Examination of the soft birth canal after childbirth. Restoring the integrity of the birth canal

Childbirth is a physiological, that is, a natural process. All stages generic activity controlled by the body of the expectant mother; the main role in this guide belongs to the nervous and hormonal system mother. V

Childbirth is a physiological, that is, a natural process. All stages of labor are controlled by the body of the expectant mother; the central role in this guidance belongs to the mother's nervous and hormonal systems. During childbirth, various changes occur in the body of the expectant mother: increased tone muscle wall uterus - contractions, cervical dilatation, fetal advancement along the birth canal, attempts, fetal delivery, separation of the placenta from the uterine wall and birth of the placenta - placenta with remnants fetal membranes and umbilical cord. The correct development of these processes is monitored by the staff of the maternity ward - doctors and midwives. Their task includes the step-by-step monitoring of the condition of the woman in labor and the fetus, as well as prevention, timely detection and elimination possible complications childbirth. Today we will talk about the methods of medical supervision used at various stages of labor.

Admission department of the maternity hospital

This is the first department of the maternity hospital to which future mom arriving for childbirth. After routine procedure paperwork, the woman in labor is invited to the examination room. It is here that the acquaintance with the doctor and the first obstetric examination takes place.

First, the expectant mother is offered to undress completely so that the doctor has the opportunity to make an external examination. The doctor examines carefully skin, paying attention to the color, skin turgor (elasticity) and the presence skin rashes... Too pale skin suggests the presence of anemia in pregnancy, a disease characterized by a decrease in the amount of hemoglobin in the blood. Hemoglobin is responsible for oxygen transport; a lack of this substance in the blood of the expectant mother can lead to fetal hypoxia, which will be further aggravated during childbirth. Redness of the skin, especially in the area of ​​the face, neck and décolleté, is often a sign of hypertension - increased blood pressure. High pressure during labor increases the risk of premature placental abruption. A bluish coloration of the nasolabial triangle, the tips of the fingers of the hands and feet may indicate heart failure of the expectant mother; this condition requires special tactics for managing childbirth.

Pronounced vascular pattern of veins lower limbs, bulging of the venous wall, pain and redness along the vessels speak of varicose veins veins and possible thrombophlebitis. In this case, the expectant mother will be helped to bandage her legs with elastic bandages; such a measure is taken to prevent thromboembolism (separation of a blood clot from the vessel wall due to a sharp change in venous pressure at the time of pushing, followed by blood flow into the vessels of other organs and their blockage) in childbirth and early postpartum period... The location of varicose veins in the perineal region increases the risk of significant blood loss during tears during childbirth, and also excludes the possibility of an episiotomy (perineal incision).

Swelling of the feet and legs, hands, anterior abdominal wall in pregnant women most often indicates the presence of a severe complication of pregnancy - preeclampsia. This pathology significantly worsens general state pregnant and fetus and also requires special obstetric tactics in the management of childbirth. Dryness and low elasticity of the skin suggests dehydration and general depletion of the body.

Hypertrichosis - excessive hair growth of the skin - can be a manifestation of hormonal imbalance in the body of the expectant mother, characterized by the predominance of "male" sex hormones (adreno-genital syndrome). In this case, the timely identification of the problem will allow the doctor to take measures to prevent the development of pathologies of labor, characteristic of the violation of hormonal regulation of labor.

Availability skin rash may be a manifestation infectious disease (chicken pox, measles, rubella, etc.). In this case, the woman in labor presents an epidemiological danger to those around her; the fetus may also be infected - after all, all viruses are able to penetrate the placental barrier. If an infection is suspected, the expectant mother is transferred to a specialized maternity hospital, and if it is impossible to transfer (the active period of labor), she is placed in a separate box in the observational department. This information can be especially valuable for pregnant women suffering from allergic skin manifestations: in order to avoid trouble, arm yourself in advance with a certificate from a dermatologist!

During an external examination, the doctor pays attention to the woman's physique, features of the shape of the pelvis, overweight or underweight, curvature of the spine. All examination data can be essential in determining the tactics of labor management. For example, in some forms of curvature of the spine, epidural anesthesia is not possible; overweight is almost always associated with hormonal disorders, and a pronounced lack of weight allows one to suspect a high probability of developing weakness of labor forces. By the shape of the abdomen, you can determine the amount of water and the location of the fetus in the uterus (longitudinal, oblique or transverse).

Then the expectant mother is offered to lie down on the couch. The midwife, under the supervision of a doctor, uses a measuring tape to determine the height of the fundus of the uterus (the distance from the top of the uterus to the pubic joint) and the circumference of the abdomen. The results obtained allow approximately (± 200 g) to calculate the estimated weight of the fetus.

With the help of a special instrument similar to a large compass - a pelvis meter - the midwife determines the size of the pelvis. Comparison of the size of the pelvis and the approximate weight of the fetus allows the doctor to conclude that physiological childbirth... Sometimes the circumference of the forearm is additionally measured just below the wrist joint (the place where the watch is worn). This study - the determination of the Solovyov index - allows you to determine the width of the bone in order to more accurately judge the true internal dimensions of the woman's pelvis based on the results of external measurements.

At the end of the measurements, the doctor listens to the fetal heartbeat through the anterior abdominal wall... The obstetrician can judge the condition of the fetus by the number of heart beats per minute, volume and rhythm of heart sounds. Listening to the baby's heart sounds is performed using a stethoscope - a tube similar to the Ai-Bolit instrument. Sometimes a portable ultrasound transducer is used - a small device that catches the fetal heartbeat through the mother's front abdominal wall and reproduces it through a speaker. In this case, the baby's heartbeat will be heard not only by the doctor, but also by the mother!

The next item on the obstetric examination is a vaginal examination. Usually it is performed on the gynecological chair of the examination room, less often on the couch. In the latter case, the expectant mother will be offered to lie on her back, widely spreading and bending her legs at the knees and hip joints... A vaginal examination of a woman in labor is performed using the hands, or rather, two fingers of the obstetrician's hand. The second hand from the outside fixes the fundus of the uterus through the anterior abdominal wall. No instruments are used for a vaginal examination at any stage of labor!

The purpose of the first vaginal examination is to determine the stage of labor (the degree of cervical dilatation), the integrity of the fetal bladder, the presenting part of the fetus (head or buttocks) and its relation to the entrance to the small pelvis (pressed or located above the entrance), the size of the head. In the case of a significant opening of the neck at the time of admission (4-5 cm or more), the doctor determines the location of the sutures and fontanelles on the baby's head relative to the pelvic axis; thus, it is possible to judge the correctness of the insertion of the head into the entrance to the small pelvis and to predict the course of labor. During a vaginal examination in an examination room, the doctor carefully examines the walls of the vagina, determining whether any bone formations will interfere with the movement of the baby through the birth canal in the second stage of labor. Such bone "protrusions" in the vaginal cavity are called exostoses and are the consequences of fractures of the pelvic bones and coccyx; they are quite rare. If there is a suspicion of water leakage in doubtful cases, during the examination process, the vaginal contents are taken for a “smear on water”.

At the end of the examination, the expectant mother goes to the enema; after an enema and shaving of the perineum, she is offered to take a shower and change clothes, and then she is taken to the maternity ward.

Rodblock

In the maternity ward, the expectant mother is accommodated in the prenatal ward or in an individual box designed for one woman in labor. Upon admission to the delivery unit, a repeated obstetric examination is performed to clarify the obstetric situation after an enema (the procedure for cleansing the intestines has a rhodostimulating effect). This time, the doctor examines the woman in labor on the usual bed of the prenatal ward. After examination, they must listen to the fetal heartbeat with a stethoscope, use the hand to determine the strength of the uterine contraction at the time of the contraction, then relax the abdomen during a pause. If necessary, cardiotocography is performed - a study of the fetal heartbeat and contractile activity uterus for 20-40 minutes using a special apparatus; at this time, the woman in labor is offered to lie on her back or on her side.

As labor develops, the doctor performs an obstetric examination at least 1 time in 3 hours. The examination is carried out in the ward, the woman in labor lies on an ordinary bed with her legs divorced and bent at the knees. According to the results of the study, it is possible to judge the speed of cervical dilatation, the correct insertion of the head, the movement of the fetus along the birth canal, the clinical compliance of the sizes birth canal and the fetal head, the adequacy of the obstetric picture to the strength of contractions and attempts, the likelihood of developing various complications.

In addition, there are special indications to conduct an "unscheduled" obstetric examination. These are situations that change the course of childbirth, and therefore require clarification of the diagnosis and obstetric tactics.

• Rupture of membranes and spontaneous effusion amniotic fluid; in this situation, examination will help prevent the umbilical cord and small parts of the fetus from falling out, make sure the head is inserted correctly and determine its relation to the entrance to the small pelvis
• Amniotomy- puncture of the fetal bladder; the procedure is indicated for polyhydramnios, oligohydramnios, "flat" (inelastic) fetal bladder, high lateral rupture of the membranes, with full dilatation of the cervix, and also when revealing weakness of labor forces. This manipulation (by the way, completely painless for mom and baby) is performed during the usual vaginal examination.
• Suspicion of the development of weakness of the birth forces; a vaginal examination will confirm or deny the diagnosis - with really weak contractions, the cervical dilatation does not increase
• Suspicion of the development of discoordination of labor- in this case, the speed of cervical dilatation does not correspond to the strength, frequency and pain of contractions
• The emergence bloody discharge from the genital tract may indicate ruptures of the cervix, vaginal walls, and also be a sign of incipient premature placental abruption. In the latter case, a timely vaginal examination will help to make a correct diagnosis, complete labor with an emergency operation. caesarean section and save the life of mom and baby.
• Solving the issue of pain relief in childbirth; in the absence of special indications, all types of anesthesia are performed no earlier than 4 cm and no later than 8 cm of cervical dilatation. Pain relief too early can trigger the development of birth weakness, too late - negatively affects the effectiveness of attempts and the condition of the newborn.
• The appearance of contractions testifies to the full disclosure of the cervix and the beginning of the movement of the fetal head along the birth canal; at this stage of childbirth, it is necessary to make sure that the head is correctly inserted into the pelvic cavity.
• Suspicion of prolonged standing of the fetal head in one plane of the pelvis in the second stage of labor is also confirmed by vaginal examination; in the absence of the effect of rhodostimulation in this case, the application of obstetric forceps is indicated.

Before each obstetric examination, the doctor thoroughly washes his hands, puts on sterile disposable medical gloves and treats the gloved hands with an antiseptic solution. With the same solution in the form of a spray, the perineum of the woman in labor is treated before each vaginal examination.

In the absence of complications from the moment of full disclosure (end of the first period) until the end of labor (birth of the placenta), a vaginal examination is not performed. In the second stage of labor, with a successful course, the doctor confines himself to an external examination of the uterus during attempts and during periods of relaxation, as well as regularly listening to the fetal heart sounds with a stethoscope after each contraction.

The third stage of labor also does not require a vaginal examination. The only indication at this stage may be the complication of the subsequent period - tight attachment placenta, retention of its lobe or part of the membranes in the uterine cavity. In this case, the doctor performs a manual examination of the uterine cavity, separation of the placenta or removal of the delayed part of the placenta. The manipulation is carried out in a small operating room, examination room or maternity ward under intravenous anesthesia... During this procedure, the postpartum woman is placed on a gynecological chair or Rakhman's bed. Manual examination of the birth canal and uterine cavity takes a few minutes.

At the end of labor, the doctor, with the help of a midwife or operating nurse, examines the birth canal for trauma and soft tissue ruptures. The procedure is performed in the delivery room, small operating room or examination room of the maternity ward. The postpartum woman is on the gynecological chair or on the Rakhmanov bed. Examination of the birth canal after childbirth is the only option for vaginal examination that involves the use of obstetric instruments (obstetric mirrors, which differ from the usual gynecological vaginal speculum, as well as special instruments for examining the cervix and, if necessary, suturing the tears). If damage to the birth canal is detected, the doctor repairs the ruptures, having previously anesthetized the surrounding tissues with an anesthetic solution. Absorbable sutures are applied to internal tears (cervix, vaginal walls). Perineal skin lesions are usually repaired with a non-absorbable material; these sutures are removed on the fifth day after childbirth in case of a successful postpartum period.

In the absence of complications in the postpartum period, the next visit to the gynecologist, accompanied by an examination on the gynecological chair, is recommended for a young mother no earlier than 6 weeks from the date of birth.

Inspection of the birth canal on mirrors

Inspection of the placenta for integrity

Isolation of the separated placenta by external methods

Target: the allocation of the separated placenta, if it is not born on its own.

Resources: equipping the delivery room, urinary catheter, kidney-shaped tray; disposable gloves.

Algorithm of action:

1. Abuladze's way:

· Remove urine with a catheter;

· Grab the anterior abdominal wall with both hands in the longitudinal fold so that both rectus abdominis muscles are tightly covered with the fingers;

· Invite the woman in labor to push.

2. Genter's way:

· Stand next to the woman in labor;

Put both hands, clenched into fists, with the back of the phalanges on the bottom of the uterus in the area of ​​the tubal corners;

· Pressing on the bottom of the uterus, gradually increase the force of this pressure until the birth of the placenta.

3. Method Crede - Lazarevich:

· Bring the uterus to the middle position;

· Make a light external massage of her bottom;

Clasp the uterus right hand so that thumb lay on the front surface of the uterus, and the palm on the fundus of the uterus, place the other four fingers on the back of the uterus;

· With movements from top to bottom, press on the uterus and achieve the birth of the placenta.

Purpose of the study: assessment of the condition of the placenta.

Resources: tray, functional table, napkin, scales, measuring tape, disposable gloves.

Algorithm of action:

1. Place the afterbirth on a smooth surface (tray) with the mother's side up, dry with a napkin and proceed to the inspection:

On the maternal side, all segments should be intact, the surface should be smooth, shiny, gray - of blue color;

· Pay attention to the edges of the placenta, to tissue changes: the presence of calcification, fatty degeneration, old blood clots.

2. Lift the afterbirth behind the umbilical cord, straighten the sheaths,

make sure the shells are intact, specify their place

the gap and the size of the gap.

3. Sequentially inspect the umbilical cord, fetal

the surface of the placenta, the course of the vessels, whether they pass

they are on the shell and if there are any additional lobules.

4. Measure and weigh the placenta after examination.

5. Record the examination data in the birth history.

Target: diagnosis of postpartum injuries.

Resources: birth bed; sterile instruments: scissors, postpartum speculum, fenestrated clamps, needle holder, surgical needles, suture material, anatomical and surgical forceps, forceps; antiseptic solution (1% iodonate solution or 2% iodine solution), sterile diaper, sterile gloves, sterile cotton swabs.

1. Explain to the postpartum woman the need for this study.

2. Treat the external genitals with an antiseptic.

3. Place a sterile diaper under the mother's buttocks.

4. Get wide postpartum mirrors from the delivery bag.

5. Sequentially insert the speculum into the vagina, exposing the cervix.

6. Pass the handles of the mirrors to the assistant. Using two fenestrated clamps, starting at 12 o'clock, clockwise, repositioning the clamps, examine the edges of the cervix for tears, carefully examine the length and beginning of the tear.

7. Taking out the mirrors, inspect the walls of the vagina. If a break is found, set its severity.

8. Using cotton swabs, inspect the external genitals, posterior commissure, perineum in sequence.

9. If a rupture of the cervix, vagina and perineum is detected, it is necessary to suture them in compliance with the rules of asepsis and antiseptics against the background of anesthesia (see the relevant standards).

An external examination is a mandatory stage of medical supervision, from which the doctor's acquaintance with a patient in any field of medicine begins. In obstetrics, he also has a very great importance: according to the features of the physique, skin color, the presence of edema and many other signs, the doctor can identify the health features of the expectant mother, which sometimes cause complications during childbirth, and take timely measures to prevent their development.

In the admission department of the maternity hospital, the expectant mother is invited to the examination room and offered to undress completely. The doctor conducts an external examination: he carefully examines the skin of a woman, paying attention to the color, elasticity of the skin and the presence of rashes on it. For example, too pale skin suggests the presence of anemia during pregnancy, when the level of hemoglobin in the blood is reduced. Hemoglobin is responsible for the transfer of oxygen, and its lack can lead to fetal hypoxia (oxygen starvation), which, as a rule, is further aggravated during childbirth.

Redness of the skin, especially around the face, neck and décolleté, is often a sign of hypertension - high blood pressure... High blood pressure during labor increases the risk of premature placental abruption. The pronounced vascular pattern of the veins of the legs, bulging of the venous wall, pain and redness along the vessels indicate varicose veins and possible thrombophlebitis. In this case, the expectant mother will be helped to bandage her legs with elastic bandages. This measure is taken to prevent thromboembolism (separation of a blood clot from the vessel wall due to a sharp change in venous pressure at the time of pushing, followed by blood flow into the vessels of other organs and their blockage) during childbirth and the early postpartum period.

Swelling of the feet, legs, hands, abdomen in the expectant mother most often indicates the presence severe complication pregnancy - preeclampsia. This pathology significantly worsens the general condition of the pregnant woman and the fetus and also requires a special approach to the management of childbirth.

Dryness and low elasticity of the skin suggests dehydration and general exhaustion of the body.

Before each obstetric examination, the doctor thoroughly washes his hands, puts on sterile disposable gloves and treats the gloved hands with an antiseptic solution. With the same solution in the form of a spray, the perineum of a woman in labor is also treated.

During an external examination, the doctor pays attention to the woman's physique, features of the shape of the pelvis, overweight or underweight, curvature of the spine.

All data from an external examination can be essential in determining the tactics of managing labor. For example, in some forms of curvature of the spine, epidural anesthesia is not possible.

Overweight is almost always associated with hormonal disorders, and a pronounced lack of weight suggests a high likelihood of developing weakness of labor forces.

By the shape of the abdomen, you can determine the amount of water and the location of the fetus in the uterus (longitudinal, oblique or transverse).

Obstetric examination

An obstetric examination in the admission department is carried out when the expectant mother enters the maternity hospital. The woman is offered to lie down on the couch. The midwife, under the supervision of a doctor, uses a measuring tape to determine the height of the fundus of the uterus (the distance from the top of the uterus to the pubic joint) and the circumference of the abdomen. The obtained results of obstetric examination allow you to approximately calculate the estimated weight of the fetus.

With the help of a pelvis meter - a special instrument similar to a large compass - the midwife determines the outer dimensions of the pelvis. Comparison of this parameter and the approximate weight of the fetus allows the doctor to draw a conclusion about the possibility independent childbirth... Sometimes the circumference of the hand is additionally measured just below the wrist joint. This study allows you to determine the width of the bone in order to more accurately judge the true internal dimensions of the woman's pelvis.

After measurements, the doctor listens to the fetal heartbeat through the abdominal wall using a special tube - an obstetric stethoscope. By the number of heart beats per minute, the volume and rhythm of the baby's heartbeat, you can assess his condition. Sometimes a handheld ultrasound sensor is used - a small machine that picks up the fetal heartbeat and reproduces it through a speaker. In this case, the baby's heartbeat will be heard not only by the doctor, but also by the expectant mother herself.

The next item on the obstetric examination is a vaginal examination. Usually it is performed on the gynecological chair of the examination room, less often on the couch. In the latter case, the expectant mother will be offered to lie on her back, widely spreading and bending her legs at the knee and hip joints. A vaginal examination of a woman in labor is performed using the hands, or rather, two fingers of the obstetrician's hand. The second hand of the obstetrician from the outside fixes the fundus of the uterus through the abdominal wall. No instruments are used for vaginal examination during childbirth, at any stage of the process!

The purpose of the first vaginal examination in childbirth is to determine the degree of cervical dilatation, the integrity of the fetal bladder, the presenting part of the fetus (head or buttocks), etc. If there is a suspicion of water leakage during the examination, the vaginal contents are taken for a “smear on water”.

As labor develops, the doctor conducts an obstetric examination at least 1 time in 3 hours. The woman in labor lies on a regular bed with her legs spread apart and bent at the knees. According to the results of vaginal examination in childbirth, one can judge the speed of cervical dilatation, the correct insertion of the head, the movement of the fetus along the birth canal, the correspondence of the size of the birth canal and the fetal head, the correspondence of the period of labor to the strength of contractions and attempts, the likelihood of various complications.

Out of plan
There are special indications for an unscheduled obstetric examination. These are situations that change the course of labor, and therefore require clarification of the diagnosis and further tactics of labor management. The doctor will necessarily conduct an examination immediately after the outflow of amniotic fluid or after a puncture of the fetal bladder (amniotomy), if there is a suspicion of the development of weakness or discoordination of labor, with the appearance of bloody discharge, when deciding on the pain relief of labor, when attempts appear and in some other cases.

Additional research methods in childbirth

Ultrasound in childbirth

Childbirth ultrasound can be used at any stage of childbirth and has a valuable diagnostic value... Ultrasound during childbirth allows you to determine the size, estimated weight and position of the baby in the uterus, the size and location of the presenting part of the fetus (the one that will be born first, often the head or buttocks) relative to the entrance to the small pelvis. All this helps doctors understand whether the baby is ready for childbirth, whether its dimensions correspond to the internal dimensions of the future mother's birth canal and whether she can give birth herself. If, when a woman enters the admission department of the maternity hospital, using an obstetric stethoscope or a portable ultrasound sensor, the doctor cannot hear the fetal heartbeat, then ultrasound will also come to the rescue.

Also, using ultrasound examination during childbirth, it is possible to determine the amount and density of waters, confirm or refute the suspicion of their leakage, exclude the entanglement of the umbilical cord, and also determine the size, degree of maturity and the place of attachment of the placenta.

Ultrasound during childbirth can be carried out in the examination room of the admission department, in the prenatal ward and even directly in the delivery room.

When is it held? This study is performed according to indications (if something confuses the doctor at any stage of childbirth, or if the last ultrasound was performed a long time ago, or there is no record of the results in the exchange card). In some maternity hospitals, ultrasound in mandatory make everyone arriving for childbirth in the admission department.

Dopplerometry during childbirth

This is a type of ultrasound examination during childbirth, which allows you to assess blood flow in the vessels of the uterus, placenta and umbilical cord. The breathing and well-being of the baby directly depends on the volume and speed of blood flow in these vessels. By measuring and comparing changes in placental blood flow rates during and in the intervals between contractions, doctors can judge the condition of the fetus, assess the perceived risks and prognosis for the upcoming birth.

When is it held? Doppler analysis is performed only according to indications (with signs of impaired placental blood flow).

CTG during childbirth

Cardiotocography during labor is used to monitor the fetal heart rate and uterine contractions. Two sensors of this device are attached to the abdomen of the woman in labor using elastic bands. One records fetal heart sounds using an ultrasound signal, the other monitors electrical impulses arising in the uterus during labor. The results of CTG during childbirth are reflected in the form of two parallel graphs on a special tape. By analyzing the record of the fetal heartbeat during contractions and in the intervals between them, doctors get the most complete picture of the baby's condition during childbirth. The CTG recording during childbirth does not imply the indispensable location of the woman in labor on her back. With the normal development of labor activity during the CTG recording, the expectant mother can lie on her side, sit on the ball and even walk calmly around the ward.

When is it held? CTG is mandatory for all expectant mothers upon admission to the maternity hospital, when water flows, with the development of any abnormalities in labor, identifying risks to the fetus (cord entanglement around the neck, mekoneal waters, a long dry interval, prolonged pregnancy, premature birth, signs of chronic fetal hypoxia), with the introduction of labor-stimulating or labor-stimulating drugs (continuously throughout the entire labor process).

Examination of the birth canal after childbirth

The doctor, with the help of a midwife or operating nurse, examines the birth canal after childbirth in order to detect injuries and soft tissue ruptures. The postpartum woman (as the newly-made mother is called) is on the gynecological chair or on the obstetric bed.

Examination of the birth canal after childbirth is the only vaginal examination option that involves the use of obstetric instruments (obstetric mirrors, as well as special instruments for examining the cervix and, if necessary, suturing the tears).

If damage to the birth canal is detected, the doctor repairs the tears, having previously anesthetized the surrounding tissues with an anesthetic solution (spray and injections are used). If epidural anesthesia was used during childbirth, vaginal nipples), absorbable sutures are applied. Damage to the skin of the perineum can be restored then for pain relief during the examination of the birth canal it will be slightly prolonged. For internal tears (cervix, spread with non-absorbable suture material - these sutures, if the postpartum period is successful, are removed on the fifth day after childbirth - or with a self-absorbable cosmetic suture.

In the early postpartum period, the soft birth canal is examined. After processing disinfectant solution external genital organs, inner surface the hips and pubic joints examine the external genitalia and the perineum, then, pushing the labia apart with a sterile tampon, the entrance to the vagina and the lower third of the vagina. Examination of the cervix is ​​performed using mirrors.

Technique for examining the cervix with vaginal mirrors and suturing its ruptures: with the left hand, the large and small labia are spread, the entrance to the vagina is widely exposed, then the rear mirror (spoon-shaped) is inserted according to the direction of the vagina (front top - backward downward), the rear mirror is located on back wall vagina and slightly pushes back the perineum; then, parallel to it, the anterior mirror is introduced, with which the anterior wall of the vagina is raised upward. If it is necessary to increase access to the cervix, flat plate mirrors are inserted into the lateral fornices of the vagina. The cervix is ​​fixed with two fenestrated forceps for the anterior lip at a distance of 1.5-2 cm. By shifting the instruments sequentially along the outer edge of the entire cervix in a clockwise direction, they are examined. If there are gaps, sutures are applied, the first suture is applied 0.5-1 cm higher from the beginning of the gap.

All detected ruptures of the soft birth canal are also sutured:

A) suturing vaginal tears- gaps are exposed with the help of mirrors and catgut sutures are applied, starting from the upper corner of the wound. Separate bleeding vessels are grasped with a clamp and ligated.

B) suturing crotch lacerations- start from the top corner of the gap

With a ruptured perineumIdegreeAND(rupture of the posterior adhesion, the walls of the vagina in the area of ​​the lower third and the skin of the perineum), the entrance to the vagina is split with two fingers of the left hand, the angle of the wound is found, then knotted catgut sutures are sequentially applied from top to bottom on the edge of the vaginal wall, stepping back from each other by 1-1, 5 cm, before the formation of the posterior commissure. Silk (lavsan) stitches, Michel's brackets are applied to the skin of the perineum. The needle should be held under the entire wound surface, since otherwise there are pockets, cracks in which blood accumulates, which interferes with the primary wound healing.

For perineal tearsIIdegree(as a rupture of the first degree + rupture of the pelvic floor muscles) first, catgut sutures are applied to the upper corner of the wound, then the torn perineal muscles are connected with several immersion sutures, and then sutures are applied to the vaginal mucosa to the posterior adhesion and to the skin.

For perineal tearsIIIdegreeAND(as a rupture of the II degree + rupture of the sphincter of the rectum and sometimes its walls) first, the wall of the rectum is restored, then the ends of the torn sphincter are found and connected, after which sutures are applied in the same order as with a rupture of the perineum of the II degree.

Target: observe the woman in labor, notice the complication in a timely manner and take urgent measures.

Indications:

Tears of the birth canal

Bleeding from the birth canal of unknown etiology

Swift and fast delivery

Equipment:

Sterile diaper;

Vaginal mirrors;

Kornzangi;

Sterile gloves;

Sterile material, wipes;

Needle holder.

Surgical needles;

Suture material;

Scissors.

1. Explain to the postpartum woman about the need for this study.

2. Local or general anesthesia.

3. Treat the external genitals with an antiseptic.

4. Place a clean, sterile diaper under the mother's buttocks.

5. Take a mirror and a lift from the birthing bag.

6. Examine the cervix with two forceps; if ruptures are found, urgently perform suturing.

7. As the mirrors are removed, the walls of the vagina are inspected; if ruptures are found, urgently perform suturing.

8. In case of ruptures of the external genital organs, suturing is done using gauze balls.

9. The suture site is treated with an antiseptic solution.

10. Care is carried out by open and dry method.

19.Algorithm for determining the duration of contractions and pauses.

Target: timely diagnosis of labor disorders and their treatment.

Equipment: stopwatch, partogram.

1. Explain to the woman in labor about the need for this study.

2. It is necessary to sit on the chair on the right, facing the woman in labor.

3. Place your hand on the belly of the woman in labor.

4. Using the second hand, determine the time of the uterus
toned - this will be the duration of the contraction, evaluate
the force of tension of the muscles of the uterus and the reaction of the woman in labor.

5. Without removing your hands from your belly, you must wait for the next fight. The time between contractions is called the pause.

6. To characterize contractions in terms of duration, frequency, strength, pain, it is necessary to assess 3-4 contractions following each other. Record the frequency of uterine contractions in 10 minutes.

Contractions lasting 20 - 25 seconds after 6 - 7 minutes, rhythmic, good strength, painless.

Write down graphic image contractions of the uterus on the partogram.

It is customary to use the following three types of hatching on the partograph:

20. There are the following types of barrier contraceptives:
1. Female: non-drug barrier and medications.
2. Male barrier products.

How it works barrier contraceptives are to block the penetration of sperm into the cervical mucus. Benefits of barrier methods contraception is as follows: they are used and act only locally, without causing systemic changes; they have a small number side effects; they largely protect against sexually transmitted diseases; they practically have no contraindications for use; they do not require the involvement of highly qualified medical personnel.

Indications for their use:
1) contraindications for use oral contraceptives and the Navy;
2) during lactation, since they do not affect either the quantity or the quality of milk;
3) in the first cycle of taking oral contraceptives from the 5th day of the cycle, when the own activity of the ovaries is not yet completely suppressed;
3) if necessary, admission medicines that are not combined with OK or reduce their effectiveness;
4) after a spontaneous abortion until a period favorable for a new pregnancy comes;
5) as a temporary remedy before the sterilization of a man or woman.