A special obstetric examination includes three main sections: external obstetric examination, internal obstetric examination and additional research methods.
External obstetric examination performed by inspection, measurement, palpation and auscultation.
The examination allows us to determine whether the pregnant woman’s appearance matches her age. At the same time, attention is paid to the woman’s height, physique, condition of the skin, subcutaneous tissue, mammary glands and nipples. Particular attention is paid to the size and shape of the abdomen, the presence of pregnancy scars (striae gravidarum), and skin elasticity.
Pelvic examination is important in obstetrics because its structure and size have a decisive influence on the course and outcome of childbirth. Deviations in the structure of the pelvis, especially a decrease in its size, complicate the course of labor or present insurmountable obstacles to it. The pelvis is examined by inspection, palpation and measurement of its size. When examining, pay attention to the entire pelvic area, but attach special importance lumbosacral rhombus (Michaelis rhombus). The Michaelis rhombus is a shape in the sacral area that has the contours of a diamond-shaped area. The upper corner of the rhombus corresponds to the spinous process of the V lumbar vertebra, the lower - to the apex of the sacrum (the origin of the gluteus maximus muscles), the lateral angles - to the superoposterior spine of the iliac bones. Based on the shape and size of the rhombus, you can evaluate the structure of the bony pelvis and detect its narrowing or deformation, which is of great importance in the management of childbirth. With a normal pelvis, the rhombus corresponds to the shape of a square. Its dimensions: the horizontal diagonal of the rhombus is 10-11 cm, the vertical diagonal is 11 cm.
During an external obstetric examination, measurements are made with a centimeter tape (circumference of the wrist joint, dimensions of the Michaelis rhombus, abdominal circumference and height of the uterine fundus above the womb) and an obstetric compass (pelvis gauge) in order to determine the size of the pelvis and its shape.
Using a centimeter tape, measure the largest circumference of the abdomen at the level of the navel (at the end of pregnancy it is 90-100 cm) and the height of the uterine fundus - the distance between the upper edge of the pubic symphysis and the fundus of the uterus. At the end of pregnancy, the height of the uterine fundus is 32-34 cm. Measuring the abdomen and the height of the uterine fundus above the womb allows the obstetrician to determine the duration of pregnancy, the expected weight of the fetus, and identify disorders of fat metabolism, polyhydramnios, and multiple births.
By the external dimensions of the large pelvis one can judge the size and shape of the small pelvis. The pelvis is measured using a pelvic meter. Only some measurements (pelvic outlet and additional measurements) can be made with a measuring tape. Usually four sizes of the pelvis are measured - three transverse and one straight. The subject is in a supine position, the obstetrician sits to the side of her and faces her.
Distantia spinarum- the distance between the most distant points of the anterior superior iliac spines (spina iliaca anterior superior) is 25-26 cm.
Distantia cristarum- the distance between the most distant points of the iliac crests (crista ossis ilei) is 28-29 cm.
Distantia trochanterica- the distance between the greater trochanters of the femurs (trochanter major) is 31-32 cm.
Conjugata externa(external conjugate) - the distance between the spinous process of the V lumbar vertebra and the upper edge of the symphysis pubis is 20-21 cm.
To measure the external conjugate, the subject turns on her side, bends the underlying leg at the hip and knee joints, and extends the overlying leg. The pelvic meter button is placed between the spinous process of the V lumbar and I sacral vertebrae (suprasacral fossa) at the back and in the middle of the upper edge of the symphysis pubis at the front.
By the size of the outer conjugate one can judge the size of the true conjugate. The difference between the external and true conjugate depends on the thickness of the sacrum, symphysis and soft tissues. The thickness of bones and soft tissues in women is different, so the difference between the size of the external and true conjugate does not always exactly correspond to 9 cm. To characterize the thickness of the bones, measure the circumference of the wrist joint and Solovyov index(1/10 of the circumference of the wrist joint). Bones are considered thin if the circumference of the wrist joint is up to 14 cm and thick if the circumference of the wrist joint is more than 14 cm. Depending on the thickness of the bones, with the same external dimensions of the pelvis, its internal dimensions may be different. For example, with an external conjugate of 20 cm and a Solovyov circumference of 12 cm (Solovyov index - 1.2), we need to subtract 8 cm from 20 cm and get the value of the true conjugate - 12 cm. With a Solovyov circumference of 14 cm, we need to subtract 9 cm from 20 cm, and at 16 cm, subtract 10 cm, - the true conjugate will be equal to 9 and 10 cm, respectively. The size of the true conjugate can be judged by the vertical size of the sacral rhombus and the Frank size. The true conjugate can be more accurately determined by the diagonal conjugate.
Diagonal conjugate(conjugata diagonalis) is the distance from the lower edge of the symphysis to the most prominent point of the promontory of the sacrum (13 cm). Diagonal conjugate determined during a vaginal examination of a woman, which is performed with one hand.
Straight pelvic outlet size- this is the distance between the middle of the lower edge of the symphysis pubis and the tip of the coccyx. During the examination, the pregnant woman lies on her back with her legs apart and half-bent at the hip and knee joints. The measurement is carried out with a pelvis meter. This size, equal to 11 cm, is 1.5 cm larger than the true one due to the thickness of the soft tissues. Therefore, it is necessary to subtract 1.5 cm from the resulting figure of 11 cm, and we obtain the direct size of the exit from the pelvic cavity, which is equal to 9.5 cm.
Transverse size of the pelvic outlet- this is the distance between the inner surfaces of the ischial tuberosities. The measurement is carried out with a special pelvis or measuring tape, which is applied not directly to the ischial tuberosities, but to the tissues covering them; therefore, to the resulting dimensions of 9-9.5 cm, it is necessary to add 1.5-2 cm (thickness of soft tissues). Normally, the transverse size is 11 cm. It is determined in the position of the pregnant woman on her back, with her legs pressed as close as possible to her stomach.
Lateral dimensions of the pelvis– the distance between the anterosuperior and posterosuperior iliac spines of the same side (14 cm), measured with a pelvis. The lateral dimensions must be symmetrical and at least 14 cm. With a lateral conjugate of 12.5 cm, childbirth is impossible.
Pelvic angle- this is the angle between the plane of the entrance to the pelvis and the horizontal plane. In the standing position of a pregnant woman, it is 45-50 0 Determined using a special device - a pelvis angle meter.
In the second half of pregnancy and during childbirth, the head, back and small parts (limbs) of the fetus are determined by palpation. The longer the pregnancy, the clearer the palpation of parts of the fetus.
Techniques of external obstetric examination (Leopold-Levitsky) is a sequential palpation of the uterus, consisting of a number of specific techniques. The subject is in a supine position. The doctor sits to her right, facing her.
First appointment with external obstetric examination. The first step is to determine the height of the uterine fundus, its shape and the part of the fetus located in the uterine fundus. To do this, the obstetrician places the palmar surfaces of both hands on the uterus so that they cover its bottom.
Second appointment of external obstetric examination. The second step determines the position of the fetus in the uterus, the position and type of the fetus. The obstetrician gradually lowers his hands from the bottom of the uterus to its right and left sides and, carefully pressing with his palms and fingers on the lateral surfaces of the uterus, determines the back of the fetus along its wide surface on one side, and the small parts of the fetus (arms, legs) on the other. This technique allows you to determine the tone of the uterus and its excitability, palpate the round ligaments of the uterus, their thickness, pain and location.
Third appointment of external obstetric examination. The third technique is used to determine the presenting part of the fetus. The third technique can determine the mobility of the head. To do this, cover the presenting part with one hand and determine whether it is the head or the pelvic end, a symptom of voting of the fetal head.
Fourth appointment of external obstetric examination. This technique, which is a complement and continuation of the third, makes it possible to determine not only the nature of the presenting part, but also the location of the head in relation to the entrance to the pelvis. To perform this technique, the obstetrician stands facing the legs of the examinee, places his hands on both sides of the lower part of the uterus so that the fingers of both hands seem to converge with each other above the plane of the entrance to the pelvis, and palpates the presenting part. When examined at the end of pregnancy and during childbirth, this technique determines the relationship of the presenting part to the planes of the pelvis.
Fetal heart sounds are listened to with a stethoscope, starting from the second half of pregnancy, in the form of rhythmic, clear beats, repeated 120-160 times per minute. With cephalic presentations, the heartbeat is best heard below the navel. In case of breech presentation - above the navel. M.S. Malinowski proposed the following rules for listening to the fetal heartbeat:
with occipital presentation– near the head below the navel on the side where the back is facing;
in rear views– on the side of the abdomen along the anterior axillary line;
with facial presentation– below the navel on the side where the breast is located (in the first position – on the right, in the second – on the left);
in transverse position– near the navel, closer to the head;
with breech presentation– above the navel, near the head, on the side where the back of the fetus is facing.
Internal (vaginal) examination performed with one hand (two fingers, index and middle, four - half-hand, whole hand). Internal examination makes it possible to determine the presenting part, the state of the birth canal, observe the dynamics of cervical dilation during childbirth, the mechanism of insertion and advancement of the presenting part, etc. In women in labor, a vaginal examination is performed upon admission to the obstetric institution, and after the rupture of amniotic fluid. In the future, vaginal examination is performed only when indicated. Vaginal examination of pregnant women and women in labor is a serious intervention that must be performed in compliance with all rules of asepsis and antiseptics.
Internal research begins from examination of the external genitalia (hair growth, development, swelling of the vulva, varicose veins), the perineum (its height, rigidity, presence of scars) and the vestibule of the vagina. Inserted into the vagina phalanges of the middle and index fingers and examine it (the width of the lumen and length, folding and extensibility of the vaginal walls, the presence of scars, tumors, septa and other pathological conditions). Then the cervix is found and its shape, size, consistency, degree of maturity, shortening, softening, location along the longitudinal axis of the pelvis, and patency of the pharynx for the finger are determined. During the examination during labor, the degree of smoothness of the cervix (preserved, shortened, smoothed), the degree of opening of the pharynx in centimeters, and the condition of the edges of the pharynx (soft or dense, thick or thin) are determined. In women in labor, a vaginal examination determines the condition of the fetal bladder (integrity, loss of integrity, degree of tension, amount of anterior water). Determine the presenting part (buttocks, head, legs), where they are located (above the entrance to the small pelvis, at the entrance with a small or large segment, in the cavity, at the pelvic outlet). Identification points on the head are sutures, fontanelles, and at the pelvic end - the sacrum and coccyx. Palpation of the inner surface of the pelvic walls makes it possible to identify deformation of its bones, exostoses and judge the capacity of the pelvis. At the end of the study, if the presenting part is high, measure the diagonal conjugata (conjugata diagonalis), the distance between the promontory and the lower edge of the symphysis (normally 13 cm). To do this, with the fingers inserted into the vagina, they try to reach the promontory and touch it with the end of the middle finger, the index finger of the free hand is brought under the lower edge of the symphysis and mark on the hand the place that directly contacts the lower edge of the pubic arch. Then remove the fingers from the vagina and wash them. The assistant measures the marked distance on the hand with a centimeter tape or a hip meter. By the size of the diagonal conjugate one can judge the size of the true conjugate. If the Solovyov index (0.1 from the Solovyov circumference) is up to 1.4 cm, then 1.5 cm is subtracted from the size of the diagonal conjugate, and if it is more than 1.4 cm, then 2 cm is subtracted.
SURVEY OF PREGNANT AND WOMEN IN LABOR
A survey of a pregnant woman and a woman in labor is carried out according to a specific plan. The survey consists of a general and a special part. All data obtained is entered into the pregnant woman’s chart or birth history.
General anamnesis
-Passport details
: last name, first name, patronymic, age, place of work and profession, place of birth and residence.
-Reasons that forced a woman to seek medical help (complaints).
-Working and living conditions.
-Heredity and past diseases.
Hereditary diseases (tuberculosis, syphilis, mental and oncological diseases, multiple pregnancies, etc.) are of interest because they can have an adverse effect on the development of the fetus, as well as intoxication, in particular, alcoholism and drug addiction in parents. It is important to obtain information about all infectious and non-infectious diseases and operations undergone in early childhood, during puberty and adulthood, their course and methods and timing of treatment. Allergy history. Previous blood transfusions.
Special anamnesis
-Menstrual function:
the time of the onset of menarche and the establishment of menstruation, the type and nature of menstruation (3 or 4 week cycle, duration, amount of blood lost, presence of pain, etc.); did menstruation change after the onset of sexual activity, childbirth, abortion; date of the last normal menstruation.
-Secretory function : the nature of vaginal discharge, its quantity, color, smell.
-Sexual function:
at what age did you begin sexual activity, what type of marriage, duration of marriage, period from the beginning of sexual activity to the onset of the first pregnancy, time of last sexual intercourse.
- Age and health of the husband.
-Childbearing (generative) function.
In this part of the anamnesis, detailed information is collected about previous pregnancies in chronological order, what the current pregnancy is, the course of previous pregnancies (were there any toxicoses, gestosis, diseases of the cardiovascular system, kidneys, liver and other organs), their complications and outcome. The presence of these diseases in the past prompts a woman to be especially closely monitored during a current pregnancy. It is necessary to obtain detailed information about the course of previous abortions, each birth (duration of labor, surgical interventions, gender, weight, growth of the fetus, its condition at birth, length of stay in the maternity hospital) and postpartum periods, complications, methods and timing of their treatment.
-Past gynecological diseases
:time of onset, duration of disease, treatment and outcome
-The course of this pregnancy (by trimester):
- 1st trimester (up to 12 weeks) – general diseases, complications of pregnancy (toxicosis, threat of miscarriage, etc.), the date of the first appearance at the antenatal clinic and the gestational age established at the first visit.
2nd trimester (13-28 weeks) - general diseases and complications during pregnancy, weight gain, blood pressure numbers, test results, date of first fetal movement.
3 trimester (29 – 40 weeks) – overall weight gain during pregnancy, its uniformity, results of blood pressure measurements and blood and urine tests, diseases and complications of pregnancy. Reasons for hospitalization.
Determining due date or gestational age
GENERAL OBJECTIVE EXAMINATION
A general objective study is carried out to identify diseases of the most important organs and systems that can complicate the course of pregnancy and childbirth. In turn, pregnancy can cause exacerbation of existing diseases, decompensation, etc. An objective examination is carried out according to generally accepted rules, starting with an assessment of the general condition, temperature measurement, examination of the skin and visible mucous membranes. Then the circulatory, respiratory, digestive, urinary, nervous and endocrine systems are examined.
SPECIAL OBSTETRIC EXAMINATION
Special obstetric examination includes three main sections: external obstetric examination, internal obstetric examination and additional research methods
.
EXTERNAL OBSTETRIC EXAMINATION
External obstetric examination is carried out by inspection, measurement, palpation and auscultation.
Inspection allows us to identify the correspondence of the type of pregnant woman to her age. At the same time, attention is paid to the woman’s height, physique, condition of the skin, subcutaneous tissue, mammary glands and nipples. Particular attention is paid to the size and shape of the abdomen, the presence of pregnancy scars (striae gravidarum), and skin elasticity.
Pelvic examination is important in obstetrics because its structure and size have a decisive influence on the course and outcome of childbirth. A normal pelvis is one of the main conditions for the correct course of labor. Deviations in the structure of the pelvis, especially a decrease in its size, complicate the course of labor or present insurmountable obstacles to it. The pelvis is examined by inspection, palpation and measurement of its size. When examining, pay attention to the entire pelvic area, but give special importance to the lumbosacral rhombus (Michaelis diamond). The Michaelis rhombus is a shape in the sacral area that has the contours of a diamond-shaped area. The upper corner of the rhombus corresponds to the spinous process of the V lumbar vertebra, the lower - to the apex of the sacrum (the origin of the gluteus maximus muscles), the lateral angles - to the superoposterior spine of the iliac bones. Based on the shape and size of the rhombus, you can evaluate the structure of the bony pelvis and detect its narrowing or deformation, which is of great importance in the management of childbirth. With a normal pelvis, the rhombus corresponds to the shape of a square. Its dimensions: horizontal diagonal rhombus is 10-11 cm, vertical- 11 cm. With different narrowings of the pelvis, the horizontal and vertical diagonals will be of different sizes, as a result of which the shape of the rhombus will be changed.
During an external obstetric examination, measurements are made with a centimeter tape (circumference of the wrist joint, dimensions of the Michaelis rhombus, abdominal circumference and height of the uterine fundus above the womb) and an obstetric compass (pelvis gauge) in order to determine the size of the pelvis and its shape.
Using a centimeter tape, measure the largest circumference of the abdomen at the level of the navel (at the end of pregnancy it is 90-100 cm) and the height of the uterine fundus - the distance between the upper edge of the pubic symphysis and the fundus of the uterus. At the end of pregnancy, the height of the uterine fundus is 32-34 cm. Measuring the abdomen and the height of the uterine fundus above the womb allows the obstetrician to determine the duration of pregnancy, the expected weight of the fetus, and identify disorders of fat metabolism, polyhydramnios, and multiple births.
By the external dimensions of the large pelvis one can judge the size and shape of the small pelvis. The pelvis is measured using a pelvic meter. Only some measurements (pelvic outlet and additional measurements) can be made with a measuring tape. Usually four sizes of the pelvis are measured - three transverse and one straight. The subject is in a supine position, the obstetrician sits to the side of her and faces her.
Distantia spinarum
- the distance between the most distant points of the anterior superior iliac spines (spina iliaca anterior superior) is 25-26 cm.
Distantia cristarum
- the distance between the most distant points of the iliac crests (crista ossis ilei) is 28-29 cm.
Distantia trochanterica
- the distance between the greater trochanters of the femurs (trochanter major) is 31-32 cm.
Conjugata externa
(outer conjugate)
- the distance between the spinous process of the V lumbar vertebra and the upper edge of the symphysis pubis is 20-21 cm. To measure the external conjugate, the subject turns on her side, bends the underlying leg at the hip and knee joints, and extends the overlying leg. The pelvic meter button is placed between the spinous process of the V lumbar and I sacral vertebrae (suprasacral fossa) at the back and in the middle of the upper edge of the symphysis pubis at the front. By the size of the outer conjugate one can judge the size of the true conjugate. The difference between the external and true conjugate depends on the thickness of the sacrum, symphysis and soft tissues. The thickness of bones and soft tissues in women is different, so the difference between the size of the external and true conjugate does not always exactly correspond to 9 cm. To characterize the thickness of the bones, measure the circumference of the wrist joint and the Solovyov index (1/10 of the circumference of the wrist joint). Bones are considered thin if the circumference of the wrist joint is up to 14 cm and thick if the circumference of the wrist joint is more than 14 cm. Depending on the thickness of the bones, with the same external dimensions of the pelvis, its internal dimensions may be different. For example, with an external conjugate of 20 cm and a Solovyov circumference of 12 cm (Solovyov index - 1.2), we need to subtract 8 cm from 20 cm and get the value of the true conjugate - 12 cm. With a Solovyov circumference of 14 cm, we need to subtract 9 cm from 20 cm, and at 16 cm, subtract 10 cm, - the true conjugate will be equal to 9 and 10 cm, respectively.
The size of the true conjugate can be judged according to the vertical size of the sacral rhombus And Franc size. The true conjugate can be more accurately determined along the diagonal conjugate
.
Diagonal conjugate
(conjugata diagonalis)
they call the distance from the lower edge of the symphysis to the most prominent point of the sacral promontory (13 cm). The diagonal conjugate is determined during a vaginal examination of a woman, which is performed with one hand.
Straight pelvic outlet size
- this is the distance between the middle of the lower edge of the symphysis pubis and the tip of the coccyx. During the examination, the pregnant woman lies on her back with her legs apart and half-bent at the hip and knee joints. The measurement is carried out with a pelvis meter. This size, equal to 11 cm, is 1.5 cm larger than the true one due to the thickness of the soft tissues. Therefore, it is necessary to subtract 1.5 cm from the resulting figure of 11 cm, and we obtain the direct size of the exit from the pelvic cavity, which is equal to 9.5 cm.
Transverse size of the pelvic outlet
- this is the distance between the inner surfaces of the ischial tuberosities. The measurement is carried out with a special pelvis or measuring tape, which is applied not directly to the ischial tuberosities, but to the tissues covering them; therefore, to the resulting dimensions of 9-9.5 cm, it is necessary to add 1.5-2 cm (thickness of soft tissues). Normally, the transverse size is 11 cm. It is determined in the position of the pregnant woman on her back, with her legs pressed as close as possible to her stomach.
Oblique pelvic dimensions
have to be measured with oblique pelvises. To identify pelvic asymmetry, the following oblique dimensions are measured: the distance from the anterosuperior spine of one side to the posterosuperior spine of the other side (21 cm); from the middle of the upper edge of the symphysis to the right and left posterosuperior spines (17.5 cm) and from the supracruciate fossa to the right and left anterosuperior spines (18 cm). The oblique dimensions of one side are compared with the corresponding oblique dimensions of the other. With a normal pelvic structure, the paired oblique dimensions are the same. A difference greater than 1 cm indicates pelvic asymmetry.
Lateral dimensions of the pelvis
– the distance between the anterosuperior and posterosuperior iliac spines of the same side (14 cm), measured with a pelvis. The lateral dimensions must be symmetrical and at least 14 cm. With a lateral conjugate of 12.5 cm, childbirth is impossible.
Pelvic angle
- this is the angle between the plane of the entrance to the pelvis and the horizontal plane. In the standing position of a pregnant woman, it is 45-50°
. Determined using a special device - a pelvis angle meter.
In the second half of pregnancy and during childbirth, the head, back and small parts (limbs) of the fetus are determined by palpation. The longer the pregnancy, the clearer the palpation of parts of the fetus. External obstetric examination techniques (Leopold-Levitsky) are sequential palpation of the uterus, consisting of a number of specific techniques. The subject is in a supine position. The doctor sits to her right, facing her.
First appointment of external obstetric examination.
The first step is to determine the height of the uterine fundus, its shape and the part of the fetus located in the uterine fundus. To do this, the obstetrician places the palmar surfaces of both hands on the uterus so that they cover its bottom.
Second appointment of external obstetric examination.
The second step determines the position of the fetus in the uterus, the position and type of the fetus. The obstetrician gradually lowers his hands from the bottom of the uterus to its right and left sides and, carefully pressing with his palms and fingers on the lateral surfaces of the uterus, determines the back of the fetus along its wide surface on one side, and the small parts of the fetus (arms, legs) on the other. This technique allows you to determine the tone of the uterus and its excitability, palpate the round ligaments of the uterus, their thickness, pain and location.
Third appointment of external obstetric examination.
The third technique is used to determine the presenting part of the fetus. The third technique can determine the mobility of the head. To do this, cover the presenting part with one hand and determine whether it is the head or the pelvic end, a symptom of voting of the fetal head.
Fourth appointment of external obstetric examination.
This technique, which is a complement and continuation of the third, makes it possible to determine not only the nature of the presenting part, but also the location of the head in relation to the entrance to the pelvis. To perform this technique, the obstetrician stands facing the legs of the examinee, places his hands on both sides of the lower part of the uterus so that the fingers of both hands seem to converge with each other above the plane of the entrance to the pelvis, and palpates the presenting part. When examined at the end of pregnancy and during childbirth, this technique determines the relationship of the presenting part to the planes of the pelvis. During childbirth, it is important to find out in which plane of the pelvis the head is located with its largest circumference or major segment. The large segment of the head is its largest the part that passes through the entrance to the pelvis in a given presentation. With an occipital presentation of the head, the border of its large segment will pass along the line of the small oblique size, with an anterior cephalic presentation - along the line of its direct size, with a frontal presentation - along the line of the large oblique size, with a facial presentation - along the line of the vertical size. The small segment of the head is any part of the head located below the large segment.
The degree of insertion of the head by a large or small segment is judged by palpation data. During the fourth external technique, the fingers are moved deeper and slide upward along the head. If the hands come together, the head is a large segment at the entrance to the pelvis or has sunk deeper; if the fingers diverge, the head is a small segment at the entrance. If the head is in the pelvic cavity, it cannot be determined by external methods.
Fetal heart sounds are listened to with a stethoscope, starting from the second half of pregnancy, in the form of rhythmic, clear beats repeated 120-160 times per minute. With cephalic presentations, the heartbeat is best heard below the navel. In case of breech presentation - above the navel.
M.S. Malinowski proposed the following rules for listening to the fetal heartbeat:
In case of occipital presentation - near the head below the navel on the side where the back is facing, in posterior views - on the side of the abdomen along the anterior axillary line,
In case of facial presentation - below the navel on the side where the breast is located (in the first position - on the right, in the second - on the left),
In a transverse position - near the navel, closer to the head,
When presented with the pelvic end - above the navel, near the head, on the side where the back of the fetus is facing.
The dynamics of the fetal heartbeat is studied using monitoring and ultrasound.
INTERNAL (VAGINAL) EXAMINATION
Internal obstetric examination is performed with one hand (two fingers, index and middle, four - half-hand, whole hand). Internal examination makes it possible to determine the presenting part, the state of the birth canal, observe the dynamics of cervical dilation during childbirth, the mechanism of insertion and advancement of the presenting part, etc. In women in labor, a vaginal examination is performed upon admission to the obstetric institution, and after the rupture of amniotic fluid. In the future, vaginal examination is performed only when indicated. This procedure allows for timely identification of complications during labor and provision of assistance. Vaginal examination of pregnant women and women in labor is a serious intervention that must be performed in compliance with all rules of asepsis and antiseptics.
Internal examination begins with examination of the external genitalia (hair growth, development, swelling of the vulva, varicose veins), the perineum (its height, rigidity, presence of scars) and the vestibule of the vagina. The phalanges of the middle and index fingers are inserted into the vagina and examined (lumen width and length, folding and extensibility of the vaginal walls, the presence of scars, tumors, septa and other pathological conditions). Then the cervix is found and its shape, size, consistency, degree of maturity, shortening, softening, location along the longitudinal axis of the pelvis, and patency of the pharynx for the finger are determined. During the examination during labor, the degree of smoothness of the cervix is determined (preserved, shortened, smoothed), the degree of opening of the pharynx in centimeters, the condition of the edges of the pharynx (soft or dense, thick or thin). In women in labor, a vaginal examination determines the condition of the fetal bladder (integrity, loss of integrity, degree of tension, amount of anterior water). Determine the presenting part (buttocks, head, legs), where they are located (above the entrance to the small pelvis, at the entrance with a small or large segment, in the cavity, at the pelvic outlet). Identification points on the head are sutures, fontanelles, and at the pelvic end - the sacrum and coccyx. Palpation of the inner surface of the pelvic walls makes it possible to identify deformation of its bones, exostoses and judge the capacity of the pelvis. At the end of the study, if the presenting part is high, measure the diagonal conjugata (conjugata diagonalis), the distance between the promontory and the lower edge of the symphysis (normally 13 cm). To do this, with the fingers inserted into the vagina, they try to reach the promontory and touch it with the end of the middle finger; the index finger of the free hand is brought under the lower edge of the symphysis and the place on the hand that directly contacts the lower edge of the pubic arch. Then remove the fingers from the vagina and wash them. The assistant measures the marked distance on the hand with a centimeter tape or a hip meter. By the size of the diagonal conjugate one can judge the size of the true conjugate. If Solovyov index(0.1 from Solovyov’s circumference) to 1.4 cm, then 1.5 cm is subtracted from the size of the diagonal conjugate, and if more than 1.4 cm, then 2 cm is subtracted.
Determining the position of the fetal head during labor
At first degree of head extension
(anterocephalic insertion) the circumference of which the head will pass through the pelvic cavity corresponds to its direct size. This circle is the large segment when inserted anteriorly.
At second degree of extension (frontal insertion) the largest circumference of the head corresponds to the large oblique size. This circle is a large segment of the head when it is inserted frontally.
At third degree of head extension
(facial insertion) the largest circle is the one corresponding to the “vertical” size. This circle corresponds to the large segment of the head when it is inserted face-on.
Determining the degree of insertion of the fetal head during labor
The basis for determining the height of the head during vaginal examination is the ability to determine the relationship of the lower pole of the head to the linea interspinalis.
Head above the pelvic inlet:
When you gently press upward with your finger, the head moves away and returns to its original position. The entire anterior surface of the sacrum and the posterior surface of the pubic symphysis are accessible to palpation.
The head is a small segment at the entrance to the pelvis:
the lower pole of the head is determined 3-4 cm above the linea interspinalis or at its level, the sacral cavity is 2/3 free. The posterior surface of the pubic symphysis is palpable in the lower and middle sections.
Head in the pelvic cavity:
the lower pole of the head is 4-6 cm below the linea interspinalis, the ischial spines are not defined, almost the entire sacral cavity is filled with the head. The posterior surface of the pubic symphysis is not accessible to palpation.
Head on the pelvic floor:
the head fills the entire sacral cavity, including the coccyx area, only soft tissues can be palpated; the internal surfaces of bone identification points are difficult to access for research.
Techniques for external obstetric examination. Leopold-Levitsky techniques.
Target: determining the position of the fetus in the uterine cavity
Indications: are used for objective examination of pregnant women in the second half of pregnancy and for examination of women in labor (childbirth).
Contraindications: threat of miscarriage
Manipulation technique:
1) Explain the purpose and how this manipulation is carried out (sequence of the upcoming procedure)
2) Relieve emotional and mental stress
3) Place the pregnant woman (mother in labor) on a couch covered with a clean sheet
4) The examiner’s hands are treated with disinfectant. solution
5) The examiner stands to the right of the pregnant woman (mother in labor).
6) When palpating the abdomen, four Leopold-Levitsky techniques are used sequentially:
First reception of Leopold Levitsky: allows you to determine the height of the uterine fundus and the part of the fetus that is located in the uterine fundus. For this purpose, the palms of both hands are placed on the fundus of the uterus, the fingers are brought together and, with gentle downward pressure, they palpate and determine the level of the fundus of the uterus, and also determine the part of the fetus located in the fundus of the uterus.
Second appointment. Serves to determine the position of the fetus and its type. Both hands are placed on the lateral surfaces of the uterus. Palpation of parts of the fetus is performed alternately, first with one hand, then with the other. Thus, in the second step, the position of the fetus is determined. In a longitudinal position, the back is determined on one side, and small parts on the other. The second step is to determine the position and type of the fetus based on the position of the back.
Third reception. Used to determine the presenting part of the fetus. To do this, the open palm of the right hand is located above the symphysis and it covers the presenting part of the fetus located above the entrance to the pelvis. With a cephalic presentation, the head is defined as a dense round part. With the head standing movably above the entrance to the pelvis, its movement is clearly felt. This part of the fetus is born first. With breech presentation, a wide part without clear contours is determined
Fourth reception. Complements the third and clarifies the level of standing of the presenting part. The subject stands facing the lower limbs of the pregnant woman. The palms of both hands are placed on the lower segment of the uterus on the right and left, the ends of the fingers determine the relationship of the presenting part to the entrance to the small pelvis and the standing height of this presenting part in relation to the pelvic cavity: above the entrance to the pelvis, at the entrance to the small pelvis, in the cavity of the small pelvis
7) Evaluation of the achieved results: The height of the uterine fundus, position, position, appearance, presentation were determined
8) Possible complications: Inferior vena cava compression syndrome. Prevention of this complication is not to leave the pregnant woman (mother in labor) on her back for a long time.
The student establishes the breech presentation of the fetus with the first, second, third and fourth methods of external examination: pure breech, mixed breech, leg presentation
The student determines the transverse position of the fetus based on the shape of the uterus and the absence of the presenting part above the entrance to the pelvis
The position of the fetus is determined by the position of the head: the head on the left is position I, on the right is position II
The back of the fetus can be located both in front and behind, both above and below
Notes:
Breech presentations are longitudinal, but the course of labor and outcome are unfavorable for the mother and fetus. The question of delivery is decided by the doctor individually for each woman.
When the full-term fetus is in transverse position, a caesarean section is always performed.
(techniques according to Leopold - Levitsky)
Goals:
Determine the position, position, presentation of the fetus; the relationship of the presenting part to the inlet of the pelvis.
External obstetric examination is carried out from 20 weeks.
1. Material resources:
§ Diaper.
§ Towel.
§ Disinfectant solution.
§ Rags for processing.
§ Couch.
2.1 Preparation for the procedure:
o Free your stomach from clothing.
2.2 Performing the procedure:
Purpose of the first appointment: determine the height of the uterine fundus and the part of the fetus located in its fundus.
· Place the palmar surfaces of both hands on the uterus so that they tightly cover its bottom; and the fingers were facing each other.
· By gently pressing downwards, determine the level of the fundus of the uterus, by which you can judge the stage of pregnancy. Use your fingers to determine the large part of the fetus located in the fundus of the uterus. It can be assumed that the fetus is presenting (if the buttocks are visible in the fundus of the uterus, this means that the presenting part is the head).
Purpose of the second reception: determine the position of the fetus, position, type of position.
· Move both hands from the bottom of the uterus to the right and left sides to the level of the navel and below.
· Determine in which direction the back and small parts of the fetus are facing (carefully press with the palms and fingers of both hands on the side walls of the uterus; palpate alternately with the right and left hands). When the fetus is positioned longitudinally, the back is palpated on one side, and small parts of the fetus are felt on the other.
· The back is defined to the touch as a wide, smooth, dense, even surface without protrusions.
· Small parts of the fetus are identified on the opposite side in the form of movable small tubercles. Sometimes rapid jerking movements of the limbs are felt.
· Backrest on the left – 1st position, backrest on the right – 2nd position.
Purpose of the third reception: determine fetal presentation.
· Performed with one hand (usually the right).
· Place your right hand just above the symphysis pubis so that the thumb is on one side and the other four fingers are on the other side of the lower segment of the uterus.
· With a slow and careful movement, immerse your fingers deep and cover the part of the fetus located above the womb (presenting part).
· The head feels like a large, round, firm part, and the buttocks feel like a large, soft part.
· This technique can determine the symptom of balding of the head. To do this, use short, light pushes to try to move the head from right to left and vice versa. The higher the head is above the entrance to the pelvis, the clearer the voting. The symptom of balloting is not determined if the pelvic end of the fetus is present.
Purpose of the fourth reception: determine the relationship of the presenting part to the entrance to the pelvis (with cephalic presentation).
· Stand facing the feet of the pregnant woman or woman in labor.
· Place the palms of both hands on the lower segment of the uterus on the right and left, the ends of the fingers reaching the symphysis.
· Gradually, moving your hands between the presenting part and the plane of the entrance to the small pelvis, clarify the nature of the presenting part and its location.
· The fingers converge - the head is above the entrance to the small pelvis, the fingers do not converge and are located at an obtuse angle - the head is pressed against the entrance to the small pelvis.
Listening and counting the fetal heartbeat
Taking into account the position of the fetus in the uterus
Goals:
Determine fetal heart sounds;
Determine the condition of the fetus.
1.Material resources:
§ Diaper.
§ Towel.
§ Obstetric stethoscope.
§ Stopwatch.
§ Couch.
§ Disinfectant solution.
§ Rags for processing.
2. Methodology for performing medical services.
2.1 Preparation for the procedure:
o Obtain the patient’s informed consent for the procedure.
o Wash your hands; lay a diaper on the couch, invite the pregnant woman to lie on her back, bend her legs at the hip and knee joints (to relax the abdominal muscles).
o Free your stomach from clothing.
o Stand on the right side facing the patient.
2.2 Performing the procedure:
· First, conduct an external obstetric examination to determine the position, position and presentation of the fetus.
· Listen to the heart sounds with a stethoscope (place the stethoscope with a wide funnel down perpendicular to the stomach, and the ear to the other end of the stethoscope, after which the hand must be removed; press the stethoscope tightly to the stomach). Place the stethoscope on the side of the abdomen where the back of the fetus is facing, closer to the head (depending on the position and presentation of the fetus):
With occipital presentation: 1st position – on the left, below the navel; 2nd position – on the right, below the navel;
With breech presentation: 1st position – on the left, above the navel; 2nd position – on the right, above the navel;
In the transverse position: at the level of the navel closer to the fetal head;
During multiple pregnancy: heard clearly in different parts of the uterus with different frequencies;
During childbirth, when the head descends into the pelvic cavity: audible
closer to the symphysis, almost along the midline of the abdomen
· Heart sounds are heard in the form of rhythmic beats on average 130 - 140 times per minute. Normal fetal heart rate is 120 – 160 beats/min. To count the fetal heart rate, start the stopwatch for 30 seconds. Multiply the result by 2.
· Upon completion of the manipulation, disinfect the workplace. Wash and dry your hands. Record the received data.
Target: assessment of physiological development.
Equipment:
· Gynecological chair.
· Sterile gloves.
· Obstetric-gynecological phantom.
· Breast phantom.
· Height meter.
· Medical scales.
1. Explain to the pregnant woman about the need for this examination.
2. Ask the pregnant woman to undress.
3. Measure and inspect in sequence:
body weight
· physique
external dimensions of the pelvis
· skin colors
· pigmentation
pathological changes
color of mucous membranes
· development of mammary glands and nipple shape
belly shapes
· pelvic shapes
Michaelis rhombus
· pattern of hair growth on the pubis and other parts of the body
4. Record the results in your medical records.
4.2. Algorithm for external obstetric examination (Leopold-Levitsky techniques)
Target: external obstetric examination of a pregnant woman using four obstetric techniques and recorded in the individual chart of the pregnant woman.
Equipment:
Couch;
Oilcloth;
Individual card for a pregnant woman.
Execution method:
1. Explain to the pregnant woman about the need for this study.
2. Treat the couch with a rag moistened with a 1% chloramine solution.
3. Lay out a clean diaper.
4. Ask the pregnant woman to undress.
5. Lay the pregnant woman on her back with her legs straight.
6. Sit on the right side of the couch facing the pregnant woman.
№ 1 № 2 № 3 № 4
7. Carry out the first appointment and determine the height of the uterine fundus and the part of the fetus that is in the uterine fundus. Place the palms of both hands on the fundus of the uterus, the ends of the fingers directed towards each other, but not touching. Determine the height of the uterine fundus in relation to the xiphoid process or navel and the part of the fetus located in the uterine fundus.
8. Using the second technique, determine position, position and appearance of the fetus in the uterine cavity. Move your hands from the bottom of the uterus to the side surfaces of the uterus (approximately to the level of the navel). Use the palmar surfaces of your hands to palpate the lateral parts of the uterus. Determine the location of the back (smooth, level surface without protrusions) and small parts (arms and legs) and draw a conclusion.
9. Carry out the third reception and determine the presenting part of the fetus to the entrance to the pelvis. Perform the technique with one right hand, while moving your thumb as far as possible from the other four. Grasp the presenting part between the thumb and middle finger above the plane of the entrance to the small pelvis and determine whether it is the head or the pelvic end. If there is a head, the symptom of balloting is determined.
10. Perform the fourth technique, which determines the nature of the presenting part and its location in relation to the planes of the pelvis. To perform this technique, the midwife turns to face the pregnant woman's feet. Places the hands on both sides of the lower part of the uterus so that the fingers of both hands seem to converge with each other above the plane of the entrance to the pelvis, palpates the presenting part, determines the nature of the presenting part and its location.
