Pubic articulation

Posted on June 3, 2020  in Pelvic diseases

Palatine joint ruptures are rare; discrepancies of the pubic joint and symphysitis , inflammation of the pubic joint in the postpartum period , are more often observed . In the dynamics of pregnancy, significant loosening of the tissues of the pubic and sacroiliac joints occurs as a result of the effect of relaxin, which is secreted by the corpus luteum and placenta. Relaxin has a relaxing effect on the ligamentous apparatus of the uterus, increases the extensibility of the neck, vagina and perineum in childbirth. The maximum accumulation of relaxin is observed towards the end of pregnancy. By this time, according to X-ray studies of the pelvis, there is a significant softening of the cartilage tissue of the symphysis and an increase in the gap between the pubic bones. In some women, this condition can cause pain during walking. When the pubic joint is broken, the pubic bones can diverge over a considerable distance. According to the data of X-ray studies of M.F. Eisenberg , the average width of the pubic joint in the first stage of labor in the first-born is 8 mm, in the re -progeny – 7.5 mm. The author determined the expansion of the pubic joint among the first-born in 35% of women, among the multiparous – in 62%. The lobes of the pubic joint are divided into spontaneous and violent. Spontaneous include gaps that occur during spontaneous birth. Violent gaps in childbirth arise from the use of fetal-extracting operations. 

Cases of rupture with manual separation of the placenta or manual revision of the uterus are described. It is more likely that the insertion of the hand into the uterus completed the gap or revealed a gap that already occurred in the first or second stage of labor. In pregnant women, a rupture of the pubic joint can occur with damage to the pelvic bones (compression, shock, sprain) or a general injury to the musculoskeletal system. Spontaneous ruptures usually occur if during delivery the greatest discrepancy of the pubic joint is noted (at the birth of a large fetus, violent labor, incorrect removal of the head when providing manual benefits). Violent ruptures are most often the result of significant efforts during delivery operations. Recognition of rupture of the pubic joint is usually not difficult. Patients noted pain in the pubic joint when trying to change the position in bed. With an external examination between the edges of the pubic joint, you can enter several fingers, and sometimes the palm. Vaginal examination supplements the data from an external study. In doubtful cases, an X-ray of the pelvic bones is performed. Upon establishing the gap, the patient is prescribed bed rest, a bandage is applied to the pelvic area. Two longitudinal sleds are placed on the headboard and one block is attached to them at the level of the pelvis. 

A wide bandage of dense canvas is applied to the pelvic area, and the ends are attached to wooden planks so that the bandage is not collected. K , Planck reinforcing cords, which pass through the blocks. A load is suspended at their ends, starting from 2 kg, which is gradually increased to 10 kg. With early recognition of a gap, a bandage is applied to obtain a pubic joint fusion for 2-3 weeks , with a late one – for 3-4 weeks . Can be used for these purposes linen bandage in the form of a hammock. The edges of the hammock are strengthened to the longitudinal slabs. The convergence of the pelvic bones occurs under the influence of the patient’s own gravity. The length of stay in the hammock is the same. With timely and proper treatment, the support function of the pelvis is fully restored. With late recognition of the gap, and sometimes regardless of this, symphysitis occurs – inflammatory processes of cartilage weaving , which greatly complicate the fusion and restoration of function.

Delivery of a narrow pelvis

Posted on May 30, 2020  in Pelvic diseases

Classification

The structurally anatomically narrow pelvis is not always also functionally, clinically narrow, that is, the size of the given birth object is not appropriate in size. In some cases, the pelvis will be “narrow” for a large fetus with a large, dense head, but normal for a fetus with a small, well-configured head. In other cases, the pelvis is dug enough in size in a primiparous woman and inadequate in the third or fourth birth in the same woman, since the size of the fetus and its head are usually larger during repeated births. That is why in clinical obstetrics the term “narrow pelvis” should not be used, but it is necessary to talk about anatomically, structurally narrow or, otherwise, narrowed pelvis and functionally, clinically narrow pelvis. The forms of the narrow pelvis are diverse and numerous. Npiboleo complete classification of the narrow pelvis comes L. Ya. Krassovsky. I. Uniformly narrowed pelvis: a) uniformly narrowed pelvis; b) pelvis of dwarfs; c) a children’s basin. II. Unevenly narrowed gas. 1. Flat basin: a) simple; b) rickety; c) luxurious (with bilateral hip dislocation); d) general judge. 2. Oblique pelvis: a) ankylotic ; b) coxalgic ; c) scoliosis ; d) kyphoscoliosis ; e) a pelvis with a unilateral dislocation of the thigh. 3. Cross- narrowed pelvis: a) ankylotic ; b) kyphotic ; c) spondylolistic ; g) funnel-shaped. 4. A collapsed pelvis: a) osteomalytic; b) rickety. 5. Split, or open in front of the pelvis. 6. The spinous basin. 7. A pelvis with a neoplasm. 8. The pelvis is closed. The given classification is currently of only theoretical interest, since many of the forms of the narrow pelvis listed in it are extremely rare in our country, and some are unfamiliar even to old experienced obstetricians. 

This is explained by the fact that in our country a wide system of protecting children’s health, nutrition and living conditions, physical education, sports, favorable working conditions for mothers, the successful fight against childhood infections, rickets contributed to the almost complete disappearance of many of the reasons that acting on the girl’s body from the moment of her birth (or rather, even before birth), they created the prerequisites for the pathological development of the female pelvis. Currently, a narrow pelvis is found in 5.8-6.3% of all pregnant women (V. A. Pokrovsky, 1964). Among this small number of abnormalities of the female pelvis, the following few forms are more often observed and therefore mostly of practical importance: A. Generally constricted pelvis. B. Flat basin: 1) simple; 2) flat-planar. B. General narrow flat pelvis. According to world literature, most often there is a flat basin (50.8-62% of the total number of narrow basins); in the second place in frequency – the all-narrowed pelvis (38-49.2%). A pelvis is called narrow in which the external conjugate is equal to or less than 18 cm. It is more correct and more accurate to determine the degree of narrowing of the pelvis by the value of the true conjugate , the measurement of which is mandatory for all pregnant women without exception. It is necessary to distinguish 4 degrees of narrowing of the pelvis. 

With the I degree of pelvic narrowing, in the vast majority of cases, childbirth ends spontaneously and their course differs little from that with a normal pelvis. In grade II, spontaneous birth is possible, but still not the rule. With grade III, the fetus cannot be born alive through the natural birth canal: it is removed only after craniotomy. IV degree of narrowing of the pelvis – an absolute indication for cesarean section, since the fetus, even reduced in size by surgery, cannot be removed through the natural birth canal. The frequency of individual degrees of narrowing of the pelvis, according to V. A. Pokrovsky, is: I – 78%, II – 21.2%, III – 0.8%; The author has never observed the narrowing of the fourth degree .

Features of the mechanism of labor in a narrow pelvis

Posted on May 22, 2020  in Pelvic diseases

Among the forms of the narrow pelvis, the uniformly narrowed and simple flat thaw is more common than others . In relation to all forms of the narrow pelvis, these two forms instead make up from 38.1 to 98.9%. Therefore, we dwell on some features of the mechanism of childbirth precisely with these two forms of narrow pelvis, which have the greatest practical significance.

With a general narrowed pelvis, the fetal head is installed, as usual , in one of the oblique dimensions of the entrance to the pelvis in the position of moderate flexion. Experiencing great resistance from the entrance side, it under the influence of strong contractions of the uterus bends more and more and stretches significantly in length. The small fontanel is very low and is located close to the pelvic axis. Often a large head tumor is formed, which can simulate the rapid advancement of the head.
In such cases, the head tumor is already shown in the genital fissure, and the base of the skull and chin are determined above the entrance to the pelvis.
Flexion and internal rotation of the head in a narrowed pelvis require considerable time and good rhythmic labor. The extremely pronounced configuration of the head sometimes leads to the fact that at birth it has a shape similar to a cucumber. With a general narrowed pelvis, the pubic arch approaches in shape to an acute angle, as a result of which the fetal head deviates posteriorly. This delays delivery even more and causes extensive ruptures of the perineum and posterior wall of the vagina. Nevertheless, with a uniformly narrowed pelvis in 80-90%, childbirth occurs spontaneously, without surgical intervention.
With a flat basin, the mechanism of labor is more complex and is characterized by three features (A. Yu. Lurie).

1. Long standing swept seam in the transverse size of the entrance to the pelvis. At the same time, the more massive occipital part of the head, encountering greater resistance of the pelvic bones, the entrance of which is narrowed in the transverse size, is delayed, and the less massive front part of the head with its bitemporal size drops the rape , resulting in its bent position to some extent .
2. In connection with the foregoing, the large fontanel descends and approaches the conductive axis of the pelvis; the small fontanel is higher than the large one and it is difficult to determine it, and sometimes it is not probed at all, since it lingers above the terminal line of the pelvis.
3. Severe asynclitism . First, the head sinks into the pelvis synclitically , that is, the sagittal suture, standing in the transverse dimension, occupies a middle position between the bosom and the cape. Further, with inconsistency and good labor, the so-called declination of the head occurs, that is, its rotation around the sagittal axis. In this case, if the cape is a greater obstacle (which is more favorable), then the anterior parietal bone is lowered earlier, and in this case the sagittal suture will be located closer to the cape. This insertion of the head is called anteroposterior , or anterior asynclitism . If the pubic articulation (which is less favorable) exerts a stronger opposition to the head, then the posterior posterior bone is lowered into the pelvis , the swept stitch is closer to the bosom; a posterotomial insertion is formed, that is, posterior asynclitism , indicating a mismatch between the dimensions of the pelvis and head.

In accordance with the described mechanism, a characteristic configuration of the head is produced: on the parietal bone that goes in front (depending on the type of asynclitism ), a birth tumor forms, the “lagging” parietal bone is flattened due to the back pressure of the corresponding part of the pelvis (cape or lobe ) and goes under the parietal shaft in front bone – the head is as if beveled sideways. On the “lagging” parietal bone from prolonged pressure, the promontory can sometimes form a deep impression, as a result of which the head is flattened in the transverse dimension and thus adapts to the pelvis flattened in the transverse dimension, that is, to a shortened direct size.

In the future, there are usually no obstacles to the birth of the head. However, with very pronounced degrees of posterior asynclitism , a very dangerous situation is sometimes created for both the fetus and the mother. In these cases, a delayed anterior parietal bone and the corresponding ear of the fetus are probed next to the bosom. The head cannot pass through the pelvis, as, descending, it is directed forward, towards the bosom, and meets an insurmountable obstacle here. The rear shoulder, falling, rests on the cape and makes it more difficult to advance the head. There is a strong overstretching of the posterior semicircle of the lower segment of the uterus, which in the absence of timely obstetric care can lead to rupture of the uterus.

The course of labor with a narrow pelvis

Posted on May 18, 2020  in Pelvic diseases

In the last weeks of pregnancy in a woman with a narrow pelvis, deviations from the physiological course of pregnancy are often noted. So, in primiparous there is a genital, and in multiparous – a drooping belly. This anomaly further prevents the correct insertion of the fetal head and adversely affects the development of labor.

A frequent complication — incorrect position and presentation of the fetus due to a mismatch in the size of the head and entry into the pelvis — is observed about 4 times more often than with normal pelvis. In particular, a narrow, especially flat pelvis will create the prerequisites for the formation of extensor prepositions .

The next deviation from the normal course of childbirth is premature and early discharge of amniotic fluid (5 times more often than with a normal pelvis), which is sometimes accompanied by the extrusion of the umbilical cord and small parts of the fetus. These complications are explained by the mobility of the fetal head for a long time, the absence of a “contact belt” and, as a result, the presence of communication between the front and back waters, which exert more than normal pressure on the amniotic fluid.
Due to the absence of the fetal bladder, there are no conditions that normally contribute to smoothing and opening the neck; therefore, in spite of a strong labor activity, labor is slow and inferior. In this regard, the following can be observed: a) a prolonged course of the first period of childbirth; b) ascending infection; c) exhaustion of the nervous system of the woman in labor and her physical fatigue; d) secondary weakness of labor (about 1/6 of all women in labor with a narrow pelvis, that is, 3-4 times more often than women with a normal pelvis); e) sharply painful, convulsive contractions and a tetanic state of the uterine muscles as a result of excessive, continuous irritation of the uterine receptors with long-standing waters and continuously increasing compression of the soft tissues of the birth canal. With such convulsive contractions, the opening of the cervix does not progress. Due to prolonged pressing of an unstressed cervix to the bones of the pelvis , edema of the anterior lip of the cervix often occurs between the head of the fetus and the pubic joint of the pelvis; sometimes there is a danger of rupture of the uterus or its separation from the arches; f) fetal asphyxiation due to a violation of the uteroplacental circulation, due to abnormal, convulsive contractions and the tetanic state of the uterus; intracranial injury to the fetus; g) rupture of the pubic joint with damage to the bladder, sometimes symphysitis ; h) atonic bleeding in the subsequent and early postpartum periods due to overstrain and secondary weakening of contractility and loss of uterine tone, the onset of infection and the development of septic endometritis, the development of afibripogenemia ; i) stillbirth, which in women with a narrow pelvis ranges from 3.88 to 9.5%.

Delivery of a narrow pelvis

Posted on May 14, 2020  in Pelvic diseases

When administering childbirth in women with a narrow basin, one should be guided by the decisions taken on this issue at the IX All-Union Congress of Obstetricians- Hypecologists . They indicate that caesarean section with a narrow pelvis can be resorted to only with strict special indications from the mother or fetus and only in cases where the possibility of spontaneous birth by a living fetus is unconditionally excluded. M. S. Malinovsky and the overwhelming majority of domestic obstetricians formulate the tactics of delivering labor with a narrow basin as follows: “conservatively expectant or expective management of labor”.

However, this method is by no means synonymous with “trial births” in primiparous with a narrow pelvis, when, with the doctor’s complete inactivity, childbirth lasted 2-4 days , and often severe complications such as urogenital fistula, intrauterine death of the fetus due to intracranial injury or asphyxia, uterine rupture, not to mention the complete depletion of the nervous system of the woman in labor.
It can be considered a rule that with the I degree of narrowing of the pelvis, childbirth is almost always, and with II – often end spontaneously; with the III degree of narrowing of a living child can be removed only with a caesarean section; a narrow pelvis of the IV degree in all circumstances, regardless of whether the fetus is alive or dead, certainly requires a cesarean section.
All pregnant women with a narrow pelvis should be hospitalized shortly before delivery. A thorough study of the anamnesis, general and obstetric status should be carried out, as a rule, before the discharge of the waters. In order to preserve the water as much as possible, especially if a vaginal examination reveals that the amniotic fluid is strained or begins to protrude into the vagina, you should enter the woman in labor, and prevent her from standing up.

To develop a plan for the most rational management of childbirth, it is necessary to take into account, first of all, the unfavorable data of obstetric history, which ceteris paribus worsen the prognosis of childbirth for mother and child. To them repose :
1) large children in the past birth;
2) the protracted course of preceding labor, the weakness of labor, surgical interventions with it, the complicated course of the postpartum period. At the same time, it is important that a woman with a narrow I-II degree pelvis in the past cannot have a safe birth by living children, which cannot guarantee a safe course and outcome of a real birth, because with each subsequent birth the fetus is large, and the uterus exorcises the neuromuscular abilities with each birth are reduced;
3) intracranial injury to the newborn in previous births;
4) operative delivery in the past: forceps, vacuum extraction, rotation, craniotomy, cesarean section in connection with a narrow pelvis;
5) reproduction of a real pregnancy at least for 1-2 weeks ;
6) the old age of primiparous (over 30 years).

The more favorable course of labor with a narrow pelvis happens in multiparous, since their birth canal was prepared by previous births.
In the event of amniotic fluid discharge, a vaginal examination must be performed immediately to accurately determine the insertion of the head, the condition and degree of opening of the cervix, presentation or prolapse of the umbilical cord or small parts of the fetus.
For a better insertion of the head in case of a general narrowed pelvis, a woman in labor is laid on the side where the nape of the fetus is facing, and with a flat one – on the opposite side. A sagging stomach should be bandaged with two towels sewn along the length.
In the case of the umbilical cord or handle falling out, they should be tucked in behind the head, which is usually easy to do if you give the woman in a saddle- elbow position. After this, it is necessary to apply the cutaneous-head forceps according to Ivanov to the head in order to prevent repeated loss. If prolapse of small parts has not occurred and labor activity develops satisfactorily, childbirth is expectant , carefully monitoring the insertion of the head into the pelvic entrance and periodically repeating vaginal examinations. In this way, with a uniformly narrowed pelvis, the dynamics of the occipital descent is determined, which is judged by the omission and approximation to the conductor axis of the pelvis of the small fontanel, the increasing configuration of the head and lowering the level (location) in the pelvic cavity of the “contact belt” of the head. These are favorable factors testifying to the physiological course and successful development of the birth process.

With a flat pelvis, factors having the same favorable value are the median insertion of the head and a small degree of its extension with a moderately pronounced anterior asynclism . In contrast, a significant extension of the head, an extra-median insertion of the head and pronounced posterior asynclitism indicate a pathological development of the labor mechanism; the obstetrician, in the case of their nrogrossing , must timely resolve the issue of cesarean section in the absence of contraindications to it (a long anhydrous period, signs of infection, progressive, untreatable intrauterine asphyxiation or fetal death that has already occurred). The aforesaid especially applies to elderly nulliparous, as well as to multiparous with burdened obstetric history.

Anomalies of labor activity — its weakness (primary, secondary) or the erratic, sometimes tetanic nature of contractions accompanied by severe pain, are a frequent complication of labor in a narrow pelvis.
Weak labor should be treated according to general rules, choosing the means and methods that are most physiological and able to improve the condition of the fetus, increase its resistance under conditions of hypoxia and intracranial injury, which is almost inevitable in such cases.
If there is a need to stimulate labor in the presence of a still insufficiently smoothed cervix and its incomplete opening, we consider it absolutely necessary to first introduce one of the antispasmodics under the skin or directly into the thickness of the anterior lip of the cervix. If the contractions are excessively strong, erratic, very painful, have a tetanic character, it is necessary to regulate them immediately, and reduce pain by applying painkillers with medications. At the same time, it is necessary to combat the excessive emotional arousal of the woman in childbirth, which is almost always accompanied by a feeling of anxiety and fear. This condition of the woman in childbirth sometimes occurs in connection with the infringement between the fetal head and the bosom of the edematous anterior lip of the cervix. Having made sure of the atom by vaginal examination and examination with the help of mirrors, the obstetrician should immediately put a restrained lip by the finger with his finger, moving it up. Usually immediately after this manipulation the pain subsides, the woman in labor calms down, contractions become regular again. If Hie infringement no lips or after tucked infringe upon the lips of pain does not decrease and the nature of labor is not normal, it is necessary to apply the medication. For this purpose, promedol (2 ml of a 1% solution), isopromedol (at the same dosage), estocin (at the same dosage) in combination with antispasmodics and ataractics andaxine (0.4 g 1-2 times inside) or trioxazine are prescribed (0.3 g). It may also be useful to take oral chlorpromazine (0.025 g) or etaperazine (0.004 g) 1-2 times a day.
Odpako must take into account the following: convulsive contractions, intolerable pains, a feeling of irresistible fear are sometimes harbingers of a threatening uterine rupture. Therefore, the use of these drugs is permissible only in cases where, through careful investigation and observation, it is established that such a threat is absent or when it is necessary to win some time to prepare an operating room for an immediate delivery of one or another delivery (craniotomy, cesarean section).
In especially severe cases, when the need arises for the urgent suppression of pathological labor due to the threat of uterine rupture, you should immediately introduce a woman in labor morphine or pantopon and give a fairly deep ether anesthesia.

Along with all these measures, you should periodically measure the temperature, count the pulse, respiration, measure blood pressure, often listen to the fetal heartbeat and, if possible, remove its fopocardiogram . It is necessary to monitor the timely emptying of the bladder and empty it if necessary using a soft catheter. Urine should also be carefully examined: the slightest admixture of blood, especially in combination with an increase in body temperature and signs of developing endometritis, indicates the beginning of the destruction of the soft tissues of the birth canal with the possible formation of a subsequent urogenital fistula. In such a situation, it is necessary to resolve the issue of immediate delivery . However, with a prolonged anhydrous period, a febrile state of a woman in childbirth, endometritis, the presence of infection, cesarean section is certainly contraindicated.
Often during childbirth, women in labor with a narrow pelvis experience false attempts with a still high head, which is accompanied by severe pain, sharp motor and mental excitement. Such pathological contractions of the muscles of the uterus and abdominal press have nothing to do with true attempts, are dangerous for the mother and fetus, and should be immediately stopped with the help of clarification, persuasion, suggestion, medications: tranquilizers, sedatives , anticonvulsants, or, in extreme cases, the use of ether anesthesia.

With physical fatigue, it is necessary to provide the woman in labor with rest. After the spa , the woman in labor resumes regular, energetic labor and delivery progresses successfully. Proper nutrition of women in labor can greatly contribute to this: hot broth, strong, very sweet coffee or tea with ascorbic acid (0.5 g) instead of lemon, half a bar of chocolate, and orange. Along with this, it is necessary to apply prolonged inhalation of oxygen. Sometimes all this is enough for the head to sink to the pelvic floor and create the opportunity to apply obstetric forceps or apply vacuum extraction.
If the head is in the pelvic cavity, and labor is insufficient, the woman in labor is tired or there are indications from the fetus (asphyxia), forceps should be applied. However, it must be remembered that an attempt to impose with a narrow basin of high forceps, that is, on the head, which has not yet passed its largest circumference through the entrance of the pelvis, is extremely dangerous for both the mother and the fetus.

Of the additional techniques that sometimes prove useful for delivering labor in women with a narrow pelvis, it should be pointed out that it is possible to increase (by 0.3-0.5 cm) the direct size of the entrance to the pelvis (true conjugates ) using the Walcher position of the woman in labor, which indicated for prolonged non-insertion of the head. G. G. Genter (1936) recommends giving the woman in labor the position of Willinka , laying a firm pillow under the sacrum for 30 minutes, a De Lee , S. D. Astrinsky , III. Y. Mikeladze, when narrowing the exit of the pelvis, they offer a position for stone cutting with knees sharply drawn to the stomach. At the same time, both the transverse and direct sizes of the exit of the pelvis slightly increase (by 0.35-0.5 cm). Thus, the main method of birth management with a general narrowed and flat pelvis is moderately expectant. Moreover, the only correct method of birth management is a strictly individual approach to each woman in labor. An obstetrician, individually resolving the issue of conducting labor with a narrow pelvis in each woman in labor and adhering, as a rule, to expectant tactics, should at the same time reasonably evaluate the conditions and indications for surgical benefits. 1. The application of obstetric forceps or a vacuum extractor is indicated when the fetal head has completely overcome the obstacle from the entrance to the pelvis. The most frequent indications for these operations: secondary weakness of labor, cardiovascular disease, physical and neuropsychic exhaustion of the woman in labor, fetal asphyxiation. 2. A fetal mutilation on the leg is permissible only if the umbilical cord, small parts of the fetus, incorrect insertions of the head ( posterior , frontal, facial presentation ) occur , but only under the following conditions: a) full mobility of the fetus in the uterus; b) a small fruit (especially the head); c) the complete absence of signs of overstretching of the lower segment of the uterus; d) a successful obstetric history in multiparous. 3. If the fetus is live, craniotomy should not be used. But as a last resort, in exceptional cases, this operation is permissible if the life of the woman in labor is in imminent danger, and there are no conditions for other delivery methods , including for caesarean section (or, more often, time is lost). In such cases, refusing a craniotomy and motivating this refusal by the presence of a living child, we rather sacrifice the life of the mother than save the life of the baby . 4. Cesarean section, of course, shown at III and IV degrees of narrowing of the pelvis. At grade IV, the narrowing is such that even a dissected fetus with a perforated head cannot be removed through the vagina; with the III degree of narrowing, it can be removed through the natural birth canal only after perforation of the head. 

Cesarean delivery may be shown in some cases and with a narrow degree of pelvic II: nulliparous, especially for breech, lobpom , personal predlezhapiyah transverse position of the fetus and categorical parents wish to have rebepka ; it is also shown at the II (and sometimes even at I) degree of narrowing at large deformations of the pelvis. Indications for cesarean section can sometimes be adverse combinations of different types of pathology, aggravating the prognosis of the outcome of childbirth, for example, narrowing of the pelvis and preeclampsia or eclampsia; narrowing of the pelvis and rapidly developing cardiovascular failure in the parturient woman; narrowing of the pelvis and Addison’s disease, etc. Finally, a cesarean section with II degree of narrowing of the pelvis is also shown in those cases when, despite a good regular, unremitting labor, the head of the fetus remains at the same height for 6 hours after draining the water or only pressed to the entrance to the basin. In these cases, waiting further, you can delay the time when it is not too late to perform a cesarean section (no infection). Ante- and postnatal prophylaxis of rickets, the correct physical and neuropsychic development of women from early childhood, rational drinking , gymnastics, moderate, rational exercise, prevention of infectious and other diseases, and further careful medical supervision in the antenatal clinic, regulation of work the load of a woman, the elimination of some possible occupational hazards (forced body position, prolonged sitting or standing, etc.), timely identification and eliminated ie the various complications of pregnancy – all of this is of great importance in the prevention of a narrow pelvis and aggravating his other complications of pregnancy. Timely detection of a narrow pelvis and timely hospitalization of a pregnant woman are the key to a successful outcome of childbirth.

Management of labor in the transverse position of the fetus

Posted on May 10, 2020  in Pelvic diseases

The transverse position of the fetus occurs in about 0.3-0.5% of all births, moreover, in multiparous children 5 times more often than in primiparous. In 1/4 of women with a transverse position of the fetus, labor occurs prematurely. With a full-term pregnancy, spontaneous delivery is impossible and threatens the life of both the fetus and, often, the mother, for whom this pathology is one of the most common causes of birth injury. The reasons contributing to the formation of the transverse position of the fetus are varied: an arched uterus ( uterus arcuatus ), inferiority of the muscles of the uterus or a violation of its tone, an abundance of amniotic fluid and, as a result, excessive fetal mobility, prematurity , twins, malformations of the fetus, narrow pelvis, placenta previa , uterine tumors. Sometimes in the process of childbirth, a spontaneous correction of the transverse hollow is observed , that is, the fetus occupies a longitudinal position and subsequently the natural termination of childbirth is observed. Premature, especially dead, the fetus can spontaneously be born by the mechanism of self – reversal . However, most often with the transverse position of the fetus, the course of labor almost from the very beginning assumes a pathological character and requires timely intervention by the obstetrician. Especially often (in 20%) there is an early discharge of amniotic fluid. At the same time, the fetal pen often falls out (in 1/5 of all cases); quite often also the umbilical cord falls out. With the loss of the umbilical cord, stillbirth reaches 50%, and with the simultaneous loss of the handle and umbilical cord – even more. 

Pa handle lowers and “hammers” into the pelvic entrance shoulder; prerequisites are created for the formation of a running lateral position. The mechanism of its occurrence is as follows: the opening of the pharynx after the discharge of water is slow or completely stopped, the water continues to flow out, contractions intensify, with each contractions the uterus more and more tightly covers the fetus, the shoulder is more and more “driven” into the pelvic entrance, the dropped handle swells; pauses between contractions are reduced, and the uterus comes into a state of totanic contraction. This condition threatens the fetus with death due to a deep violation of the uterine and placental circulation with the subsequent development of intrauterine asphyxiation, and the mother with rupture of the uterus and severe infection. In such an obstetric situation, a big mistake on the part of the doctor would be an attempt to perform a turning operation, which in such cases is absolutely contraindicated, since it can lead to a violent rupture of the uterus. For proper management of labor in the transverse position of the fetus, it is necessary, firstly, to establish the correct diagnosis in a timely manner and, secondly, to prevent the appearance of a neglected transverse position. Typically, a diagnosis is presented but presents difficulties : the pregnant woman’s stomach is pulled out in a transverse dimension; the height of the bottom of the uterus corresponds to the gestational age, the bottom of the uterus is missing a large part (head or buttocks); above the bosom, the precursor part is also not defined, and the hand, upon palpation, freely penetrates the entrance to the pelvis, which is not filled with any precursor part. The head or buttocks are palpated in the right or left half of the uterus at the level of the navel. The heartbeat is heard at the same level also on the right or left. The position is set by the location of the head: the first position when the head is on the left, the second on the right. Most often, the back of the fetus is facing anteriorly and somewhat downward – the front view; flight – small parts are determined in front, and the back is facing the spine – rear view. In the outgoing waters, if the uterus tightly covers the fetus, and the abdominal walls are also tense, it can be difficult, and sometimes impossible, to obtain all the required data with an external examination. In this case, you can determine the position of the fetus by the dropped handle. 

First of all, you should find out which pen fell out. It is necessary to mentally “say hello” to the fetus by the hand; if the right hand of the obstetrician and the handle of the fetus meet one another correctly, as during a handshake, the dropped handle is the right; if the left hand of the obstetrician is suitable for a handshake, the left handle fell out. You can also navigate by turning the dropped handle with your palm forward (up): if the thumb of the handle is turned to the right – the right handle, and vice versa. The position of the fetus can be accurately judged only after vaginal examination: lifting two examining fingers along the handle, they reach the axilla of the fetus: if it closes to the left, the first position; to the right is the second position. If at the same time the scapula is facing posteriorly, it is a rear view, anteriorly it is a front view. If the shoulder blade is difficult to reach, you can navigate along the ribs. Sometimes with vaginal examination it is difficult to distinguish between the handle and the leg. But the toes of the legs are short, small, the thumb is closely pressed to the other fingers; the fingers of the handle are longer, of unequal size, between the thumb and forefinger a large gap. The main distinguishing feature of the legs is the calcaneal tuber. Vaginal examination with a whole fetal bladder must be done extremely carefully so as not to burst the bladder. If this study is used when the transverse position of the fetus is neglected, the degree of mobility (or complete immobility) of the fetus should also be determined, since the accuracy of further delivery management tactics depends on the accuracy and proper assessment of all these data. The study and determination of the degree of fetal mobility when running lateral position requires extreme caution, as the slightest violence during palpation can lead to uterine rupture. 

Along with this, an insufficiently careful assessment of the degree of neglect of the transverse position and all the attendant circumstances (a long anhydrous period, the condition of the fetus, the degree of mobility of it, the appearance of the dropped handle, signs of infection in the mother) can lead to erroneous decisions. So, the fetus can die when it was still possible to make a turn (of course, with proper precautions); on the other hand, a turning operation may be undertaken when it is already contraindicated, which leads to rupture of the uterus. Once again, we cite the symptoms of a neglected lateral position: a) the discharge of water a few hours ago and the “hammering” of a shoulder; b) lack of fetal mobility in the uterus; c) overstretching of the lower segment of the uterus and the presence of a contraction ring (“ retraction ” ring) in the form of an oblique groove reaching the navel level and above, which indicates the complete impossibility of further stretching of the uterus; d) fetal death due to a deep disturbance, and then the termination of placental circulation as a result of prolapse of the umbilical cord, tetanic state of the uterus, placental abruption. The only preventive measure that can be used to prevent severe complications in the lateral position of the fetus is an external rotation of the fetus onto the head. The general rules for this operation are the same as for pelvic sentences. However, with the transverse position of the fetus, unsuccessful results are observed more often. 

This is due to the fact that in these cases either the shape of the uterus is incorrect, or the tone of its muscles is significantly impaired. As a result of this, even after a successful rotation, the fetus often again occupies a transverse position. Nevertheless, a pregnant woman with a transverse position of the fetus should be hospitalized at the 34-36th week of pregnancy, and after appropriate preparation, an external preventive turn is performed. After surgery, the fetus should be fixed in a longitudinal position using bandaged semi-rigid ridges, and the pregnant woman must be left in the hospital until delivery . Currently, the method of correcting incorrect positions by applying a complex of gymnastic exercises (I. I. Grishchenko and A. E. Shuleshov ) is widely used . Contraindications to rotation , placenta previa, insufficient fetal mobility, nephropathy, febrile postpartum period after previous births, history of cesarean section, uterine fibroids. With an external rotation of the fetus, it is necessary to avoid the formation of extensor previa of the head. To do this, in the rear view, you need to move the head in the first position clockwise, l in the second – counterclockwise. The same can be done with the front view, but only in those cases when the back is facing forward. If the back is facing not only anteriorly, but also to the crib , displacement of the head and rotation of the fetus must be done in a long way – pa 270 °, that is, in the first position – counterclockwise, and in the second – clockwise. The rotation of the fetus is carried out with both hands: one palm is placed on the head, the other on the pelvic end. The fetus is moved simultaneously with both hands, and the pressure on the head and pelvic end is produced in the opposite direction; thereby the movement of these parts takes place in one direction. The pressure exerted by the hands of the obstetrician should be smooth, rhythmic, continuous, without jerking and the strength of the impact is exactly the same for both hands. 

If a preventive turn was not made in a timely manner with the transverse position of the fetus, childbirth is recommended to the bone , adhering to the following basic rules (according to L. Yu. Lurie). 1. Childbirth has just begun, the fetal bladder is intact; the cervix is ​​not smoothed and passes (or does not pass) the finger. Put the woman in labor in bed, prohibit sudden movements, make every effort to ensure that the fetal bladder is kept intact for as long as possible. With good fetal mobility and the absence of contraindications, try to observe the maximum caution to make an external turn on the head. If the rotation fails, enter the colpeirinter in order to preserve the waters until they are fully opened. 2. The waters withdrew in the absence of contractions and a small neck opening. It is necessary to proceed with the delivery by Caesarean section. If there are no conditions for a cesarean section and it is not possible to transport a woman in childbirth to a hospital, you can use a metrerider to save water and give birth . After ron; denia of the metreurter (full opening), make a turn followed by extraction of the fetus. 3. The waters are intact or recently (2-4 hours ago) have departed; the fetus is mobile; full opening of the cervix. Immediately under anesthesia, make an internal rotation of the fetus on the leg and immediately remove it. 4. The waters departed davpo ; full opening of the cervix. With an immovable fetus – a fruit- destroying operation even with a living fetus. The rotation of the fetus in this situation often causes uterine rupture and pedigree damage to neighboring organs. After the operation, a manual examination of the uterus is necessary to make sure that there is no rupture of the uterus. In the transverse position of the fetus, one should not resort to turning but Wraxton – Hicks , perform a cesarean section in whole waters and incomplete opening of the cervix, undertake a vaginal cesarean section, cut off the fallen out handle. The combination of the transverse position of the fetus with placenta previa or with a narrow pelvis with a live fetus and significant bleeding, but without obvious infection in the uterus, of course, serves as an indication for caesarean section.

Pelvic injuries and injuries

Posted on May 6, 2020  in Pelvic diseases

The frequency of injuries and damage to the pelvis. During the Great Patriotic War, gunshot wounds of the pelvis were found in 3.8-4% of the wounded. Foreign medical statistics unites in one group injuries of the pelvis, kidneys and urinary tract. Nevertheless, in the first and second world war, injuries of these organs were noted in no more than 5% of the wounded. According to the materials of the American war in Vietnam, the average damage mentioned was 4.5% (O. Salvatiera , T. Oschner , F. Busch , 1969). Thus, the percentage of injuries of the pelvis, kidneys and urinary tract during the last wars remains stable. Closed pelvic injuries were rare in past wars. However, it can be assumed that with the use of nuclear weapons, the number of closed pelvic injuries will increase significantly. Closed pelvic injuries with and without damage to the continuity of the pelvic ring and pelvic organs In the group of closed pelvic injuries, soft tissue injuries are distinguished, as well as closed pelvic bone fractures with or without damage to the pelvic organs. Pelvic bruises are sometimes accompanied by the formation of subcutaneous hematomas or skin detachment. Perineal bruises can be complicated by urethral ruptures. Among the closed injuries of the pelvic bones, there are: 1) isolated fractures of the pelvic bones without violating the integrity of the pelvic ring; 2) pelvic fractures with a violation of the integrity of the pelvic ring; 3) double vertical fractures of the pelvic bones; 4) pelvic fractures with damage to the pelvic organs. 1. Fractures of the pelvic bones without violating the continuity of the pelvic ring are mild. 

These include: fractures of the iliac wing, fractures of the sacrum below the sacroiliac joints, tailbone fractures, the remains of the ilium, isolated fractures of one of the branches of the pubic or ischium, fractures of the edge or bottom of the acetabulum, fracture of the sciatic tubercle, etc. Such fractures usually occur with the direct mechanism of injury, when the force of the traumatic agent is directed directly to the surface of one of the bones of the pelvis. Symptoms: pain in the fracture area (in the pubic area – with a fracture of the pubic bone, in the perineum – with a fracture of the sciatic bone, etc.), aggravated by leg movements. Pelvic compression in the lateral and anteroposterior directions, palpation of the pubis, sciatic tubercle, iliac spine, etc., gives pain in the fracture area. Sometimes in the fracture zone, swelling can be detected. In case of fractures of the sacrum and tailbone, a digital examination of the rectum is necessary. X-ray of the pelvic bones confirms the diagnosis of a fracture. 2. Fractures with a violation of the continuity of the pelvic ring are classified as severe injuries. They are often accompanied by traumatic shock and damage to the pelvic organs, internal bleeding into the retroperitoneal tissue. There are single and bilateral fractures of the pubic and sciatic bones, vertical iliac fractures near the sacroiliac joint, a double vertical pelvic fracture in which the pelvic ring breaks in the anterior and posterior parts ( Malgaigne fracture ), pelvic dislocation fracture – rupture of the pubic symphysis and vertical fracture of the posterior half ring, rupture of the sacroiliac joint and fracture of the anterior semiring. With fractures of the anterior pelvic ring (fractures of both branches of the pubic bones, horizontal branches of the pubic bone and ascending branches of the ischium), severe pain in the inguinal region and perineum is noted. The function of the lower extremities is impaired. 

When the pelvis is squeezed laterally ( Vernewil symptom ) due to simultaneous pressure on the wings of the ilium, or dilution of the latter ( Larrey symptom ), the pain intensifies. The legs are bent at the knee and hip joints and slightly divorced. The patient cannot lift a leg straightened in the knee joint (symptom of a “sticking heel”). This symptom is explained by the fact that the ileo-rib muscle of the lower back, and the ileo -lumbar muscle during contraction lead to the displacement of fragments, causing sharp pain. With bilateral injuries, the mentioned symptoms are expressed on both sides and more distinctly. When double vertical fractures and perelomovyvihah pelvis marked asymmetry of the pelvis, an apparent shortening of the limb on the side of damage due to displacement under the action of thrust iliopsoas muscles, iliopsoas-costal lumborum, square thigh muscles and oblique muscles of the abdomen damaged half pelvis with limb in the cranial direction. The limb is somewhat reduced and rotated outwards; the anterior superior spine on the lesion side is higher than on the healthy one. This is determined both by a comparative examination of the patient in a supine position, and by comparatively measuring the distance from the base of the xiphoid process of the sternum to the right and left front upper spine. With a rupture of the pubic symphysis, the legs are bent at the knee joints, the hips are shown. When you try to dissolve their pain intensifies, it is especially severe when combining a rupture of the pubic symphysis with a fracture of the bones of the anterior half ring. 

The symptom of a “sticking heel” is noted, as with an isolated fracture of the anterior half ring. With pelvic fractures, with a developed vasculature, there may be hemorrhages in the perineum or in the inguinal region. Imbibition of subcutaneous tissue and skin with blood is detected in the first hours or a day after an injury. Similar bruising, only more common, also occurs with fractures of the posterior pelvic half ring. Abundant hemorrhages during fractures of the pelvic bones are due to the fact that the damaged intrathoracic vessels do not subside and the fracture site constantly bleeds. Significant bleeding occurs with fractures of the posterior pelvic ring, where the pelvic bones are more massive. The spilled blood, accumulating in the fiber, leads to the formation of extensive retroperitoneal hematomas, often simulating a picture of an “acute abdomen” – the abdomen is swollen, tense and painful, and stool and urination are delayed. With percussion – dullness of the sound in the lower abdomen, the symptom of Shchetkin-Blumberg ( Blumberg ) is positive. The hemoglobin and hematocrit values ​​at the beginning of the formation of such retroperitoneal hematomas may not be changed, but in a later period anemia that is persistent and permanent in nature increases. With unilateral and bilateral complete fractures of the pelvic ring, a symptom of Volkovich may be noted: the hips are slightly open , the lower extremities are rotated outward and slightly bent at the knee and hip joints (frog pose). The clinical picture of a rare vertical iliac fracture with splitting of only the upper edge of the acetabulum ( Duverney type fracture ) is characterized by a partial preservation of active movements and a significant amount of passive movements in the hip joint, which does not happen with fractures with disruption of the pelvic ring. The nature of the displacements of the fragments and the morphology of the fracture are specified radiographically. 3. Pelvic fractures complicated by damage to the pelvic organs average 15% of all pelvic fractures. Displaced fragments of the ascending branches of the sciatic bones and descending branches of the pubic bones most often damage the urethra and bladder, less often the prostate gland. With fractures of the left iliac bone and the left half of the sacrum, the rectal ampoule can be damaged. Damage to large vessels during pelvic fractures is accompanied by large (1.5-2 l) blood loss. Clinic. 

The condition of the victims is usually severe. Symptoms of acute blood loss and traumatic shock prevail. When ruptured or squeezed by fragments of the anterior half of the urethra or neck of the bladder, there is a delay in urination. Ruptures of the urethra can be full or partial. In both cases, there is a delay in urination, the bladder is full, the patient is worried about the frequent inconclusive urge to urinate. An enlarged bladder is palpated above the pubic symphysis. With extraperitoneal ruptures of the bladder, urine infiltrates the pelvic tissue, then urinary leakage can spread to the perineum, hips and buttocks, causing purulent-septic complications over time. With intraperitoneal ruptures of the bladder, urine enters the abdominal cavity, which leads to the development of peritonitis. A digital examination of the rectum facilitates the diagnosis of pelvic fractures and related injuries.

Lnguinal hernia

Posted on May 2, 2020  in Pelvic diseases

Inguinal hernias are the most common type of hernia (87–90%).

Etiology, pathogenesis of inguinal hernia

Contributing factors are: Nezar – schenie processus vaginalis of the peritoneum, atrophy of the fatty tissue in the inguinal canal with a decrease in body weight, muscle degeneration in obesity in old age. Passage to the embryonic period of development (6-8 months of pregnancy) through the inguinal canal of the descending testicle, spermatic cord in men and the round ligament of the uterus in women creates anatomical conditions that, if there are predisposing and producing causes, can lead to the development of a hernia. By the 7th month of life, a complete overgrowth of the vaginal process occurs in 35% of cases, by 12 months – in 41%, and in adults – in 90%. With a congenital hernia, the elements of the spermatic cord are spread over the hernial sac (its posterior wall) and are intimately connected with it, the testicle lies in the wall of the hernial sac and its own membrane stands in the lumen of the sac.

Direct hernia

It leaves the abdominal cavity through the internal inguinal fossa, has a direct passage, wide gates, a short canal, a semicircular shape, does not descend into the scrotum, the spermatic cord lies outwards from the sac.

Oblique hernia

It exits through the external inguinal fossa, has an oblique direction, descends into the scrotum, the hernial sac lies inward from the membranes of the spermatic cord, on its inner surface.
The size of the initial hernia is distinguished – the hernial sac is only felt in the depth of the inguinal canal; incomplete – the hernial sac does not come out of the external opening of the inguinal canal; complete – hernial space is located outside the inguinal canal; inguinal-scrotal, descending into the scrotum; large – the hernial sac descends, pulling the scrotum down to the middle third of the thigh or to the knee joint.

Inguinal hernia clinic

With a correctable hernia, the tumor-like formation is felt in a typical place, appears with tension and disappears in the supine position and with pressure; a hernial ring is palpated in the abdominal wall; transmission of a cough impulse is noted; when leaving the hernia sac of the intestine over the protrusion, tympanitis is determined. With an irreducible hernia, the hernial protrusion does not adjust and has a localization typical of a hernia . Often, a tumor-like formation increases with straining . From the anamnesis it is known that in the past it was easily adjusted. When a finger is inserted into the inguinal canal after the hernia is repositioned, the expanded hernial gates are oval or triangular in shape. On palpation during straining , the outgoing hernial contents are determined. The diagnosis is not very difficult. Incomplete hernias are determined only by inserting a finger into the inguinal canal. The corrected hernia must be differentiated with the nipple , the expansion of the veins of the spermatic cord, and the irreducible hernia with the tumor and dropsy of the testicle.

Inguinal hernia in children

Inguinal hernia is the release of organs of the abdominal cavity (mainly the intestines) into non-growing vaginal peritoneum.

Incidence of inguinal hernias

Inguinal hernias are found mainly in boys (due to the lowering of the testicle), mostly unilateral, more often on the right). Injured inguinal hernias occupy third place in terms of specific prevalence among acute surgical diseases of childhood.

Inguinal hernia classification

1. Inguinal hernia. 2. Inguinal- Kalitkov hernia: a) testicular , b) cords (90% of inguinal hernias). The contents of the hernial sac are loops of the small intestine, omentum, in girls, in addition, ovaries, fallopian tubes.

Causes of inguinal hernias

Inheritance of the disease, deficiency of hormones of the mother and fetus, adverse environmental factors.

Clinic and diagnosis of inguinal hernia

Painless protrusion of a round or oval shape in the groin, which increases with a scream, elastic consistency. On palpation – a characteristic rumbling. Symptom “push” when coughing a child. Injury of an inguinal hernia. Sudden pain in the inguinal region, symptoms of irreversible hernia. Vomiting, intestinal obstruction. In the external opening of the inguinal canal there is a painful hernial protrusion.

Differential diagnosis of inguinal hernia

Differential diagnosis is carried out with testicular dropsy, cryptorchidism, testicular ectopia, enlarged lymph nodes, and in girls – Nukke cyst .

Inguinal hernia treatment

Conservative In case of numbness in the inguinal hernia – antispasmodics (atropine), painkillers ( promedol ), warm bath, horizontal position of the child with a raised pelvis. Prompt. Duhamel’s operation is cutting off the hernial sac without opening it and duct plastic. Operation Krasnobaev – cutting off the hernial sac with plastic inguinal canal without opening the front wall. Martinov’s operation is rarely used – cutting off the hernial sac with plastic of the inguinal canal with the opening of the front wall.

Birth injury as a cause of bleeding

Soft birth trauma is observed much more often than pathological bleeding from the birth canal, although the trauma itself is the cause of these bleeding relatively rarely. Only rupture of varicose nodes, large venous and arterial vessels (anastomoses and individual branches) leads to bleeding that requires urgent surgical intervention. Finding out the cause of bleeding from the genital tract during childbirth or the early postpartum period, it is necessary first of all to exclude the trauma of the birth canal. Rupture of the uterus can cause a serious condition of women in childbirth and puerperas (shock, bleeding, infection).

Rupture of varicose nodes of the perineum and vagina

Despite the relative rarity of pronounced varicose nodes in the vulva and vagina, this pathology in violation of the integrity of the enlarged venous plexuses can cause severe bleeding. Varicose nodes of the perineum and vagina are recognized before the onset of labor, they are more often observed in multiparous. The expansion of venous vessels is often symmetrical on both the labia minora and labia minora. In a patient who is in an upright position, it resembles a tumor-like formation that completely closes the entrance to the vagina. Blood filling the vasculature of the vulva is easily squeezed out when the labia are compressed by the rollers or palmar surfaces of the hands. After the cessation of compression, the blood vessels are again filled with blood . In no patient did we observe the formation of trophic ulcers in the vulva and spontaneous rupture of varicose nodes with subsequent bleeding. With the right preventive measures, it is possible to reduce the development of varicose veins of this area during pregnancy and to almost completely eliminate the rupture of varicose nodes in childbirth. To this end , a strip of 4-6 cm wide is attached to the usual belt (abdomen), which is recommended to be worn with beerep , with one end to the front and the other to the back surface. The middle part of the strip is sewn from soft fabric (flannel), and the end ones are made of braided rubber mite, used for belts (bellies). Put on the belt in a prone position and in the same position fasten the end on the front surface of the belt.
In childbirth in the presence of varicose veins of the vulva, the most dangerous moments when a vascular injury occurs are the end of the second period of childbirth, the moment of cutting and eruption of the head. To prevent overflow of varicose nodes with blood during attempts, continuous (during the attempt) compression of the labia majora with palms or strips of matter is necessary, which are laid in the same way as described above.

When there is a risk of rupture of the tissues of the labia, a perineotomy is performed (with episiotomy , varicose nodes can be cut), which eliminates the obstacle to the passage of the fetal head. The rupture of the varicose nodes of the vulva is always accompanied by significant bleeding immediately after the birth of the fetus. Treatment for these conditions should include immediate ligation of the broken vessels. In the presence of a large network of varicose- dilated vessels, flashing them blindly can lead to the formation of an extensive hematoma of the labia majora with its spread to the vagina and perineum. Therefore, it is necessary to strive to separate the torn ends of the vessels (this is not always possible) and dress them with catgut. Stitching of varicose nodes blindly through the thickness of the spongy vascular tissue, as a rule, leads to disruption of the integrity of varicose nodes and the formation of an extensive hematoma. In these cases, the wound has to be wide open, a conglomerate of nodes is sifted out and repeatedly stitched in the transverse direction with respect to the length of the large lip. After this, a pressure dressing is applied for 24 hours. If the operation is performed by an inexperienced doctor, it may be ineffective and lead to severe anemia of the patient.

Rupture of the cavernous bodies of the clitoris

The rupture of the cavernous bodies of the clitoris is much more common than the varicose nodes of the vulva. If the rupture of the varicose nodes of the shameless lips is usually observed in multiparous women, then the rupture of the cavernous bodies of the clitoris usually occurs in the primiparous during spontaneous delivery, operative delivery (forceps, fetus extraction, fruit- destroying operations) or a violation of the methodology for managing the second stage of labor ( cutting and teething fetus).
Violation of the integrity of the cavernous bodies of the clitoris is always accompanied by bleeding, the intensity of which usually depends on the degree of damage to the cavernous bodies.
We had to observe the most severe cases of anemia due to the late recognition of the cavernous rupture or the ineffective stop of bleeding.
It is not difficult to establish the presence of bleeding from the cavernous bodies of the clitoris. When breeding the labia and displacement upward of the foreskin of the clitoris, the latter is completely exposed. Typically, clitoris tears are localized on its posterior wall and are in a longitudinal or transverse position with respect to the clitoris length Rupture of the cavernous bodies can be on one or both sides.
Bleeding from cavernous bodies occurs in a continuous small stream. When reducing the lower extremities, it sometimes stops for a while due to thrombosis , and then starts again.
Stopping bleeding does not present technical difficulties. It is necessary to stitch, and then dress with catgut completely one of the cavernous bodies, closer to its base. You can not pierce the cavernous body, which was not damaged during childbirth.

Diagnosis of a narrow pelvis

Diagnosis of a narrow pelvis is usually not difficult. Already a careful external examination of the pregnant woman is often a doctor vozpikaet thought of having a narrow pelvis: general physical hypoplasia, short stature ( mepype 150 cm), sharp lordosis, signs of childhood rickets (square skull, chicken breast, sablevidnoizognutye leg and so on.). Scoliosis, kyphosis, shortening of one of the legs, ankylosis, dislocations of the hip joints always signal the presence of certain pelvic deformities. The doctor receives very valuable data upon careful examination and measurement with a centimeter tape of the Michaelis rhombus . In well-built women with a normal pelvis, the rhombus has the shape of an almost regular square set on one of the corners (A. Yu. Lurie). With a uniformly narrowed pelvis, the transverse size of the rhombus is reduced by 1-1.5 cm, that is, it is 8-7.5 cm (instead of 9 cm); the longitudinal (vertical) size is slightly increased compared to the norm – 11 cm. The upper and lower corners of the rhombus approach acute, and the side corners approach obtuse. In other words, the rhombus is slightly flattened vertically. With a flat basin, on the contrary, the longitudinal size of the rhombus is reduced by 3-4 cm, while the transverse remains unchanged. Sometimes the upper half of the rhombus is so flattened horizontally that its upper corner disappears, and the rhombus turns into a triangle with a vertex facing down.

The asymmetrical shape of the rhombus usually indicates an oblique pelvis.
If you suspect a narrow pelvis, all its dimensions must be measured especially carefully and, moreover, repeatedly: during pregnancy and at the beginning of the first stage of labor. The fact that the pelvis during pregnancy peskolko increases obviously under the influence of hormonal influences: the true conjugate is extended to 0.5 cm In addition, during pregnancy is still impossible to judge the size of the fetal head at the time of delivery and its appropriate size. pelvis.

If a narrow pelvis is suspected, along with the usual measurement of the external dimensions, it is determined and compared with the following indicators.
1. The circumference of the pelvis. It is measured at the upper corner of the Michaelis rhombus , iliac scallops and the upper edge of the symphysis. Normally, the circumference of the pelvis is 85 cm. If its size approaches 75 cm, this indicates a significant narrowing of the pelvis. 2. Lateral conjugates (right and left). The measurement is made with a tazomer between the anterior and posterior iliac spine on each side; normal sizes of the lateral conjugates are 14.5-15 cm. Shortening them to 13 cm indicates a significant narrowing of the pelvis. 3. The oblique dimensions of the pelvis – the distance along the tazomer from the anteroposterior iliac spine of one side to the posterior- superior spine of the other. Each oblique size of a normal pelvis is 22.5 cm. A symmetrical decrease in these sizes is observed with a uniformly narrowed pelvis. The difference between the right and left oblique dimensions indicates the asymmetry of the pelvis. 4. The height of the pubic joint. It is determined by capturing with the thumb and forefinger the upper and lower edges of the pubic joint (A. Yu. Lurie). The distance between the toes was measured tazomera (in normo it is equal to 4-5 cm). The higher the pubic articulation, the smaller the true conjugate . At high lonnom articulation on the size of the true conjugates need to take 0.5 cm. Thus, if in normo true conjugate less diagonal average of 1.5 cm, the flat pelvis it is smaller by 2 cm. The diagonal conjugate is measured at the first intravaginal study of women in childbirth. Suspicion of a narrow pelvis is itself an indication for immediate vaginal examination with the obligatory measurement of diagonal conjugates . Simultaneously with the measurement, conjugates examine all the piles of the pelvis with your fingers to get an idea of ​​the structure, shape and capacity of the pelvis. 5. About the thickness of the bones of the woman in childbirth (and therefore about the thickness of the bones of the pelvis) gives an idea of ​​the Soloviev index – the value of the circumference of the wrist of the woman in labor , measured with a centimeter tape, write the styloid process. In norm, the Soloviev index is 14.5-15 cm. If the wrist thickness is less, then the bones of the woman, and therefore the pelvic bones are thin, and the capacity of the pelvic cavity, all other things being equal, will be greater. With a wrist thickness of 16 cm or more, the capacity of the pelvis with the same external dimensions will be less due to the thickness of the bones. 6. The angle of inclination of the pelvis , determined by a special tazomer , is also important : the larger the angle of inclination of the pelvis (on average it is 60 °), the greater the true conjugate , which with a narrow and especially with a flat basin is a favorable indicator. 7. The size of the fetal head can be judged approximately by the length of the fetus and the diameter of the head, measured with a tazomer across the entire thickness of the abdomen, which is very inaccurate, and in cases of an excessively thick, strained abdominal wall. Therefore, the following two methods for determining the relationship between the fetal head and the mother’s pelvis are of great practical importance. Sign of Vasten . The doctor, standing on the side of the woman in childbirth, puts a palm on her pubis, straightening her fingers, and then moves the brush with a sliding motion upward on the head. In this case: 1. The edge of the palm of the hand of the obstetrician, when moving upward, encounters, as it were, a hill protruding above the upper edge of the symphysis. This is the head of the fetus; it is pressed to the symphysis and is not inserted, since its dimensions do not correspond to the dimensions of the pelvis. Therefore, it will stand, as if hanging over the symphysis. This position is referred to as positive vasten . 2. The edge of the brush, when moving upward, as if jumps from the upper edge of the symphysis to the fetal head, since the head is freely inserted into the pelvic entrance and its surface is located below the surface of the symphysis; in such a case they say: ” negative vasten “, which indicates the absence of any mismatch between the size of the fetal head and the entrance to the mother’s pelvis. 3. The edge of the hand freely moves upward from the symphysis, to the fetal head, remaining in the same plane, since the surface of the symphysis and the fetal head, firmly pressed to the entrance to the pelvis (but not yet inserted), are also in the same plane. This polo { ix called ” Vastu level.” It indicates the presence at the moment of some slight mismatch between the pelvis and the head, which, as a rule, is overcome with the development of good labor and a pronounced configuration of the fetal head. There is reason to believe that the head will pass the entrance of the narrowed pelvis. The Vasten sign is one of the very important criteria for assessing pelvic functional failure. However, its character can only be judged with a fixed fetal head. For greater persuasiveness of the results obtained using the Vastep method, the Zapgemeister method is used . In a standing position, women in labor determine the external conjugate of the pelvis with a tazomer ; remembering the figure obtained and without shifting the buttons of the posterior jaw of the tazomere , the button of the front jaw is moved from the upper edge of the symphysis to the most prominent point of the underlying fetal head.

 If the resulting figure is less than the magnitude of the external conjugates , the prognosis is good; if more, the forecast is bad, if the numbers are the same, the forecast is uncertain: everything will depend on the nature of labor and the configuration of the head. We repeat: with a narrow pelvis during childbirth, repeated vaginal examination is necessary. In this case, the ratio of the fetal head with the entrance to the pelvis, asynclitism and its types, degree of head configuration, condition and location of the fontanelles, insertion of the head, presence and location of the birth tumor, features of the pelvis (determination of the true conjugates , degree of coccyx mobility, the presence of exostoses, the nature of the promontory are determined , capacities and forms of the sacral cavity ). Without knowledge of all these data, proper management of labor is impossible. At I and II degrees of narrowing of the pelvis, delivery through the natural birth canal is possible in most cases, but under the following conditions (according to A. Yu. Lurie): 1) the circumference of the pelvis is at least 75-80 cm; 2) lateral conjugates – not less than 14 cm; 3) Soloviev index – not more than 14 cm; 4) the direct and transverse dimensions of the outlet of the pelvis – not less than 10 cm; 5) bosom height – no more than 5 cm; 6) the angle of inclination of the pelvis approaches 60 °; 7) The direct resolution of the head (on paruzhnomu definition tazomera ) – no more than 10-11 cm; 8) ” vasten is negative” or “level”; 9) “ Tsangmeister is positive” in favor of external conjugates . To this it is necessary to add carefully analyzed data on the size of the fetus, the degree of configuration and the nature of the insertion of the head; strength, duration, regularity and productivity of labor pains; amniotic fluid; the state of the fetus (often listening to his heartbeat or, better, with the help of phonoelectrocardiography ); the general condition of the woman in labor, the degree of her fatigue.