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Scar cervical changes and vagina. Such dystation of soft tissues of the genital tract creates an irresistible obstacle to the opening of the cervix and expulsion of the fetus, since the scar tissue is not sufficient stretching. Expulsion of the fetus can lead to undesirable, form and topography ruptures of soft tissues of the generic paths, so such pathology has been recognized by many obstetres by unconditional indication cesarean section [Lurie A. Yu., 1958; Havlasek L, 1955; Martin N., 1962, etc.].
In particular, it should be borne in mind that scar changes The cervical cervix, macroscopically defined, can occur after the cone-shaped diathermakexisia about the papillary-follicular erosion or surgical plastics of the cervix. Such scar joints of the cervix and vagina were indicated to Cesarean section, on our material, quite often - 25 times (2.0%); In 18 cases there was a scar separation of the cervix and in the 7th vagina.
The urinary and intestinal fistulas in the past and present. It is known what severe suffering are these diseases, difficult to treat. Therefore, the risk of resuming the fistula after eliminating such pathology or an increase in the existing fistula in vaginal childbirth cannot be considered justified. In addition, the sewn or unimpressed fistulas are accompanied by scarsing changes in soft generic paths, it is difficult to stretch. The presence of this pathology in a woman requires a mandatory delivery of its abdominal method [Baksht G. A., 1940; Greenhill J., 1953; Havlasek L., 1955, and others]. On our material, in 4 cases, the cesarean section was produced about the sewn of urinary fistula and in 7 - about the intestinal fistula (only 0.9% of cases).

Did the cervix.

The pathological condition of the lower segment of the cervix - rigidity, spastic or paralytic state - occurs about 1% of all kinds. Usually, fencers with cereal distation are mistakenly attributed to a group of women who have a childhood generic activityBecause they are delayed by a generic act. In some cases, the crooked dystocy is so much expressed and is not amenable to conservative therapythat there is a need for a surgical pathway. Abdominal delivery is most often produced when there is an additional pathology in childbirth (for example, threatening the intrauterine asphyxia of the fetus), in older origin and rarely - in severe cases of dying the cervix. O. Jones (1953), Haskins et al. (1955), A. Posner et al. (1954), S. Gordon (1957) allocate severe cases cereal distation in independent test To Cesarean section. The proportion of this testimony to the surgical delivery among others in these authors is from 0.4% to 1.7%.

Vices for the development of the uterus and vagina.

With vices of the uterus, if pregnancy remains to the end, may occur, in particular, incorrect positions or presence of the fetus, the weakness of generic activity, which sometimes lead to the need for a root separation by cesarean sections. But some types of malformations of the uterus themselves make it impossible or dangerous delivery through natural generic paths. In one case, a cesarean section was produced on our material in connection with the presence of a transverse partition of the vagina and the atresia of the cervix.
From the work of N. Philpot, J. Ross (1954) it can be seen that the malformations of the uterus are rarely indicated to abdominal delivery: for 39 100 genera, they only observed 41 cases of pregnancy with the presence of one or another malformation of the uterus, of which only in 6 cases Rhodework was produced by cesarean section, and in all cases due to transverse positions and pelvic prelations of the fetus, weakness of generic activities and the pathology of the placenta. In 3 cases, the cesarean section in our clinical observations was made due to the presence of the transverse partition of the vagina.

Elevation of external genital organs.

A significant edema of external genital organs can sometimes be indicated to Abdominal Rhodework. In the literature there are reports of such cases [Yuryeva L. V., 1956; Olow V., 1950; Bryant R., 1956]. According to N. Kustner (1952), spontaneous childbirth in such cases can lead to the external genitals of external genital organs. The edema of the outer genital bodies as indicated to the cesarean section mention L. havlasek (1955) and N. Martin (1962), which are considered to be shown cesarean section, as well as abscesses, phlegmon, extensive dondlomes and cancer of external genital organs.

Varicose extension of the cervix cervix, vagina and outdoor genital organs.

This pathology in childbirth is a great danger: the breaks of varicose nodes can give deadly bleeding. Z. L. Karas (1939) reports about several dozen cases of genera in women who have had such pathology collected in the literature, with 50% maternal mortality. Ligation of bleeding nodes may be unsuccessful. A. Yu. Lurie (1958), L. S. Persianinov (1960), L. Havlasek (1955), N. Martin (1962) It is believed that the presence of such varicose nodes justifies the delivery of the surgical path. In this regard, the clinical observation is indicative, which is disassembled by L. S. Persianinov in the "Obstetric Seminar" (1960).

R. Bryant (1956) reported 4, and V. Shneider (1954) - about 5 cases of abdominal delivery on the varicose vein extension of the outdoor genital organs. N. Ehrlich (1953) observed the varicose veins, exciting the entire cervix, which required the production of cesarean section. G. G. G. G. Genger (1932) leads its observation of childbirth in a woman with hemangioma of external genital organs, which ended with a cesarean section due to the progressive increase in the volume of the tumor in the disclosure period.

Fibromomomomomoma of the uterus.

The combination of pregnancy and fibromomy of the uterus is occurring in less than 1%, while the course of pregnancy is complicated at about 60% of cases. Not touching various complications of pregnancy within the deadlines, when the fruit is still unsuitable, it should be noted that in childbirth, premature or urgencies, there is a significant frequency of transverse or oblique provisions of the fetus, the pelvic presence of the fetus, premature or early departing of the water, the prelationship of the placenta, the weakness of labor activity, hypo- and atonic bleeding and others.
Such complications by themselves create a problem of the delivery. In addition, the unfavorable (cervical) arrangement of fibromatous nodes creates an irresistible obstacle for the generic process, both in terms of the opening of the cervix, and in terms of fetal advancement. L. S. Persianinov (1952) observed two bursts of the uterus, the reason for which the crooked knots appeared. On the other hand, the development of pregnancy may cause the occurrence of the necrosis of the fibromatous assembly and its suppuration. However, despite all these dangers, in most cases (80%), women in women with fibromyoma of the uterus may be favorable [Mogilev M. V., 1951], so an individual approach to each such pregnant or guinea is needed.

The tactics of the doctor, the leading childbirth in a woman having a fibromy of the uterus, is determined, on the one hand, the amount, the number, topography and the state of fibromatous nodes, on the other hand, the course of the generic act. If fibromyoma requires surgical treatmentIt is necessary to bring pregnancy to the possibly greater vitality of the fetus and then produce a cesarean section with subsequent surgical treatment of fibromyoma. The transverse or oblique position of the fetus in itself requires a root separation by caesarean sections. Other complications, in particular, the weakness of labor activity, especially in the presence of a pelvic prevention of the fetus, already as such create prerequisites for abdominal delivery.
Low-positioned fibromatous nodes that prevent the delivery through the natural generic paths are rare. Such cases require unconditional delivery abdominal.
L. S. Persianinov (1960) warns of the need for careful observation of the fetal heartbeat in pregnant women and women in which there is a fibromyoma of the uterus. When the uterine fibromic during pregnancy, there are adverse conditions for the uterine-placental circulatory circulation, and the emergence of labor activity and other complications in childbirth leads to hypoxia of the fetus or enhances it. Signs of threatening intrauterine asphyxia of the fetus may appear at the first fights. The emergence of these signs should certainly influence the choice of the accelerated method of the delivery.
The frequency of the fibromomomomomomy among other testimony to the cesarean section is small: on our material as an independent testimony for 1242 operations, this tumor of the uterus met only 5 times (0.4%), in all these cases there was a multiple fibromyoma of the uterus with the cervic location of one of the nodes. In addition, in 7 cases (0.6%), the uterine fibromyomomomomomomomoma was a concomitant testimony for a cesarean section, of which, in 2 cases (during the prelation of the placenta), it had little effect on the choice of the route of delivery and 4- taken into account in one way or another In the forecast of childbirth.
In some authors, the frequency of the fibromomy of the uterus as indications for abdominal delivery is significantly large. On the material V. S. Layuk et al. (1979), specific gravity Misa uterus amounted to 6% among the testimony for abdominal delivery.

Offic tumors.

Combination malignant tumors The ovaries with pregnancy refers to the region of casuisics. It is rarely complicated by pregnancy with benign tumors of ovaries, and dermoid cysts are most often found from all types of tumors [Petersburg F. E., 1958]. According to G. Gustafson et al. (1954), the frequency of the ovarian cyst ranges from 1: 1000 to 1: 8000 pregnant women.

The greatest danger is tumors remaining during pregnancy and childbirth in a small pelvis - they reduce the pelvic capacity and, blocking generic paths, can lead to different complications, up to the uterus break. Under the pressure of the pre-section, these tumors can break the rear vaginal arch or the front wall of the rectum, followed by birth in front of the fruit [Petersburg F. E., 1958]. In addition, during the promotion of the preemptive part of the fetus, there is a nutrition, the kneading wall of the cystoma, up to its rupture and occurrence of peritonitis.
We should not forget that the ovarian tumor itself requires the fastest surgical treatment. Therefore, with a dead pregnancy or during childbirth, the existence of the ovarian tumor, the more blocking generic paths, requires laparotomy with the production of cesarean cross-section and the subsequent removal of the tumor.
In our practice there were 4 cases of cesarean section in connection with the presence benign tumor ovaries.

Cervical cancer.

According to the national statistics of G. A. Baksta (1934), cervical cancer was indicated to Cesarean section of 0.36% of cases. Currently, such cases are even more rare - in the USA, they amounted to 0.033%, for other foreign countries - 0.033% and USSR - 0.06%. On our material, this pathology occurred more often - in 0.34% of all cases of cesarean sections.
If a pregnant woman has a cervical cancer, then in the presence of a viable fetus, and even more so in childbirth, it is always a delivery of abdominal by abdominal, followed by the relevant therapy of the cancer process. Rhodework through natural generic paths is contraindicated due to structural changes in the cervix caused by cancer tumor: The injury of cancerous tissue leads to the appearance of bleeding, reinforced metastasis and serious infectious complications, and the rigid cervix can contribute to the emergence of the uterus.
All of the above also relates to a combination of vaginal cancer and pregnancy. S. S. Rogornko (1954) collected in the literature a description of 26 such cases, analyzed 23 of them. Of the 13 patients who gave birth independently, 5 immediately after childbirth or miscarriages died, with 2 women died and not allowed. The rest of the patients after giving birth became completely inactive. For the same reasons, a delivery is carried out by cesarean section, if pregnant or feminine have cancer of outdoor genitals, rectum or bladder.

Keeping dystation

The crooked dystation may be a consequence of functional or organic changes in the cervix. Functional gear distation is associated with the features of innervation and receptor apparatus, Because of which, at the time of the spread of the excitation wave through the muscle of the uterus, it causes no disclosure of the cervix, but of circular fibers. Ceetic dystation with organic cervical changes is caused by the impossibility of opening the cervix due to her anatomical features. At the same time, there is a significant predominance of connective tissue that is not capable of stretching. Such features of the cervix are observed with cervical changes of the cervix, arising after delivery, abortions, surgical operations, diathermoelectro-adaging, after inflammatory diseases of the cervix.

Clinic:The fights are different in strength, painful, mainly with pain in the lumbar-sacrum region. Prior vaginal research is possible various options cervix. However, the main feature is the spasmodization of the cervix in the fights and with a vaginal study. At the same time, the predatory part follows the neck of the uterus and puts on it. A generic tumor appears on the head of the fetus. The magnitude of it corresponds to the opening of the cervix, the boundaries coincide with the edges of the external zea of \u200b\u200bthe cervix. With dynamic observation, the slow down opening of the cervix is \u200b\u200bdetected, despite the presence of good generic activity. With the outer hysterography, various variants of SDM (normo, hyper-, or hypodynamic) are detected, with or without discordination elements.

Guiding childbirth:When the cereal dotition is detected, a fundamental decision on the choice of the tactics of the root separation should be made. In the case of high risk factors for the fetus, the issue is solved in favor of the cesarean section. When conducting labor through natural labor pathways, the CDM correction is performed.

1. As a whole, the fruit bubble produces amniotomy.

2. Spasmolitis (aproofen, but-shpa, Galidor, Baratgin, etc.) are introduced. According to the testimony, the introduction of spasmolitics can be repeated after 2 hours. Assigned Sedukesen, Relanium Per OS.

3. In the hypidamic type of SDM after amniotomy, a GVEK is entered, which can be repeated after 2 hours.

4. In the fater of the feminine, the medical obstetric anesthesia (GOM with premedication) is given.

5. When weakening the generic activity after sleep, it is possible to use a GVEK, active regime, cleansing enema.

6. With the secondary weakness of labor activity, with a satisfactory state of the fetus, the correction of the SDM intravenous drip administration of uterotonic means is shown.

Birth is a complex, multicomponent process of interaction of nervous and humoral systems. female organism, the result of which is the emergence of a new life. Until now, the reasons for the start of generic activity have not been established, but it is precisely known that their prosperous flow and completion is possible only under the unity and harmony of the functioning of organs and systems in the female body.

The optimal contractual ability of the uterus is the foundation of a prosperous delivery without complications for the guinea and child.

According to statistics, about 20% of childbirth are manifested by abnormal generic activities, and a third of them end with the cesarean operation.

Normal generic activity

In order to start the normal generation mechanism, it is necessary to have a generated "generic dominant", which includes: changes in the work of the central and peripheral nervous system; The ability of organs responsible for the production of hormones, neurotransmitters, biologically active substances, produce them in the required quantities; proper degree of fetal maturity; Natural aging of placenta and fetal shells; The readiness of the uterus to perceive the nerve impulses and react to them.

The process of preparing the body to childbirth can be divided into two main blocks. The first block is the coordinated work of the cerebral cortex, hypothalamus, pituitary gland, nerve endings in the uterus, and this work is being implemented due to the action of oxytocin, prostaglandins and neurotransmitters. The second block is a uterus and a fetoplacentage complex.

Cervical Disclosure Mechanism

With the complete readiness of the body of the woman to childbirth, the contractile activity of the uterus begins, which leads to the disclosure of the neck and the birth of the child.

The disclosure of the cervix marks the first period of childbirth. This period in women who give birth for the first time, lasts 10-11 hours, in repaid 7-9 hours. Street stages:

The optimal estrogen content provides a reduction action of oxytocin on the myometrium, in addition, the fight is impossible without the proper level of prostaglandins and neurotransmitters - acetylcholine, adrenaline, norepinephrine - substances that ensure nerve impulses From the nervous end to the muscular cell.

The body of the uterine body has a longitudinal orientation, and the muscles of the lower segment are circular, transverse. Reducing the longitudinal muscles of the body provide neurotransmitters of adrenaline and norepinephrine, reducing the transverse muscles in the lower segment - acetylcholine.

In the process of the contraction, three processes occur at the same time:

1. Reducing the body of the uterus (contract).
2. Displacement of muscle fibers relative to each other and fixing this position (retraction).
3. Relaxation of the lower segment adjacent to the neck (distraction).

As a result of the uterine contractile activity, its lower part relaxes and the neck is revealed, and the reduction in the lower solid segment is accompanied by relaxation of the body of the organ. The achieved disclosure is fixed. Then there comes a pause - a rest, in which the balance of the necessary proteins, ions, energy is restored in muscle cells.

In addition to the fight, the driving force of the disclosure is the pressure of the fetus and the fetal bubble on the inner zev, as well as the increase in pressure inside the fruit chamber.

In the insolvency of any of the above-mentioned launch links, weakness of generic activity arises.

Pathology of the preliminary period, primary and secondary weakness of labor

The preparatory period of childbirth is considered anomalous in painful disorderly fights, the absence of ripening of the neck and constant tone of the uterus. The neck remains long, dense, zev closed. Lowings the pathological preparatory period of 1-2 days.

The cause of an abnormal preparatory period is considered pathology contractile function The uterus, which arises as a result:

• low estrogen levels;
• lack of neurotransmitters of adrenaline and norepinephrine;
• low serotonin level;
• anomalous feed of nerve impulses in the central nervous system.

The pathology of the preliminary period is considered precursor of disadvantaged delivery. Thus, in a third of the birthdayries further arises the discordination of childbirth, the fifth part is the weakness of the generic process.

If the neck is immature, it is forbidden to open the olive bubble. In the case of a whole fruit bubble, the lack of disclosure, immature cervix, satisfactory state of the fetus, such birth is called false.

Treatment: Apply sedatives intravenously (priedol, diazepam); For the purpose of stopping, the bocoles (Ginipral, Hexoprenaline, etc.) are used, with the aim of stimulating childbirth for the speedy ripening of the neck, prostaglandins are used (Dinoprotton, probdyl-gel, etc.), which are laid in the cervical canal, as well as estrogen preparations with ascorbic acid and Vitamins group B (intravenously).

The physiologically flowing first period of birth is indicative of productive regular fights that lead to disclosure. In the latent phase, the disclosure rate is 0.35 cm / h, in an active 1.5 - 2.5 cm / h, in a slow motion 1 - 1.5 cm / h.

The reason for the weakening of labor is considered to be a violation of the transfer of nerve impulses from the uterus to the brain and the impossibility of it to perceive the impulses incoming to it as a result:

For the primary weakness of childbirth, it is characteristic: initially low frequency, intensity and duration of kits, which continues during the period of disclosure and expulsion of the fetus. Parameters are evaluated by cardiotockography.

The secondary weakening of childbirth is characterized by the attachment of the above features after the normally flowing process.

For the feminine observed about 8 hours. If the frequency of the bouts in the active phase is less than 3 in 10 minutes, and during regular sampling, the neck revealed less than 4 cm, then they are talking about the weakness of labor.

Treatment is to stimulate the generic process. But before proceeding to relatives, the doctor should appreciate the relevance of appointments. Similar symptoms may be present in the inconsistency of the head parameters and the linen pelvis ( narrow pelvis).

With a strong fatigue of the feminine, an obstetric sleep is used (in the absence of threatening hypoxia of the fetus), followed by stimulation. According to individual indications and in the presence of disclosure is possible amniotomy (with integers spindle wateroh). Basic stimulation methods:

Rhodesimulation is carried out only under the control of cardiotockography.

In the early power of water and weakness of labor activity increases the danger of the emergence of a long anhydrous period (more than 6 hours), which threatens serious infectious complications In the fetus (congenital pneumonia, sepsis, etc.) therefore, in the absence of a proper effect of stimulation, it is necessary to consider the issue of cesarean sections.

Excessive generic activities and discoordination

Allocate fast I. rapid childbirth. In the first case, the delivery occurs after 6 hours from the moment of regular battles in primorinders and after 4 hours at reappliances. In the second case - after 4 hours at first, and after 2 hours in reparaging.

The danger of a hyperactive uterus lies in the possibility of its break, trauma of the fetus, the defect of the placenta separation.

The main method of treatment is the introduction of tocolic preparations (depressing contractile activity): Athosibal, Fenoterol, Ginipral, Hexoprenaline. Bed regimen is required.

Discordination in childbirth is characterized by the complete absence of coordination of uterine contractions, chaotic contractual activity.

The reasons:

• malformations of the uterus;
• frequent abortions;
• scar changes;
• inflammatory diseases of reproductive organs;
• tumors of the uterus.

Yatrogenic causes are not excluded (overdose of stimulating drugs of medicines).

Development mechanism:

• migration of the rhythm driver horizontally and vertical, as a result of which each section of the uterus is reduced with its rhythm, frequency and intensity;
• an excess of acetylcholine and, as a result, the overexcitation of the lower solid segment;
• overexcitation of nerve centers due to continuous promise of nerve impulses;

Clinical picture. Fights irregular, frequent (more than 6 per 10 min.), Sharply painful, the following one after another without rest. Sommonty cuts may appear both the top and in the lower departments, both in the right and in the left department. The opening of the neck does not occur, or minor. There is a long reduction in the lower segment, which leads to dotition of the neck.

Did the cervix - it is dangerous pathological state, in which the risk of breaking the uterus and bleeding is increasing. With a vaginal inspection, the neck is palpable as a tight, a dense ring, it is sharply spasmed, edema, together with the lower segment of the uterus represents a single whole. The uterus at distation takes the form of an oval. Characterized by Schiekel's symptom: when the neck is brused, it is not relaxed, but is reduced with greater power. The fruit is not able to move along the generic paths.

In some cases, erroneous adoption of discoordination is possible for a weak generic process, while stimulating drugs can have a fatal effect.

Restrain is restless, urination is difficult, nausea and vomiting is possible. Material and placental blood flow violates, hypoxia of the fetus increases.

Long-term indiscriminate uterine reductions are injected into a permanent hypertonus, which can end the Tetanus (total dystonia) and fibrillation (trepidation) of the uterus. Births stop.

In the absence of treatment, discoordination can lead to the rupture of the uterus, generic injury, hypoxia of the fetus.

The most rational treatment is epidural anesthesia and the introduction of tocolic drugs. In childbirth, constant monitoring with the help of cardiotockography and hysterography. In the absence of the result of treatment, a cesarean section is carried out.

III degree (total dilitation of the uterus)

The heaviest option (degree) of the discharge of the cutting of the uterus in childbirth, which is characterized by total spasm of cervical, lower segment, body, tube angles of the uterus and vagina.

At the same time, there is not one "rhythm driver", and a few (the displacement of the "rhythm driver" vertically and horizontal). The uterus is divided into several zones, each of which takes on the function of the starting center. Each uterus segment has its own rhythm, amplitude and cutting frequency, which do not coincide with each other.

The fibrillation of myometrium occurs like flickering and trembling of the heart. Tonus of the uterus all the time persists high, all muscle fibers, especially circular, are in a state of tonic tension. The total effect of action is extremely low. Birth slows down and stop.

Generic activity stops. The threshold of the excitation of some cell groups is very high, others are very low. The excitation waves and cuts cannot cover all the myometrium, since one piece of muscle beams is reduced in one rhythm, the other is different. The spread of the reduction waves has opposite directions: at the same time up and down, right to left and vice versa.

The fights become rare, short, weak, but, unlike the true weakness of the generic activity, the hypertonus of myometrium is preserved. There is no phase of relaxation and peace.

According to the clinical picture, total dilution of the uterus in childbirth resembles the weakness of labor. The main difference is the tone of the uterus. In the discoorination of the generic activity, it is always elevated, with weakness of generic activity, the uterus is reduced.

The clinical picture of the hypertensive form of weakness is very characteristic. After spastic, painful kits occurs a period of visible weakening of generic activity. The feminine is no longer shouting, does not dare, behaves more calm, but indifferent. Complains only on stupid constant pain in the sacrum and in the lower back. This often gives a reason to the doctor to establish an erroneous diagnosis of the secondary weakness of generic activity and prescribe a rhodium-immutting therapy, which is categorically contraindicated in the discount of generic activity.

Total Tetanus of the uterus indicates the paradoxical phase of the parabitony of muscle contractions. Skin Covers Pale Feelnians, there are acricyanosis, skin marble. Pulse frequent, easily compressed, weak. The feminine independently flies, with the catheterization of the bladder, small portions of urine containing protein, red blood cells, leukocytes, cylinders are distinguished.

In the outdoor obstetric study, the uterus is determined by the narrowed in the diameter due to the thetanic reduction of the myometrium. The uterus tightly covers the fruit. Palpation of the predatory part is difficult. Even with the transverse or oblique position of the fetal, the uterus retains the shape of an elongated ovoid and so squeezes the frozen, which is the impression of its longitudinal location. A strained convex dense bottom segment is often accepted for the preserved part. The fruit suffers, the heartbeat is frequent or rare, arrhythmical, deaf or ringing with a metal tint.

In the vaginal study, the tense muscles of the pelvic dna, spastically narrowed vagina, edema, thick rigid edges of the uterine zea are applied. The degree of disclosure of the uterine zoom is slowed down. Compared with the data of the previous vaginal study, it seems that the opening of the neck is not only does not progress, but becomes less.

Determine the integrity of the fruit bubble is difficult due to dense fetal shells, which are literally tensioned on the head, the front waters are practically absent.

There is a pronounced generic tumor on the head, because of which it is difficult to identify seams and springs.

Sometimes it seems that the fetus head has advanced to the pelvic bottom. However, the palpation of the entire free rear surface of the pubic symphiz indicates a high standing of the head, although the generic tumor can reach the pelvic bottom, which causes vicious sweats.

After birth, the fruit is not at all gigantic, not large, but a very medium size (2900-3100 g) or even small.

With any form of discoordination of generic activity in women with normal anatomical sizes, the pelvis is much more common than in the overall population, there is an extension of the head (frontal, rear view of the facial), high straight standing of the sagittal seam, a reckable asynclothic insert, as well as the rear view. They do not relate to adaptive mechanisms even when anomalous forms pelvis. This is a consequence of the violation of tone and contractile activity.

Spontaneous restoration of normal contractual activity of the uterus without drug correction is extremely rare. The manufacturer quickly increases the body temperature, endomiometrite, chorionnionitis, worsening the forecast of childbirth for mother and the fetus.

With total dilution of the uterus, if the situation (no infection, increased temperature Body, lively fruit, not too long anhydrous interval) Rhodework must be carried out only by cesarean sections.

Conservative guidance, the erroneous use of contraindicated relatives can lead to a hazardous complications.

Conditions are created for the penetration of accumulating waters into the venous system of the mother (embolism of the octoloplodic waters). May develop at least heavy complication - Ischemia of a separate portion of the uterus and the rupture of the wall of it. Most often it is a typical localization: the left edge, the lower uterine segment, the front wall of the uterus.

Having highlighting various forms of discordination (hypertensive dysfunction) of contractile activity of the uterus, two circumstances should be emphasized.

The first is the dependence of the severity of this pathology on the severity and depth of violations of the vegetative and miogenic regulation of the cutting of the uterus in childbirth.

The second is the progression and aggravation of the severity of discoordination in the insufficiency of compensatory mechanisms in the body of the pregnant and its fetus, or in the absence of timely adequate treatment and ancestration.

These literature indicate that the lack of endorphins violates the metabolism of catecholamines and supports muscle spasm internal organs (including uterine, intestines, ureters).

Currently, it is proved that an excessively high emission of catecholamines reduces their protective role in ischemic damage to the neurons of the mother's brain and the fetus.

Without medication therapy, spontaneous restoration of normal generic activity is rarely observed.

We present our own clinical observation of total dilution of the uterus.

The feminizer, 27 years old, entered the maternity hospital with docking pregnancy, head preview, active generic activity, which lasts 8 hours.

Water poured 36 hours ago. Fight irregular: then long (50-60 s), then short (15-20 seconds), painful. The feminine is tired, wants to sleep. Body temperature 38.6 ° C. Hell 140 / 90-150 / 100 mm RT. Art., pulse 120 ice / min. Skin covers are hyperemic. Language dry, covered with a white bloom. The belly will be off. The uterus of an oval shape, tightly covers the fruit. In the field of the lower segment at the height of four transverse fingers above the pubic symbol, a spastic reduction of the uterus is determined in the form of a ring-shaped recess. Fetal heartbeat is not auditioned.

Vaginal study: cervical neck up to 2 cm long, hangs into the vagina. The cervical channel freely skips two fingers. The inner zev in the form of a dense spastic ring is open for 2 cm. There is no fruit bubble. The fetus head is pressed to the entrance of a small pelvis. Seams and springs cannot be determined. The tank is good. Selection of muddy, in moderate quantity.

From anamnesis: This pregnancy is not the first, as noted in the accompanying document, and the second: 10 years ago the first pregnancy is interrupted by artificial medical abortion under a period of 12 weeks. According to the patient, the neck of the uterus opened up with great difficulty and her "twice filmed from the chair" to prepare for an abortion by applying spasmolitics. Abortion passed without complications.

Sister-twin at the age of 20 died in childbirth from bleeding. The mother of the patient reported that the pregnancy in which both twin sisters were born, heavily flowed, with phenomena of the threat of interrupt. Up to 20 weeks accepted hormonal therapy. Children often hurt. Menarh has both from 15 years old, 3-4 days after 30-35 days, but pregnancy has come from both sisters in the first year of sexual life.

After an urgent and complete clinical examination, a diagnosis was made: "Pregnancy 40 weeks; head prepay; Discordination of generic activities (total disal dyat); Early oral influence; intranatal death of the fetus; endomyometritis. "

Considering the presence acute infection, the death of the fetus, the high danger of peritonitis, it was decided to refuse to abandon the operational delivery. For several hours, antispasmodic, antibacterial, detoxification therapy was carried out. Provided medical Son. For 3 hours, conducted toocolized by the accountish system for 3 hours, which allowed to reduce the basal tone, reduce the spastic state of the uterus. Epidural anesthesia did not apply due to skin infection.

However, the generic activity was practically absent. Against the background of continuing drip administration, careful relaxation of PGA 2 preparation was carried out with simultaneous cardiomonitorial and hysterographic control. Fights after 3 min (3 per 10 min) of 60 from the middle force. Fender hacking (drip administration of 1% mortality of morphine, sadocent). After 10 hours, the disclosure is complete, the head is a large segment in the inlet of a small pelvic.

The state of the feminine gradually improved, the body temperature decreased to 37.3 ° C, pulse 96-100 ° C / min. AD 130 / 90-120 / 80-110 / 70 mm RT. Art. Under the presence of conditions for a fertilizing operation, craniotomy and cranioclasia are produced under endotracheal oxygen anesthesia. Fruit tractions are difficult. The fruit fruit is removed without a brain (body weight 3100 g, length 54 cm). In the field of the shoulders and at the level of the eaves of the fetus, a pronounced compression of soft tissues, a change in (blue-bugs) of fabrics, was marked. The prevention of bleeding with methyl ergometrine (1.0 ml) was carried out. After 5 minutes, it was separately separated and immediately shared. With a control manual study of the walls of the uterus, the wall integrity disorders is not detected. Sheck ruptures II degree sewn with ketgutov seams. In the postpartum period - the submissiveness of the uterus, endomyometritis, secondary healing of the crotch wound.

After 2 years repeated pregnancy. The mioma of the uterus is revealed, the size of 8 cm in diameter. It has been produced by the degree of cesarean section in a planned order with a dead pregnancy. During operation, the internal zev of the uterus is passing only for the tip of the finger.

Considering the presence of an intertpete myomatous node large sizes, the danger of the delay of Lohi, produced a supervised amputation of the uterus. Postoperative period Because without complications. In the study of the remote drug, the cellular proliferating mioma of the uterus was detected, almost complete atresia of the internal zone, the presence of Ba-Hall chronic endomyometritis. In the newborn - Vezikulosis, congenital pneumonia, Ommalitis. Translated to the fill in the children's hospital. Check inspection after 2 months - mother and child are healthy.

The rapid transition of pathology in a more severe stage often makes it difficult for childbirth and their maintenance. Currently, taking into account the principles of modern obstetrics, they do not allow such a long and traumatic leading of labor. Nevertheless clinical cases May take place for each practitioner doctor.

20.6.5. Diagnosis of Discordination of generic activities and its options

Upon receipt of the guinea to the maternity hospital, you should familiarize yourself with medical records (exchange card data, a guide diagnosis). When collecting anamnesis, besides well-known information, you need to pay attention to the risk factors that threaten the violation of the coordination of the cutting of the uterus in childbirth (vegetionerevosis, stress, overwork, anomalies of the uterus, the pathology of the cervix - erase the uterus, FPN, neuroendocrine pathology, etc.). It is necessary to evaluate general status, somatic health, obstetric situation. Eliminate anatomically narrow pelvis, one or another degree of disproportion pelvis and fetal head; The inferiority of the myometrium, which can lead to the rupture of the uterus in childbirth and premature details of the placenta. Mark, there are prenatal signs of the pathology of the cutting of the uterus (dense, long neck, the pathological preliminary period, the movable head of the fetus, the prenatal expulsion of the water, the migration of the pregnancy).

To assess the nature of the generic activity should be determined every 1-2 hours:

The dynamics of the structural changes of the cervix in accordance with the past clock of labor activity, given the parity of childbirth (the first, repeated);

Opening of the cervical (ukey) in centimeters, the state of the edges of the cervix (soft, militant; dense, rigid, poorly stretch; thick - thin), including the state of the edges of the uterine zea during the contraction (soft, but are compacted throughout the circle or separate section);

The functional is the fullness of the fruit bubble (poured into the fight) or inferiority (flat shape, the shell is stretched on the head), the characteristic of the shells (dense, rough, elastic). Mark the fetus bubble voltage during and outside the contraction, as well as the number of accumulating waters (little, much, normal);

Preview, insertion, type of fetus, compliance of biomechanism for one or another period of generation, the location of the head in relation to the main planes of the pelvis, the rate of its promotion;

Frequency of kits for 10 minutes of the control time (determined by the stopwheel); rhythm; The duration of the reduction (sisteners of contractions) and relaxation (diastole contamination) of the uterus;

The basal tone of myometrium during the fight and outside the contamination using a tonic meter or comparison of the voltage of the uterus with the lateral widespread muscle of the patient (the tone of the thigh muscles is 10 mm Hg. Art.); Conduct differential diagnosis between weakness and discoordination of generic activities.

For the diagnosis of native anomalies, an outdoor hysterography, an internal trocographics, KTG, use an external hysterography.

Outdoor multichannel hysterographyit gives the opportunity to identify the violation of a triple downward gradient, the hyperton of the lower segment, the irregular struggle, the decrease in the diastology of the fight and the reduction of the pause time between the fights.

The method allows you to detect complexes of dyscoordated cuts of the uterus (double, triple type of contraction). The vertex of the hysterographic curve is not a peak-shaped rounding, but a plateau with uneven gear contours, rhythm kits uneven, the amplitude of the cutting bottom of the uterus is significantly lower than in the lower segment. With the help of hysterography, you can catch thetaic cuts of the uterus, when it is not relaxing for a number of uterine cycles.

Inner topographyrepresents quantitative, and therefore a more accurate estimate of the duration mastechnic cycle, systoles and diastologies of contractions. Allows you to determine the amplitude of the reduction, basal tone of the uterus, the general intrauterine pressure during the contraction, the speed and nature of its increase during the systole period and diastologists, as well as to calculate the operation of the uterus and the uterine activity. All these indicators are expressed in numerical calculus.

The amplitude of individual cuts of the uterus during the discoordination of the generic forces can vary widely: from 20 to 80 mm Hg. Art., What confirms the unevenness of the strength of the fight. Against the background of the hypertonus of the uterus and its insufficient relaxation between the fights, the intensity (power, amplitude) contractions are reduced. The duration of the systole scaffold increases 1.5-2 times, the duration of the diastole decreases by 50-60%. The asymmetry coefficient of contractions (the ratio of the duration of systole to diastole) is equal to one and more.

Increased intrauterine pressure occurs uniformly, but jumps like it is the main cause of the late expulsion of the oily water. We have studied the main characteristics of the contractile activities of the uterus in physiological and abnormal childbirth (weakness and discoordination of generic activities).

Differential diagnosis of the pathology of the cutting of the uterus during the discsordination and weakness of the generic activity is presented in Table. 20.2.

Table 20.2. Characteristic of the contractile activity of the uterus in physiological and abnormal labor activity

Main indicators of contractile activities of the uterus in childbirth	Physiological gods	Discordination of generic activity	Primary weakness of activity
Miscurity of myometrium	Normal	Increased	Reduced
Tone of the uterus, mm Hg. Art.	Normal (10-12)	Improved (13-18)	Reduced (9-6)
Rhythm of fights	Rhythmic	Nertmichy	Rhythmic
Frequency for 10 min	3-5	Various	1-2
Duration of contractions, with	60-90	100-120	20-30
The force of the fight (the amplitude of the reduction, mm Hg. Art.)	30-35	< 30	< 30
Systole scaffold duration, with	30-40	40 or more	< 30
Duration diastole contractions, with	40-60
The asymmetry coefficient of contractions (systole ratio to diastole)	0,7	1-1,5	0,7
Soreness of fights	Low-escaled, moderately painful	Sharply painful	Undoubleseed
Opening of the cervix	Progres	Sharply slowed down	Slowed down
Promotion of fruit	»	Also	»
Food bubble fullness	Full	Defective	Defective
General intrauterine pressure, mm RT. Art.	40-60	Less than 40.	Less than 40.
Increase intrauterine pressure in systole fastener, mm RT. Art.	0,6-0,9	From 0.4 to 1.5	0,6
Reducing the intrauterine pressure in diastole, mm RT. Art.	0,5-0,7	From 1.0 to 0.8	0,5

Due to the fact that the methods of multichannel hysterography and internal trocographics are quite rarely used in practical enthusiastic institutions, attention should be paid to the symptom complex or individual clinical symptoms characteristic of hypertensive dysfunction of bages.

With confidence, it can be assumed that the reason for the disassembled discoordination of the generic activity is:

"Immature" by the date of birth of the cervix;

Pathological preliminary period;

Migration of pregnancy;

Antenatal influence of the oily water with the "immature" cervix;

Breaks and scramble cervix;

Extensive vaginal breaks;

Hypoxic-traumatic damage to the fetus.

These disorders and complications also accompany the clinically narrow pelvis, the threat of an incomplete myometrium gap. The reason is a consequence, as a result, it becomes the cause of the development of complications.

20.6.6. Treatment

When choosing corrective therapy for discooring of labor activities should be proceeding from a number of provisions.

Before conducting childbirth through natural generics with complex multicomponent violations of the regulation of contractual activity of the uterus, including the Mio-Gennic (the most ancient and durable in evolutionary Development Human), it is necessary to make a forecast of childbirth, providing outcomes for mother and fetus.

The forecast and plan for conducting births are based on the age, anamnesis, health states, the flow of pregnancies, an obstetric situation, the results of the evaluation of the state of the fetus.

TO unfavorable factors relate:

Late and young age primary age;

Burdened obstetric-gynecological history (infertility, induced pregnancy, the birth of a sick child with hypoxic, ischemic, hemorrhagic damage to the CNS or spinal cord);

The presence of any severe diseasein which a dangerous protracted course of childbirth and physical exercise;

Heavy gestosis, narrow pelvis, transferred pregnancy, scar in the uterus;

Development of discoordination of bouts at the very beginning of childbirth (latent phase);

Late expulsion of spindlewater waters at the "immature" cervix with a small opening of the uterine diet; critical anhydrous interval (10-12 h);

The formation of a generic tumor at a high-resistant head and a small (4-5 cm) opening of the uterine zone;

Violation of the normal biomechanism of labor;

Chronic hypoxia of the fetus, its too small (less than 2500 g) or large (3800 g and more) sizes that do not correspond to the average gestational periods; pelvic preview, rear view, reducing blood flow in the fetus.

2. With all the listed risk factors, it is advisable to elect the method of delivery by caesarean sections without an attempt to conduct corrective therapy.

The woman in labor may have vital dangerous complications: Uterine rupture, embolism of octoplodic waters, premature detachment of placenta, extensive trips of generic paths, combined hypotonic and coagulopathic bleeding.

3. In the absence of risk factors or in the presence of contraindications to cesarean section, a multicomponent correction of generic activity is carried out.

Rhodesumulating therapy by oxytocin, prostaglandins and other drugs that increase the tone and contractile activity of the uterus, during the discordination of generic activities, is contraindicated.

I degree (dystopia of the uterus).The main components of the treatment of discoordination of generic activity in I severity are: spasmolitis, anesthetics, tocolitics (β-adrethomimetics), epidural anesthesia.

Throughout the first and second period of labor, it is necessary to introduce (intravenously and / or intramuscularly) every 3 h drugs spasmolitical(but-Shpa, Baratgin, Diprofen, Gangleron) and anesthetic(Promedol, morpho-like drugs) actions. A 5-10% glucose solution with vitamins are used ( ascorbic acid, Vitamin B 6, E and A in the daily dosage).

The use of spasmolitics starts with the latent phase of labor and finish with the full opening of the uterine.

From the most effective techniques Upon elimination of the basal hypertonus of the uterus, the use of β-adrenomimetics (PARTYSISEN, Alupent, Brikanil) should be allocated. The therapeutic dose of one of the listed drugs is dissolved in 300 ml or 500 ml of 5% glucose solution or isotonic solution sodium chloride and administered intravenously initially at a speed of 5-8 drops / min, then every 15 minutes the frequency of droplets are increased by 5-8, reaching the maximum frequency of 35-40 drops / min. After 20-30 minutes, the fights are almost completely stopped. There is a period of retreat of uterine activity. Tocoliz finish 30 minutes from the beginning of the normalization of the tone of the uterus or termination of the generic activity.

After 30-40 minutes, the fights independently renew and are regular.

Indications for toxolism of the uterus in childbirth are:

Hypertensive dysfunction of the contractile activity of the uterus and its options;

Fast and rapid labor;

Tightening pathological preliminary period.

With unfinished pathological probinian period (no more than a day) you can apply a tocolic inside once (Brikanil 5 mg).

4. When discoordination, the fights need to eliminate the defective fruit bubble. Food shell Must be divorced (taking into account conditions and contraindications for artificial amniotomy).

Amniotomy is made immediately after intravenous administration of antispasmodics (but-shp 4 ml or baraglin 5 ml) so that the reduction of the volume of the uterus occurred against the background of the action of spasmolitics.

5. Due to the fact that the abnormalities of generic activities are accompanied by a decrease in the uterine and uterine-placental blood flow and the hypoxia of the fetus, in childbirth, the means regulating the blood flow.

These funds include:

Vasodilators (Eufillin);

Drugs, normalizing microcirculation processes (Reopolylukin, glucosonocaine mixture with agapurine or trental);

Means that improve the absorption of glucose and normalizing tissue metabolism (actovegin, cocarboxylase);

Means for the protection of the fetus (Seduksen at 0.07 mg / kg of body weight of the Body Fee).

All medical therapy must be regulated by the hour.

Birth leads under cardiomonitorial and hysterographic control. Safety spruses are constantly introduced. The base solution for antispasmodics is a glucosonocine mixture (10% glucose solution and a 0.5% novocaine solution in equal proportion) or a 5% glucose solution with a trental (5 ml), which improve microcirculation and reduce the pathological excessive pulsation of the uterus.

In case of late expulsion of accumulate waters, it is necessary to intravenously introduce antispasmodics. When the cervix is \u200b\u200bdisclosed for 4 cm - to produce epidural anesthesia.

The progress of childbirth is measured by the degree of revelation of the cervix and lowering the child in the area of \u200b\u200bthe pelvis. For this you need the following:

• Regular and strong contractions.
• The size of a child, allowing to go through the pelvis, and its correct position.
• The width of the pelvis is sufficient to pass the child.

If the fights are not strong enough to uncover the cervix, you will be given medicines forcing the uterus to shrink. Sometimes regular contractions suddenly stop in the middle of childbirth. If this happens and the generic process stops for several hours, the doctor may suggest breaking up an integral bubble, if it has not yet broken, or stimulate childbirth oxytocin.

Problems in the course of childbirth are as follows:

Loading early stage of childbirth. This happens if the cervix did not open up to 3 cm, despite regular contractions, in 20 hours, if it is the first childbirth, and after 14, if the birth is not the first.

Sometimes progress is slow, as these are not real delivery. You have false contractions that do not contribute to the disclosure of the neck. Some painkillers used during labor can give undesirable consequences in the form of a deceleration of the generic process, especially if they are used too early.

Treatment. Whatever the reason, if the cervix has not yet revealed when you arrived at the hospital, and the fights are not very strong, the doctor can offer certain measures to speed up the labor process. You may be suggested to go back home and relax. Often for the tightened first stage of childbirth best medicine - relaxation. You can give any soothing means.

Protective active childbirth. Early stage Giving birth can go smoothly, but the process will slow down during the active phase. Birth is considered protracted if the cervix does not open about 1 cm for an hour, after the disclosure has reached 4-5 cm. The process can go, but too slowly or to stop at all. A sharp cessation of the process after good fights may mean that the size of your pelvis does not correspond to the size of the child's head.

Treatment. If the active stage is progressing, the doctor may leave your childbirth to continue naturally. You may be suggested to like or change the position to help the process. With prolonged births, you can enter fluid intravenously to avoid dehydration.

However, if B. active childbirth There was no progress for several hours, the doctor can apply oxytocin, opening the oxygen bubble or both to speed up the process. Sometimes it is enough to resume contractions and allow you to give birth without complications.

Protecting swells. Sometimes attempts to push the child through generic canal Slow or ineffective, which depletes the power of the mother. If this is the first child, the sweat is longer than three hours are usually considered protracted. If you have already had children who dragged at the exceeding two hours.

Treatment. The doctor will appreciate how far a child has passed into the generic canal and whether it is impossible to eliminate the problem by changing the position of the head. If you still have the strength and the child does not show signs of a distress, you may be allowed to continue to live. Sometimes, if the child passed quite far away, the head can be carefully free to release with a tongs or vacuum. You may be asked to take the position of the middle trip, squatting or on all fours, which will help to push the child. If the child is too high in the genital channel and other measures do not help, the cesarean section may be required.

Intervention during childbirth

If childbirth is delayed or developing complications, doctors intervention may be required. Tools - nippers or vacuum extractor - can be used if the neck is completely revealed, the child fell, but there were difficulties with its appearance. Intervention may also be necessary if the child's head is in the wrong position and can be stuck in the pelvic area. If the heart of the child beats weakly and it needs to be quickly removed, if you are too excavated to continue to sleep, childbirth can be accelerated with tongs or vacuum. This is the fastest and safest way to extract the child.

Applying forceps. Tongs have the shape of two spoons connected like a salad layout fixture. They are neatly introduced into the vagina and cover the child's head. When the uterus is shrinking and you are treated, the doctor gently sends a child through the generic channel, and it can exit outside the next fight.

Tongs today are applied, only if the child's head fell well and is close to the outlet from the pelvis. If the head has fallen not enough, you may need a cesarean section.

Application of vacuum. Instead of tongs, a vacuum can be used if the child's head fell into the pelvis. A rubber or plastic cap is put on the child's head, the suction is turned on, and the doctor gently displays a child through the birth's way when the mother is being worried. Vacuum extractor takes less space than forceps, and the mother is less injured. But for the child, its use is somewhat more risky.

What to expect. Such kind are short, but it will take 30-45 minutes to prepare you for the procedure. You will need epidural or spinal anesthesia And the introduction of the catheter for emptying the bladder. Cuts can be made to expand the vagina to facilitate the yield of the child.

Tools helping the child's exit are very important and generally safe. Keep in mind that tongs can leave abrasions and red traces on the child's head. From the vacuum device can be a leaf or a bump on the top of the scalp and hematoma under the skin. Absadins will disappear in about a week. Bryer and red - a few days later. In any case, serious damage is rare.

The solution than to use - forceps or vacuum, it is better to provide your doctor. Experience in the use of tools is the best guarantee of complications.