Nursing management of childbirth by periods. The impact of childbirth on the mother's body

Periods of labor

Childbirth- an unconditional reflex act aimed at expelling the fertilized egg from the uterine cavity upon reaching a certain degree of maturity. The gestation period must be at least 28 weeks, the fetal body weight must be at least 1000 g, and the height must be at least 35 cm. With the onset of labor, a woman is called a woman in labor, and after the end of labor, she is called a puerpera.

There are three periods of labor: the first is the period of dilation, the second is the period of expulsion, and the third is the afterbirth period.

Disclosure period begins with the first regular contractions and ends with the complete opening of the external os of the cervix.

Exile period begins from the moment the cervix is ​​fully dilated and ends with the birth of the child.

Succession period begins from the moment the child is born and ends with the expulsion of the placenta.

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

Disclosure period

During the opening period

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

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

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

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

Iphase (latent) begins with regular contractions and continues until the uterine os is 4 cm dilated. It lasts from 5 hours in multiparous women to 6.5 hours in primiparous women. Opening speed 0.35 cm/h.

Phase II (active) characterized by increased labor activity. It lasts 1.5-3 hours. The opening of the uterine pharynx progresses from 4 to 8 cm. The speed of opening is 1.5-2 cm/hour in primiparous women and 2-2.5 cm/hour in multiparous women.

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

Contractions are usually accompanied by pain, the degree of which varies and depends on the functional and typological characteristics nervous system women in labor. Pain during contractions is felt in the abdomen, lower back, sacrum, and groin areas. Sometimes in the first stage of labor reflex nausea and vomiting may occur, in in rare cases- semi-fainting state. For some women, the period of dilation may be almost or completely painless.

The dilatation of the cervix is ​​facilitated by movement amniotic fluid towards the cervical canal. With each contraction, the muscles of the uterus exert pressure on the contents of the fertilized egg, mainly on the amniotic fluid. There is a significant increase in intrauterine pressure; due to uniform pressure from the fundus and walls of the uterus, amniotic fluid, according to the laws of hydraulics, rushes towards the lower segment of the uterus. Here, in the center of the lower section of the fetal sac, the internal os of the cervical canal is located, where there is no resistance. Amniotic fluid rushes to the internal os under the influence of increased intrauterine pressure. Under the pressure of amniotic fluid, the lower pole of the fertilized egg peels off from the walls of the uterus and penetrates into the internal os of the cervical canal. This part of the membranes of the lower pole of the egg, which penetrates along with the amniotic fluid into the cervical canal, is called the amniotic sac. During contractions, the amniotic sac stretches and wedges deeper and deeper into the cervical canal, expanding it. The amniotic sac promotes expansion of the cervical canal from the inside (eccentrically), smoothing (disappearance) of the cervix and opening of the external os of the uterus.

Thus, the process of opening the pharynx is carried out due to stretching of the circular muscles of the cervix (distraction), which occurs in connection with the contraction of the muscles of the uterine body, the introduction of a tense fetal bladder, which expands the pharynx, acting like a hydraulic wedge. The main thing that leads to dilatation of the cervix is ​​its contractile activity; contractions cause both distraction of the cervix and an increase in intrauterine pressure, as a result of which the tension of the fetal bladder increases and it penetrates the pharynx. The amniotic sac plays an additional role in opening the pharynx. The main importance is the distraction associated with the retraction rearrangement of muscle fibers.

Due to muscle retraction, the length of the uterine cavity decreases slightly; it seems to slide off the fertilized egg, rushing upward. However, this sliding is limited by the ligamentous apparatus of the uterus. The round, uterosacral and partially broad ligaments keep the contracting uterus from moving too far. Tense round ligaments can be felt in a woman in labor through the abdominal wall. In connection with this action of the ligamentous apparatus, contractions of the uterus contribute to the advancement of the fertilized egg downwards.

When the uterus is retracted, not only its cervix, but also the lower segment is stretched. The lower segment (isthmus) of the uterus is relatively thin-walled, there are fewer muscle elements in it than in the body of the uterus. Stretching of the lower segment begins during pregnancy and intensifies during childbirth due to retraction of the muscles of the body or the upper segment of the uterus (the hollow muscle). With the development of strong contractions, the boundary between the contracting hollow muscle (upper segment) and the stretching lower segment of the uterus begins to appear. This boundary is called the boundary, or contraction, ring. The boundary ring usually forms after the rupture of amniotic fluid; it looks like a transverse groove that can be felt through the abdominal wall. During normal childbirth, the contraction ring does not rise high above the pubis (no higher than 4 transverse fingers).

Thus, the mechanism of the opening period is determined by the interaction of two forces having the opposite direction: upward drive (retraction of muscle fibers) and downward pressure (amniotic sac, hydraulic wedge). As a result, the cervix is ​​smoothed, its canal, together with the external uterine os, turns into a stretched tube, the lumen of which corresponds to the size of the nascent head and body of the fetus.

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

In first-time mothers, the internal os opens first; then the cervical canal gradually expands, which takes the shape of a funnel, tapering downwards. As the canal expands, the cervix shortens and finally completely flattens (straightens); Only the outer pharynx remains closed. Subsequently, stretching and thinning of the edges of the external pharynx occurs, it begins to open, its edges are pulled to the sides. With each contraction, the opening of the throat increases and finally becomes? full.

In multiparous women, the external os is already slightly open at the end of pregnancy due to its expansion and tears during previous births. At the end of pregnancy and at the beginning of labor, the pharynx freely allows the tip of the finger to pass through. During the period of opening, the external pharynx opens almost simultaneously with the opening internal pharynx and smoothing of the cervix.

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

During each contraction, amniotic fluid rushes to the lower pole of the fertilized egg; the amniotic sac is stretched (filled) and inserted into the pharynx. After the end of the fight, the water partially moves upward, tension amniotic sac weakens. Free movement of amniotic fluid towards the lower pole of the ovum and back occurs as long as the presenting part is mobile above the entrance to the pelvis. When the head descends, it comes into contact with the lower segment of the uterus on all sides and presses this area of ​​the uterine wall against the entrance to the pelvis.

The place where the head is covered by the walls of the lower segment is called the contact belt. The contact zone divides the amniotic fluid into anterior and posterior. The amniotic fluid located in the amniotic sac below the contact zone is called anterior water. Most of the amniotic fluid located above the contact zone is called posterior water.

The formation of the contact belt coincides with the beginning of the entry of the head into the pelvis. At this moment, the presentation of the head (occipital, anterior cephalic, etc.) and the nature of insertion (synclitic, asynclitic) are determined. Most often, the head is installed with a sagittal suture (small oblique size) in the transverse dimension of the pelvis ( occipital presentation), synclitically. During this period, preparations begin for forward movements during the period of exile.

The amniotic sac, filled with anterior fluid, becomes more and more engorged under the influence of contractions; by the end of the period of dilatation, the tension of the amniotic sac does not weaken in the pauses between contractions; he's ready to break. Most often, the amniotic sac ruptures when the pharynx is fully or almost fully dilated, during a contraction (timely release of water). After the rupture of the membranes, the anterior waters leave. The posterior waters usually burst immediately after the birth of the child. Rupture of the membranes occurs mainly due to their overstretching by amniotic fluid rushing to the lower pole of the fetal bladder under the influence of increased intrauterine pressure. The rupture of the membranes is also facilitated by the morphological changes that occur in them towards the end of pregnancy (thinning, decreased elasticity).

Less commonly, the amniotic sac ruptures when the pharynx is not fully dilated, sometimes even before labor occurs. If the amniotic sac ruptures when the pharynx is not fully dilated, they speak of early rupture of water; The discharge of amniotic fluid before the onset of labor is called premature. Early and premature rupture of amniotic fluid adversely affects the course of labor. As a result of untimely rupture of the membranes, the action of the fetal bladder (hydraulic wedge), which plays important role in smoothing the cervix and opening the pharynx. These processes occur under the influence of the contractile activity of the uterus, but over a longer period of time; in this case, complications of childbirth often arise that are unfavorable for the mother and fetus.

If the membranes are too dense, the fetal bladder ruptures after full dilatation of the pharynx (late rupture of the fetal bladder); sometimes it persists until the period of expulsion and protrusion of the presenting part from the genital slit.

The part of the head located below the contact belt, after the departure of the anterior waters, is under atmospheric pressure; the superior part of the head and the fetal body experience intrauterine pressure, which is higher than atmospheric pressure. In this regard, the conditions for outflow change venous blood a birth tumor forms from the presenting part and on it.

Maintaining the disclosure period

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

The condition of the woman in labor is important (complaints, skin color, mucous membranes, blood pressure dynamics, pulse rate and filling, body temperature, etc.). It is necessary to pay attention to the function of the bladder and bowel movements.

It is important to correctly assess the nature of labor, the duration and strength of contractions. By the end of the first stage of labor, contractions should recur after 2-3 minutes, last 45-60 seconds, and gain significant strength.

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

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

The degree of opening of the uterine pharynx is determined by the level of the contraction ring above the upper edge of the womb (Schatz-Unterbergon method), by the height of the uterine fundus relative to the xiphoid process of the woman in labor (Rogovin's method). The opening of the uterine pharynx is most accurately determined by vaginal examination. A vaginal examination during labor is performed at the onset of labor and after the release of amniotic fluid. Additional studies are carried out only when indicated.

The progress of the presenting part is monitored using external obstetric examination techniques.

The time of rupture and the nature of amniotic fluid are monitored. When the water is poured out until the uterine os is fully opened, vaginal examination. You should pay attention to the color of the amniotic fluid. The waters indicate the presence of fetal hypoxia. When the uterine os is fully dilated and the amniotic sac is intact, an amniotomy should be performed. The results of monitoring the woman in labor are recorded in the birth history every 2-3 hours.

During childbirth, a routine should be established for the mother in labor. Before the amniotic fluid ruptures, a woman in labor can usually take an arbitrary position and move freely. If the fetal head is moving, bed rest is prescribed; the woman in labor should lie on the side of the fetal head, which facilitates the insertion of the head. After inserting the head, the position of the woman in labor can be arbitrary. At the end of the first period, the most physiological position is for the woman in labor to be on her back with her torso raised, since it promotes the advancement of the fetus along the birth canal, since the longitudinal axis of the fetus and the axis of the birth canal in this case coincide. The diet of a woman in labor should include easily digestible high-calorie food: sweet tea or coffee, pureed soups, jelly, compotes, milk porridge.

During childbirth, it is necessary to monitor the emptying of the bladder and bowels. The bladder has a common innervation with the lower segment of the uterus, and therefore, overfilling of the bladder leads to dysfunction of the lower segment of the uterus and weakening of labor. Therefore, it is necessary to recommend that the woman in labor urinate every 2-3 hours. If urination is delayed for up to 3-4 hours, catheterization of the bladder is resorted to. Great importance has timely bowel movements. The first time a cleansing enema is given when a woman in labor is admitted to the maternity hospital. If the opening period lasts more than 12 hours, the enema is repeated.

To prevent ascending infection, careful adherence to sanitary and hygienic measures is of utmost importance. The external genitalia of a woman in labor is treated with a disinfectant solution at least once every 6 hours, after each act of urination and defecation and before vaginal examination.

The period of dilatation is the longest of all periods of labor and is accompanied by pain of varying degrees of intensity, so maximum pain relief during labor is mandatory. To relieve labor pain, drugs that have an antispasmodic effect are widely used:

Atropine 0.1% solution, 1 ml IM or IV.

Aprofen 1% solution, 1 ml IM. The greatest effect is observed when aprofen is combined with analgesics.

No-spa 2% solution, 2 ml subcutaneously or intramuscularly.

Baralgin, spazgan, maxigan 5 mg IV slowly.

In addition to these drugs, epidural anesthesia, which provides a pronounced analgesic, antispasmodic and hypotensive, can be used for pain relief in the 1st stage of labor. It is performed by an anesthesiologist and is performed when the uterine pharynx is dilated by 4-3 cm. Of the narcotic drugs that act primarily on the cerebral cortex, the following are used:

Nitrous oxide mixed with oxygen (2:1 or 3:1, respectively). If there is no sufficient effect, trilene is added to the gas mixture.

Trilene has an analgesic effect at a concentration of 0.5-0.7%. Trilene is not used for intrauterine fetal hypoxia.

GHB is administered as a 20% solution, 10-20 ml IV. Anesthesia occurs in 5-8 minutes. And continue for 1-3 hours. Contraindicated in women with hypertension syndrome. When administering GHB, premedication is carried out with a 0.1% atropine solution - 1 ml.

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

Exile period

During the period of exile

In the second stage of labor, the fetus is expelled from the uterus through the birth canal. After the water pours out, the contractions stop for a short time (a few minutes); at this time, muscle retraction and adaptation of the uterine walls to the reduced (after the waters break) volume continues. The walls of the uterus become thicker and come into closer contact with the fetus. The expanded lower segment and the smoothed neck with an open pharynx form, together with the vagina, the birth canal, which corresponds to the size of the head and body of the fetus. By the beginning of the expulsion period, the head is in intimate contact with the lower segment (internal attachment) and together with it is closely and comprehensively adjacent to the walls of the small pelvis (external attachment). After a short pause, contractions resume and intensify, retraction reaches its highest limit, and intrauterine pressure increases. The intensification of expelling contractions is due to the fact that the dense head irritates the nerve endings more than the amniotic sac. During the expulsion period, contractions become more frequent, and the pauses between them are shorter.

The fights soon join attempts- reflexively occurring contractions of the striated abdominal muscles. The addition of pushing to expulsion contractions means the beginning of the process of expulsion of the fetus.

During pushing, the mother's breathing is delayed, the diaphragm lowers, the abdominal muscles become very tense, and intra-abdominal pressure increases. Increasing intra-abdominal pressure is transmitted to the uterus and fetus. Under the influence of these forces, the “formation” of the fetus occurs. The fetal spine straightens, the crossed arms are pressed more tightly to the body, the shoulders rise to the head and the entire upper end of the fetus takes on a cylindrical shape, which helps expel the fetus from the uterine cavity.

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

The appearance of the head from the genital slit only during pushing is called cutting out heads. It indicates the end of the internal rotation of the head, which is installed in the cavity of the exit from the small pelvis; a fixation point is being formed. During the further course of the birth act, the head turns out to be so deeply embedded in the genital slit that it remains there beyond the attempt. This position of the head indicates the formation of a fixation point (suboccipital fossa with anterior view of the occipital insertion). From this moment, under the influence of ongoing attempts, it begins teething, heads. With each new attempt, the fetal head comes out more and more from the genital slit. First, the occipital region of the fetus erupts (is born). Then the parietal tubercles are installed in the genital fissure. The tension in the perineum reaches its maximum at this time. The most painful, albeit short-lived, moment of childbirth begins. After the birth of the parietal tubercles, the forehead and face of the fetus pass through the genital fissure. This ends the birth of the fetal head. The fetal head has erupted (born), this corresponds to the end of its extension.

After birth, the head makes an external rotation in accordance with the biomechanism of childbirth. In the first position, the face turns to the mother's right thigh, in the second position - to the left. After external rotation of the head, the anterior shoulder lingers at the pubis, the posterior shoulder is born, then the entire shoulder girdle and the entire body of the fetus, along with the posterior waters pouring out of the uterus. The posterior waters may contain particles of cheese-like lubricant, sometimes an admixture of blood from small tears in the soft tissue of the birth canal.

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

The woman in labor experiences severe fatigue and rests after intense muscular work. The heart rate gradually decreases. After the birth of a child, a woman in labor may experience severe chills, associated with a large loss of energy during strong pushing. The expulsion period for primiparous women lasts from 1 hour to 2 hours, for multiparous women - from 15 minutes to 1 hour.

Managing the period of exile

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

mother's condition;

the nature of labor;

condition of the fetus: determined by listening to its heartbeat after each effort in the middle of the pause, fluctuations in the frequency of fetal heart sounds in the second stage of labor from 110 to 130 beats. per minute, if it levels out between attempts, it should be considered normal;

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

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

Delivery reception carried out on a special Rakhmanov bed, well adapted for this. This bed is higher than usual (convenient to provide assistance in the 2nd and 3rd stages of labor), consists of 3 parts. The head end of the bed can be raised or lowered. The foot end can be retracted: The bed has special footrests and “reins” for the hands. The mattress for such a bed consists of three parts (polsters), covered with oilcloth (which facilitates their disinfection). In order for the external genitalia and perineum to be clearly visible, the pad located under the legs of the woman in labor is removed. The woman in labor lies on Rakhmanov’s bed on her back, her legs are bent at the knees and hip joints and rest against the stands. The head end of the bed is raised. This achieves a semi-sitting position, in which the axis of the uterus and the axis of the small pelvis coincide, which facilitates easier movement of the fetal head through the birth canal and facilitates pushing. To intensify efforts and be able to their to regulate, the woman in labor is recommended to hold on to the edge of the bed or special “reins” with her hands.

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

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

individual sterile kit for initial treatment of a newborn: 2 Kocher clamps, Rogovin staple, forceps for its application, triangular gauze, pipette, cotton balls, tape 60 cm long and 1 cm wide for anthropometry of the newborn, 2 oilcloth bracelets, catheter or balloon for suction of mucus.

From the moment the head is cut in, everything should be ready for delivery. The external genitalia of the woman in labor are disinfected. The midwife who delivers the baby washes her hands as before abdominal surgery, puts on a sterile gown and sterile gloves. Sterile shoe covers are put on the laboring woman’s feet; The thighs, legs and anus are covered with a sterile sheet, the end of which is placed under the sacrum.

During the cutting in of the heads, one is limited to monitoring the condition of the woman in labor, the nature of the pushing and the fetal heartbeat. Delivery begins during the eruption of the head. The woman in labor is provided with manual assistance, which is called “perineal protection” or “perineal support.” This manual is aimed at promoting the birth of the head smallest size for this insertion, to prevent disruption of intracranial blood circulation of the fetus and injury to the soft birth canal (perineum) of the mother. When providing manual assistance for cephalic presentation, all manipulations are performed in a certain sequence. The person delivering the baby usually stands to the right of the woman in labor.

First point - preventing premature extension of the head. The more the fetal head is bent in the anterior view of the occipital presentation, the smaller the circumference it erupts through the genital slit. Consequently, the perineum is less stretched and the head itself is less compressed by the tissues of the birth canal. By delaying the extension of the head, the doctor (midwife) attending the birth promotes its eruption in a bent state with a circle corresponding to a small oblique size (32 cm). If the head was not bent, it could be cut in a circle corresponding to the straight size (34 cm).

The period of cervical dilatation - from the beginning of regular contractions until the complete dilatation of the cervix and the outpouring of amniotic fluid - is the longest, lasting on average 13-18 hours for primiparous women, and 6-9 hours for multiparous women. Contractions are initially weak, short-term, rare, then gradually intensify, become longer (up to 30-40 s) and frequent (after 5-6 minutes). Due to contractions of the uterus, its cavity decreases, the lower pole of the amniotic sac surrounding the fetus begins to wedge into the canal of the cervix, contributing to its shortening and opening. This removes the obstacle to the fetus' path through the birth canal. At the end of the first period, the membranes rupture and amniotic fluid flows out of the genital tract. In rare cases, the membranes do not rupture, and the fetus is born covered with them (“in a shirt”). During each contraction, three processes occur simultaneously in the muscles of the uterus: 1 - contraction of the muscle fibers of the uterus (contraction), 2 - mutual displacement of the fibers relative to each other friend (retraction), 3 - stretching of muscle fibers (distraction). In the body of the uterus, with a predominance of muscle fibers, contraction and retraction mainly occur. During contractions, muscle elements, which are significantly stretched in length, shorten, shift, and intertwine with each other during contraction. During the pause, the fibers do not return to their original location, as a result of which a significant part of the muscles in the lower parts of the uterus shifts to the upper ones.

The principle of a triple downward gradient: the wave of uterine contraction has a certain direction - from top to bottom. Contraction of the uterus begins in the area of ​​one of the tubal angles, which is called the pacemaker. Then the wave of contraction spreads from one uterine angle to another, passes to the body with decreasing duration and strength down to the lower segment. The speed of propagation of uterine contractions is 2-3 cm/s. After 15-20 contractions, the entire uterus is covered. Despite the fact that various parts of the uterus begin to contract in different times, the maximum contraction of all muscles occurs simultaneously, which creates optimal conditions implementation of contractile activity of the uterus;

The duration of the contraction wave decreases as it moves from the fundus of the uterus to the lower segment, providing a more pronounced effect of the action of the upper parts of the uterus;

The intensity (amplitude) of uterine contraction also decreases as it spreads from the upper to the lower parts of the uterus. In the body, the force of contraction of the uterus creates a pressure of 50-120 mmHg. Art., and in the lower segment - only 25-60 mm Hg. Art., i.e. the upper parts of the uterus contract 2-3 times more than the lower parts, causing an upward displacement of the muscle fibers of the uterine body.

Clinical assessment of labor during the period of dilatation is the longest. It begins with the appearance of regular uterine contractions (contractions) and ends with the complete opening of the external os of the cervix. The onset of labor is characterized by the appearance of regular contractions (every 20 minutes) and typical changes in the cervix: shortening, smoothing, dilation. Regular contractions are usually preceded by a number of signs that are harbingers of labor. However, labor may occur without obvious warning signs, especially in multiparous women. Labor pains are usually painful. Degree pain different. This largely depends on the functional characteristics of the nervous system of women in labor. Women in labor report pain in the abdomen, lower back, sacrum, groin areas. The pain is more pronounced towards the end of the opening period. The latent phase is the time from the beginning of regular contractions until the appearance of structural changes in the cervix (until the opening of the uterine pharynx by 3-4 cm). In the latent phase, the contractile activity of the uterus responds well pharmacological effects. The duration of the latent phase in a primipara is 4-8 hours, and in a multiparous woman it is 4-6 hours and depends on the state of cervical maturity, parity, the influence of pharmacological agents and does not depend on the weight of the fetus. Following the latent phase comes the active phase of labor, which is characterized by rapid opening of the uterine pharynx from 4 to 8 cm. After the opening of the cervix by 8 cm, with the beginning of the descent of the head, the deceleration phase begins. Its occurrence is explained by the passage of the cervix behind the head at the end of the first stage of labor, when the rapid descent of the fetal head begins. From the very beginning of labor, with each contraction, the round uterine ligaments become tense and the uterus moves its bottom closer to the anterior abdominal wall. The upward and anterior movement of the uterine fundus during contractions changes the relationship between the axis of the fetus and the axis of the birth canal. The movement of the fetal trunk is communicated to the presenting head, the anterior parietal bone of which descends below the level at which it stood during the pause. With each contraction, the contraction ring becomes more and more pronounced and rises above the womb. By the end of the dilation period, the uterine fundus is in the hypochondrium for most, and the contraction ring is 5 transverse fingers above the pubic arch. An important indicator of the progress of labor is the rate of cervical dilatation. The speed of cervical dilatation at the beginning of labor (latent phase) is 0.35 cm/h, in the active phase - 1.5-2 cm/h in primiparous women and 2-2.5 cm/h in multiparous women. Bottom line the normal speed of opening of the uterine pharynx in the active phase in primiparous women is 1.2 cm/hour, and in multiparous women it is 1.5 cm/hour. The opening of the uterine pharynx from 8 to 10 cm (deceleration phase) occurs more slowly - 1 - 1.5 cm/hour. The rate of cervical dilatation depends on contractility myometrium, cervical resistance and their combinations.

When contractions become particularly strong and begin to repeat every 3-4 minutes, the cervix usually dilates completely or almost completely. The amniotic sac becomes tense not only during contractions, but also outside of them. Then, at the height of one of the contractions, the fetal bladder ruptures, and the anterior waters pour out in an amount of 100-200 ml. Rupture of the membranes occurs in most cases within the uterine os.

Management of labor during dilatation

Women in labor usually enter the maternity hospital during the dilation period. Each of them has an exchange card in her hands, which contains all the information about her state of health and the results of the examination throughout the pregnancy. Upon admission to the maternity hospital, a woman in labor goes through a sanitary inspection room, where, after measuring body temperature and blood pressure, the passport part of the birth history is filled out, the hair on the perineum is shaved, an enema, and a shower. After this, putting on sterile linen and a gown, she goes to the prenatal ward. If the amniotic sac is intact, contractions are not very strong, or if the fetal head is fixed at the entrance to the pelvis, the woman in labor is allowed to stand and walk. It is better to lie on your side, which prevents the development of “inferior vena cava compression syndrome.” During childbirth, the patient is not fed, since at any moment the question of providing anesthesia may arise. Care for a woman in labor in the first stage of labor consists of washing the external genitalia every 6 hours and, in addition, after defecation and before vaginal examination.For this purpose, use a 0.5% solution of potassium permanganate in boiled water. The woman in labor must have an individual bedpan, which is thoroughly disinfected after each use. During the period of cervical dilatation, careful observation is necessary. general condition women in labor, the nature of labor, the condition of the uterus, dilation of the cervix, advancement of the head. Monitoring the general condition of the woman in labor. Assessment of uterine contractility. Uterine tone, determined by hysterography. The intensity of contractions increases as labor progresses. Normally, in the first period it ranges from 30 to 50 mm Hg. The duration of contractions in the first stage of labor, as they progress, increases from 60 to 100 s. The interval between contractions as labor progresses decreases, amounting to 60 s. Normally, 4-4.5 contractions occur in 10 minutes. Maintaining a partogram. The condition of the uterus and the fetus in it can be determined during an external obstetric examination. It is carried out systematically and repeatedly; entries in the birth history should be made at least every 4 hours. Monitoring the condition of the fetus. Observation of the fetal heartbeat during the period of dilatation with an undisturbed amniotic sac is carried out every 15-20 minutes, and after the release of amniotic fluid - every 5-10 minutes. conduct auscultation, count fetal heartbeats. Use intrapartum cardiotocography (CTG) to monitor the condition of the fetus and contractile activity of the uterus during childbirth. To conduct the study, an external ultrasound sensor is mounted on the anterior abdominal wall of the mother in the area of ​​best hearing of fetal heart sounds. A vaginal examination in the first stage of labor is performed during the first examination of the woman in labor, after the rupture of amniotic fluid, or if complications arise in the mother or fetus. Initially, the external genitalia and perineum are examined. During a vaginal examination, the condition of the pelvic floor muscles, vagina, and cervix is ​​determined. The degree of smoothing of the cervix is ​​noted, whether the opening of the pharynx has begun and the degree of dilatation, the condition of the edges of the pharynx, the presence of a section of placental tissue within the pharynx, a loop of the umbilical cord, and a small part of the fetus. If the amniotic sac is intact, the degree of its tension during contractions and pauses is determined. In case of cephalic presentation, the sutures and fontanelles are palpated and, based on their relation to the planes and dimensions of the pelvis, one judges the position, presentation, insertion (synclitic or asynclitic), the presence of flexion (small fontanel below the large one) or extension (large fontanel below the small one, forehead, face). During a vaginal examination, in addition to identifying identifying points of the head, they find out the features bone base birth canal, examine the surface of the walls of the small pelvis. Based on a vaginal examination, the relationship of the head to the planes of the pelvis is determined. The following positions of the head are distinguished: above the entrance to the pelvis, a small or large segment at the entrance to the pelvis; in the wide or narrow part of the pelvic cavity, at the pelvic outlet.

18. Second period - period of exile. It lasts 1-2 hours for primiparous women, 5 minutes-1 hour for multiparous women. The advancement of the fetus along the birth canal occurs under the influence of contractions of the uterine muscles. During this period, rhythmically repeating contractions reaching greatest strength and duration, contractions of the abdominal muscles and diaphragm are added - pushing occurs. During the birth process, the fetus makes a series of sequential and strictly defined movements that facilitate its birth. The nature of these movements depends on the position of the fetus in the uterus. Usually it is located longitudinally, with the head down, while above the entrance to the pelvis of the woman in labor there is often the back of the head of the fetus, facing to the right or left (occipital presentation of the fetus). At the beginning of the period of expulsion of the fetus, its head is pressed against the chest (bent), then, moving along the birth canal and turning around its longitudinal axis, it is positioned with the back of the head in front, and the face behind (towards the sacrum of the woman in labor). When the fetal head, emerging from the pelvic cavity, begins to put pressure on the pelvic floor muscles, on the rectum and anus, the woman in labor feels a strong urge to lower herself, and the pushing increases sharply and becomes more frequent. During pushing, the head begins to appear from the genital slit; after the end of pushing, the head disappears again (head embedding). Soon there comes a moment when the head, even in pauses between attempts, does not disappear from the genital slit (eruption of the head). First, the back of the head and parietal tubercles erupt, then the fetal head unbends, and its facial part, facing posteriorly, is born. With the next push, the born head, as a result of turning the fetal body, turns its face towards the right or left thigh of the woman in labor. After this, after 1-2 attempts, the shoulders, torso and legs of the fetus are born. Clinical course of labor during the period of exile. After complete dilatation of the cervix, the expulsion of the fetus from the uterine cavity begins. Following the opening of the amniotic sac and the release of amniotic fluid, a weakening of labor is observed for some time. The walls of the uterus tightly envelop the fetus. The “posterior waters” are pushed toward the fundus of the uterus and, during cephalic presentation, fill the space between the buttocks and the wall of the fundus of the uterus. Labor intensifies after a few minutes. Contractions with increasing strength follow one after another every 4-3 and even 2 minutes. At the top of each contraction, the contractions of the uterus are joined by a contraction of the abdominal muscles, which marks the appearance of attempts, their force is aimed at expelling the fetus from the birth canal. The contraction ring becomes especially pronounced during the period of expulsion, however, during the physiological course of labor, the level of its standing does not change: it continues to remain 5 transverse fingers above the womb (10 cm).

Under the influence of contractions and pushing, first of all, the presenting part, and then the fetus, gradually passes through the birth canal. When the head comes into contact with the pelvic floor muscles, they begin to reflexively contract. These contractions intensify as the head moves forward. The pain from contraction of the uterus is accompanied by pain from the pressure of the head on the sacral nerve plexuses. The woman in labor has an irresistible desire to push and squeeze the head out of the birth canal. To enhance the action of the abdominal press, the woman in labor is looking for support for her arms and legs. By this she achieves increased pushing. The face of the woman in labor turns red during pushing, the neck veins swell, the skin becomes moist, and sometimes cramps appear calf muscles. When a pause occurs, the woman in labor takes a normal position in bed and rests from the tension she has just experienced. Under the influence of pushing, the fetus moves along the birth canal in accordance with the direction of its axis, making flexion, rotation, extension movements, overcoming the resistance of the contracting muscles of the pelvic floor, and also the Boulevard Ring. Normally, the speed of advancement of the head along the birth canal depends on the effectiveness of the expulsion forces and is 1 cm/h for primiparous women, and 2 cm/h for multiparous women. From the moment the fetus approaches the entrance to the pelvis, the perineum of the woman in labor begins to protrude, at first only during pushing, and subsequently in pauses between them. Protrusion of the perineum is accompanied by expansion and gaping anal opening. With further forward movements of the fetal head, the genital slit begins to open. During pushing, a small section of the head is shown from the opening genital slit, which is hidden again outside the pushing, and the genital slit closes. The head is being cut in. The cutting in of the yearling indicates that the internal rotation of the head ends and its extension begins. With the further development of pushing activity, the cutting head protrudes more and more forward and is no longer hidden after the cessation of pushing; the genital slit does not close, but gapes wide. If the head does not disappear after the cessation of pushing, they speak of the eruption of the head. With occipital presentation, the occipital part of the fetal head first erupts, and then the parietal tubercles appear from the genital fissure, the tension of the perineum at this time reaches highest limit. The most painful, albeit short-lived, moment of childbirth begins. After the birth of the back of the head and the crown of the head, with strong attempts, the forehead and face of the fetus are released from the birth canal.

The newly born head faces backwards, the face turns blue, and mucus is released from the nose and mouth. When pushing resumes after the birth of the head, the fetal body rotates, as a result of which one shoulder turns to the pubic symphysis, the other to the sacrum. The rotation of the fetal body causes rotation of the born head: in the first position, the face turns to the mother’s right thigh, in the second - to the left. The birth of hangers occurs in the following way: the front shoulder is delayed under the symphysis pubis, the back shoulder is rolled out over the perineum - the shoulder facing the perineum, then the entire shoulder girdle is born. After the birth of the head and shoulder girdle, the body and legs of the fetus are born without difficulty, sometimes together with the posterior water pouring out of the uterus, mixed with a small amount of blood and cheese-like lubricant. The newborn, born slightly cyanotic, takes his first breath, emits a cry, moves his limbs and begins quickly turn pink.

Management of childbirth during the period of exile

requires a lot of stress physical strength women in labor. The fetus often suffers during this period of labor, as the head is compressed, intracranial pressure increases, and with strong and prolonged pushing, the uteroplacental circulation is disrupted.

Monitoring the general condition of a woman in labor consists of periodically informing about her well-being, the nature, strength and location of pain, the behavior of the woman in labor, systematically determining the pulse, measuring blood pressure.Assessing the contractile activity of the uterus is important. In the second stage of labor, the tone of the uterus increases approximately 2 times compared to that in the first period, the intensity of uterine contractions decreases, but due to the addition of contractions of the striated muscles of the abdominal press and perineum (pushing), the amount of pressure developed reaches 100 mm Hg. Art., the duration of the effort is approximately 90 s, and the intervals between contractions are about 40 s.

When palpating the abdomen, the degree of contraction of the uterus and its relaxation outside of attempts, the tension of the round ligaments, and the height of the contraction ring are determined. attention to the condition of the lower segment of the uterus - whether it is thinning and painful, swelling of the external genitalia - compression of the soft tissues of the birth canal. Bloody discharge - beginning placental abruption or damage (rupture, abrasion) of the soft tissues of the birth canal. To determine the nature of the advancement of the presenting part of the fetus along the birth canal, repeated external and vaginal examinations are performed. The third and fourth rounds of external obstetric examination, as well as during vaginal examination, determine the relationship of the fetal head to various planes of the small pelvis.

Control of the forward movement of the head. obstetric and vaginal examination, using the Piskacek method: with the fingers of the right hand, wrapped in gauze, press on the tissue in the area of ​​the lateral edge of the labia majora until it “meets” the fetal head. At normal course During childbirth, there is a sequential movement of the head through the birth canal. Normal speed the advancement of the fetal head along the birth canal in first-time mothers is 1 cm/hour, and in multiparous women - 2 cm/hour. In the second stage of labor, the condition of the fetus is determined by listening to its heartbeat, constantly recording the heart rate using a cardiac monitor, and determining indicators of acid-base status and oxygen tension (Po) in the blood of the presenting part.

Obstetric aid for cephalic presentation.

First moment - prevention premature extension of the head. At the moment of birth, the head should pass through the vulvar ring into bent position. Under such conditions, it cuts through the genital slit with a circle drawn through a small oblique size (32 cm) instead of a straight size (35 cm), as happens with an extended head. When erupting in a bent state, the head is minimally compressed by the tissues of the birth canal, and at the same time the muscles of the perineum are less stretched. To prevent premature extension of the head, the midwife puts left hand on the pubic symphysis and the erupting head. In this case, the palmar surfaces of the four fingers of the left hand tightly adjacent to each other are located flat on the head, carefully delaying its extension and fast promotion along the birth canal. The head is bent until the suboccipital fossa fits under the symphysis pubis and a fixation point is formed. The second point is to reduce the tension in the perineal tissue. At the same time as delaying premature extension of the head, it is necessary to reduce the force of the circulatory pressure on the soft tissues of the pelvic floor and make them more pliable by “borrowing” from the labia area. The right hand, with the palmar surface, is placed on the perineum so that four fingers fit tightly to the area of ​​the left, and the most abducted finger to the area of ​​the right labia. The fold between the thumb and index finger is located above the scaphoid fossa of the perineum. Gently pressing the ends of all fingers on soft fabrics along the labia majora, bring them down to the perineum, while reducing its tension. At the same time, the palm of the right hand gently presses the erupting head of the perineal tissue, supporting them. Thanks to these manipulations, the tension in the perineal tissues is reduced; blood circulation remains normal in them, which increases their resistance to rupture. The third point is the regulation of pushing. The danger of rupture of the perineum and excessive compression of the head greatly increases when it is inserted into the vulvar ring by the parietal tubercles. rapid advancement of the head can lead to rupture of the perineal tissue and injury to the head. It is no less dangerous when the advancement of the head is delayed or suspended due to the cessation of pushing, as a result of which the head long time is subjected to compression by the stretched tissues of the perineum. After the head is positioned by the parietal tubercles in the genital fissure, and the suboccipital fossa has approached the pubic symphysis, it is advisable to continue removing the head without further attempts. the woman in labor is asked to breathe deeply and frequently open mouth. In such

traffic policemen, pushing activity is impossible. At this time, both hands delay the advancement of the head until the end of the attempt. right hand using sliding movements, remove tissue from

fetus At this time, with the left hand, they slowly raise the head forward, straightening it. The fourth moment is the release of the shoulder girdle and the birth of the fetus. After the birth of the head, the last moment of the birth mechanism occurs - the internal rotation of the shoulders and the external rotation of the head. To do this, the woman in labor is asked to push. During pushing, the head turns to face the right thigh in the first position, and to the left thigh in the second position. In this case, the independent birth of shoulders is possible. If this does not happen, then use your palms to grab the head by the temporo-buccal areas and apply posterior traction until a third of the anterior shoulder fits under the symphysis pubis. After the shoulder is brought under the womb, the head is grabbed with the left hand, lifting it up, and with the right hand the tissue of the perineum is moved from the rear shoulder, bringing the latter out. After the birth of the shoulder girdle, the index fingers of both hands are inserted into the armpits from the back and the torso is raised upward, corresponding to the axis of the pelvis. This contributes to the careful and rapid birth of the fetus. The release of the shoulder girdle must be done very carefully, without excessively stretching the cervical spine of the fetus, since in this case injuries to this section are possible. You also cannot be the first to remove the front handle from under the symphysis pubis, since it or the clavicle may be fractured. When there is a threat of rupture of the perineum, it is dissected - perineotomy or median episiotomy.

19. Third period - successive 9 – time from the birth of the fetus to the birth of the placenta (placenta with membranes and umbilical cord). 5-30 min. Blood loss 300-500 ml. The separation of the placenta occurs in the spongy layer of the mucous membrane at the site of its attachment to the uterine wall (placental platform). After the expulsion of the fetus, the placental platform significantly decreases in size, the placenta rises above the placenta. a platform in the form of a fold, which leads to a disruption of the connection between them and to a rupture of the uterine platform. vessels. The blood that flows out forms a retroplacental hematoma, which contributes to further placental abruption. The placenta with the membranes falls down and, with pushing, is born from the birth canal, turning outward with its fruiting surface - a variant of the placenta separation according to Schultze (separation of the placenta begins from its center)

According to Duncan - department pl. starts from its edge. The blood flows down freely and does not form retropl. Hematoma. Pl. born in a cigar-shaped shape with the maternal surface facing outward

Active intervention in III period necessary if: 1. blood loss exceeds 500 ml or 0.5% of body weight 2. less blood loss. but deterioration in general comp. women in labor 3. succession period over 30 minutes.

Signs of separation of the platform: Schroeder - if the area separated and descended into the lower segment or into the vagina, the fundus of the uterus rises up and is located above and to the right of the navel; The uterus takes on an hourglass shape. Chukalov-Kustner - when pressing with the edge of the hand on the suprapubic. In the area where the placenta is separated, the uterus rises up, but the umbilical cord does not retract into the vagina, but, on the contrary, comes out even more. Alfeld is a ligature placed on the umbilical cord at the genital slit of the woman in labor; when the placenta is separated, it descends 8-10 cm or lower from the vulvar ring. Davzhenko – If at deep breath the umbilical cord does not retract into the vagina, the placenta has separated. Klein - The woman in labor pushes, if the placenta has not separated, the umbilical cord is retracted into the vagina.

External methods for removing separated placenta: Abuladze - After emptying the bladder, the anterior abdominal wall is grasped in a fold with 2 hands, tightly clasping both rectus abdominis muscles with your fingers. The woman in labor is asked to push. The afterbirth is born. Crede-Lazarevich - 1. empty the bladder with a catheter 2. bring the fundus of the uterus to the median position 3. lightly stroking the uterus 4. grasp the fundus of the uterus with a brush so that the palmar surfaces of its four fingers are on back wall uterus, the palm is at the very bottom of the uterus, and thumb on its front wall 5. simultaneously press on the uterus with the whole hand in 2 directions (fingers - front to back, palm - top to bottom) towards the pubis until the placenta is born.

Determination of the integrity of the placenta - the placenta, with the maternal surface facing upward, is placed on a smooth tray and the placenta is carefully examined first, then the membranes, for the presence of defects in the lobule or part of the lobule and the integrity of the membranes.

20. Segments of the head (large, small). Greater segments head - that greatest circumference of which it passes through various planes of the small pelvis. Depending on the presentation of the fetus, the largest circumference of the head passing through the plane of the small pelvis is different. When the head is bent (occipital presentation), its large segment is manifested. a circle passing in a plane of small oblique size. With moderate extension (anterior cephalic presentation), the circumference of the head passes in the plane of the straight dimension, with maximum extension (facial presentation) - in the plane of the vertical dimension.

Any head segment smaller in volume than the large one is small.

The fetal head with a large segment at the entrance to the small pelvis means that the plane passing through the large segment of the head coincides with the plane of the entrance to the small pelvis.

The fetal head is motionless in a small segment at the entrance to the pelvis, most of it is located above the entrance to the pelvis, a small segment of the head is below the plane of the entrance to the pelvis.

21. Schemes. sequence of actions during pain relief during childbirth: 1. at the beginning of labor (latent phase of labor, cervical dilatation by 3-4 cm) with relatively less painful contractions, the use of tranquilizers (trioxazine - 0.6 g or elenium - 0.05 g, seduxen - 0.005 g) 2. with the development of regular labor and the appearance of expression. painful contractions, combined or independent use of inhaled or narcotic drugs is indicated. analgesics in combination with sedatives or antispasmodics. 3. In case of ineffectiveness of these methods or in the presence of extragenital pathology, gestosis, it is advisable to use epidural (epidural) anesthesia. We can recommend the following. combinations: 20-40 mg promedol + 40 mg no-shpa; 20-40 mg promedol + 40 mg papaverine; 2 mg Moradol + 10 mg Seduxen + 40 mg No-Spa; 50-100 mg meperidine + 25 promethazine.

Pain relief with analgesics should be started in case of expression. painful contractions, and stop 2-3 hours before the expected moment of birth due to possible narcotic depression of the fetus.

22. Physiological blood loss is 300-500 ml; 0.5% body weight. Blood loss exceeding 0.5% of body weight (250-400 ml) is considered pathological, and more than 1000 ml or more (1% or more of body weight) is considered massive. The causes of bleeding in the third period are: violation of the separation of the placenta and the discharge of the placenta from the uterus; soft tissue injuries of the birth canal; hereditary and acquired disorders of hemostasis. Bleeding from the genital tract in the early postpartum period: retention of part of the placenta in the uterine cavity; hypotension and atony of the uterus; hereditary or acquired hemostasis defects; ruptures of the uterus and soft tissues of the birth canal.

23. The born child is placed on a disinfected, warmed tray covered with a sterile diaper. The child is wiped with sterile wipes. After birth, they begin to treat the baby’s eyes and prevent gonoblennorrhea (1% solution of silver nitrate, or 30% solution of sodium sulfacyl). First, wipe the eyelids with a dry cotton swab. Then the upper and lower eyelids are lifted and one drop of solution is dripped onto the mucous membrane. The remainder of the umbilical cord on the child’s side is wiped with a sterile swab soaked in a 0.5% solution of chlorhexidine gluconate at 70%. ethyl alcohol, then the umbilical cord is pressed between the thumb and forefinger. In special sterile forceps insert a sterile metal cornea staple and place it on the umbilical cord, 0.5 cm from the skin edge of the umbilical ring; close the forceps with the staple until they are pinched. The remainder of the umbilical cord is cut 0.5-0.7 cm above the edge of the bracket. The umbilical wound is treated with a solution of 5% potassium permanganate. After applying the staple to the umbilical cord, film-forming drugs can be used. Treatment of the skin is carried out with a sterile cotton swab or a disposable paper napkin moistened with sterile vegetable oil from an individual disposable bottle. Remove cheese-like lubricant and remaining blood.

Determination of the newborn’s condition on the Apgar scale (0/1/2 points, respectively): heartbeat – absent/less than 100 per minute/100-140 per minute; breathing – absent/rare units. breath movement/good, scream; reflex excitability - there is no reaction to irritation of the soles/a grimace or movements/movements appear, a loud cry; muscle tone – absent/reduced/active movements; skin color is white or sharply cyanotic/pink, limbs are blue/pink.

24. Breech presentation divided into gluteal (flexion) and leg (extensor)

Gluteal: purely gluteal - the buttocks are facing the entrance to the pelvis: the legs are extended along the body - bent at the hips and extended at the hips knee joints and feet are located in the chin and face area. Mixed yag. presentation - the buttocks are facing the entrance to the small pelvis along with the legs bent at the hip and knee joints, slightly extended in ankle joints. Leg presentation: incomplete leg presentation - one leg is presented, extended at the hip and knee joints, and the other is bent at the hip and knee joint, located higher. Full leg - both legs of the fetus are presented at the entrance to the pelvis, slightly extended at the hip joints and bent at the knee joints. Kneeling presentation - the legs are extended at the hip joints and bent at the knees, and the knees are presented to the entrance to the pelvis.

Presumable factors for breech presentation: Maternal – anomalies of the uterus, uterine tumors, narrow pelvis, scar on the uterus. Fruit - prematurity, multiple births, congenital anomalies fetus Placental – placenta previa, its location in the fundus and corners of the uterus, oligohydramnios, polyhydramnios.

Diagnosis: 4 Leopold maneuvers, vaginal examination, Ultrasonography, amnioscopy.

25. There are 6 moments of the mechanics of childbirth during breech: 1 – internal rotation of the buttocks – begins when the buttocks transition from the wide part to the narrow part. When turning, at the outlet of the pelvis, the transverse size of the buttocks turns out to be straight size pelvis 2 – lateral flexion of the lumbar part of the fetal spine - the posterior buttock rolls out over the perineum, followed by the anterior buttock finally being born from under the pubic joint. The hangers come into their own transverse size in oblique size of the entrance to the pelvis. 3- internal rotation of the shoulders and external rotation of the body - ends with the installation of the shoulders in the direct size of the exit 4- lateral flexion of the cervicothoracic part of the spine - the birth of the shoulder girdle and arms 5- internal rotation of the head (occiput to the front) - during the transition from the wide to the narrow part of the pelvis the head makes an internal rotation, with the sagittal suture being in the direct size of the exit, and the suboccipital fossa under the pubic symphysis. 6- flexion of the head – the head erupts in a small oblique size (less often medium oblique).

With leg presentation it is different - the legs are shown first from the genital slit instead of the buttocks (with complete presentation). In the latter case, the straightened leg (presenting) leg is usually the anterior one. When the leg is born up to the knee, the buttocks enter the pelvis.

26. Delivery tactics for breech presentation must be determined before birth: - spontaneous onset of labor and delivery through the natural birth canal; - induction of labor at or before the due date; - delivery by caesarean section as planned.

In the 1st period, the woman in labor must remain in bed. The woman in labor is placed on the side where the back of the fetus is facing, which helps insert the presenting part of the fetus, enhance activity, and prevent prolapse of the umbilical cord loops. Monitoring of the cardiac activity of the fetus and contractile activity of the uterus is required. In the 2nd period with the profile goal, intravenous drip administration of uterotonic agents (oxytocin) is recommended. To prevent cervical spasm, it is recommended to administer 1.0 ml of 0.1% atorpin sulfate solution or other antispasmodic agent. Manual assistance is required. During birth in the pelvis, 4 stages are distinguished: 1- birth of the fetus to the navel 2- from the navel to the lower angle of the shoulder blades 3- birth of the shoulders of the belt and arms 4- birth of the head.

27. manual on Tsavyanov The main goal is to keep the legs extended and pressed against the fetal body during the expulsion period, which helps maintain the normal position of the fetus. Technique - after the buttocks have erupted, I grab them with my hands so that the thumbs of both hands are located on the fetal hips pressed to the stomach, and the other four fingers of both hands are on the surface of the sacrum. As birth progresses, the fetal legs are pressed against the abdomen thumbs, the remaining fingers are moved up the back, gradually moving the hands towards the genital slit, preventing the legs from falling out and the arms being thrown over the head. The fetal buttocks must be directed somewhat posteriorly to facilitate the birth of the fetal anterior arm from under the pubic arch. To birth the posterior arm, the fetus is lifted anteriorly and the posterior arm is born from the sacral cavity. After this, the chin, mouth, and nose of the fetus appear in the depths of the gaping genital slit.

1. Preparation for childbirth for first-time mothers begins from the moment the fetal head is cut in, and for multiparous women - from the moment the cervix is ​​fully dilated. The woman in labor is transferred to the delivery room and equipment, instruments, sterile material and linen are prepared for the newborn’s toilet.

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

A. Research has shown that the most comfortable position during childbirth - half-sitting. To do this, leg holders are attached to the table. This position of the woman in labor does not affect the condition of the fetus and reduces the need for the use of obstetric forceps.

b. The perineum is treated with iodine solution. Choose a method of pain relief. By mutual agreement of the woman in labor and the doctor, childbirth can be carried out without anesthesia. If an episiotomy is expected, infiltration anesthesia of the perineum or pudendal anesthesia is performed.

3. Obstetric aid for anterior occipital presentation

A. Removal of the head. Obstetric aid is necessary to ensure that the head passes through the vulvar ring with its smallest diameter - small oblique size. Obstetric care is to prevent premature extension of the head, and then carefully bring out the face and chin of the fetus by pressing on the perineum and pushing it posteriorly and downward. This reduces tension in the perineum and reduces the risk of rupture. Another method is to actively extend the fetal head by pressing one hand on the fetal chin through the perineum and the other on the back of the fetal head. This method is more traumatic and is used only in the intervals between contractions. After the birth of the head, mucus is removed from the nasopharynx and oropharynx of the fetus using a catheter connected to a special suction. If meconium is detected, before removing the shoulders, the nasopharynx and oropharynx, as well as the fetal stomach, are freed from meconium using a special suction. It should be remembered that with excessive irritation of the posterior wall of the fetal pharynx, reflex bradycardia is possible. If it is difficult to remove the shoulders, aspiration of mucus is performed only after their birth. By inserting a finger into the vagina, they determine whether the umbilical cord is entwined around the neck. In case of entanglement, they try to move the umbilical cord to the back of the head or torso. If this fails, two clamps are placed on the umbilical cord, it is cut and labor continues.

b. Removing the shoulders. In order to help the birth of the anterior shoulder, the fetal head is slightly tilted downwards, sometimes the assistant is asked to press on suprapubic region women in labor. After the anterior shoulder comes out from under the pubic arch, the head is lifted upward and the posterior shoulder is carefully removed. Cutting through the hangers requires special attention, since this causes significant stretching of the soft tissues and a possible rupture of the perineum.

V. The final stage. After the birth of the baby’s shoulders, holding the back of the neck with one hand and the buttocks with the other, they remove him and turn him over onto his stomach to free the nasopharynx from mucus. Then the child is placed on the table, the remaining mucus from the nasopharynx is sucked out, two clamps are placed on the umbilical cord and it is crossed so that the remainder of the umbilical cord is 2-3 cm. Then the umbilical ring is examined to exclude umbilical hernia and hernia of the umbilical cord. The baby is briefly placed on the mother's stomach (for first contact) and then placed in the incubator.

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

A. Indications

1) Prevention of perineal rupture.

2) Prevention of pelvic floor stretching.

3) Prevention of birth trauma.

b. Risk assessment. Although perineotomy and episiotomy are widely used in obstetrics, their effectiveness has not been demonstrated in prospective studies. It should be noted, however, that a wound from a perineo- or episiotomy always heals better than perineal lacerations. In the postpartum period, a postpartum woman may experience pain and swelling of the tissues in the area of ​​surgery for several days. Dyspareunia (pain during intercourse) may occur for several weeks after birth. Most serious complication- wound infection.

V. Time. The operation is performed at the moment when a section of the head with a diameter of 3-4 cm is shown into the contraction from the genital slit. If the incision is made earlier, large blood loss is possible, and later - stretching of the perineum and vagina.

g. Technique of operation. Superficial, pudendal or spinal anesthesia is used. The perineal tissues are lifted above the fetal head and, at the height of the next attempt, they are cut towards the opening anus. On the one hand, the incision should be sufficient so that it does not turn into a rupture during childbirth, on the other hand, injury to the rectum and anal sphincter should be avoided. If the perineum is low, an episiotomy is performed. The birth is carried out carefully, trying to prevent the incision from turning into a rupture; to do this, the perineum is pressed with a hand. It is important to remember that most deliveries can be performed successfully without perineotomy or episiotomy.

1st stage of labor – period of cervical dilatation. A traditional hospital birth is led by a doctor together with a midwife.

1. Women in labor are admitted to the maternity hospital during the dilation period. Each of them should have an exchange card in their hands, which contains all the information about their health status and the results of the examination throughout the pregnancy. In the emergency room of the maternity hospital, a “Childbirth History” is filled out for each woman in labor, full or partial sanitary treatment is carried out, then the woman in labor is transferred to the maternity ward.

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

3. The woman in labor is placed in bed, walking is allowed with fluid flow and the head of the fetus is pressed; if the head is mobile, the woman in labor is recommended to lie down, preferably on her side (prevents the development of “inferior vena cava syndrome”). To speed up labor, it is recommended to lie on your side, where the back of the fetal head is located.

4. Nutrition of the woman: during childbirth the patient is not fed, since at any moment the question of providing anesthesia may arise ( intravenous anesthesia, intubation, artificial ventilation).

5. During the period of dilation, labor anesthesia is used, and the dilation of the cervix should be 3-4 cm or more.

6. During the opening period, you should monitor

A) the condition of the woman in labor - the degree of pain, the presence of dizziness, headache, visual disturbances, etc., heart sounds, pulse, blood pressure (on both arms)

B) monitoring the condition of the fetus - if the amniotic sac is intact, the heartbeat should be listened to every 15-20 minutes, and if the water has leaked - every 5-10 minutes. Normal heart rate is 120-140 (up to 150) beats per minute. after a contraction, the heartbeat slows down to 100-110 beats. in 1 minute, but after 10-15 seconds. is being restored. Most informative method monitoring the condition of the fetus and the nature of labor is cardiac monitoring.

C) the relationship of the presenting part to the entrance to the pelvis (pressed, mobile, in the pelvic cavity, speed of advancement).

D) the condition of the uterus, dilatation of the cervix.

D) the nature of labor: regularity, quantity, duration, strength of contractions. The nature of labor can be determined by calculating Montevideo Unit (EM) = Number of contractions in 10 minutes. × contraction intensity, normally 150-300 IU.

To register labor activity, you can use: a) clinical registration contractile activity of the uterus - counting the number of contractions by palpation of the abdomen, b) external hysterography (using Moray's capsule, which is alternately placed on the fundus, body and lower segment of the uterus, to register a triple descending gradient); c) internal hysterography (tocography) or radiotelemetric method (using the “Capsule” device, a capsule can be inserted into the uterine cavity for registration total pressure in the uterine cavity: maximum pressure in the uterine cavity is normally 50-60 mmHg. Art., minimum – 10 mm Hg. Art.). With all types of recording of contractile activity of the uterus in the first and second stages of labor, waves of a certain amplitude and duration are recorded, corresponding to contractions of the uterus. Tone The uterus, determined by hysterography, increases as the labor process progresses, normally amounting to 8-12 mm Hg. Art. Intensity Contractions intensify as labor progresses. Normally in the first period it ranges from 30 to 50 mm Hg. Art. Duration Contractions in the first stage of labor increase from 60 to 100 seconds as they progress. Interval Between contractions it decreases to 60 seconds. Normally, 4-4.5 contractions occur in 10 minutes.

E) over the course of labor - to assess the course of the labor process is carried out Partograph. This also takes into account the advancement of the presenting part of the fetus (head, pelvic end) along the birth canal.

G) the condition of the amniotic sac, the nature of the amniotic fluid.

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

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

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

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

8. Vaginal examination is mandatory Twice – When a woman enters and when amniotic fluid leaves; additional vaginal examinations can be carried out if it is necessary to clarify the dynamics of cervical dilatation, if complications arise in the mother, if the condition of the fetus worsens, in the delivery room. Initially, the external genitalia are examined ( varicose veins, scars, etc.) and perineum (height, old tears, etc.). During a vaginal examination, the condition of the pelvic floor muscles (elastic, flabby), vagina (wide, narrow, presence of scars, septa), and cervix is ​​determined. The degree of smoothing of the cervix is ​​noted, whether dilatation has begun and the degree of dilatation (in centimeters), the condition of the edges of the pharynx (thick, thin, soft or rigid), the presence of a site within the pharynx placental tissue, umbilical cord loops, small parts of the fetus. If the amniotic sac is intact, the degree of its tension during contractions and pauses is determined. Excessive tension even during a pause indicates polyhydramnios, flattening indicates oligohydramnios, and flabbiness indicates weakness of labor. The presenting part of the fetus and identification points on it are determined. In case of cephalic presentation, the sutures and fontanelles are palpated and, based on their relation to the planes and dimensions of the pelvis, the position, presentation, insertion, and the presence of flexion (small fontanelle below the large one) or extension (large fontanel below the small one or at the same level) are judged. During a vaginal examination, the features of the bone base of the birth canal are also clarified, and the surface of the pelvic walls is examined (for deformations, exostoses, etc.). Based on a vaginal examination, the relationship of the fetal head to the pelvic planes is determined. The following positions of the head are distinguished: above the entrance to the pelvis, a small or large segment at the entrance to the pelvis, in a wide or narrow part of the pelvic cavity, at the pelvic outlet.

The 2nd stage of labor is the period of expulsion. During the period of exile it is necessary:

1. Carefully observe the general condition of the woman in labor, the color of the skin and visible mucous membranes, ask about her health (the presence of headaches, dizziness, visual disturbances and other symptoms indicate a deterioration in the condition of the woman in labor, which may pose a threat to the life of the woman and the fetus), count pulse, measure blood pressure on both arms.

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

3. Monitor the progress of the presenting part along the birth canal, using the third and fourth methods of external obstetric examination, as well as vaginal examination (to clarify the position of the head). The passage of the head through the birth canal can be monitored using Piskacek method: with the fingers of the right hand, wrapped in gauze, press on the tissue in the area of ​​the lateral edge of the labia majora until it “meets” the fetal head. This is possible if the fetal head is in a narrow part of the pelvic cavity. It should be taken into account that with large birth tumor the method does not work reliable result. Prolonged standing of the head in one plane of the pelvis indicates the occurrence of some obstacles to the expulsion of the fetus or a weakening of labor and can lead to compression of the soft tissues of the birth canal and bladder, followed by poor circulation and urinary retention.

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

4. The condition of the fetus is determined by listening to its heartbeat and constantly recording the frequency of contractions using cardiac monitors. In women giving birth in groups high risk development of intrapartum pathology, indicators of the acid-base state and oxygen tension in the blood of the presenting part are determined. In the absence of constant cardiac monitoring, it is necessary to listen to fetal heart sounds after each push and contraction, and count the heartbeat every 10-15 minutes. During the expulsion period with cephalic presentation, the basal heart rate ranges from 110 to 170 per minute. In response to pushing during cephalic presentation, early U-shaped decelerations up to 80 beats/min are more often recorded, as well as V-shaped decelerations up to 75-85 beats/min outside of uterine contractions or short-term accelerations up to 180 beats/min.

5. Monitor the condition of the external genitalia to prevent perineal rupture. Perineal ruptures range from 7-10%. Signs of a threat of perineal rupture are:

– cyanotic perineum due to compression venous system;

– swelling of the external genitalia;

– shiny crotch;

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

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

6. Monitor the nature of vaginal discharge: bloody discharge may indicate incipient placental abruption or damage to the soft tissues of the birth canal; admixture of meconium during cephalic presentation is a sign of fetal asphyxia; purulent discharge from the vagina indicate the presence of an inflammatory process.

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

8. From the moment the heads erupt, they begin to Obstetrical benefits – childbirth. Obstetric aid for cephalic presentation (“perineal protection”) Consists of manipulations performed in a certain sequence.

1) the first point is the prevention of premature extension of the head. At the moment of birth, the head must pass through the vulvar ring in a bent position, then it erupts through the genital slit with the smallest circle drawn through the small oblique dimension. To do this, the midwife places her left hand on the pubic symphysis and the erupting head, the palm is placed flat on the head, carefully delaying its extension and rapid movement along the birth canal.

2) the second point - reducing the tension of the perineal tissues, creating a “loan” of tissues To prevent perineal rupture. The loan is made as follows: the right hand is placed with the palmar surface on the perineum so that four fingers fit tightly to the area of ​​the left, and the maximally abducted thumb to the area of ​​the right labia. Gently pressing the ends of all fingers on the soft tissues along the labia majora, bring them down to the perineum, while reducing its tension.

3) the third point - regulation of pushing: Turn off or weaken when necessary. Removal of the head after its fixation (III moment of the biomechanism of childbirth) is preferably carried out without pushing. To do this, during a contraction, the woman is asked not to push, but simply to breathe deeply and often with her open mouth. In this state, pushing activity is impossible. At this time, until the end of the push, both hands delay the advancement of the head until the end of the push. After the end of the pushing, the tissues are removed from the fetal face using sliding movements with the right hand. With the left hand, slowly lift the head forward, straightening it. If necessary, the woman in labor is asked to voluntarily push outside of contractions.

4) the fourth moment - the release of the shoulder girdle and the birth of the torso. After external rotation of the head, when the woman pushes, spontaneous birth of the shoulders is possible. If this does not happen, then use your palms to grab the head by the temporobuccal areas and apply posterior traction until a third of the anterior shoulder is fixed to the pubic arch. Then, with your left hand, grab the head, lifting it up, and with your right hand, carefully remove the perineum from the back shoulder and remove the back shoulder. After the birth of the shoulder girdle, the index fingers of both hands are inserted into the armpits from the back and the torso is raised upward, according to the wire axis of the pelvis. It is necessary to remove the shoulder girdle carefully, without excessively stretching the cervical spine, as injury may occur. You should also not be the first to remove the front handle from under the symphysis pubis, since it or the collarbone may be broken. After birth, the baby's condition is assessed using the Apgar score after 1 and 5 minutes. A satisfactory condition is indicated by a score of 8-10 points.

The 3rd stage of labor is the afterbirth period.

1. Lead tactics afterbirth expectant with physiological blood loss, in the absence of signs of placental separation, with good condition women in labor. Active intervention becomes necessary in following situations:

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

– with less blood loss, but deterioration in the general condition of the woman in labor;

- if the succession period continues for more than 30 minutes, even if the mother is in good condition and in the absence of bleeding.

2. Immediately after the birth of the child it is necessary Using a catheter to release urine from a woman and apply Mammary reflex to speed up uterine contractions. In the future, it is necessary to monitor the function of the bladder to prevent it from overflowing, as this inhibits the afterbirth contractions and disrupts the process of placental abruption and expulsion of the placenta.

3. Constantly monitor the general condition of the woman in labor, her well-being, pulse (it should be well filled, no more than 100 beats/min), blood pressure should not decrease by more than 15-20 mm Hg. Art. compared to the original, the color of the skin and visible mucous membranes, the nature and quantity bloody discharge from the genital tract.

4. If the woman in labor is in good condition and there is no bleeding, she should wait for spontaneous placental abruption and the birth of the placenta. And constantly It is necessary to monitor Signs of placental separation , The most important of which are:

A) Schroeder's sign – Changes in the shape and height of the fundus of the uterus - the uterus rises up, above the navel, flattens, becomes narrower and deviates to the right (the round ligament on the right is shorter);

B) Alfeld's sign – Lengthening the outer section of the umbilical cord - a clamp placed on the umbilical cord at the genital slit is lowered by 10-12 cm;

B) Kustner-Chukalov sign – When pressing with the edge of the palm on the suprapubic area when the placenta has separated, the umbilical cord does not retract;

D) Dovzhenko's sign – At deep breathing In women, the umbilical cord does not retract;

D) Klein's sign – When the woman in labor strains, the end of the umbilical cord lengthens and after the end of the strain, the umbilical cord does not retract;

E) Mikulicz sign – The urge to push – the separated placenta descends into the vagina, the urge to push appears (the sign is not permanent);

G) the appearance of a protrusion above the symphysis As a result, the separated placenta descends into the thin-walled lower segment, and the anterior wall of this segment, together with the abdominal wall, rises.

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

5. If there are signs of separation of the placenta, but the placenta does not stand out, without waiting 30 minutes, use Methods for isolating separated placenta:

A) Abuladze’s method – After emptying the bladder and gentle massage of the uterus, the anterior abdominal wall of the woman in labor is grasped with both hands in a longitudinal fold so that both rectus abdominis muscles are tightly grasped with the fingers; the woman in labor is asked to push and the separated placenta is easily delivered due to the elimination of the discrepancy of the rectus abdominis muscles and a significant reduction in the volume of the abdominal cavity;

B) Genter's method – Having asked the woman in labor to relax, hands clenched into fists are placed on the bottom of the uterus in the area of ​​the tubal angles and slowly press inward and downward;

B) Crede-Lazarevich method – Performed in a certain sequence, without anesthesia; anesthesia is necessary only in cases where it is assumed that the separated placenta is retained in the uterus due to spastic contraction of the uterine pharynx:

– empty the bladder;

– bring the fundus of the uterus to the middle position;

– perform light stroking (not massage!) of the uterus in order to contract it;

- grasp the fundus of the uterus so that the palmar surfaces of the four fingers are located on the posterior wall of the uterus, the palm is on the very bottom of the uterus, and the thumb is on its anterior wall;

- simultaneously press on the uterus with the entire hand in two intersecting directions (fingers - front to back, palm - top to bottom) towards the pubis until the placenta is born from the vagina;

D) Mitlin's method – A hand clenched into a fist is placed on the anterior abdominal wall above the pubis back side to the symphysis; move the fist upward, pressing it tightly against the anterior abdominal wall of the woman in labor; Having reached the bottom of the uterus, they press towards the spine and ask the woman to push.

6. After the birth of the placenta, it is carefully examined to ensure the integrity of the placenta and membranes, since retention of parts of the placenta or membranes in the uterus can lead to serious complications (bleeding, septic postpartum diseases). Remaining parts of the placenta and membranes must be removed. After examination, the placenta is measured and weighed, and the data is entered into the birth history.

7. After the birth of the placenta, the external genitalia, perineal area and internal genitalia (vagina and cervix) must be examined. If there are ruptures, they must be sutured, this is a preventative measure. postpartum hemorrhage And infectious diseases, as well as prolapse and prolapse of the internal genital organs.

8. The postpartum woman is observed for 2 hours in the delivery room and then transferred to the postpartum ward.

The course of premature birth is characterized by a number of features:

• - up to 40% of premature births begin with premature rupture of amniotic fluid;
• -anomalies of labor;
• - increasing the duration of labor;
• - the occurrence of fetal asphyxia;
• - bleeding in the afterbirth and early postpartum period;
• - not uncommon infectious complications in childbirth.

The management of preterm birth depends on:

• - stages of premature birth;
• - gestational age;
• - condition of the amniotic sac;
• - mother's condition;
• - degree of cervical dilatation;
• - presence of signs of infection;
• - the presence of labor and its severity;
• - presence of bleeding and its nature.

Depending on the situation, they adhere to expectant-conservative or active tactics of labor management.

Management of women with onset of preterm labor. You should try to stop labor: prescribe one of the drugs that inhibit contractile activity uterus or their combination (25% solution of magnesium sulfate - 5 - 10 ml intramuscularly 2 - 3 times a day, 0.5% solution of novocaine 50 - 100 ml intravenously under blood pressure control). The most effective use of betamimetic drugs is that they reduce the intensity of uterine contractions and lead to persistent relaxation of the uterine muscles. Partusisten is started to be administered intravenously, 10 ml per 250 ml. saline solution at a rate of 10 - 15 drops per minute for 4 - 6 hours. The rate of drug administration depends on individual tolerance, which is manifested by side effects such as tachycardia, hand tremors, decreased blood pressure, and nausea. After graduation intravenous administration partusistene, the same drug is prescribed in tablets. Contraindications to the use of beta mimetics: heart disease, thyrotoxicosis, diabetes mellitus, intrauterine infection, bleeding associated with placental pathology.

At the same time, to prevent SDR in newborns, dexamethasone is prescribed at a dose of 18 - 24 mg per course. This drug is used to accelerate the maturation of the lungs in the fetus.

Management of women with premature pregnancy complicated by premature rupture of amniotic fluid in the absence of labor. In 25 - 40% of pregnant women premature birth begin with premature rupture of amniotic fluid, while in 12 - 14% labor does not develop independently after rupture of the membranes. In such pregnant women, the method of choice is conservative expectant management. This is because perinatal mortality at the same time, it is significantly lower than with active tactics (immediate induction of labor);

often it is not possible to induce labor even with repeated use of birth-stimulating drugs; the frequency of chorioamnionitis and purulent-septic diseases in newborns depends on strict adherence to antiseptic measures and taking into account contraindications for choosing this tactic;

Due to vasospasm in the uteroplacental circulatory system, after the administration of oxytotic drugs, the cardiac activity of the fetus often changes.

Indications for conservative expectant management: during pregnancy 28 - 34 weeks, in cases of longitudinal position of the fetus, no signs of infection, no severe obstetric and extragenital pathology.

Necessary conditions for conservative expectant tactics are strict adherence to aseptic and antiseptic measures, the creation of therapeutic protective regime. In case of premature rupture of amniotic fluid, pregnant women must be hospitalized in a special ward, processed according to the same schedule as the maternity ward. Linen is changed daily, and sterile linens are changed 3-4 times a day. A hygienic shower is performed every 3-4 days. Tests of blood, urine, vaginal smears, and cultures from the cervical canal for microflora are carried out once every 5 days.

After taking smears, the vagina is treated with a tampon soaked in a disinfectant solution.

Therapy with conservative expectant management:

• 1. Antispasmodics (isoverine 1 ml 2 times a day intramuscularly, platiphylline 1 ml of a 0.1% solution 2 times a day intramuscularly, etc.)
• 2. Tocolytic drugs (magnesium sulfate 25% - 10.0 2 times a day intramuscularly, papaverine 1 - 2 ml of a 2% solution intramuscularly, etc.)
• 3. Prevention of fetal hypoxia (Nikolaev’s triad, sigetin 2 - 4 ml intramuscularly, vitamin C 5 ml intravenously with 20% or 40% glucose solution, 10% solution of gutimin 10 ml intramuscularly once a day).

As the duration of the anhydrous interval increases, in case of increased contractile activity of the uterus or changes in the cardiac activity of the fetus, one of the listed drugs or their combination is again prescribed. If pregnancy continues for more than 10-14 days, therapy is repeated. Bed rest shown only in the first 3 - 5 days.

Indications for preparing a pregnant woman for delivery after prolonged leakage of amniotic fluid are: prolongation of pregnancy to 36 - 37 weeks with an estimated fetal weight of at least 2500 g; the appearance of signs of infection (leukocytosis with a shift of the formula to the left, microflora in cervical canal); deterioration of the fetus' condition. In these cases, in within three days, therapy is prescribed aimed at preparing the body for childbirth:

glucose - 40% solution with 5 ml of 5% vitamin C intravenously, ATP 1 ml intramuscularly, folliculin or sinestrol 20,000 - 30,000 IU intramuscularly 2 times a day, solution calcium chloride 1 tablespoon 3 times a day orally, oxygen therapy, isoverine - 1 ml 2 times a day intramuscularly.

If labor does not develop within 1 - 2 days, then labor induction begins.

When an intrauterine infection develops, estrogens and antispasmodics are prescribed, and after 4-6 hours labor is induced (2.5 units of oxytocin in combination with 2.5 mg of prostaglandin F2? in 500 ml of saline). Delivery must be done through the natural birth canal. At the same time, intensive antibiotic therapy, the use of drugs that increase the body’s immunological reactivity, and correction of electrolyte disturbances are indicated.

During childbirth, all women in labor must be prevented from fetal hypoxia once every 3-4 hours.

Contraindications to conservative expectant management:

Absolute:

• 1. Transverse and oblique presentation of the fetus, foot presentation with central rupture of the membranes and an open cervical canal;
• 2. Presence of signs of intrauterine infection;
• 3. Gestational age is 36 weeks or more.

Relative:

• 1. Gestation period 34 - 35 weeks;
• 2. Leg presentation with high rupture of membranes and a closed cervical canal;
• 3. Indication of criminal intrauterine intervention, but without obvious signs infections;
• 4. Severe extragenital pathology in the mother, nephropathy, multiple pregnancy;
• 5. Leukocytosis with a shift of the formula to the left when normal temperature body, pathogenic microflora in the vagina or degree of vaginal cleanliness of the III degree.

In this case, preparation for childbirth, prevention of fetal hypoxia and treatment of the underlying disease are carried out within 3 - 5 days. In the absence of labor, labor induction is resorted to.

Indications for active management of preterm birth:

• 1. absence of amniotic sac;
• 2. presence of regular labor;
• 3. presence of signs of infection;
• 4. intrauterine fetal suffering;
• 5. heavy somatic diseases mothers;
• 6. complications associated with pregnancy that cannot be treated;
• 7. suspicion of deformity or abnormal development of the fetus.