the CLINICAL DIAGNOSIS
the Diagnosis: Labors III, urgent, pathological. Two at a birth. Only cluneal presentation I of a fetus. An antenatal vention of amniotic waters. Secondary delicacy of patrimonial activity. The classical manual grant. Absolutely short umbilical cord I of a fetus. An anemia. A Rh-negative blood without antibodies. A chronic intra-uterine hypoxia of a fetus.

the SUBSTANTIATION of the DIAGNOSIS
Labors urgent (labors in 37 weeks at multifetal pregnancy are not considered premature), pathological (two at a birth at both alive fetuses), complicated with an antenatal vention of amniotic waters (amniotic waters were gave vent 3 hours of 15 minutes prior to occurrence of regular patrimonial activity), secondary delicacy of patrimonial activity (was not from the very beginning of labors, and has come in some hours of regular patrimonial activity with fights of sufficient force). Only cluneal presentation I of a fetus - on the basis of external obstetric research (third reception Leopolda determines the voluminous softish part which is not having the spherical form) and vaginalnogo of research (are determined presenting breeches, adpressed to an input in a small basin, linea interthrochanterica). Absolutely short umbilical cord I of a fetus - 30 sm (in norm average length of a umbilical cord " to length newborn also makes 50-52 sm). Anemia - on the basis of the general analysis of a blood (erythrocytes - 2,9*10¹²/ë at norm not less than 3,9*10¹²/ë, a haemoglobin 106 g/l at norm not less than 120 g/l). A rhesus a negative blood without antibodies (according to laboratory researches). A chronic intra-uterine hypoxia of a fetus (presence of two fetuses in a uterus, a site of the placental detachment, the expressed toxicoses during pregnancy).

Initial processing newborn and processing of a umbilical cord.
the Born child wipe off sterile cotton or a gauze. Sterile ballonchikom pump out slime from a nose and a mouth of the child and put it between the bent and divorced legs of mother on podogretuju sterile pelenku. The umbilical cord should not be tense. Before initial processing newborn carefully wash arms, wipe their alcohol and put on sterile gloves; the nose and a mouth close sterile a mask.
prophylaxis oftalmoblennorei as the opportunity of an infection of eyes newborn is not excluded at his passage through patrimonial ways Is obligatory. For the prevention oftalmoblennorei 2 % use a solution of Sodium nitritum of silver (argentum nitricum). Solution store in a bottle from a dark glass with pritertoj a fuse. He should be fresh (to vary daily), and an inscription on a label - distinct. For everyone newborn use a separate sterile pipette.
Now for prophylaxis gonorrheal blennorei 30 % a solution of sodic salt of Albucidum (Sulfacylum-natrium) are used.
Prophylaxis is made by the midwife after a pretreatment of arms an antiseptic solution and vytiranija their sterile gauze napkin and a globule with alcohol.
At once after a birth of the child and rendering to it of the necessary grant start processing eyes for what in the beginning wipe veki dry sterile cotton a separate tampon for each eye from an external angle to internal. Then slightly delay a lower eyelid and raise top, drip on a mucosa bottom transitive skladki eyes one drop of 30 % of a solution of sodic salt of Albucidum. Lavages of eyes after zakapyvanija it is not made.
Processing of a umbilical cord at the newborn child carry out in 2 stages. Before reception of labors the midwife processes an arm, as before surgical operation by one of the accepted methods.
the First stage: after the termination of a pulsation of a umbilical cord on it impose 2 clamps, one on distance of 10 sm from a umbilical ring, and the second on 2 sm knaruzhi from him. The site of a umbilical cord which is taking place between clamps, 5 % an alcohol solution of Iodum process and cross it.
the Second stage: the child separated from mother transfer to a tray on pelenalnyj a table then the midwife again processes arms. The rest of a umbilical cord wipe a sterile gauze napkin, a umbilical cord hardly wring out between index and big fingers. Then in special forcepses put a sterile metal bracket, a umbilical cord enter between branshami brackets so that the bottom edge of it has been posed on distance of 0,5-0,7 sm from dermal edge of a umbilical ring. Forcepses with a bracket close up to them zashchelkivanija.
If at mother a Rh-negative accessory of a blood newborn instead of a bracket on the rest of a umbilical cord in length of 5 sm impose a sterile silk ligature that the hemotransfusion through vessels of a umbilical cord in case of need was possible to lead. The dressing of a umbilical cord a silk ligature practises all cases if there are no brackets. On distance of 2,5 sm knaruzhi from a place of a deligation or a bracket dissect a umbilical cord sterile scissors. The surface of a section of a umbilical cord is processed with 5 % an alcohol solution of Iodum. The rest of a umbilical cord with the bracket imposed on him remains open, and a leaving of it carry out without a bandage. If the silk ligature a stump fasten a sterile gauze napkin as kolpachka is imposed on the rest of a umbilical cord.
After processing a umbilical cord make initial processing integuments newborn. The sterile wadded globules moistened with a sterile liquid paraffin, delete syrovidnuju greasing, and also the rests of a blood, slime and amniotic waters from the person, a pilar part of a head, a breast, a stomach, a back, extremities. Having finished a toilet, newborn weigh, measure his body height (from a vertex up to pjatok), the sizes of the head and a coat hanger, on handles put on bracelets from a white sterile oilcloth. On bracelets preliminary ink write a surname, a name, a patronymic of mother, number of a history of labors, a sex of the child, mass of a body and body height, date of a birth. After that the child put on a sterile warm baby's undershirt, wrap it in trerilnuju pelenku and a blanket, put in a bed and leave at 2 o'clock under observation of the midwife. Then the child translate in chamber of newborns. On newborn the following documentation is filled: a history of development newborn, the information on a birth, the passport newborn and 4 brasletki.

the RESUME of LABORS
******** **** *****************, 34 years, has acted on September, 10, 2002. 12-n pregnancy, III labors. Labors urgent, pathological in term 37 weeks complicated with an antenatal vention of amniotic waters, secondary delicacy of patrimonial activity. Absolutely short umbilical cord I of a fetus - 30 see is marked. Duration 1-st period of labors of 8 hours of 15 minutes, the second - 35 minutes, the third - 5 minutes. General duration of labors - 8 hours of 55 minutes. The volume of the general hemorrhage in labors has made 250 ml. 2 girls in mass on 2680 g everyone and length 50 and 51 see were born. At an evaluation on Apgar 1-st child has received 5 points, the second - 8 points.

the Biomechanism of labors I of a fetus.
It is accepted to distinguish 6 moments of the mechanism of breech labors of a fetus.
At the end of pregnancy and the beginning of labors of a breech in the transversal size settle down above one of the slanting sizes of an input in a basin (at the forward kind, the first position above the left slanting size). Promotion of a fetus on the patrimonial canal begins usually by the end of complete disclosing uterine fauces.
During all period of exile the fetus and patrimonial ways continuously influence against each other. Thus the fetus aspires to stretch according to the form patrimonial ways which aspire densely to capture a fetus with back waters environmental it and to adapt for the form. As a result of interaction of a fetus and patrimonial ways and patrimonial ways the form fetal eggs and the patrimonial canal gradually pass in complete conformity each other. Walls of the patrimonial canal densely cover all fetal egg, except for the lowermost piece (segment) of the head. In result favorable conditions for an expulsion of the fetus from the patrimonial canal are frameed.
All processes of moving of a fetus pass under influence of patrimonial activity and expelling force of fights, at presence of resistance of muscles of a pelvic bottom.
1. The first moment- an internal version of breeches. He begins at transition of breeches from a wide part of a pelvic cavity in narrow. Turn is made in such a manner that in an output of a basin the transversal size of breeches appears in the direct size of a basin. The forward breech approaches under a pubic arch (between the big trochanter and edge of an ileal bone), forming a point of bracing, back is established above a tail - bone. At this trunk of a fetus is exposed to an insignificant lateral flexion camber behind according to a flexure of a sacrum.
2. The second moment- a lateral flexion of a lumbar part of a backbone of a fetus. The further progress of a fetus results in the greater lateral flexion of a backbone of a fetus. Thus the back breech is rolled out above a perineum and after it from under a pubic joint the forward breech finally is born. At this time a coat hanger enter in the transversal size the same slanting size of an input in a basin through which have passed breeches.
3. The third moment- an internal version of a coat hanger and an external version of a trunk. This turn comes to the end with an establishment of a coat hanger in the direct size of an output. Thus the backrest turns aside, the forward brachium of a fetus approaches under a pubic arch (on border of the top and average third), and back is established ahead of a tail - bone above a perineum.
4. The fourth moment- a lateral flexion of a cervicothoracic part of a backbone. The birth of a shoulder girdle and handles which drop out is connected to this moment or are released with the help of the manual grant.
5. The fifth moment- an internal version of the head (a nape ahead). The head enters in the small slanting size the slanting size of an input in a basin opposite to a volume in which passed a coat hanger (that is in right slanting). At transition from wide in a narrow part of a basin the head makes an internal version as a result of which sagittalnyj (sagittal) seam appears in the direct size of an output, and podzatylochnaja a fossa - under a pubic joint where the point of bracing is formed.
6. The sixth moment- a flexion of the head. Consequence of it is the disengagement (birth): the chin, a mouth, a nose, temja and a nape are consistently rolled out above a perineum. The head prorezyvaetsja in the small slanting size. The disengagement in the average slanting size that results in a strong stretching of a perineum and to its possible break is less often observed.
the Patrimonial tumour at cluneal presentations settles down more on one of breeches: in this case (the first position) - on the left breech. Owing to a fast birth of the subsequent head there is no its configuration, and it has the spherical form.
During a birth of the child there was a grant on TSovjanovu at only cluneal presentation.
As soon as breeches were cut, them have grasped arms in such a manner that the big fingers settled down on adpressed legs to a stomach, and other fingers of both arms - along a sacrum. Such locating of arms warns premature abaissement of legs, svisanie trunks downwards. The born trunk was referred upwards, on continuation of an axis of the patrimonial canal. On a measure of a birth of a trunk of a fetus of an arm of the doctor moved ahead in the direction of a sexual cleft of the parturient woman, continuing cautiously to press the extended legs to a stomach the big fingers, other fingers of arms moved up on a back.
As after a birth of a trunk up to the bottom angle of scapulas the birth of handles and the head labored (labors did not come to the end within 2-3 minutes), the manual grant has been rendered. The doctor one arm has lifted legs of a fetus sharply forward and aside, opposite to a backrest of a fetus, and two fingers of other arm has entered into a vagina on a backrest of a fetus, and then, projdja on a brachium, has made an inclination for a ulnar fold and has lowered the handle so, that it has made " O?UoaON?y?«N" movement. From a vagina the elbow, then a forearm and a brush have seemed. After that from a vagina the forward handle of a fetus was independently released. The head is taken on Brahtu (the trunk of a fetus thus was referred up).

the Biomechanism of labors of II fetus.
(the Forward kind of an occipital presentation, I a position - a sagittal seam in the right slanting size).
1. The first moment- a flexion of the head. Under influence of endometrial and intrabelly pressure the cervical part of a backbone is incurvated, the chin comes nearer to a thoracal cell, the nape falls downwards. On a measure of lowering of a nape the small fontanel is established below big, gradually comes nearer to a median (wire) line of a basin and becomes at last most low posed part of the head - a wire point. The flexion of the head allows it to pass through a cavity of a small basin in the size least or close to it - small slanting (9,5 sm). However at a normal parity of the sizes of a basin and the head of necessity for the maximal flexion of the head it does not happen: the head is incurvated so as far as it is necessary for passage from a wide cavity in a narrow part of a small basin.
2. The second moment- an internal version of the head. The head of a fetus at the progress in a cavity of a small basin at its transition from wide in a narrow part, meeting an obstacle to the further promotion, simultaneously with a flexion starts to turn about the axis. Thus the nape, slipping on a lateral wall of a basin, comes nearer to a pubic joint, the forward department of the head departs to a sacrum. The sagittal seam, settling down up to described turn in a cavity of a small basin in transversal or one of the slanting sizes, further passes in the direct size. Turn of the head comes to an end, when the sagittal seam is established in the direct size of an output, and podzatylochnaja the fossa is established under a pubic joint. This turn of the head is preparatory by the third moment of labors which without it would be made with the big work or has not taken place at all.
3. The third moment- an extension of the head. The head of a fetus continues to move ahead on the patrimonial canal and simultaneously with it starts to be unbent. The extension at physiological current of labors occurs in an output of a basin. The extension begins after podzatylochnaja the fossa rests against the bottom edge of a pubic joint, forming a point of bracing (gipomohlion). The head rotates the transversal axis around of a point of bracing (the bottom edge of a pubic joint) and in some attempts completely is unbent and born. Thus from a sexual cleft consistently there is a parietal area, a forehead, the person and a chin. The birth of the head through vulvarnoe a ring occurs in its small slanting size.
4. The fourth moment- an internal version of a trunk and an external version of the head. During an extension of the head a coat hanger of a fetus are inserted into the transversal size of an input or in one of his slanting sizes on a measure of promotion of the head. In a plane of an output of a basin, after it a coat hanger of a fetus spirally move ahead on the pelvic canal. They in the transversal size pass from transversal in slanting, and at an output - in the direct size of a basin. This turn is transferred the born head, thus the nape of a fetus turns to the left femur of mother (the first position). The forward brachium turns to a pubic joint, back - to a sacrum. Then the shoulder girdle in the following sequence is born: first the top third of the brachium inverted in front, and then due to a lateral flexion of a backbone a brachium inverted behind. All trunk of a fetus further is born.
All listed moments of the mechanism of labors are made at progress of the head of a fetus, and is strict differentiations between them are not present.

the POSTLABOR PERIOD
11.09. The general condition satisfactory. Complaints to colicy pains in the bottom of a stomach. Physiological departures: the emiction regular, painless, a chair was not. t °=36,5, pulse - 70 impacts in one minute. A blood pressure=120 and 80. Dairy Ferri lactases soft, are not present some milk, the colostrum is allocated; papillas erectile. Height of standing of a uterine fundus - 18 sm from a pubic joint. Lochias bloody, moderate amount.
12.09. The general condition satisfactory. Complaints to nagging pains in the bottom of a stomach, delicacy, fast fatigability. Physiological departures: an emiction, a chair - without features. t °=36,6, pulse - 72 impacts in one minute. A blood pressure=120 and 80. Dairy Ferri lactases - without changes. Height of standing of a uterine fundus - 16 sm from a pubic joint. Lochias bloody, moderate amount.
13.09. The general condition satisfactory. Complaints to fatigability, weakness, anxiety. Physiological departures without features. t °=36,4, pulse 74 impacts in one minute. A blood pressure=120 and 80. The puerpera marks swelling dairy Ferri lactases, a heavy feeling in them. Height of standing of a uterine fundus - 12 sm from a pubic joint. Lochias krovjanisto-serous, less plentiful, than yesterday.

the EPICRISIS
1. ******** **** *****************, 34 years, has acted in a maternity home 10.09.02.
2. Pathological labors. General duration of labors of 8 hours of 55 minutes, a hemorrhage in labors - 250 ml.
3. 2 girls were born: 1-n - mass 2680, length - 50 sm, on Apgar - 5á (with absolutely short umbilical cord), 2-n - mass 2680, length - 51 sm, on Apgar - 8á.
4. The postlabor period proceeds normally, a little bit reduced rate of a postlabor involution of a uterus is marked. For the best reduction of a uterus the puerpera receives in poslerodovm the period uterotonicheskie agents.

ADVICE AT the EXTRACT
the Leaving of dairy Ferri lactases:
1. It is recommended to wash them of 0,5 % a solution of liquid ammonia or warm water with soap before and after a feeding. Papillas process 1 % a solution of Acidum boricum and dry a sterile cotton plug. Processing by their alcohol solution of diamond greens or Rivanolum is possible also.
2. To put the child to a breast it is recommended not in 3 hours (as it was recommended earlier), and at will and to requirements of the child. Only a thoracal feeding till 6 months (without artificial prikarmlivanija).
3. After a feeding the rests of milk are necessary for decanting up to complete oporozhnenija dairy Ferri lactas for exception of stagnation of milk (it promotes improvement of a lactemia and is prophylaxis nagrubanija and an infection of Ferri lactases). In norm dairy Ferri lactases should be in regular intervals dense, painless, at pressing milk should be allocated for a papilla. On a surface of a papilla there should not be cracks.
4. It is recommended to wear a bra for the prevention excessive nagrubanija dairy Ferri lactases.
5. At appreciable nagrubanii dairy Ferri lactases it is recommended to limit a drink, to destination the doctor to accept purgative, diuretics.
the Leaving of a body.
1. it is daily necessary to take a shower. The temperature of water should not be hot, and pleasantly warm or hardly invigorating.
2. External genitals should be washed boiled water with addition 1-2 kristallikov potassium permanganate (a light pink solution) not less than 2 times day - in the morning and in the evening. Dairy Ferri lactases should be washed warm water with soap before each feeding.
3. To take a bath it is possible not earlier, than in 4 weeks after labors.
4. The underwear should be changed daily, bed - not less often than 1 time a week, but it is better - than 2-3 times a week.
a Feed:
1. The general diet at a normal lactemia should be enlarged on 1/3 in comparison with usual as the lactemia demands an appreciable power consumption. Daily caloric content of a ration of feeding mother should make 3200 kcal. A diet - 5-6 times day. I peep it is necessary to accept 20-30 minutes prior to a feeding of the child a breast.
2. The basic role in a ration belongs to fiber. From 120 g fibers which to the woman should be received in day, not less than 67 g should make fibers of an animal parentage. The total of Adepses included in a ration should make 90 g, of them about 30 % vegetative. Carbohydrates it is required in day no more than 310-330. A plenty is easy usvojaemyh carbohydrates (Saccharum, sweets) promotes an adiposity and brakes a lactemia.
3. Consumption of a liquid - up to 2000 ml day. It is recommended to drink extracts of a currant, a dogrose as they strengthen a lactemia. This is promoted also by beer yeast, walnuts, juice of a potato, a nicotinic acid, apilak.
4. For prophylaxis of an anemia it is necessary to include in a ration products, rich iron: a liver, leguminous, Haematogenum, buckwheat a croup, salad, spinach, fennel, a parsley. Vitamins And, E, Â12, Â1, Â2, PP, C, Acidum folicum, a nicotinic acid are necessary.
5. Acute dishes, canned food, hard to digest nutrition (fat meat, peas), highly allergenic products (coffee, a plenty of citrus, synthetic products, products with the high maintenance of stains, aromatizatorov and other alimentary additives) are not recommended. Alcoholic drinks are forbidden.
6. Smoking is forbidden.
the Exercise stress.
the Gymnastics can be begun already about 2-3 days after labors.
Exercises should be directed on:
1) correct diaphragmatic respiration, especially an exhalation at which belly muscles are reduced,
2) restoration of elasticity and impellent ability of muscles of a prelum abdominale - for elimination zastoev a venous blood in a pelvic cavity
3) prophylaxis and elimination of constipations and delays of an emiction
4) prophylaxis otvisanija a stomach, improvement of a circulation.
It is necessary to exclude excessively complex movements demanding the big dexterity, flexibility, sharp changes of a position of a body.
serious physical work, a raising of gravities Is forbidden. The work which is not demanding appreciable muscular efforts, not causing appreciable fatigue is recommended.
Another.
· observation at the akushera-gynecologist on a residence which will give answers to arising questions is recommended, and also can advise suitable contraceptives as offensive of an ovulation and pregnancy to a background of a lactemia within the first months after labors is possible, despite of frequent presence anovuljatornyh cycles.
· an advisable interval between a birth of the following child - not less than 3-4 years (the organism of the woman for this time has time to have a rest, get stronger, the uterus restores the frame)
· sexual life is authorized not earlier, than in 42 days after labors after consultation and survey of the akushera-gynecologist.
· if during labors it was carried out epiziotomija or a perineotomy, during the first 3 weeks after labors to the woman are impossible to sit.
· at feeding women because of a high level of Prolactinum gonadotrophic function of a pituitary body that causes a lactational amenorrhea is braked.
· it is recommended to be on a regular basis on fresh air, frequently to air a premise, to support dwelling in cleanliness (wet cleaning).
· it is necessary to avoid stresses, excessive troubles, to try to support good relations with relatives.

the List of the literature:
1. An obstetrics. Under edition of academician G.M.Saveljevoj. Moscow, 2000.
2. I.V.Duda, V.I.Duda. A clinical obstetrics. Minsk, 1997.
3. V.I.Bodjazhina, K.N.Zhmakin, A.P.Kirjushchenkov. An obstetrics. Moscow, 1986.
4. A management on an obstetrics and gynecology. T 2. Moscow, 1963.
5. A physiological obstetrics (Methodical indicatings for students to practical occupations on an obstetrics). Under edition of professor A.I.Matsueva. Voronezh, 1983.

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Keywords: a history of labors, an obstetrics, labors, pathological labors, an antenatal vention of waters, a cluneal presentation, two at a birth, a chronic intra-uterine hypoxia of a fetus, a hypoxia of a fetus, secondary delicacy, patrimonial activity, a chronic intra-uterine hypoxia of a fetus, labors, two at a birth, twins

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