How Does Birth Occur? Birth and Postpartum Follow-up

It refers to the vaginal delivery (expulsion) of a fetus, with its membranes and placenta, outside of the uterus, between 21 and 42 weeks. They get the following names according to their weeks.
What is an immature (immature) birth? : Birth occurs between the 21st and 27th weeks of pregnancy. Note: If the pregnancy ends before the 20th week, it is called abortion.
What is premature (premature) birth? : It is the event that occurs between the 28th and 37th weeks of birth. They are divided into two as early premature and late premature. Here, the indicator is the week of pregnancy and the weight of the baby.
What is a mature birth? : It is the end of pregnancy between 38 and 42 weeks. The main desired normal delivery time is between these weeks.
What is postmature birth? :Termination of pregnancy after 42 weeks.
Human pregnancy lasts 280 days, but only about 5% of all pregnancies end on the expected day.

The normal termination of a pregnancy depends on three main factors. These; It can be classified as uterine-related, baby-related, and maternal bone-related factors. These three factors are;

1- factors related to the uterus (birth pains, contractions)
2- factors related to the mother’s bone roof (narrow or wide roof)
3- factors related to the baby (the baby’s weight, the way of arrival)

In order for the cervix to open, the uterus must contract at regular intervals and there should be no obstacle to the opening of the cervix in the face of these contractions. The contractions that continue after the uterus opens will push the baby out of the uterus. In order to provide this push, the baby should be in the appropriate position and there should be no obstacles in front of him.

Finally, in order for a normal delivery to take place, there should be no incompatibility between the path the baby will pass and the passenger (baby). If the baby is larger than normal or the path is narrower than normal, it will prevent the normal course of delivery.

How to understand that the birth has begun?
1-What is engagement bleeding? : In general, the first signs of approaching the birth are irregular contractions and what is known as “aiming” among the people. The cervix is ​​closed with a slimy plug throughout pregnancy. This plug protects the baby against external factors. Just before the onset of labor, there is a slight opening in the cervix and this plug is thrown out of the body in the form of a bloody discharge.

2-What is labor pain? : Regular uterine contractions. It comes 3 minutes apart. It takes 45 seconds. It is 60mm of mercury pressure. It does not go away with rest, it progresses.

3-What is water coming at birth? (opening of head water): Coming of water is another sign of childbirth. In general, action begins spontaneously within 24 hours after the membranes are opened. Sometimes it may be necessary to support the labor with artificial labor.

While false labor pains come and go at irregular intervals, are short (15-20 seconds) and are mild pains, real labor pains, which come and go at more regular intervals, increase in intensity and shorten the intervals, lasting up to 45-60 seconds, cause opening and effacement in the uterus. are pain. To summarize;

What is real labor pain?
The contractions repeat regularly and the contraction intervals become more frequent and decrease to every 2-4 minutes.
The intensity of the contractions gradually increases and lasts for 45-60 seconds.
It causes softening and opening of the cervix.

What is false labor pain?
The contractions occur at irregular intervals, the intervals are long and there is no regular repetition.
The intensity of the contractions remains the same, they are temporary pains.
The contractions are mostly relieved by rest and do not cause the opening of the cervix.

What is the benefit of the water bladder (Amniotic fluid)?
Amniotic fluid is an important ingredient that protects the baby from external traumas and infections, as well as feeding the baby in the womb. As a result of the rupture of the amniotic membrane, both the baby and the expectant mother may be exposed to infections with the arrival of water.

What is artificial pain in childbirth?
Pains usually start spontaneously within the first 12 hours after the waters come. If labor does not start despite this prolongation, it would be appropriate to initiate labor with artificial induction (artificial labor with serum), since the risk of infection in the baby and mother increases. Artificial pain is also applied to pregnant women whose day (week) is past (42nd week).

There are three basic stages of birth
Stage I of labor (full opening of the cervix): It is the process from the beginning of the contractions that will cause the opening of the cervix to the full opening of the cervix (10 cm). At this stage, with the increase in the cervical opening, the baby’s head goes down by making some maneuvers inside. Pains that come every 3 minutes and last for 45 seconds and have a force of approximately 60mm of mercury pressure; It allows the cervix to open more than 1 cm every 2 hours and at the same time, it allows the baby’s head to go down about 1 cm. If this is not the case, there is either insufficient pushing power of the uterus or there is a mismatch between the child’s head and the mother’s roof. According to this, the preparation for the cesarean section begins after the evaluation is made. The first stage of labor is approximately 16 hours for first births, and approximately 8 hours for those who have given more than 2 births.

Birth II. Stage (birth of baby): It refers to the process from the full opening of the uterus (approximately 10 cm), until the baby is fully born. This period should not be more than 2 hours in first births. If the baby is still not born even after more than 2 hours, some help should be provided. In the meantime, it is necessary to prevent the baby’s heart sounds from being disturbed and to be stressed by being without oxygen. The second stage of labor lasts for a maximum of half an hour in multiparous (mothers who have given birth more than once). As soon as the head is at the outlet, an episiotomy is opened to the vagina and perineum (the part between the vagina and anus) with local anesthesia, so that the baby can come out easily. After the episiotomy incision is removed, the placenta and its appendages are removed, the tears in the cervix and the vagina are checked and the bleeding is normal, the episiotomy (incision) opened with self-dissolving sutures is sutured aesthetically.

Birth III. Stage (birth of placenta): It is the process from the full birth of the baby to the expulsion of the placenta (partner) and its attachments. As a result of this phase, birth is concluded. If the placenta and its appendages do not come out on their own after waiting for 30 minutes, they are removed by manually entering the uterus. Bleeding is controlled. After a normal delivery, the amount of bleeding should be below 500cc. Some evaluations are made for bleeding above this. These can be counted as non-collecting of the uterus (atonia), remaining fragments attached to the placenta and its appendages, suturing tears in the cervix or vagina, or evaluation of blood clotting problems.

By what mechanism does birth occur?
The most valid theory; It is due to the stimulation of the reproductive center for the uterus to come to a certain size and start the pains.

Uterine contractions are provided by the hormone “oxytocin” secreted from the pituitary gland of the brain. In addition, changes in the concentration of some substances called “prostaglandins” in the body can trigger contractions. Knowing these mechanisms gives us the chance to initiate uterine contractions or stop preterm labor.

When is it necessary to go to the hospital for delivery?
As stated above, childbirth should be performed when the pains become more frequent and their severity increases. It is sufficient to apply to the hospital with pain that lasts for 30-40 seconds every 20 minutes in first births and gets more and more frequent, and pains come every 30 minutes in 2nd and subsequent births. When real labor pains begin, the pregnant may perceive that it is different from the others.

Having a snot-like discharge with the onset of pain (” engagement“) is almost a harbinger of birth. There is no need for panic in this engagement bleeding. In the first birth, labor pains begin approximately 6 hours after the engagement bleeding.

Sometimes the labor pains never begin. amniotic water (opening of the head water, water coming at birth) may come. The coming of water can be slightly but constantly, or it can be in a way that makes the legs suddenly wet. In this case too urgentlycall your doctor.

Pregnancy and bleeding It is a risky situation during pregnancy. Any bleeding should be carefully evaluated. The presence of a little or a lot of bleeding is a harbinger of delivery, but it can also indicate a problem with the pregnancy.

What is the importance of baby movements at birth?
If the baby’s movements have decreased in the last 2-3 days or the baby has not played at all in the last 24 hours, the hospital should be consulted. This could be a sign that the baby is in distress. In this case, it is usually decided by taking NST (non-stress test) and ultrasound evaluation. A cesarean section plan is made accordingly.

POST-BIRTH FOLLOW-UP and QUESTIONS

The puerperium (puerperium) begins with the birth of the placenta (the baby’s partner), until the uterus returns to its pre-pregnancy state. This period is about 6 to 8 weeks. In postpartum follow-up, close follow-up and information is required in terms of breastfeeding, newborn baby care, family planning (protection) options, postpartum hemorrhage and postpartum infection, postpartum bathing and postpartum sexual intercourse.

Postpartum Observation
Follow-up of Postpartum Bleeding
In terms of postpartum hemorrhages, blood pressure is measured every 15 minutes in the first hour and every 30 minutes in the next 2 hours. Bleeding is followed by checking whether the uterus has hardened or not. Monitoring of bleeding in early puerperium is very important to save the woman’s life. It should be known that the biggest cause of postpartum maternal deaths all over the world is postpartum hemorrhage. These bleedings happen for a number of reasons.
1-Atoni bleeding: Bleeding due to the inability of the uterus to collect (not contracting and remaining loose) constitutes the biggest cause of postpartum hemorrhages. For bleeding over 700cc, immediate blood transfusion is required. In addition, uterine massage and pressure are performed. As drugs, uterine contraction drugs such as oxytocin and methylergonin are given. If it does not respond to all these, the hypogastric artery is surgically ligated. If this is not a solution, a subtotal hysterectomy (removal of 2/3 of the uterus) operation is performed.
2-Bleeding due to vulva (external genital organ), vagina, cervix (cervix) tears: It forms the second group of postpartum hemorrhages. As soon as the tears here are detected, they should be checked under anesthesia and sutured.
3-Postpartum hemorrhages due to remaining placental fragments: Placental remnants should be considered in excessive bleeding, especially after the patient is discharged from the hospital. The patient is checked again under general anesthesia, an abortion is performed, and the presenting residues are cleaned. In the meantime, abortion is not sufficient in cases where the placenta called placenta acreata invades the intrauterine myometrium. It can go up to the removal of 2/3 of the uterus.

Postpartum Infection
Streptococcus and bacteriodes microorganisms are responsible. Symptoms: Postpartum fever, foul-smelling discharge and uterine tenderness.

Postpartum Sexual Intercourse and Protection (family planning)
It is okay to have sexual intercourse after 20 days after giving birth. However, it is necessary to be conscious about family planning. A surprise pregnancy can occur, especially in mothers who do not breastfeed. Prevention should also be done in breastfeeding mothers. There is no such thing as milk protection. Since the arrival of milk sometimes completely disrupts ovulation, the woman may not have a menstrual period for 6 months to 1 year. During this period, when there is a sudden ovulation, pregnancy occurs and when you go to the doctor 7-8 months after birth, you may encounter a 2-3 month surprise pregnancy. In this regard, it is necessary to apply family planning. The best contraceptive method for lactating mothers can be spirals. Birth control pills are not recommended as they spoil breast milk.

Postpartum Bath and Nutrition
Bathing is free the day after birth. However, after 10 days in the form of a shower, you can take a bath in any way. No nutritional restriction is applied to the mother after birth.

Postpartum Depression and Pessimism
Postpartum pessimism occurs within the first 15 days of birth. It is not a major inconvenience. Self-healing occurs within 1 month. However, postpartum depression is a condition that requires treatment and controls.

What are the changes in the postpartum woman?
1-In the reproductive (sexual) organs: Immediately after birth, the uterus descends like a ball below the navel. Then, after a few hours, it rises above the navel due to the blood filling of the uterus. After 15 days, it returns to its pre-pregnancy place and gets smaller. The blood and remnants of dead membranes expelled from the uterus after birth are called lochia. This lochia discharge is bloody in the first days, pink in the following days, and turns white after the 10th day. Menstrual bleeding after delivery, especially in breastfeeding mothers, is bleeding without ovulation. Therefore, dryness occurs in the outer vulva and vagina due to estrogen deficiency. As a result, postpartum sexual intercourse becomes difficult and painful. (dyspareunia)
2- Postpartum breast and breastfeeding: Breastfeeding begins immediately after birth. Thus, the arrival of milk is stimulated. It usually takes 72 hours for real milk to arrive. Breast care is done before and after breastfeeding. Mothers who do not want to breastfeed should apply a breast bandage. Postpartum breastfeeding is important for the baby’s health. It is possible to protect the child from both infectious diseases and allergic diseases by breastfeeding for 6 months.
3- Postpartum weight loss: Postpartum hemorrhage in normal delivery is below 500cc. This amount of bleeding can be up to 1000cc in cesarean deliveries. Immediately after birth, 5 to 6 kilograms are lost. 7 days after birth, an additional 3 to 5 kilos are lost.

REASONS FOR caesarean section

What is a cesarean delivery?
The baby, the placenta (partner) and their appendages are not vaginally; It is an interventional removal operation through the abdomen. Cesarean section anesthesia can be 1-General anesthesia, 2-Epidural anesthesia, 3-Spinal anesthesia. Which of these anesthetics will depend on the patient’s weight, hypertension, diabetes, the position of the child’s arrival, and whether there is any problem in the waist.

In which cases is a cesarean section performed?

1- Head and roof incompatibility (mismatch of the size of the baby’s head and the mother’s roof bone)
2- Elderly first pregnant (first pregnancy after 33 years)
3-Former cesarean section (repeated cesarean section)
4-Past myomectomy operation
5- Non-progressive action: normally every 2 hours, the cervix should open more than 1 cm and the child’s head should go down more than 1 cm. If the child does not have a stroke in the head or open the cervix despite 12 hours of labor, it is taken by cesarean section.
6-Plesanta previa totalis (in case the placenta settles down and completely covers the mouth of the uterus
7-Ablatio placenta (detachment of the placenta) (premature separation of the placenta before birth and bleeding into the uterus)
8-Fetal distress (in cases where the baby is deprived of oxygen in the womb and the heart sounds are impaired or the heart rate drops more than 20 percent after the pains)
9-Cord prolapse or cord presentation (amnion sac has burst in cord prolapse. The cord has hung from the uterus to the vagina. By pushing the cord towards the uterus by hand, the baby’s death is prevented and the baby goes to the operating room in that way. It is a very urgent situation. In cord presentation, the amniotic sac is not torn. pulsations are felt.)
10- In cases where the leading part of the baby is TERS (breech presentation, foot arrival, arm drooping, side posture (transverse posture), face presentations where the chin comes from behind and the pubis bone is inserted), cesarean section is performed.
11-Precious baby (pregnancy after prolonged infertility treatment)
12-Social indication (patients with a high degree of fear of normal birth)

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