Clinic and management of childbirth with abnormalities of uterine contractility. Discoordination of labor

Modern medicine has accumulated a large amount of factual material in the field of disorders of contractile activity of the uterus. There are 2 variants of this pathology:

primary weakness of labor - inadequate dilation of the cervix in the presence of contractile activity;
secondary weakness of labor - associated with the cessation of contractions immediately at the time of labor and occurs after normal contractile activity of the uterus.

Also, in some cases, other types of contractile activity disorders are identified: atony ( complete absence contractile activity of the muscles of the uterus), erratic contractile activity, hypotonic dysfunction of the uterus, the presence of irregular contractile activity, rapid labor and contraction ring - dystocia are also distinguished separately.
Hypertensive dysfunction of uterine contractions is a separate type of labor disorder; it has several variants of its course - from contraction of the uterine muscles in the form of an hourglass to convulsive contractions. In some cases, unspecified changes in the labor of the uterus are observed, delaying the process of childbirth in general or only one of its periods.
Disturbances in the contractile activity of the uterus develop as a result of various types of malfunction of organs reproductive system and other body systems that affect normal processes preparation for childbirth. Moreover, the causes of this pathology may be associated with the maternal body and the development of the fetus.
The reasons from the maternal body are as follows:

disorders in the nervous system: decreased functional activity of the brain centers regulating the processes of preparing the mother’s body for childbirth;
diseases of organs that are not directly related to the reproductive (genital) system of a woman (liver, kidneys, cardiovascular system, etc.);
diseases of neuroendocrine organs - adrenal glands, thyroid gland, hypothalamus, etc.;
structural changes in the muscular layer of the uterus (cause problematic labor). Such changes are caused by operations on the uterus, abortion, the presence of fibroids and congenital anomalies development of the uterus and appendages;
excessive overstretching of the muscular layer of the uterus in the case of multiple pregnancies, a large fetus or a large amount of amniotic fluid;
internal obstacles - anatomically narrow pelvis, transverse position of the fetus, incorrect insertion of the fetal head, as well as external obstacles - tumors in the pelvis;
genetically determined protein depletion of the uterine muscles; as a result, the muscle tissue lacks contractile proteins, so adequate contractile activity of the uterus is impossible.

On the part of the fetus, the most common causes of the development of disturbances in the contractile activity of the uterus during childbirth are:

malformations of the nervous and endocrine systems of the fetus;
underdevelopment of the cortical structures of the fetal adrenal glands;
abnormalities in the location of the placenta;
underdevelopment of placental structures or overripening of the placenta;
disorders of the uteroplacental and placental-fetal blood flow.

Also, the development of disorders of the prenatal period and the birth act is influenced by the insufficient readiness of the mother and fetus for the birth act, which can be physiologically explained by a large number of factors, both internal and external: excessive use of birth-stimulating or antispasmodic drugs, the use of narcotic analgesics. Thus, taking the latter provides some inhibition of the labor activity of the uterine muscles, which is required in case of fatigue of the patient and in case of insomnia. full disclosure cervix. While the drug is in effect, the body's strength is restored, after which contractile activity resumes with proper force.
Formation normal course the prenatal period and subsequent labor is determined by the observance of numerous measures during pregnancy. First of all, good nutrition is required. It is important that during pregnancy the female body receives the required amount of protein, fats, carbohydrates, vitamins, microelements and amino acids (arachidonic, linoleic). It is these amino acids that are involved in the synthesis of prostaglandins - the main biological substances involved in the contractile activity of the uterine muscles. Nonessential amino acids are synthesized in the body from incoming nutrients. Essential amino acids must be supplied from food required quantity for mother and fetus, since they are not synthesized in the body. In many ways, the change in taste preferences during pregnancy is explained by a lack of certain amino acids, vitamins and microelements. But good nutrition and the supply of necessary nutrients, vitamins and minerals to the mother’s body do not always cover the increasing needs of the pregnant woman’s body. Often, it is during pregnancy that the failure of certain organs and systems of the body is discovered. Due to disturbances in the functioning of organs and systems, a lack of certain structural proteins, fats, and amino acids occurs. Therefore, even against the background of adequate intake of all substances, disturbances occur in the prenatal period and childbirth.
Each of these reasons can lead to a malfunction in the “mother-placenta-fetus” system. Next, the mechanisms that cause disturbances in the contractile activity of the muscles of the uterus are directly launched. Thus, the adequate contractile activity of the uterus is influenced by the level of body hormones: a lack of estrogen leads to a slow process of preparing the birth canal for childbirth. Estrogens in the bloodstream of a pregnant woman circulate constantly, but at some point their level should rise significantly, this is what ensures maturation. structural elements cervix and muscular layer of the uterus to overstretch and contraction during childbirth. Irregular release of the hormone oxytocin has no less effect on the contractile activity of the muscles of the uterus. But excessive synthesis of prostaglandins (derivatives of unsaturated fatty acids) causes excessive contractile activity of the uterine myometrium and, as a rule, either leads to rapid labor or causes discoordinated labor activity.
In the formation of labor activity, a special place is occupied by the formation and work of α- and β-adrenergic receptors, the function of which is to coordinate the processes of contraction and relaxation of the uterus.
Discoordination of labor in most cases is associated with not enoughα- and β-adrenergic receptors or the inability to adequately perceive impulses from the central nervous system and its peripheral parts both in the prenatal period and during childbirth.
Particular attention deserves the participation of the autonomic nervous system in the preparation for childbirth and the birth act, since thanks to it, it becomes possible to coordinate the entire complex of mechanisms that ensure the normal contractile activity of the uterus.
Sometimes, even with normal operation of all mechanisms, disturbances in the contractile activity of the uterus are observed, which is associated with problems in the structure of the muscular lining of the uterus - slowdown biochemical reactions in the muscle, maintaining the energy component at the proper level. Quite often, the cause of problems during childbirth is a change in the location of the direct “driver” of the rhythm of contractile activity of the uterus, which from the tubal angle, where it is normally located, shifts to the center, to the body area or even to the lower segment of the uterus.
The combination or predominance of certain disturbance factors changes the entire process of the normal physiological course of contractile activity of the uterus, weakening the strength and effectiveness of contractions in the prenatal period and the birth act.
Most often, labor activity against the background of combined disorders is characterized by weak contraction of the uterine muscles and inadequate opening of the birth canal for the passage of the fetus.
However, the pathological process of weakness of labor is largely due to a decrease in the tone of the autonomic nervous system and in the muscular layer of the uterus.

Primary weakness of labor

With the development of primary weakness of labor, an important role is played by the initially low tone of the uterine muscles, which leads to weak and rare contractions and a small opening of the uterine pharynx. Estimate functional activity labor activity can be done by taking into account the frequency of contractions and their intensity. Primary birth weakness characterized by a frequency of contractions of 1-2 per 10 minutes. In this case, the duration of the contraction is 15-20 seconds, and the intensity of contractions does not exceed 20-25 mm Hg. Art. There is also an increase in the period of relaxation between contractions by an average of 1.4-2 times compared with a normally physiological birth.
The intensity of uterine contractions, duration and frequency of contractions are assessed using a special device that operates on the principle of measuring an electrocardiogram. As a result, the contractile activity of the uterus is recorded as a curve on paper. Next, the doctor evaluates the nature of this curve, the contractile activity of the uterus and the condition of the fetus, since at the same time the fetal heart rate is recorded on the paper of the second curve.
The reasons for the weakness of labor are numerous, but the course of all processes in the myometrium (the muscular layer of the uterus) is typical. In particular, slow processes are noted in the structural changes of the cervix (shortening, smoothing, opening of the cervical canal) in the latent phase. Since the birth canal is not ready for the passage of the fetus, there is a prolonged presence of the presenting part of the fetus pressed against the entrance to the pelvis, which often leads to fetal pathologies (hematoma, disorders of the neuro-reflex apparatus).
With adequate contractile activity of the uterus, high blood pressure inside the fetal bladder, so the fetal bladder is tense and promotes the opening of the birth canal. In turn, with weak labor, the fetal bladder is sluggish, weakly pours into the contraction and does not contribute to dilatation, but only interferes. Therefore, they resort to premature opening of the bladder to speed up the course of labor. Against this background, the process of synchronous and proper opening of the uterine pharynx and advancement of the head along the birth canal is disrupted, which cannot always be restored without complications for the mother and fetus.
In addition to recording labor activity with the device, an assessment of the state of labor activity is carried out by an obstetrician after vaginal examination women. The doctor counts the frequency of contractions and evaluates the opening of the uterine pharynx. Due to prolonged weakness of labor, difficulties arise both during the passage of the fetus through the birth canal and in the postpartum period. This becomes the cause of bleeding in most cases.
In this case, the birth act is significantly prolonged, and the resulting fatigue of the woman in labor can prevent the spontaneous end of labor. A significant duration of labor is dangerous in cases where premature rupture of amniotic fluid has occurred, since such a situation increases the risk of ascending infection into the uterine cavity and infection of the fetus. At the same time, the likelihood of respiratory failure and intrauterine fetal death increases.

An unfavorable moment is the prolonged immobile standing of the fetal head in one plane, both for the fetus and for the mother’s body.
When identifying a violation of the contractile activity of the uterus, it is necessary to take into account possible influence another pathology - inferiority of the muscular layer of the uterus, associated with the failure of the scar on the uterus, after opening its cavity, removing tumors on the muscle of the uterus, a previous cesarean section. The discrepancy between the sizes of the fetal head and the pelvis of the woman in labor (anatomically narrow pelvis) also leads to disruption of the contractile activity of the uterus. bad condition fetus due to disturbances of uteroplacental and fetal-placental blood flow, syndrome respiratory disorders child, lack of oxygen, fetal malformations, intrauterine growth retardation.

Secondary weakness of labor

Secondary weakness of labor is characterized by a gradual development, while the onset of labor is characterized by a completely normal frequency of contractions and adequate opening of the uterine pharynx. For some reason, labor activity weakens from a certain point, the frequency of contractions decreases until a gradual complete cessation. At the same time, the tone and excitability of the uterine muscles decrease, even to external stimuli and medications.
In the case when the weakness of labor develops before the complete opening of the uterine pharynx, against the background of reduced contractile activity of the uterus, the opening of the uterine pharynx slows down, reaching 5-6 cm. As a result of this, the presenting part of the fetus does not move further along the birth canal and stops in one of the cavities small pelvis.
Basically, secondary weakness of the contractile activity of the uterus develops at the end of the period of dilatation or already during the period of birth of the fetus.
Like primary weakness of labor, secondary weakness develops due to many malfunctions in the reproductive system and other organs and systems of the body. Often, secondary weakness of labor becomes the result of depletion of the compensatory capabilities of the woman in labor, which up to a certain point could cope with the increasing load.
In many cases, secondary weakness of labor is associated with the fatigue of the woman in labor after psycho-emotional stress (sleepless night, stressful situations, negative emotions), fasting days. But after proper rest (medicated sleep), the weakness of labor disappears, and the birth act ends with the independent birth of the fetus.

Mechanical obstacles during labor can be:

available scar changes cervix after cauterization of cervical erosion, removal of cervical cysts;
anatomical narrowings in individual planes bony pelvis women;
clinically narrow pelvis - discrepancy between the size of the pelvis and the size of the fetus;
incorrect entry of the fetal head into the birth canal, which prevents the free passage of the fetus and easy delivery.

It is necessary to note another reason for the development of secondary weakness of labor - the unreasonable use of certain medications in the prenatal period and during childbirth. First of all, this concerns overuse antispasmodic and analgesic drugs, including narcotic analgesics.
An additional reason for labor disruption may be weakness of the abdominal muscles, leading to ineffective pushing.
For signs of the course of secondary weakness of labor activity of the muscles of the uterus, a significant lengthening of the active phase of labor or the period of fetal birth is characteristic. In this case, even when the cervix is fully dilated, the fetal head does not sink to the pelvic floor. There are unsuccessful attempts that do not have the proper impact on the process of childbirth. As a result, the woman in labor quickly gets tired, physical and psycho-emotional exhaustion, weakness, pain throughout the body, apathy and a state of anxiety and restlessness appear.
Premature attempts occur reflexively in response to the infringement of the cervix in the area of contact of the fetal head with the back wall of the pubic joint. Such a reaction of the uterus is observed very clearly with a wedge-shaped insertion of the fetal head with a generally uniformly narrowed uterine pelvis.
There is no single approach to the treatment of primary and secondary weakness of labor activity. The basis of the effectiveness of all therapeutic measures is an individual approach in each case. In many ways, the choice of method is justified by the reason causing development weakness of labor. An assessment of the correspondence between the size of the pelvis of a woman and the estimated size of the fetus is carried out when deciding whether it is possible to further stimulate the labor activity of the uterus. This assessment very important, since such a discrepancy will lead to a significant delay in childbirth naturally and to development various complications- uterine rupture, depletion of uterine muscles, injury or death of the fetus.
Equally important is the assessment of the intrauterine state of the fetus and its compensatory capabilities. This study is carried out by assessing the fetal heart rate (normally, the fetal heart rate is 140-160 beats/min), performing an ultrasound of the fetus to determine the entwined umbilical cord, the nature of the amniotic fluid, and the blood supply to the organs. Slow and excessively strong fetal cardiac activity indicates increasing fetal hypoxia, lack of oxygen, life threatening fetus
In case of unfavorable results, preference is given to surgical delivery via cesarean section. In this case, the doctor takes greater responsibility for the correctness of the choice made.
The combination of weakness of labor with prenatal discharge of amniotic fluid creates additional difficulties for the process of labor and requires a more thorough approach to treatment, since an anhydrous period of 8 hours or more is dangerous for the introduction of infection. The maximum possible water-free interval before delivery (especially surgical delivery) should not exceed 10-12 hours. In the case when the cause of weakness in labor becomes functional disability the fetal bladder is opened artificially, this also helps eliminate polyhydramnios.

In some cases, to trigger the contractile activity of the uterus, preliminary artificial rupture of the membranes and preparation of the birth canal are performed by introducing biologically active substances and hormones. At the same time, drugs are used to maintain the body’s energy potential, improve uteroplacental, fetal-placental blood flow and prevent oxygen starvation of the fetus.

Discoordinated labor

Discoordination of labor is characterized by the occurrence of excessively strong labor along with periods of weak labor. In this case, variants of discoordination are associated with the degree of imbalance of the nervous system. The development of incoordination of labor is caused by biochemical disorders, in which the body cannot maintain metabolic processes at the proper level, and energy depletion of the contractile activity of the uterus.
According to research, all processes occurring in the uterus are regulated by the autonomic nervous system and the cerebral cortex. Violation or complete absence of autonomic influence will lead to severe disorders and incoordination of labor. This is explained by the relationship of the nervous system with humoral regulation and hormonal saturation of tissues.

Discoordination of labor can result from:

pathological changes in the muscles of the body and cervix: malformations of the uterus (bicornuate, saddle-shaped, etc.), inflammatory and cicatricial changes in the cervix after abortion, diagnostic curettage;
mechanical obstacle during childbirth: narrow pelvis, incorrect position fetus, excessive density of water membranes;
excessive overdistension of the uterus, insufficiency of uteroplacental blood flow, various diseases cardiovascular system, thyroid gland, liver, kidneys, diabetes puerperas, etc.;
improper assistance to a woman during childbirth, prescribing labor induction or strong labor stimulation hormonal drugs, insufficient or excessive pain relief during labor, etc.

Discoordinated labor is characterized by a violation of all characteristics of the contractile activity of the uterus, premature rupture of amniotic fluid with insufficient opening of the cervical canal. Against the background of pronounced tension in the muscles of the uterus, weakness of the internal and external os of the uterus is noted. Characteristic wrong rhythm labor activity, periods of contraction and relaxation of the uterus are sometimes long, sometimes, on the contrary, short. With such a course of labor, pronounced pain appears not only in the sacrum and lumbar region, but also in the hypochondrium, outer surface hips, excessive fatigue of the woman in labor, a woman’s concern for her life and for the life of the fetus. Quite often there are difficulties when urinating.
With discoordinated labor activity, the processes of shortening the smoothing and opening of the cervix are significantly delayed, both phases of the birth act are lengthened. The advancement of the fetus stops, and the presenting part is in the same position for a long time in each plane of the small pelvis, the period of fetal birth is lengthened by an order of magnitude. A long stay of the head in the plane of exit from the small pelvis leads to the formation of hematomas and trauma to the fetus. In this case, the presentation of the fetus often changes, a rear view or extension of the head occurs, and the articulation of the fetus is disturbed. Increased tension in the muscles of the uterus often leads to prolapse of the umbilical cord, legs or arms, and extension of the fetal spine.
Depending on the severity of certain symptoms, three degrees of severity of the course of discoordinated labor are distinguished.
I degree of severity is characterized by moderately painful contractions, the duration of the relaxation period is slightly reduced, and there are heterogeneous areas of softening in the structural changes of the cervix.
II degree of severity is characterized by a fairly pronounced pain syndrome, discoordination develops from the very beginning of labor. There is increased tension in the muscular layer of the uterus.
III degree of severity - severe, incoordination of labor in this case is characterized by extensive and prolonged spasm of the muscles of the body and cervix, dilatation stops at the earliest stages. Against the background of such pronounced discoordination of the contractile activity of the uterus, labor slows down and stops. L
Taking into account possible disorders and complications, the risk of injury to the birth canal, the occurrence of early and unproductive attempts increases, which leads to the development of swelling of the vagina and cervix and damage to the edematous tissue. The aqueous membranes are not detached from the lower walls of the uterus and are tightly pressed to the fetal head, and the amniotic sac is incomplete due to low pressure amniotic fluid does not perform its role in childbirth properly. This is dangerous due to premature placental abruption.
A characteristic complication of incoordination of labor is impaired blood and lymph circulation in the area of the internal pharynx. The edges of the cervix are dense, thicker to the touch, numb when palpated, and cannot be stretched mechanically. At the same time, the main task of the obstetrician is not only to promptly recognize this complication, but also to distinguish it from other possible pathology.
Complications of incoordination of the labor activity of the uterus are also the development of various kinds of autonomic disorders (nausea, vomiting), excessive heartbeat or slow heart rate, increased or decreased blood pressure, pallor or pronounced filling of facial vessels with blood, increased body temperature up to 38 ° C, chills, weakness.
During discoordinated labor, it cannot be ruled out that there is an increased risk of developing such severe complications as uterine rupture, massive and severe bleeding in the placenta and early postpartum period, the development of disseminated intravascular coagulation syndrome, etc.
In the presence of discoordinated labor, the question of the method of delivery is first decided: continue independent childbirth or resort to a caesarean section. For this purpose, all indicators of the size of the pelvis and fetus are carefully analyzed, the condition of the woman in labor and the fetus is assessed, the time of labor and the presence of concomitant diseases organs and systems that can complicate the course of labor. To this kind of prognostic unfavorable factors relate:

late and young age of mother;
presence of problems in previous births;
infertility and previously established gynecological pathology;
development of incoordination of contractions at the very beginning of labor;
gestosis in the second half of pregnancy;
clinically narrow pelvis;
post-term pregnancy;
untimely discharge of amniotic fluid;
chronic oxygen starvation fetus and diagnosed malformations.

Given all these factors, it is advisable to choose the method of surgical delivery - caesarean section.
In other cases, it is possible to use drug therapy without the use of birth-stimulating drugs (oxytopin or prostaglandins).
Treatment of incoordination of labor primarily involves the use of painkillers and antispasmodics, means to prevent premature birth(tocolytics) or epidural anesthesia - pain relief through the spinal canal.
If discoordination of uterine contractions is noted in the first stage of labor, antispasmodics (no-spa, baralgin) and anticholinergics (diprofen, gangleron) are administered. Quite often discoordination is blocked narcotic analgesics(promedol, morphine-like drugs). The use of antispasmodics begins already in the latent phase of childbirth, even with the normal course of childbirth, and ends after the birth of the fetus.
In the second stage of labor, one of the methods to prevent injury to the mother and fetus, as well as to speed up the period of birth of the fetus, is a dissection of the perineum. This manipulation allows you to reduce mechanical impact on the fetal head. During the same period, it is necessary to prevent bleeding by administering methylergometrine and oxytocin.
The use of drugs is effective in the case of the first degree of severity of incoordination of labor.

In the second degree of severity, it is advisable to use epidural (spinal) anesthesia, therapeutic anesthesia or reintroduction seduxen and fentanyl for complete cessation of labor. This is necessary in order to stop labor in order to allow further independent delivery.
In the case of the third degree of severity of labor discoordination, in most cases they resort to operative delivery.

Rapid labor

One of the types of disorders of contractile activity of the uterus is rapid labor. A rapid birth is considered to be a birth lasting no more than 3 hours, while a rapid birth is a birth lasting no more than 4-5 hours.
The course of such labor is characterized by a pronounced increase in the excitability of the uterine muscles, as a result of which the frequency of contractions is significant - more than 5 per 10 minutes. Due to the rapidity of such births, such births are very dangerous due to traumatization of the mother and fetus.
As a rule, the course of such labor is characterized by severe pain. With rapid labor, labor occurs suddenly, and due to rapid development, it can even occur on the street.
Low resistance of the isthmus and cervix, which is most often caused by cervical pathology, predisposes to such a course of labor, which is why the threat of premature birth is diagnosed early in such women.
The most unfavorable course of labor occurs with initially normal contractile activity without signs of discoordination, since in this case only accelerated elimination fetus The main problems of such childbirth are associated with a violation of the physiological relationship between the processes of cervical dilatation and fetal advancement. In some cases, the cause of such a course of labor is not a violation of the innervation of the uterus, but the unreasonable use of birth-stimulating drugs.
An option for rapid labor may be childbirth with increased tone and impaired contractile function of the uterus. With them, contractions are painful, prolonged, frequent, and time muscle relaxation shortened. Thus, one fight is layered on top of another.

The main reasons for rapid labor are:

excessively strong effects on the muscles of the uterus of biologically active substances, hormones - adrenaline and norepinephrine;
underdevelopment or abnormal development of the fetus;
simultaneous spontaneous discharge of a large amount of amniotic fluid with polyhydramnios.

The basis of therapeutic measures for rapid labor is the use of drugs to immediately relax the muscles of the uterus. In the case when labor stimulation is carried out, it should be stopped immediately to normalize the birth act.
In other situations, rapid labor can be stopped only with the use of general anesthesia. In any case, substances are injected intravenously that relax muscle layer uterus and improve uteroplacental blood flow and oxygen supply to the fetus.
During rapid labor, labor is not completely stopped. The use of medications only reduces muscle excitability and normalizes the tone of the uterus, reduces the frequency of contractions, and increases the relaxation time between them.
When managing rapidly progressing labor, bleeding prevention is mandatory.
Any abnormalities in the contractile activity of the uterus cause disturbances, which subsequently lead to the accumulation of toxins in the tissue respiration system, which significantly complicates the condition of the mother and fetus. Similar violations cause rapid depletion of glycogen and glucose reserves and interfere with further normal development labor activity.

The diagnosis of labor anomalies is established after dynamic observation of the woman in labor for 8 hours in the latent phase and 4 hours in the active phase in comparison with the graph of the normal partogram of cervical dilatation and advancement of the presenting part along the birth canal.

The pathological preliminary period is characterized by significant pain and disorder of preparatory contractions of the uterus and the absence of structural changes in the cervix before childbirth (immature cervix at the due date). A pregnant woman is worried about cramping pain in the lower abdomen and lower back, irregular in frequency, duration and intensity, lasting more than 6-10 hours, disrupting sleep and wakefulness, and increased fatigue.

Weakness of labor is characterized by insufficient strength, duration and frequency of contractions, slow effacement and dilatation of the cervix, and advancement of the fetus through the birth canal.

Primary weakness of labor is a pathological condition in which contractions are weak and ineffective from the very beginning of labor. It can continue during the first and second periods.

Secondary weakness of labor forces (secondary hypotonic dysfunction of the uterus) is observed, as a rule, against the background of normal uterine tone. Contractions at first are regular and of sufficient strength, and then gradually weaken, becoming less frequent and shorter. The opening of the pharynx, having reached 4–6 cm, does not occur further; the progress of the fetus through the birth canal stops. The etiological factors of secondary weakness of labor are the same as the primary ones, but they are joined by fatigue as a result of long and painful contractions, and a discrepancy between the size of the fetus and the mother’s pelvis.

As a result of hypertonic dysfunction of the uterus (excessively strong labor activity), childbirth can be rapid. Rapid labor is characterized by frequent, very strong contractions and attempts, the process of smoothing the cervix occurs very quickly. Immediately after the outflow of water, violent, rapid attempts begin, the expulsion of the fetus and placenta can occur in 1-2 attempts. The duration of rapid labor in primiparous is less than 4 hours, in multiparous - less than 2 hours. Women in labor often have deep ruptures of the soft tissues of the birth canal, premature detachment of the placenta or a violation of the process of its detachment in the afterbirth period, hypo- and atonic bleeding are possible. The fetus is often observed hypoxic and traumatic lesions.

With discoordination of labor, the zone of generation and propagation of action impulses (pacemaker) shifts from the tubal angle to the middle of the body or to the lower segment of the uterus (vertical displacement of the pacemaker). Myometrium loses its main property - synchrony of contraction and relaxation individual areas uterus. An inadequately high basal tone of the myometrium develops, associated with an increased frequency and weakening of the effectiveness of contractions. With seemingly strong contractions of the uterus and sharply painful contractions, the cervix does not open, and, as a result, tetanus of the uterus occurs and cessation of labor. A particular risk in this pathology is such severe complications as rupture of the uterus, as well as severe bleeding in the afterbirth and early postpartum periods, due to the pathology of the contractile activity of the uterus. There is a risk of fetal distress syndrome.

PATHOLOGICAL PRELIMINARY PERIOD

CLINICAL PICTURE

One of the common forms of abnormalities in the contractile activity of the uterus is the pathological preliminary period, characterized by the premature appearance of contractile activity of the uterus with a full-term fetus and a lack of biological readiness for childbirth. The clinical picture of the pathological preliminary period is characterized by irregular pain in frequency, duration and intensity in the lower abdomen, in the sacrum and lumbar region, lasting more than 6 hours. The pathological preliminary period disrupts the psycho-emotional status of the pregnant woman, upsets circadian rhythm sleep and wakefulness, causes fatigue.

DIAGNOSTICS

The diagnosis of the pathological preliminary period is made based on the following data:
· medical history;
·external and internal examination of the woman in labor;
·hardware examination methods (external CTG, hysterography).

TREATMENT

·Correction of uterine contractile activity until optimal biological readiness for childbirth is achieved with b-adrenomimetics and calcium antagonists, non-steroidal anti-inflammatory drugs:
- infusion of hexoprenaline 10 mcg, terbutaline 0.5 mg or orciprenaline 0.5 mg in 0.9% sodium chloride solution;
- infusion of verapamil 5 mg in 0.9% sodium chloride solution;
- ibuprofen 400 mg or naproxen 500 mg orally.
·Normalization of a woman’s psycho-emotional state.
·Regulation of the circadian rhythm of sleep and rest (medicated sleep at night or when the pregnant woman is tired):
- benzadiazepine drugs (diazepam 10 mg 0.5% solution IM);
- narcotic analgesics (trimeperidine 20–40 mg 2% solution IM);
- non-narcotic analgesics(butorphanol 2 mg 0.2% or tramadol 50–100 mg IM);
- antihistamines(chloropyramine 20–40 mg or promethazine 25–50 mg IM);
- antispasmodics (drotaverine 40 mg or bencyclane 50 mg IM);
· Prevention of fetal intoxication (infusion of 500 ml of 5% dexrose solution + sodium dimercaptopropanesulfonate 0.25 g + ascorbic acid 5% - 2.0 ml.
Therapy aimed at “ripening” the cervix:
- PG-E2 (dinoprostone 0.5 mg intracervically).

In case of a pathological preliminary period and optimal biological readiness for childbirth during full-term pregnancy, drug induction of labor and amniotomy are indicated.

PRIMARY WEAKNESS OF LABOR

Primary weakness of labor is the most common type of anomaly of labor.
The primary weakness of contractions is based on a decrease in the basal tone and excitability of the uterus, therefore this pathology is characterized by a change in the tempo and strength of contractions, but without a disorder in the coordination of contractions of the uterus in its individual parts.

CLINICAL PICTURE

Clinically, the primary weakness of labor is manifested by rare, weak, short-term contractions from the very beginning of the first stage of labor. As labor progresses, the strength, duration and frequency of contractions do not increase, or the increase in these parameters is expressed insignificantly.

Primary weakness of labor is characterized by certain clinical signs.
· Excitability and tone of the uterus are reduced.
· Contractions from the very beginning of labor remain rare, short, weak (15–20 sec):
Gfrequency in 10 minutes does not exceed 1–2 contractions;
The contraction force is weak, the amplitude is below 30 mm Hg;
G contractions are regular, painless or slightly painful, since the myometrial tone is low.
·Lack of progressive dilatation of the cervix (less than 1 cm/hour).
· The presenting part of the fetus remains pressed to the entrance to the pelvis for a long time.
· The amniotic sac is sluggish, weakly engorged during contractions (functionally defective).
·At vaginal examination During a contraction, the edges of the uterine os are not stretched by the force of the contraction.

DIAGNOSTICS

The diagnosis is based on:
· assessment of the main indicators of contractile activity of the uterus;
slowing down the rate of opening of the uterine pharynx;
· lack of forward movement of the presenting part of the fetus.

It is known that during the first stage of labor, latent and active phases are distinguished (Fig. 52-29).

Rice. 52-29. Partogram: I – primiparous; II – multiparous.

The latent phase is considered the period of time from the beginning of regular contractions until the appearance of structural changes in the cervix of the uterus (until the opening of the uterine pharynx by 4 cm).

Normally, the opening of the uterine pharynx during the latent phase of the first period in primiparous women occurs at a speed of 0.4–0.5 cm/h, in multiparous women - 0.6–0.8 cm/h. The total duration of this phase is about 7 hours for primiparous women, and 5 hours for multiparous women. With weak labor, effacement of the cervix and opening of the uterine pharynx slows down (less than 1–1.2 cm/hour). Mandatory diagnostic event in such a situation, assessing the condition of the fetus, which serves as a method for choosing adequate management of labor.

TREATMENT

Therapy for primary weakness of labor must be strictly individual. The choice of treatment method depends on the condition of the mother and fetus, the presence of concomitant obstetric or extragenital pathology, and the duration of labor.

The therapeutic measures include:
amniotomy;
·prescribing a complex of drugs that enhance the effect of endogenous and exogenous uterotonics;
· administration of drugs that directly increase the intensity of contractions;
· use of antispasmodics;
·prevention of fetal hypoxia.

The indication for amniotomy is incompleteness of the amniotic sac (flat sac) or polyhydramnios. The main condition for this manipulation is the opening of the uterine pharynx by 3–4 cm. Amniotomy can contribute to the production of endogenous PGs and increased labor.

In cases where weakness of labor is diagnosed when the uterine pharynx is dilated 4 cm or more, it is advisable to use PG-F2a (dinoprost 5 mg). The drug is administered intravenously, diluted in 400 ml of 0.9% sodium chloride solution at an initial rate of 2.5 mcg/min. Monitoring the nature of contractions and the fetal heartbeat is mandatory. If labor is insufficiently enhanced, the rate of solution administration can be doubled every 30 minutes, but not more than 20 mcg/min, since an overdose of PG-F2a can lead to excessive myometrial activity up to the development of uterine hypertonicity.

It should be remembered that PG-F2a is contraindicated in hypertension of any origin, including gestosis. In asthma it is used with caution.

SECONDARY WEAKNESS OF LABOR

Secondary hypotonic dysfunction of the uterus (secondary weakness of labor) is much less common than primary. With this pathology, in women in labor with good or satisfactory labor, it weakens. This usually occurs at the end of the opening period or during the expulsion period.

Secondary weakness of labor complicates the course of labor in women with the following features:

· burdened obstetric and gynecological history (menstrual irregularities, infertility, abortion, miscarriage, complicated childbirth in the past, diseases of the reproductive system);

complicated course real pregnancy(preeclampsia, anemia, immunological conflict during pregnancy, placental insufficiency, post-maturity);

· somatic diseases (diseases of the cardiovascular system, endocrine pathology, obesity, infections and intoxication);

·complicated course of real labor (long anhydrous interval, large fetus, breech presentation of the fetus, polyhydramnios, primary weakness of labor).

CLINICAL PICTURE

With secondary weakness of labor, contractions become rare, short, their intensity decreases during the period of opening and expulsion, despite the fact that the latent and, possibly, the beginning of the active phase can proceed at a normal pace. The opening of the uterine pharynx, the forward movement of the presenting part of the fetus along the birth canal, slows down sharply, and in some cases stops.

DIAGNOSTICS

Contractions at the end of the first and second stages of labor, the dynamics of the opening of the uterine pharynx and the advancement of the presenting part are assessed.

TREATMENT

The choice of stimulants is influenced by the degree of opening of the uterine pharynx. When the dilation is 5–6 cm, at least 3–4 hours are required to complete labor. In such a situation, the use of intravenous drip administration of PG-F2a (dinoprost 5 mg) is rational. The rate of administration of the drug is normal: initial - 2.5 mcg/min, but not more than 20 mcg/min.

If within 2 hours it is not possible to achieve the required stimulating effect, then the infusion of PG-F2a can be combined with oxytocin 5 units. To avoid adverse effects on the fetus, intravenous drip administration of oxytocin is possible for a short period of time, so it is prescribed when the uterine pharynx is 7–8 cm dilated.

In order to promptly adjust labor management tactics, it is necessary to conduct constant monitoring of the fetal heartbeat and the nature of contractile activity of the uterus. Changes in a doctor’s tactics are influenced by 2 main factors:
absence or insufficient effect of drug stimulation of labor;
fetal hypoxia.

Depending on the obstetric situation, one or another method of quick and gentle delivery is chosen: CS, abdominal forceps with the head located in a narrow part of the pelvic cavity, perineotomy.

Violation of the contractile activity of the myometrium can spread to the afterbirth and early postpartum period, therefore, to prevent hypotonic bleeding intravenous administration Uterotonic drugs should be continued in the third stage of labor and during the first hour of the early postpartum period.

EXCESSIVELY STRONG LABOR ACTIVITY

Excessively strong labor activity refers to hyperdynamic dysfunction of the contractile activity of the uterus. It is characterized by extremely strong and frequent contractions and/or pushing against the background of increased uterine tone.

CLINIC

Excessively strong labor is characterized by:
·extremely strong contractions (more than 50 mmHg);
rapid alternation of contractions (more than 5 in 10 minutes);
· increased basal tone (more than 12 mm Hg);
the excited state of a woman, expressed by increased physical activity, increased heart rate and respiration, increased blood pressure. Possible autonomic disorders: nausea, vomiting, sweating, hyperthermia.

With the rapid development of labor due to disruption of the uteroplacental and fetal placental circulation, fetal hypoxia often occurs. Due to very fast promotion Along the birth canal, various injuries may occur to the fetus: cephalohematomas, hemorrhages in the brain and spinal cord, clavicle fractures, etc.

DIAGNOSTICS

Required Objective assessment the nature of contractions, the dynamics of the opening of the uterine os and the advancement of the fetus through the birth canal.

TREATMENT

Treatment measures should be aimed at reducing the increased activity of the uterus. For this purpose, fluorotane anesthesia or intravenous drip administration of b-adrenomimetics (hexoprenaline 10 mcg, terbutaline 0.5 mg or orciprenaline 0.5 mg in 400 ml of 0.9% sodium chloride solution) is used, which has a number of advantages:
· rapid onset of effect (after 5–10 minutes);
· the ability to regulate labor by changing the rate of drug infusion;
Improvement of uteroplacental blood flow.

The administration of b-agonists as needed can be carried out before the birth of the fetus. If the effect is good, the infusion of tocolytics can be stopped by switching to the administration of antispasmodics and antispasmodic analgesics (drotaverine, ganglefen, metamizole sodium).

For women in labor suffering from cardiovascular diseases, thyrotoxicosis, diabetes, b-adrenergic agonists are contraindicated. In such cases, intravenous drip of calcium antagonists (verapamil) is used.

The woman in labor should lie on the side opposite to the position of the fetus. This position slightly reduces the contractile activity of the uterus.

An obligatory component of the management of such childbirth is the prevention of fetal hypoxia and bleeding in the successive and early postpartum periods.

DISCOORDINATED LABOR ACTIVITY

Discoordination of labor is understood as the absence of coordinated contractions between different parts of the uterus: the right and left halves, the upper (fundus, body) and lower parts, all parts of the uterus.

The forms of discoordination of labor are varied:
·propagation of a wave of uterine contraction from the lower segment upward (dominant of the lower segment, spastic segmental dystocia of the uterine body);
lack of relaxation of the cervix at the time of contraction of the muscles of the uterine body (cervical dystocia);
spasm of the muscles of all parts of the uterus (uterine tetany).

Discoordination of the contractile activity of the uterus quite often develops when the woman’s body is not ready for childbirth, including when the cervix is immature.

CLINIC

· Sharply painful frequent contractions, varying in strength and duration (sharp pains, often in the sacrum, less often in the lower abdomen, appearing during contractions, nausea, vomiting, a feeling of fear).
·There is no dynamics of cervical dilatation.
· The presenting part of the fetus remains mobile or pressed against the entrance to the pelvis for a long time.
·Increased basal tone.

DIAGNOSTICS

The nature of labor and its effectiveness are assessed based on:
· complaints of the woman in labor;
general condition of the woman, which largely depends on the severity pain syndrome, as well as autonomic disorders;
·external and internal obstetric examination;
·results of hardware examination methods.

During a vaginal examination, signs of a lack of dynamics of the birth act can be detected: the edges of the uterine yawn are thick, often swollen.

The diagnosis of discoordinated contractile activity of the uterus is confirmed using CTG, external multichannel hysterography and internal tocography. Hardware studies reveal irregular frequency, duration and strength of contractions against the background of increased basal myometrial tone. CTG, carried out dynamically before delivery, allows not only to monitor labor activity, but also provides early diagnosis fetal hypoxia.

TREATMENT

Childbirth complicated by incoordination of myometrial contractile activity can be performed through the natural birth canal or completed with a CS operation.

To treat discoordinated labor, infusions of b-adrenergic agonists, calcium antagonists, antispasmodics, and antispasmodic analgesics are used. When the uterine pharynx is dilated more than 4 cm, long-term epidural analgesia is indicated.

In modern obstetric practice, tocolysis of a bolus form of hexoprenaline (25 mcg intravenously slowly in 20 ml of 0.9% sodium chloride solution) is often used to quickly relieve uterine hypertonicity. The mode of administration of the tocolytic agent should be sufficient to completely block contractile activity and reduce uterine tone to 10–12 mm Hg. Then tocolysis (10 mcg of hexoprenaline in 400 ml of 0.9% sodium chloride solution) is continued for 40–60 minutes. If within the next hour after stopping the administration of b-adrenergic agonists the normal nature of labor is not restored, then drip administration of PG-F2a is started.

Prevention of intrauterine fetal hypoxia is mandatory.

Indications for abdominal delivery
· burdened obstetric and gynecological history (long-term infertility, miscarriage, unfavorable outcome of previous births, etc.);
· concomitant somatic (cardiovascular, endocrine, bronchopulmonary and other diseases) and obstetric pathology (fetal hypoxia, postmaturity, breech presentation and incorrect insertion of the head, large fetus, narrowing of the pelvis, gestosis, uterine fibroids, etc.);
first-time mothers over 30 years old;
· lack of effect from conservative therapy.

PREVENTION

Prevention of contractile activity anomalies should begin with the selection of women from the group high risk submitted pathology. These include:
first-time mothers over 30 years of age and under 18 years of age;
· pregnant women with an “immature” cervix on the eve of childbirth;
· women with a burdened obstetric and gynecological history (menstrual irregularities, infertility, miscarriage, complicated course and unfavorable outcome of previous births, abortions, uterine scar);
·women with pathologies of the reproductive system (chronic inflammatory diseases, fibroids, developmental defects);
pregnant women with somatic diseases, endocrine pathology, obesity, psychoneurological diseases, neurocirculatory dystonia;
· pregnant women with a complicated course of pregnancy (preeclampsia, anemia, chronic placental insufficiency, polyhydramnios, multiple pregnancy, large fetus, breech presentation of the fetus);
· pregnant women with reduced pelvic size.

Great importance for the development of normal labor activity has the readiness of the body, especially the state of the cervix, the degree of its maturity, reflecting the synchronous readiness of the mother and fetus for childbirth. As effective means To achieve optimal biological readiness for childbirth in a short time, kelp and PG-E2 preparations (dinoprostone) are used in clinical practice.

Anomalies of uterine contractile activity include deviations from the norm in such indicators as the basal tone of the uterus, which determines the frequency and strength of contractions. Abnormalities of contractile activity during childbirth lead to disruption of the mechanism of cervical dilatation and the advancement of the fetus through the birth canal.

Epidemiology
The frequency of abnormal labor ranges from 10 to 30% of the total number of births and is the main cause of hypoxic-traumatic damage to the fetus, rupture of the birth canal, and obstetric hemorrhage. Every third caesarean section is performed during labor due to labor anomalies.

The frequency of abnormal labor activity is manifested by weakness of labor activity in relation to all births (10%), less often there is discoordination of labor activity (1-3%) and even less often - excessively strong labor activity (less than 1%).

Classification
In our country, the following classification of labor anomalies has been adopted:
- pathological preliminary period;
- primary weakness of labor;
- secondary weakness of labor;
- excessively strong labor activity, leading to rapid and rapid labor;
- discoordination of labor

Etiology and pathogenesis
The effectiveness of labor determines the processes of cervical dilation and fetal advancement along the birth canal, which, in turn, are associated with intra-amniotic (intramyometrial) pressure and resistance of the lower pole of the uterus (lower segment, internal os, cervix).

This resistance can be high due to the spastic state of muscle tissue and weak, which can cause rapid and rapid labor.

Factors contributing to the development of abnormal labor:
Obstetric factors:
- premature rupture of amniotic fluid (prenatal and early);
- disproportion between the sizes of the fetal head and the mother’s pelvis (clinically narrow pelvis);
- overdistension of the uterus (polyhydramnios, large fetus);
- multiple pregnancy;
- premature and delayed births;
- breech presentation;
- obstacles to the dilation of the cervix and the advancement of the hearth, functionally defective amniotic sac.

Factors associated with pathology of the reproductive system:
- infantilism; hypoplasia, malformation of uterine vessels;
- developmental anomalies of the uterus (saddle-shaped, bicornuate);
- multiple births (>3);
- late age of primigravida (>35 years);
- neuroendocrine diseases;
- operations on the uterus (presence of a scar);
- uterine fibroids, adenomyosis;
- genetic predisposition.

General somatic diseases, chronic infections, intoxications, metabolic syndrome, diabetes, systemic diseases connective tissue.
Fetal factors (fetal growth retardation, chronic hypoxia, malformations, placental insufficiency)
Iatrogenic factors: inadequate corrective therapy, excessive use of painkillers and antispasmodics; induction of labor with an insufficiently mature cervix.

All of these factors are divided conditionally, since during pregnancy and childbirth the organisms of the mother and fetus are connected by the placenta into a single functional system by many hormonal, humoral and neurogenic connections.

With anomalies of labor in the uterus, disorganization of the conduction system, built on gap junctions with intercellular channels, occurs.

A disturbance in the conduction system and a displacement of the center of formation and generation of electrical impulses (the “pacemaker” of contractions) causes uncoordinated, asynchronous labor activity, when individual zones of the myometrium contract and relax in different rhythms and at different time periods, which is accompanied by sharp pain in contractions and lack of effect. Childbirth practically stops.

When labor is weak, there is a decrease in cAMP, inhibition of the tricarboxylic acid cycle, and an increase in the content of lactate and pyruvate in myocytes. In the pathogenesis of weakness of labor activity, a decrease in the formation of α-adrenergic receptors, a weakening of the function of the adrenergic mechanism of the myometrium, and a decrease in estrogen balance play a role. A decrease in the “density” of specific α- and β-adrenergic receptors makes the myometrium insensitive to uterotonic substances.

With anomalies of labor activity, underoxidized products of impaired metabolism accumulate in the uterus, the tissue respiration system changes - aerobic glycolysis is replaced by uneconomical anaerobic.

Glycogen and glucose reserves are quickly depleted.

Impaired blood flow in the myometrium, which is combined with hypotonic and/or hypertensive dysfunction of the uterus, sometimes leads to such profound metabolic disorders that destruction of the synthesis of α- and β-adrenergic receptors can occur. Such stubborn inertia of the uterus develops that repeated and prolonged labor stimulation becomes absolutely unsuccessful. Anomalies of labor are often preceded by a pathological preliminary period, the presence of which indicates a violation of the contractile activity of the uterus.

Pathological preparatory (preliminary) period as a harbinger of labor anomalies
In the Anglo-American literature, the pathological preliminary period is called “false labor” (false labor), or “false contractions” (“false contractions”), occurs in 10-17%, coinciding with the frequency of abnormal labor.

The pathological preliminary period is characterized by spastic contraction of circular muscle fibers in the isthmus. No structural changes in the cervix occur, but every contraction of the uterus is felt by the woman as pain.

In the pathological preliminary period, the cervix remains long and dense by the time of delivery, the external os is open, the cervix is located eccentrically in relation to the pelvic axis (anterior or posterior).

The pathological preliminary period is characterized by the following clinical signs.

Preparatory (preliminary) contractions of the uterus occur not only at night, but also during the day, are irregular and do not transform into labor for a long time. The duration of the pathological preliminary period can range from 1 to 3-5 days. However, the duration of the pathological preliminary period has not been established, and the pathogenesis has not been studied.
There is no proper deployment of the lower segment, which (with a mature cervix) should also involve the supravaginal portion of the cervix, so the presenting head of the fetus is not pressed against the pelvic inlet.
The excitability and tone of the uterus are increased. Due to the hypertonicity of the uterus, palpation of the presenting part and small parts of the fetus is difficult.
Contractions of the uterus for a long time are monotonous: their frequency does not increase, their strength does not increase. A woman’s behavior (active or passive) does not have any influence on them (it does not strengthen or weaken).
The pathological preliminary period disrupts the psycho-emotional state of a woman, upsets the circadian rhythm, leads to fatigue, and sleep disturbances.
Irregular contractions of the uterus worsen the blood supply to the fetus, which is especially unfavorable in chronic placental insufficiency, post-term pregnancy.

The pathological preliminary period passes either into discoordination of labor activity or into primary weakness of contractions and is often accompanied by severe vegetative disorders (sweating, tachycardia, instability of blood pressure, fear of childbirth, anxiety over their outcome, irritability, nervousness, impaired bowel function, increased and painful movement fetus).

A characteristic complication of the pathological preliminary period is prenatal rupture of amniotic fluid, which reduces the volume of the uterus and reduces the tone of the myometrium. If at the same time the cervix has sufficient maturity, the contractile activity of the uterus can normalize and go into normal labor activity.

The ineffectiveness of treatment (the use of painkillers and antispasmodics), the presence of other aggravating factors on the part of the mother (term pregnancy, preeclampsia, narrow pelvis) and the fetus (hypoxia, fetal growth retardation, large size) are sufficient grounds for delivery by caesarean section. The primary weakness of labor is characterized by the fact that contractions from the very beginning are short, rare, weak, ineffective, while the basal tone of the uterus is reduced. Ineffective contractions remain so throughout all stages of labor. Childbirth takes a protracted nature, their duration lasts 17-19 hours or more.

The following clinical signs are characteristic of the primary weakness of labor activity:
- excitability and tone of the uterus are reduced, uterine tone is 10 mm Hg. and less (normally 12-14 mm Hg);
- the frequency of contractions 1-2 in 10 minutes is not only at the beginning of labor, in the latent phase, but also in the active phase of labor, when normally the rate of opening of the uterine os should be 2-2.5 cm / h, the frequency of contractions is 3- 5 in 10 minutes;
- the duration of the contractions does not exceed 20 s, their strength (amplitude) of contraction is recorded within 20-25 mm Hg, the duration of the contraction systole is short, the diastole is also reduced, the pauses between contractions are up to 4-5 minutes or more;
- the overall effect of contractions is reduced due to reduced intrauterine (intra-amniotic) pressure. Structural changes in the cervix (shortening, smoothing, opening of the cervical canal) occur slowly. The presenting part of the fetus remains pressed to the entrance to the small pelvis for a long time and then lingers for a long time in each plane of the small pelvis. The synchronicity of the processes of opening the uterine pharynx and the simultaneous movement of the fetus along the birth canal is disrupted;
- the amniotic sac is flaccid, flows poorly during contractions (functionally defective);
- during vaginal examination during a contraction, the edges of the uterine pharynx remain soft, do not tense, are quite easily stretched by the examining fingers (but not by the force of the contraction) and remain so for a long time;
- weak contractile activity of the uterus that occurs in the first stage of labor can continue during the period of expulsion of the fetus, in the afterbirth period (which disrupts the process of separation of the placenta) and in the early postpartum period, often accompanied by hypotonic bleeding.

Premature rupture of amniotic fluid (in 35-48%) extends the anhydrous interval, which threatens the development of an ascending infection, fetal hypoxia and even intrapartum death.

Diagnostics
The diagnosis of primary weakness of labor is established on the basis of characteristic clinical picture, detected during observation for 3-4 hours. Contractions do not increase in intensity, their frequency, strength and duration do not increase significantly. Proper opening of the cervix (uterine os) does not occur. On the partogram (graphic representation of labor), the latent and active phases of labor are lengthened. In establishing the diagnosis, an important role is played by the lack of proper dynamics of cervical dilatation, the transition of the latent phase to the active phase of labor, low efficiency labor, too slow movement of the fetus through the birth canal.

You should be attentive to the mother's complaints about painful contractions. It is necessary to compare the dynamics of changes in the cervix: how the uterine os opens after 2-3 hours of labor, how the length of the cervix has changed (shortened, smoothed). The rate of opening of the uterine pharynx every hour should be 0.5-1.0 cm in the latent phase and 2-2.5 cm/hour in the active phase of labor. When a diagnosis of “primary weakness of labor” is established, labor stimulation should begin. But first of all, it is necessary to exclude an unfavorable obstetric situation in which stimulation of labor is contraindicated.

These include:
- narrow pelvis;
- inferiority of the myometrium (uterine scar, fibroids, endometritis);
- unsatisfactory condition of the fetus and/or mother.

Treatment
When a diagnosis of primary weakness of labor is established, treatment should begin. Methods to enhance labor: artificial opening of the membranes (amniotomy), administration of uterotonics (oxytocin, prostaglandins).

Algorithm of actions before prescribing labor stimulation:
- clarify the diagnosis of weakness of labor. Conduct differential diagnosis with incoordination of labor, in which uterine stimulating therapy is contraindicated;
- assess the risk factors in mother and fetus during prolonged labor and labor-stimulating therapy: preeclampsia, arterial hypertension, placental insufficiency, fetal growth retardation, hypoxia, the possibility of defective myometrium (abortion, large fetus, uterine surgery);
- pay attention to the nature of amniotic fluid: the presence of meconium, signs of infection;
- during a vaginal examination, recognize presentation, insertion of the fetal head to exclude situations where vaginal delivery is impossible or extremely difficult (frontal presentation, posterior parietal asynclitism, high direct insertion, wedge-shaped insertion, etc.).

For the purpose of labor stimulation, oxytocin and prostaglandins (enzaprost) are used. At the same time, the issue of adequate pain relief is addressed. If the woman in labor is tired, then stimulation of labor begins after providing her with short-term medicated sleep - rest.

Rod stimulation with oxytocin
Intravenous oxytocin is the most common known and proven method of stimulating muscular dystonia syndrome. It increases the tone of the uterus, synchronizes the interaction of differently located smooth muscle bundles, layers and layers of the myometrium, stimulates the formation and synthesis of prostaglandins at the border of contact between the fetal membranes and the decidua.

If the density of specific adrenergic receptors on the smooth muscle cells of the myometrium is insufficient, rodostimulation with oxytocin may be ineffective. Oxytocin can be used only when the amniotic sac is opened; it is a drug in the active phase of labor and is most effective when the uterine os is opened by 4 cm or more.

Before choosing this particular method of birth stimulation, you need to know its negative properties:
- exogenously administered oxytocin reduces the production of its own endogenous oxytocin. Stopping its intravenous administration may lead to a weakening of labor. Oxytocin has an antidiuretic effect, promotes water intoxication and decreased diuresis;
- long-term, many-hour administration of oxytocin has a hypertensive effect. Labor induction and labor stimulation with oxytocin are contraindicated in severe preeclampsia, severe arterial hypertension and renal failure.

Oxytocin does not have any adverse effects on a healthy fetus. In chronic hypoxia (fetal growth retardation, post-term pregnancy), oxytocin reduces the content of endorphins in the fetal brain, increases its pain sensitivity, suppresses the formation of the surfactant system of the fetal lungs, which in turn contributes to intrauterine aspiration of amniotic fluid, impaired fetal blood flow, hypoxic damage to the central nervous system, decreased anti-stress resistance of the fetus.

An overdose of oxytocin can cause rupture of the birth canal, uterine rupture, and pelvic hematomas. Oxytocin is administered intravenously, in strictly dosed doses, using the titration method. Preparation of solution for infusion pump. 1 ml of oxytocin containing 5 units is diluted in 20.0 ml of isotonic solution for an infusion pump. For a dropper, oxytocin is diluted in 400 ml of a sterile 5% solution or in a 0.9% sodium chloride solution. Then the vein is punctured and an infusion pump or a dropper with a solution is attached to the needle. Oxytocin is administered through an infusion pump at a rate of 5 units per 3 hours. Intravenous drip administration of the solution begins slowly at 8 drops/min. If there is no effect after 30 minutes, the number of drops is increased by 5 and so on until the desired effect is obtained, 3-5 contractions in 10 minutes.

The administration of oxytocin is not stopped until the end of labor. Stimulation of labor with oxytocin is effective when the cervical dilatation is at least 2 cm/h and the observed advancement of the presenting part of the fetus. The duration of stimulation should not exceed 4-5 hours. During this time, you should decide whether it is possible to continue childbirth through the natural birth canal.

To stimulate labor, prostaglandins F2a and E2 (pro-stenon, enzaprost) are successfully used; 5 mg of prostaglandin is diluted in 500 ml of saline and administered intravenously, starting at 10 drops/min, increasing the dose to 40 drops depending on the effect. The tonomotor effect of prostaglandin on the uterus appears in the first 30 minutes of infusion.

Currently, a synthetic analogue of prostaglandin is used - 15-methyl-prostaglandin E2, the reducing effect of which is 10 times stronger than that of oxytocin, and therefore the dose is 10 times less (0.5 mg). Rhodostimulation must be treated with great attention and caution, since it is possible serious complications(premature placental abruption, distress and intrapartum death of the fetus, uterine rupture, deep ruptures of the birth canal, bleeding). For the effectiveness of labor stimulation and timely diagnosis possible complications the following should be provided:
- informed consent of the woman in labor;
- constant monitoring of the mother and fetus;
- administration of antispasmodics (if necessary);
- providing adequate pain relief.

Secondary weakness of labor
With secondary weakness of labor activity, initially quite normal active contractions weaken, become less frequent, shorter and may gradually stop. The tone and excitability of the uterus decrease. Most often, secondary weakness develops in the active phase of labor or in the second period during the expulsion of the fetus. The opening of the uterine pharynx, having reached 6-7 cm, no longer progresses, the presenting part of the fetus does not advance along the birth canal, stopping in one of the planes of the pelvic cavity. Prolonged standing of the head in one plane can cause compression of the soft tissues of the birth canal, disruption of their blood supply and the formation of fistulas.

Secondary weakness of labor is often a consequence of the fatigue of the woman in labor or the presence of an obstacle that stops labor. After a certain period of attempts to overcome the obstacle, the contractile activity of the uterus - its mechanical work - weakens and may stop altogether for some time. Secondary weakness of labor may be associated with inferiority of the uterine wall during childbirth.

The causes of secondary weakness are numerous. Among them are:
- fatigue, fatigue of the woman in labor;
- large fruit;
- delayed pregnancy, delayed delivery;
- obstacles to the advancement of the fetus (low-lying uterine fibroids, pelvic exostoses, disruption of the biomechanism of labor, etc.).

Treatment
Labor is stimulated with oxytocin or prostaglandins. It is advisable to combine oxytocin with one of the prostaglandin preparations at half the dosage. The duration of corrective therapy for secondary weakness of labor should not exceed 2-3 hours. Changes in labor management tactics are influenced by the following factors:
- absence or insufficient effect of stimulation of labor;
- fetal hypoxia;
- deterioration of the mother's condition.

Depending on the obstetric situation, one or another method of delivery is chosen (obstetric forceps, vacuum extraction of the fetus, cesarean section).

Rapid labor
"Swift" - " quick birth“or “very fast” labor (partus praecipitatus) are not strictly distinguished from each other and small differences in the periods of their duration are insignificant. The concepts of rapid and rapid labor are used as synonyms, labor lasts 2-3 hours.

A very rapid birth takes a woman unexpectedly. Expulsion of the fetus can occur on the street, in transport, that is, in the most unexpected place. As a rule, this does not happen in women in a supine position, but occurs during active behavior in a standing, sitting, or walking position.

Rapid labor is for a woman stressful situation. There are virtually no clinical manifestations of contractions and pushing, as well as pain. An important factor in the short duration of labor is the lack of resistance from the internal os of the cervix, which is more often observed in multiparous women and with isthmic-cervical insufficiency.

Rapid labor is often accompanied by extensive ruptures of the birth canal (cervix, vagina, cavernous bodies of the clitoris, perineum), hypoxic-traumatic damage to the fetus and newborn (trauma, cerebral hemorrhages, umbilical cord separation), as well as great blood loss(hypo- or atonic bleeding).

Rapid labor is characterized by extreme increased excitability of the myometrium and a high frequency of contractions (more than 5 per 10 minutes). The amplitude of contractions increases from 70 to 100 mm Hg, intrauterine pressure increases to 200 mm Hg. and higher, while the periods of uterine relaxation (diastole of contractions) are shortened by 2 times or more compared to the norm. The total contractile activity of the uterus exceeds 300 units. Montevideo. Rapid labor can lead to threatening rupture uterus, intrapartum fetal death. Rapid labor is dangerous for the health of the mother and fetus not only due to severe complications associated with obstetric trauma, but also because they are difficult to eliminate.

Etiology
Excessively strong effects on the uterus of uterotonic substances, mediators of the autonomic nervous system (norepinephrine, acetylcholine).
Decreased tone and, consequently, resistance of the lower segment of the uterus, failure of the obturator function of the internal uterine os as a result of old deep ruptures of the cervix, the presence of isthmic-cervical insufficiency.
The simultaneous discharge of a large amount of amniotic fluid is accompanied by a sharp decrease in the volume of the uterine cavity. At this moment, there is a cascade release of prostaglandins, oxytocin, mediators, catecholamines.
Iatrogenic causes associated with hyperstimulation of labor (non-compliance with the rules of labor stimulation, excessive large doses administered drugs of tono-motor action, an unreasonable combination of strong stimulants that potentiate the action of each other, etc.).

Clinical picture
The behavior of the woman in labor is restless. There may even be a detachment of a circular fragment of the cervix, which is born along with the fetal head. This variant of the contractile activity of the uterus should be differentiated from the threat of uterine rupture and premature detachment of a normally located placenta.

Treatment
Currently, apart from the use of myometrial relaxants (β-agonists, tocolytics), there are no other methods. Any mechanical resistance to the rapidly advancing fetal head is contraindicated, as this can lead to rupture of the uterus, intracranial hemorrhage in the fetus. The main method of treatment is the intravenous administration of tocolytics, adrenergic agonists with a selective effect on the β-adrenergic receptors of the myometrium, which reduce the concentration of calcium in the myofibrils: ginipral, fenoterol, partusisten.

Ginipral - solution for infusion, 1 ml contains 5 mcg effective start hexoprenaline sulfate. For acute tocolysis (rapid suppression of contractions), administer slowly intravenously at a dose of 10 mcg (in 10.0 ml of sodium chloride or glucose solution) over 20-30 minutes. When using tocolytics, it is necessary to monitor the pulse and blood pressure of the woman in labor, and conduct cardiac monitoring of the fetus.

You should not achieve a complete cessation of labor, as is done when there is a threat of premature birth; it is enough to reduce the excitability of the myometrium, normalize the tone of the uterus, reduce the frequency of contractions, and increase the interval between contractions. An obligatory component is the prevention of hypotonic (atonic) bleeding in the early postpartum period by administering methylergometrine (1 ml intravenously immediately after expulsion of the fetus) followed by drip administration of oxytocin.

Discoordination of labor
Discoordination is an abnormal labor activity in which coordinated contractions between the upper and lower sections, or between all parts of the uterus.

Forms of labor anomalies have different clinical and pathogenetic variants. The most frequent of them:
- discoordination of contractions (discoordination of labor activity);
- cervical dystocia (hypertonicity of the lower segment of the uterus), "hard neck";
- convulsive contractions (tetany of the uterus);
- contraction ring.

All options are united by one common factor- hypertonicity of the myometrium, against the background of which the physiology of uterine contractions is distorted. With incoordination of labor, the tone of the uterus, including the lower segment and internal os of the uterus, is increased. The rhythm of contractions is incorrect, periods of contraction and relaxation of the uterus (systole and diastole of contractions) are sometimes long, sometimes short. The amplitude (strength of the contraction) and intra-amniotic pressure are uneven; contractions are notoriously painful. The behavior of the mother in labor is restless.

Perhaps discoordination syndrome of muscular dystonia is more common than weakness of labor, but is less often diagnosed. Their forms are more varied clinical manifestation, complex in the mechanism of development, more difficult to diagnose.

Etiology
The etiology of this pathology has not been sufficiently studied, however, the main factors can be identified. These include:
- disturbances in the functional balance of the autonomic nervous system (vegetative neuroses, autonomic dysfunction);
- an irremovable obstacle to the opening of the uterine os (uterine fibroids, scar tissue deformation), difficulty in advancing the fetus (narrow pelvis);
- weakening of the regulatory role of the central nervous system (stress, overwork, for example: trying to give birth to a child between two exams, fear of childbirth);
- insufficient pain relief during labor, leading to general muscle tension;
- hyperstimulation with contractile agents (oxytocin, prostin E and F, prostaglandins E1);
- Structural pathology of the myometrium and cervix:
- uterine malformations, long dense cervix;
- excessive density of the membranes (functional inferiority of the membranes).

Pathogenesis
The pathogenesis of hypertensive dysfunction is unknown, but a disturbance in the functional balance of the autonomic nervous system is suggested. There is dysfunction of the sympathetic-adrenal and predominant tone of the parasympathetic (cholinergic) autonomic nervous system.

The essence of discoordination of labor activity lies in the violation of neurogenic and myogenic regulation. The periodicity of contraction and relaxation of the body and lower segment of the uterus disappears; synchronicity of interaction between differently located muscle bundles, layers, and sections of the uterus; reciprocity of interaction between the sympathetic and parasympathetic nervous systems.

Prevail:
- uterine hypertonicity (hypertensive dysfunction (muscular dystonia syndrome);
- compaction of the internal os of the uterus into contractions, which is palpated in the form of a dense cushion;
- formation of cervical dystocia due to impaired blood and lymph circulation. The cervix is defined as dense, thick, rigid, edematous and unevenly compacted;
- formation of a double, triple rhythm of contractions, during which the uterus does not relax and contractions are layered on top of each other.

Contractions are painful, frequent, prolonged; During diastole and the pause between contractions, the uterus hardly relaxes. During the development of labor, two or more “pacemakers” can be formed in the uterus. Since both “pacemakers” have different rhythms of contractile activity, their action is asynchronous. The impulses of uterine contraction do not propagate from top to bottom, but from bottom to top. The myometrium is divided into segments that contract independently of each other, with different amplitudes, durations and frequencies. The tone of the uterus is higher than normal values, reaching 15-20 mm Hg, and sometimes more. There are many options for discoordination of contractions, up to uterine tetanus, against the background of which contractions become rare, weak, but sharply painful. There is a real threat of histopathic uterine rupture.

Clinic
Contractions are frequent, active, irregular, uneven after 1-2-5-2 minutes, sometimes there is an overlap of contractions on top of each other.
The uterus does not relax enough between contractions.
Attention is drawn to the increased tone of the myometrium, the presenting part is determined with difficulty.
The neck is dense, thick, rigid, does not stretch during contraction, but thickens in a separate area (Schikkele's symptom).
The development of labor activity is often preceded by a long pathological preliminary period.
Due to the hypertonicity of the lower segment, the fetal head is not pressed against the entrance to the small pelvis for a long time, it is not fixed in the plane of the entrance in accordance with the biomechanism of childbirth.
Often there is premature rupture of amniotic fluid (antenatal and early) with an immature cervix.
Palpation of the uterus is determined in the form of an elongated ovoid, which tightly covers the fetus.
Often oligohydramnios occurs in combination with fetoplacental insufficiency (delayed fetal development).

The behavior of the woman in labor is restless and requires pain relief even at the very beginning, in the latent phase of labor. Complaints of a woman in labor are typical:
- crushing pain in the sacrum and lower back, autonomic disorders;
- difficulty urinating (with full proportionality between the fetus and the mother’s pelvis!), oliguria, paradoxical ischuria(during catheterization of the bladder, urine is easily excreted in large quantities);
- change in the nature of cervical dilatation. Instead of stretching the edges of the uterine pharynx, the spastically contracted tissue is forcibly overcome due to ruptures. Possible crushing of the cervix, scalped ruptures of the vagina, deep ruptures of the perineum, up to the third degree;
- violation of the synchronism of fetal advancement in accordance with the opening of the uterine pharynx. The presenting part stands for a long time in each plane of the small pelvis, as is the case with a narrow pelvis. The period of expulsion of the fetus (unproductive attempts) is prolonged when the fetus is small in size;
- frequent disruption of the biomechanism of labor due to hypertonicity of the lower segment.

Often there is a posterior view or extension of the head, a violation of the articulation of the fetus. Due to a constant or uneven increase in the tone of the uterus, increased intra-amniotic pressure, prolapse of the umbilical cord, legs or arms, and extension of the fetal spine often occur.
- frequent occurrence of early attempts as a consequence of infringement of the cervix between the fetal head and the pelvic bones, and the result of prolonged spasm, swelling of the cervix and vagina.
- early formation of a birth tumor on the fetal head, corresponding to the place of infringement by the spastically contracted uterine os, even with its small opening (5 cm).
- the cervix is thickened, swollen, of a dense structure, does not open during contractions or ruptures with the transition to the lower segment of the uterus (when trying to increase the efficiency of labor through stimulation).

During uncoordinated contractions, the amniotic sac is, as a rule, functionally defective, does not act as a hydraulic wedge and does not contribute to the opening of the uterine pharynx. The amnion is not detached from the walls of the lower segment of the uterus and is tightly adjacent to the fetal head. Outside of contractions, the amniotic sac remains tense. The membranes of the bubble feel unusually dense. This symptom is easily determined by vaginal examination.

Quite often, early rupture of amniotic fluid occurs (when the cervix is not yet smoothed and its opening is small). Early rupture of water to a certain extent can normalize labor activity of the uterus. Preservation of a functionally defective amniotic sac during labor is dangerous, since an increase in the pressure gradient by at least 2 mm Hg. in the amniotic cavity or intravillous space can lead to serious complications such as embolism amniotic fluid, premature placental abruption.

A particular risk in case of discoordination of contractions is posed by such complications as uterine rupture, which is possible even in first-time mothers with a burdened obstetric history (abortion), massive bleeding in the placenta and early postpartum periods.

Diagnostics
To assess the nature of labor, you should monitor:
- dynamics of structural changes in the cervix in accordance with the elapsed hours of labor, taking into account the parity of births (first, repeated);
- opening of the cervix (uterine pharynx) in centimeters, the condition of the edges of the cervix (soft, pliable; dense, rigid, poorly extensible; thick - thin), including the condition of the edges of the uterine pharynx during contractions (soft, but compacted around the entire circumference or in a separate area);
- functional usefulness of the amniotic sac (filled with contractions) or inferiority ( flat shape, the shells are stretched on the head), the characteristics of the shells (dense, rough, elastic). Note the increased tension of the membranes during and outside of contractions, as well as the amount of amniotic fluid (little, much, normal).

To clarify the diagnosis of labor anomalies, external hysterography and internal tocography are used.

Differential diagnosis
Differential diagnosis of the pathology of uterine contractions with incoordination and weakness of labor is presented in the table.

Treatment
The prognosis and labor management plan are based on the age, medical history, health status of the mother in labor, the course of the pregnancy, the obstetric situation, and the results of assessing the condition of the fetus.

When choosing corrective therapy for labor incoordination, one should proceed from a number of provisions.

Unfavorable factors include:
- late age of primigravida;
- burdened obstetric and gynecological history (infertility, IVF, birth of a sick child with hypoxic, ischemic, hemorrhagic damage to the central nervous system or spinal cord);
- women have a disease in which prolonged labor and physical activity are dangerous;
- preeclampsia, narrow pelvis, post-term pregnancy, uterine scar;
- untimely discharge of amniotic fluid with an “immature” cervix or with a small opening of the uterine pharynx;
- violation of the adaptive biomechanism of childbirth, which does not correspond to the abnormal shape of the narrowed pelvis;
- chronic hypoxia of the fetus, its size is too small (less than 2500 g) or large (4000 g or more); breech presentation, posterior view, decreased uteroplacental and fetal placental blood flow.

If labor is discoordinated, a woman in labor may experience life-threatening complications: uterine rupture, amniotic fluid embolism, premature placental abruption, extensive ruptures of the birth canal, combined hypotonic and coagulopathic bleeding. Therefore, with this pathology, it is advisable to carry out delivery by cesarean section.

Stimulating therapy with oxytocin, prostaglandins and other drugs that increase the tone and contractile activity of the uterus, in case of incoordination of labor, is strictly contraindicated. The effectiveness of multicomponent therapy for the correction of incoordination of contractions (antispasmodics, tocolytics) has not been proven. In other cases of discoordinated labor, cesarean section should be preferred. If there is no effect with caesarean section The method of choice for treating incoordination of labor is regional anesthesia (epidural, spinal).

Prevention
Prevention of abnormalities of uterine contractility should begin with the selection of women at high risk for this pathology.

These include:
- first-time mothers over 30 years of age and under 18 years of age;
- pregnant women with an “immature” cervix on the eve of childbirth;
- women with a burdened obstetric and gynecological history (menstrual irregularities, infertility, miscarriage, complicated course and unfavorable outcome of previous births, abortions, uterine scar);
- women with pathologies of the reproductive system (chronic inflammatory diseases, fibroids, developmental defects);
- pregnant women with somatic diseases, endocrine pathology, obesity, psychoneurological diseases, neurocirculatory dystonia;
- pregnant women with a complicated course of pregnancy (preeclampsia, anemia, chronic placental insufficiency, polyhydramnios, multiple births, large fetus, breech presentation of the fetus;
- pregnant women with reduced pelvic size.

Of great importance for the development of normal labor activity is the readiness of the body, especially the condition of the cervix, the degree of its maturity, reflecting the synchronous readiness of the mother and fetus for childbirth. Laminaria and PG-E2 preparations are used in clinical practice as effective means for achieving optimal biological readiness for childbirth in a short time.

Childbirth is a complex physiological process that begins and ends with the interaction of many body systems.

Regulation of the motor function of the uterus is carried out by nervous and humoral pathways. In the regulation of contractile activity of the uterus, timely labor and its physiological course, the amount of estrogens, gestagens, corticosteroids, oxytocin, prostaglandins and many biologically active substances are of great importance. Without a doubt, the hypothalamic-pituitary and adrenal systems of the fetus play a leading role in the development of labor and the course of labor. The central nervous system carries out high regulation of the birth act. Of great importance for the occurrence and uncomplicated course of labor is the readiness of the pregnant woman’s body for childbirth, the maturity of the cervix, and the sensitivity of the uterus to uterotonic substances.

There are three degrees of readiness of the cervix for childbirth:“mature”, “not mature enough” and “immature”. In this case, the consistency of the cervix, the length of the vaginal part, its location in the small pelvis according to the pelvic axis and the patency of the cervical canal are taken into account. In addition, pay attention to the location of the presenting part of the fetus. Thus, with a “mature” cervix, the presenting part is fixed to the entrance to the pelvis, which indicates the readiness and deployment of the lower segment of the uterus. At the same time, the cervix is “mature” and palpable - soft, centered, located along the wire axis of the pelvis, reduced to 1-1.5 cm, cervical canal misses 1.5-2 fingers. The “immature cervix” of the uterus is dense, deviated to the coccyx or into the womb, up to 2 cm long, the external pharynx allows the tip of the finger to pass through, the presenting part is not pressed to the plane of the entrance to the small pelvis and is located high. The “insufficiently mature cervix” of the uterus occupies an intermediate position.

In addition to the readiness of the cervix for childbirth, there are many more factors for a successful delivery:
— Dimensions of the bone pelvis;
— Dimensions of the fetal head;
— Intensity of uterine contractions
— Ability of the fetal head to change
— .

Recently, there has been a reduction in the duration of labor. Now in all maternity hospitals and institutions, an active-expectant tactic of childbirth has been adopted, or “management” of childbirth is being carried out. This consists in the use of physical and preventive preparation for childbirth, in widespread use antispasmodic and analgesic substances, the use of uterotonic drugs according to indications. Average duration childbirth in women who give birth for the first time is 11-12 hours, again - 7-8 hours. According to modern ideas, pathological births include those that last more than 18 hours.

a) primary;
b) secondary.
3. Excessively strong labor activity.

4. Discoordinated labor activity (discoordination, hypertonicity of the lower uterine segment, circulatory dystonia of the uterine tetany).

Clinic and management of childbirth with abnormalities of uterine contractility. Discoordination of labor

Primary weakness of labor

Secondary weakness of labor

Discoordinated labor

Rapid labor

More on the topic Anomalies of the contractile activity of the uterus (clinic, diagnostics):

EPIDEMIOLOGY

CLASSIFICATION

ETIOLOGY

PATHOGENESIS

PATHOLOGICAL PRELIMINARY PERIOD

CLINICAL PICTURE

DIAGNOSTICS

TREATMENT

PRIMARY WEAKNESS OF LABOR

CLINICAL PICTURE

DIAGNOSTICS

TREATMENT

SECONDARY WEAKNESS OF LABOR

CLINICAL PICTURE

DIAGNOSTICS

TREATMENT

EXCESSIVELY STRONG LABOR ACTIVITY

CLINIC

DIAGNOSTICS

TREATMENT

DISCOORDINATED LABOR ACTIVITY

CLINIC

DIAGNOSTICS

TREATMENT

PREVENTION