Pathological preliminary period. Varicose veins of the cervix cervix, vagina and outdoor genital organs

The date: 06.04.2019

1. Preparatory cuts of uterine are painful, worried irregularity and do not go into generic activities for a long time, deprive a woman's sleep and peace; PPP duration - more than 6-10 hours.

2. No structural changes in the cervix (maturation) does not occur.

3. Ecavitability and tone of the uterus are increased.

4. The preempting head of the fetus is not pressed to the inlet in a small pelvis (even in the absence of any imbalance).

5. Due to the hypertonus of the uterus, the palpation of the prey part and small parts of the fetus is difficult.

6. The psycho-emotional state of pregnant woman is disturbed (it becomes unbalanced, irritable, afraid of childbirth).

7. The PPP is often accompanied by vegetative impairment (tremor of hands, sweating, sleep disorders, vegetative-vascular dystonia).

8. A characteristic feature for the PPP is the late influence of the accumulating waters.

Treatment of pathological principle:

Toocoliz for the normalization of excitability and withdrawing its contractile activities (Ginipral 5 ml in 250 ml of 0.9% NAcl - 6-12 CAP. IN MIN.)

Single morpho-like opiates (Promedol 20-40 mg, 15-20 mg tram)

Epidural anesthesia

PPP + immature cervix: Treatment of the PPP and the preparation of the cervix with prostaglandins E2 (disengone, dinoprotonton, probdilyl-gel, which are introduced into the cervical channel or rear vaginal arch) or the mifepristone 200 mg per OS (once or with a repeated reception after 12-24 hours).

In order to prepare the cervix, you can also use laminaries.

Pre-adduction preparation of the cervix with mifepristone, misoprostol:

Used as a fetal bubble.

Funny pregnancy in the absence of biological readiness for childbirth ("immature" cervix)

Gestosis (light and medium forms)

Hemolytic fruit disease (light shapes)

Transferred pregnancy (?!)

Chronic placental failure and hypotrophy of the fetus

Kidney disease in the absence of renal failure,

Light forms of diabetes

PPP + Mature cervix: amniotomy, observation 4-6 hours. In the absence of spontaneous generic activity - generic acid oxytocin

PPP + immature cervical cervix + spilled oily water: cesarean section

PPP + mature cervical cervix + spilled oily water: Observation 4-6 hours. In the absence of spontaneous generic activity - careful reception

Distation of the cervix:

Distation of the cervix -it is a violation of blood and lymph in the tissues of the cervix, as a result of which the edges of the uterine zea become thick, edema, rigid, poorly stretched, sometimes uneven thickening and tissue density are observed.

Most often, dystation of the cervix arises against the background of the organic structural pathology of the neck (scars, unstoppable breaks).

Tactics when dides the cervix - Caesarean section.

Hypertonus of the lower segment (reverse gradient):

The pathological state of generic activity, when the reduction wave begins in the lower umbistral segment and at the same time the lower segment is reduced stronger than the body of the uterus and the bottom. Such contractions are little effective in relation to the disclosure of shakimatki and advancement of the fetus, since the bulk of muscle muscles is in the bottom of the uterus. The peculiarity of the reverse gradient is such that these cuts (especially at an early stage) are directed rather to closing the cervix, than on the disclosure.

The etiology of this pathology is not clear,but it is precisely established that the hypertonus of the lower segment often happens with the "immature" or rigid cervix.

Obstetric tactics . Toocoliz for the normalization of excitability and withdrawing its contractile activities (Ginipral 5 ml in 250 ml of 0.9% NAcl - 6-12 CAP. IN MIN.)

Antispasmodics (Baratgin 5 ml, but-shpa 4 ml in / 2 times a day), sedative

Epidural anesthesia

In the absence of effect - COP

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. The skin of the labels are pale, 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 with abnormal shapes of the 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 a total dilution of the uterus, if the situation (the absence of infection, elevated body temperature, live fruit, not too long anhydrous gap) is considered to 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). It may develop no less severe complication - ischemia of a separate section of the uterus and the rupture 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 the spasm of muscle fibers of the internal organs (including uterus, 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, pregnancy took hormone 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 preview; Discordination of generic activities (total disal dyat); Early oral influence; intranatal death of the fetus; endomyometritis. "

Considering the presence of an acute infection, the death of the fetus, the high risk of peritonitis, from operational delivery declarations decided. For several hours, antispasmodic, antibacterial, detoxification therapy was carried out. A medical sleep was provided for 3 hours, conducted toocolized by the accountish system for 3 hours, which made it possible 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, re-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 intertensive myomatous node of large sizes, the risk of a delay of succeeds, the uterine amputation is made. The postoperative period proceeded 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, such clinical cases may occur for each practitioner's 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 the general condition, somatic health, an 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 topographyit represents quantitative, and therefore a more accurate estimate of the duration of the uterine cycle, systole and diastole 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 activities	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 taking birth through natural generics in case of complex multicomponent violations of the regulation of contractual activity of the uterus, including the Mio-Gene (the most ancient and strong in the evolutionary development of a person), it is necessary to form a generation forecast, 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.

Adverse factors include:

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 a severe disease in which a dangerous protracking flow and physical exertion;

Heavy gestosis, narrow pelvis, transferred pregnancy, scar on 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.

Life-hazardous complications may have a vital complication: the uterus break, the embolism of the octolawic waters, the premature detachment of the placenta, extensive trips of the 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 (ascorbic acid, vitamin B 6, E and A in the daily dosage) is used.

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

Of the most effective methods for eliminating the basal hypertonus of the uterus, the use of β-adrenomimetics (PARTYSISEN, Alupent, Brikanil) should be allocated. The healing dose of one of the above preparations is dissolved in 300 ml of or 500 ml of a 5% solution of glucose or isotonic solution of sodium chloride and administered intravenously slowly at a speed of 5-8 drops / min, further every 15 minutes the frequency of droplets are increased by 5-8, reaching the maximum Frequencies 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 a non-elone pathological principal period (no more than a day), you can apply a tocolic inside once (briquanyl 5 mg).

4. When discoordination, the fights need to eliminate the defective fruit bubble. Fercent shells should 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 medication 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.

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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. The expulsion of the fetus can lead to undesirable, form and topography to the ruptures of soft tissues of the genital tract, therefore, such pathology by many obstetres was recognized as an unconditional indication to Cesarean section [Lurie A. Yu., 1958; Havlasek L, 1955; Martin N., 1962, etc.].
In particular, it should be borne in mind that ceropic changes in the cervix, macroscopically fuzzy-defined, may occur after cone-shaped diathermakexisia about 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. Typically, fencers with cereal dyes are mistakenly attributed to a group of women who have a birth of generic activities, since they are delayed by a generic act. In some cases, the neckful distation is so much expressed and is not amenable to conservative therapy, which the need for a surgical order arises. 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 of cereal dyes in an independent testimony to cesarean cross 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 kind of malformations of the uterus by themselves make it impossible or dangerous delivery through natural generics. 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 the fibromyoma requires surgical treatment, it is necessary to bring pregnancy to the possibly greater vitality of the fetus and then produce a cesarean cross 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), the share of Misa of the uterus was 6% among the testimony to abdominal delivery.

Offic tumors.

The combination of malignant ovarian tumors with pregnancy belongs to the area of \u200b\u200bcasuisics. 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 production due to the presence of a benign egg tumor.

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 generics is contraindicated due to structural changes in the cervix caused by a cancer tumor: injury of cancerous tissue leads to the appearance of bleeding, enhanced metastasis and serious infectious complications, and the rigid cervix can contribute to the occurrence 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 feminines have cancer of external genital organs, rectum or bladder.

I. degree (cervical dystopia)

Due to the above, the causes of the auto-exclusion of the vegetative nervous system (sympathetic and parasympathetic), but with the preservation of the dominant of the sympathetic and adrenal system.

The emission of mediators, catecholamines, under the influence of which in the systole of the fight occurs a simultaneous reduction in longitudinal and circular muscle fibers. The triple downward gradient is preserved, the reduction force of the upper segment prevails over the reduction of the lower segment (the cage of the uterus).

The basal tone of the uterus is moderately elevated (13-14 mm Hg. Art.). The fights are frequent, long, painful, reduced the duration of the diastole (phase of relaxation).

Structural changes in the cervix (shortening, smoothing, disclosure) occur slowly. The uterine zev is revealed not only due to the reinforced stretching of circular muscles, but also due to breaks and abuses, inevitable with this pathology.

With a vaginal study, attention is drawn to the seal and stress (rigidity) of the edges of the cervix during the contraction. The fetic bubble has a flat shape, the shell - dense, the front waters are not enough, out of the contrast of the fetus bubble stress. In the fight edge of the cervix are compacted.

In case of artificial autopsy of the fetal bubble or spontaneous power of the octal water, the contractile activity of the uterus and the musometry tone can be normalized. Fights gradually become regular, more efficient, less painful, the relaxation period of the uterus increases. Births can end normally, but almost always take the cervical breaks and vagina.

If the fetal bubble is not timely eliminated, the contourization of the uterus is corrected using antispasmodic and painkillers, the coordination breach is continuing and aggravated. Hypertonus myometrium is increasing. Birth takes a long course. The feminine quickly gets tired, energy resources are depleted in the uterus.

Discordination of generic activities can go into weakness (hypotonic).

Attention should be paid to pronounced vegetative disorders in childbirth: nausea, vomiting, difficulty urination, tachycardia, moderately pronounced arterial hypertension, an increase in body temperature.

20.6.4.2. II. degree (segmental dystopia uterus)

The second, heavier, degree of violation of the coordination of uterine reductions in childbirth occurs either independently, as an option if the initial vegetative violations are deeper, or is exacerbated by the previous degree with an irrational knowledge of childbirth or an attempt to apply notioned relatives.

Often this pathology develops with a significant mechanical obstacle in childbirth (clinically narrow pelvis).

This form of hypertensive dysfunction can be considered as a heavily form of impaired neurogenic and myogenic regulation of the cutting of the uterus.

"Rhythm driver" shifts vertically on the border of the lower segment. Instead of relaxation, the segmental spasm of the circular muscles of the lower segment and (or) the area of \u200b\u200bthe inner session by the type of long tonic voltage appears.

Despite long-term generic activities (8-10 hours or more), the cervix remains dense, long, the inner zev is determined in the form of a dense roller. The cervical channel and the vaginal part of the cervical cervix have an inactive length with a difference of 1-2 cm, which indicates the absence of the necessary deployment of the lower segment.

Because of the spastically abbreviated inner zoom and insufficient deployment of the lower segment of the uterus, which did not enter the overall part of the cervix, the predatory part remains moving over the entrance of a small pelvic.

The basal tone of myometrium is high (14-20 mm Hg. Art.), The walls of the uterus (or its individual sites) are in a state of hypertonus. Intaminiotic pressure in separate (convulsive) contractions, when 2-3 uterine cycles merge into the thetanic complex, can increase by 2-3 mm Hg. Art. Above normal values, as a result of which embolism is an accumulating waters.

The pressure gradient may change to the other side, which will cause no less severe complication - premature placenta detachment. Discordination of generic activity remains the leading cause of this complication (with the exception of gestosis in which the premature detachment of the placenta is a consequence of the formation of antibodies to the placenta).

The influence of the octal water does not change the spastic nature of the bumps. Often, the rupture of the fetal shell remains unnoticed due to the lack of anterior waters. Amnion literally stretched on the fetus head and is tightly connected to the decidual cloth of the lower segment of the uterus. It is not possible to determine the integrity of the fruit bubble or its absence.

From DiscordinationI. the degrees of segmental dystocia is distinguished by the predominance of spasm not only in the field of internal zea, but also in the overlying uterine departments.

HyperStimulation of the contractile activity of the muscles of the internal state of the uterus, the formation of the contracting ring on the border of the lower segment and the uterus body can cause the so-called hanging dalion of the cervix. The latter is characterized by the fact that it is possible to rapidly stretch the outer zev, the cervix, and the inner zev is preserved in the form of a spastic ring. There arises and gradually increases swelling swelling, vagina, crotch, as it is observed in the threat of a break of the uterus.

Discordination of generic activity of this type can simulate the picture of the clinically narrow pelvis. The uterus tightly covers the fruit, takes the shape of an elongated oscillation or the shape of the "hourglass". The head of the fetus is inflicted, the biomechanism of labor takes pathological forms.

Fights wear not only spastic, but at times the tetanic character, the automatic rhythm of the bumps is disturbed. Their frequency, duration, force - uneven. Separate contractions enjoy each other, causing a sense of the incessant stupid pain.

The pronounced symptoms of vegetative dysfunction, which quickly pass at the end of childbirth are drawn attention.

The feminine behaves restlessly, shouting, meswords, becomes unmanaged. The skin of the face is hyperemic, vomiting, increased sweating, the body temperature (38.5-39.0 ° C) increases rather quickly, tachycardia (90-100 ° C / min) occurs. Arterial pressure increases, a pronounced vascular dystonia may occur. Language dry, covered with a white bloom. It is characterized by Oliguria or even paradoxical Ishuria (a lot of urine catheter). With a passing urethra and full proportionality of the fetus and the pelvis, independent urination ceases. In urine tests, erythrocytes, leukocytes are found in blood - hyperglycemia, leukocytosis, blood formula shift to the left, signs of the acute wrench of the FDS syndrome.

In segmental dyes, the uterus breaks, the tip of the cervixIII degree with the transition to the lower segment of the uterus. Such incomplete breaks of the cervix can be diagnosed, palp by climbing or inspecting the cervix from the cervical canal, since from the vagina side, the tip of the cervix may not reach the lower segment. Renewable uterine bleeding in the early postpartum period may be a consequence of an unrecognized incomplete rupture of the wall of the uterus just above the inner domestic language.

In a vaginal study, an increase in the tone of muscles of the pelvic bottom, a narrow vagina (reduction of circular muscles).

The edges of the cervix remain thick, dense, uneven, poorly stretched. During the fight, the neck is even more compacted (symptom of chickel). In childbirth, there are often bleeding, caused by cervical breaks, dumping the walls of the uterus, as well as the premature detachment of the placenta.

With inadequate therapy or an attempt to stimulate childbirth (when the weakness is erroneously diagnosed, instead of the discordination of generic activity), very heavy complications may occur, up to the development of the generic shock (which, however, is almost no longer found in our time).

Complications arising from the fetus are due not only to the impairment of the IPC, hypoxia, but also the so-called core compression at the level of the fetus neck or in the field of the umbilical ring, kidneys, adrenal, liver. In the Anglo-American literature, the indicated impact on the fruit is designated by the term "constrictRing. "-" Spastic Ring ".

Spastic segmental dystation should be distinguished from a bandl ring arising from the threat of a break of the uterus in a narrow basin. The Bandl Ring is the border between the body and the lower segment of the uterus. The spastic ring can be formed at the level of the lower segment.

Segmental dyes is accompanied by focal uterine ischemia. If there is a myomatous node in this place, necrosis may occur.

When conducting births complicated by segmental dyes, it is necessary to pay special attention to the chronometry of the bouts, CTG-control over the heartbeat of the fetus during the delivery process.

Spastic dystation, hypertonus myometrium, frequent and long-term contractions cause an overflow of intervalic spaces with venous blood with a reduced arterial inflow.

Initially, the violations are partially offset due to hypertension, increasing heart rate, increase the minute heart rate. The fetus develops moderate, and then pronounced tachycardia (180 ° C. or more), replacing moderate and severe bradycardia (less than 100 oct / min), arrhythmia.

The presence of arrhythmic palpitations of the fetus and a change in the tone soundness (muffled, metal sound, deafness) indicate the need for immediate delivery. However, these signs should be attributed to late.

Permanent cardiomonitorial control in childbirth allows you to identify early and late decelerations that appear in response to Discordated contractions.

The introduction of glucose, vitamins does not have a positive effect on the fruit, since this type of heart activity disorders is associated not only with biochemical changes in blood and hypoxia, and with mechanical heads of the head and neck with a spastic segmental ring of the uterus.

Combined damaging effect on the fruit is hypoxia, acidosis, metabolic disorders in combination with mechanical long-term compression. Numerous toxic damage to the nervous, endocrine system, parenchymal bodies of the fetus are developing. In the blood of the mother, the products of paracoagulation, proteolysis, free histamine, etc., penetrating the placenta to the fetus through the microchannels are accumulated.

It has been established that with this pathology in the blood of the newborn, the content of acetylcholine and norepinephrine is increased. It is possible that this is one of the reasons for the disorder of respiratory movements in a newborn. Increased in the blood of the mediators of the vegetative nervous system causes the gaping of the voice slot in the fetus and deep respiratory movements, which may cause aspiration of spindle water, often contaminated by admixture of meconium.

The high level of acetylcholine in the blood of the fetus determines the increased secretion of the bronchi and the pulmonary fabric, the development of respiratory distress syndrome.

In the pathogenesis of respiratory failure, the newborn has the significance of a violation of the microcirculation of light fetus when squeezing the chest is a spastically abbreviated royal ring. Hemodynamic disorders, insufficient perfusion alveoli lead to the destruction of the surfactant - the substance on which the strength of the surface tension in the alveoli. Atelectases arise, an increase in alveolar permeability, pulmonary edema and hyaline membranes.

But most often in a child born in the conditions of spastic segmental dyes, ischemic-hypoxic and traumatic damage to the central nervous system, brain substances, intracranial hemorrhages.

The last weeks of the intrauterine development of the brain of the fetus is characterized by the formation of protective mechanisms from mechanical overloads, which are experiencing fruit in the process of birth. Perestroika occurs in the vascular system of the fetus brain. Arteriovenous anastomoses are formed, playing an important role in the redistribution of blood flow in mechanical compression of the fetus head.

Hypoxic-traumatic damage to the CNS of the fetus is dangerous not only by the appearance of intracranial, subarachnoid, subdural hemorrhages, but also by the lesion of the substancebrain at the cellular level. The brain trunk is the main brainwater distributor through adrenergic and cholinergic fibers, innervating spinal and brain vessels.

The asphyxia and long-term compression of the neck (or head) of the fetus initially causes an increase in blood flow in the spinal cord and in the brain trunk (these zones are most vital). Then the white substance and the large brain bark are inspected. There is a disunity of neurons, violation of correlative ties, metabolism. brain. In some structures of the brain there comes a decrease in blood flow, in others - a violation of exchange.

When self-defense mechanisms are exhausted, irreversible changes in brain cells occur. And then, the intranatal death of the fetus is not the worst outcome of the childhood, rather than the birth of a child who will be a deep disabled since childhood.

Due to excessive mechanical overloads with dyscoordated fights, spinal cord injuries may occur. The cervical department and vertebral artery are particularly affected. Segmental disitor of the uterus, which comes on the lumbar fetus, can cause a long compression of the umbilical ring and the adrenal glands of the fetus. Foci of hemorrhage to the vertebral fetal canal, damage to nerve plexuses with subsequent paresis, paralysis of the upper and lower extremities.

20.6.4.3. III degree (total dilitation of the uterus)