Female pelvis. Fetus as the object of labor.

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• Female pelvis. Fetus as the object of labor.
• Obstetric terminology
• METHODS OF EXAMINATION
• doc. Stelmakh O.Y.

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Female pelvis

• Birth canal is divided into bone and soft parts
  tobone belongs small pelvis and to soft -
  cervix, vagina,muscle-fascial system of the
  pelvic floor.Bone part of the pelvisFemale
  pelvis with obstetric considerations are divided
  into two sections the large andsmall pelvis.
  The boundary between them passes through an
  unmarked line (linea innominata). Large pelvis
  bounded on the sides of the iliac wings,back -
  the spine. Small pelvis formed in frontbranches
  of the pubic bones and symphysis on each side -
  Part bonesconstitute acetabular and ischial
  bones, behind -the sacrum and coccyx.During
  childbirth small pelvis as dense bone tunnel
  limits anddetermines the size, shape and
  direction of the birth canal, which fetuspasses,
  and has to adapt by changing their own
  configuration.

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The main dimensions of the pelvis

• Of all the methods of the pelvis examination is
  essential it measurement.Most internal pelvic
  sizes available for measurement, sousually
  measured by its external dimensions and evaluate
  them about internal.Measurement of pelvic
  spend by pelviometr.Usually measured four basic
  dimensions of the pelvis three transverse and
  one direct.

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The main dimensions of the pelvis

• Distantia spinarum - the distance between the
  upper anterior iliac spine bones. This size is
  25-26 cmDistantia cristarum - the distance
  between the most distant points of wings iliac
  bone. On average it is 28 cmDistantia
  trochanterica - the distance between the
  trochanter major of hipbones. This size is 31
  cm

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The main dimensions of the pelvis

• external conjugate external size of pelvis. End
  of pelviometr set onmiddle of the upper margin
  of symphysis, the other end is over the sacral
  fossa contained between fifth lumbar vertebra and
  the beginning of the first sacral vertebra.
  External conjugate is 20 cm

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The planes of the pelvis and their dimensions

• In obstetric practice are important dimensions of
  the pelvis, fromwhich depends on the course and
  outcomes for both mother and fetus. But most
  sizes pelvis can not be measured directly.Great
  pelvis for childbirth substantial does not
  matter, but in itssize may indirectly informates
  about the form and size of the pelvis.Pelvic
  cavity is the space between the walls, which the
  top and bottom limited inlet and outlet planes of
  the pelvis. It looks like a cylinder. In pelvic
  cavity are four planesinlet, greatest
  dimention,narrow part (midpelvis) and outlet.

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The planes of the pelvis and their dimensions

• The plane of the inlet of a small pelvis bounded
  behind promontory of sacral bone, laterally-
  arcuate lines iliac bone, antioriorly-
  uppermargin of the pubic bone and symphysis.

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Small pelvis. The planes and the size of the
pelvis

• At the pelvic inlet there are 4 sizes
  antirior-postirior, transvers and two oblique.
  Direct size - distance from sacral promontory to
  the point that most appear on the inner surface
  of the upper margin of the pubic symphysis - is
  true or obstetric conjugate (conjugata vera),
  which is 11 cm away from promontory the to the
  middle of the upper part of symphysis anatomical
  conjugate to 0.3-0.5 cm greater than the
  obstetric .

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Small pelvis. The planes and the size of the
pelvis

• Dimensions plane of the pelvic inlet 1
  antirior-posterior size, 2 - transverse size, 3 -
  left oblique size, 4 - right oblique sizeThe
  transverse size of the distance between the
  inniminata lines is 13 cm
• Two oblique, right and left, which have 12 cm
  Right oblique size goes from the right
  iliac-sacral junction to the left eminentia
  iliopubis. Left oblique size- from the left
  iliacsacrum junction to the right eminentia
  iliopubis.

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Small pelvis. The planes and the size of the
pelvis

• Plane of widest part of the pelvic cavity has the
  following limitsfront - a middle inner surface
  of the pubic symphysis, laterally - mid
  acetabulum hollow, back - the place II and III
  sacral vertebrae. Direct and transverse
  dimensions of the plane are equal to 12,5 cm

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Small pelvis. The planes and the size of the
pelvis

• The plane of the narrow part of the pelvic cavity
  is limited to the lower edge of the front pubic
  symphysis, laterally ishial spine behind -
  sacro-coccygeal joints. Direct size is 11-11,5 cm
  transvers - 10.5 cm

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Small pelvis. The planes and the size of the
pelvis

• Plane of pelvic outlet has the following borders
  anteriorly- lower margin of the pubic symphysis,
  laterally tuber ischii, posteriorly- the tip of
  the coccyx. Direct size - 9.5 cm, and the
  transvers - 11.5 cmThe line connecting the
  centers of all direct sizes of pelvis, called the
  main axis of the pelvis

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Measuring the size of the pelvis

• Diagonal conjugate measured during vaginal
  examination from the lower margin of pubis to
  promontory. Normally, this distance is 12,5-13 cm
  for the determination of the real conjugates of
  bias should be deducted 1.5-2 cmIndex Soloviev -
  average circumference of wrist is 14 cmRhombus
  of Michaelis - upper angle contained hollow under
  the spinous processes of the 5 lumbar vertebrae
  Lateral angles correspond posterior-superior
  iliac spine, lower- top sacrum. In women with a
  normal pelvis it has the correct form,
  approaching the square, its dimensions are 10.11
  cm, height of the upper triangle 3-3.5 cm

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Fetus as the object of labor

• From all parts of the mature fetus most
  interesting head, because of the following
  reasons 1) head has the big circumference and
  dense part of thefetus, which can withstand the
  greatest resistance from the birth canal and puts
  most pressure on them that determines the outcome
  of labor, 2) depending on the density and
  mobility of the cranial bones is greatly damage
  the birth canal of the mother and the fetus, and
  3) the head of the fetus has a large number of
  cognitive items, which helps in diagnosing
  insertion and promotion in the bones of the
  pelvis.At the head of the fetus can distinguish
  two parts (Fig. 1) a relatively small front
  lower jaw (1), maxilla (2) and very voluminous -
  brain. The latter consists of seven bones two
  frontal (3), two parietal(4), one occipital (5),
  two temporal (6).

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Fetus as the object of labor

• Sutures and fontanelles skull newborn (seen from
  above)1 - frontal suture, 2 - coronal suture 3
  - sagittal (sagittal) suture 4 - occipital
  suture, 5 - Small fontanel 6 - large
  fontanel All bony parts are interconnected
  fibrous membranes, allowing the process of
  childbirth crossbones go one after another, thus
  reducing the size of the head

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Fetus as the object of labor

• These fibrous membrane called sutures There are
  the following joints 1) frontal sutura (sutura
  frontalis) 2) coronal suture (sutura coronaria),
  connecting on each side of the frontal and
  parietal bones, and 3) sagittal (sagittal) suture
  (sutura sagittalis), combining two parietal bone,
  4) or lyambdoid occipital suture (sutura
  lambdoidea), connecting occipital bone with the
  parietal, 5) temporal suture (sutura temporalis),
  connecting on each side of the parietal temporal
  bone (mostly).

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Fetus as the object of labor

• Fibrous membrane at the intersections of joints
  called fontanelles. There are two main fontanel
  and two pairs of secondary. The main fontanelles
  include large and small fontanel Large fontanel
  (fonticulus magnus s. Bregmaticus) located at the
  intersection of coronary, windshield and sagital
  suture and a diamond shape. Acute angle of the
  diamond sent to the forehead, and - back. It is
  easily determined by finger. Small (5) fontanel
  is located at the intersection sagital and
  occipital sutures. Unlike large, small fontanel
  poorly defined because it is already ripe fetus
  filled bone.

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Fetus as the object of labor

• At the head term fetus can distinguish the
  following dimensions and perimeter 1. vertical
  size (diameter sublinguo-bregmatica) distance
  from the hyoid bone to the middle of the large
  fontanel, is equal to 9.5 cm on the contours of
  the head, measured through these points vertical
  size, (circumferentia sublinguo-bregmatica) - 32
  cm2. Large oblique size (diameter
  mento-occipitalis) - from the chin to the
  farthest point of the neck, length - 13 cm from
  the perimeter (circumferentia mento-occipitalis)
  - 41 cm

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Fetus as the object of labor

• 8. Direct size (diameter fronto-occipitalis) -
  from the nose to the occipital hill, length - 12
  cm by 34 cm contours of equal
• 7. Average oblique size (diameter
  suboccipito-frontalis) - from suboccipital fossa
  to the anterior border of the scalp, length of 10
  cm, and contours (circumferentia
  suboccipito-frontalis) - 33 cm
• 6. Small oblique size (diameter
  suboccipito-bregmatica) - from the middle
  suboccipital fossa large fontanel, length - 9.5
  cm, and circumference suboccipito-bregmatica - 32
  cm

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Fetus as the object of labor

• 7. Small transverse size (diameter bitemporalis)
  - the distance between the most distant points of
  the coronal suture, - 8 cm8. Large transverse
  size (diameter biparietalis) - the distance
  between the parietal bones, length - 9.5 cm
  Circumferences of shoulders is 34cm (12cm),
  circumferences of pelvic part is 28cm (9,5cm).

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Fetus as the object of labor

• The transverse size of the buttocks (distantia
  bisiliacalis) length and 9.5 cm in perimeter an
  incomplete presentation buttocks - 32 cm , with
  full foot previa - 28 cm , with full presentation
  buttocks - 34 cm . 11. Contours (in cm) newborn
  body in full foot presentation shoulder with
  handles (34) buttocks (28). 12. Contours (in
  cm) newborn body in complete breech presentation
  shoulder (34) buttocks with legs (34). 

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Obstetric terminology

• definitions of "fetal lie, "position", "view",
  "presentation"Accurate knowledge of the position
  of the fetus in the uterus, is of great
  importance for practical obstetrics. It is
  achieved by the examination of women in late
  pregnancy, when you can set fetus habitus, its
  lie , presentation, position and variety.

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Obstetric terminology

• Attitude of fetus (habitus) - is the ratio of the
  limbs of the fetus and the head to his body. In
  the most favorable habitus - curved spine,
  resulting in back arched outwards, head bent,
  chin close to the chest. The legs are flexed at
  the hip and knee joints, intersect and pinned to
  the lower abdomen. Handles are flexed at the
  elbows and intersect on his chest.

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Obstetric terminology

• Fetal lie (situs) - is the ratio of the axis of
  the fetus to the axis of the uterus. The axis of
  the fetus - a line that passes through the neck
  and buttocks. Can meet the following options for
  the of the fetus lie fetal axis coincides with
  the uterus - longitudinal lie (situs
  longitudinalis) - occurs in 99 of cases fetal
  axis intersects the uterus - transverse (situs
  transversus) or oblique fetal lie (situs
  obliguus).

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Obstetric terminology

• Position of the fetus (positio) - is the ratio of
  the fetus back to the left (I position 2/3 cases)
  or right (second position, 1/3 of cases) the
  uterine wall. In transverse position of the fetus
  position is determined by the placement
  head.Type of position (visus) - the ratio of the
  fetus back to the front or back wall of the
  uterus. In the front form the back of the fetus
  is facing the front wall of the uterus, at the
  back of the form - to the back wall of the
  uterus.Fetal presentation (presentatio) - is the
  ratio of the lowest placed a large part of the
  fetus to enter the pelvis (main or breech).

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Fetal head station

• -2 (fixed to pelvic inlet)
• -1(small segment of fetal head in pelvic inlet)
• 0 (large segment of fetal head in pelvic inlet)
• 1 (fetal head in plane of greatest dimension)
• 2 (fetal head in plane of least dimension)
• 3 (fetal head in the pelvic outlet

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METHODS OF EXAMINATION

• Anamnesis womenWhen taking history clarifies the
  following issues 1) Passport part last name,
  first name, age, pregnancy, occupation, address,
  phone, and 2) carried diseases childhood,
  adulthood, pregnancy, and 3) family history, and
  4) working and living conditions, and 5) special
  history menstrual, sexual, reproductive and
  secretory functions, 6) the occurrence of
  pregnancy.

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METHODS OF EXAMINATION

• Overview pregnantDuring the general examination
  pay attention to height, body structure,
  completeness, condition of skin, shape of the
  abdomen, development of breasts and nipples,
  pubic hair growth

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METHODS OF EXAMINATION

• External measurementIn order to have an idea
  about the size of the fetus, measure the size of
  the abdomen measuring tape sight abdoman. In the
  supine position at the navel at the end of
  pregnancy, this woman is 110 cm and the height
  stoyanyya uterus above the pubis - 37 cm to
  determine the mass of fetal abdominal perimeter
  must be multiplied by the height of standing
  uterus (110 cm x 37 cm 4070 g).

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METHODS OF EXAMINATION

• External examinationExternal examination
  -Leopold-Levitsky manuversThe first external
  method
• Obstetrician sits to the right of the pregnant
  woman, facing her. Palmar surface of the hand
  puts the fundus of the uterus, is trying to bring
  together the nail phalanges. This reception
  determine the height of standing and form the
  uterus (normal, saddle, two-horned), the part of
  fetus that is at its fundus .

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METHODS OF EXAMINATION

• The second external method.. The doctor pulls the
  two arms of the uterus on the side wall of the
  abdomen and one by one, then another, then
  another hand, carries palpation. If it finds one
  side smooth, wide, curved surface - back (left -
  the first position to the right - the second
  position), which is facing forward (front view)
  or back (posterior view.

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METHODS OF EXAMINATION

• The third external method . Obstetrician palm and
  thumb and other four fingers of his right hand
  covers and squeezes the fetus placed above the
  entrance to a smallpelvis, attempts to displace
  it to the right or left side, verifying the
  presence or absence of symptoms ballotment. If
  above the pubic joints palpated soft and broad,
  it can be suspected breech presentation, and if
  solid and rounded -cefalic .

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METHODS OF EXAMINATION

• Fourth external method is performed as follows
  Obstetrician stands face to legs bent at the
  knees pregnant tips and palmar surfaces of the
  fingers of both hands gently and gradually slides
  along the side of the head down, gets between her
  and the plane door in a small bowl and returns
  back up, checking the results. In transverse
  position of the fetus peredlezhascha part on the
  pubic joints not palpable and fingers freely
  agree among themselves high above the vagina.
  When cephalic this method allows to determine the
  place of accommodation. If peredlezhascha part
  above the entrance to the small pelvis, the
  fingers of both hands freely converge under it,
  and when returning back - apart

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METHODS OF EXAMINATION

• Vaginal examinationVaginal examination is
  required in the following cases the first - at
  the time of admission to the hospital pregnant,
  the second - after the discharge of amniotic
  fluid or early labor activity and the third -
  when changing obstetric situation fourth - early
  in the second stage of labor Vaginal
  examination provides information on the status of
  the genital tract before birth, there exostosis,
  bone tumors, deformities of the pelvis, dynamic
  opening of the cervix, the presence of amniotic
  mamrane, the mechanism of insertion and passage
  of the birth canal presenting part.

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Estimation of diagonal conjugate
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METHODS OF EXAMINATION

• Ultrasonic dating of the pregnancy and an
  ultrasonic fetal survey to detect gross
  abnormalities have been recommended in some
  clinics as a routine part of early prenatal care.
  Routine ultrasonography is most cost effective
  in patients in whom the date of the last
  menstrual period is uncertain and in patients
  with a family history of congenital anomalies.
  Considerable individualization should be
  exercised in making the decision to order this
  evaluation. If ultrasonography is performed, it
  is most informative between 11-13 and18-20 weeks.

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METHODS OF EXAMINATION

• Auscultation. In cephalic presentation, the
  point of maximal intensity of fetal heart sounds
  is usually midway between the maternal umbilicus
  and the anterior-superior spine of her ilium.