Obstetrics

Synonyms in the broadest sense

Maternity aid

Introduction

Obstetrics, also known as tocology or obstetrics, is a medical specialty that deals with the monitoring of normal and pathological pregnancies, as well as birth and postnatal care. Obstetrics is a subspecialty of gynecology. The activities of obstetricians and midwives also fall within the field of obstetrics.

For a long time, obstetrics was the only medical field that specifically treated women. Other pathological abnormalities in women were not treated by specially trained doctors. Thus, the field of gynecology developed only in the modern era.

The field of obstetrics was considered a women’s domain until the 17th century. Only then were men also trained as so-called obstetricians. The predominantly practical activities of midwives have been handed down from ancient Greece.

The transition from midwife to doctor was then fluid. Since early modern times, special emphasis has been placed on the professional training of midwives. This is how midwifery textbooks and midwifery regulations came about.

The first printed midwifery textbook for obstetrics dates from 1513 and was written by the physician Eucharius Rösslin. However, the resulting midwifery regulations also brought disadvantages. The midwives were gradually ousted from their leading positions, and the city physicians, who had learned their knowledge from the midwives themselves, took the leading positions.

Prenatal diagnostics, on the other hand, only underwent a change in the middle of the 20th century. Until then, midwives and doctors had to rely on simple procedures and physical examination. Through the development of the Contact Compound Scanner in 1957 by Ian Donald, and the construction of a Real-Time Scanner in 1965 by Richard Soldner, it was possible to gain much more precise knowledge about a pregnancy, its course and the child.

This has not only brought great advantages for the obstetricians, but also for the expectant mothers. In addition to prenatal diagnostics, the field of abortion has also undergone a major change. Whereas in the past abortion was associated with great risks, today the complications are so minor that an abortion can hardly ever lead to a dangerous situation for the mother.

The care of pregnant women during the entire period of pregnancy and during childbirth is the field of activity of obstetricians. The first examination and consultation of a pregnant woman should take place as soon as possible after the beginning of the pregnancy in order to detect abnormalities, such as an ectopic pregnancy. If the pregnancy is unremarkable, the following examinations can be carried out according to the maternity guidelines, i.e. every 4 weeks until the 32nd week of pregnancy (SSW), then every 2 weeks until the birth date.

These are health insurance benefits. In practice, however, an examination scheme according to Saling is recommended. In the first 4 months (up to the 1st – 16th week of pregnancy) a preventive examination is performed every 4 weeks, in the following 3 months (17th – 28th week of pregnancy) every 3 weeks and in the following 2 months (29th – 36th week of pregnancy) every 2 weeks.

Thereafter, the patient is examined weekly until the 40th week of pregnancy, and every 2 days after the calculated date of birth. If the child is still not born 10 days after the calculated date of birth, a hospital admission of the mother is indicated. The initial examination of pregnant women for obstetrics includes a thorough anamnesis, i.e. age, name, marital status, profession, number of previous births and pregnancies.

Problems or abnormalities in previous pregnancies should also be discussed. In addition, chronic diseases of the mother or infections such as hepatitis, HIV and rubella should be checked, as well as other known diseases in the family. To be able to calculate the exact date of birth, it is helpful to know the woman’s cycle, and thus the first day of her last menstrual period.

The following examinations should be carried out at every preventive examination: A thorough anamnesis of the current situation. For example, changes in the last few weeks regarding child movements, bleeding, or other complaints. The mother’s body weight should also be measured each time.

A weight gain of 1-1.5 kg/month is considered normal. To detect pregnancy-induced hypertension, it should be measured regularly.The limit value is 140/90mmHg. Urine should also be checked regularly for proteins or sugar in order to detect gestational diabetes early.

In addition, a blood test should be performed regularly to rule out anemia. As a physical examination method for optimal obstetrics, in principle the fundus level should be palpated to check the timely development of the child and a vaginal examination is performed to assess the cervix, cervix and pelvic situation. Other preventive measures in obstetrics include 3 ultrasound examinations during pregnancy, unless the pregnancy is a high-risk pregnancy.

These ultrasound screenings take place around the 10th, 20th and 30th week of pregnancy. The first ultrasound serves to determine the position of the child in the uterus. In addition, the date of birth can be calculated by the size of the child.

The other two ultrasound examinations are mainly used to exclude fetal malformations and to check for timely development. In addition, the calculated due date is checked again and corrected if necessary. In addition, from the 28th week of pregnancy onwards, the child’s heartbeat should be checked regularly using a CTG.

In the case of Rh- negative mothers, rhesus prophylaxis should be carried out at this time to avoid possible complications during the birth of a Rh- positive child. From the 30th week of gestation onwards, it is important to determine the exact position of the child. That is, whether the child is lying with his head towards the pelvis.

A hepatitis B screening is performed as close as possible to the date of birth. If the child has passed the birth date, very regular checks of the heartbeat and ultrasound examinations showing the blood flow in the fetal organs are essential to detect a possible undersupply of the child. The activity of midwives in obstetrics covers a wide field and is not very different from that of doctors.

A midwife is trained according to the midwifery law to perform a birth without a doctor. However, a doctor may not give birth without a midwife. During the birth, the midwife assists the expectant mother in coping with premature labor pains.

She gives advice and helps with pain management. In the case of a physiological spontaneous birth, she should also respond to the wishes and worries of the woman giving birth. For example, the position can be changed.

However, the midwife must also distinguish a physiological from a pathological birth process and act in case of doubt, or consult a doctor. In emergency situations, a midwife should be able to act independently, for example to free a trapped shoulder of the child. If a doctor needs to be consulted, the midwife acts as obstetrician to the doctor and also assists during a caesarean section.

The midwife takes over the birth control during the birth. She admits the mother to the delivery room, monitors her general condition, checks her contractions and gives oxytocicides or contraceptives after consultation with the doctor. In addition, she must assess the progress of the birth by checking the opening of the cervix and the baby’s attitude and position as well as stepping down into the pelvis in order to detect abnormalities in posture or other complications at an early stage.

Furthermore, she is responsible for the constant monitoring of the child by means of CTG, she assesses the amniotic fluid for pathological bleeding and, if necessary, she can perform a fetal blood analysis to better assess the fetal situation. During the expulsion phase, she prevents the baby from pressing too early to prevent uterus rupture by guiding the mother to breathe properly. In the interest of both mother and child, the expulsion period should not last longer than 60 minutes.

Throughout the entire expulsion period the proper rotation of the fetal head must be checked. In addition, the child must be constantly monitored by CTG. The midwife also has the task of protecting the perineum from rupturing, possibly an episiotomy must be performed.

After the birth, she is responsible for cutting the cord and the subsequent first aid. Height, weight and head circumference are measured. In addition, it is checked whether all body orifices are correctly positioned, and other abnormalities must be detected.

In addition to caring for the newborn, the midwife also takes care of the mother’s aftercare directly after the birth.The midwife is also an important contact person for the mother during the course of the postpartum period. She gives important tips on nutrition and care of the baby, checks the mother’s tissue regression and offers regression gymnastics. Only about 4% of all pregnant women give birth exactly on the calculated date.

Most children are born +/- 10 days around the calculated date. Obstetrics begins a few weeks before the calculated date of birth. About 4 weeks before the actual birth, the uterus begins to lower.

This is accompanied by slight contractions. During this time, the head also enters the maternal pelvis. In multiparturient women, the head may have entered the pelvis relatively little before the birth.

A few days before the birth, uncoordinated contractions occur. In addition, the cervix becomes softer in the days before birth and the cervix opens slightly. If the cervical mucus is then expelled with added blood, this is a sign that the birth is about to begin.

The normal birth process is divided into 3 phases. In the opening period the contractions slowly become regular. The opening contractions occur every 3-6 minutes and the whole phase lasts 7-10 hours for first-time mothers and about 4 hours for multiple mothers.

In addition, at the beginning of this phase, a rupture of the bladder occurs. The opening phase ends with the complete opening of the cervix. The expulsion phase begins with the opening of the cervix.

This phase lasts about 1h, i.e. about 20 contractions for first-time mothers and about 30min for multi mothers. During this phase, continuous monitoring by means of CTG is essential. If the child’s head or rump is lower, the pressing urge begins to increase.

If there is a risk of overstretching or perineal tears, an episiotomy should generally be performed to prevent uncontrolled tearing. At the moment the head passes through, pressing is prohibited and perineal protection is applied. The midwife places one hand on the perineum and thus tries to avoid tearing.

During the whole birth, the child must take 5 turns to stay in the optimal position. After the birth/obstetrics, the so-called afterbirth period occurs. First the umbilical cord of the child must be cut.

There are 3 possible times for this. Directly after the birth, after approx. 1. min or after the umbilical cord pulsation has stopped.

The contractions in the afterbirth phase serve on the one hand to reduce the size of the uterus and on the other hand to expel the placenta. This usually takes about 30 minutes. The blood loss during placental detachment is usually about 300ml.

In order to speed up the process of detachment and to keep blood loss as low as possible, contraceptives are often given. If the placental detachment is delayed or only partial detachment takes place, the placenta can be detached manually. To reduce pain during birth, Buscopan® can be given to reduce muscle spasms.

If the contractions are too strong, the birth does not run regularly, a caesarean section can be performed, or an epidural can be applied at the request of the mother. In this procedure, a local anesthetic is injected into the epidural space in the lower vertebral region. There is no risk of spinal cord injury.

As a third option, a pudendal block can be performed. Here, a local anesthetic is injected into the genital region to relieve the perineal stretching pain. This relaxes the pelvic floor muscles, the perineal area, vulva and lower vaginal area are anaesthetized without affecting the pain in labour or the pressing urge.

Indications for this are a vaginal operative delivery, at the request of the mother or an early episiotomy. The regular birth is the most common form of delivery. However, there are various positional anomalies that can lead to problems during delivery, require intervention by obstetricians/birth attendants or necessitate a caesarean section.

Postural anomalies are when the baby’s head is not held regularly, i.e. with the chin pressed lightly against the chest. Postural anomalies are usually not unexpected conditions, as they often represent an adjustment to the birth canal. A distinction is made between the anterior main position.

Here the child keeps the head relatively straight. Thus the diameter, which must pass the center of the pelvis, becomes larger. This is often underestimated.

Another possibility is the forehead position. Here, the child overstretches its head and at birth the forehead emerges from the birth canal first.Since the diameter is the largest here, this is the most unfavorable position. The last type of postural anomalies is the facial position.

Here the head is completely overstretched. It is often possible to give birth spontaneously, but a caesarean section should not be delayed if it is indicated. In about 5% of births, the child is born from the breech presentation.

The child is not born with its head in front, but with its rump. This is less suitable as a dilator of the birth canal due to its flexibility and its smaller size in contrast to the head. In addition, at a certain point during birth, the umbilical cord is compressed, resulting in an oxygen deficiency in the child.

Furthermore, the head must be born against a much higher resistance. As a result, the pressure and tensile loads on the head, neck and spine are significantly greater and can lead to neurological abnormalities. For these reasons, a breech presentation should always be thoroughly monitored.

If there is the slightest doubt that the birth can proceed without complications, a Caesarean section should be performed. Pelvic end positions are more frequent in premature births, since the child lies physiologically in the pelvic end position until the end of the 2nd trimenon and does not rotate until the 3rd trimenon. Due to the great effort and high rate of complications, children born before the 36th week of pregnancy should be conceived with a Caesarean section in the breech presentation.

A distinction is made between different forms of the breech presentation. The breech-only position means that the feet pinch the head and only the breech precedes. These two positional anomalies are the most favorable and can lead to a natural birth without caesarean section in an otherwise uncomplicated birth.

In the foot position, the legs are stretched out and the feet lead the way, while in the imperfect foot position, one leg is stretched out but the other is angled. Both positional anomalies make a natural birth very difficult and are indications for a cesarean section. Absolute indications for a Caesarean section from the pelvic end position are an estimated weight > 4000g, a foot position, overextension of the head, in case of a previous Caesarean section or if malformations or hydrocephalus (hydrocephalus) are suspected.

Another positional anomaly is the transverse position, which occurs in 0.7% of births. The reason for this is an extremely high mobility of the child in the pelvis which can have different reasons. These include a very small child in premature birth, a lot of amniotic fluid and a flaccid uterine wall and abdominal wall in multiparturient women.

However, obstacles such as multiple births or uterine anomalies can also lead to a transverse position. If this is not treated, a prolapsed arm can occur after the rupture of the bladder and the shoulder can get stuck. If the contractions increase, a permanent contracture and a tearing of the uterus can occur.

A caesarean section is absolutely indicated in such a situation. Multiple births are also always considered to be high-risk births. After the birth of the 1st child there is a risk of early placental abruption and thus a life-threatening situation for the 2nd child.

If the twins are both in a cranial position and there is no reason for complications, there is usually nothing to prevent a natural birth process. Even if the second twin is in the breech presentation, a spontaneous birth is possible, as long as it is relatively small. In all other cases and with more than 2 children, a direct Caesarean section is normally performed.