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Cervlcul Check ln Lubor

The Process
Durlng lubor, the uttendunt (u doctor, mldwlfe or nurse) wlll lnsert thelr gloved
flngers lnto the vuglnu to feel for chunges ln the cervlx. The most common
posltlon for u womun huvlng u cervlcul exum ls lylng on her buck wlth knees bent,
ulthough some uttendunts ure comfortuble checklng ln other posltlons.
Cervlcul Chunges
Your mldwlfe, doctor or nurse wlll be looklng for slgns thecontructlons huve
cuused chunges ln the cervlx. These slgns lnclude posltlon of cervlx, dllutlon,
effucement, stutlon of the buby und sometlmes the posltlon of the buby.
Before lubor beglns, the cervlx drops lnto the vuglnul cunul ut un ungle thut mukes
lt polnt towurd the buck (posterlor). One slgn of progress ls thut the cervlx hus
become unterlor, meunlng thut lt's posltlon hus reullgned to ullow the buby to drop
lnto the vuglnu (blrth cunul). Thls ls generully u chunge thut huppens eurly ln
lubor.
Dllutlon und effucement work together to open the cervlx to ullow the buby to
drop lnto the vuglnu. Durlng pregnuncy the cervlx lengthens und thlckens to
protect the buby. Durlng lubor, the cervlx softens und shortens to ullow the buby
to puss through. Effucement refers to the thlckness or thlnness of your cervlx.
Effucement ls meusured by percentuge, wlth 0% belng u thlck und hurd cervlx und
100% belng u very soft thln cervlx thut ls "gone."
Durlng lubor, the cervlx opens wlder to ullow the buby to puss through. Dllutlon
refers to how blg the openlng of the cervlx ls und ls meusured from 0 (closed
cervlx) to 10 (fully opened cervlx). A cervlx wlll need to effuce before lt wlll huve
uny greut progress ln dllutlng.
The stutlon of the buby refers to the progress of the heud through the pelvls. The
uttendunt wlll try to estlmute where the buby's heud ls ln relutlon to the lschlul
splnes of the pelvls (the nurrowest purt). Before the buby's heud reuches the
lschlul splnes, the stutlon ls glven ln negutlve numbers. At the lschlul splnes the
stutlon ls meusured us 0. After the top of the heud hus pussed through the ureu of
the splnes, stutlon ls glven ln posltlve numbers.
Some uttendunts wlll ulso use u cervlcul exum to conflrm the posltlon of the buby
ln the pelvls. By feellng the posltlon of the bones on the top of buby's heud, the
uttendunt cun determlne whlch dlrectlon the buby ls fuclng (to the front, buck or
leunlng to u slde).
Concerns About Cervlcul Checks
In the trudltlonul method of meusurlng progress ln lubor, progress ls bused on the
lnformutlon leurned durlng u cervlcul exum. For thls reuson, some uttendunts wlll
do muny cervlcul exums durlng u lubor.
However, lt ls lmportunt to remember thut the lnformutlon gulned durlng u cervlcul
check does not ulwuys llne up wlth true lubor progress. The trudltlonul progress ls
for the cervlx to dllute one centlmeter per hour durlng lubor. Yet, muny women
wlll huve two or more hours wlthout dllutlon, und then two or three strong
contructlons thut open the cervlx fully. Informutlon gulned durlng u cervlcul check
should be used ln con|unctlon wlth lnformutlon gulned from the physlcul und
emotlonul reuctlons of the mother, not ln pluce of them.
If cervlcul exums show no progress (no dllutlon) for severul hours, some mothers
become frustruted und concerned for no reuson. Some uttendunts ulso become
frustruted und concerned slnce they huve been tuught thut u normul lubor wlll
produce dllutlon ulong u regulurly spuced lntervul. In these cuses, women ure
encouruged to use medlcutlons to speed lubor, so thut thelr lubor cun progress
"normully."
Another druwbuck of cervlcul exums ls thut every exum lncreuses the rlsk for
lnfectlon ln the mother. Huvlng the hunds wushed und gloved mukes llttle
dlfference, slnce the flngers must puss through the openlng of the vuglnu. The
cervlcul mucus wushes ull bucterlu down und out of the vuglnul cunul to rest ut the
openlng of the vuglnu. A cervlcul exum pushes thut bucterlu rlght buck up to the
cervlx. Becuuse of thls, most uttendunts wlll not do vuglnul exums more thun once
or twlce lf your bug of wuters hus broken (unother rlsk fuctor for lnfectlon).
Cervlcul exums ure ulso uncomfortuble, especlully durlng contructlons when the
most lnformutlon cun be gulned. Some uttendunts feel |ustlfled ln usklng luborlng
women to chunge posltlon so they cun perform u "necessury" cervlcul check. The
most common posltlon for u cervlcul check, lylng on the buck, ls the most
uncomfortuble posltlon for luborlng.
How Your Practitioner Checks Your Cervix
Youve been in labor for several hours and you are anxious to find out about your
progress. You might get very excited when your practitioner agrees that it's time
to check your cervix. You watch him or her don the sterile glove, you feel fingers
being inserted into your vagina, and you hear the approving announcement that
you have dilated to 4 cm. But what on earth did the practitioner just do? What
does the number mean?
When doctors or midwives do vaginal exams, they are able to feel three different
things with their fingers. They measure cervical dilation, which is the amount
that the cervix has opened, and fetal station, which is the relationship between
the largest part of the fetal head and the midpoint of the maternal pelvis. If the
cervix is dilated far enough, they can even feel the position of the babys head.
(See Chapter 12 for details on fetal positions.)
Cervical dilation is easy to measure. After identifying the cervical opening
overlaying the babys head, the practitioner slips one or two fingers into the
opening cervix. If only one finger can be admitted, the cervix is approximately 1
cm. dilated. If two fingers can be placed in the opening, the cervical dilatation is
2 cm. or greater, depending on how wide the fingers can spread. As the cervix
approaches full dilatation, an ever-smaller rim of the cervix can be felt at the
outer edge of the fetal head. At 10 cm., no cervix can be felt at all.
As the cervix dilates, it is not only opening wider; it is also thinning out, or
effacing. Before labor begins, the cervix is 2 to 3 cm. long. As labor progresses,
it becomes shorter. This effacement is described in relation to the original length
of the cervix. When it is half as long as the original measurement, the cervix is
50 percent effaced. When it is paper thin, it is 100 percent effaced.
Fetal station is measured by determining the location of the largest part of the
fetal head in relation to the midpoint of the mother's pelvis. If the largest part is
at the midpoint of the maternal pelvis, the station is 0. If the biparietal diameter
of the fetal head is 1 cm. above the midpoint, the station is -1. As labor
progresses, the babys head descends into the pelvis, ultimately culminating at
+5; at that point, the fetal head is at the vaginal opening. When your
practitioner explains your progress, he or she will refer to both these numbers.
For example, if you are examined after several hours of latent phase labor, your
exam may show 4 cm., 0 station. Several hours later you may have progressed
to 7 cm., +1 station. This means that in the intervening time, the cervix has
dilated an additional 3 cm. and the babys head has descended 1 cm.
If the cervix is sufficiently dilated, your practitioner may be able to determine the
position of the babys head. This is done by feeling for landmarks on the head.
The bones that make up the babys skull are separate and not fused together, as
they are in the adult skull. The space between each bone is called a suture,
which can be clearly felt between the bones. At the places where several bones
adjoin, there are even larger spaces called fontanelles. The fetal head has two
fontanelles, anterior and posterior, commonly referred to as "soft spots." By
feeling the location of the fontanelles and the sutures, your practitioner may be
able to determine which direction your baby is facing (occiput anterior or
posterior, for example) and whether its chin is tucked on its chest.
In most cases, it is not possible to feel the landmarks on the babys head clearly
and accurately until the membranes of the amniotic sac rupture. When the sac is
intact, the membranes overlaying the babys head feel like a balloon, and the
details of the head cannot be discerned.
In early labor, especially if the babys head is high, the cervical exam may be a
bit uncomfortable. As labor progresses, the cervix dilates more and the head
descends closer to the vagina. Consequently, each additional exam is usually
easier for the mother than the last.
Umbilical cord
From Wikipedia, the free encyclopedia
Umbilical cord

Umbilical cord of a three-minute-old child. A medical clamp has been
applied.
Latin funiculus umbilicalis
Code TE E6.0.2.2.0.0.1
In placental mammals, the umbilical cord (also called the birth
cord or funiculus umbilicalis) is the connecting cord from the
developing embryo or fetus to the placenta. During prenatal
development, the umbilical cord is physiologically and genetically part of
the fetus and (in humans) normally contains two arteries (the umbilical
arteries) and one vein(the umbilical vein), buried within Wharton's jelly.
The umbilical vein supplies the fetus withoxygenated, nutrient-
rich blood from the placenta. Conversely, the fetal heart pumps
deoxygenated, nutrient-depleted blood through the umbilical arteries
back to the placenta.
Contents
[hide]
1 Physiology in humans
o 1.1 Development and composition
o 1.2 Connection to fetal circulatory system
o 1.3 Physiological postnatal occlusion
o 1.4 Problems and abnormalities
2 Medical protocols and procedures
o 2.1 Clamping and cutting
2.1.1 Early versus delayed clamping
2.1.2 Umbilical nonseverance
2.1.3 Umbilical cord catheterization
o 2.2 Storage of cord blood
3 The umbilical cord in other mammals
o 3.1 Anatomy
o 3.2 Cord disposal
4 Other uses for the term "umbilical cord"
5 Additional images
6 See also
7 References
[edit]Physiology in humans
[edit]Development and composition


Cross section of umbilical cord. Top right and top left: umbilical artery, bottom: umbilical vein, middle:
remnant of allantois.
The umbilical cord develops from and contains remnants of the yolk
sac and allantois (and is therefore derived from the same zygote as the
fetus). It forms by the fifth week of fetal development, replacing the yolk
sac as the source of nutrients for the foetus.
[1]
The cord is not directly
connected to the mother's circulatory system, but instead joins
the placenta, which transfers materials to and from the mother's blood
without allowing direct mixing. The length of the umbilical cord is
approximately equal to the crown-rump length of the fetus throughout
pregnancy. The umbilical cord in a full term neonate is usually about
50 centimeters (20 in) long and about 2 centimeters (0.75 in) in
diameter. This diameter decreases rapidly within the placenta. The fully-
patent umbilical artery has two main layers: an outer layer consisting of
circularly arranged smooth muscle cells and an inner layer which shows
rather irregularly and loosely arranged cells embedded in
abundant ground substance staining metachromatic.
[2]
The smooth
muscle cells of the layer are rather poorly differentiated, contain only a
few tiny myofilaments and are thereby unlikely to contribute actively to
the process of postnatal closure.
[2]

The umbilical cord is composed of Wharton's jelly, a gelatinous
substance made largely frommucopolysaccharides. It contains one vein,
which carries oxygenated, nutrient-rich blood to the foetus, and two
arteries that carry deoxygenated, nutrient-depleted blood away.
Occasionally, only two vessels (one vein and one artery) are present in
the umbilical cord. This is sometimes related to fetal abnormalities, but it
may also occur without accompanying problems.
It is unusual for a vein to carry oxygenated blood and for arteries to carry
deoxygenated blood (the only other examples being the pulmonary
veins and arteries, connecting the lungs to the heart). However, this
naming convention reflects the fact that the umbilical vein carries blood
towards the fetus's heart, while the umbilical arteries carry blood away.
The blood flow through the umbilical cord is approximately 35 ml / min at
20 weeks, and 240 ml / min at 40 weeks of gestation.
[3]
Adapted to the
weight of the fetus, this corresponds to 115 ml / min / kg at 20 weeks
and 64 ml / min / kg at 40 weeks.
[3]

[edit]Connection to fetal circulatory system
The umbilical cord enters the fetus via the abdomen, at the point which
(after separation) will become the umbilicus (or navel). Within the fetus,
the umbilical vein continues towards the transverse fissure of the liver,
where it splits into two. One of these branches joins with thehepatic
portal vein (connecting to its left branch), which carries blood into the
liver. The second branch (known as the ductus venosus) allows the
majority of the incoming blood (approximately 80%) to bypass the liver
and flow via the left hepatic vein into the inferior vena cava, which
carries blood towards the heart. The two umbilical arteries branch from
the internal iliac arteries, and pass on either side of the urinary
bladderbefore joining the umbilical cord.
[edit]Physiological postnatal occlusion
In absence of external interventions, the umbilical cord occludes
physiologically shortly after birth, explained both by a swelling and
collapse of Wharton's jelly in response to a reduction in temperature and
by vasoconstriction of the blood vessels by smooth muscle contraction.
In effect, a natural clamp is created, halting the flow of blood. If left to
proceed naturally, this physiological clamping will take as little as five
minutes and up to 20
[4]
minutes. In water birth in a warm waterbirth tub,
where the temperature of the water may be equal to inside the body,
normal pulsation can be 5 minutes and longer.
[5]

Closure of the umbilical artery by vasoconstriction consists of multiple
constrictions which increase in number and degree with time. There are
segments of dilatations with trapped uncoagulated blood between the
constrictions before complete occlusion.
[6]
Both the partial constrictions
and the ultimate closure are mainly produced by muscle cells of the
outer circular layer.
[2]
In contrast, the inner layer seems to serve mainly
as a plastic tissue which can easily be shifted in an axial direction and
then folded into the narrowing lumen to complete the closure.
[2]
The
vasoconstrictive occlusion appears to be mainly mediated by 5-
hydroxytryptamine
[7][8]
and thromboxane A
2
.
[7]
The artery in cords of
preterm infants contract more to angiotensin II and arachidonic acid and
are more sensitive to oxytocin than in term ones.
[8]
In contrast to the
contribution of Wharton's jelly, cooling causes only temporary
vasoconstriction.
[8]

Within the child, the umbilical vein and ductus venosus close up, and
degenerate into fibrous remnants known as the round ligament of the
liver and the ligamentum venosum respectively. Part of each umbilical
artery closes up (degenerating into what are known as the medial
umbilical ligaments), while the remaining sections are retained as part of
the circulatory system.
[edit]Problems and abnormalities


A knotted cord on a newborn baby.
A number of abnormalities can affect the umbilical cord, which can
cause problems that affect both mother and child:
[9]

Nuchal cord, when the umbilical cord becomes wrapped around the
fetal neck
[10]

Velamentous cord insertion
Single umbilical artery
Umbilical cord prolapse
Vasa praevia
[edit]Medical protocols and procedures
[edit]Clamping and cutting


The umbilical cord is about to be cut with scissors at a caesarian section


Umbilical cord clamp


The cord stump of a seven-day-old baby
General hospital-based obstetric practice introduces artificial clamping
as early as 1 minute after the birth of the child. In birthing centers, this
may be delayed by 5 minutes or more, or omitted entirely. Clamping is
followed by cutting of the cord, which is painless due to the lack of
anynerves. The cord is extremely tough, like thick sinew, and so cutting
it requires a suitably sharp instrument. Provided that umbilical severance
occurs after the cord has stopped pulsing (520 minutes after birth),
there is ordinarily no significant loss of either venous or arterial blood
while cutting the cord.
There are umbilical cord clamps which combine the cord clamps with the
knife. These clamps are safer and faster, allowing one to first apply the
cord clamp and then cut the umbilical cord. After the cord is clamped
and cut, the newborn wears a plastic clip on the navel area until the
compressed region of the cord has dried and sealed sufficiently. The
remaining umbilical stub remains for up to 710 days as it dries and then
falls off.
[edit]Early versus delayed clamping
The health implications of early versus delayed cord clamping are
receiving attention in medical journals.
[11][12][13]

Delayed clamping may be supported by various health benefits: A recent
analysis of attended home births over a 6-year period reported that none
of the infants experienced adverse outcomes as a result of delayed cord
clamping.
[14]
A meta-analysis
[15]
showed that delaying clamping of the
umbilical cord in full-term neonates for a minimum of 2 minutes following
birth is beneficial to the newborn in giving improved hematocrit, iron
status as measured by ferritin concentration and stored iron, as well as a
reduction in the risk of anemia (relative risk, 0.53; 95% CI, 0.40-
0.70).
[15]
A decrease was also found in a study from 2008.
[14]
However,
a Cochrane Review from 2008 showed that, although there is higher
hemoglobin level at 2 months, this effect did not persist beyond 6
months of age.
[16]

Negative effects of delayed cord clamping include an increased risk
of polycythemia. Still, this condition appeared to be benign in
studies.
[15]
The 2008 Cochrane review found that infants whose cord
clamping occurred later than 60 seconds after birth had a statistically
higher risk of neonatal jaundice requiring phototherapy.
[16]
Conversely, a
recent randomized, controlled trial noted in the 2008 Examination of the
Newborn & Neonatal Health compared the timing of cord clamping on
the newborn venous hematocrit and reported an increase in anemia in
the infants whose cords were clamped immediately.
Delayed clamping is not recommended for health care providers as a
solution to cases where the newborn is not breathing well and needs
resuscitation. Rather, the recommendation is instead to immediately
clamp and cut the cord and perform cardiopulmonary
resuscitation.
[17]
The umbilical cord pulsating is not a guarantee that the
baby is receiving enough oxygen.
[18]

[edit]Umbilical nonseverance
Some parents choose to omit cord severance entirely, a practice called
"lotus birth" or umbilical nonseverance. The entire intact umbilical cord is
allowed to dry like a sinew, which then separates naturally (typically on
the 3rd day after birth), falling off and leaving a healed umbilicus.
[19]

[edit]Umbilical cord catheterization
As the umbilical vein is directly connected to the central circulation, it can
be used as a route for placement of a venous catheter for infusion and
medication. The umbilical vein catheter is a reliable alternative to
percutaneous peripheral or central venous catheters or intraosseous
canulas and may be employed in resuscitation or intensive care of the
newborn.
[edit]Storage of cord blood
Main article: Cord blood
Recently, it has been discovered that the blood within the umbilical cord,
known as cord blood, is a rich and readily available source of
primitive, undifferentiated stem cells (of type CD34-positive and CD38-
negative). These cord blood cells can be used for bone marrow
transplant.
Some parents have chosen to have this blood diverted from the baby's
umbilical blood transfer through early cord clamping and cutting, to
freeze for long-term storage at a cord blood bank should the child ever
require the cord blood stem cells (for example, to replace bone
marrowdestroyed when treating leukemia). This practice is controversial,
with critics asserting that early cord blood withdrawal at the time of birth
actually increases the likelihood of childhood disease, due to the high
volume of blood taken (an average of 108ml) in relation to the baby's
total supply (typically 300ml).
[14]
The Royal College of Obstetricians and
Gynaecologists stated in 2006 that "there is still insufficient evidence to
recommend directed commercial cord blood collection and stem-cell
storage in low-risk families".
The American Academy of Pediatrics has stated that cord blood banking
for self-use should be discouraged (as most conditions requiring the use
of stem cells will already exist in the cord blood), while banking for
general use should be encouraged.
[20]
In the future, cord blood-derived
embryonic-like stem cells (CBEs) may be banked and matched with
other patients, much like blood and transplanted tissues. The use of
CBEs could potentially eliminate the ethical difficulties associated
with embryonic stem cells (ESCs).
[21]

While the American Academy of Pediatrics discourages private banking
except in the case of existing medical need, it also says that information
about the potential benefits and limitations of cord blood banking and
transplantation should be provided so that parents can make an
informed decision.
Cord blood education is also supported by legislators at the federal and
state levels. In 2005, the National Academy of Sciences published
anInstitute of Medicine (IoM) report which recommended that expectant
parents be given a balanced perspective on their options for cord blood
banking. In response to their constituents, state legislators across the
country are introducing legislation intended to help inform physicians and
expectant parents on the options for donating, discarding or banking
lifesaving newborn stem cells. Currently 17 states, covering two-thirds of
U.S. births, have enacted legislation recommended by the IoM
guidelines.
Research in this area that has the potential to revolutionize medicine is
advancing rapidly and it is difficult for professional medical societies, and
other resources that expectant parents turn to for information, to keep
pace.
Physicians and researchers are making significant progress evaluating
the safety and efficacy of umbilical cord blood stem cells for therapeutic
uses far beyond cancers and blood disorders. The use of cord blood
stem cells in treating conditions such as brain injury
[22]
and Type 1
Diabetes
[23]
is already being studied in humans, and earlier stage
research is being conducted for treatments of stroke,
[24][25]
and hearing
loss.
[26]

The fundamental differences between private and public cord blood
banking should be noted. Cord blood stored with private banks is
reserved for use of the donor child only. In contrast, cord blood stored in
public banks is accessible by anyone with a closely matching tissue
type. The terms public and private do not necessarily indicate the
funding source, but rather the availability of use.
The utilization of cord blood from public banks is rising rapidly. Currently
it is used in place of a bone marrow transplant in the treatment of blood
disorders such as leukemia, with donations released for transplant
through one registry, Netcord, passing 9000. This is usually when the
patient cannot find a matching bone marrow donor. It is this "extension"
of the potential donor pool which has driven the expansion of public
banks.
Private banks which collect for specific individuals store on the premise
of future technologies and uses of cord blood. While this is a valid
reason for private donation, it must be remembered that for many
diseases such as leukemia, it is actually preferable to not use your own
cord blood. This is because the disease may be in latent form in your
own cord blood, as well as a graft-versus-tumor effect.
[edit]The umbilical cord in other mammals
[edit]Anatomy
The umbilical cord in some mammals contains two distinct umbilical
veins, rather than just one (as is the case for humans). Examples include
cows and sheep.
[27]

[edit]Cord disposal
In some animals, the mother will gnaw through the cord, thus separating
the placenta from the offspring. It (along with the placenta) is often eaten
by the mother, to provide nourishment and to dispose of tissues that
would otherwise attract scavengers or predators. In chimpanzees, the
mother focuses no attention on umbilical severance, instead nursing her
baby with cord, placenta, and all, until the cord dries and separates
within a day of birth, at which time the cord is discarded. (This was first
documented by zoologists in the wild in 1974.
[28]
)
[edit]Other uses for the term "umbilical cord"
The term "umbilical cord" or just "umbilical" has also come to be used for
other cords with similar functions, such as the hose connecting asurface-
supplied diver to his surface supply of air and/or heating, or a space-
suited astronaut to his spacecraft. Engineers sometimes use the term to
describe a complex or critical cable connecting a component, especially
when composed of bundles of conductors of different colors, thickness
and types, terminating in a single multi-contact disconnect.