Below, “Pregnancy, childbirth, and puerperium” describes diseases that are classified in this category according to ICD-10 (O00-O99). The ICD-10 is used for the International Statistical Classification of Diseases and Related Health Problems and is recognized worldwide.
Pregnancy, childbirth, and postpartum
Pregnancy and lactation are special phases in a woman’s life. Giving birth to a new life is a beautiful and special experience in which the pregnant woman has a special responsibility. Attention is now paid not only to one’s own body, but also to the body of the unborn child. Expectant mothers should therefore create the best conditions for a pleasant pregnancy and a healthy growth of the new life. Preventive care protects the life of the pregnant woman and that of the unborn child.
Anatomy of the birth canal
The birth canal consists of the bony pelvis and the soft tissue tube. Bony pelvis
The bony pelvis has a transverse oval annular structure in the obstetrically relevant pelvic inlet, the boundaries of which are:
- Posteriorly, the sacrum (Os sacrum) above + coccyx (Os cocccygis) below.
- Laterally and arching forward the two hip bones (Ossa coxae).
The bones are connected by cartilage and ligaments. Important are the ileosacral joints (ISG; Articulationes sacroiliacae) and the symphysis (cartilaginous connection of the two hip bones). Both are very mobile due to pregnancy hormones and facilitate the entry of the head into the pelvis. The same applies to the cartilaginous connection of the sacrum and coccyx. In contrast to the male pelvis, the female pelvis typically has a low bony height, bilateral protrusion and a wide pubic arch. In terms of obstetrical mechanics, the so-called small pelvis, which is relevant for obstetrics, is divided into the following pelvic spaces:
- Pelvic entrance space
- Shape: transverse oval
- Boundary: promontory → upper edge of the symphysis.
- Diameter:
- Straight diameter 11-12 cm
- Oblique diameter 11.5-12.5 cm
- Transverse diameter 13 cm
Conjugata vera: the smallest and most important distance for the entry of the head between the posterior surface of the symphysis and the promontory. In a normally configured pelvis, it measures 11 cm. (To detect grosser shape abnormalities, the pelvis is routinely tested out before birth. Accessibility of the promontory implies a narrowing of the straight diameter. Conjugata diagonalis (distance from the promontory to the lower edge of the symphysis) is measured with a finger. By subtracting 1.5-2 cm, an approximate measure of the conjugata vera is obtained. The normal value of the conjugata diagonalis is 12.5-13 cm. If the lateral portions of the linea terminalis are reached, this is an indication of a narrowing of the transverse diameter. In addition, exploration of the bony pelvis involves checking the shape of the sacral cavity, the coccyx position, and any insertion of the ischial spines (spinae ischiadicae) into the pelvic lumen).
- Pelvic center
- Shape: round
- Boundary: lower edge of the symphysis → coccyx.
- Diameter: all diameters 13 cm
- Basin outlet space
- Shape: longitudinal oval
- Boundary: roof-like, connecting line: lower edge of symphysis → coccyx → tubera ischiadica (ischial tuberosity).
- Diameter:
- Straight diameter 11.5 cm
- Transverse diameter 11 cm
The pool spaces have a different shape:
- Basin entrance → transverse oval
- Basin center → round
- Basin outlet → longitudinal oval
This means that as the child passes through the pelvis, the preceding part of the child (head/butt) must conform to these given conditions. Soft tissue tube
The soft tissue tube consists of:
- The cervix uteri
- Of the vagina
- The pelvic floor
- The vulva
Relevant to the mechanics of birth are the cervix and the muscles of the pelvic floor. The cervix must be stretched by contractions to the point that it is completely used up to allow the baby’s head or rump to enter deeper in the birth canal. If labor is insufficient or the cervix is rigid, this can decisively delay the birth process.The pelvic floor consists of several muscle layers that are relevant to the mechanics of childbirth. Looking at the layers from below, the musculature consists of one:
- External sphincter layer (Musculus transversus pernei superficialis, Musculus ischiocavernosus, Musculus bulbospongiosus, Musculus sphincter ani externus), above it →.
- Symphyseal
- From the urogenital diaphragm; it is stretched out at the angle of the pubis and contains the transversus perinei profundus muscle and parts of the urethral sphincter
- Coccygeal
- From the diaphragm pelvis, the crucial muscular part of the pelvic floor; the main component is the levator ani muscle. It forms a broad muscular plate that pulls in a v-shape from the tip of the coccyx, or ligamenta anococcygea, anteriorly downward and attaches broadly to the lateral pelvic walls.
In terms of birth mechanics, the arrangement of the pelvic floor muscles in the form of a double inclined plane has an important function in directing the head towards the symphysis while rotating in the straight diameter.
Anatomy of the head: the child’s head as the preceding part
In 90% of all births, the child’s head is the leading part. From the standpoint of birth mechanics, the configurability of the infant’s head to the conditions of the pelvis is of critical importance. The bony skull consists of:
- Base of the skull
- Facial skull
- Brain skull
The base of the skull and facial skull are not deformable during the passage of the head through the birth canal. In contrast, the bone structures surrounding the brain (cerebral skull) are highly deformable, i.e. configurable. The cerebral skull consists of:
- Two frontal bones (ossa frontalia).
- Two switch legs (Ossa parietalia)
- Two temporal bones (Ossa temporalia)
- One occipital bone (Os occipitale)
Suturae
The bones are connected by connective tissue sutures (suturae):
- Frontal suture (Sutura frontalis: suture between the ossa frontalia.
- Arrow suture (Sutura sagittalis): suture between the ossa parietalia.
- Wreath suture (sutura coronalis): suture between the ossa temporalia and parietalia.
- Lamddanaht (Sutura lambdoidea): suture between the Ossa parietalia and the Os occipitale.
Fontanelles
Where several bones meet, larger connective tissue-free areas called fontanelles (fonticuli cranii) are formed. In the front of the head is the large fontanelle (fonticulus anterior), and in the back of the skull is the small fontanelle (fonticulus posterior). The sutures and the fontanelles are important orientation parameters during the vaginal examination to determine the progress of labor, the depth of descent and the position of the fetal head in the birth canal. Head shape
The typical shape of the human head is the long skull (dolichocephaly). The head is asymmetrical, long and narrow. In plan view, the anterior transverse diameter through the parietal bones (diameter bitemporalis) is 8.5 cm, the posterior transverse diameter through the temporal bones (diameter biparietalis) is 9.5 cm. Head diameter (Diameter)
Only diameters that are important from the point of view of birth mechanics and that can be seen in the lateral view of the head are listed:
- Diameter suboccipitobregmatica (small oblique diameter: nuchal-large fontanel): 10.5 cm (most important obstetric diameter in the birth from anterior occipital position (occipitoanterior flexion posture of the head), which occurs in >90%).
- Diameter frontooccipitalis (straight diameter: glabella (hairless area between the eyebrows)-occipital): 12.0 cm.
- Diameter mentooccipitalis (large oblique diameter: chin-occiput): 14.0 cm.
Common diseases in the context of pregnancy, childbirth and puerperium
- Abortion (miscarriage)
- Cervical insufficiency (weakness of the cervix)
- Threat of premature birth
- Extrauterine pregnancy (ectopic pregnancy)
- Gestational diabetes mellitus (gestational diabetes).
- Gestational hypertension – new onset of hypertension (high blood pressure) during pregnancy without further complications.
- Hyperemesis gravidarum (pregnancy vomiting).
- Hypotension (low blood pressure)
- Mastitis (inflammation of the mammary glands)
- Placental insufficiency (placental weakness)
- Postnatal depression (postpartum depression).
- Preeclampsia (EPH-gestosis or proteinuric hypertension) – new-onset hypertension (high blood pressure) during pregnancy with proteinuria (excretion of protein in urine; > 300 mg/24 h) after 20 weeks of gestation.
- Pyrosis (heartburn)
- Delayed birth and birth arrest
- Premature rupture of membranes
The most important risk factors for diseases in the context of pregnancy, childbirth and the postpartum period
Behavioral causes
- Diet
- Consumption of stimulants
- Alcohol consumption
- Caffeine consumption
- Tobacco consumption
- Psycho-social situation
- Stress
- High physical stress
- Overweight
- Underweight
Causes due to disease
- Anemia (anemia)
- Autoimmunological diseases such as Hashimoto’s thyroiditis (chronic inflammation of the thyroid gland).
- Endocrine disorders such as diabetes mellitus (diabetes mellitus type 1, diabetes mellitus type 2), hyperthyroidism (hyperthyroidism), hypothyroidism (hypothyroidism).
- Eating disorders associated with underweight
- Hypertension (high blood pressure)
Please note that the enumeration is only an extract of the possible risk factors. Other causes can be found under the respective disease.
The most important diagnostic measures for diseases in the context of pregnancy, childbirth and puerperium
- Ultrasound diagnostics – routinely performed during pregnancy.
- Vaginal ultrasonography (ultrasound examination by means of an ultrasound probe inserted into the vagina (vagina)) – in early pregnancy.
- Abdominal fetal sonography/ultrasound examination of the child, for further diagnosis of:
- Singleton? Multiple babies?
- Growth in time?
- Timely development?
- Amniotic fluid volume (oligohydramnios, amniotic fluid volume < 500 ml; polyhydramnios, amniotic fluid volume > 2,000 ml).
- Repeated blood pressure measurements
- Antibody screening test (rhesus incompatibility?)
- Infectious serological tests (rubella HAH test (HAH = hemagglutination inhibition) with the question of sufficient protection against rubella; detection of Chlamydia trachomatis DNA; lues search reaction; HIV test; HBs antigen; if necessary, also test for toxoplasmosis).
- Oral glucose tolerance test (oGTT) – screening for the presence of gestational diabetes (gestational diabetes).
- Sonographic examination (ultrasound examination) of fetal nuchal translucency (NT) at 11-14 weeks of gestation.
- Differentiated organ diagnostics – in the 19th-22nd week of pregnancy.
- Cardiotocography (CTG; heart sound contractions).
- Doppler sonography (ultrasound examination that can dynamically visualize fluid flows (especially blood flow); measures blood flow pattern in uterine arteries (uterine arteries) and fetal blood flows in arteries and veins) in the pregnant woman – to assess fetal supply/fetal care (Doppler sonography can detect impending placental insufficiency/uterine placental weakness as early as 20 to 24 weeks of gestation)
- Vaginal sonographic measurement of the cervix length (cervical length).
- If necessary, streptococcus B test
- Mammasonography (ultrasound examination of the breast; breast ultrasound) – if mastitis puerperalis (inflammation of the mammary glands in the puerperium) is suspected.
Which doctor will help you?
In the case of illnesses in the context of pregnancy, childbirth and the postpartum period, the gynecologist should be consulted. Another appropriate contact in many cases is the midwife.
