Sunteți pe pagina 1din 6

Travaliu

Stadiul 1: stergerea si dilatarea colului uterin


Debutul acestui stadiu are loc odata cu debutul CUD ritmice ca frecvente, intensitate si
durata ce vor duce la stergerea si dilatarea colului uterin, si se incheie cand colul este
dilatat complet ~ 10cm, ce permite, astfel, expulzia fatului.
Intervalul dintre CUD scade progresiv, de la 1-3 CUD in 10 min la debut de travaliu, la
aprox. 1 CUD/ min in timpul expulziei fatului.
Stergerea colului reprezinta scurtarea acestuia de la dimensiunile sale de aprox. 2cm la un
simplu orificiu circular, prin incorporarea fibrelor musculare de la nivelul orificiului
cervical intern in cadrul segmentului inferior, in timp ce orificiul cervical extern ramane
intact. Acest fenomen va determina expulzia dopului gelatinos.
Din cauza rezistentei scazute a segmentului inferior si a cervixului, forta generata de
CUD va determina dilatarea colului.
Dilatatia colului este determinata de:
- presiunea exercitata asupra cervixului de catre prezentatia fetala, in special cand
aceasta este ferma si are forma regulata, ex: craniul fetal, ajutand la buna
propagare a CUD
- tractionarea in sens longitudinal a cervixului de catre segmentul superior al
uterului, astfel, dupa fiecare constractie, segmentul superior uterin devine mai
gros si mai scurtata, in timp ce segmentul inferior devine mai alungit, mai subtire
si mai destins, dilatand progresiv colul
Dilatarea colului este impartita in 2 faze:
- faza de latenta, ce dureaza pana la o dilatatie de 3-5cm
- faza activa, ce se incheie odata cu dilatatia completa a colului, si este la randul ei
impartita in:
faza de acceleratie
faza de panta maxima
faza de deceleratie

II.2. PERIOADELE TRAVALIULUI


Travaliul este mprit n patru perioade (Tabel 3): I dilatarea colului uterin; II expulzia ftului; III
expulzia placentei (delivrena); IV consolidarea hemostazei (luzia imediat).
Tabel 3 Perioadele travaliului
perioada travaliului
I
tergerea i
dilatarea colului
variabil;
II
expulzia
15 minute 1 or
III
delivrena
n medie, 5 10
minute
IV
luzia imediat
nceputul perioadei I a travaliului este greu de precizat cu exactitate. Perioada I a travaliului se ncheie
cnd se ajunge la dilataie complet.
1
erioada I are evoluie variabil interindividual, este cea mai puin predictibil dintre perioadele
travaliului. Ea este submprit n dou faze:

2
faza de laten, ntre debutul travaliului (greu de precizat) i dilataia de 2 cm (debutul fazei
active a travaliului);
faza activ, de la dilataie de 2 cm la dilataie complet.
Faza activ a travaliului se mparte, la rndul su, n trei subfaze:
faza de acceleraie viteza cu care se produce dilataia crete constant, pe msur ce crete
intensitatea contraciilor uterine; acest fenomen se nregistreaz, de obicei, pn la dilataie de 4 5 cm;
faza de pant maxim viteza cu care se realizeaz dilataie este maxim i constant; progresiunea
dilataiei prezint aceste caracteristici, de obicei, ntre 4 5 cm i 8 cm;
faza de deceleraie viteza cu care se realizeaz dilataia ncepe s scad, mobilul fetal poate ncepe s
abordeze interiorul bazinului osos; progresiunea dilataiei prezint aceste caracteristici, de obicei, de la 8
cm la dilataie complet.
ATENIE! Subfazele fazei active ale travaliului se definesc n funcie de viteza cu care se produce
progresiunea dilataiei. Reperele metrice sunt doar orientative, empirice.
Perioada II a travaliului, expulzia, ncepe din momentul cnd dilatarea colului este complet i se ncheie
n momentul expulziei ftului. n accepiunea obstetricii clasice, abordarea de ctre mobilul fetal a
interiorului bazinului osos i coborrea mobilului fetal nu poate avea loc dect dup dilataia complet a
colului, prin urmare perioada II a travaliului i timpul mecanic al naterii descris drept coborrea se
suprapun temporal. Aceasta este o viziune prea schematic, fals simplificat; de fapt, coborrea mobilului
fetal n bazinul osos, dincolo de strmtoarea superioar, poate ncepe de la debutul subfazei de deceleraie a
fazei I (vezi curba Friedman, progresiunea prezentaiei n raport cu progresiunea dilataiei). Mai frecvent
la primipare, angajarea i nceputul coborrii se produc n succesiune rapid, la debutul fazei de deceleraie,
n timp ce la multipare angajarea se produce nainte chiar de debutul travaliului, iar coborrea se produce
rapid, dup dilatarea complet a orificiului uterin. Conform lui Friedman (1978), singurele elementele utile
n predicia evoluiei travaliului sunt progresiunea dilataiei i progresiunea prezentaiei. nregistrarea
grafic a progresiunii dilataiei (cervicograma), n raport cu progresiunea pezentaiei, realizeaz curba
Friedman (Fig. 3). De asemenea conform lui Friedman, desfurarea normal a fazei de pant maxim, n
perioada de dilataie, este un criteriu pentru eficiena contractilitii uterine, iar desfurarea normal a fazei
de deceleraie este un criteriu pentru inexistena unui conflict feto-pelvic.
Perioada III a travaliului, delivrena, ncepe imediat dup expulzia ftului i se ncheie n momentul
expulziei placentei. Prin consens larg, se admite n prezent c durata normal a delivrenei este sub 30 de
minute.
Perioada IV a naterii se ntinde pe durata primelor dou ore dup delivren, moment n care hemostaza
la nivelul patului de inserie placentar este definitivat prin retracie i contracie uterin. Este denumit
luzia imediat.
Preocuparea caracteristic perioadelor III i IV ale travaliului este evitarea sngerrii materne excesive.

n momentul cnd ncepe micarea de deflexiune a craniului, operatorul susine cu mn dreapt perineul,
prin apsare blnd, i menine occiputul n podul palmei stngi, pentru a modula deflectarea. Presiunea
blnd, cu mna stng, asupra occiputului evit deflectarea brusc, posibil traumatizant, iar susinerea
perineului cu mn dreapt l protejeaz; n acelai timp, printr-o uoar micare n jos a minii drepte
(apsare spre
anus), este favorizat alunecarea tegumentelor perineale pe faa fetal (manevra Ritgen inversat).

reported that the mean length of first- and second-stage labor


was approximately 9 hours in nulliparous women without
regional analgesia, and that the 95th percentile upper limit
was 18.5 hours. Corresponding times for multiparous women
were a mean of 6 hours with a 95th percentile maximum of

13.5 hours. These authors defined labor onset as the time


when a woman recalled regular, painful contractions every 3 to
5 minutes that led to cervical change
Second Stage of Labor
This stage begins with complete cervical dilatation and ends
with fetal delivery. The median duration is approximately 50
minutes for nulliparas and about 20 minutes for multiparas,
but it is highly variable
Labor is characterized by brevity and considerable biological
variation. Active labor can be reliably diagnosed when cervical dilatation is 3 cm or more in the presence of uterine contractions. Once this cervical dilatation threshold is reached,
normal progression to delivery can be expected, depending
on parity, in the ensuing 4 to 6 hours
Identification of Labor
Although the differentiation between false and true labor is di- f f
ficult at times, the diagnosis usually can be clarified by contraction frequency and intensity and by cervical dilatation. In those
instances when a diagnosis of labor cannot be established with
certainty, observation for a longer period is often wise.
Pates and associates (2007) studied the commonly used
recommendations given to pregnant women that, in the
absence of ruptured membranes or bleeding, uterine contractions 5 minutes apart for 1 hourthat is, 12 contractions
in 1 hourmay signify labor onset. Among 768 women
studied at Parkland Hospital, active labor defined as cervical
dilatation 4 cm was diagnosed within 24 hours in three
fourths of women with 12 contractions per hour. Bailit and
coworkers (2005) compared labor outcomes of 6121 women
who presented in active labor defined as uterine contractions
plus cervical dilatation 4 cm with those of 2697 women
who presented in the latent phase. Women admitted during
latent-phase labor had more active-phase arrest, more frequent need for oxytocin labor stimulation, and higher rates
of chorioamnionitis. It was concluded that physician interventions in women presenting in the latent phase may have
been the cause of subsequent labor abnormalities
Second Stage of Labor:
Fetal Descent
In many nulliparas, engagement of the
head is accomplished before labor begins.
That said, the head may not descend further until late in labor. In the descent pattern of normal labor, a typical hyperbolic

curve is formed when the station of the


fetal head is plotted as a function of labor
duration. Station describes descent of the
fetal biparietal diameter in relation to a line drawn between maternal ischial spines (Chap.
22, p. 449).
Active descent usually takes place after dilatation has progressed
for some time (Fig. 21-8). In nulliparas, increased rates of
descent are observed ordinarily during cervical dilatation phase
of maximum slope. At this time, the speed of descent is also
maximal and is maintained until the presenting part reaches the
perineal floor (Friedman, 1978).
Pelvic Floor Changes During Labor
The birth canal is supported and is functionally closed by
several layers of tissues that together form the pelvic floor.
These anatomical structures are shown in detail in Chapter 2
(p. 22). The most important are the levator ani muscle and
the fibromuscular connective tissue covering its upper and
lower surfaces. There are marked changes in the biomechanical properties of these structures and of the vaginal wall during parturition. These result from altered extracellular matrix
structure or composition (Lowder, 2007; Rahn, 2008). The
levator ani consists of the pubovisceral, puborectalis, and iliococcygeus muscles, which close the lower end of the pelvic
cavity as a diaphragm. Thereby, a concave upper and a convex
lower surface are presented. The posterior and lateral portions of the pelvic floor, which are not spanned by the levator
ani, are occupied bilaterally by the piriformis and coccygeus
muscles.
The levator ani muscle varies in thickness from 3 to 5 mm,
although its margins encircling the rectum and vagina are
somewhat thicker. During pregnancy, the levator ani usually
undergoes hypertrophy, forming a thick band that extends
backward from the pubis and encircles the vagina about 2 cm
above the plane of the hymen. On contraction, the levator ani
draws both the rectum and the vagina forward and upward in
the direction of the symphysis pubis and thereby acts to close
the vagina.
In the first stage of labor, the membranes, when intact,
and the fetal presenting part serve to dilate the upper vagina.
The most marked change consists of stretching of the levator ani muscle fibers. This is accompanied by thinning of
the central portion of the perineum, which becomes transformed from a wedge-shaped, 5-cm-thick tissue mass to a
thin, almost transparent membranous structure less than
1 cm thick. When the perineum is distended maximally, the
anus becomes markedly dilated and presents an opening that

varies from 2 to 3 cm in diameter and through which the anterior wall of the rectum bulges.
Third Stage of Labor: Delivery of
Placenta and Membranes
This stage begins immediately after fetal delivery and involves
separation and expulsion of the placenta and membranes. As
the neonate is born, the uterus spontaneously contracts around
its diminishing contents. Normally, by the time the newborn
is completely delivered, the uterine cavity is nearly obliterated.
The organ consists of an almost solid mass of muscle, several
centimeters thick, above the thinner lower segment. The uterine fundus now lies just below the level of the umbilicus.
This sudden diminution in uterine size is inevitably accompanied by a decrease in the area of the placental implantation
site (Fig. 21-9). For the placenta to accommodate itself to this
reduced area, it increases in thickness, but because of limited
placental elasticity, it is forced to buckle. The resulting tension pulls the weakest layer
decidua spongiosafrom that site.
Thus, placental separation follows the disproportion created
between the relatively unchanged placental size and the reduced
size of the implantation site.
Cleavage of the placenta is aided greatly by the loose structure of the spongy decidua, which may be likened to the row
of perforations between postage stamps. As separation proceeds, a hematoma forms between the separating placenta/
decidua and the decidua that remains attached to the myometrium. The hematoma is usually the result rather than the
cause of the separation, because in some cases bleeding is
negligible.
Fetal Membrane Separation and Placental Extrusion.
The great decrease in uterine cavity surface area simultaneously
throws the fetal membranesthe amniochorion and the parietal deciduainto innumerable folds (Fig. 21-10). Membranes
usually remain in situ until placental separation is nearly completed. These are then peeled off the uterine wall, partly by
further contraction of the myometrium and partly by traction
that is exerted by the separated placenta.
After the placenta has separated, it may be expelled by
increased abdominal pressure. Completion of the third stage
is also accomplished by alternately compressing and elevating
the fundus, while exerting minimal traction on the umbilical cord (Fig. 27-12, p. 546). The retroplacental hematoma
either follows the placenta or is found within the inverted
sac formed by the membranes. In this process, known as
the Schultze mechanism of placental expulsion, blood from

the placental site pours into the membrane sac and does not
escape externally until after extrusion of the placenta. In the
other form of placental extrusion, known as the Duncan
mechanism, the placenta separates first at the periphery and
blood collects between the membranes and the uterine wall
and escapes from the vagina. In this circumstance, the placenta descends sideways, and its maternal surface appears
first.
Phase 4 of Parturition: The Puerperium
Immediately and for about an hour or so after delivery, the
myometrium remains in a state of rigid and persistent contraction and retraction. This directly compresses large uterine
vessels and allows thrombosis of their lumens to prevent hemorrhage (Fig. 2-11, p. 27). This is typically augmented by uterotonics (Chap. 27, p. 547).
Uterine involution and cervical repair, both remodeling processes that restore these organs to the nonpregnant state, follow
in a timely fashion. These protect the reproductive tract from
invasion by commensal microorganisms and restore endometrial responsiveness to normal hormonal cyclicity.
During the early puerperium, there is onset of lactogenesis
and milk let-down in mammary glands, as described in Chapter
36 (p. 672). Reinstitution of ovulation signals preparation for
the next pregnancy. This generally occurs within 4 to 6 weeks
after birth, but it is dependent on the duration of breast feeding and lactation-induced, prolactin-mediated anovulation and
amenorrhea.