Drawing up a plan for the management of physiological birth. Assessment of the fetus

Date of: 23.04.2019

1st period of labor - cervical dilatation period. A traditional birth in a hospital is conducted by a doctor together with a midwife.

1. Women in labor enter the maternity hospital during the period of opening. In their hands, each of them should have an exchange card, which contains all the information about the state of health, the results of the examination throughout the pregnancy. In the emergency room of the maternity hospital, a "History of Birth" is filled out for each woman in labor, full or partial sanitary treatment is carried out, then the woman in labor is transferred to the birth ward.

2. In the prenatal ward, the doctor clarifies the anamnestic data, conducts an additional examination of the woman in labor and a detailed obstetric examination (external obstetric examination and vaginal examination), be sure to determine the blood group and Rh factor, and examine the urine and morphological picture of the blood. Data is recorded in the birth history.

3. A woman in childbirth is put to bed, walking is allowed under whole waters and the fetal head is pressed, if the head is movable, it is recommended that the woman in labor be lying on her side, preferably on her side (prevents the development of the “lower vena cava syndrome”). To accelerate the birth, it is recommended to lie on your side, where the nape of the head of the fetus is determined.

4. Nutrition of a woman: during childbirth, the patient is not fed, because at any time the question may arise about the provision of anesthetic benefits (intravenous anesthesia, intubation, mechanical ventilation).

5. In the period of disclosure, labor pain relief is used, while the opening of the cervix should be 3-4 cm or more.

6. During the period of disclosure should be monitored

A) for the state of the woman in labor - the degree of pain, dizziness, headache, visual disturbances, etc., heart sounds, heart rate, blood pressure (on both hands)

B) for the condition of the fetus - with a whole fetal bladder, the heartbeat should be listened every 15-20 minutes, and with spilled waters - every 5-10 minutes. Normally, the heart rate is 120-140 (up to 150) beats in 1 min. after the fight, the heartbeat slows down to 100-110 beats. in 1 min., but after 10-15 seconds. is being restored. The most informative method of monitoring the condition of the fetus and the nature of labor is cardiomonitoring.

C) for the ratio of the underlying part to the entrance to the small pelvis (pressed, movable, in the cavity of the small pelvis, progression speed).

D) for the state of the uterus, the opening of the cervix.

D) the nature of labor: regularity, quantity, duration, strength of labor. The nature of labor can be determined by calculating Montevideo Unit (EM) = The number of fights in 10 minutes × intensity of the bout, normal 150-300 EM.

To register labor activity, you can use: a) clinical registration of uterine contractility - counting the number of contractions by palpation of the abdomen, b) external hysterography (using the Morea capsule, which is alternately placed on the bottom, body and lower segment of the uterus, to register a triple downward gradient); c) internal hysterography (tocography) or radio telemetry method (using the Capsule apparatus, a capsule can be inserted into the uterine cavity to record the total pressure in the uterine cavity: the maximum pressure in the uterine cavity is normally 50-60 mm Hg, the minimum is 10 mmHg) With all types of registration of contractile activity of the uterus in the first and second periods of labor, waves of a certain amplitude and duration corresponding to contractions of the uterus are recorded. ToneThe uterus, determined by hysterography, rises with the development of the birth process, normally amounting to 8-12 mm RT. Art. IntensityContraction increases as childbirth develops. Normally, in the first period ranges from 30 to 50 mm RT. Art. DurationContraction in the first stage of labor as they progresses increases from 60 to 100 seconds. IntervalBetween contractions decreases, amounting to 60 seconds. Normally, 4-4.5 contractions occur in 10 minutes.

E) for the course of childbirth - to assess the course of the birth process Partogram.In this case, the advancement of the present part of the fetus (head, pelvic end) along the birth canal is also taken into account.

G) the condition of the fetal bladder, the nature of the amniotic fluid.

H) for the function of the bladder of the woman in childbirth - every 2-3 hours a woman should urinate, if necessary, a catheterization of the bladder is performed.

I) for bowel movement - a cleansing enema is given to the woman in labor upon admission to the maternity ward and every 12-15 hours if she has not given birth.

K) for compliance with hygiene rules - treatment of the external genitalia should be carried out every 5-6 hours, and after the act of urination and defecation, before the vaginal examination. For this purpose, apply a 0.5% solution of potassium permanganate in boiled water.

7. The condition of the uterus and the fetus located in it can be determined by external obstetric examination. It is carried out systematically and repeatedly, entries in the history of childbirth should be made At least every 4 hours.

8. Vaginal examination is mandatory Twice – When a woman enters and when amniotic fluid flows away; additional vaginal examinations can be carried out if necessary to clarify the dynamics of the opening of the cervix, in case of complications in the mother, with the deterioration of the fetus, in the delivery room. Initially, an examination of the external genitalia (varicose nodes, scars, etc.) and the perineum (height, old tears, etc.) is performed. With a vaginal examination, the condition of the muscles of the pelvic floor (elastic, flabby), the vagina (wide, narrow, the presence of scars, partitions), and the cervix are ascertained. The degree of smoothing of the neck is noted, whether the opening and degree of opening (in centimeters), the condition of the edges of the pharynx (thick, thin, soft or rigid), the presence of a placental tissue within the throat, an umbilical cord loop, a small part of the fetus are noted. With a whole fetal bladder, the degree of its tension during the bout and pause is determined. Excessive stress even during a pause indicates polyhydramnios, flattening indicates low water, flabbiness indicates weakness of labor. The pre-existing part of the fetus and the identification points on it are determined. With head presentation, the sutures and fontanels are probed and, based on their relation to the planes and sizes of the pelvis, they judge the position, presentation, insertion, the presence of flexion (small fontanel lower than large) or extension (large fontanel lower than small or at the same level). During vaginal examination, the features of the osseous basis of the birth canal are also clarified, the surface of the walls of the pelvis is examined (for deformities, exostoses, etc.). Based on the vaginal examination, the ratio of the fetal head to the pelvic planes is determined. The following head positions are distinguished: above the entrance to the pelvis, small or large segment at the entrance to the pelvis, in the wide or narrow part of the cavity of the small pelvis, at the exit of the pelvis.

2nd period of childbirth - the period of exile.In the period of exile it is necessary:

1. Carefully monitor the general condition of the woman in labor, the color of the skin and visible mucous membranes, and ask about her well-being (the presence of headache, dizziness, visual impairment and other symptoms indicate a deterioration in the state of the woman in labor, which can lead to a threat to the life of the woman and the fetus), take a pulse, measure blood pressure on both hands.

2. Observe the nature of labor (strength, duration, frequency of attempts) and the condition of the uterus. Palpation to determine the degree of contraction of the uterus and its relaxation outside contractions, tension of the round ligaments, standing height and nature of the contraction ring, condition of the lower segment of the uterus.

3. To monitor the progress of the present part along the birth canal, using III and IV methods of external obstetric examination, as well as vaginal examination (to clarify the position of the head). The passage of the head through the birth canal can be monitored using Piskachek Method: fingers of the right hand wrapped with gauze, press on the tissue in the lateral region of the labia majora until the “meeting” with the fetal head. This is possible if the fetal head is in a narrow part of the pelvic cavity. It should be borne in mind that with a large birth tumor, the method does not give a reliable result. Prolonged standing of the head in the same plane of the pelvis indicates the occurrence of some obstacles to the expulsion of the fetus or a weakening of labor and can lead to compression of the soft tissues of the birth canal, urinary bladder, followed by impaired circulation and delayed urination.

In the second stage of labor there is a rule: the head during the period of exile with its large segment should not be in the same plane of the small pelvis above 2 h in primiparas and 1 hour - in multiparous.

4. The condition of the fetus is determined by listening to his heartbeat, constantly recording the frequency of contractions using cardiomonitors. In women in high-risk groups of development of intranatal pathology, the indicators of the acid-base state and oxygen tension in the blood of the predominant part are determined. In the absence of constant cardiac monitoring, it is necessary to listen to the heart tones of the fetus after each attempt and contractions, and count the heartbeat every 10-15 minutes. In the period of exile with head presentation, the basal heart rate is from 110 to 170 per minute. In response to attempts at head presentation, early U-shaped decelerations up to 80 beats / min, as well as V-shaped decelerations up to 75-85 beats / min outside the uterine contraction or short-term accelerations up to 180 beats / min are more often recorded.

5. Monitor the condition of the external genitalia to prevent rupture of the perineum. Perineal tears are 7-10%. Signs of a crotch rupture threat are:

- cyanosis of the perineum as a result of compression of the venous system;

- edema of the external genitalia;

- shiny crotch;

- pallor and thinning of the perineum as a result of the attachment of compression of the arteries.

If there is a threat of rupture of the perineum, it is necessary to dissect the perineum (perineo - or episiotomy).

6. Monitor the nature of vaginal discharge: bloody discharge may indicate a beginning detachment of the placenta or damage to the soft tissues of the birth canal; an admixture of meconium with head presentation is a sign of fetal asphyxiation; purulent discharge from the vagina indicates the presence of an inflammatory process.

7. Birth in a special bed (Rakhmanov’s bed), in the position of the woman in labor on her back. By the end of the period of exile, the woman's legs are bent at the hip and knee joints and spread apart, the head end of the bed is raised, which facilitates attempts and facilitates the easier passage of the present part of the fetus through the birth canal.

8. From the moment the teething heads begin to Obstetric benefits - birth. Obstetric allowance for head presentation ("Crotch protection")It consists of manipulations performed in a certain sequence.

1) the first moment is the prevention of premature extension of the head.At the time of birth, the head should pass through the vulvar ring in a bent position, then it cuts through the genital gap with the smallest circle drawn through the small oblique size. To do this, the midwife puts her left hand on the pubic joint and teething head, the palm is flat on the head, carefully delaying its extension and rapid advancement through the birth canal.

2) the second moment - reducing the tension of the perineal tissues, creating a “loan” of tissuesTo prevent rupture of the perineum. A loan is made as follows: the right hand is placed with the palm surface on the crotch so that four fingers fit snugly on the area of \u200b\u200bthe left, and the maximally allocated thumb is on the area of \u200b\u200bthe right labia. Gently pushing the ends of all fingers on the soft tissues along the labia majora, lower them down to the perineum, while reducing its tension.

3) the third point is the regulation of attempts:Turn off or loosen when necessary. Withdrawal of the head after its fixation (III moment of the biomechanism of childbirth) is preferably carried out without trying. To do this, during the fight, the woman is asked not to bother, but simply to breathe deeply and often with her mouth open. In this state, laborious activity is impossible. At this time, until the end of the attempt with both hands, the head is delayed until the end of the attempt. After the end of the attempt, the tissues are removed from the face of the fetus with the right hand with sliding movements. Left hand slowly raise the head anteriorly, unbending it. If necessary, women in labor offer randomly push out of the fight.

4) the fourth moment - the release of the shoulder girdle and the birth of the body.After the external rotation of the head, when the woman is pushing, self-birth of shoulders is possible. If this does not happen, then grab the head with the palms of the temporo-buccal regions and perform traction posteriorly until a third of the front shoulder is fixed to the pubic arch. Then, with the left hand, they grab the head, lifting it up, and with the right hand they carefully lower the crotch from the back shoulder and bring out the rear shoulder. After the birth of the shoulder girdle, the index fingers of both hands are introduced into the armpits from the back and the body is lifted upward, respectively, of the pelvic axis. It is necessary to withdraw the shoulder girdle carefully, without stretching the cervical spine excessively, as there may be injuries. You can also not be the first to remove the front handle from under the pubic joint, since a fracture of her or collarbone is possible. After birth, the condition of the baby is evaluated on the Apgar scale after 1 and 5 minutes. A satisfactory condition is indicated by a score of 8-10 points.

3rd period of childbirth - the subsequent period.

1. The tactics of maintaining the last period is expectant with physiological blood loss, in the absence of signs of separation of the placenta, with a good condition of the woman in labor. Active intervention becomes necessary in the following situations:

- the amount of blood loss during bleeding exceeds 500 ml, or 0.5% of body weight;

- with less blood loss, but worsening of the general condition of the woman in labor;

- with the continuation of the subsequent period of more than 30 minutes, even with a good condition of the woman in labor and in the absence of bleeding.

2. Immediately after the birth of the baby is necessary Release a woman's urine with a catheter and apply Mammary reflex to accelerate uterine contractions. In the future, it is necessary to monitor the function of the bladder preventing its overflow, as this inhibits subsequent contractions and disrupts the process of placental abruption and expulsion of the placenta.

3. Constantly monitor the general condition of the woman in childbirth, her well-being, pulse (it should be of good filling, not more than 100 beats / min), blood pressure should not decrease by more than 15-20 mm RT. Art. compared with the original, for the color of the skin and visible mucous membranes, the nature and amount of bloody discharge from the genital tract.

4. With a good condition of the woman in labor and the absence of bleeding, it is necessary to wait for an independent detachment of the placenta and the birth of the afterbirth. And constantly Need to keep track of Signs of separation of the placenta , The most important of which are:

A) Schroeder sign – Change in the shape and height of the uterine fundus - the uterus rises, above the navel, flattenes, becomes narrower and deviates to the right (the round ligament on the right is shorter);

B) the sign of Alfeld – Lengthening of the outer segment of the umbilical cord - the clamp applied to the umbilical cord at the genital fissure falls by 10-12 cm;

C) the sign of Kustner-Chukalov – When pressing the edge of the palm on the suprapubic region with a separated placenta, the umbilical cord is not retracted;

D) sign Dovzhenko – With a woman's deep breathing, the umbilical cord does not retract;

D) a sign of Klein – When straining a woman in labor, the end of the umbilical cord lengthens and after the end of the effort, the umbilical cord does not retract;

E) sign of Mikulich – Call for an effort - the separated placenta descends into the vagina, an urge for an attempt appears (sign is not constant);

G) the appearance of protrusion over the symphysis As a result, the separated placenta is lowered into the thin-walled lower segment, and the front wall of this segment is raised together with the abdominal wall.

With the physiological course of the last period, the separated afterbirth is allocated independently. If there are signs of placental separation, it is necessary to empty the bladder and invite the woman to push; under the influence of the abdominal press, the separated placenta is easily born.

5. If there are signs of separation of the placenta, but the placenta does not stand out without waiting 30 minutes, apply Ways to isolate the separated placenta:

A) the method of Abuladze – After emptying the bladder and gentle massage of the uterus, the anterior abdominal wall of the woman in labor is grabbed with both hands into the longitudinal fold so that both rectus abdominal muscles are tightly covered by the fingers; a woman in labor is offered to push and the separated afterbirth is easily born at the same time due to eliminating the discrepancy between the rectus abdominis muscles and a significant reduction in the volume of the abdominal cavity;

B) the method of the Generator – Having asked the woman in labor to relax, her hands clenched into fists are placed on the bottom of the uterus in the area of \u200b\u200bthe tube angles and slowly press inward and downward;

C) the method of Crede-Lazarevich – It is carried out in a certain sequence, without anesthesia; anesthesia is necessary only in cases where it is assumed that the separated afterbirth is delayed in the uterus due to spastic contraction of the uterine pharynx:

- empty the bladder;

- bring the bottom of the uterus to a middle position;

- produce a light stroking (not massage!) Of the uterus in order to reduce it;

- wrap around the bottom of the uterus so that the palmar surfaces of the four fingers are located on the back of the uterus, the palm on the very bottom of the uterus, and the thumb on the front wall of the uterus;

- simultaneously press on the uterus with the whole brush in two intersecting directions (with fingers - front to back, palm - from top to bottom) in the direction of the pubis until the latter is born from the vagina;

D) the method of Mitlin – A hand clenched into a fist is placed on the front abdominal wall above the bosom with the back to the symphysis; they shift the fist upward, tightly pressing it to the front abdominal wall of the woman in labor; Having reached the bottom of the uterus, they press towards the spine and ask the woman to push.

6. After the birth of the placenta, it is carefully examined to verify the integrity of the placenta and membranes, since a delay in the uterus of parts of the placenta or membranes can lead to serious complications (bleeding, septic postpartum diseases). The remains of the parts of the placenta and membranes must be removed. After examination, the placenta is measured and weighed, the data recorded in the history of childbirth.

7. After the birth of the placenta, the external genitalia, the perineum and the internal genital organs (vagina and cervix) must be examined. If there are gaps, they must be closed, this is the prevention of postpartum hemorrhage and infectious diseases, as well as prolapses and prolapses of the internal genital organs.

8. The postpartum woman is monitored for 2 hours in the delivery room, and then transferred to the postpartum unit.

The problem of protecting the health of mothers and children is considered as an important component of health care, which is of paramount importance for the formation of a healthy generation of people from the very early period of their life. Preterm birth is one of the most important issues of this problem. The relevance of preterm birth is due to the fact that they determine the level of perinatal morbidity and mortality.

Premature infants account for 60-70% of early neonatal mortality and 65-75% of infant mortality; stillbirth in premature births is observed 8–13 times more often than with timely deliveries.

Perinatal mortality of premature infants is 33 times higher than that of full-term.

The problem of preterm birth also has a psycho-social aspect, since the birth of an inferior child, his illness or death is a severe mental trauma. Women who have lost children feel fear for the outcome of a subsequent pregnancy, a sense of self-guilt, which ultimately leads to a noticeable decrease in their life activity, conflicts in the family, and often to abandon pregnancy. In this regard, the problem of preterm birth has not only medical, but also great social significance.

In our country, it is customary to consider preterm birth - childbirth, which occurred when the gestational age is from 28 to 37 weeks of pregnancy; fetal weight 1000 g. According to WHO recommendations, perinatal mortality is recorded from 22 weeks of gestation with a fetal weight of 500 g or more.

Risk Factors for Preterm Birth

Based on the clinical and clinical and laboratory analysis of the outcome of preterm birth for mother and fetus in 1000 pregnant women, we found that the risk factors for preterm birth are socio-demographic: unsettled family life, low social level, young age; as well as medical ones: every third woman with premature birth is a pregnant woman, risk factors include previous abortions, premature births, spontaneous miscarriage, urinary tract infections, and genital inflammatory diseases. An important role in the occurrence of preterm birth is played by the complicated course of this pregnancy, and the threat of abortion prevails in the structure of complications. A special place belongs to an infection during pregnancy (ARVI and other viral infections). However, these factors do not predict the outcome of preterm labor for the fetus.

Risk factors for perinatal morbidity and mortality in premature births are gestational age and fetal weight, especially the course of the preterm birth itself. These factors are abnormal position and presentation of the fetus, including pelvic presentation, detachment of a normal or low located placenta, fast or rapid birth, which increase the risk of perinatal mortality by 5 times compared with the uncomplicated course of premature birth in head presentation. Premature discharge of amniotic fluid contributes to the development of premature birth in 25-38% of cases.

Drug support for preterm birth

Currently, in the fight against threatening preterm birth, certain successes have been achieved thanks to the use of drugs in obstetric practice that suppress the contractile activity of the uterus. Beta mimetics or tocolytics, the group of substances specifically acting on beta receptors and causing uterine relaxation, are most widely used in modern conditions.

Tocolitic drugs can cause side effects and complications: palpitations, decreased blood pressure (especially diastolic), sweating, tremors, anxiety (agitation), nausea, vomiting, chills, headache, flatulence. Side effects and complications are usually associated with an overdose of the drug and very rarely with its intolerance. Therefore, for therapeutic purposes, you should reduce the dose or stop the administration of tocolytics. In the treatment with beta-mimetics, monitoring of heart rate, blood pressure, and blood sugar is necessary. To eliminate the side effects of beta-mimetics, they are combined with phenoptin at 0.04 (1 tablet) 3-4 times a day. This drug, being a calcium antagonist, not only removes the side effects of beta-mimetics, but also reduces the contractile activity of the uterus, enhancing their effect. It is possible to achieve a reduction in the dosage of medications by combining drug therapy with physiotherapy - magnesium electrophoresis by sinusoidal modulated current (SMT). Of modern beta-mimetics, the domestic drug Salgim attracts attention. A feature of this drug is that the beta particle is located on a molecule of succinic acid, an important component of the "respiration" of the cell. Therefore, there are fewer side effects when taking Salgim than with other beta-mimetics, and the effectiveness of the therapeutic effect is the same. The effectiveness of beta mimetics is 86%.

With the threat of abortion manifested by increased uterine tone, a scheme has been developed for the use of indomethacin, an inhibitor of prostaglandin synthesis. Indomethacin is prescribed at a dose of 200 mg per day in tablets or suppositories on the 1st day, 50 mg 4 times in tablets (in suppositories, 100 mg 2 times), 2–3 days after 10 m after 8 hours, 4–6 days 50 mg after 12 hours, 7-8 days, 50 mg at night. The total dose should not exceed 1000 mg. The duration of the treatment is 5-9 days. Contraindications for the use of indomethacin are gastrointestinal diseases, bronchial asthma. Inhibition of contractile activity of the uterus begins 2-3 hours after taking the drug and is expressed in a decrease in tone, a gradual decrease in the amplitude of contractions. Complete normalization of the uterus occurs 3-4 days after the start of therapy. The effectiveness of indomethacin is 72%.

The drug does not adversely affect the condition of the fetus in the indicated doses. The effectiveness of using indomethacin depends on the duration of pregnancy and the severity of changes in the cervix. If the threat of interruption is at the stage when the cervix is \u200b\u200bshortened or smoothed, indomethacin is less effective than beta-mimetics. If the contractile activity of the uterus is characterized by a high tone of the uterus, and the cervix is \u200b\u200bpreserved, then the effectiveness of indomethacin is not inferior to beta-mimetics. Side effects of indomethacin are less pronounced than in beta-mimetics and can be in the form of a headache, an allergic rash, pain in the gastrointestinal tract.

To consolidate the effect, it is advisable to use a combination of indomethacin with magnesium electrophoresis (CMT).

The therapy of threatened miscarriages and premature births by intravenous drip of 2% magnesium sulfate solution in a dose of 200 ml is carried out for 1 hour with a course of treatment of 5-7 days. Tocolytic therapy with magnesium sulfate does not adversely affect the fetus, lowers blood pressure in the mother, increases diuresis, and has a favorable sedative effect. However, the effectiveness is lower than when using beta-mimetics and indomethacin, and is 67%.

For the treatment of threatening preterm labor, it is necessary to make wider use of non-pharmacological and physiotherapeutic means of influencing the muscles of the uterus. The uterus is electro-relaxing.

With the threat of preterm birth, an integral part of therapy is the prevention of respiratory distress syndrome in newborns by prescribing a pregnant glucocorticoid drug.

Under the influence of glucocorticoids administered to a pregnant woman or directly to the fetus, more rapid lung maturation is observed, as accelerated synthesis of surfactant occurs.

Pregnant women are prescribed 8-12 mg of dexamethasone (4 mg 2 times a day intramuscularly for 2-3 days or in tablets 2 mg 4 times on the first day, 2 mg 3 times on the second day, 2 mg 2 times in the third day). The appointment of dexamethasone in order to accelerate the maturation of the fetal lungs makes sense when therapy aimed at maintaining pregnancy does not give a stable effect and premature birth occurs after 2-3 days. Since it is not always possible to predict the success of the therapy in preterm delivery, corticosteroids should be prescribed to all pregnant women who are injected with tocolytic drugs. Contraindications for glucocorticoid therapy are: peptic ulcer of the stomach and duodenum (intramuscular route of administration can be used), circulatory failure of the third degree, endocarditis, nephritis, active tuberculosis, severe diabetes, osteoporosis, severe nephropathy.

In combination therapy with beta-mimetics and glucocorticoids in case of intolerance or overdose, cases of the development of pulmonary heart failure with pulmonary edema are described. For the prevention of these serious complications, tight monitoring of the state of the pregnant woman and all hemodynamic parameters is necessary.

Prevention of respiratory distress syndrome makes sense for gestational periods of 28-33 weeks. In earlier gestational periods, antenatal lung maturation requires a longer use of the drug. Although there is no great effectiveness from repeated courses of glucocorticoids. In cases where it is not possible to prolong the pregnancy, it is necessary to use surfactant for the treatment of respiratory distress syndrome in the newborn. Antenatal prophylaxis of respiratory distress syndrome using surfactant introduced into the amnion, as a rule, is not effective. After 34 weeks of gestation, the fetal lungs already have enough surfactant and there is practically no need to prevent respiratory distress syndrome.

In order to reduce birth injury during the period of exile, the benefit is without protection of the perineum. The midwife or doctor taking the baby inserts the fingers into the vagina and stretching the vulvar ring contribute to the birth of the fetal head. In women in labor with a high rigid or scarred perineum, the perineum must be dissected to facilitate the eruption of the fetal head. |

The child is taken on a special stand, at the level of the mother's crotch. You should not raise the child or lower below the level of the uterus, so as not to create hyper- or hypovolemia in the newborn, which can cause difficulties in his cardiac activity. It is necessary to take the baby in a warm diaper. It is advisable to separate it from the mother within the first minute after birth and, if necessary, proceed with resuscitation (carefully, carefully, preferably in the incubator). Prescription of contraceptive medications (lobedine hydrochloride, caffeine) is contraindicated in a premature baby, as they can cause seizures.

Prevention of bleeding in the subsequent and early postpartum periods is carried out according to the usual method (intravenous administration of methylergometrine or oxytocin).

The clinical manifestations of rapid preterm birth are frequent, painful, prolonged contractions. The contractile activity of the uterus during rapid preterm birth or complicated by an excessively strong labor is characterized by a number of features: an increase in the rate of cervical dilatation, exceeding 0.8-1 cm / hour in the latent phase and 2.5-3 cm / hour in the active phase of labor, the frequency of contractions of 5 or more in 10 minutes, the intensity of contractions of more than 5 kPa, uterine activity in the Alexandria units - 2100 AE in the latent phase and 2430 AE in the active phase of labor.

To predict a quick preterm birth upon admission of patients, tokograms are recorded for 10-20 minutes to assess the frequency of contractions, their intensity, and a repeated vaginal examination is performed after 1 hour to assess the rate of cervical dilatation. If the parameters for evaluating the contractile activity of the uterus and the dynamics of the opening of the cervix fit into the above criteria, then fast or rapid delivery can be expected.

Correction of contractile activity disturbance during rapid preterm delivery is carried out by intravenous drip of partusisten (0.5 mg of partusisten in 250-300 ml of 0.9% physiological sodium chloride solution).

For a preliminary assessment of the reaction of the uterus to the introduction of the drug for the first 10 minutes, partusisten is administered at a dose of 0.8 μg / min (10 drops per 1 minute).

With discoordinated labor, this dose is sufficient to normalize it. In case of overly active labor, rapid labor, the dose of partusisten is increased to 1.2-3.0 μg / min, i.e. up to 40 drops per minute, to suppress an excessively high uterine activity, while a decrease in uterine contractility occurs on average after 10 minutes. Then gradually the rate of administration of the drug is reduced until regular contractions appear on the monitor with a frequency of 3-4 contractions in 10 minutes. Tocolysis continues for at least 2-3 hours under the constant supervision of hysterography. Since, often after rapid drug withdrawal, discoordinated contractions or uterine hyperactivity reappear. In the process of drug administration, it is necessary to constantly monitor the pulse and blood pressure level.

Tocolysis is stopped when the cervix is \u200b\u200bopened 8-9 cm, i.e. 30-40 minutes before the expected birth. In the subsequent and early postpartum periods, hemorrhage should be prevented by the introduction of methylergometrine 1.0 or oxytocin 5 ED in 300 ml of physiological saline.

During childbirth, the fetus is assessed based on a dynamic study of the cardiogram. With the introduction of tocolytics at a rate of 40 drops per 1 minute (1.2-3 μg / min), the fetus determines an increase in the basal rate of heart rate - up to 160-170 beats per 1 minute with single accelerations, which can be explained by the reaction of the fetus to the introduction of large doses of tocolytics , a decrease in the dose of the drug administered led to the normalization of fetal heart rate. Nevertheless, with threatening hypoxia, the introduction of small doses of partusisten led to a normalization of heart rate. In the dosages used, partusisten does not adversely affect the condition of the fetus and newborn.

Maintaining rapid preterm birth under the guise of tocolytics helps to reduce the rate of cervical dilatation and a smoother flow of labor, normalizes contractile activity of the uterus, which is reflected in a reduction in the frequency of contractions, an increase in pauses between contractions, and a decrease in their intensity, along with the absence of a significant reduction in the duration of contractions.

The intravenous use of partusisten or other tocolytics, under the control of external tocography, is an effective tool for the prevention and correction of birth disorders in preterm birth, which creates the basis for the prevention of trauma to the premature fetus and thereby reduce perinatal losses.

If there is a weakness in labor in the II stage of labor, endonasal administration of oxytocin can be used. For this, a preparation is taken from an oxytocin ampoule containing 5 IU of oxytocin and pipetted into a dose of 1-2 drops in each half of the nose after 20 minutes.

The use of the Kresteller method, a vacuum extractor for a premature fetus, is contraindicated. The use of obstetric forceps is possible with gestational periods of 34-37 weeks.

With pelvic presentation of the fetus, manual benefits should be given very carefully, using the techniques of the classic manual. The method of Tsovyanov with a purely gluteal presentation in deeply premature infants is not advisable to use, due to the slight vulnerability of the premature baby (risk of hemorrhage in the cervical spinal cord).

The issue of delivery by cesarean section in preterm pregnancy is decided individually. Currently, a caesarean section up to 34 weeks of gestation is performed according to the vital indications of the mother. In the interests of the fetus, during these gestational periods, the question may be raised about surgery in the complicated course of labor in the pelvic presentation, in the transverse, oblique position of the fetus in women with a burdened obstetric history (infertility, miscarriage) in the presence of intensive care intensive neonatal service. If surgical delivery is necessary with an undeveloped lower segment of the uterus, it is better to use a longitudinal G section on the uterus, since removing the fetus during a transverse section can be difficult. One of the most common complications of preterm birth is the premature rupture of the membranes (PRPO), which is observed in 38-51% of women with premature births. The possibility of infection with PRPO has a decisive influence on the management of pregnancy. The risk of fetal infection with PRPO is higher than that of the mother, which is understandable from the point of view of immature defense mechanisms in the fetus. Currently, in premature pregnancy and PRPO, they adhere to expectant tactics with control over the possible development of infection. Expectant tactics are more preferable than a shorter gestation period, since longer lengthening of the anhydrous period results in more accelerated maturation of the surfactant of the fetal lungs and a decrease in the incidence of hyaline membrane disease.

The following monitoring of the state of health of the mother and the fetus is required: to measure the circumference of the abdomen and the height of the bottom of the uterus, to monitor the quantity and quality of the leaking water, to measure the pulse rate, body temperature, and heart rate of the fetus every 4 hours. Determine the content of leukocytes every 12 hours, with an increase in leukocytosis, watch the leukocyte blood count. Sowing from the cervical canal, smears every five days. In the presence of an immunological laboratory, more sensitive tests for detecting an emerging infection can be used: assessment of the T-cell immunity, the appearance of C-reactive protein, spontaneous test with nitro-blue tetrazolium (with HCT).

Currently, the most informative tests for the occurrence of infection in the fetus are the determination of levels of pro-inflammatory cytokines in the peripheral blood or il-6 in the mucus of the cervical canal, which increase 2-5 weeks before preterm delivery. The definition of fibronectin is also of prognostic value. If the fibronectin level is higher than 27% during premature outflow of water in the separated cervical canal, then this indicates intrauterine infection.

With PRPO, it is necessary to decide on the use of tocolytic therapy, prevention of distress syndrome by glucocorticoids and the use of antibiotics.

Tocolytic therapy can be prescribed to a pregnant woman with PRPO in case of threatening and beginning preterm birth for prophylaxis of respiratory distress syndrome for 48-72 hours, then tocolytic therapy is canceled and observation continues. In the event of labor onset, it is no longer suppressed.

The use of glucocorticoids for the prevention of respiratory distress syndrome is one of the difficult issues in PRPO and premature pregnancy, since their use can increase the risk of infectious complications in the mother and fetus. Experience shows that the use of glucocorticoids for the prevention of respiratory distress syndrome must be used before the gestational age of 34 weeks, which favorably affects the perinatal mortality of premature infants. However, the risk of infectious complications in the mother increases.

The use of antibiotics in patients with PRPO is indicated in pregnant women at risk of infectious complications: taking glucocorticoids for a long time, with isthmic-cervical insufficiency, pregnant women with anemia, pyelonephritis, etc., chronic infections, as well as patients who have been made several times due to the obstetric situation vaginal examinations even in the absence of signs of infection. In all the others, when the slightest signs of infection appear, prescribe antibiotics, create a hormonal background with subsequent labor excitement.

Causes of Preterm Birth

Due to the peculiarities of obstetric tactics and the different outcome of labor for the fetus, we consider it appropriate to divide the preterm birth into three periods, taking into account the gestational age: premature birth at 22-27 weeks; premature birth at 28-33 weeks; premature birth at 34-37 weeks of gestation.

According to some reports, preterm birth at 22-27 weeks (fetal weight from 500 to 1000 g) is most often caused by isthmic-cervical insufficiency, infection of the lower pole of the fetal bladder and its premature rupture. Therefore, in this group of women, as a rule, there are few pre-pregnant women. The presence of infection in the genital tract excludes the possibility of prolonging pregnancy in most pregnant women. The lungs of the fetus are immature and it is not possible to accelerate their maturation by the administration of medications to the mother in a short period of time. In this regard, the outcome for the fetus in this group is the most unfavorable. Perintal mortality and morbidity are extremely high.

Preterm birth with a gestational age of 28-33 weeks (fetal weight 1000-1800 g) is due to more diverse causes than earlier preterm births. There were more than 30% of pre-pregnant women in this category of childbirth. More than half of the women had a wait-and-see tactic and prolongation of pregnancy. Despite the fact that the fetal lungs are still immature, glucocorticoids can be administered to achieve their accelerated maturation in 2-3 days. Therefore, the outcome of labor for the fetus of this gestational age is more favorable than in the previous group.

Preterm birth with a gestational age of 34-37 weeks (fetal weight 1900-2500 g or more) is due to even more diverse reasons, the percentage of infected women is much less than in previous groups and more than 50% of pre-pregnant women. Most women in this group may have expectant management of labor. However, due to the fact that the lungs of the fetus are almost mature, management is not required to stimulate the maturation of the surfactant and prolongation of pregnancy does not significantly change the indicators of perinatal mortality.

The largest percentage of termination of pregnancy occurs in terms of 34-37 weeks of pregnancy (55.3%), while in pregnancy 22-27 weeks 10 times less likely (5.7%).

Birth periods

Childbirth - an unconditioned reflex act aimed at expelling the fetal egg from the uterine cavity when the latter reaches a certain degree of maturity. Pregnancy must be at least 28 weeks, fetal body weight at least 1000 g, height - at least 35 cm. With the onset of labor, a woman is called a woman in childbirth, after the end of childbirth - the woman in labor.

There are three periods of childbirth: the first is the period of disclosure, the second is the period of exile, the third is the aftercare period.

Disclosure period begins with the first regular contractions and ends with the full disclosure of the external pharynx of the cervix.

Exile period starts from the moment the cervix is \u200b\u200bfully opened and ends with the birth of the baby.

Successive period starts from the moment of birth and ends with the expulsion of the afterbirth.

Let us dwell in more detail on the description of the clinical course and management of labor in each of these periods.

Disclosure period

This period of labor is the longest. In primiparas it lasts 10-11 hours, and in multiparous - 6-7 hours. For some women, the onset of labor is preceded by a preliminary period (“false birth”), which lasts no more than 6 hours and is characterized by the appearance of irregular contractions in frequency, duration and intensity uterus, not accompanied by severe pain and not causing discomfort in the well-being of the pregnant woman.

In the first stage of childbirth, a gradual smoothing of the cervix occurs, the external pharynx of the cervical canal opens to a degree sufficient to expel the fetus from the uterine cavity, and establish the head in the pelvic entrance. Smoothing of the cervix and opening of the external pharynx are carried out under the influence of labor pains. During contractions in the muscles of the uterus, the following occur: a) contraction of muscle fibers - contraction; b) the displacement of contracting muscle fibers, a change in their relative position - retraction. The essence of retraction is as follows. With each contraction of the uterus, temporary movement and interweaving of muscle fibers is noted; as a result, the muscle fibers lying before the contractions one after the other in length are shortened, moved into the layer of neighboring fibers, lie next to each other. In the intervals between contractions, the displacement of muscle fibers is maintained. With subsequent contractions of the uterus, the retraction of muscle fibers increases, which leads to an increasing thickening of the walls of the uterus. In addition, retraction causes stretching of the lower uterine segment, smoothing of the cervix and opening of the external pharynx of the cervical canal. This happens because the contracting muscle fibers of the uterine body pull the circular (circular) muscles of the cervix to the sides and up - the distraction of the cervix; at the same time, shortening and expansion of the cervical canal are increasing with each scrum.

At the beginning of the opening period, contractions become regular, although they are still relatively rare (after 15 minutes), weak and short (15-20 seconds by palpation). The regular nature of contractions in combination with structural changes in the cervix makes it possible to distinguish the beginning of the first stage of labor from the preliminary period.

Based on the assessment of the duration, frequency, intensity of contractions, uterine activity, the rate of neck opening and head advancement during the first stage of labor, three phases are distinguished:

I phase (latent)begins with regular contractions and lasts up to 4 cm of opening of the uterine pharynx. It lasts from 5 hours in multiparous to 6.5 hours in primiparous. Opening speed 0.35 cm / h.

II phase (active)characterized by increased labor. It lasts 1.5-3 hours. The opening of the uterine pharynx progresses from 4 to 8 cm. The opening rate is 1.5-2 cm / h in nulliparous and 2-2.5 cm / h in multiparous.

III phasecharacterized by some slowdown, lasts 1-2 hours and ends with the full opening of the uterine pharynx. Opening speed 1-1.5 cm / h.

Contractions are usually accompanied by pain, the degree of which is different and depends on the functional and typological features of the nervous system of the woman in labor. Pain during contractions is felt in the abdomen, lower back, sacrum, and inguinal areas. Sometimes in the first stage of labor, reflex nausea and vomiting may occur, in rare cases, a half-fainting state. In some women, the period of disclosure can be almost or completely painless.

The opening of the cervix is \u200b\u200bfacilitated by the movement of amniotic fluid in the direction of the cervical canal. At each fight, the muscles of the uterus exert pressure on the contents of the fetal egg, mainly on the amniotic fluid. There is a significant increase in intrauterine pressure, due to uniform pressure from the bottom and the walls of the uterus, amniotic fluid, according to the laws of hydraulics, rushes towards the lower segment of the uterus. Here in the center of the lower part of the fetus is the internal pharynx of the cervical canal, where there is no resistance. Amniotic fluid rushes to the internal pharynx under the influence of increased intrauterine pressure. Under the pressure of amniotic fluid, the lower pole of the fetal egg exfoliates from the walls of the uterus and penetrates into the internal pharynx of the cervical canal. This part of the shells of the lower pole of the egg, which penetrates along with the amniotic fluid into the cervical canal, is called the fetal bladder. During contractions, the fetal bladder is stretched and wedged deeper and deeper into the cervical canal, expanding it. The fetal bladder contributes to the expansion of the cervical canal from the inside (eccentrically), smoothing (disappearance) of the cervix and opening the external pharynx of the uterus.

Thus, the opening of the pharynx is carried out by stretching the circular muscles of the cervix (distraction), which occurs in connection with the contraction of the muscles of the uterus, the introduction of a strained fetal bladder, which expands the pharynx, acting like a hydraulic wedge. The main thing that leads to the disclosure of the cervix is \u200b\u200bits contractile activity; contractions cause both cervical distraction and an increase in intrauterine pressure, as a result of which the tension of the fetal bladder increases and its introduction into the pharynx takes place. Fetal bubble in the opening of the pharynx plays an additional role. Of primary importance is the distraction associated with the retraction rearrangement of muscle fibers.

Due to muscle retraction, the length of the uterine cavity decreases slightly, as it slides from the fetal egg, rushing up. However, this creep is limited to the ligamentous apparatus of the uterus. Round, sacro-uterine and partially wide ligaments keep the contracting uterus from excessive displacement. Tense round ligaments can be felt from the woman in labor through the abdominal wall. In connection with the indicated action of the ligamentous apparatus, uterine contractions contribute to the advancement of the fetal egg downward.

When the uterus is retracted, not only its neck, but also the lower segment is stretched. The lower segment (isthmus) of the uterus is relatively thin-walled, there are less muscle elements in it than in the uterus. Stretching of the lower segment begins even during pregnancy and increases during childbirth due to retraction of the muscles of the body or upper segment of the uterus (hollow muscle). With the development of strong contractions, the boundary between the contracting hollow muscle (upper segment) and the stretching lower uterine segment begins to become apparent. This boundary is called the boundary, or contraction, ring. The boundary ring is usually formed after the discharge of amniotic fluid; it has the form of a transverse groove that can be felt through the abdominal wall. In normal childbirth, the contraction ring does not rise high above the pubis (no higher than 4 transverse fingers).

Thus, the mechanism of the opening period is determined by the interaction of two forces that have the opposite direction: attraction from the bottom up (retraction of muscle fibers) and pressure from the top down (fetal bladder, hydraulic wedge). As a result, the cervix is \u200b\u200bsmoothed out, its channel, together with the external uterine pharynx, turns into an extended tube, the lumen of which corresponds to the size of the birth head and trunk of the fetus.

Smoothing and opening of the cervical canal in primiparous and multiparous occur differently.

In primiparas, an internal pharynx is first revealed; then the cervical canal gradually expands, which takes the form of a funnel, tapering downward. As the channel expands, the cervix is \u200b\u200bshortened and finally completely smoothed (straightened); only the external pharynx remains closed. In the future, there is a stretching and thinning of the edges of the external pharynx, it begins to open, its edges are pulled to the sides. With each fight, the opening of the pharynx increases and, finally, becomes? complete.

In multiparous, the external pharynx is ajar already at the end of pregnancy due to its expansion and tears in previous births. At the end of pregnancy and at the beginning of labor, the pharynx freely passes the tip of the finger. During the opening period, the external pharynx opens almost simultaneously with the opening of the internal pharynx and smoothing of the cervix.

The opening of the pharynx occurs gradually. First, it passes the tip of one finger, then two fingers (3-4 cm) or more. As the pharynx opens, its edges become thinner; by the end of the opening period, they have the form of a narrow, thin border, located on the border between the uterine cavity and the vagina. Disclosure is considered complete when the pharynx has expanded by 11-12 cm. With this degree of disclosure, the pharynx misses the head and body of a mature fetus.

During each fight, amniotic fluid rush to the lower pole of the fetal egg; the fetal bladder is pulled (poured) and embedded in the pharynx. After the end of the bout, the water partially moves upward, the tension of the fetal bladder weakens. The free movement of amniotic fluid towards the lower pole of the ovum and vice versa occurs until the preceding part is movable above the entrance to the pelvis. When the head is lowered, it is on all sides in contact with the lower segment of the uterus and presses this area of \u200b\u200bthe uterine wall to the entrance to the pelvis.

The place of head coverage by the walls of the lower segment is called the contact belt. The contact belt divides amniotic fluid into front and back. Amniotic fluid located in the fetal bladder below the contact belt is called the front waters. Most of the amniotic fluid, located above the contact belt, is called back waters.

The formation of the contact belt coincides with the beginning of the entry of the head into the pelvis. At this moment, the presentation of the head (occipital, anterolateral, etc.), the nature of the insertion (synclitic, asynclitic) are determined. Most often, the head is installed with a sagittal suture (small oblique size) in the transverse size of the pelvis (occipital presentation), synclitically. During this period, preparation for progressive movements in the period of exile begins.

The fetal bladder, filled with front waters, pours more and more under the influence of contractions; by the end of the opening period, the tension of the fetal bladder does not weaken in the pauses between contractions; he is ready for a break. Most often, the fetal bladder bursts with full or almost full opening of the pharynx, during the bout (timely discharge of water). After rupture of the fetal bladder, the front waters depart. Back waters usually pour out immediately after the birth of the child. The rupture of the membranes occurs mainly in connection with their overstretching of the amniotic fluid, rushing to the lower pole of the fetal bladder under the influence of increased intrauterine pressure. The rupture of the membranes is also facilitated by the morphological changes that occur in them by the end of pregnancy (thinning, decreased elasticity).

Less often, the fetal bladder bursts with incomplete opening of the pharynx, sometimes even before the onset of labor. If the fetal bladder bursts with incomplete opening of the pharynx, they speak of an early outflow of water; the discharge of amniotic fluid before the onset of labor is called premature. Early and premature discharge of amniotic fluid adversely affects the course of labor. As a result of untimely rupture of the membranes, the action of the fetal bladder (hydraulic wedge), which plays an important role in smoothing the cervix and opening the pharynx, is excluded. These processes occur under the influence of contractile activity of the uterus, but for a longer time; this often leads to complications of childbirth, adverse to the mother and fetus.

With excessive density of the membranes, the fetal bladder ruptures after the opening of the pharynx (delayed rupture of the fetal bladder); sometimes it persists until the period of expulsion and protrusion from the genital gap of the present part.

The part of the head located below the contact belt, after the discharge of the front waters, is under atmospheric pressure; the superior part of the head, the fetal body is experiencing an intrauterine pressure that is above atmospheric. In this regard, the conditions for the outflow of venous blood from the underlying part change and a birth tumor forms on it.

Maintaining disclosure period

When maintaining the first period, based on the above features of its course, it is necessary to take into account the following points:

Of great importance is the condition of the woman in childbirth (complaints, skin color, mucous membranes, dynamics of blood pressure, pulse rate and filling, body temperature, etc.). It is necessary to pay attention to the function of the bladder and bowel administration.

It is important to correctly assess the nature of labor, the duration and strength of labor. By the end of the first period of labor, contractions should be repeated after 2-3 minutes, last 45-60 sec., Gain significant strength.

The condition of the fetus is monitored by listening to the heartbeat after 15-20 minutes, and in the case of spilled waters, after 10 minutes. Fluctuations in the frequency of heart sounds of the fetus from 120 to 160 in the first period of labor is considered normal. The most objective method for assessing the condition of the fetus is cardiography.

Monitoring the condition of the soft birth canal helps to identify the condition of the lower segment of the uterus. With the physiological course of labor, palpation of the lower segment of the uterus should not be painful. As the pharynx opens, the contraction ring rises above the bosom, and when the uterine pharynx is fully opened, it should be no higher than 4-5 transverse fingers above the upper edge of the bosom. Its direction is horizontal.

The degree of opening of the uterine throat is determined by the level of standing of the contraction ring above the upper edge of the womb (Schatz-Unterbergona method), by the height of the uterine fundus relative to the xiphoid process of the woman in labor (Rogovin method). The most accurate opening of the uterine pharynx is determined by an attraction study. Vaginal examination in childbirth is performed with the onset of labor and after amniotic fluid flow. Additional studies are carried out only according to indications.

Monitoring of the progress of the presenting part is carried out using external methods of obstetric research.

The time of outflow and the nature of amniotic fluid is monitored. When water is poured out until the uterine pharynx is fully opened, a vaginal examination is performed. Attention should be paid to the color of amniotic fluid. Water indicates the presence of fetal hypoxia. With the full opening of the uterine pharynx and the whole fetal bladder, an amniotomy should be performed. The results of monitoring a woman in labor are recorded in the history of childbirth every 2-3 hours.

In childbirth, the regimen of the woman in labor should be established. Before the amniotic fluid is poured out, a woman in labor can usually occupy an arbitrary position and move freely. With the moving head of the fetus, bed rest is prescribed, the woman in labor should lie on the side of the nape of the fetus, which contributes to the insertion of the head. After inserting the head, the position of the woman in labor can be arbitrary. At the end of the first period, the most physiological position is the woman in labor on her back with a raised body, since it helps to advance the fetus along the birth canal, because the longitudinal axis of the fetus and the axis of the birth canal in this case coincide. The woman's diet should include easily digestible high-calorie foods: sweet tea or coffee, mashed soups, jelly, stewed fruit, milk porridge.

During childbirth, it is necessary to monitor the emptying of the bladder and intestines. The bladder has a common innervation with the lower segment of the uterus, in this regard, overflow of the bladder leads to dysfunction of the lower segment of the uterus and weakening of labor. Therefore, it is necessary to recommend a woman in labor to urinate every 2-3 hours. If urination is delayed up to 3-4 hours, resort to catheterization of the bladder. Of great importance is the timely emptying of the intestine. The first time a cleansing enema is given when a woman in childbirth enters a maternity hospital. If the disclosure period lasts more than 12 hours, the enema is repeated.

For the prevention of ascending infection, careful observance of sanitary and hygienic measures is of extreme importance. The external genitals of the woman in labor are treated with a disinfectant solution at least once every 6 hours, after each act of urination and defecation and before the vaginal examination.

The period of disclosure is the longest of all periods of childbirth and is accompanied by pain of varying degrees of intensity, therefore, maximum pain relief for childbirth is mandatory. For labor pain relief, drugs with an antispasmodic effect are widely used:

Atropine 0.1% solution of 1 ml IM or IV.

Aprofen 1% solution of 1 ml / m. The greatest effect is observed with a combination of aprofen with analgesics.

No-spa 2% solution of 2 ml subcutaneously or in / m.

Baralgin, spazgan, maxigan po5mg iv slowly.

In addition to these drugs for pain relief in the 1st stage of labor, epidural anesthesia can be used, giving a pronounced analgesic antispasmodic and hypotensive. It is performed by an anesthesiologist and is performed at the opening of the uterine pharynx by 4-3 cm. Of the drugs that have an effect mainly on the cerebral cortex, the following are used:

Nitrous oxide mixed with oxygen (2: 1 or 3: 1 respectively). In the absence of a sufficient effect, triylene is added to the gas mixture.

Trilene has an analgesic effect in a concentration of 0.5-0.7%. With intrauterine hypoxia of the fetus, trilene is not used.

GHB is introduced in the form of a 20% solution of 10-20 ml.v / v. Anesthesia occurs in 5-8 minutes. And last 1-3 hours. Contraindicated in women with hypertension syndrome. With the introduction of GHB, predication of a 0.1% atropine solution is carried out - 1 ml.

Promedol 1-2% solution –1-2 ml or fentanyl 0.01% –1 ml, but no later than 2 hours before the birth of a baby, because depresses his respiratory center.

Exile period

Exile period

In the second stage of labor, the fetus is expelled from the uterus through the birth canal. After the outflow of water, contractions for a short time (several minutes) cease; at this time, the retraction of the muscles and the adaptation of the walls of the uterus to a reduced (after the discharge of water) volume continue. The walls of the uterus become thicker and more closely adjoin to the fetus. The expanded lower segment and the smoothed neck with the open pharynx form, together with the vagina, the birth canal, which corresponds to the size of the head and trunk of the fetus. By the beginning of the period of exile, the head is intimately in contact with the lower segment (internal fit) and with it closely and comprehensively adheres to the walls of the small pelvis (external fit). After a short pause, contractions resume and intensify, retraction reaches its highest limit, intrauterine pressure increases. Strengthening expelling contractions due to the fact that a dense head is more irritating to nerve endings than the fetal bladder. During the period of exile, contractions become more frequent, and the pauses between them are shorter.

Fights soon join attempts- reflexively occurring contractions of the striated abdominal muscles. Attachment of attempts to expelling contractions means the beginning of the process of expulsion of the fetus.

During the attempts, the childbirth’s breathing is delayed, the diaphragm lowers, the abdominal muscles become very tense, and the abdominal pressure increases. Increasing abdominal pressure is transmitted to the uterus and fetus. Under the influence of these forces, the “formation” (“formation”) of the fetus occurs. The spine of the fetus is unbent, the crossed arms are pressed closer to the body, the shoulders rise to the head and the entire upper end of the fetus acquires a cylindrical shape, which contributes to the expulsion of the fetus from the uterine cavity.

Under the influence of increasing intrauterine and joining intra-abdominal pressure, translational movements of the fetus through the birth canal and its birth occur. Translational movements occur along the axis of the birth canal; in this case, the precursor part performs not only translational, but also a series of rotational movements that facilitate its passage through the birth canal. With increasing force of expelling contractions and attempts, the underlying part (normally the head) overcomes resistance from the muscles of the pelvic floor and the vulvar ring.

The appearance of the head from the genital gap only during attempts is called cuttingheads. It indicates the end of the internal rotation of the head, which is installed in the cavity exit from the small pelvis; the fixation point is being formed. With the further course of the birth act, the head appears to be so deeply cut into the genital fissure that it remains there outside of the effort. This position of the head indicates the formation of a fixation point (suboccipital fossa with the front view of the occipital insertion). From this moment, under the influence of ongoing attempts, teethingheads. With each new effort, the fetal head more and more leaves the genital gap. First, the occipital region of the fetus erupts (is born). Then, parietal tubercles are installed in the genital fissure. The crotch voltage reaches its maximum at this time. There comes the most painful, albeit short-term moment of childbirth. After the birth of the parietal tubercles, the forehead and the face of the fetus pass through the sexual fissure. This ends the birth of the fetal head. The fetal head was cut (born), this corresponds to the end of its extension.

After birth, the head makes an external rotation according to the biomechanism of childbirth. In the first position, the face turns to the right thigh of the mother, in the second position - to the left. After an external rotation of the head, the anterior shoulder is delayed at the pubis, the posterior shoulder is born, then the entire shoulder girdle and the entire trunk of the fetus along with the back waters flowing from the uterus. The back waters may contain particles of a cheese-like lubricant, sometimes an admixture of blood from small ruptures of the soft tissues of the birth canal.

The newborn begins to breathe, scream loudly, actively move his limbs. His skin turns pink quickly.

The woman in labor experiences great fatigue and rests after intense muscular work. The heart rate gradually decreases. After giving birth, a pregnant woman may experience severe chills, associated with a large loss of energy during intense attempts. The period of exile in primiparas lasts from 1 hour to 2 hours, in multiparous - from 15 minutes to 1 hour.

Maintaining an exile period

In the second stage of labor, it is necessary to monitor:

state of mother;

the nature of labor;

fetal condition: determined by listening to his heartbeat after each attempt in the middle of a pause, fluctuations in the heart rate of the fetus in the second stage of labor from 110 to 130 beats. in minutes, if it is leveled between attempts, it should be considered normal;

the state of the lower segment of the uterus: assessed by the level of standing of the contraction ring above the upper edge of the womb;

advancement of the present part of the fetus (head).

Childbirth carried out on a special bed Rakhmanov, well suited for this. This bed is higher than usual (it is convenient to assist in the II and III periods of childbirth), consists of 3 parts. The head end of the bed can be raised or lowered. The foot end can be retracted: The bed has special footrests and reins for the hands. The mattress for such a bed consists of three parts (polsters) covered with oilcloth (which facilitates their disinfection). In order for the external genitalia and perineum to be clearly visible, the polster located under the legs of the woman in labor is removed. A woman in labor is lying on Rakhmanov’s bed on her back, her legs are bent at the knee and hip joints and rest against the coasters. The head end of the bed is raised. This results in a semi-sitting position in which the axis of the uterus and the axis of the pelvis coincide, which favors easier movement of the fetal head through the birth canal and facilitates attempts. To strengthen efforts and be able to themto regulate, women in labor are recommended to hold hands on the edge of the bed or for special “reins”.

To receive each child in the delivery room, you must have:

individual set of sterile linen (blanket and 3 cotton diapers), heated to 40 ° C;

individual sterile kit for primary processing of a newborn: 2 Kocher clamps, Rogovin bracket, forceps for applying it, triangular gauze, pipette, cotton balls, tape 60 cm long and 1 cm wide for anthropometry of a newborn, 2 oilcloth bracelets, catheter or balloon for suctioning mucus.

From the moment of cutting the head, everything should be ready to receive childbirth. The external genitalia of the woman in labor are disinfected. A midwife taking birth, washes her hands, as before an abdominal operation, puts on a sterile gown and sterile gloves. Sterile shoe covers are put on the woman in labor; the hips, legs and anus are covered with a sterile sheet, the end of which is placed under the sacrum.

During cutting, the heads are limited to monitoring the state of the woman in labor, the nature of the attempts and the heartbeat of the fetus. To receive birth begin during teething. The mother gives a manual benefit, which is called "perineum protection", or "maintaining the perineum." This manual is aimed at contributing to the birth of the head with the smallest size for this insertion, to prevent disturbances in the intracranial circulation of the fetus and trauma to the maternal soft birth canal (perineum). When providing manual benefits for head presentation, all manipulations are performed in a certain sequence. The childbearing person usually stands to the right of the woman in labor.

The first moment isprevention of premature extension of the head. The more the fetal head is bent with the front view of the occipital presentation, the smaller the circumference it cuts through the genital fissure. Consequently, the perineum is less stretched and the head itself is less compressed by the tissues of the birth canal. By delaying the extension of the head, the delivery doctor (midwife) promotes her eruption in a bent state with a circle corresponding to a small oblique size (32 cm). With an unbent head, it could be cut by a circle corresponding to the direct size (34 cm).

Usually, the second stage of labor, when the fetus is expelled, is considered to be the most important. But the subsequent, third period of labor, although it is the shortest, also plays a large role in the successful completion of the process. He is also called the next. The third period begins its countdown from the moment the baby is born and ends with the release of the afterbirth.

Although the final stage of labor is short, it can pose a certain danger to the woman in childbirth, since there is a risk of bleeding. Much attention is paid to the examination of the placenta, cervix and the general condition of the mother.

What is a afterbirth?

The latter is called the separated placenta, amniotic membranes and the umbilical cord. Through the placenta during pregnancy, the fetus was supplied with oxygen and nutrients.

The third stage of labor is characterized by the appearance, which in their intensity is significantly inferior to contractions during the opening of the cervix. They are necessary for the gradual separation of the placenta from the uterine walls. After several attempts, the placenta emerges and the birth process can be considered completed.

The duration of the birth of the afterbirth is 2-3 minutes, and the stage itself should last no more than 15-20 minutes.

Tactics of conducting the third stage of labor

As soon as the baby is born, the umbilical cord pulsation is expected to end, and then the newborn is separated from the mother.

One of the catchphrases known in obstetrics is: “Hands off the uterus in the posterior period!”. It does not need to be understood absolutely literally. It is understood that in the third period, the main method of conducting birth is waiting. Uncontrolled pressure on the organ can trigger bleeding.

In a healthy woman and with the normal course of the first two stages of childbirth, you need to wait for the independent birth of the placenta. Active management is necessary in those cases when the natural exit of the afterbirth does not occur after 30 or more minutes after the end of the exile stage. According to WHO recommendations, active management of the third period involves the intravenous administration of oxytocin, controlled pulling on the umbilical cord, and stimulation of the nipples of the woman in labor in order to prevent bleeding.

A number of factors can cause complications during this phase. Pathologies include:

heavy bleeding caused by injuries or ruptures;
delay in separation of the placenta or its incomplete exit;
premature
dense increment or ingrowth of the placenta.

Premature detachment of the placenta, which threatens the condition of the baby, can occur in the second stage of labor. In this case, bloody discharge with clots is observed, and meconium appears in the amniotic fluid.

All pathologies of the subsequent one, as well as the first days after delivery, are associated with violations of the normal course of pregnancy, when a woman had severe, anemia, heart or kidney failure, tuberculosis.

Department of the placenta

There are several signs by which the separation of the placenta is determined, we give an example of some of them:

a change in the height of the bottom of the uterus, which rises up;
with deep breathing of the woman in labor, the umbilical cord is not retracted;
when pressing sideways on the suprapubic area, the umbilical cord does not retract into the birth canal;
the placenta is located in the vagina, provoking attempts (not always);

The separation of the placenta is judged by a combination of several signs. If with symptoms of separation the placenta lingers in the uterus, the woman is asked to push in order to speed up the process. If birth does not occur, it is isolated manually.

There are several ways to manually isolate the afterbirth. All of them involve the creation of sufficient intra-abdominal pressure. After emptying the bladder and gentle massage of the uterus, manipulations are performed that contribute to the manual allocation of the placenta.

A born afterbirth must be carefully examined. The delay of even small parts of it in the uterus can adversely affect the health of the mother. If there is a suspicion of a delay in placental tissue residues, curettage under general anesthesia is necessary.

It should be noted such a rare pathology as the growth of the placenta. As a rule, she is diagnosed at the prenatal stage. Most often, ingrowth occurs when there is a scar on the uterine wall from previous curettage or other manipulations, in the presence of fibroids or abnormalities in the structure of the organ. In these cases, caesarean section and surgical removal of the placenta are indicated.

How high is the risk of bleeding?

The third period of labor ends with the release of the afterbirth, and the woman, now called the puerpera, can rest. In a newly minted mother, the respiratory rate, pulse, and emotional state are gradually restored. An assessment of its general condition is important: skin color, indicators of pressure and pulse, presence or absence, and other damage to the birth canal.

Blood loss in the 3rd stage of labor should not exceed 200-400 ml. To control the volume of blood under the pelvis, women lay a tray or vessel. If there are cracks or tears, they are sutured. This is necessary for quick healing and prevention of infection. On the lower abdomen is shown the application of cold.

A woman should be in the maternity ward for two hours to closely monitor her condition.

Pathological bleeding in the 3rd stage of labor is the allocation of blood with a volume exceeding 400 ml. Symptoms of the pathology are as follows:

intermittent leakage of blood, the presence of clots;
a sharp drop in blood pressure;
sagging of the uterus, determined by palpation;
dizziness, pallor of the skin;
general severe weakness, threat of fainting.

The cause of bleeding can be trauma of the birth canal, poor contractility of the uterus, pathologies associated with poor blood coagulation. But most often, the cause of bleeding becomes a violation in the separation of the placenta. Provoking factors can be severe toxicosis in the second half of pregnancy, violations of the utero-placental blood flow, the birth of a child with a large weight or.

Immediate treatment should be aimed at stopping bleeding, which threatens the life of the mother. A woman is given hemostatic drugs, solutions to increase blood pressure, funds to enhance the contractility of the uterus, transfusion, a concentrated plasma solution, blood substitutes. The stopping of bleeding is facilitated by the manual allocation of placental tissue.

It is forbidden to transport a woman to the ward until her blood pressure stabilizes. If necessary, carry out artificial respiration and indirect heart massage.

In order to significantly reduce the risk of complications in the subsequent period, rational management of childbirth as a whole is necessary, eliminating unreasonable pressure on the uterus, careful use of funds that stimulate its reduction, and cesarean section, if there are appropriate indications.

1. Preparation for taking birth in primiparous begins from the moment of cutting the fetal head, and in multiparous - from the moment of full opening of the cervix. The woman in labor is transferred to the birth hall and equipment, instruments, sterile material and underwear for the toilet of the newborn are prepared.

2. The position of the woman in childbirth. The woman is in a gynecological position, leaning slightly on her left side (to prevent compression of the aorta and inferior vena cava by the pregnant uterus). This position provides the obstetrician with good access to the perineum. A woman in labor can also sit or take a knee-chest position.

but. Studies have shown that the most comfortable position in childbirth is half-sitting. For this, leg holders are attached to the table. This position of the woman in labor does not affect the condition of the fetus and reduces the need for the application of obstetric forceps.

b. The crotch is treated with iodine solution. Choose anesthesia method. By mutual consent, women in labor and the doctor can give birth without anesthesia. If an episiotomy is suspected, perineal infiltration anesthesia or pudental anesthesia are performed.

3. Obstetric benefit in the anterior position of the occipital presentation

but. Head withdrawal. Obstetric allowance is necessary so that the head passes through the vulvar ring with its smallest diameter - a small oblique size. The obstetric aid is to prevent premature extension of the head, and then carefully withdraw the face and chin of the fetus by pressing on the perineum and pushing it back and down. This reduces the tension of the perineum and reduces the risk of rupture. Another method is the active extension of the fetal head by pressing with one hand on the chin of the fetus through the perineum, and the other on the back of the fetus. This method is more traumatic and is used only in the intervals between contractions. After the birth of the head, mucus is removed from the nasopharynx and oropharynx of the fetus using a catheter connected to a special suction. If meconium is detected, before removing the shoulders, the nasopharynx and oropharynx, as well as the fetal stomach, are freed from meconium using a special suction. It should be remembered that with excessive irritation of the posterior pharyngeal wall, reflex bradycardia is possible. With difficult removal of the shoulders, mucus is aspirated only after their birth. By inserting a finger into the vagina, it is determined whether the cord is entangled around the neck. In the case of entanglement, they try to shift the umbilical cord to the back of the head or body. If this does not succeed, two clamps are applied to the umbilical cord, cross it and continue the delivery.

b. Removing the shoulders. In order to help the birth of the anterior shoulder, the fetal head is slightly tilted down, sometimes the assistant is asked to put pressure on the suprapubic region of the woman in labor. After the front shoulder is pulled out from under the pubic arch, the head is lifted up and the posterior shoulder is carefully withdrawn. The eruption of the shoulders requires special attention, since this causes a significant stretching of the soft tissues and a rupture of the perineum.

at. The final stage. After the birth of the child’s shoulders, holding with one hand behind the neck, with the other - behind the buttocks, is removed and turned on the stomach to release the nasopharynx from the mucus. Then the child is laid on the table, the remaining mucus from the nasopharynx is sucked off, two clamps are placed on the umbilical cord and crossed so that the remainder of the umbilical cord is 2-3 cm. Then the umbilical ring is examined to exclude umbilical hernia and umbilical cord hernia. The child is briefly placed on the mother’s stomach (for the first contact), and then placed in a couveuse.

4. Perineo- and episiotomy are perineal dissection operations to expand the birth canal. The crotch is dissected with scissors or a scalpel along the midline (perineotomy) or on the sides of it (episiotomy).

but. Indications

1) Prevention of rupture of the perineum.

2) Prevention of stretching the pelvic floor.

3) Prevention of birth injury.

b. Risk assessment. Although perineo- and episiotomy in obstetrics are used very widely, their effectiveness could not be confirmed in prospective studies. However, it should be noted that a wound from a perineo- or episiotomy always heals better than perineal ruptures. In the postpartum period, the postpartum woman for several days may be bothered by pain and swelling of the tissues in the area of \u200b\u200bthe operation. Dyspareunia (pain during intercourse) may occur within a few weeks after birth. The most serious complication is wound infection.

at. Time. The operation is performed at the moment when a portion of the head with a diameter of 3-4 cm is shown from the genital fissure. If an incision is made earlier, greater blood loss is possible, later - stretching of the perineum and vagina.

d. Technique of operation. Apply superficial, pudental or spinal anesthesia. Tissues of the perineum are lifted above the fetal head and at the height of the next effort they are dissected towards the anus. On the one hand, the incision should be sufficient so that during childbirth it does not turn into a gap, on the other hand, injuries to the rectum and sphincter of the anus should be avoided. With a low perineum, an episiotomy is performed. They lead the birth carefully, trying to prevent the incision from turning into a gap, for this, the crotch is pressed with a hand. It is important to remember that most births can be successfully performed without perineo- and episiotomy.