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Women Health. Causes of postpartum hypotonic bleeding high parity in obstetrics

Table of contents of the topic "Diagnosis of pregnancy. Signs of pregnancy. Pregnant examination.":
1. Diagnosis of pregnancy. Early diagnosis of pregnancy. Late diagnosis of pregnancy.
2. Signs of pregnancy. Symptoms of pregnancy. Presumable (doubtful) signs of pregnancy.
3. Probable signs of pregnancy. Objective signs of pregnancy.
4. Symptom of Gorvian - Hegare. Sign of exchange. Sign of Pischek. Sign of gubareva and Gaus. Sign of gener. Increase the uterus. Changing the consistency of the uterus.
5. Inspection of external genital organs. Inspection technique. Inspection of genital organs with mirrors. Inspection technique. Cusco mirror. Flag-like mirror.
6. Vaginal (finger) study of pregnant. Two-handed (bimanual) study of pregnant.
7. Reliable signs of pregnancy. Undoubted signs of pregnancy. Diagnosis of pregnancy on ultrasound (ultrasound research).
8. Pregnant examination. Map of pregnant. Examination in women's consultation.
9. Peditary function. What is the real pregnancy? Nulligravida. GRAVIDA. Nullipara. Primipara. Multipara.

Parity (from lat. Pario) - the presence of childbirth in history, or the number of births in the past.

-The course of previous pregnancies: There was no early toxicosis and gestosis (salivation, vomiting, swelling, etc.), diseases of the cardiovascular system, kidneys and other organs. In the case of the presence of these diseases, in the past, it is necessary to especially carefully observe a woman at a real pregnancy.

You need to get detailed information about the flow. each pregnancy of childbirth and postpartum periods. If a woman had miscarriage, then their character should be established: spontaneous or artificial, at what month miscarriages occurred, disease after it and their character. Premature childbirth and spontaneous abortions indicate genital infantilism or presence of diseases that adversely affect the course of pregnancy (endocrine disorders, infectious diseases, damage to the cervix and the coil of the uterus, etc.). In spontaneous and artificial miscarriages, inflammatory diseases of the genital organs often develop, a tendency to premature interruption of pregnancy occurs, there are incorrect generic activities and bleeding during childbirth.

-The character of previous birth(Timely, belated or premature), their current. The correct course of previous birth shows good health of the pregnant and lack of deviations from the norm in the birth paths. Complications and surgical interventions in early childbirth, still-breeding or death of a child after birth indicate possible abnormalities of generic pathways, pregnancy complications, pregnant diseases. Pathological gifts in the past (burdened obstenesis) give reason to expect the development of complications with this pregnancy and childbirth. It is necessary to identify whether postpartum diseases have been observed, since they can cause serious complications in subsequent births (genital anomalies, the increment of placenta, bleeding, the uterus break, including the header, if the previous births ended with the cesarean section, and the postoperative period proceeded with complications).

Answers to this question on the forums and in social networks are only confused, because the information that women gave the past this period will very much. The fact is that the process of the appearance of a baby into the light in each mommy passes in its own way and depends on many reasons.

Duration of childbirth

Duration of childbirth in every woman in labor is different. It is never impossible to predict how much childbirth will last, whether or, on the contrary, rapid contractions. The average duration of childbirth from the first fastement or departing of water from primary women - 7-12 hours. In women who give birth to the second child, about 7- 8 hours. Third and subsequent childbirth usually pass according to the scenario of the second or a little faster, there are no special patterns for them.

As you know, childbirth consists of three stages or periods: contractions, waiting and leaders. Read more. The main duration of time falls for the first period - contractions. It is the speed, dynamics of disclosure, smoothing and thinning of the cervix depends on parity (that is, quantities) of labor. In repeated women, the neck of the uterus can already be a few centimeters a few weeks.

In women who give birth to for the first time, the inner zev is first begins to open, and only then outdoor. Thus, the cervix opens as it were from the inside. So, the cervical opening rate depends on:

  1. parity parity;
  2. the psychological state of women - fear or, on the contrary, positive mood for childbirth;
  3. the presence of anomalies, tumors or scar changes in the uterus and neck (caesarean cross section in history, scar deformations of the cervix, coagulated cervical syndrome, myomatous nodes, counya uterus);
  4. the presence of concomitant diseases: hypothyroidism, arterial hypertension, heart disease, fever, and so on;
  5. presence of complications of pregnancy and childbirth: premature births, multi-way, gestosis, large fetus, weakness or discoordination of labor;
  6. the use of stimulating drugs and techniques: oxytocin, prostaglandins, amniotomy.

The lamp period does not have a direct dependence on parity of childbirth. The speed of expulsion of the fetus depends to a greater extent on the strength of the fights and the fence, the size of the fetus and its presence and, it is important, the behavior of the woman itself. On average, the waist period takes from 5 to 30 minutes.

The last period is absolutely independent of the number of previous birth. The placenta with the fruit shell leaves the uterine cavity on average in 5-60 minutes from the moment of the child. Since the birth of the last birth can be considered complete.

Rims: Concept, Causes and Complications

Some women dream to give birth in two hours and with pleasure listen to the stories of the girlfriends about rapid births.

Births at the primordin, which occur in 4-6 hours are considered rapid. In experienced mothers, this figure is 2-4 hours. In a separate pathology of generic activity, rapid genera are distinguished. Their duration of primary and repeatedly less than four and two hours, respectively. In fact, there is nothing good in such childbirth. A child who literally flies through the birth's paths does not have time to adapt to changes in pressure, oxygen levels and carbon dioxide, more susceptible to trauma.

Causes of rapid labor:

  1. heredity;
  2. features of the nervous system of a particular woman;
  3. hormonal disorders, such as hyperthyroidism, excess endogenous factors provoking childbirth;
  4. incorrect use of drugs for stimulating genera, opening of the octal water.

The consequences of rapid birth There are both for the child and for the mother:

  1. hypoxia fetal in childbirth due to excessive pressure of the cutting uterus on the vessels of the placenta and umbilical cord;
  2. newborn: fracture of clavicle, kefalohematomes, brain hemorrhage;
  3. generic mother injuries: cervical breaks, vagina, crotch;
  4. premature pairing placenta and massive bleeding.

Depending childbirth: concept, causes and complications

The concept of protracted childbirth has changed over the centuries many times. Another ancient healer Hippocrates said that a giving birth woman should not see more than one sunrise, that is, normal childbirth should not last more than a day. In the modern interpretation of protracted are considered to be more than 18 o'borns. For women, giving birth re-- more than 12 hours.

However, in different manuals, these figures vary, great emphasis on the duration of the so-called "anhydrous interval". After the removal of the oily waters, it should not pass for more than 12 hours, otherwise the danger of infection of the uterine cavity, shells and fetus occurs.

Causes of protracted birth

  1. pregnancy transferred over 42 weeks;
  2. premature labor when the uterine activity is insufficient for adequate generic activity;
  3. fatigue, bad sleep and food pregnant;
  4. psychological unaware of the future mother for childbirth;
  5. anomalies for the development of the uterus, scar changes in the uterus and cervix;
  6. improper presence of the fetus or insertion of the head;
  7. narrow pelvis in the woman in labor;
  8. overture of the uterus due to excess of spindle water, fetus with a large body weight, multiple pregnancy;
  9. the insufficiency of endogenous hormones of oxytocin and prostaglandins;
  10. improper use of medication to stimulate birth;
  11. ethrenal amniotomy in childbirth.

Obstechers are very wary of the protracted birth. This is quite explained, because long labor is subjected to many risks mom and child:

  1. hypoxia of the fetus, up to the intrauterine asphyxia;
  2. generic injuries of the fetus caused by long-term squeezing of the head in the birth paths;
  3. infection of the fetus, uterine cavity;
  4. the formation of urinary or straightforward fistulas in a woman with a long standing of the fetus head in the birthway.

The best option will be spontaneous, independently started birth, the fruit of normal sizes, adequate behavior of the feminine and competent leading of the genera.

Alexander Pechkovskaya, obstetrician gynecologist, especially for website

Useful video:

At the first appeal of a woman in a consultation on pregnancy, the doctor meets the general and obstetric and gynecological history, paying particular attention to the heredity suffered in childhood and the mature age of somatic and gynecological diseases, features of the menstrual cycle and reproductive function. Receive in the history of infections transmitted by sex (genital herpes, syphilis, gonorrhea, chlamydia, ureaplasmosis, mycoplasmosis, HIV / AIDS, hepatitis B and C), the use of contraceptive means.

It turns out the age and state of the health of the husband, the group of its blood and rezes affiliation, as well as professional harmfulness and bad habits, socio-economic status of the family.

With the first inspection, its body assess its physique, refine information about the initial mass of the body to pregnancy (redundant or insufficient), which matters for nutrition recommendations during pregnancy. The pregnant woman measures the body weight, blood pressure on both hands, pay attention to the color of the skin and mucous membranes, listened to the tones of the heart, lungs, palprate the thyroid gland, the mammary glands, regional lymph nodes; Assess the state of the nipples. In case of obstetric examination, the outer sizes of the pelvis, the dimensions of the diagonal conjugate and lumbosacral rhombus are determined. In the second half of pregnancy, the base height of the uterus and a stomach circumference, using external techniques of obstetric examinations (Leopold methods), determine the presence of the fetus, its position, view, attitude towards a small pelvis.

A vaginal study is performed with a mandatory inspection of the cervix and the walls of the vagina in the mirrors, as well as the area of \u200b\u200bthe perineum and anus. In women with the physiological course of pregnancy, in the absence of changes in the field of vagina and cervix, the vaginal study is carried out once, and in the future according to the testimony.

When you first visit a woman on the basis of a survey and data of an objective examination, the term of pregnancy and alleged childbirth are specified.

After inspecting an obstetrician-gynecologist, a pregnant woman is sent to a laboratory examination, as well as to those skilled in the art: the therapist, which examines it for a physiologically flowing pregnancy twice (after the first inspection of the obstetrician-gynecologist and on the period of 30 weeks), dentist, ophthalmologist and otorinolaryngologist.

The results of the first clinical laboratory survey allow you to allocate and evaluate the risk factors that threaten the normal course of pregnancy. The risk factors of perinatal pathology include socio-biological (mother's age up to 18 years or over 35 years, professional harmfulness, tobacocco, alcoholism, drug addiction); a burdened obstetric-gynecological history (high parity of childbirth, repeated or complicated abortions, operational interventions in the uterus and appendages, infertility, disintegration of pregnancy, stillbirth; the birth of children with congenital and hereditary diseases, complicated by the course of previous pregnancy); Extractive diseases (cardiovascular: heart defects, hyper- and hypotensive disorders, urinary tract diseases, blood disease, liver, lungs, hemostasis violation); Complications of real pregnancy (threat of interrupting pregnancy, pregnancy, multi-way, placental insufficiency, anemia, reserves and av0-isosentilation, improper position of the fetus, transferred pregnancy), as well as multiplodes and pregnancy, which has occurred as a result of using auxiliary technology reproductions.

In the physiological course of pregnancy, a practically a healthy woman is recommended to re-visit the obstetrician-gynecologist with the results of analyzes and the conclusions of doctors 7-10 days after the first appeal, and then 1 time per month in terms of up to 28 weeks, after 28 weeks - 2 times a month, after 37 weeks - every 7-10 days. With each re-visiting, the doctor controls blood pressure, in the second half of pregnancy, the height of the bottom of the uterus and the circumference of the abdomen is measured, evaluates the weight gain of the body of pregnant. Weekly weight gain should not exceed 250-300 g. The total weight gain of the body in one-bed pregnancy is an average of 10-12 kg, with multiple - 20-22 kg.

Laboratory examination during physiological pregnancy includes a three-year-old clinical analysis of blood (when visited, in terms of 20 and 30 weeks); urine analysis every time visiting; two-time microscopic study of the discharge vagina (at the first inspection and in terms of 30 weeks); Definition of blood type and rhesus accessories (with a rhesus-negative blood of a pregnant woman need to examine her husband to rhesia affiliation and determine the group of its blood). The reaction of the Wasserman and the blood test for HIV is made three times (when you first visited, in a period of 30 weeks and 2-3 weeks before delivery). Biochemical blood test, including the definition of sugar levels, is carried out at the first visit and 30 weeks.

All survey results are entered into a special exchange card, which is issued to the patient in 23 weeks of pregnancy.

In order to diagnose the congenital and hereditary pathology of the fetus, the ultrasound is carried out three times (in terms of 10-14, 20-24 and 32-34 weeks). Biochemical screening on the congenital and hereditary pathology of the fetus involves the study of the blood of a pregnant woman on Rarr-A and B-xG in 10-13 weeks, A-fetoprotein, B-xg at 16-20 weeks.

In addition to the diagnosis of congenital and hereditary pathology, under ultrasound, the localization and state of the placenta, the fetal growth indicators, the amount of accumulating waters, the cervix state of the uterus are determined. At the end of pregnancy, the ultrasound is carried out in order to clarify the prelation of the fetus and the determination of its intended mass. The dilacies of ultrasound during pregnancy is determined individually taking into account the state of the mother and the fetus. Dopplerometry of blood flow in the system of mother-placenta-fruit for predicting and diagnosing placental insufficiency is carried out from the end of the trimester of pregnancy.

After 20 weeks of pregnancy, with each visit to the woman, the fetal heartbeat listened, record the main results of clinical and laboratory surveys. With 32 weeks, the study of the cardiac activity of the fetus is carried out with the help of cardiotockography.

All pregnant risk groups according to the indications are sent to a consultation to the relevant specialists to solve the issue of pregnancy prolongation and make up an individual plan for further reference with the clarification of the timing of prenatal hospitalization and the definition of a hospital for ancestration. Pregnant clarify the need for surveys and hospitalization according to indications.

Special observation requires smokers pregnant, consumed alcohol or narcotic drugs. In such cases, pregnant women should be convinced to refer to the psychiatrist narcologist at the place of residence in the interests of preserving his health and health of the future child. Further observation of pregnancy, as well as after childbirth, an obstetrician-gynecologist is carried out with the implementation of the recommendations of the psychiatrist-narcologist.

Pregnant, infected HIV, are observed by an obstetrician-gynecologist of women's consultation together with an infectious person who appoints courses of relevant therapy in coordination with the territorial center for the prevention and control of AIDS and defines the hospital for the delivery.

Providing a sheet of disability to pregnant and maternity hospitals.Pregnant women in our country enjoy many benefits. From the moment of establishing pregnancy, women are not allowed to work in adverse conditions, at night. Pregnant women from the 4th months of pregnancy are not attracted to overtime work.

When transferring to the lightweight work for pregnant women, salary remains at the rate of last 6 months.

Provided benefits contribute to the correct course of pregnancy and the development of the fetus in favorable conditions. Complete use of all these benefits depends on the timely and correct definition of the period of pregnancy.

A sheet of disability is issued with 30 weeks of pregnancy at a time duration of 140 calendar days. With multiple pregnancy, a sheet of disability on pregnancy and childbirth is issued from 28 weeks, while the total duration of the prenatal and postpartum vacation is 180 days.

With complicated births, women, including non-resident, disability sheet is issued additionally for 16 calendar days a medical and prophylactic institution where childbirth occurred. In these cases, the total duration of the prenatal and postpartum vacation is 156 calendar days.

At childbirth, up to 30 weeks pregnancy, and the birth of a living child, a leaflet of disability on pregnancy and childbirth is issued to a medical and prophylactic institution where childbirth occurred, 156 calendar days, and in the case of the birth of a dead child or his death within 7 days after delivery - 86 calendar days.

A sheet of disability on an anatomous vacation duration of 90 calendar days is issued to women living in settlements undergoing radioactive pollution. The total duration of maternity leave is 160 days.

A woman who adopted a newborn, a sheet of disability issues a hospital at its birth site for 70 calendar days from the birthday.

With an extracorporeal fertilization and "embryo transfer", a disability sheet is issued for a period of hospitalization before establishing pregnancy.

Basics of rational food pregnant women

The principles of rational food of pregnant women concluded in the preferential consumption of proteins, a sufficient number of fats and in the restriction of carbohydrates. The diet is individually taking into account the initial mass of the body and the flow of pregnancy. With overweight, the energy value of food is reduced by carbohydrates and fats. Pregnant with reduced body weight follows, on the contrary, to increase the energy value of the diet with the preservation of the correct ratios of the main ingredients.

If in the first half of pregnancy the power mode can be relatively free, then in the second half it is necessary to approach it more strictly. In the second half of pregnancy, food techniques must be more frequent (5-6 times a day).

From products containing proteins and indispensable amino acids, non-fat boiled meat, chicken, fish, lactic acid products (kefir, cottage cheese, cheese), milk, eggs. It should be excluded from the diet roasted meat, sharp dishes with spices, smoked meats, meat soups. The number of vegetables and fruits is not limited, they allow you to painlessly reduce the consumption of the cooking salt (up to 8 g against ordinary 12-15 g).

At the beginning of pregnancy, the amount of liquid (water, soups, compotes, tea, juices, milk, sweets) are not limited. In the second half of pregnancy, it is possible to use only 1.5 liters of fluid per day in order to avoid the development of edema.

During pregnancy, especially in the second half, the need for calcium increases (calcium is consumed to build a skeleton and soft tissues of the fetus). In this regard, some women increase the likelihood of caries. The daily dose of calcium in the first half of pregnancy is 1 g, in the future - 1.5 g, and at the end of pregnancy - 2.5 g per day. As a rule, rational food with the inclusion of calcium-containing products (cheese, egg yolk, milk) provides the need for pregnant in calcium.

The food should be enough iron, the daily need in which 7 mg is during pregnancy. Without an exogenous addition, almost no pregnant can be considered secured by the necessary amount of iron, the disadvantage of which leads to iron deficiency anemia. It is recommended to use products rich in iron: liver, red meat, beans, green vegetables, dried fruits, grain bread.

During pregnancy, about twice the need for vitamins, which are necessary both for the physiological flow of metabolic processes in the mother and for the correct development of the fetus are increasing. The high need for vitamins is satisfied, in addition to food, additional appointment of drugs of vitamins and trace elements, especially in winter and spring. Of particular importance, the additional intake of vitamins has for pregnant women with multi-flow, for smoking patients. Strict vegeteriants are prescribed vitamin B12.

An additional intake of folic acid (before the occurrence of pregnancy and in its early terms) reduces the risk of the anomalies of the development of the BSN of the Fetal (defects of the nervous tube).

Mode and Personal Hygiene Pregnant

Pregnancy is a physiological process, requires changing the operation and compliance with hygiene rules. In accordance with the legislation, pregnant women are exempt from work at night associated with the rise and movement of weights, vibration, exposure to high temperature, increased radiation or chemical substances that have a harmful effect on the fetus. It is also recommended to temporarily limit the classes of sports that are associated with severe exercise.

A sedentary lifestyle (hypodynamia) can also adversely affect the course of pregnancy and childbirth, and therefore pregnant women are recommended at any time of the year to perform outdoor walks. The duration and pace of walking should be contracted with the degree of training, age and the state of health pregnant.

A calm dream is very important to a duration of at least 8 hours in a well-wedrid room. The use of sleeping pills is undesirable, the drugs and Valerian drugs are prescribed according to the indications.

Sex hygiene issues deserve attention. A sex life should be limited in the first 2-3 months and in recent months of pregnancy. More stringent restrictions relate to patients with the threat of abortion and with a complicated obstetric anamnesis.

Pregnant should avoid contact with patients with infectious diseases. It is necessary to eliminate all the foci of infection, which arose before and during pregnancy (tonsillitis, caries and other inflammatory diseases of the dental profile, colpit, furunculese, etc.)

Skin care during pregnancy is very important. To ensure complex skin functions, it is necessary to monitor its purity (shower, wipes). This contributes to excretory, respiratory and other functions of the skin, has a beneficial effect on the vascular and nervous system, regulates the dream and other activities of the body. The intensive action of sun rays should be avoided. To prevent the occurrence of eaves of pregnancy on stomach and dairy glasses, it is recommended to use special creams.

The prevention of the cracks of the nipples and mastitis is in the daily kneading glands of water temperature with the subsequent rubbing of a terry towel. With dry leather 2-3 weeks before childbirth, it is useful to lubricate the skin of the mammary glands daily daily, including AREOLU, neutral cream (children's cream, etc.). Air baths for the mammary glands spend 10-15 minutes several times a day. With flat and drawn nipples, a massage is recommended to which a woman teaches a doctor or midwife.

The clothes of the pregnant woman should be comfortable, not disturbing the respiratory, excretory, thermostatic and other skin functions. You should wear comfortable bras that do not constrain the chest. In order to avoid stagnant phenomena, the dairy glands should be in a raised position. In the second half of pregnancy, we recommend wearing a special prenatal bandage.

Principles of pregnant women to childbirth

Physiopsychoprophylactic preparation includes individual conversations and lectures (psychoprophylactic preparation); classes with special gymnastics; The use of natural factors (light, air, water) to promote health and the use of physical therapy tools.

Psychophylactic preparationit is aimed at eliminating negative emotions and the formation of positive conditionaloreflex relationships - the removal of fear of childbirth and generic pains, attracting to active participation in the generic act.

Psychophylactic preparation significantly reduces generic pain, provides multilateral, in particular, the organizing, influence on a woman contributes to a favorable course of pregnancy and childbirth.

The method is absolutely harmless to mother and fetus, therefore there are no contraindications to its mass application. The disadvantage is the need for painstaking and long-term individual work with the patient.

The method of psychoprophylactic training was proposed in our country. Velvovsky and k.I. Platonov (1940). Later, the method was improved by G.d. Read (1944), F. Lamaze (I970) and found widespread in many countries of the world.

The main objectives of the psycho-physiological preparation of pregnant women to childbirth:

To develop a conscious attitude towards pregnancy, teach to perceive childbirth as a physiological process;

Create a good emotional background and confidence in a favorable course of pregnancy and the completion of childbirth;

Teach mobilize your will to overcome fear before childbirth.

At the first meeting with a pregnant, it is necessary to find out its attitude towards pregnancy, family relationships, education, profession, mental injuries, to establish a pregnant woman's representation about childbirth (fear of childbirth, fear of pain). It is important to find out the characterological features of pregnant women, its emotional and volitional qualities. Pregnant women with psychological problems can be sent to a consultation to a medical psychologist or psychotherapist.

Along with the individual psychoprophylactic work, which an obstetrician-gynecologist conducts a pregnant woman with each visit, recommended group classes on psychoprophylactic preparation for childbirth.

The interior of the Cabinet for group classes should create psychological comfort in the patient. The office should have a couch or comfortable chairs, a set of visual material (drawings, tables, slides, movies) to clarify the generic act.

For psychoproprophylactic training, groups of 6-8 people are formed, preferably taking into account the psycho-emotional status of patients.

Classes start with 33-34 weeks of pregnancy, spend weekly during the month (4 classes of 25-30 minutes). The first lesson may last about an hour.

First lessonconsists of introductory and main parts. In the introductory part, they stop in the management of activity in childbirth by volitional effort. You can train autogenic workout and finger self-massage of certain areas (crescents, lower abdomen). The use of finger self-massage in childbirth contributes to the removal of psycho-emotional voltage and a decrease in generic pain.

The main part reports brief information about the structure of female genital organs, the development of the fetus, the mother-placental-fruit system. Stress that the uterus is an environment for the fetus. It is necessary to submit a childbirth as a natural physiological act, explaining the periods of childbirth, to draw the attention of pregnant women to the ability to distribute their strength in childbirth, to instruct the medical personnel.

To secure the skills gained pregnant women, it is recommended to repeat the occupations of the house for 7-10 minutes.

On the second lessonthe doctor explains the physiology of the first birthday period. Position the mechanism of bouts that contribute to the disclosure of the cervix. Pregnant women are offered techniques to reduce soreness of bruses, explain how to breathe in the time of contractions and remove the muscle tension between the fights (stroking the lower parts of the abdomen with palms from the midline to the sides; when the position on the side is pressed with thumbs on the crushes; when the back is on the back Make a front for ridges of pelvic bones).

On the third lessonpregnant familiar with the course of the second period of childbirth. Explain what swells are and how to facilitate the right birth of a child. Inform about the last and early postpartum period, about blood loss in childbirth. I am convinced that it is important to carry out the recommendations of the midwife in the process of childbirth, carry out training with breathing delay and, on the contrary, with frequent surface breathing. Tell me how to stand.

On the fourth lessonbriefly repeat the entire course of previous activities and secure acquired skills and techniques.

Physical exercises It is recommended to carry out early pregnancy. These exercises are aimed at training the breath and muscle group, which will have to be especially intense work during childbirth (abdominal press, pelvic bottom muscles). Claims on physical training are carried out under the guidance of an instructor on therapeutic physical education.

Prenatal diagnostics

Prenatal diagnosis is aimed at identifying congenital defects of the development and chromosomal diseases of the fetus in terms of pregnancy up to 22 weeks. Prenatal diagnosis includes medical and genetic consulting, non-invasive (ultrasound, study of biochemical serum markers in I, II trimesters) and invasive (biopsy of chorion, amniocentesis, cordocentsis, placentocentsis) examination methods, as well as preimplantation diagnostics with vitro incense.

When forming a risk group for congenital anomalies of the fetal development, the following factors should be considered:

Mother's age over 35 years old;

The presence in the family of a child with congenital pathology;

Hereditary diseases in the family, blood relationship of spouses;

Professional and environmental harm;

Alcoholism, drug addiction;

Infertility, frossable pregnancy, spontaneous miscarriages in history;

Threat to interrupt, receiving teratogenic drugs, viral infections in the first trimester of this pregnancy.

Approximately 13% of pregnant women who are not included in the risk group are born children with congenital anomalies, therefore screening studies are shown in early pregnancy.

Screening (non-invasive) methods of prenatal diagnostics include: ultrasound in 10-13 and 20-22 weeks; Determination of the level of RARR-A (plasma protein associated with pregnancy) and B-xG in 10-13 weeks, A-FP and B-xG in 16-20 weeks).

With an ultrasound of 10-13 weeks, the visualization of the coarse defects of the development of the central nervous system (aenencephalia, meningocele, volumetric spinal cerebral hernias, the agenies of organs, large skeletal anomalies) are available. The echographic markers of chromosomal pathology in the first trimester of pregnancy are non-immune waterfront of the fetus, ommophalcela, anesthesia, or aplasia of the nasal bone, megazis (enhanced urine bubble), a non-compliance (decrease) of the Kopchiko-Dumpy Embrycotia term of the gestation. Of great importance is attached to an increase in the thickness of the collar space (Fig. 8.1) - the echonegative zone between the skin of the fetus and the soft tissues of the cervical spine.

Fig. 8.1. Swelling of collar space

With ultrasound in the II trimester of pregnancy (20-22 weeks), it is possible to diagnose almost all anomalies for the development of the fetus. The spectrum of markers of chromosomal pathology of the fetus detected in the II trimester is much wider than in the first trimester. These include cysts of vascular plexuses of side ventricular brain, excess cervical fold, ventriculomalia, abnormal shapes of the skull ("strawberry", "lemon") and cerebellum ("banana"), pyelectasia, cystic neck hygroma, intestinal hyperochogeneity, non-immune fetal Symmetric form of fetal growth delay (Fig. 8.2).

Fig. 8.2. Cystic hygroma neck (1 - fetal head; 2 - hygroma)

Detection of malformations in the I and II trimesters serves as a basis for interrupting pregnancy. Ecomarkers of chromosomal pathology determine the testimony for karyotyping of the fetus.

To screening methods for the diagnosis of congenital and hereditary pathology of the fetus also include determining the level biochemical serum markers In the blood of the mother (Rarr-A, A-FP, B-xG). The levels of RARR-A and B-XG are determined in 10-13 weeks, A-FP and B-xG - at 16-20 weeks.

During pregnancy, the fruit with Down syndrome is the level of RARR-A and below, and the level of B-xG is higher than the norm for the respective gestational terms.

The increase in the concentration of A-FP and the reduction in the level of B-xG in the blood of the mother may indicate the defects of the development of the central nervous system (anencephalia, encephanycele, the spinal out hernia), the front abdominal wall (ommophalcela, gastrossisis), persons (splitting the upper lip and solid sky). The reduction in the level of A-FP is associated with an increased risk of Down syndrome in the fetus.

Deviations from the rate of RARR-A levels, A-FP and B-xG are not absolutely specific to congenital pathology of the fetus. At the levels of biochemical markers affect:

Pathology of placenta: hypo- and hyperplasia, cysts, tumors, sections of detachment;

Body mass of pregnant;

Sugar diabetes, liver disease, prestosis;

Resh conflict;

Multipleness, frozen pregnancy, threat of miscarriage, intrauterine fetal death.

By risk factors, as well as according to the results of screening surveys (ultrasound 10-13 and 20-22 weeks, Rarr-A and B-xG in 10-13 weeks, A-FP and B-xG in 16-20 weeks) form indications to invasive methods of prenatal diagnostics.

The effectiveness of the diagnosis of chromosomal pathology increases when using computer programs, calculating the individual risk of the hereditary disease of the fetus. These programs take into account the age of the patient, the term of pregnancy, the thickness of the collar space, as well as the levels of biochemical serum markers. The risk of the chromosomal pathology of the fetus of more than 1 to 250 is considered high (threshold) and is an indication for invasive prenatal diagnosis in order to karyotyping the fetus.

TO invasive methods Predatal diagnostics, allowing to carry out a cytogenetic study of fruit tissues, include chorion biopsy (8-12 weeks), amniocentesis (16-22 weeks, including early 13-14 weeks), cordocentsis (from 22 weeks), placentocentsis (II Trimester ), Fetal tissue biopsy (II trimester). The choice of the method of invasive intervention depends on the period of pregnancy and on the technical capabilities of the laboratory.

Indications for the use of invasive methods of prenatal diagnostics: echomarkers of chromosomal pathology of the fetus, changes in the levels of biochemical markers in the serum of a pregnant woman, as well as a high risk of a child with chromosomal pathology (more than 1 to 250).

Invasive methods of prenatal diagnostics make it possible to diagnose all forms of chromosomal pathology of the fetus, to determine the gender of the fetus, as well as to carry out the molecular diagnosis of a number of common hereditary diseases (hemophilia, phenylketonuria, fibrosis, Miodistrophia Duzhenna, etc.).

Preimplantation genetic diagnostics.In recent years, a preimplantational genetic diagnosis has been carried out during extracorporeal fertilization.

Chromosomal defects are detected by biopsy of the embryo at stage 6-8 blastomeres (Fig. 8.3) or polar taurus (Fig. 8.4).

Fig. 8.3. Embryo biopsy in stage 8 blastomeres

Fig. 8.4. Biopsy Polar Taurus

Preimplantation diagnostics in vitro in vitro fertilization makes preventing embryos with genetic diseases.

Birth is a natural programmed process that proceeds at certain stages. The disclosure of the uterine zois turns into the next stage. The second period of childbirth begins from the moment of the attachment of the fence - an irresistible desire to fit. This is the time of expulsion of the fetus, one of the most responsible moments. The health of the child's health and integrity of the mother's pathways depends on the correct behavior of the feminine and skills of midwifery.

Features of a wave period

An indicator of the beginning of the second period of childbirth is the complete disclosure of the uterine zoom. Fights are added to the fights - the desire that reflexively occurs. At the same time, by the time of the maximum fight, the muscles of the press are strained, which help to drive out the fruit. But this happens gradually: the form of the generic paths is not perfect, there are protruding sections of the bones of the pelvis. Therefore, the fetus head must be configured - acquire the form of the generic channel. This happens due to the displacement of the cranial box bones relative to each other, the neglected spring makes it easy to change the form.

The skull of the child fits tights to the tissues of the generic canal. Below the belt of contact is disturbed by the outflow of blood and lymph, the physiological edema is developing - a generic tumor. A few days after birth, it passes without a trace.

The duration of the 2 birthday period depends on how many times and how often a woman gave birth. The average duration of the second period of primary 30-60 minutes. For those women who came to the hospital re-this stage lasts 15-20 minutes. If the Hife has high parity (frequency and quantity) of childbirth, then this time can decline.

For the birth of a child, 5-10 pots are enough. A woman should carefully listen to the teams of midwives and a doctor that the physiological process does not become pathological. The second period should last no more than the maximum period. Otherwise, it threatens a circulatory disorder in a placental system, which suffers from the cervical spine of the child.

Medical Help

After the vaginal examination, the doctor can estimate the state of the uterine and diagnose the full disclosure. It is recommended to take the position on the side. In this case, the following happens:

  • the head is easier through the axis of a small pelvis;
  • the tone of the uterus decreases slightly;
  • improves placental blood flow;
  • frequency increases.

Artificial stimulation of generic activity at this point is contraindicated. It can lead to anomalies insertion of the fetus head. It is necessary to wait for her natural omission to the pelvic bottom. It is also not recommended to be stuck.

The fruit is moving gradually. First, the crotch is protruding. Then, from the stagnation of venous blood, it acquires a blue shade. The upper pole of the head becomes noticeable in the opened floor slot. She can hide several times after dyuch. But gradually it is cutting down: after the end of the contraction, the head remains in place.

The maintenance of the second birth period provides for manual obstetric benefits - manipulations that help prevent the development of complications. The fetal head at the time of teething from the germ is inflicted. The midwife must restrain it a bit so that the extension does not happen before. Then the head passes through the generic path with its smallest size - 32 cm around the circumference.

The crotch protection from breaks is made by reducing the voltage in it. Obstep Hands helps to pull the fabrics on the head of the fetus. Protect the crotch helps her stretching outside the dyg. At this time it is very important to listen to the midwife and the doctor who lead the process. They may instruct the battle in the absence of contraction. It is necessary that the birth of the head occurred with the smallest tissue tension.

If there are signs of a threatening break, then at this moment they produce a crotch cut. Manipulation is performed on a maximum of contractions. The need for episiotomy is explained by lighter healing of the cutting wound than torn.

Before the birth of the head, it is important to control the child's condition. When there is a stance, blood flow in the placenta, which is why the state of the fetus suffers. Fetal heartbeat is controlled after each sweat by listening to an obstetric stethoscope - a special short tube. If after the fight the slow heartbeat was not restored, then children's resuscitors are invited to the Rodzal, who will be engaged in a child after birth.

After the birth of the head of the midwife helps to free her hangers, while the head makes a small turn. Usually, the shoulders are born on their own, but sometimes assistance is needed. For this, the midwife captures the child behind the head and pulls her down a little bit down a little, so that one shoulder spawned from under the Lonnoy Junction. Then the child is lifted up, the back shoulder is born. The rest of the torso comes out without difficulty. The second period of childbirth ends after the birth of the child.

Possible complications

Incorrect behavior of feminine and inadequate medical care can lead to complications. The duration of the second birth period is different for first and repeated. But the excess of this time can lead to intrauterine. The lack of oxygen may affect the general condition, the newborn will need to help resuscitatologists.

Dangerous long standing of the fetus in one position in the birth paths. In such children after birth, instead of a generic tumor, a cheefalohematoma can be formed - hemorrhage in the region of the skull's periosteum. This requires careful observation of the child and treatment in the postpartum period.

The second period should include 5-10 dyg. With the right benefit of this quantity. More prolonged sweats lead to a violation of blood flow in the cervical department. It is fraught with:

  • hemorrhage in the spinal cord or his shell;
  • supervision and increasing vessel permeability;
  • partial or complete gap of the spinal cord.

Treatment of these states occurs hard, often they are the cause of children's cerebral paralysis.

Rapid childbirth, uncontrolled midwives are dangerous not only for feminine, but also for a child. They can lead to the following complications:

  • gap of the vagina;
  • injuries of soft tissues (hematoma);
  • defeat of the nervous system of the newborn.

In case of difficulty, the appearance of the shoulders, especially in large fruits, sometimes there is a fracture of the clavicle. Often fractures occur with the butt-made preservation of the child.

The sign of the beginning of the second period of childbirth in the form of a complete disclosure of the oz and the appearance of the feeness requires increased attention. At this moment, the preparation is carried out to the reception of the girlfriend, the doctor no longer departs from the bed of pregnant. Women with a high parity before cutting heads are translated into an obstetric chair, because The birth of the child proceeds faster.

Firstborn suggests to practice the battle in bed. As soon as the head is finally cut and stops riding in the sex harness between the fights, the woman is neatly translated into the roar. The favorable outcome depends on the further concerted actions of the guinea and midwife.

About the first period of childbirth (as it flows, how many lasts, what to prepare for), read in the previous article, by.

In most European countries, multiple pregnancy ranges from 0.7 to 1.5% of all pregnancies.

Since the auxiliary reproductive technologies, the ratio of spontaneous (i.e. arising from Eco) and induced pregnancy, have changed, are actively used (i.e.) of multiple pregnancy: 70 and 30% in the end of the 90s years, respectively.

The main factors contributing to multiple pregnancies include: Mother's age older than 30-35 years old, hereditary factor (on the maternal), high parity (large, over 3x, quantity), uterus development anomalies (doubling), occurrence of pregnancy immediately after stopping the use of oral contraceptives, against the background of using funds for Stimulation of ovulation, with eco.

The prevention of multipleness is possible only when using auxiliary reproductive technologies and is to limit the number of portable embryos.

CLASSIFICATION

Depending on the amount of fruits in multiple pregnancy, they speak about twins, triple, fourth, etc.

Two varieties of twins are distinguished: Double (blade) and one-way (monosigital). Children born offered twins are called "twins" (in foreign literature - " fraternal »or " nOT Identical."), And children from one-way twins - twins (in foreign literature -" identical"). "Twins" can be both one and different floors, whereas "Gemini" are only one-sex.

Double double - The result of the fertilization of two eggs, the ripening of which, as a rule, occurs during one ovulatory cycle in both the same and both ovaries.

In the literature, describe cases " superfetation."(The interval between fertilization of two eggs is more than one menstrual cycle) and" superfeCundation"(Egg fertilization of eggs occurs during one ovulatory cycle, but as a result of various sexual acts). For diavigot Double Each embryo / fetus is formed its own placenta, and each of them is surrounded by its own amniotic and chorial shells, therefore, the intermedicular partition consists of four layers. Such a two-day twin called bichorial Biamniotic. The frequency of bilayer twins (among the two) is 70%.

For single-sided twin One egg cell is fertilized. The number of emerging placenta with this type of twins depends on the period of dividing the single fertilized egg. If division occurs during the first three days after fertilization (up to the Morula stage), two embryos are formed, two amnions, two chorions / placenta. The intermedicular septum, as well as during the bilayer double, consists of four layers. Such a single-line twin is also called bichorial Biamniotic.

When the division of the egg takes place in the range of 3-8 days after fertilization (at the blastocyst stage), two embryos are formed, two amnions, but one chorion / placenta. The intermedicular septum consists of two layers of amnion. This type of one-way twins is called monochorial biamniotic.

When dividing an egg in the interval 8-13 days after fertilization, one chorion is formed and two embryos, surrounded by a single amniotic shell, that is, there is no intermedicular partition. Such a single-fledged twin call monochorial monoamniotic.

The result of dividing fertilized egg in a later date (after the 13th day), when embryonic discs are already formed - comedy twins.

DIAGNOSTICS

Prior to the introduction of an ultrasound in obstetric practice, a diagnosis of multiple pregnancy was often established in the later dates or even during childbirth.

Assuming the presence of multiple pregnancy is possible in patients who have the size of the uterus exceed the gestational norm both in a vaginal study (in early time) and in the outdoor obstetric study (in late terms). In the second half of the pregnancy, it is sometimes possible to recharge a lot of small parts of the fetus and two (or more) large running parts (fruit heads). Also, the symptoms are suspended in different parts of the uterus cordial tones of fruits. Cardiac activity of fruits in multi-flow can be recorded simultaneously when using special cardiomonitors for twins (equipped with two sensors).

The basis for the diagnosis of multiple pregnancy in modern obstetrics - ultrasound. The ultrasound diagnosis of multipleness is possible since early pregnancy terms (4-5 weeks) and is based on the definition of several fruit eggs and embryos in the uterine cavity.

The course of pregnancy

Multiple pregnancy - Serious test for the body of a woman: a cardiovascular system, light, liver, kidneys and other organs function with high voltage. Maternal morbidity and maternal mortality in multiple pregnancy increases in 3 times compared with one-lodge; At the same time, the higher the procedure for multiplot, the higher the risk of maternal complications.

In women with combined somatic diseases, they note their aggravation in almost 100% of cases.

Frequency of development toxicosis of the second half of pregnancy (gestosis) in women with multi-flow reaches 45%. With multiple pregnancy, gestosis, as a rule, occurs earlier and proceeds heavier than in one-bedless pregnancy, which is explained by an increase in the volume of placental mass ("hyperplactosis").

Anemia, the frequency of which in pregnant women with twins reaches 50-100%, consider "ordinary" complication, which is associated with an increase in intravascular volume. Physiological anemia with multipleness is more pronounced. A significant increase in erythropoese (erythrocyte formation) during pregnancy doubles can lead in some patients to the depletion of limited iron reserves and play the role of a starting mechanism in the development of iron deficiency anemia.

Multiple pregnancy is often complicated delay of the growth of one of the fruits, the frequency of which is 10 times higher in case of unionless pregnancy and constitutes with mono and bichorial double 34 and 23%, respectively. More expressed dependence on the type of placentating the frequency of the growth of the growth of both fruits: 7.5% with monochorial and 1.7% with a bichorial double.

One of the most frequent complications of multiple pregnancy - premature birththat may be the result of opposing the uterus. At the same time, the more fruit, the more often the premature births are observed. So, when twin, childbirth, as a rule, occur in 36-37 weeks, with triple-in 33.5 weeks, at the fourth-in 31 weeks.

Pregnancy

Patients with multi-flow d olna visit female consultation more oftenThan with one-bedless: 2 times a month to 28 weeks (when a sheet of disability is issued for pregnancy and childbirth), after 28 weeks - once every 7- 0 days. During pregnancy, the patient should visit the therapist three times.

Given the increased need for calorieness, proteins, minerals, vitamins for multiple pregnancy, special attention should be paid to issues of complete balanced nutrition Pregnant. Optimal with multipleness, unlike single-lodge pregnancy, total gain of 20-22 kg.

Pregnant with multi-flow from 16 weeks are prescribed Antianemic therapy (oral taking iron-containing preparations and folic acid for three months).

For Prevention of premature births Pregnant women with multi-flow recommend restriction of physical activity, an increase in the duration of the day relaxation (three times of 1 h). Expand the testimony for the issuance of the hospital sheet. Multi-flow maternity leave is 194 calendar days and is issued on 28 weeks of pregnancy.

Dates of pregnancy from 22-24 to 25-27 weeks - "Critical" for pregnant women with multipleness with respect to the risk of premature births.

The flow and maintenance of labor

Caring for multiplodies characterized by high frequency of complications: Primary and secondary weakness of generic activity, premature oral influence, falling out of the pupil loops, small parts of the fetus. One of the serious complications in childbirth is a premature detachment of a normal placenta of the first or second fetus. The cause of the detachment after the birth of the first fetus can be a rapid decrease in the volume of the uterus and the decrease in intrauterine pressure, which represents a special danger in monochorial double.

Rare (1 per 800 pregnancies twins), but a heavy complication - the crollizer of fruits in the pelvic preview of the first fetus and the head preview of the second. At the same time, the head of one fetus clings to the second head and they simultaneously enter into the input of a small pelvis. When the twins collision, an emergency caesarean section is used by the method (COP).

In the postpartum and early postpartum period due to the emotions of the uterus possible Hypotonic bleeding.

The method of delivery is depends on the prelationship of fruits. The optimal method of roostening with the head / head presence of both fruits - childbirth through natural generics, with the transverse position of the first fetus - COP. Pelvic preview of the first fetus at primible - indication for the COP.

When heading the first and pelvic preview of the second selection method, childbirth through natural generic paths are served. In childbirth, the outer turn of the second fetus is possible with the transfer of it to the head preview under the control of the ultrasound.

The greatest risk for fruits is childbirth for monochorial monoamniotic double, which requires particularly thorough ultrasound monitoring for the growth and state of fruits and at which, in addition to specific complications inherent in monochorial twins, often observe clear Pupovin.

The optimal method of the delivery is the type of multipleness consider CS in 33-4 weeks of pregnancy. By the COP, the delivery is also carried out with the twins (if this complication was diagnosed late).

In addition, the indication for the planned COP is considered to be pronounced fragrance of the uterus at the expense of large children (total mass of fruit 6 kg or more) or multi-way. When pregnancy, three and more fruits also show the root separation by the COP in 34-35 weeks.

The question of the COP during childbirth during multiple pregnancy can also stand for other reasons: persistent weakness of generic activity, loss of small parts of the fetus, cord loops with a head preview, symptoms of acute hypoxia of one of the fruits, pairing placenta and others.

What you need to know the future mom:

If you expect twins, you need to be fully and rationally feed, the caloric content of the diet must be no less than 3500 kcal per day.

Preventive reception is required charity preparations.

Common body weight gain for pregnancy It should be at least 18-20 kg, while the weight gain in the first half of pregnancy is important (at least 10 kg) to ensure the physiological growth of fruits.

Day holiday needed! As for physical activity, it also needs to be reduced. If you before pregnancy led an active lifestyle and engaged in sports, then the offensive of pregnancy does not mean, of course, that now you need to heal in the bed and lie the deck to the birth. Not at all. It is about to reduce the load, avoid strength and aerobic training. Perfect classes in the pool, yoga, pilates, etc. If you have never drove yourself in the gym, then pregnancy, especially multiple, is completely inappropriate time for the start of sports. You can afford only completely commemorative exercises. Why? Because there is a formidable complication, as unbearable in multiple pregnancy, especially relevant.

Regular visits to women's consultation is required!

Confidence and positive attitude - beautiful allies. Therefore, keep peace of mind, fulfill the recommendations of your doctor and no complications will not be overtaken.