Childbirth outside the hospital: features of first aid at the prehospital stage. When to call an ambulance during childbirth

When contacting the medical unit of the unit, omedb, hospital that do not have maternity ward, women with the onset of labor, rupture of amniotic fluid, bloody discharge from the genital tract or puerperal must be provided urgent hospitalization to a maternity facility. Obstetric benefits are provided on the spot to women in labor during the period of exile and in the afterbirth period. Symptoms of the period of exile: the appearance of attempts (attachment to regular contractions of muscle contractions abdominals), protrusion of the perineum, gaping of the anus, insertion of the fetal head (with cephalic presentation).

First and pre-medical care

Urgent hospitalization.

Medical emergency

Medical Center

When contacting a part of a woman with labor that has begun on the spot, decide on the possibility of delivering a woman in labor to a hospital or calling a specialist doctor to a woman in labor; in case of impossibility of hospitalization - reception of childbirth.

Omedb, hospital

The position of the woman in labor is lying on her back with her legs bent at the hip and knee joints. The fetal head is removed by unbending it after fixing the suboccipital fossa under the pubic arch. They raise their heads. After the birth of the posterior handle of the fetus, its chest is covered with both hands, placing the thumbs on its front surface. With a slight upward pull, the birth of the lower part of the fetal body occurs without difficulty.

According to the indications, a perineal dissection (perineotomy) is performed. In order to prevent bleeding in the postpartum and early postpartum period, at the time of the eruption of the fetal head, a woman in labor is injected intramuscularly with 1 ml of oxytocin (pituitrina). Immediately after the birth of the newborn, the contents are aspirated from the respiratory tract, then the umbilical cord is crossed between two clamps at a distance of at least 30 cm from the umbilical ring. The newborn is swaddled with a clip on the umbilical cord without removing the cheese-like lubricant from skin and wrapped in a blanket. After the birth of the child, the woman is urinated with a catheter.

In the postpartum period - control over the condition of the woman, the amount of blood loss and the appearance of signs of separation of the placenta. If there are signs of separation of the placenta, the woman in labor is offered to push.

To date, childbirth is positioned as a normal process of the body for the expulsion of the fetus, fetal membranes and placenta from the uterus through birth canal. At the stage of providing primary medical care rescuer may encounter different periods childbirth, in which it is necessary to provide different types benefits.

Everyone should be able to diagnose the period of childbirth and the birth itself medical worker, as well as every physician should be able to choose the right tactics reference.

When does an out-of-hospital birth occur?

Most often, such births occur during premature pregnancy, in multiparous women.

Classification of genera

There are genera:

1. Premature. The pregnancy ended at 22 to 37 weeks. As a result of such births are born premature babies. These children are characterized by low body weight (500 g - 2500 g), body length from 19 to 46 cm, immaturity of all organs and systems;
2. Urgent ( normal childbirth ). These births begin at 38 to 42 weeks of gestation. As a result, a child is born with a body weight of 3200 g and a height of 46 cm;
3. Overdue. The pregnancy ended at more than 42 weeks. At the same time, the child shows signs of postmaturity, and these are narrow fontanelles and sutures, dry skin, dense skull bones. With such childbirth, the baby is often born with injuries;
4. Physiological;
5. Pathological.

Tactics in the management of childbirth outside the hospital

1. It is necessary to resolve the issue of transporting a woman in labor to a hospital;
2. Collect anamnesis: how many pregnancies and childbirth were there before, the course and complications in them;
3. Determine position real pregnancy, that is, a general increase in body weight, the possibility of a threat of interruption, changes in urine and blood tests, changes in blood pressure over time. These details must be marked on the exchange card;
4. Conduct an objective study and assess the condition;
5. Determine what period of childbirth is at the moment;
6. 6. Examine the position of the fetus in the uterus using four methods of external examination;
7. Listen to the fetal heartbeat;
8. To assess the nature of the discharge from the genital tract of the woman in labor;
9. If it is necessary to carry out a vaginal examination;
10. Establish a diagnosis of childbirth;
11. Hospitalize in a specialized obstetric and gynecological hospital. If there is no possibility of transportation, childbirth should be taken on the spot.

Taking birth at home

Before childbirth, a woman is given a cleansing enema, the hair in the perineal area is shaved, and the external genitalia are washed with clean, warm water and soap. After that, bed and underwear is changed. An oilcloth is placed under the sheet. A homemade pillow wrapped in sheets is also used, which is also placed under the pelvis of the woman in labor. This pillow is called a polster. The polster is needed to open free access to the perineum.

The biomechanism of childbirth, or how to understand that childbirth has begun?

This term refers to a complex of rotational and translational movements of the fetus passing through the birth canal.

The first stage is the insertion of the head into the small pelvis with its oblique size.

The second stage is the internal rotation of the head. The head passes through a wide part of the pelvic cavity with moderate flexion by one of the oblique dimensions. The internal rotation itself ends in the small pelvis. Thus, from an oblique size, the head turns into a straight one.

The third stage of labor is the extension of the head. A fixation point is formed between the pubic joint and the suboccipital fossa of the baby's head. Extension occurs around this point. First, the crown is born, then the forehead, face and, finally, the chin.

The fourth stage is the internal rotation of the shoulders, as well as outer turn heads. When the head is born, it turns with the back of the head to the left thigh of the mother, and facing the right thigh. Gradually, the child bends and the back shoulder is born, after which the rest of the body and legs are born.

A newborn baby inhales atmospheric air for the first time, screams and actively moves his legs and arms, turns pink.

Further observation

For a woman in labor in this period of childbirth, close observation. The newborn is also examined, his vital functions and motor activity are assessed.

Actions of the host

Before giving birth, a person washes his hands and treats with any skin antiseptic that is at hand. The task of the birth attendant is the obstetric benefit. It is necessary to help in childbirth, but the main thing is not to interfere with the physiological process.

When the head begins to erupt, the midwife clasps the perineum with her hand with a clean, and preferably sterile, napkin and tries to restrain the premature extension of the baby's head during the contraction. This movement contributes to the exit of the child's head from under the pubic symphysis.

The removal of the head begins only at the moment when the suboccipital fossa passes under the pubic joint.

At this moment, the woman in labor does not need to push, and she is informed about this. The outgoing head is clasped with a hand, the crotch is clasped with the other hand, and slowly removed from the head, gradually freeing the entire head. The removal of the head is carried out until then. Until the perineum comes off the baby's chin. Of course, all these manipulations are performed only in between contractions.

In addition, after the birth of the head, it is necessary to remove all mucus and fluid from the baby's mouth, so as not to lead to aspiration of masses into the lungs during the first breath.

When the head is born, the presence of entanglement of the umbilical cord is checked. If cord entanglement occurs, gently remove it through the head.

Actions after the birth of the head

You should not rush into the birth of other parts of the body in the absence of any indications, for example, intrauterine asphyxia of the fetus or bleeding. You should wait until the child independently turns in the birth canal. To do this, the woman is asked to push.

After both shoulders are born, the baby is lifted up and carefully, without sudden movements, is pulled out of the birth canal.

In order to save the perineum, it is not worth releasing the head until the back of the baby’s head is connected to the pubic joint, since otherwise injuries of the perineum ruptures are frequent, which heal very difficult and cause a lot of inconvenience to the woman.

When teething the head, the obstetrician's allowance should not be forced. On the contrary, the grant is carried out very carefully and accurately. The newborn is placed between the legs of the mother and covered in order to prevent hypothermia.

Assessment of the state of the baby on the Apgar scale

Evaluation is carried out at 1 and 5 minutes. IN this method include the definition:

• heartbeat;
• breathing;
• skin color;
• muscle tone.

The assessment of the child's condition is carried out in points:

• 7-10 points - resuscitation is not required;
• 4-6 points - children have cyanotic skin, weak muscle tone, heart rate over 100 per minute, increased reflex excitability. These children have high chances for survival and life without consequences;
• From 3 to 0 points. These children are in a deep asphyxia and need resuscitation. In this case, 0 points indicates a stillbirth.

Actions after the first breath of the child

When the child screamed, it is necessary to separate him from the mother, that is, bandage and cut the umbilical cord. The umbilical cord is treated with alcohol at a distance of 8-10 cm from the baby's umbilical ring, tied with a sterile thread from the baby's side and from the mother's side. Between dressings, the umbilical cord is cut with sterile scissors, and then treated with a 5% iodine solution.

childbirth- the process of expulsion of the fetus and placenta from the uterus. Births occurring within 37-42 full weeks from the first day are considered urgent. last menstrual period, premature - childbirth that occurred before the full 37 weeks - up to 28 weeks, late - childbirth that began after the full 42 weeks from the first day of the last menstruation.
The birth act begins with a period of disclosure, which is determined by the appearance of regular contractions of the smooth muscles of the uterus (contractions). Contractions ensure the opening of the cervix and the expulsion of the fetus. Contractions occur involuntarily, continue at the beginning of labor for 20-30 seconds, at the end of 80-90 seconds. The intervals between contractions as labor progresses are all reduced, reaching 2-3 minutes at the end. A certain value in the opening of the cervix belongs to the fetal bladder, which is understood as part membranes and amniotic fluid located in front of the presenting part of the fetus.
The duration of the period of disclosure or the first period of labor, in primiparous is 10-12 hours, in multiparous 6-8 hours. At the end of the period of disclosure, the rupture of the fetal bladder and the outflow of amniotic fluid occur. In 30-40% of all births, rupture of the membranes is observed earlier - at the beginning and during the period of disclosure (early outflow of water) or even before the onset of labor ( premature effusion waters).
The second period of childbirth - the period of exile - is the birth of the fetus. Attempts are added to contractions - reflex contractions of the striated muscles of the body, primarily the abdominals. Under the influence of attempts, the fetus performs translational and rotational movements along the birth canal: flexion of the head, internal rotation of the head, extension (birth) of the head, internal rotation and birth of the body, as the head approaches the pelvic floor during attempts, the perineum protrudes, the anus gapes, sometimes the anterior wall of the rectum is also exposed. Appears from the genital slit during an attempt and then goes inside hairy part heads (head plunge). In the future, an increasing part of the head does not disappear without an attempt (eruption of the head).
The birth of the head begins with occipital region, then the parietal tubercles, forehead and face of the fetus are born. After passing the head, the hangers are installed in direct size the exit of the pelvis, while the head faces the left or right thigh of the mother. When the anterior shoulder is fixed at the lower edge of the pubic joint, the posterior shoulder is born, then the rest shoulder girdle, trunk and legs of the fetus. The duration of the second period in primiparas is about 1 hour, in multiparous 5-10 minutes.
The third - afterbirth - period consists in the birth of the placenta and membranes (afterbirth), in contrast to the first two periods, it is accompanied by bleeding from the vessels of the placental site. The duration of the period is 10-15 minutes, no more than 30 minutes. Physiological blood loss during childbirth 200-250 ml.
Conducting a birth act requires a certain skill. The frequency and intensity of contractions are established, an external obstetric examination is performed, in which the position of the fetus (longitudinal, transverse, oblique), the presenting part (head, pelvic presentation), its relation to the entrance to the small pelvis (pressed, small, large segment at the entrance to the pelvis, in the pelvic cavity).
With the help of an obstetric stethoscope, the fetal heartbeat is heard, which is normally 130-140 beats per minute. Assess the condition of the fetal bladder, taking into account the indication of the woman in labor to the outflow of water, observing the leakage of water from the poppy tract.
If necessary, complete the birth at home, in public place, in sanitary transport, a woman in labor is given comfortable posture- on the back, with knees bent and legs wide apart. A roller, pillow, polster are placed under the pelvic end. The external genital organs of a woman in labor are disinfected with a solution of potassium permanganate 0.02% or iodonate (1% solution of free iodine), or gebitan (0.5% alcohol solution of chlorhexidine bigluconate), or alcohol tincture iodine (3-5% solution). The doctor's hands are treated with gebitan or pervomur (recipe C-4 for 30-33% hydrogen peroxide and 85-100% formic acid), in their absence - with alcohol and iodine.
After the eruption of the head, they proceed to the obstetric benefit. To do this, the doctor stands to the right of the woman in labor and places the palm of his right hand with the 1st and 2nd fingers apart on the perineum, protecting it from rupture. The most crucial moment comes after the birth of the occiput and suboccipital fossa: birth begins largest size heads, which can contribute to perineal injury. If there is an entanglement of the umbilical cord around the fetal neck, it must be gently, carefully removed through the head.
After the birth of the head, the woman in labor is offered to push, which contributes to the internal rotation of the shoulders. It should be remembered that the birth of the shoulder girdle of the fetus also contributes to severe stretching and trauma to the tissues of the perineum. Therefore, obstetric assistance in removing the shoulders is provided with great care. At birth, the shoulders should not be twisted and squeezed on the baby's head. After the birth of the shoulders, the fetal body is born without difficulty, with the support of the host. Healthy child loudly screaming, active.
The third, successive, period is carried out by observing the condition of the woman, counting the pulse, measuring blood pressure. A container is placed under the pelvis of the woman in labor to collect the lost blood (vessel, kidney-shaped basin, etc.). The bladder is emptied with a catheter, the filling of which interferes with the process of placental abruption and the birth of the placenta.
Attempts to accelerate the separation of the placenta by external massage of the uterus, pulling on the umbilical cord, etc. are unacceptable. A number of signs indicate the separation of the placenta from the uterine wall, of which the following is the most informative; pressure on the uterus in the suprapubic region with the edge of the palm leads to retraction of the umbilical cord, if the placenta has not detached from the wall of the uterus, otherwise the umbilical cord is not retracted
In some cases independent birth placenta after placental abruption does not occur. Therefore, making sure that the process of placental abruption is completed, they help the birth of the placenta by external methods. Most Accepted next move: the uterus is brought to the middle position, it is produced light massage causing a fight. The bottom of the uterus is grasped by hand so that four fingers lie on its back surface, and thumb- on the front wall of the uterus (the doctor stands to the right of the woman in labor). After that, the uterus is compressed in an anteroposterior size and put pressure on its bottom - forward and down, which helps the birth of the placenta.
Together with the puerperal, the placenta must be delivered to the obstetric hospital, since a thorough assessment of its integrity by an obstetrician is necessary. To determine the integrity of the shells, the placenta is turned with the maternal side down, the shells hang down, which allows them to be examined well. To examine the maternal part of the placenta, the placenta is laid out on a large smooth plane (tray) and the integrity of each lobule is checked: bleeding dents indicate separation of a part of the placenta (delay in the uterine cavity).
At the end of childbirth, the external genital organs are toileted, disinfected and examined, including examination of the cervix and vagina. If there are gaps, incisions, they are sewn up. If the gap cannot be sutured in place and there is bleeding from the injured tissues, the vagina is tamponed with sterile gauze before transportation, a pressure bandage is applied to the area of ​​damage to the perineum and clitoris. All efforts in this case should be directed to the urgent delivery of the puerperal to the obstetric hospital.
For delivery, it is advisable to use a disposable sterile obstetric kit. In addition, you should have sterile packages for the initial treatment of the newborn, which contain a catheter for suctioning mucus from the upper respiratory tract (this can be done by connecting the catheter to a rubber balloon), cotton swabs, a pipette for the prevention of ophthalmoblenorrhea, three Kocher clamps, scissors, anatomical tweezers.
Primary toilet of the newborn. The child is accepted, if possible, on sterile material (gauze, napkins, diapers), placed between the legs of the mother so that there is no tension on the umbilical cord. If necessary, aspirate mucus from the respiratory tract with a sterile balloon with a catheter.
Examine and evaluate the child on the Apgar scale, which includes five signs: heart rate, depth and adequacy of breathing, reflex excitability nervous system, state muscle tone, skin coloration. A well-pronounced corresponding sign is estimated at 2 points, a deviation from the norm or the absence of a sign - at 1 and 0 points, respectively. Grade healthy newborn at the 1st and 5th minute after birth (estimation time indicated signs) corresponds to 8 points or more, with mild hypoxia, his condition is estimated at 6-7 points, with moderate hypoxia - 4-5 points, with severe and prolonged hypoxic condition - 1-3 points.
Immediately after the birth of a child, ophthalmoblenia is prevented. The eyes are wiped with various sterile cotton swabs, 2-3 drops of a 30% solution of sodium sulfacyl are instilled into the inverted conjunctiva of the upper eyelid (the shelf life of the solution is one day). For girls, 2-3 drops of the same solution are applied to the vulva area.
The umbilical cord is grasped with two Kocher clamps, applying the first clamp at a distance of 8-10 cm from the umbilical ring of the child, the second at a distance of 15-20 cm. Ligatures can be applied instead of clamps. Between the clamps (ligatures), the umbilical cord is crossed with scissors, having previously treated the intersection with 95-degree alcohol. The newborn is wrapped in sterile material, wrapped warmly (risk of chilling), and taken to the hospital. maternity hospital. Further processing of the newborn - his skin, umbilical cord, weighing, measuring growth, etc. - is desirable to perform in an obstetric hospital, since this requires maximum sterility conditions.

If future mom was in the hospital in advance, she will be under vigilant control. But what to do, what to do if the birth started at home, and there is no way to get to the hospital? Then a team of doctors who arrived on an emergency call will take an emergency birth. For this purpose, a special standard for providing assistance during childbirth outside hospitals has been developed.

Childbirth is one of common causes call an ambulance. The emergency physician may be confronted with any moment of the act of childbirth - the period of disclosure, the period of exile, the afterbirth and the early postpartum period.

If the birth started at home, then it is necessary to assess the possibility of transporting the woman in labor to the maternity hospital, assess the period of labor and the possibility of delivering the woman in labor before the birth of the child.

If there are no such opportunities, it is necessary to start providing medical care for childbirth outside the hospital. To begin with, the woman needs to put cleansing enema, shave off pubic hair, wash vulva boiled water with soap, change the linen on the bed, laying an oilcloth under the sheet.

How to take birth with a woman at home in each of the periods labor activity, detailed on this page.

How to take an emergency delivery to a woman outside a hospital: the first period

Childbirth begins with a period of disclosure, with the onset of regular contractions. They ensure the opening of the cervix and contribute to the expulsion of the fetus. Contractions occur involuntarily, first lasting 15-20 seconds, then 80-90 seconds. The interval between contractions is at first 10-12 minutes, then it is reduced to 2-3 minutes.

The management of the first period (disclosure) of physiological labor outside the medical institution should be expectant.

It is necessary to observe the development of contractions, the fetal heartbeat and the advancement of the presenting part (usually the head). At emergency delivery it is necessary to make an external obstetric examination, which allows you to determine the position of the fetus (longitudinal, transverse, oblique), the presenting part (head, pelvic presentation) and its relation to the entrance to the small pelvis. The fetal heartbeat is heard in the pauses between contractions, most often it is clearly audible to the left below the navel. The fetal heart rate is 120-140 beats per minute, the fetal heart sounds are normal. In the period of disclosure, a certain value belongs to the fetal bladder, which is a part of the membranes and amniotic fluid located in front of the presenting part of the fetus. The duration of the period of disclosure in a primiparous woman is 16-18 hours, in multiparous women - 8-12 hours. With the physiological course of childbirth at the end of the first period, the rupture of the fetal bladder and the outflow of amniotic fluid occur. But in some cases, the rupture of the membranes can occur earlier - at the beginning or during the period of disclosure, or even during pregnancy, before the onset of contractions. If there is no rupture of the fetal bladder, in the period of exile, he is the first to be "born" from the genital gap. In this case, when providing first aid during childbirth outside the hospital, it is necessary to artificially open the bladder with a forceps, Kocher's clamp, otherwise the child will be born in the membranes. This will disrupt the process of transition to extrauterine respiration and lead to asphyxia of the newborn. As labor activity develops and increases, the fetal head presses against the entrance to the small pelvis and somewhat enters it at the end of the first stage of labor. The first stage of labor usually ends by the time full disclosure uterine os (10 cm), at the same time, amniotic fluid is poured out.

The fetal head is determined pressed against the entrance to the small pelvis. If above the entrance to the small pelvis is determined soft part fetus, then there is a breech presentation.

During emergency childbirth, manual assistance must be provided and can be performed by an obstetrician or midwife. If the presenting part is not defined above the entrance to the small pelvis, and the contours of the uterus approach the transverse arch, this is characteristic of the transverse or oblique position of the fetus.

Under these conditions, childbirth through the natural birth canal is impossible, and the risk of uterine rupture is very high. In order to avoid rupture, it is necessary to take measures for the urgent delivery of the woman in labor to the maternity hospital for delivery by the abdominal route. In order to avoid rupture of the uterus, when assisting in childbirth at home, it is necessary to give ether anesthesia with a mask (through a nasal catheter, establish inhalation 02).

How to take birth at home with a woman in the second period

The second period of childbirth - the period of exile - ends with the birth of the fetus. At this time, attempts are added to the contractions. After the outflow of amniotic fluid, the myometrium adapts to the changed volume of the uterus.

During this period, the load on the body of the woman in labor increases especially, clinical manifestations increase late toxicosis more often develops decompensation in cardiovascular diseases.

Due to frequent and strong contractions of the myometrium, intrauterine fetal hypoxia may develop, which is facilitated by the features of the umbilical cord (short umbilical cord, entanglement of the umbilical cord around the trunk or neck of the fetus, true knots umbilical cord, etc.). In order to take an emergency birth correctly, it is necessary to carefully monitor general condition women in labor, the nature of the attempts, the emergency of the fetus and the advancement of the fetal head through the birth canal. The fetal heartbeat is auscultated after each attempt, a decrease in heart rate to 120 beats / min or less or an increase of more than 150 beats / min is characteristic of intrauterine fetal hypoxia. This is evidenced by the appearance of meconium in the flowing amniotic fluid during head presentation.

How to take birth at home in the second period of labor? First you need to prepare. The woman's torso is placed across the bed, and her head is placed on a chair set up to the bed, a pillow is placed under the pelvis. The external genitalia and the perineal area are washed again with warm water and soap, the external genitalia are treated with 5% tincture of iodine, the anus area is sealed gauze napkin. Before assisting with physiological childbirth the recipient must treat their hands (wash them with soap, treat with alcohol and iodine).

From the beginning of the process of childbirth, a woman is called a woman in labor, after postpartum period- childbirth. From the moment the heads appear in the genital slit, they begin manual reception to protect the perineum. The deliverer stands to the right of the woman in labor, left hand located above the bosom, while trying to move the head towards the perineum. With the right hand, the person taking delivery outside the hospital clasps the perineum, covered with a sterile napkin, and during the contraction tries to delay the premature extension of the head, removing the back of the head from under the symphysis.

After the head has crashed and does not go into the vagina in the pauses between attempts, it is necessary to carefully bring the suboccipital fossa, which is the point of fixation, under the lower edge of the womb. Around this point, the fetal head will make an extensor movement. When the fixation point came under the lower edge of the womb, the woman in labor should stop pushing. At this time, providing emergency assistance during childbirth, it is necessary to straighten the head very carefully, and soft tissues gently remove the perineum from the head.

After the birth of the fetal head, it turns with the back of the head to the right or left thigh of the mother. At this point, the delivery person grabs the head of the fetus with both hands and the woman is asked to push, which helps to fix the anterior shoulder under the bosom. After this has happened, it is necessary to lift the fetus slightly up by the head, allowing the posterior shoulder to be born. Further, after the birth of the back shoulder, the front shoulder and the whole fetus are born without any effort.

Standard of First Aid for Physiological Birth at Home: Examination of the Baby

The newborn is taken on a sterile material (gauze, napkin, diaper) and placed between the mother's legs so that the umbilical cord does not stretch. After the birth of a child, mucus and amniotic fluid are sucked out of his nose and mouth with the help of a rubber pear boiled in advance.

After the home birth, the baby is examined and assessed by the Apgar method, based on 5 clinical signs: heart rate, depth and adequacy of breathing, reflex excitability of the NS, the state of muscle tone, skin color.

The absence of a sign is characterized as 0, a deviation from the norm - 1, a well-defined sign - 2.

• Satisfactory condition of the newborn is estimated at 8-10 points;
• with mild asphyxia - 6-7 points;
• with asphyxia of moderate severity - 4-5 points;
• in severe hypoxic condition -1-3 points;
• 0 points corresponds to the concept of "stillborn".

Reassessment on the Apgar scale is carried out after 5 minutes, which makes it possible to judge the effectiveness of resuscitation.

Clinical assessment of the state of the newborn 1 and 5 minutes after birth according to the Apgar scale:

Home birth attendance: treatment of the newborn

Having taken an emergency delivery, after the first cry and respiratory movement, assessing the condition of the newborn, proceed to its primary treatment of the newborn:

• retreating 8-10 cm from the umbilical ring, the umbilical cord is treated with alcohol and cut between 2 sterile clamps and tied with thick surgical silk, a thin sterile gauze ribbon;
• the umbilical cord stump is lubricated with 5% iodine solution and a sterile bandage is applied to it;
• bracelets are put on both hands of the child indicating the sex of the child, the surname and name of the mother, the date of birth;
• further prevention of ophthalmoblenorrhea and ligation of the umbilical cord are carried out in the obstetric department;
• then the newborn is wrapped in a sterile material (gauze, napkin), wrapped warmly and delivered to the maternity hospital;
• if the child was born in a state of asphyxia, resuscitation is carried out, for which it is better to put the child on the table and, first of all, suck out the contents of the oral cavity, nose, and trachea. The time of resuscitation measures in a newborn in the absence of their effectiveness should not be more than 15 minutes.

Help with home births in emergency situations in the third period

After the birth of the fetus, the third, postpartum period begins. During delivery in emergency situations, it is necessary to monitor the condition of the woman in labor, the color of the skin and visible mucous membranes, and complaints; count pulse, measure blood pressure. During this period, the placenta separates from the walls of the uterus and the birth of the placenta - it lasts no more than 30 minutes. It is necessary to empty the bladder of a woman in labor with a catheter, because. filling it interferes with the process of placental abruption and the birth of the placenta. Assistance during childbirth in the third period begins with the introduction of intravenous methylergometrine 1.0 ml of a 0.02% solution to prevent atonic bleeding.

The following signs indicate the separation of the placenta from the uterine wall:

• change in the shape of the uterus and the height of its bottom - immediately after childbirth, the uterus has a rounded shape and is located at the level of the navel; after placental abruption, the bottom of the uterus rises 2-4 fingers above the navel, it deviates to the right, becomes narrower in diameter;
• sign of Chukalov - Kyustner - pressure on the uterus with the edge of the palm in the suprapubic region leads to retraction of the umbilical cord if the placenta has not separated from the uterus; if the umbilical cord does not retract, this indicates the separation of the placenta;
• a sign of Mikulich - the separated placenta, being born in the vagina, contributes to the urge to attempt. The born placenta is carefully examined, checking the integrity of the placenta (spread out with the maternal surface up). Delay in the uterus of parts of the placenta or its lobules does not allow the uterus to contract well, which is the cause of hypotonic bleeding. In the absence of a placental lobule, a manual examination of the uterine cavity is immediately performed, and the delayed lobule is removed by hand.

To attend births in an ambulance, you must have a sterile obstetric kit disposable, there should be a bix with sterile packages for the initial treatment of the newborn. The packages contain a catheter for suctioning mucus from the upper respiratory tract, cotton swabs, Kocher clamps, anatomical tweezers, scissors, ligatures. There should be medicines necessary for childbirth and primary treatment of the newborn: ethyl alcohol 95%, iodonate 1% solution, sulfacyl sodium solution 30%, permanganate solution potassium 0.02%, as well as methylergometrine 0.02% solution, 1.0 ml each.

Help with home birth breech presentation, transverse or oblique position of the fetus and other presentations of the fetus, in which childbirth through the birth canal is impossible is doomed to failure. In these cases, everything must be done to deliver the woman in labor to the hospital. In case of a complicated course of the birth act, the woman in labor or the puerperal must also be taken to the maternity hospital. And even after providing first aid for uncomplicated childbirth at home, the puerperal woman, along with the newborn, must be taken to the obstetric department.

The article has been read 1,625 times.

Childbirth - f physiological process of expulsion of the fetus, fetal membranes and placenta through the mother's birth canal.

The SMP doctor may be faced with any period of the birth act: disclosure, expulsion, afterbirth and early postpartum period. The doctor should be able to diagnose the periods of childbirth, assess their physiological or pathological course, find out the condition of the fetus, choose a rational tactics for managing labor and the early postpartum period, prevent bleeding in the afterbirth and early postpartum period, and be able to provide obstetric care for head presentation.

Childbirth outside the hospital most often occurs with preterm pregnancy or with full-term pregnancy in multiparous women. In such cases, childbirth proceeds, as a rule, rapidly.

CLASSIFICATION

There are premature, urgent and delayed births.

Childbirth that occurs between 22 and 37 weeks of gestation, resulting in premature babies, is considered premature. Premature babies are characterized by immaturity, with body weight from 500 to 2500 g and height from 19-20 to 46 cm. They are characterized by a high percentage of both perinatal mortality and mortality and morbidity premature babies, especially those born in terms of 22-27 weeks of pregnancy (body weight from 500 to 1000 g).

Childbirth that occurred at a gestational age of 40 ± 2 weeks and ends with the birth of a live full-term fetus weighing approximately 3200-3500 g and growing from 46 cm is considered urgent.

Childbirth that occurred at a gestational age of more than 42 weeks and ended with the birth of a fetus with signs of postmaturity: dense bones of the skull, narrow seams and fontanelles, pronounced desquamation of the epidermis, dryness of the skin, are considered post-term. Delivery by a post-term fetus is characterized by a high percentage of birth traumatism.

There are physiological and pathological births. A complicated course of childbirth develops in pregnant women with extragenital pathology, aggravated obstetric and gynecological history or pathological course of pregnancy. The following states are relevant:

■ menstrual dysfunction;

■ history of infertility;

■ inflammatory diseases internal genital organs;

■ artifacts and spontaneous abortions in history;

■ uterine fibroids;

■ ovarian tumors;

■ scar on the uterus after caesarean section;

■ nulliparous older than 30 and younger than 18;

■ heart defects (congenital and acquired);

■ hypertonic disease;

■ diseases of the respiratory system, kidneys, liver;

■ diseases thyroid gland, nervous system, musculoskeletal system;

■ diabetes mellitus.

During childbirth, three periods are observed:

■ period of cervical dilatation;

■ period of expulsion of the fetus;

■ follow-up period.

CLINICAL PICTURE

Childbirth in primiparas takes 12-14 hours, in multiparous - 8-10 hours.

First stage of labor (cervical dilation period) begins with the first regular labor pains and ends with a complete (9-10 cm) opening of the cervix, sufficient for passage through the birth canal of the fetus. Contractions are characterized by spontaneouscontractions of the smooth muscle cells of the uterine body, followed by the opening of the cervix and the advancement of the fetus along the birth canal beyond maternal organism. Contractions at the beginning of labor continue for about 15-20 seconds, at the end - 80-90 seconds, and the intervals between contractions from 10-12 minutes (at the beginning of labor) are reduced to 2-3 minutes.

During contractions, shortening, smoothing, opening of the cervix and the formation of the birth canal occur.

During the contraction, the presenting part of the fetus slides along the inner wall of the birth canal, exerting pressure on it, and the walls of the lower segment of the uterus and the birth canal resist the descending presenting part.

The fetal bladder (part of the membranes and amniotic fluid located in front of the presenting part of the fetus) during the contraction is poured and wedged into the cervical canal, which contributes to its opening. Disclosure of the cervical canal with a whole amniotic sac occurs faster than in its absence.

Untimely rupture of the fetal bladder (premature or late) often disrupts the physiological course of childbirth. Premature rupture of the fetal bladder contributes to the formation of a large birth tumor, cephalohematoma, on the head of the fetus, causes a violation of the intracranial circulation of the fetus; it is one of the most common causes of fetal asphyxia, stillbirth and early mortality newborn.

During the physiological course of childbirth, the fetal bladder opens at the end of the opening period at the height of one of the contractions and amniotic fluid in the amount of 100-200 ml is poured out.

IN rare cases by the end of the cervical opening period, the fetal bladder does not rupture and it is the first to be born from the genital slit, in such cases it is necessary to artificially open the fetal bladder with any instrument (branches of bullet forceps, Kocher forceps, forceps) or a finger, otherwise the fetus will be born in the membranes, which can lead to disruption of the process of transition to extrauterine respiration and asphyxia of the newborn.

Management of the first stage of physiological labor — active-expectant.

It is necessary to monitor the development of regular labor activity, the fetal heartbeat, the advancement of the presenting part (head). To assess the nature of regular labor, determine the duration, intensity, frequency, pain of contractions with a hand located flat on the stomach of the woman in labor.

When the contractions become especially strong and begin to recur after 3-4-5 minutes (4-5 contractions in 10 minutes), one can think of a complete opening of the uterine os.

Listening to the fetal heartbeat during the opening period is carried out every 15 minutes until the amniotic fluid is poured out, and after the water is poured out - every 5-10 minutes. Normally, the fetal heart rate ranges from 120 to 140 per minute, heart sounds are clear, rhythmic. A persistent slowing of heart tones to 100 per minute and below, as well as an increase to 160 per minute and above, indicates the onset of intrauterine fetal asphyxia.

In the normal course of childbirth, the process of opening the cervix coincides with the gradual advancement of the fetal head; at the end of the first stage of labor, the head is pressed against the entrance to the small pelvis and even somewhat enters into it.

If the presenting part is unclear, suspicion of rare variant inserts ( frontal presentation, back view facial presentation, high straight standing of the head), transverse or oblique position fetus, it is necessary to take all measures for the urgent transportation of the woman in labor to the obstetric hospital.

To prevent uterine rupture during transportation, a woman in labor is given ethereal mask anesthesia, while oxygen is inhaled through a nasal catheter.

Second stage of labor (exile period) - the time from the moment of full disclosure of the uterine pharynx to the birth of the fetus. After the outflow of water, the contractions stop for a while. The volume of the uterine cavity decreases. The uterine cavity and vagina are the birth canal. Contractions intensify again, the presenting part of the fetus (head or pelvic end) sinks to the pelvic floor. Reflexively occurring at the same time, contractions of the abdominal press also cause the woman in labor to push, repeating more and more often - after 5-3-2 minutes. The presenting part of the fetus stretches the genital gap and is born, behind it the body is born. Together with the birth of the fetus, the back waters are poured out.

ADVICE TO THE CALLER

It is necessary to keep in touch the caller until the ambulance arrives.

The woman in labor must be reassured, isolated from others, laid on a clean cloth or oilcloth that is at hand. Tight clothing that squeezes the stomach and interferes with breathing must be removed. Touching the stomach with your hands, stroking it should not be, because. this can cause irregular contractions and disrupt the birth process.

external genitalia and inner surface it is recommended to wash the hips, if possible, with soap and water or wipe them with cotton wool moistened with 5% alcohol solution of iodine or vodka,

close the anus with cotton wool or a piece of clean cloth. Under the buttocks should put a clean cloth, towel, sheet.

ACTIONS ON A CALL

Diagnostics

You need to do the following.

■ Decide on the possibility of transporting a woman in labor to a maternity hospital.

■ Assess the data of the general and obstetric anamnesis: □ number of pregnancies and childbirth in anamnesis, their course, presence of complications;

□ current pregnancy: threatened miscarriage, overall weight gain, blood pressure dynamics, changes in blood tests (according to exchange card);

□ data from a general objective study.

■ Assess the period of labor: the onset of contractions, their regularity, duration, intensity, pain. Carry out 4 receptions of an external examination (Fig. 16-9) and determine the height of the uterine fundus, the position and position of the fetus, the nature of the presenting part and its

relation to the plane of the entrance to the small pelvis (movable above the entrance to the pelvis, fixed by a small segment, a large segment at the entrance to the pelvis, in the cavity of the small pelvis, on the pelvic floor. Auscultate the fetus.

■ Assess the nature of the discharge: the presence of bloody discharge, leakage of amniotic fluid, the presence of meconium in them.

■ If necessary, perform a vaginal examination (Fig. 16-P) -

■ Diagnose childbirth: □ first or repeated;

□ urgent or premature or late;

□ the period of childbirth - disclosure, exile, succession;

□ the nature of the outflow of amniotic fluid - premature, early, timely;

□ complications of pregnancy and childbirth;

□ features of obstetric and gynecological history;

□ concomitant extragenital pathology.

If there are conditions and possibilities of transportation, it is necessary to make an urgent hospitalization in an obstetric hospital.

REQUIRED QUESTIONS

Careful history taking includes finding out the parity of the pregnant woman, which pregnancy and childbirth are in a row), the course of this pregnancy, the presence of any complications, complaints.

INSPECTION AND PHYSICAL EXAMINATION

Four receptions of external obstetric research pregnant. 1st reception - determination of the height of the uterine fundus. 2nd reception - determination of the position of the fetus. 3rd technique - determination of the presenting part of the fetus, 4th technique - determination of the presenting part (head) to the plane of the entrance of the small pelvis.

Birth management

In the absence of the possibility of transporting a woman in labor to the maternity hospital, labor should be started. A woman in labor is given a cleansing enema, pubic hair is shaved, the external genitalia are washed with boiled water and soap, a change is made bed linen, an oilcloth is placed under it, a home-made polster is prepared - a small pillow wrapped in several layers of sheets (preferably sterile).

During childbirth, the polster is placed under the pelvis of the woman in labor, which gives it an elevated position and provides free access to the perineum.

MANAGEMENT OF THE FIRST PERIOD OF LABOR

Maintaining the disclosure period, as a rule, is active-waiting.

It is necessary to observe the development of contractions, the fetal heartbeat and the advancement of the presenting part (usually the head). It is necessary to find out the state of health - the degree pain, the presence of dizziness, headache, visual disturbances, listen to heart sounds, systematically measure the pulse, blood pressure. It is necessary to monitor urination and emptying of the rectum. The overflow of these organs leads to a violation of the period of disclosure, the expulsion of the fetus and the discharge of the placenta.

The contractility of the uterus is regularly assessed. The tone of the uterus, the interval between contractions, rhythm and frequency are taken into account.

One of important points conducting the first period is to monitor the condition of the fetus. Observation of the fetal heartbeat during the period of disclosure with an undisturbed fetal bladder is performed every 15-20 minutes, and after the outflow of amniotic fluid - after 5-10 minutes. During auscultation, attention is paid to the frequency, rhythm and sonority of the fetal heartbeats.

SECOND LABOR MANAGEMENT

Starting with the full or almost full disclosure of the cervix, the progressive movement of the fetus through the birth canal (the biomechanism of childbirth) begins. The biomechanism of childbirth is a set of translational and rotational movements produced by the fetus passing through the birth canal.

During the period of exile, systematic monitoring of the condition of the woman in labor and the fetus is carried out (observation of the fetus - how the fetal head advances). When observing the fetus, it should be borne in mind that during the physiological course of labor in the period of expulsion, the head with a large segment should not stand in the same plane of the small pelvis for more than 2 hours, and the entire period of exile should not last more than 4 hours.

Starting with the full or almost full disclosure of the cervix, the progressive movement of the fetus through the birth canal begins. This moment is called the biomechanism of childbirth.

Childbirth in the occipital presentation is about 96% of all births, the anterior view of the occipital presentation is more often observed.

Childbirth in a transverse, oblique position, with extensor insertions, breech presentation of the fetus at home is impossible, emergency hospitalization in an obstetric hospital is necessary. When diagnosing primary and secondary weakness, discoordination of labor activity, the independent actions of the doctor must be stopped and the patient urgently hospitalized in a specialized medical institution.

In this period of childbirth, the condition of the woman in labor, the nature of labor, and the heartbeat of the fetus are monitored. The heartbeat must be listened to after each attempt, attention should be paid to the rhythm and sonority of the fetal heart sounds. It is necessary to monitor the progress of the presenting part - during the physiological course of childbirth, the head should not stand in the same plane of the small pelvis for more than 2 hours; for the nature of the discharge from the genital tract - during the period of disclosure and expulsion of bloody discharge from the genital tract should not be.

As soon as the head begins to cut in, that is, at the moment when, when an attempt appears, the head appears in the genital gap, and with the end of the attempt it goes into the vagina, one must be ready to receive childbirth. The woman in labor is placed across the bed, and her head is placed on a chair set to the bed, a home-made polster is placed under the pelvis of the woman in labor. Another pillow is placed under the head and shoulders of the woman in labor so that the woman in labor is in a slightly semi-sitting position - in this position it is easier for her to push.

The external genital organs are repeatedly washed with warm water and soap, treated with 5% iodine solution. Anus cover with sterile cotton wool or a diaper.

The delivery person washes and sanitizes hands thoroughly with soap and water; if available, it is advisable to use a sterile disposable obstetric kit.

The reception of childbirth consists in the provision of obstetric benefits.

With cephalic presentation, obstetric assistance in childbirth is a set of sequential manipulations at the end of the second stage of labor, aimed both at promoting the physiological mechanism of childbirth and at preventing injuries to the mother and fetus.

As soon as the head crashes into the genital gap and will maintain this position outside the contraction, the eruption of the head begins; from that moment on, the doctor or midwife, standing to the right of the woman in labor, sideways to her head, with the palm of her right hand with a widely abducted thumb, clasps the perineum covered with a sterile napkin and through the latter tries to delay the premature extension of the head during a contraction, contributing to this exit of the occiput from under the symphysis .

The left hand is "ready" in case the forward movement of the head was too strong and one right hand could not hold it. As soon as the suboccipital fossa fits under the pubic arch (the delivery person feels the back of the head in the palm of his hand), and the parietal tubercles can be felt from the sides, they begin to remove the head. The woman in labor is asked not to push; with the palm of the left hand, they clasp the protruding part of the head, and with the palm of the right hand with the thumb retracted, they clasp the perineum and slowly, as if removing it from the head (from the face), at the same time carefully lift the head up with the other hand.

In this case, the forehead is first shown above the perineum, then the nose, mouth and, finally, the chin. By all means, you need to remove the head until the perineum "comes off" from the chin - until the chin comes out. All this must be done outside the fight, since during a fight it is very difficult to slowly withdraw the head, and with a quick withdrawal, the perineum is torn. At this moment, the outflowing mucus should be sucked out of the fetal mouth, since the child can take the first breath and the mucus can get into Airways causing asphyxia.

After the birth of the head, a finger is passed along the neck of the fetus to the shoulder: they check if the umbilical cord is wrapped around the neck; if there is an entanglement of the umbilical cord, the loop of the latter is carefully removed through the head.

The born head usually turns with the back of the head towards the mother's thigh, sometimes the external rotation of the head is delayed. If there are no indications for the immediate end of labor ( intrauterine asphyxia fetus, bleeding), one should not rush, one must wait for the independent external rotation of the head, in such cases the woman is asked to push, while the head turns with the back of the head towards the mother's thigh and the front shoulder fits under the bosom.

If the front shoulder does not fit under the womb, help is provided: the turned head is grasped between both palms - on the one hand by the chin, and on the other - by the back of the head, or the palms are placed on the temporo-cervical surfaces and gently, slightly rotate the head with the back of the head towards the position, at the same time carefully pulling it down, bringing the front shoulder under the pubic joint.

Then they clasp the head with their left hand so that its palm rests on the lower cheek and lifts the head, and right hand, just as it was done when removing the head, carefully shift the crotch from the rear shoulder.

When both shoulders are out, they carefully grab the baby by the torso in the area of ​​​​the armpits and, lifting it up, remove it completely from the birth canal.

The principle of "protection of the perineum" in front view occipital presentation is to prevent premature extension of the head; only after the back of the head comes out and the suboccipital fossa rests against the lunar arch, the head is slowly released over the perineum - this important condition to preserve the integrity of the perineum and the birth of the head smallest size- small oblique.

If the head erupts in the genital gap with a small oblique size (with occipital presentation), it can easily break.

Birth trauma of the newborn (intracranial hemorrhages, fractures) can often be associated with the technique and methodology of childbirth.

If the obstetric manual aid is rude during the eruption of the head or the delivery person presses his fingers on the head, this can lead to the indicated complications. To avoid similar complications it is recommended to eliminate excessive counterpressure of the stretching perineum on the fetal head, for which the perineal dissection operation is used - perineo- or episiotomy.

The obstetric manual aid during the eruption of the head should always be as gentle as possible, it is aimed primarily at helping the birth healthy child without causing him any injury, and at the same time to preserve the integrity of the pelvic floor as much as possible. This is the only way to understand the term "crotch protection".

Immediately after the birth of the head from upper parts pharynx and nostrils, it is necessary to suck out mucus and amniotic fluid using a pre-boiled rubber bulb. To avoid aspiration of the contents of the stomach by the newborn, the contents of the pharynx are sucked off first, and then the nose.

The born baby is placed between the legs of the mother on sterile diapers, on top of the child they are covered with another diaper to prevent hypothermia. The child is examined and evaluated according to the Apgar method immediately at birth and after 5 minutes. The Apgar fetal assessment method allows for a quick, preliminary assessment of 5 signs physical condition newborn:

■ heart rate - with the help of auscultation;

■ breathing - when observing movements chest;

■ the baby's skin color is pale, cyanotic, or pink;

■ muscle tone - according to the movement of the limbs;

■ reflex activity when slapping on the plantar side of the foot.After the appearance of the first cry and respiratory movements, retreating 8— 10 cm from the umbilical ring, the umbilical cord is treated with alcohol and cut between two sterile clamps and tied with thick surgical silk, thin sterile gauze ribbon (Fig. 16-21). The stump of the umbilical cord is lubricated with 5% iodine solution and a sterile bandage is applied to it.

Cannot be used to tie the umbilical cord thin thread so she can cut through the umbilical cord along with its vessels. Immediately, bracelets are put on both hands of the child with the indication of the sex of the child, the surname and name of the mother, the date of birth and the birth history number.

Further processing of the newborn (skin, umbilical cord, prevention of ophthalmoblenorrhea) is carried out only in an obstetric hospital, under conditions of maximum sterility forprevention of possible infectious and purulent-septic complications. In addition, inept reprocessing of the umbilical cord can cause bleeding that is difficult to control after the umbilical cord has been severed from the umbilical ring. Urine is released to the woman in labor using a catheter, methylergometrine 1.0 ml of 0.02% solution is injected intravenously and the third (postpartum) period of labor is started.
SUBSEQUENT MANAGEMENT

The afterbirth period is the time from the birth of the child to the birth of the placenta. IN

during this period, placental abruption occurs along with its membranekami from the uterine wall and the birth of the placenta with membranes - the placenta.

With the physiological course of childbirth in their first two periods (disclosure

and expulsion) placental abruption does not occur.The follow-up period lasts normally from 5 to 20 minutes andaccompanied by bleeding from the uterus. A few minutes after birth.

SUBSEQUENT MANAGEMENT

The afterbirth period is the time from the birth of the child to the birth of the placenta. During this period, placental abruption occurs along with its membranes from the uterine wall and the birth of the placenta with membranes - the placenta. With the physiological course of childbirth in their first two periods (disclosure and expulsion), placental abruption does not occur.

The follow-up period normally lasts from 5 to 20 minutes and is accompanied by bleeding from the uterus. A few minutes after the birth of the child, contractions occur and, as a rule, bloody issues from the genital tract, indicating detachment of the placenta from the walls of the uterus. The bottom of the uterus is above the navel, and the uterus itself, due to gravity, deviates to the right or left; at the same time, an elongation of the visible part of the umbilical cord is noted, which is noticeable by the movement of the clamp applied to the umbilical cord near the external genitalia. After the birth of the placenta, the uterus enters a state of sharp contraction. Its bottom is in the middle between the bosomand the umbilicus and it is palpated as a dense, rounded formation. The amount of blood lost in the afterbirth period usually should not exceed 100-200 ml.

After the birth of the placenta, the woman who gave birth enters the postpartum period. She is now called a mother. The management of the postpartum period is conservative. In this periodnot even for a minute be separated from the woman in labor. It is necessary to monitor whether everything is safe, i.e. whether there is bleeding, both external and internal; it is necessary to control the nature of the pulse, the general condition of the woman in labor, the signs of separation of the placenta; urine should be expelled, since an overfilled bladder interferes with the normal course of the afterbirth period. To avoid complications, it is unacceptable to perform an external massage of the uterus, pull the umbilical cord, which can lead to violations physiological process separation of the placenta and the occurrence of severe bleeding.

Released from the vagina children's place(placenta with membranes and umbilical cord) are carefully examined: it is laid out flat with the maternal surface up. Pay attention to whether all the lobules of the placenta came out, whether there are additional lobules of the placenta, whether the membranes are completely separated. Delay in the uterus of parts of the placenta or its lobules does not allow the uterus to contract well and can cause hypotonic bleeding.

If there is not enough placental lobule or part of it and there is bleeding from the uterine cavity, you should immediately perform a manual examination of the walls of the uterine cavity and remove the delayed lobule by hand. Missing shells, if there is no bleeding, can not be removed: they usually come out on their own in the first 3-4 days of the postpartum period.

The born placenta must be delivered to an obstetric hospital for a thorough assessment of its integrity by an obstetrician. After childbirth, the toilet of the external genital organs is made, their disinfection. Examine the external genitalia, the entrance to the vagina and the perineum. Existing abrasions, cracks are treated with iodine, tears must be sewn up in a hospital.

Assessment of the state of the newborn by Apgar