Management Of Normal Birth

The birth is a series of rhythmic, involuntary, forward-contractions of the uterus, a slow depletion (thinning and shortening) and dilating the cervix cause. The triggering stimulus for the birth is unknown, but digital manipulation or mechanical dilating the cervix during the investigation increases the contractile activity of the uterus, most likely by a stimulus to the release of oxytocin from posterior pituitary. A normal birth begins the expected date within 2 weeks (before or after). In a first pregnancy, the entire course of birth takes an average of 12-18 hours; following births are often shorter, an average of 6-8 hours. The treatment of complications during childbirth requires additional measures (induction of labor). Beginning of the birth Bloody drawing (a small amount of blood with mucous discharge from the cervix) may precede the beginning of the birth by a maximum of 72 hours. Bloody drawing can be differentiated from abnormal vaginal bleeding in the third trimester because the amount is small, it is usually mixed with mucus and no pain of placental abruption (premature detachment) are available. For most pregnant women ultrasonography has already been carried out and excluded previa placenta. However, If a vaginal bleeding and was a placenta previa not excluded by ultrasound, as long as a placenta previa must be believed until it was excluded. A digital vaginal examination is contraindicated, and an ultrasound is done as soon as possible. The birth starts varying intensity with irregular uterine contractions (contractions). Apparently soften (mature) it the cervix, which begins to shorten and open. With progression of the birth pangs are increasing in duration, intensity and frequency. Stages of birth There are three stages of birth: The first stage – from the beginning of the birth until full dilation of the cervix (about 10 cm) – has two phases, a dormant and active. During the resting phase, the irregular contractions are becoming better coordinated, the complaints are minimal, and the cervix shrinks and opens up to 4 cm. It is difficult to determine the resting phase time accurately, and the duration is different: an average of 8 hours at primiparous and 5 hours at multiparous women. The period of time is considered to be abnormal if it exceeds 12 hours at primiparae 20 hours or in multiparous women. During the active phase, the cervix opens fully, and the previous part occurs well deeper into basin center. On average, the active phase lasts 5-7 hours at first-time mothers and 2-4 hours at multiparas. The cervix should open up at first-time mothers by 1.2 cm / hour and at multiparas by 1.5 cm / hour. Vaginal examinations are performed every 2-3 hours to assess the progress of childbirth. An insufficient progress in the opening and in the descent of the preceding portion may be a sign of dystocia (relative mismatch). If the amniotic sac is not bound spontaneously cause some physicians in the active phase routinely Amniotomy (iatrogenic rupture) through. As a result, the birth proceeds often faster, and meconium-stained amniotic fluid is observed earlier. At this stage, amniotomy for internal monitoring of the fetus may be required to confirm his well-being. A Amniotomy should be avoided in women with HIV infection or hepatitis B or C, so that the fetus is not exposed to pathogens. Maternal heart rate and blood pressure and fetal heart rate should be during the first stage of labor continuously through electronic monitoring or intermittently monitored by auscultation (monitoring of the fetus). If the presenting part enters deeper into the pelvis, the pregnant woman may feel the urge to press for the first time. Yet you should be discouraged from pressing, as long as the cervix is ??not fully opened, so they do not tear the cervix and not wasted their energy. The second stage will be the period from full cervical dilatation until delivery of the fetus. On average it takes 2 hours at primiparous (median 50 minutes) and 1 hour at multiparous women (mean 20 minutes). It can continue for another hour or more if a nerve block (epidural) or a strong sedation was applied with an opiate. To give birth spontaneously, pregnant women need to support the contractions of the uterus with austreibendem presses. In the second stage, the pregnant woman should constantly cared for and the fetal heart tones are monitored continuously or after each contraction. The contractions should be monitored either by palpation or electronically. The third stage of labor begins with the birth of the child and ends with the delivery of the placenta. Rupture of the amniotic sac Occasionally jumps (amnion and chorion) before the birth starts, and amniotic fluid seeps through the cervix and vagina. A rupture of membranes, no matter what time before birth is called premature rupture of membranes called (PROM; Premature rupture (PROM)). Some pregnant women with PROM feel come a rush of fluid from the vagina, followed by a continuous oozing. If seeping fluid is observed during the examination of the cervix, a further confirmation is required. In less clear cases, a test may be required to confirm. For example, the pH of the vaginal fluid is tested with litmus paper, which is at a pH of> 6.5 (pH of the amniotic fluid: 7.0-7.6) turns deep blue; False-positive results can occur when the vaginal blood or semen contains or pass certain infections. You can apply a secretion sample from the posterior fornix or cervical onto a slide, air dry and microscopically examined after Farnkrautphänomen. The Farnkrautphänomen (crystallization of NaCl in a palm leaf-like pattern in the amniotic fluid) usually confirms the rupture of membranes. If a rupture of the membranes is still unconfirmed, provides an ultrasound showing the image of a Oligohydramnions (lack of amniotic fluid), further evidence that hardens the suspected PROM. Rarely an amniocentesis is performed by instillation of a dye to confirm a rupture of membranes. The PROM is confirmed when the dye is again found in the vagina or in a tampon. When the amniotic sac jumps that pregnant women should immediately contact their doctor. Approximately 80-90% of pregnant women with PROM at term and about 50% of pregnant women with early PROM spontaneously begin with contractions within 24 hours; > 90% of pregnant women with PROM start with contractions within 2 weeks. takes the sooner before 37 SSW skips the amniotic sac, the longer the delay between onset of labor and rupture of membranes. If the rupture occurs at term, but the birth does not begin within a few hours, the birth is usually taken to reduce the risk of maternal or fetal infection. Gebärmöglichkeiten Most women prefer a hospital birth before, and most health practitioners in Germany (specialists) recommend it because during labor and birth or after birth unexpected maternal and fetal complications can occur even in women with no risk factors. Approximately 30% of all hospital births go with an obstetric complication associated (z. B. injury, postpartum). Among the other complications include placental abruption, abnormal fetal heart rate patterns, shoulder dystocia, need for emergency even caesarean delivery, asphyxia and depression or malformation of the newborn. Nonetheless, many pregnant women for childbirth want a more homely atmosphere; in response, some hospitals hold less formal Gebäreinrichtungen with less rigid rules, but emergency equipment and constantly available personnel ready. Birth centers can either be housed in their own homes or in hospitals; the care is similar or the same in both places. In some hospitals the care of low-risk pregnancies in large part by Examinierte Midwives done. The midwives work with a doctor who is continuously available for consultation and operative deliveries (eg., By forceps, ventouse or caesarean). All Gebärmöglichkeiten should be discussed. For many pregnant women, the presence of the father of the child, partner or another caregiver during labor is helpful and should be commended. Moral support and encouragement and women have placed affection reduce anxiety and make them the birth less frightening and unpleasant feeling. Courses for birth preparation can prepare the parents on both a normal and complicated birth process. The burden of birth and to share the vision and the first cry of their own child together seems to create strong bonds between parents and between parents and child. Parents should be set fully advised of all complications. Inclusion in the delivery room usually pregnant women are advised to go to the hospital if she believes that her water is bound or if they felt contractions lasting at least 30 seconds and occur regularly at intervals of about 6 minutes or less. Within 1 hour after the presentation in a hospital, can usually be decided on the basis of regular and continuous painfully felt labor pains, bloody drawing, rupture and completely depleted of cervix if a pregnant woman is actually in labor. If these criteria are not met, Braxton Hicks contractions may be a preliminary diagnosis. The pregnant woman is observed for a certain time in the usual way and, if the birth does not begin within a few hours, go home. When shooting a pregnant blood pressure, heart and respiratory rate, temperature and weight are recorded and noted the presence or absence of edema. It is given both a urine sample for protein and glucose measurement and blood for a complete blood count and decreased blood typing. Then a physical examination. During the examination of the abdomen, the doctor size, location and setting of the fetus judged (The Leopold’s handles.) Using the Leopold’s handles. The doctor recorded the presence and frequency of fetal heart tones as well as the site for auscultation. First estimates of the strength, frequency and duration of labor are also noted. A helpful reminder in the study are the 3 Ps: driving forces (= powers, i.e., frequency and duration of the contractions..), Passage (Beck dimensions) and passenger (e.g., size, location, heart rate pattern of the fetus.). The Leopold’s handles. (A) The uterine fundus is palpated to determine which portion of the fetus fills the fundus. (B) The maternal abdomen is sampled on both sides, to detect on which side of the spine and on which the extremities are located. (C) above the symphysis is scanned to locate the previous part of the fetus and thus be seen how deep deszendiert the fetus and whether it is set low and fixed in the pelvis. (D) A hand exerts pressure on the fundus, while the index finger and thumb of the other hand feel for the preceding part to confirm setting and reference to the pelvis. If the contractions are active and the pregnancy is at term, a doctor examined with two fingers of one reinforced by glove the cervix to assess the progress of birth. In existing (especially against strong) bleeding the test is delayed until the localization of the placenta is detected by ultrasound. If the bleeding result of placenta previa, vaginal examination can cause serious bleeding. Is not an active labor available, but the amniotic sac bound a mirror adjustment is first performed in order to document store and shortening of the cervix and to evaluate the ride height (position of the preceding member). Digital investigations are, however, delayed until it comes to active labor or problems (falling z. B. fetal heart sounds). When the amniotic sac has jumped, should be based on potential fetal meconium (which leads to a green-brown discoloration of the amniotic fluid) are respected, as this may be signs of fetal stress situation. If early (<37 weeks) contractions occur or have not yet begun, only a sterile speculum, B should be obtained in the bacteriological smears on gonorrhea, chlamydia and streptococcus group is. The opening of the cervix, as indicated, the diameter of a circle in centimeters; 10 cm will be considered complete. Using up is estimated as a percentage, from zero to 100%. By burning off the cervix is ??shortened and diluted, this can be given in centimeters, wherein one is based on the normal, non-thinned, average cervical length of 3.5-4.0 cm. The ride height is given in centimeters above or below the level of maternal spines ischiadicae. The Inter Spina plane corresponds to a height level of 0; Planes above (+) or below (-) the spines are described in increasing centimeters. Fetal position, location and setting are to be described. The document describes the relationship between the body longitudinal axis of the fetus to the mother of the (longitudinal, obliquely, transversely); Setting describes the part of the fetus, which is set in cervix (z. B. buttocks, apex, shoulder). Position (. Translator's note. D .: in German often referred to as backing) describes the relationship of the selected part to the maternal pelvis (z. B. anterior posterior position [vHHL] or occipitoposterior [hHHL] the skull on or breech [BEL] the rump) Regulations. Preparation for childbirth The pregnant woman is taken to the delivery room for close observation until birth. With active labor she should take up little or nothing orally to prevent possible vomiting or aspiration during birth or in the event that an emergency even childbirth must be performed under general anesthesia. Shaving or cutting of vulva and pubic hair was not indicated; it increases the risk of wound infections. Using a large-bore intravenous catheter preferably, which is placed in a vein in the hand or on the forearm, with the i.v. Infusion of Ringer's lactate solution begin. During a normal birth of 6-10 hours duration, the pregnant woman should receive 500-1000 ml of this solution. This infusion prevents a dehydration during the birth and then following hemoconcentration and maintains an adequate circulating blood volume upright. If necessary, the venous catheter allows immediate access for the delivery of drugs or blood. Volume replacement, in the case of a planned epidural or spinal anesthesia of great value. Analgesia analgesics can be given during labor as needed, but it should only be the minimum dose that makes sure that it goes well the mother, be administered as they cross the placenta and may cause respiratory depression in the newborn. In some cases of poisoning in newborns occur that degrades the transmitted medicine after severing the umbilical cord much more slowly than liver metabolism and urine output because its metabolism and elimination processes are still immature. Preparation for and education about the birth reduce the anxiety, which significantly reduces the need for analgesics. More and more often offer doctors as a pain treatment of choice during labor epidural injection (which leads to a regional anesthetic) to. Typically, a local anesthetic (eg. B. ropivacaine 0.2%, 0.125% bupivacaine) infused continuously into the lumbar epidural space, often together with an opiate (eg. As fentanyl, sufentanil). Initially, the anesthetic is given very careful so as not to mask the perception of the pressure which is an irritant for the pressing urge and to avoid a blocking of the motor impulses. Reaches an epidural injection is insufficient, or is an i.v. Administration it is preferable, it is often used fentanyl (100 ug) or morphine sulfate (? 10 mg) every 60-90 minutes i.v. is given. These opiates result in only a small total dose to good analgesia. If signs or symptoms of toxicity occur, respiration is supported and can be the newborn i.m. naloxone 0.01 mg / kg, i.v., s.c. or give endotracheal as specific antagonists. Depending on the reaction of the newborn, it is possible to give naloxone again if necessary after 1-2 minutes. Physicians should examine the newborn 1-2 hours after the first dose of naloxone because the effect of the previous dose wears off. Is the analgesic effect of fentanyl or morphine is insufficient, an additional dose of the opioid analgesic or another analgesic method instead of a so-called synergistic drug (z. B. promethazine) having no antidote, are selected. (These drugs actually have an additive, not synergistic.) Synergistic drug action are sometimes still used because they reduce the nausea caused by the opiate; it should be applied low doses Fetal monitoring the condition of the fetus must be monitored during labor. The main factors are the baseline fetal heart rate and its variability, especially v. a. how this change in relation to the labor and maternal movement. Because the interpretation of the fetal HR may be subjective, certain parameters have been defined (see Table: Definitions for fetal monitoring). Definitions for Fetal monitoring parameter definition heart rate: Output value is meant a HR over a 10 minute period, be identified without periods of high variability, rounded to nearest 0 or 5 must for ? 2 min (but not necessarily two consecutive min) Heart rate: variability difference between highest and lowest HR value in a 10-minute period acceleration: Age-appropriate <32 weeks EGA: ? 10 bpm> baseline HR of ? 10 s ? 32 weeks EGA: ? 15 bpm

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