…close to reality Obstetrical medicine background SIM one ™ www.3bscientific.com
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
…close to reality
Obstetrical medicine background
SIMone™www.3bscientif ic .com
SIMone™
Ongoing research and the continued accumulation of practical experience result in constant changes in the realm of medical knowledge. Information contained in software and product descriptions is collected with the greatest possible care to ensure that it always reflects the actual state of current knowledge. 3B Scientific GmbH cannot assume liability regarding the dosage or application of medications. The user is specifically reminded or indeed expected to always ascertain the accuracy of medical specifications in terms of dosage and the methods of application based on the latest package inserts accompanying the medications, as well as to consult other literature sources and obtain the advice of specialists in fields where this may be relevant. All doses and applications are administered at the user’s own risk. The user is advised to inform 3B Scientific GmbH of any new information or changes in accuracy of which he/she may become aware.
© 2008 3B Scientific GmbHThis publication and its components are subject to copyright laws. Any use of this information in cases other than that authorized by law, therefore, requires the prior written permission of 3B Scientific GmbH.
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
SIMone™
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
SIMone™
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).
8
SIMone™
Ill. 1a – r
ad
gj
m
p
be
hk
nq
cf
il
or
9
Ill.1
a–r
The
bir
thm
echa
nism
Usi
nga
var
iety
of
aspe
cts
illus
trat
ion
Ill.1
sho
ws,
from
left
tor
ight
,the
beh
avio
uro
fth
ein
fant
‘sh
ead
asit
mov
es
thro
ugh
the
birt
hca
nal.
Top
row
:si
dev
iew
Mid
dle
row
:fr
onta
lvie
wBo
ttom
row
:vi
ewfr
omb
elow
The
para
lleli
llust
rati
ons
are
show
ndu
ring
the
sam
est
age:
Ill.1
a–
cAt
its
entr
ance
into
the
pelv
icc
avit
y,th
ehe
adp
roce
eds,
wit
ha
virt
ually
tran
sver
ses
agit
talp
lane
,int
oth
etr
ansv
erse
ov
alp
elvi
cin
let.
Ill.1
d–
iD
urin
gth
epr
ogre
ssio
nth
roug
hth
epe
lvic
cav
ity,
the
head
mak
esa
twis
ting
mot
ion:
itp
roce
eds
mor
ede
eply
(cha
nge
ofle
vel),
ben
ds(c
hang
eof
pos
itio
n)a
ndtu
rns
(cha
nge
ofp
rese
ntat
ion)
.
Ill.1
j–l
Upo
nth
ehe
ad’s
exit
from
the
birt
hca
nal,
the
head
mak
esa
nex
tend
ing
mot
ion
(defl
exio
n),t
hus
chan
ging
its
pres
en-
tati
on.
Ill.1
m–
rAf
ter
the
head
isb
orn,
itm
akes
ano
ther
out
war
dm
otio
n,s
oth
atth
ein
fant
’sfa
ceis
faci
ngth
em
othe
r’sth
igh.
The
sa
gitt
alp
lane
iso
nce
agai
nvi
rtua
llytr
ansv
erse
.
10
SIMone™
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
12
SIMone™
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.
14
SIMone™
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
16
SIMone™
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
17
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
18
SIMone™
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
20
SIMone™
- 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
22
SIMone™
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)
24
SIMone™
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
26
SIMone™
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.
28
SIMone™
4 Amniotomy
Breakingtheamnioticsacwithaninstrumentmayshortenthelatentphaseof
labor.Thedeliveryassistantormidwifecanbreaktheamnioticsacusingasterile
amniotichook,aspiralelectrodeorsurgicalforceps
29
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
30
SIMone™
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.
32
SIMone™
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.
34
SIMone™
• 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.
35
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
36
SIMone™
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)
38
SIMone™
Notes
39
3B Scientific GmbHRudorffweg8•21031Hamburg•Germany
www.3bscientific.com•[email protected]
XP81
8GM
H_U
S09
Related Documents
