Masaryk University School of Medicine and Brno University Hospital Department of Obstetrics and Gynecology Head: Prof. Pavel Ventruba, MD, DSc. Emergency situations in Obstetrics and Gynecology The conduct of labour – present and future Gerychová Romana Janků Petr 2004/2005 1. Definition n expeling fetus, placenta, umbilical cord, amniotic fluid from the mother body during labour n delivered fetus – newborn child with signs of life ( heart rate, spontaneous breathing, movements, pulsate umbilical cord ) of any weight or without signs of life with weight 1000g and more n Premature labour 24 – 36 gestational weeks n Term labour 38 – 42 gestational week n Post term labour after 42 gestational week n until 24 gestational week - abortion 2. Labour date n estimated data of the labour n average pregnancy duration: - 40 weeks ( 280 days ) from the last date of the menstrual period - 38 weeks ( 266 days ) from the conception Estimating labour date according n first fetal movement n date of the conception n ultrasound measurement n date of the last menstrual period 3. Clasification n spontaneous labour n medicamental labour ( spontaneous beggining ) n induced labour n operative labour n physiologiacal labour n pathological labour 4. „ Delivery tract „ n hard „ delivery tract „ - pelvis n soft „ delivery tract „ low segment cervix vagina external pelvic floor 5. Labour force n uterine contractions - frequency,intensity syntocinon, prostaglandins (E2, F2 alpha) n abdominal press n gravitation 6. Fetus The most freqent fetus presentation – cephalic. Fetus head- the biggest problem during delivery ( size, shape ) – influence on conduct of labour, labour outcome Skull: two frontal bones, two parietal bones, two temporal bones, one occipital bone Joints- frontal, saggital, lambdoid, occipital Fontanelle – big and small n Good prognosis - during delivery fetus head is coming into the pelvis with small oblique diameter ( middle of the big fontanelle - 9 cm ) 7. Delivery progress n 7.1. Preparatory stadium dolores praesagientes preparing of uterine muscles going down uterus cervical slimy secretion n Delivery beginning - regular uterine contractions - rupture of membranes Expectant and active conduct of labour n 7.2. I.labour stage ( openig ) latens – cervical rippening active – cervical dilatation to 8 cm transitory – 8 cm and more n 7.3. II labour stage ( expeling ) fetus expeling, episiotomy Fetus head delivery – flexis, internal rotation, deflexis, external rotation Fetus shoulders delivery n 7.4. III. labour stage expeling placenta and fetal membranes n 7.5. IV.labour stage 2-3 hours after delivery n Delivery duration 6 – 12 hours ( primipara ) 3 – 9 hours ( multipara ) 60 minutes and less …..precipitous delivery 8. Delivery room incoming n anamnesis, external examination, obstetric examination n nonstress test, amnioscopy, ultrasound Doppler sonography n blood presure, pulse, body temperature blood and urine testing, vaginal cultivation n delivery preparing ( shower, bath ) 9. Labour monitoring n women status – blood presure, pulse, body temperature, pain, psychical status n uterine contractions – external examination and monitoring n labour progression – internal examination n fetus status – fetal heart rate, cardiotocography, amniotic fluid quality n bleeding and coagulability 10. Fetal monitoring n cardiotocography ( external, internal ) n intrapartal fetal pulse oxymetry n S – T analysis ( fetal EKG ) n ultrasound examination - presentation, estimated fetal weigt n Doppler ultrasound examination – umbilical cord, haematoma 11. Conduct of labour n doctors and midwifes role n paediatrician and nurse n neonatus examination and treatment n II. and IV. stage of labour n injury, blood loss, umbilical cord testing genitals hygiene, blood presure and pulse, urination, hydratation, psychic status, rest, transfer to the rest room n forceless delivery n accompanied father n home delivery n mother position during delivery n water birth n elective Caesarean Section n induced delivery n analgesis during delivery n relaxing technic n musicotherapy n aromatherapy n backbone and perineal massage n prelabour preparation u basic u enlarged u breast feeding u neonatal care Obstetrics bleeding Jelínek, J., Hudeček, R. Obstetrics bleeding - introduction n Spectrum ranges from small show with little clinical significance to a catastrofic haemorrhage which qiuckly causes to death. n Bleeding can occur at any stage of pregnancy or labour. Obstetrics bleeding - incidence Obstetrics bleeding - summary n Ectopic pregnancy n Second trimester n Placenta praevia n Vasa praevia n Placental abruption n Other conditions n Unexplained n Postpartum haemorrhage n Retained placenta n Coagulopathy n Uterine atony n trauma - rupture n long-term complications Ectopic pregnancy - risk factors n High risk: u tubal surgery, prevoius ectopic pregnancy, use of IUD, tubal patology n Moderate risk: u infertility, previous genital infection n Slight risk: u cigarete smoking, previous abdominal surgery Ectopic pregnancy - symptoms n Abdominal pain n Vaginal bleeding n Abdominal and Adnexal tenderness n History of infertility n Use of an IUD n Previous ectopic pregnancy Ectopic pregnancy - diagnosis n 5 - 9 weeks of amenorrhoea n Pelvic pain n Vaginal bleeding n Positiv pregnacy test hCG n No dunling time of hCG elevation n US - no suc is seen within the uterus n Laparoscopy Ectopic pregnancy - treatment n Surgical u radical - salpingectomy u konzervative - longitudinal incision n Medical u MTX u Prostaglandins, hyperosmolar glucose n Expectant u monitoring of hCG levels Ectopic pregnancy - risk factors n High risk: u tubal surgery, prevoius ectopic pregnancy, use of IUD, tubal patology n Moderate risk: u infertility, previous genital infection n Slight risk: u cigarete smoking, previous abdominal surgery