Lecture difficult delivery due to the pelvis

2021-03-18 12:00 AM

To assess the distortion of the asymmetric narrow pelvis one must rely on fillings Michaelis. Canarium Michaelis is limited to the lumbar spine 5

General perception

Difficulty due to abnormal pelvic causes previously met with the rate of nearly 5%. Previously, difficult delivery due to pelvic causes was paid special attention by physicians to cause preterm labor, to avoid the risk of pelvic mismatch and fetus if waiting for the fetus to reach full term. Today, thanks to the advances of science in general and medicine in particular, including the contribution of nutrition, pediatrics, endocrinology ... the type of birth is difficult due to the decreasing and decreasing pelvic causes. Thanks to good performance of assisted reproductive work, including planned delivery, good pregnancy management examination, continuous progress of resuscitation, especially cesarean section through the uterus segment in In the early twentieth century, the indications for cesarean section were widely applied, the crown-of-the-crown method was completed. So, difficult delivery due to pelvic causes is diagnosed early and handled promptly and is no longer a complicated cause. The pelvis is divided into two parts: a large pelvis (also called a large frame) and a small pelvis (or sub-frame). To measure the diameters of the scaffold, the obstetric compass (also called the Baudelocque compass) is used. The frame consists of 3 notable horizontal diameters:

Diameter of upper pot bipolar: 22.5cm.

Diameter of pot crest: 25.5cm.

Baudelocque diameter of the femur: 27.5cm and has a anterior and posterior diameter, also known as Baudelocque diameter of 17.5cm.

But the big frame has little important role in obstetrics. However, if the framework is too small, it will lead to the narrow sub-frame causing difficulties for childbirth.

The subframe is envisioned to be a tubular shape consisting of three waist:

Upper waist: is the top plane of the subframe. When the fetus crosses this plane, it is called a leap, consisting of diagonal, transverse and anterior and posterior diameters, but the most important one is that the anterior and posterior diameter> 10.5cm is limited when the anterior and posterior diameter: 8.5cm 10.5cm, when the front and back diameter <8.5cm is narrow pelvis.

Middle waist: People are interested in one diameter is bipolar: normally this diameter: 10.5 cm.

Lower waist: The most interested in diameter is seated amphibian, normal: 11cm. The anterior and posterior diameter can be enlarged because the coccyx is pushed out after the fetus is pressed.

In addition, people are also interested in the lower corner of the defense, if this angle is <80 °, the fetus will be very difficult and prone to trauma.

There are many ways to divide narrow pelvic types. In which, the author divided into:

Narrow symmetrical pelvis.

Narrow asymmetric pelvis: including pelvic types with uneven narrow diameters, deformed pelvis often found in people with deformities or trauma such as hip dislocation, tuberculosis or scoliosis. living...

Abnormal pelvis after orthopedic.

To assess the distortion of the asymmetric narrow pelvis one must rely on fillings Michaelis. Michaelis fillet is limited to the lumbar spine 5 (S5), the bottom is the apex of the gluteal fold, the two sides are two upper posterior pelvic spines. Normally, the vertical and horizontal diagonal lines intersect each other to divide the vertical diagonal into two unequal parts, the upper part 4cm and the bottom part are 7cm, and the horizontal diagonal is divided into two equal parts of 0.5cm each.

Again, the author divides the abnormal pelvic type in a way that is simpler and closer to clinical reality. These are the types of pelvis:

Upper waist narrow: when the front - rear diameter (protruding diameter - defender) <8.5cm.

Middle waist stenosis: When the diameter of the hip biceps is <10.5cm

Lower waist stenosis: when the diameter of the bipolar sitting <11cm.

On the other day, the narrow middle and lower waist pelvis, obstetricians agree to tend to cesarean section to avoid pregnancy failure and neonatal trauma, on the other hand to also avoid trauma to the mother because of normal lower births. This type of pelvis often requires a lot of intervention by obstetric procedures.

Based on the diameter of the protrusion - defender, assess the normal, limited, or narrow pelvis and whether or not Michaelis is balanced or not, decide whether to continue to follow the labor or to specify a cesarean section and have experiments. France conquered the crown or not.

Introduction of symmetrical, narrow pelvis

Narrow pelvis does not move

Narrow pelvis completely symmetrical and symmetrical:

It is a type of pelvis that all diameters are smaller than usual but are: front and back diameters, diagonal diameters, small horizontal diameters. This type of pelvis is found in small people, often mothers in Vietnam are short <l, 45m. This pelvic type all 3 waist of the subframe are narrow.

Flat pelvis:

These pots have small front and back diameters, but other diameters can be normal and symmetrical. The cause is often due to being too early or carrying too heavy.

Narrow horizontal pelvis:

Also known as Maygrier pelvic type, it bears the name of a French obstetrician. The pelvis has narrow transverse diameters in both the upper and lower waist. The cause is almost like a flat pelvis.

Flat and narrow pelvis:

This type of pelvis is increasingly rare. The cause is rickets or malnutrition from early childhood.

The diameters are all reduced, especially the front and rear diameters.

Narrow pelvis does not move much

Pelvic bone disease (B. ostéomalacique) :

Common in North Africa in adulthood due to malnutrition, lack of vitamin D and some inorganic salts, especially serious disease during pregnancy makes the pelvis deformed. A common disease in rice straw may have had normal premature births. Caesarean section followed by sterilization to avoid the disease repeated in the following pregnancies.

Pelvic part of cartilage dysplasia (B.achondroplacique) :

The cause is synaptic cartilage sclerosis of long bones. This is an infrequent genetic disease passed by a random mother. An unbalanced dwarf mother: short limbs, normal body, short and large head. The pelvis is usually narrow.

Narrow pelvis deformation and displacement

The posterior curvature of the hunchback (B.cyphotique) deformation and displacement of the pelvis due to deformation of the spine, common in spinal tuberculosis. The posterior pelvis has a wide upper waist, narrow lower waist. Diagnosing this type of pelvis is not difficult.

Pre-curved pelvis (B.Cordotique) :

Distortion and displacement caused by movement: limb limb. This type of pelvis has a narrow upper waist but a wide lower waist, women lying on their backs can pass their arms over the back and bed easily.

A s abominable forms of narrow pelvis not e amniotic value

Narrow, non-rigid pelvis of animal origin. Lame limp on one side

Common in people with unilateral hip dislocation, unilateral paralysis, unilateral tuberculosis.

Diagnosing the misaligned pelvis in these women is not difficult. The pelvis of these women had irregular diagonal diameters and irregularly distorted Michaelis fillings.

An asymmetrical narrow pelvis originating from the spine

Typically, the pelvis of people with scoliosis (Scoliose). With the special shape of these women, guessing is not difficult.

An asymmetrical narrow pelvis originating from the pelvis.

These are underdeveloped pelvis, fractured bones or bone tumors.

These pelvis deformations and altered diameters make delivery difficult.

Examination, discovery and management direction before a narrow pelvis

clinical

Asking disease:

Questioning is the first and important part of the examination. We will find out the causes of rickets and malnutrition in childhood. Or previous spinal and pelvic diseases such as tuberculosis of the hip joints, paralysis, trauma, ... Pregnant and premature births are often difficult, require much intervention or ventouse or íorceps or tearing the epithelium. broad and complex subjects ...

Body examination:

Body examination often found a short woman <l, 50m, especially when <1.45m. In addition, there are also sequelae of previous diseases: high chest of childhood rickets, limping gait of the dislocated pelvis due to unilateral hip injury: tuberculosis of the hip, hip dislocation ... or unilateral legs short and one side long due to previous orthodontics ...

Pelvic exam:

Measuring the outer diameters of the pelvis (macroscopy) will see a significant decrease. Measure the fillings Michaelis will see imbalance in the pelvis deviation.

Measuring the diameters of the subframe is especially important, the protrusion - posterior of the upper waist will see <10.5cm. The lower angle of the body is also measured if the angle is <80 ° and the seated amphibian <11cm means that the narrow pelvis under the pregnancy book will be difficult. The way to measure the diameter of the sitting dual-dock is to find two seated mounds, then measure with a Baudelocque compass, and add 0.2 cm. Or find 2 mounds sitting with 2 thumbs of both hands facing the pubic side into each other and gradually translating under the two branches of the hip guard.

In addition, one can also use the Muller method or the Pinard method to compare the fetal head and pelvis.

Muller method: one hand inserted into the vagina and one hand pushes the uterus or fetal head above the guard to direct the fetal head into the subframe to estimate whether the fetus is still born.

Pinard method: push the fetal position in midfield into the subframe and estimate whether the fetus can fall.

Non-clinical

X-ray method:

This method determines whether the upper waist is narrow or not. When shooting for X-rays going perpendicular to the upper waist, placing a grid below each cm2 and for proper ray distance (taking Télé), we will have an image that is almost the same as the real image, it will be relative assessment. exactly the waist diameter on the pelvis.

Direction of treatment

Before a narrow pelvis if it is too clear: protruding diameter - defender <8.5cm and normal fetus, indications for cesarean section are no longer debatable.

If there is any hesitation and there is a suspicion of fetal and pelvic mismatch and if the throne is a cusp "test of the crown" will be reasonable. Avoid complications that can happen to mother and fetus. Pelvic organs with suspected abnormalities should be monitored for delivery at the surgical site and should be examined meticulously during pregnancy management. Nowadays, the cause of premature labor in narrow pelvis is no longer used, as caesarean surgery is complete with clear indications and avoids the burden of pediatrics, taking care of babies Weak premature births but their development future is the money of each nation.

Solution to the throne

It is the test of whether or not the fetus can pass through, when the fetus is a clearly specialized crown and the teacher suspects that there is a fetal and maternal disproportionate mismatch.

The only designation to do the test falls through the crown

The pelvic limit that the fetus is normal.

The test was conducted in the pelvis with the diameter protruding - defenders from 8.5 to 10.5 cm. The fetus is a crown, the fetus has normal weight and has actually had labor.

Suspected pregnancy and pelvic mismatch

This designation includes the above restriction pelvic designation. The pelvis here can be normal, but the fetus is large or even spacious but the fetus is too big, the doctor suspects that there is a fetal and pelvic mismatch. But always remember that the test is only performed when there is real labor and the fetus must be the crown.

Conditions to test the throne

The fetus must be a crown, which is a prerequisite for the test of the dharma.

It must be done in a place where pregnancy can be taken. Trichotomy can be successful and can also fail, especially when it is done, there may be adverse events, risks such as: prolapse of the vegetable cord, the threat of rupture of the uterus or fetal failure ... It takes time for the pregnant woman to go away, there will be complications for the mother and the fetus. And if more cautious should test the method when the facility has the qualifications and good means of resuscitation.

Must have had real labor

It is only allowed to test the crown of the crown when the cervix has opened> 4cm in the chicken and> 5cm in the male. This has two implications.

In order to avoid the procedure before labor, we will make the surgery more difficult because it has caused premature rupture of membranes, artificial premature rupture of goats to amniotic fluid infection, fetal failure ... On the other hand when At 4-5cm the cervix will open faster than the tendon lcm / 1 hour (according to VViliams obstetrics), the duration of the test is not prolonged, avoiding complications for the mother and fetus.

There must be close and careful monitoring

Best practice is done and monitored regularly by a certain person on continuous Monitoring. Especially when using prostaglandin or oxytocin. All changes on the part of the mother and fetus must be recorded and analyzed meticulously.

How to conduct the test of the throne

Amniocentesis

Is the first impact of the solution to the crown. Immediately after that it is necessary to evaluate the amount of amniotic fluid, amniotic fluid color, fetal progression, fetal status through the fetal heart and uterine contraction and possible complications. After amniocentesis: vegetable cord prolapses, sa chi ... After the ruptured amniotic fluid, check the throne carefully, so, that way to decide whether to continue to conduct the procedure or to have cesarean section if the throne (front lip, forehead ...).

Watch for uterine contractions

Uterine contractions are the main driver of labor, so monitoring of uterine contractions is essential and important. Ideally, on continuous monitoring, you will evaluate all three: intensity, amplitude, and frequency and calculate uterine activity in Montévideo units. Uterine activity should be consistent with the stage of labor and in harmony with the uterine opening.

If the uterine contraction is weak, it will conduct a command delivery with intravenous drip oxytocin (preferably through a pump), one millie of oxytocin will be calculated into the mother's body. Oxytocin infusion is also an art: so that the uterine contraction is almost like the natural physiological nature of labor, the seizure.

uterine contraction must be in harmony with each stage of cervical openeration. If impatience is transmitted too quickly, with a dose too large, not only does labor not progress and sometimes causes serious complications: uterine rupture, fetal failure, neonatal asphyxia ... Only stop the infusion. oxytocin at the end of the third stage of labor, meaning that vegetables are flaky and completely lost; If the infusion of oxytocin is stopped immediately after the birth certificate, it can cause bleeding, leakage of the uterus after delivery. If the uterine contraction is too strong, the mechanical cause must be immediately sought; Abnormal position, fetal disproportionate and pelvis ... If yes, must stop the test immediately and appoint a cesarean section. After no mechanical causes are found, new uterine contractions are reduced with drugs: papaverine, spasmaverin ...

Keep track of the mother's condition

Maternal health directly affects the fetus through the vegetable-fetus circulation, so the whole mother must always be closely monitored through the spirit and physical: pulse, temperature, blood pressure ...

Whether or not the crowning test is successful or not is not a small part of the mother's cooperation with the physician.

Monitoring the condition of the fetus

Best follow-up on continuous Monitoring. Fetal status is shown by fetal heart rate fluctuations: normal physiological or pathological occasions occur uterine contractions. The conception test must be stopped immediately when there is a clear state of fetal impairment. It is also possible to monitor the fetal status using classic methods if there is no monitoring such as stethoscope, amniocentesis monitoring, mother's feeling of fetal movement ... In general, these methods are either inaccurate or impartial.

Monitor and evaluate the progress of the fetus

The purpose of the test is to challenge whether the fetus can fall, fall and pass, that is, whether it can deliver through the lower line or not, so monitoring the birth of the fetus is very weighty and must be conducted regularly. The 'external examination' or the vagina is very short to avoid cervical edema, which makes it difficult to open the cervix and upstream infection because we have already poked the amniotic sac.

Track the cervical opening

If the test is successful, the uterus will open harmoniously over time, the fetus will pass and the delivery will be performed through the lower line. Many times the solution

failure only because the cervix is ​​not open (which clinicians are accustomed to calling the cervix not progressive); Nowadays, in advanced countries, thanks to modern means of monitoring, with adequate medicine, people have very little failure to do a laparoscope due to the non-cervical opening.

Time to do the experiment

Usually, physicians agree to take the time point of 06 hours. Because after 6 hours of amniocentesis, the test continues to be prolonged, doctors worry that there will be potential infection or fetal failure. But here the time is also filial and flexible depending on the general situation: if it has been 06 hours of the test but have to wait 30 minutes or 1 hour, the delivery will end with the bottom lane without any risk big for mother and fetus, it is still possible to continue the test. However, there are also cases that, only 1 to 2 hours later, the physician has evaluated whether to continue or stop the test. In some cases, if the amniocentesis has been punctured and she has had fetal insufficiency or vegetable cord prolapse, the cessation test must be stopped immediately to indicate a caesarean section.