyintothevaginabyallowingthehandletodropdown-
ward.Therightforcepsbranchliesovertheleftforcepsbranch.
• Theforcepsisnowclosed(Ill.6e).
• Itisvitalthatacheckiscarriedouttodeterminethatnomaternalsofttissue
isbeinggraspedalongwiththefetalheadandtobesurethattheforcepsis
properlypositionedonthefetalhead.Todothis,holdtheforcepswithone
handwhileusingtheothertochecktheforceps’positioninthevagina.
• Thencarryoutatestpull:Withthelefthand,grasptheforcepshandlefrom
above.Inordertopreventexcessivepressureonthefetalhead,theleftindex
fingercanbepushedbetweenthetwoforcepshandles2.Withtherighthand,
checktheloweringofthefetalheadduringcontraction.
2 Other methods used in order to prevent excessive pressure on the fetal head include:• Placing a rolled towel between the two forceps handles or neck parts.• Placing the middle finger of the right hand between the two neck parts.
21
a
b
c
d
e
f
g h
Ill. 6a – h Placing the forceps and extraction (using a transverse forceps as an example)
• Holdingtheforceps(Ill.6g):Withthelefthand,holdtheforcepshandlesfrom
aboveandwiththerighthand,holdaBuschhookfromabove.Inorderto
avoidplacingexcessivepressureonthefetalhead,placeeitherarolledtowel
orafingerbetweenthehandlesortheneckoftheforceps.
• Pull:Thenpull,synchronouslywiththecontraction,inthedirectionofthe
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forcepshandles(Ill.7a),untilthecentralpositionofthevulvaisvisible.This
meansthatthehypomochlionhasarrivedatthebottomedgeofthepubic
bonejoint.
• Lifttheforcepshandlesastheheaddescends(Ill.7b).Nowthesurgeongoes
totheleftsideofthemotherandholdstheforcepsinhis/herrighthand,
transverselyoverthepubis(Ill.6h)
• Ifanepisiotomyisnecessary,thisisnotcarriedoutuntilthefetalheadis
positionedonthepelvicfloor.
• Protecttheperineumwiththelefthand
Ill. 7a A pull synchronously with the contraction in the direction of the handles of the forceps (a transverse forceps is used in the example)
Ill. 7b Lifting the forceps handles (a transverse forceps is used in the example)
23
• Withtherighthand,lifttheforcepshandletowardsthemotherinorderto
leadtheheadaroundthepubicbone(Ill.7c).
• Theforcepsmayberemovedpriortoorafterthebirthofthehead.The
formermayhelptodiminishperinealtrauma.Theinfantisextractedinthe
normalmannerafterwards.
Ill. 7c Lifting the forceps handle towards the mother’s abdomen (a transverse forceps is used in the example)
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3.3 Vacuumextractor
Therearevarioustypesofvacuumextractors:metalvacuumextractorsandsili-
convacuumextractors,eachwithdifferentcharacteristics.Thecommonfeatureis
thatthevacuumextractorisplacedontheleadingfetalpart,withvariousope-
ningdiameters:40mm,50mmand60mm.
3.4 Vacuumextractiondelivery
Vacuumextractionisanalternativemethodofspeedingupabirth.
Onceoneoftheconditionsspecifiedatthebeginningofthischapterhasbeenmet,
thefollowingpreparationsshouldbecarriedout:
• Positionthemother(dorsosacralposition)
• Ifnecessary,stimulatecontractionswithmedication
• Emptytheurinarybladder
• Disinfectthehandsofthesurgeonandthevulva
• Vaginalexamination:osuteriwidth,positionandpresentationofthefetal
head
• Analgesia,forexampleepiduralanesthesiaorpudendalblock
Ifoneofthefollowingsituationsisobserved,vacuumextractioniscontraindicated3:
• Faceorforeheadpresentation
• Prematurity<34WOP
• ActivebleedingfromtheFSBAincisionsite
• Knownthrombocytopenia
• Absenceofbirthprogressduringpushing
3 Please also read the user information with regard to conditions and contraindications.
25
3.4.1 Techniqueforvacuumextraction
• Spreadthelabiaforpresentationofthevaginalintroitus
• Choosethelargestpossiblevacuumextractor
• Introducethevacuumextractor(Ill.8):
- Introducethemetalvacuumextractortransversely
- Compressandintroducethesiliconvacuumextractor
• Placethevacuumextractor:
- Withthefetalheadrotatedtowardsthecentralposition
- Ifthepositionalchangeisincomplete,placeitinwhatistobetheleading
area
• Checktobesurethatnomaternalsofttissueisbeinggraspedalongwiththe
extractorandthatthevacuumextractorhasbeenplacedproperlyaroundthe
fetalhead.
• Graduallyincreasevacuum4force
• Afterthefirststageofthevacuum,checkoncemoretobesurethatnomater-
nalsofttissueisbeinggrasped.
• Increasevacuumforcegraduallyuntilavacuumof0.6–0.8kg/cm²hasbeen
reached4
4 Please note the applicable manufacturer’s specifications that are enclosed with the pump with regard to the gradual pressure decrease.
Ill. 8 Introducing a vacuum extractor, with a metal vacuum extractor in the example
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a b
c
• Thencarryoutatestpull:Holdthehandleofthevacuumextractorwithone
handandtouchthecentralpositionwiththeother,checkingtobesurethat
theinfantisfollowingthepull.
• Extraction:Pullingiscarriedoutsimultaneouslytopushingbythemother,in
synchronywiththecontractions,withincreasinganddecreasingforce.This
allowsthefetalheadtoremaininpositionwithoutslidingbackinwhena
contractionsubsides.
• Pull(Ill.9a–c):Thepulling,synchronouswithcontractions,followsin
accordancewiththeparabolaofthebirth(inlinewiththepelvis).
Ill. 9a – c Pulling direction during vacuum extraction with occipito-anterior position
4 Please note the applicable manufacturer’s specifications that are enclosed with the pump with regard to the gradual pressure decrease
27
• Possiblyacolleaguecanprovideadditionalassistancebyperforminga
Kristeller’smaneuver.
• Ifnecessary,anepisiotomycanbecarriedoutoncethefetalheadisonthe
pelvicfloor.
• Onehandprotectstheperineum.
• Afterthebirthofthehead,graduallydecreasethevacuumofthevacuum
extraction.
• Thevacuumextractorcanberemovedduringthedeliveryofthebody.
Theheaddeformationcausedbythismethod(caputsuccedaneum)willsubside
within12–24hours.
Thevacuumextractormayonlybeplacedtwice.Afterithasbeenplacedtwice,
thebirthmustbeterminatedwithaforcepsor,ifnecessary,byCaesareansection.
Thisisbecause,ontheonehand,theheaddeformationthathasbeencreated
makesfurtherfixationofthevacuumextractormoredifficultandontheother
hand,intracranialpressurefluctuationsmightleadtocerebralhemorrhage.
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4 Amniotomy
Breakingtheamnioticsacwithaninstrumentmayshortenthelatentphaseof
labor.Thedeliveryassistantormidwifecanbreaktheamnioticsacusingasterile
amniotichook,aspiralelectrodeorsurgicalforceps
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Anepisiotomytakesthestressofftheperineumandmayshortenthesecond
stageoflabor.Italsotakesthepressureoffthefetalhead.
Indicationsforanepisiotomyarethefollowing:
• Extremelytautsofttissue
• Unfavorablepresentationofthefetalhead(deflexionposition,occiput
posterior)
• Threatenedperinealrupture
• Shorteningoftheexpulsiveperiodduetofetalhypoxia
• Forcepsdelivery(notimperative)
• Vacuumextraction(notimperative)
• Breechpresentation
Therearethreedifferenttypesofepisiotomy:
1. Mediolateralepisiotomy:
Theincisioniscarriedoutcommencingexactlyattheanteriorcommissure,at
anangleof45°inalateraldirection
2. Medianepisiotomy:
Commencingattheposteriorcommissure,thedeliveryassistantseparatesthe
connectivetissuepartoftheperineuminthecentretowardstheanus.
3. Lateralepisiotomy:
Theincisioniscarriedout1–2cmbesidethemidlineoftheposteriorcom-
missuretowardstheTuberossisischii.
Thechoiceofincisionalwaysdependsupontheindications.Forexample,
amediolateralepisiotomyispreferredforavacuumextraction.
5 Episiotomy
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Anabdomino-operativeterminationofthepregnancyorbirthisindicatedin
thefollowingcases:
• PossiblyinthecaseofapreviousCaesareansection
• Onbreechpresentationinaprimiparaormultiplepregnancy
• Transversepresentation
• Pelvicdeformities
• Suspecteddisproportionbetweenfetalheadandmaternalpelvis
• Threateneduterinerupture
• Placentalabruption
• Protracteddurationofbirth
• Threatenedfetalhypoxia
• Infectionsinthemother,suchasHerpesgenitalis
• Placentapraeviatotalis(marginalis)
• Eclampsia
• Amnioticfluidembolism
• Umbilicalcordprolapse
• HELLPsyndrome
6 Caesareansection
31
Themedicalstimulationofcontractionsusingoxytocinisindicatedinsituations
whereastrikinglyslowprogressofbirthoracessationofprogressisobserved,
causedbyweakcontractionswithoutindicationsofahindrancetothebirth.5
Situationsthatwouldprohibitvaginalbirthcontraindicatetheuseofoxytocin.
Thesecanbe:
• Birthmechanismhindrance
• Pathologicalanatomyofthepelvis
• Placentapraevia
• Vasapraevia
• Prolapseofumbilicalcord
• Statuspost-myomectomywithtransgressionoftheuterinecavity
• Invasivecervicalcarcinoma
7 Contractionstimulationforinefficientcontractions
5 Because there are various dosing schedules for the application of oxytocin, it is important that the applicable guidelines and recommendations and the manufacturer‘s information be taken into consideration when this medication is used.
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8 Inhibitionofcontractions(tocolysis)
Inhibitionofprematurecontractionsusingmedicationisindicatedinorderto
effecttheprolongationofapregnancyifthereisariskofthreatenedpremature
birth.
Excessivelystrongcontractionsduringbirthcanalsobeanindicationfortocolysis.
Intrauterinehyperactivitycanresultinaworseningofthefetalcondition.
Sustainedcontractionsleadingtoanacuteoxygendeficitmustbecorrected
bywayofemergencytocolysis.Emergencytocolysisisanadditionalaidinthe
monitoringofmaternalcirculatoryparameters.Polysystole(excessivecontraction
rates)alsorequiresintervention.
Basedontheminimalhalf-lifetimeofoxytocininplasma(approx.3min.)and
intheuterinetissue(approx.15min.),anoxytocininfusioniseasytomanage.
Shoulduterinehyperactivityoccurduringsuchtreatment,thedosagecanbe
decreased.
Generalcontraindicationsfortocolysisarethefollowing:
• Fetalmaturity
• Fetalindicationsforterminationofthepregnancy
• Maternalindicationsforterminationofthepregnancy
• Intrauterineinfections
• Intrauterinefetaldeath
Medicationsthatinhibitcontractions(tocolytics)are:
• ß-sympathomimetics,suchasphenoterol
• Magnesium,suchasmagnesiumsulphate
• ProstaglandinsynthesisinhibitorssuchasIndomethacin
• Calciumantagonistssuchasnifedipin
• Oxytocinantagonists
• NO-donatorssuchasnitroglycerin
33
Thechoiceoftocolyticdepends,firstofall,uponwhatislicensedinagivencoun-
tryandsecondlytheindicationsandcontraindicationsofagivenmedication.
9 Analgesiaandanesthesiaduringdelivery
Analgesiaandanesthesiacontrolpain,resultinginarelaxationofthepelvicfloor
musclesandthusmakingthedeliverymoretolerable.
Medicaltreatmentforthepainofbirthiseffectedbymeansofsystemicanalgesia
andregionalanesthesia.
Inadditiontoanalgesicssuchasopiatesandopioids,whichareusedforsystemic
analgesiaforthealleviationofpain,spasmolyticsandsometimesnitrousoxide
areused.
Othertypesoftreatmentforpainincludeacupuncture,transcutaneouselectrical
nervestimulation(TENS),homeopathicmedicationsandthepracticeofrelaxation
techniques.
Thetypeofregionalanesthesia,aslistedbelow,usedtocontrolthepainofbirth
dependsupontheindication,meaningthebirthassistancesituationandthe
reasonforthepain.
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• Epidural anesthesia (EA, peridural anesthesia):
Forepiduralanesthesia,eitherthesingle-injectiontechniqueorthecatheter
techniqueisusedtoadministeralocalanestheticand/oropioidintothe
epiduralcavityattheleveloftheintervertebralspaceL2/3orL3/4.
• Spinal anesthesia:
Forspinalanesthesia,eitherthesingle-injectiontechniqueorthecatheter
techniqueisusedtoinjectalocalanestheticand/oropioidintotheepi-
duralcavityattheleveloftheintervertebralspaceL2/3orL3/4intothe
subarachnoidspace.
• Combined spinal-epidural anesthesia:
Thisprocedureinvolvesacombinationofspinalanesthesia(usingthe
single-injectiontechnique)andepiduralorepiduralanesthesia(usingthe
cathetertechnique).Afterpuncturingtheepiduralcavityatthelevelofthe
intervertebralspaceL2/3orL3/4,aspinalneedleisintroducedthrough
thecannulaandthesubarachnoidspaceispunctured.Aftertheinjection
ofalocalanestheticand/oropioidsandtheremovalofthespinalneed-
le,theanesthetistplacesandfixestheepiduralcatheterintheepidural
cavity.
• Pudendal block:
Forthecontrolofperinealdilationpainandtorelaxthepelvicfloor
muscles,thepudendalnerveanditsbranchesareblockedbytheinjection
ofalocalanestheticfromthevaginaonbothsidesofthepudendalnerve
region.
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10 Assessmentofthenewborn
VirginiaApgardevelopedasystemthatentailedthestandardizationoftheassess-
mentofnewborns.
Theso-calledAPGARscoreiscomprisedofthefollowingfivecomponents:
1. Heartrate
2. Breathing
3. Reflexes
4. Muscletone
5. Skincolor
Eachcomponentisratedafter1,5and10minutesbywayofapointssystem
(0to2points):ahealthynewborninfantshouldscorebetween7and10points.
IftheAPGARscoreisbetween3and6,theinfantindicatesamildtomoderate
depressivestate.AnAPGARscoreof0to2indicatesaseriousdepressivestate.
Atthesametime,thisindicatestheneedformeasuresthatcanbetakeninorder
tosupportthenewborninadaptingtoitsnewcircumstancesafterbirth.
Criterion 0points 1 point 2 points
Heart rate none <100Bpm >100Bpm
Breathing none slow,irregular regular,crying
Reflex response and sucking reflex
none decreased crying
Muscle tone limp sluggishflexion activemovement
Skin color pale,bluetrunkrosy,
extremitiesbluerosy
Tab. 1 APGAR score
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11 Bibliography
Thefollowingliteraturesourceswereusedinthepreparationofthishandbook:
• AmericanCollegeofObstetriciansandGynecologists:Intrapartumfetalheart
ratemonitoring.ACOGTechnicalBulletinNo132.Washington,DC(1989)
• CunninghamFG,LevenoKJ,BloomSL,HauthJC,GilstrapIIILC,WenstromKD:
WilliamsObstetrics,22ndedition,McGraw-Hill(2005)
• DiedrichK,HolzgreveW,JonatW,SchneiderKTM,WeissJM:Gynäkologieund
Geburtshilfe,Springer-Verlag,Berlin,Heidelberg(2000)
• DudenhausenJW,PschyrembelW:PraktischeGeburtshilfemitgeburtshilf-
lichenOperationen,19.,fullyrevisededition,WalterdeGruyter,Berlin,New
York(2001)
• GoerkeK,StellerJ,ValetA:KlinikleitfadenGynäkologie,Geburtshilfe,
6.Auflage,Urban&FischerVerlag,München,Jena(2003)
• HalleH:MitUnterdruckodermitZange?GynäkologieundGeburtshilfe4,
18-20(2006)
• LeitliniederDeutschenGesellschaftfürGynäkologieundGeburtshilfe:
AbsoluteundrelativeIndikationenzurSectiocaesareaundzurFrageder
sogenanntenSectioaufWunsch.AWMFRegister-Nr.015/024(2006)
• LeitliniederDeutschenGesellschaftfürGynäkologieundGeburtshilfe:
Vaginal-operativeEntbindungen.AWMFRegister-Nr.015/023(2007)
• LeitliniederDeutschenGesellschaftfürGynäkologieundGeburtshilfe:
37
AnwendungdesCTGwährendSchwangerschaftundGeburt.
AWMFRegister-Nr.015/036(2007)
• MaedaK.FIGONews:ReportoftheFIGOStudyGroupontheAssessmentof
NewTechnology.Evaluationandstandardisationoffetalmonitoring.
IntJGynaecolObstet59,169–173(1997)
• NICHD(NationalInstituteofChildHealthandHumanDevelopment).Electro-
nicfetalheartratemonitoring:Researchguidelinesforinterpretation.Re-
searchPlanningWorkshop.AmJGynaecolObstet177,1385–1390(1997)
• RoothG,HuchA,HuchR.FIGONews:Guidelinesfortheuseoffetalmonito-
ring.IntJGynaecolObstet25,159–167(1987)
• RoyalCollegeofObstetriciansandGynaecologists:TheUseofElectronicFetal
Monitoring.Evidence-basedClinicalGuidelineNumber8(2001)
• SchneiderH,HussleinP,SchneiderKTM:DieGeburtshilfe,3.Auflg.,
Springer-Verlag,Berlin,Heidelberg(2007)
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Notes
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