Clinic and management of childbirth with anomalies of the contractile activity of the uterus. Discoordination of labor activity

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

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

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

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

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

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

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

Primary weakness of labor activity

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

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

Secondary weakness of labor activity

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

Mechanical obstacles during childbirth can be:

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

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

In some cases, to start the contractile activity of the uterus, a preliminary artificial rupture of the fetal bladder is performed, the preparation of the birth canal by introducing biologically active substances and hormones. Along with this, drugs are used to maintain the energy potential of the body, improve uteroplacental, fetal-placental blood flow and prevent oxygen starvation of the fetus.

Discoordinated labor activity

For discoordination of labor activity, the occurrence of excessively strong labor activity along with periods of weak labor activity is characteristic. At the same time, variants of discoordination are associated with the degree of imbalance of the nervous system. Biochemical disturbances, in which the body cannot maintain metabolic processes at the proper level, and energy depletion of the contractile activity of the uterus, lead to the development of discoordination of labor activity.
According to research, all processes occurring in the uterus are regulated by the autonomic nervous system and the cerebral cortex. Violation or complete absence of vegetative influence will lead to severe disorders and discoordination of labor activity. This is due to the relationship of the nervous system with humoral regulation and hormonal tissue saturation.

Discoordination of labor activity can lead to:

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

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

late and young age of the mother;
the presence of problems in previous births;
infertility and previously established gynecological pathology;
the development of discoordination of contractions at the very beginning of childbirth;
preeclampsia in the second half of pregnancy;
clinically narrow pelvis;
delayed pregnancy;
untimely discharge of amniotic fluid;
chronic oxygen starvation fetus and diagnosed malformations of its development.

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

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

Rapid delivery

One of the varieties of violations of the contractile activity of the uterus is rapid childbirth. Births lasting no more than 3 hours are considered to be rapid, in turn, births lasting no more than 4-5 hours are called rapid births.
The course of such childbirth is characterized by a pronounced increase in the excitability of the muscles of the uterus, as a result of which the frequency of contractions is significant - more than 5 per 10 minutes. Due to the rapidity of the flow, such childbirth is very dangerous by traumatizing the woman in labor and the fetus.
As a rule, severe pain is characteristic for the course of such childbirth. With rapid childbirth, labor activity occurs suddenly, and due to rapid development, it can even occur on the street.
The low resistance of the isthmus and cervix predisposes to such a course of childbirth, which is most often due to the pathology of the cervix, which is why such women are diagnosed early with the threat of preterm birth.
Childbirth proceeds most unfavorably with initially normal contractile activity without signs of discoordination, since only accelerated elimination fetus. The main problems of such childbirth are associated with a violation of the physiological ratio of the processes of opening the cervix and the advancement of the fetus. In some cases, the cause of such a course of labor is not a violation of the innervation of the uterus, but the unreasonable use of labor-stimulating drugs.
A variant of rapid childbirth can be childbirth with increased tone and violations of the contractile function of the uterus. With them, contractions are painful, prolonged, frequent, and time muscle relaxation shortened. Thus, one fight is superimposed on another.

The main causes of rapid labor are:

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

The basis of therapeutic measures for rapid labor is the use of drugs to immediately relax the muscles of the uterus. In the event that labor stimulation is performed, it should be stopped immediately to normalize the birth act.
In other situations, it is possible to suspend the course of rapid labor only with the use of general anesthesia. In any case, substances are administered intravenously that relax muscle layer uterus and improve uteroplacental blood flow and oxygen supply to the fetus.
With rapid childbirth, they do not achieve a complete cessation of labor activity. The use of drugs only reduces muscle excitability and normalizes the tone of the uterus, reduces the frequency of contractions, and increases the relaxation time between them.
When conducting a rapidly flowing birth, bleeding prevention is mandatory.
Any abnormalities in the contractile activity of the uterus cause disturbances, which further lead to the accumulation of toxins in the tissue respiration system, which greatly complicates the condition of the mother and fetus. Similar violations cause rapid depletion of glycogen and glucose stores and interfere with further normal development tribal activity.

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

The pathological preliminary period is characterized by significant soreness and disorder of preparatory contractions of the uterus and the absence of structural changes in the cervix before childbirth (an immature cervix by the time of delivery). A pregnant woman is disturbed by cramping pains in the lower abdomen and lower back that are irregular in frequency, duration and intensity, lasting more than 6-10 hours, disrupting sleep and wakefulness, increased fatigue.

The weakness of labor activity is characterized by insufficient strength, duration and frequency of contractions, slow smoothing and opening of the cervix, and advancement of the fetus through the birth canal.

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

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

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

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

PATHOLOGICAL PRELIMINARY PERIOD

CLINICAL PICTURE

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

DIAGNOSTICS

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

TREATMENT

Correction of the contractile activity of the uterus to achieve optimal biological readiness for childbirth with b-adrenergic agonists and calcium antagonists, non-steroidal anti-inflammatory drugs:
- infusions of hexoprenaline 10 mcg, terbutaline 0.5 mg or orciprenaline 0.5 mg in 0.9% sodium chloride solution;
- infusion of verapamil 5 mg in 0.9% sodium chloride solution;
ibuprofen 400 mg or naproxen 500 mg orally.
· Normalization of a woman's psycho-emotional state.
Regulation of the daily rhythm of sleep and rest (drug sleep at night or when pregnant women are tired):
- preparations of the benzadiazepine series (diazepam 10 mg 0.5% solution i / m);
- narcotic analgesics (trimeperidine 20-40 mg 2% solution i/m);
- non-narcotic analgesics(butorphanol 2 mg 0.2% or tramadol 50–100 mg IM);
- antihistamines(chloropyramine 20–40 mg or promethazine 25–50 mg IM);
- antispasmodics (drotaverine 40 mg or benciclane 50 mg IM);
Prevention of fetal intoxication (infusion of 500 ml of 5% dexrose solution + sodium dimercaptopropanesulfonate 0.25 g + ascorbic acid 5% - 2.0 ml.
Therapy aimed at "ripening" of the cervix:
- PG-E2 (dinoprostone 0.5 mg intracervically).

With a pathological preliminary period and optimal biological readiness for childbirth with a full-term pregnancy, medical stimulation of labor and amniotomy are indicated.

PRIMARY WEAKNESS OF LABOR

The primary weakness of labor activity is the most common type of anomalies of labor forces.
The basis of the primary weakness of contractions is a decrease in the basal tone and excitability of the uterus, therefore this pathology is characterized by a change in the pace and strength of contractions, but without a disorder in the coordination of uterine contractions in its individual parts.

CLINICAL PICTURE

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

For the primary weakness of labor activity, certain clinical signs are characteristic.
The excitability and tone of the uterus are reduced.
Contractions from the very beginning of the development of labor activity remain rare, short, weak (15-20 seconds):
G frequency for 10 minutes does not exceed 1-2 contractions;
The force of contraction is weak, the amplitude is below 30 mm Hg;
The contractions are regular, painless or slightly painful, since the tone of the myometrium is low.
· Lack of progressive cervical dilatation (less than 1 cm/h).
The presenting part of the fetus remains pressed against the entrance to the small pelvis for a long time.
The fetal bladder is sluggish, weakly pours into the contraction (functionally defective).
·At vaginal examination during the contraction, the edges of the uterine os are not stretched by the force of the contraction.

DIAGNOSTICS

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

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

Rice. 52-29. Partogram: I - nulliparous; II - multiparous.

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

Normally, the opening of the uterine os in the latent phase of period I in primiparas occurs at a rate of 0.4-0.5 cm / h, in multiparous - 0.6-0.8 cm / h. The total duration of this phase is about 7 hours for primiparas, and 5 hours for multiparous ones. With the weakness of labor, the smoothing of the cervix and the opening of the uterine os slows down (less than 1–1.2 cm / h). Mandatory diagnostic event in such a situation - an assessment of the condition of the fetus, which serves as a method for choosing an adequate management of childbirth.

TREATMENT

Therapy of primary weakness of labor should be strictly individual. The choice of treatment method depends on the condition of the woman in labor and the fetus, the presence of concomitant obstetric or extragenital pathology, the duration of the birth act.

The composition of therapeutic measures includes:
amniotomy;
Appointment of a complex of agents that enhance the action of endogenous and exogenous uterotonics;
the introduction of drugs directly increasing the intensity of contractions;
the use of antispasmodics;
prevention of fetal hypoxia.

The indication for amniotomy is the inferiority of the fetal bladder (flat bladder) or polyhydramnios. The main condition for this manipulation is the opening of the uterine os by 3–4 cm. Amniotomy can contribute to the production of endogenous PGs and intensify labor activity.

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

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

SECONDARY WEAKNESS OF GENERAL ACTIVITIES

Secondary hypotonic dysfunction of the uterus (secondary weakness of labor) is much less common than primary. With this pathology in women in labor with good or satisfactory labor activity, its weakening occurs. This usually occurs at the end of the period of disclosure or during the period of exile.

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

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

Complicated course real pregnancy(preeclampsia, anemia, immunological conflict during pregnancy, placental insufficiency, overmaturity);

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

Complicated course of real childbirth (long anhydrous period, large fetus, breech presentation of the fetus, polyhydramnios, primary weakness of labor activity).

CLINICAL PICTURE

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

DIAGNOSTICS

Assess the contractions at the end of the I and in the II period of labor, the dynamics of the opening of the uterine os and the advancement of the presenting part.

TREATMENT

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

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

In order to timely adjust the tactics of labor management, it is necessary to conduct constant monitoring of the fetal heartbeat and the nature of the contractile activity of the uterus. Two main factors influence the change in doctor's tactics:
absence or insufficient effect of drug stimulation of childbirth;
fetal hypoxia.

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

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

EXCESSIVELY STRONG LABOR ACTIVITY

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

CLINIC

For excessively strong labor activity is characterized by:
extremely strong contractions (more than 50 mm Hg);
fast alternation of contractions (more than 5 in 10 minutes);
increase in basal tone (more than 12 mm Hg);
Excited state of a woman, expressed by increased motor activity, an increase in the pulse of respiration, a rise in blood pressure. Autonomic disorders are possible: nausea, vomiting, sweating, hyperthermia.

With the rapid development of labor due to a violation of the uteroplacental and fetal-placental circulation, fetal hypoxia often occurs. Due to very rapid advance various injuries can occur along the birth canal in the fetus: cephalohematomas, hemorrhages in the brain and spinal cord, fractures of the clavicle, etc.

DIAGNOSTICS

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

TREATMENT

Therapeutic measures should be aimed at reducing the increased activity of the uterus. For this purpose, halothane anesthesia or intravenous drip of b-adrenomimetics (hexoprenaline 10 μg, terbutaline 0.5 mg or orciprenaline 0.5 mg in 400 ml of 0.9% sodium chloride solution) is used, which has several advantages:
fast onset of effect (after 5–10 minutes);
the possibility of regulating labor by changing the rate of infusion of the drug;
Improvement of uteroplacental blood flow.

The introduction of b-adrenergic agonists, as necessary, can be carried out before the birth of the fetus. With a good effect, the infusion of tocolytics can be stopped by switching to the introduction of antispasmodics and antispasmodic analgesics (drotaverine, ganglefen, metamizole sodium).

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

The woman in labor should lie on her side, opposite the position of the fetus. This position somewhat reduces the contractile activity of the uterus.

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

DISCOORDINATED LABOR ACTIVITIES

The discoordination of labor activity is understood as the absence of coordinated contractions between the various sections of the uterus: the right and left half of it, the upper (bottom, body) and lower sections, all sections of the uterus.

Forms of discoordination of labor activity are diverse:
Distribution of the wave of contraction of the uterus from the lower segment upwards (dominant of the lower segment, spastic segmental dystocia of the body of the uterus);
lack of relaxation of the cervix at the time of contraction of the muscles of the body of the uterus (dystocia of the cervix);
spasm of the muscles of all parts of the uterus (tetany of the uterus).

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

CLINIC

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

DIAGNOSTICS

Evaluate the nature of labor activity and its effectiveness on the basis of:
Complaints of the woman in labor;
The general condition of a woman, which largely depends on the severity pain syndrome, as well as otvegetative disorders;
external and internal obstetric examination;
The results of hardware examination methods.

Vaginal examination reveals signs of the absence of the dynamics of the birth act: the edges of the uterine os are thick, often edematous.

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

TREATMENT

Childbirth complicated by discoordination of the contractile activity of the myometrium can be carried out through the natural birth canal or completed with a CS operation.

For the treatment of discoordinated labor activity, infusions of b-agonists, calcium antagonists, antispasmodics, and antispasmodics are used. With the disclosure of the uterine pharynx more than 4 cm, long-term epidural analgesia is indicated.

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

Prevention of intrauterine fetal hypoxia is mandatory.

Indications for abdominal delivery
burdened obstetric and gynecological history (prolonged infertility, miscarriage, poor outcome of previous births, etc.);
Concomitant somatic (cardiovascular, endocrine, bronchopulmonary and other diseases) and obstetric pathology (fetal hypoxia, overmaturity, breech presentation and incorrect insertion of the head, large fetus, narrowing of the pelvis, preeclampsia, uterine fibroids, etc.);
primiparous older than 30 years;
Lack of effect from conservative therapy.

PREVENTION

Prevention of anomalies of contractile activity should begin with the selection of women in the group high risk given pathology. These include:
primiparous older than 30 years and younger than 18 years;
Pregnant women with an "immature" cervix on the eve of childbirth;
women with a burdened obstetric and gynecological history (menstrual irregularities, infertility, miscarriage, complicated course and unfavorable outcome of previous births, abortions, uterine scar);
women with pathology of the reproductive system (chronic inflammatory diseases, fibroids, malformations);
pregnant women with somatic diseases, endocrine pathology, obesity, neuropsychiatric diseases, neurocirculatory dystonia;
Pregnant women with a complicated course of this pregnancy (preeclampsia, anemia, chronic placental insufficiency, polyhydramnios, multiple pregnancy, large fetus, breech presentation of the fetus);
Pregnant women with reduced pelvis sizes.

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

Anomalies of the contractile activity of the uterus include deviations from the norm of such indicators as the basal tone of the uterus, which determines the frequency and strength of contractions. Anomalies of contractile activity during childbirth lead to a violation of the mechanism of opening the cervix, the advancement of the fetus through the birth canal.

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

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

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

Etiology and pathogenesis
The effectiveness of labor activity determines the processes of opening the cervix and moving the fetus through the birth canal, which, in turn, are associated with intra-amniotic (intramyometrial) pressure and resistance of the lower pole of the uterus (lower segment, internal os, cervix).

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

Factors contributing to the development of abnormal labor activity:
Obstetric factors:
- premature rupture of amniotic fluid (antenatal and early);
- disproportion in the size of the fetal head and the mother's pelvis (clinically narrow pelvis);
- overstretching of the uterus (polyhydramnios, large fetus);
- multiple pregnancy;
- premature and delayed childbirth;
- pelvic presentation of the hearth;
- obstacles to the opening of the cervix and the advancement of the hearth, a functionally defective fetal bladder.

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

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

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

With anomalies of labor activity in the uterus, the conduction system is disorganized, built on gap junctions with intercellular channels.

A disturbance in the conduction system and a shift in the center of formation and generation of electrical impulses (the “pacemaker” of contractions) causes uncoordinated, asynchronous labor activity, when individual zones of the myometrium contract and relax in different rhythms and at different time intervals, which is accompanied by sharp pain in contractions and no effect. Childbirth practically stops.

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

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

Glycogen and glucose stores are quickly depleted.

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

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

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

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

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

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

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

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

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

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

Premature rupture of amniotic fluid (35-48%) lengthens the anhydrous period, which threatens the development of ascending infection, fetal hypoxia and even intranatal death.

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

You should be attentive to the complaints of the woman in labor about the pain of contractions. It is necessary to compare the dynamics of changes in the cervix: how the uterine os opens after 2-3 hours of labor, how the length of the cervix has changed (shortened, smoothed out). The rate of opening of the uterine os every hour should be 0.5-1.0 cm in the latent and 2-2.5 cm/hour in the active phase of labor. When the diagnosis of "primary weakness of labor" is established, labor stimulation should be started. But first of all, an unfavorable obstetric situation should be excluded, in which the stimulation of labor is contraindicated.

It includes:
- narrow pelvis;
- inferiority of the myometrium (scar on the uterus, fibroids, endometritis);
- unsatisfactory condition of the fetus and / or mother.

Treatment
When the diagnosis of primary weakness of labor activity is established, treatment should be started. Ways to enhance labor activity: artificial opening of the fetal bladder (amniotomy), the introduction of uterotonic drugs (oxytocin, prostaglandins).

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

For the purpose of labor stimulation, oxytocin and prostaglandins (enzaprost) are used. At the same time, the issue of adequate anesthesia is being addressed. If the woman in labor is tired, then they begin to stimulate labor activity after providing her with a short-term medical sleep - rest.

Oxytocin labor stimulation
Intravenous administration of oxytocin is the most common known and proven method of stimulating muscular dystonia syndrome. It increases the tone of the uterus, synchronizes the interaction of variously located smooth muscle bundles, layers and layers of the myometrium, stimulates the formation and synthesis of prostaglandins at the interface between the fetal membranes and the decidua.

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

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

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

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

The introduction of oxytocin is not stopped until the end of labor. Effective stimulation of labor with oxytocin when the cervix is dilated at least 2 cm / h and the observed advance of the presenting part of the fetus. The duration of stimulation should not exceed 4-5 hours. During this time, it should be decided whether it is possible to continue childbirth through the natural birth canal.

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

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

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

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

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

Treatment
Stimulation of labor activity is carried out by oxytocin or prostaglandins. It is advisable to combine oxytocin with one of the half-dose prostaglandin preparations. The duration of corrective therapy for secondary weakness of labor should not exceed 2-3 hours. The following factors influence the change in the tactics of labor management:
- absence or insufficient effect of stimulation of labor activity;
- fetal hypoxia;
- Deterioration of the mother's condition.

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

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

Very fast childbirth finds a woman unexpectedly. The expulsion of the fetus can occur on the street, in transport, that is, in the most unexpected place. As a rule, this does not happen in women in a lying position, but occurs with active behavior in a standing position, sitting, walking.

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

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

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

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

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

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

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

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

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

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

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

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

Etiology
The etiology of this pathology is not well understood, however, the main factors can be identified. These include:
- violations of the functional balance of the autonomic nervous system (vegetoneurosis, autonomic dysfunction);
- an unremovable obstacle to the opening of the uterine os (uterine fibroids, cicatricial deformity of the tissue), difficult fetal advancement (narrow pelvis);
- weakening of the regulatory role of the central nervous system (stress, overwork, for example: an attempt to give birth to a child between two exams, fear of childbirth);
- insufficient anesthesia of childbirth, leading to general muscle tension;
- hyperstimulation with contracting agents (oxytocin, prostin E and F, prostaglandins E1);
- Structural pathology of the myometrium and cervix:
- uterine malformations, long dense cervix;
- excessive density of the membranes (functional inferiority of the fetal bladder).

Pathogenesis
The pathogenesis of hypertensive dysfunction is unknown, but it suggests a violation of the functional balance of the autonomic nervous system. There is a dysfunction of the sympathetic-adrenal and the predominance of the tone of the parasympathetic (cholinergic) autonomic nervous system.

The essence of discoordination of labor activity lies in the violation of neurogenic and myogenic regulation. The frequency of contraction and relaxation of the body and the lower segment of the uterus disappear; synchrony of interaction of variously located muscle bundles, layers, sections of the uterus; reciprocity of the interaction of the sympathetic and parasympathetic nervous system.

Predominate:
- uterine hypertonicity (hypertonic dysfunction (muscular dystonia syndrome);
- compaction of the internal os of the uterus in a contraction, which is palpated in the form of a dense roller;
- the formation of dystocia of the cervix due to impaired blood and lymph circulation. The neck is determined by dense, thick, rigid, edematous and unevenly compacted;
- the formation of a double, triple rhythm of contractions, in which the uterus does not relax and the contractions overlap each other.

Contractions are painful, frequent, prolonged; in diastole and a pause between contractions, the uterus almost does not relax. In the process of development of labor activity in the uterus, two or more "pacemakers" can form. Since both "pacemakers" have different rhythms of contractile activity, their action is asynchronous. The impulses of uterine contraction do not spread from top to bottom, but from bottom to top. The myometrium is divided into segments that contract independently of each other, with different amplitude, duration and frequency. The tone of the uterus is higher than normal values, reaching 15-20 mm Hg, and sometimes more. There are many options for discoordination of contractions, up to tetanus of the uterus, against which the contractions become rare, weak, but sharply painful. There is a real threat of histopathic uterine rupture.

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

The behavior of the woman in labor is restless, she asks for anesthesia even at the very beginning, in the latent phase of childbirth. Complaints of the woman in labor are characteristic:
- breaking pains in the sacrum and lower back, vegetative disorders;
- difficulty urinating (with full proportionality of the fetus and mother's pelvis!), oliguria, paradoxical ischuria(during catheterization of the bladder, urine is easily excreted in large quantities);
- change in the nature of the disclosure of the cervix. Instead of stretching the edges of the uterine os, there is a forced overcoming of the spastically reduced tissue due to ruptures. Crushing of the neck, scalped ruptures of the vagina, deep ruptures of the perineum, up to degree III, are possible;
- violation of the synchrony of the advancement of the fetus in accordance with the opening of the uterine os. The presenting part stands for a long time in each plane of the small pelvis, as is the case with a narrow pelvis. The period of expulsion of the fetus (unproductive attempts) is lengthened with a small size of the fetus;
- frequent violation of the biomechanism of childbirth due to hypertonicity of the lower segment.

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

The fetal bladder with uncoordinated contractions, as a rule, is functionally defective, does not play the role of a hydraulic wedge and does not contribute to the opening of the uterine os. The amnion is not detached from the walls of the lower segment of the uterus and is tightly adjacent to the fetal head. Outside of the contraction, the fetal bladder remains tense. The membranes of the bladder feel unusually dense. This symptom is easily determined by vaginal examination.

Quite often, an early discharge of amniotic fluid occurs (with the cervix still unsmoothed and its small opening). Early outflow of water to a certain extent can normalize the labor activity of the uterus. The preservation of a functionally defective fetal bladder during childbirth is dangerous, since an increase in the pressure gradient by at least 2 mm Hg. in the amniotic cavity or intravillous space can lead to severe complications such as embolism amniotic fluid, premature detachment of the placenta.

Complications such as uterine rupture, which is possible even in primiparas with a burdened obstetric history (abortions), massive bleeding in the afterbirth and early postpartum periods, are of particular risk in discoordination of contractions.

Diagnostics
To assess the nature of labor activity, it is necessary to control:
- the dynamics of structural changes in the cervix in accordance with the past hours of labor, taking into account the parity of childbirth (first, repeated);
- opening of the cervix (uterine os) in centimeters, the condition of the edges of the cervix (soft, pliable; dense, rigid, poorly extensible; thick - thin), including the condition of the edges of the uterine os during labor (soft, but compacted around the entire circumference or in a separate area);
- functional usefulness of the fetal bladder (poured into a fight) or inferiority ( flat shape, the shells are stretched on the head), the characteristics of the shells (dense, rough, elastic). Note the increased tension of the fetal bladder during and outside the contraction, as well as the amount of amniotic fluid (little, much, normal).

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

Differential Diagnosis
Differential diagnosis of the pathology of uterine contraction with discoordination and weakness of labor activity is presented in the table.

Treatment
The prognosis and plan for the management of childbirth are based on the age, history, health status of the woman in labor, the course of pregnancies, the obstetric situation, and the results of assessing the condition of the fetus.

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

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

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

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

Prevention
Prevention of anomalies of contractile activity of the uterus should begin with the selection of women at high risk for this pathology.

These include:
- primiparous older than 30 years and younger than 18 years;
- pregnant women with an "immature" cervix on the eve of childbirth;
- women with a burdened obstetric and gynecological history (menstrual disorders, infertility, miscarriage, complicated course and unfavorable outcome of previous births, abortions, uterine scar);
- women with pathology of the reproductive system (chronic inflammatory diseases, fibroids, malformations);
- pregnant women with somatic diseases, endocrine pathology, obesity, neuropsychiatric diseases, neurocirculatory dystonia;
- pregnant women with a complicated course of this pregnancy (preeclampsia, anemia, chronic placental insufficiency, polyhydramnios, multiple pregnancy, large fetus, breech presentation of the fetus;
- pregnant women with reduced pelvis sizes.

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

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

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

There are three degrees of readiness of the cervix for childbirth:"mature", "not mature enough" and "immature". This takes into account the consistency of the cervix, the length of the vaginal part, its location in the small pelvis according to the wire axis of the pelvis and the patency of the cervical canal. In addition, pay attention to the location of the presenting part of the fetus. So, with a "mature" cervix, the presenting part is fixed to the entrance to the pelvis, which indicates the readiness and deployment of the lower segment of the uterus. At the same time, the cervix is \u200b\u200b“mature” and palpation is soft, centered, located along the wire axis of the pelvis, reduced to 1-1.5 cm, cervical canal skips 1.5-2 fingers. The "immature cervix" of the uterus is dense, rejected to the coccyx or in the womb, up to 2 cm long, the external pharynx passes the tip of the finger, the presenting part is not pressed against the plane of the entrance to the small pelvis and is high. An "insufficiently mature cervix" of the uterus occupies an intermediate position.

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

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

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

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

Clinic and management of childbirth with anomalies of the contractile activity of the uterus. Discoordination of labor activity

Primary weakness of labor activity

Secondary weakness of labor activity

Discoordinated labor activity

Rapid delivery

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

EPIDEMIOLOGY

CLASSIFICATION

ETIOLOGY

PATHOGENESIS

PATHOLOGICAL PRELIMINARY PERIOD

CLINICAL PICTURE

DIAGNOSTICS

TREATMENT

PRIMARY WEAKNESS OF LABOR

CLINICAL PICTURE

DIAGNOSTICS

TREATMENT

SECONDARY WEAKNESS OF GENERAL ACTIVITIES

CLINICAL PICTURE

DIAGNOSTICS

TREATMENT

EXCESSIVELY STRONG LABOR ACTIVITY

CLINIC

DIAGNOSTICS

TREATMENT

DISCOORDINATED LABOR ACTIVITIES

CLINIC

DIAGNOSTICS

TREATMENT

PREVENTION