Weakness of labor activity causes. Clinical forms of weakness of labor activity and methods of its treatment

This is hypotonic dysfunction of the uterus in childbirth. Despite regular labor, the tone of the uterus is low, the frequency of contractions is rare, and the amplitude of contraction is weak. The period of relaxation of the myometrium (diastole contractions) significantly prevails over the duration of contraction (systole). The opening of the cervix and the progress of the fetus are slowed down.

What provokes / Causes of Primary weakness of labor:

• History of indications of weakness of labor in the mother, sisters.
• Pathology of the myometrium (uterine fibroids, adenomyosis, chronic endometritis).
• Overstretching of the uterus due to polyhydramnios, multiple pregnancy, large fetus.
• Late (35 years and older) or young (under 18 years old) age of the primipara.
• The presence of vegetative-metabolic disorders (obesity, hypofunction thyroid gland and adrenal cortex, hypothalamic syndrome).
• Features of the location of the placenta (bottom, anterior wall of the uterus).
• Structural failure of the myometrium (abortion, caesarean section, a large number of births - 4 or more).
• This or that degree of disproportion in the size of the fetus and the pelvis of the woman in labor (anatomically or clinically narrow pelvis).
• Chronic placental insufficiency.
• Unsatisfactory condition of the fetus.

Symptoms of Primary weakness of labor:

The following clinical signs are characteristic of the primary weakness of labor activity.

• The excitability and tone of the uterus are reduced. The tone of the uterus is less than 10 mm Hg. Art.
• The frequency of contractions for 10 minutes of the control time does not exceed 1-2, the duration of the contraction is 15-20 s, the strength (amplitude) of contraction remains within 20-25 mm Hg. Art. Contraction systole is short, diastole is 1.5-2 times longer.
• Contractions can be regular or irregular: painless or slightly painful, since the tone of the myometrium is low, spastic uterine contractions are not characteristic of this pathology, intrauterine pressure is not enough to overcome the resistance of the cervix.
• Due to the low intrauterine (intra-amniotic) pressure, the total effect of the action is reduced:
  • structural changes in the cervix (shortening, smoothing, opening of the cervical canal) in the latent phase and opening of the uterine os in the active phase of labor proceed slowly;
  • presenting part of the fetus for a long time remains pressed to the entrance to the small pelvis and then lingers for a long time in each plane of the small pelvis.
• The synchrony of the processes of disclosure of the uterine pharynx and the advancement of the fetus through the birth canal is disturbed.
• 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, and are rather easily stretched by the probing fingers, but not by the force of the contraction.
• Weak contractile activity of the uterus can continue in the period of expulsion of the fetus, in the afterbirth period (which disrupts the process of separation of the afterbirth) and in the early postpartum period, often accompanied by hypotonic bleeding.

The duration of childbirth with primary weakness of labor activity increases, which is often accompanied by fatigue of the woman in labor. There are also untimely discharge of amniotic fluid (in 35-48%), lengthening of the anhydrous gap, the danger of ascending infection, fetal asphyxia, and even intrauterine fetal death.

Prolonged standing of the fetal 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.

It must be taken into account that a decrease in the tone and contractile activity of the uterus can be defensive reaction the mother's body in the presence of:

• inferiority of the myometrium ( insolvent scar on the uterus;
• disproportions in the size of the fetal head and the pelvis of the woman in labor (anatomical or clinical narrow pelvis);
• unsatisfactory condition of the fetus (impaired uteroplacental and fetal-placental blood flow, distress, hypoxia, malformations, fetal IUGR).

Diagnosis Primary weakness of labor activity:

The diagnosis is established on the basis of a clinical assessment of the low effectiveness of contractions, a decrease in their frequency, low tone, and slow dynamics of the labor process. To establish the diagnosis of weakness of labor activity, it is necessary to control the dynamics of labor within 5-6 hours.

Treatment of primary weakness of labor activity:

With the weakness of labor activity, the behavior of the woman in labor is usually calm, since contractions are rare, short, weak and not painful. However, differential diagnosis is necessary.

With a prolonged latent phase, it is necessary first of all to exclude a narrow pelvis, myometrial failure, an unsatisfactory condition of the fetus, and also to carry out differential diagnosis with a pathological preliminary period.

When prolonging the active phase of labor, attention should be paid to the possibility of fatigue of the woman in labor, the tension of her neuropsychic state (sleepless night, fatigue, negative emotions).

To assess the degree of delay in labor, it is necessary to analyze the comparative data of two or three vaginal examinations performed with a difference of 1-2 hours.

It is desirable to confirm the clinical diagnosis of weakness of labor activity by indicators of objective observation (cardiomonitor, hysterographic, tocographic control).

big practical value has a differential diagnosis of primary (hypotonic) weakness of labor activity with discoordination (hypertonic) dysfunction of uterine contraction, since treatment should be different.

So, if in 5-6 hours of regular contractions there is no transition of the latent phase to the active phase of labor, and in the active phase of labor the rate of opening of the uterine os is slowed down, a diagnosis of abnormal labor activity should be established.

It is necessary to conduct a differential diagnosis between the two main types of pathology: hypotonic or hypertonic dysfunction of uterine contraction. The primary weakness of labor activity is characterized by: reduced basal tone of the myometrium; weak contractile activity of the uterus, regular, but rare, short, weak and little or painless contractions; slowing down structural changes and opening of the cervix; prolonged standing of the head in each plane of the small pelvis.

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Other diseases from the group Pregnancy, childbirth and the postpartum period:

Obstetric peritonitis in the postpartum period

Anemia in pregnancy

Autoimmune thyroiditis during pregnancy

Fast and rapid delivery

Management of pregnancy and childbirth in the presence of a scar on the uterus

Chickenpox and herpes zoster in pregnancy

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Secondary weakness of labor activity

Secondary hypercortisolism (Itsenko-Cushing's disease) in pregnant women

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Malignant tumors of the breast during pregnancy

Group A streptococcal infections in pregnant women

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candidiasis in pregnant women

C-section

Cephalhematoma with birth trauma

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lactation mastitis in the postpartum period

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uterine fibroids during pregnancy

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Non-developing pregnancy

Missed miscarriage

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Parvovirus infection in pregnant women

Diaphragm paresis (Cofferat's syndrome)

Paresis of the facial nerve during childbirth

Pathological preliminary period

Primary aldosteronism during pregnancy

Primary hypercortisolism in pregnant women

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Postpartum thyroiditis

- insufficient in strength, duration and frequency of contractile activity of the uterus, due to its hypotonic dysfunction. The weakness of labor activity is manifested by rare, short and ineffective contractions, slowing down the opening of the cervix and advancement of the fetus. Pathology is diagnosed through observation, cardiotocography, vaginal examination. In the treatment of weakness of labor activity, rhodostimulation is used; according to indications, a caesarean section is performed.

General information

Weakness of labor is one of the forms of violation of the contractile function of the uterus, characterized by low tone of the myometrium, a rare frequency of contractions, and a weak amplitude of contractions. There is a predominance of diastole of contractions (a period of relaxation) over systole (a period of contraction), which slows down the opening of the cervix and the progress of the fetus through the birth canal.

The weakness of labor activity may be due to the late or young age of the primipara; preeclampsia; premature birth or post-term pregnancy; overstretching of the uterus with multiple pregnancy, large fetus, polyhydramnios; disproportion between the size of the fetus and the pelvis of the woman in labor (narrow pelvis); early discharge of water. Placenta previa, the course of pregnancy in conditions of chronic placental insufficiency, fetal pathology (hypoxia, anencephaly, etc.) can lead to the development of weakness in labor activity.

In addition, the weakness of labor activity can be aggravated by the asthenization of a woman (overwork, excessive mental and physical stress, poor nutrition, insufficient sleep); fear of the woman in labor, uncomfortable environment, inattentive or rude service. The weakness of labor activity is often a direct continuation of the pathological preliminary period of childbirth.

Types of weakness of labor activity

According to the time of occurrence, primary weakness of labor activity and secondary are distinguished. The primary weakness is considered a situation in which, from the very beginning of childbirth, insufficiently active (weak in strength, irregular, short) contractions develop. They speak of secondary weakness if there is a weakening of contractions at the end of the 1st or the beginning of the 2nd period of labor after the initially normal or violent nature of labor.

The varieties of weakness of labor activity include segmental and convulsive contractions. Convulsive contractions are characterized by prolonged (more than 2 minutes) uterine contractions. With segmental contractions, not the entire uterus contracts, but its individual segments. Therefore, despite the continuity of segmental contractions, the effect of them is extremely small. Determination of the clinical form of weakness of labor activity allows you to choose differentiated tactics in relation to the treatment of disorders.

Symptoms of weakness in labor

Clinical manifestations of the primary weakness of labor activity are: decreased excitability and tone of the uterus; frequency of contractions - 1-2 within 10 minutes; the duration of contractions is not more than 15-20 seconds; amplitude (strength) of contractions of the myometrium - 20-25 mm Hg. Art. The period of contraction of the uterus is short, the period of relaxation is 1.5-2 times longer. There is no increase in intensity, amplitude, frequency of contractions over time.

Contractions with primary weakness of labor activity can be regular or irregular, painless or slightly painful. The course of structural changes in the cervix (shortening, smoothing and opening of the cervical canal and uterine os) is slowed down. The weakness of the contractile activity of the uterus often accompanies the period of exile, as well as the subsequent and early postpartum period, which leads to hypotonic bleeding. The primary weakness of labor activity leads to a delay in the duration of labor, fatigue of the woman in labor, untimely discharge of amniotic fluid, lengthening of the anhydrous period.

In the case of secondary weakness of labor activity, initially effective contractions weaken, become shorter and less frequent, up to a complete cessation. This is accompanied by a decrease in the tone and excitability of the uterus. The opening of the uterine os can reach 5-6 cm without further progression; the progress of the fetus through the birth canal stops. The danger of weak labor is an increased risk of ascending infection of the uterus, the development of fetal asphyxia or intrauterine death. With prolonged standing of the fetal head in the birth canal, birth injuries of the mother (hematomas, vaginal fistulas) may develop.

Diagnosis of weakness of labor activity

To determine the nature of labor activity, clinical assessment the effectiveness of contractions, the tone of the uterus, the dynamics of childbirth. During childbirth, monitoring of uterine contractions (tocometry, cardiotocography) is carried out; analysis of the frequency, duration, strength of contractions and their comparison with the norm. So, in the active phase of the 1st period, contractions lasting less than 30 seconds are considered weak. and intervals over 5 minutes; for the 2nd period - shorter than 40 sec.

With the weakness of labor activity, the opening of the cervix occurs by less than 1 cm per hour. The degree and speed of opening are assessed during the vaginal examination, as well as indirectly - by the height of the contraction ring and the advancement of the head. Weakness of labor activity is said if the 1st stage of labor lasts more than 12 hours for primiparas, and more than 10 hours for multiparous ones. Weakness of labor forces should be differentiated from discoordinated labor activity, since their treatment will be different.

Treatment of weakness in labor

The choice of treatment regimen is based on the causes, the degree of weakness of labor, the period of labor, the assessment of the condition of the fetus and mother. Sometimes, to stimulate the intensity of contractions, it is enough to catheterize the bladder. If the weakness of labor activity is due to

In the process of pregnancy management by an obstetrician-gynecologist, it is necessary to assess risk factors for the development of weakness in labor, and if such factors are identified, preventive medication and psychophysical training should be carried out. The weakness of labor activity almost always leads to a deterioration in the condition of the fetus (hypoxia, acidosis, cerebral edema), therefore, simultaneously with labor stimulation, prevention of fetal asphyxia is carried out.

The content of the article

Weak labor activity, which is one of the most frequent and severe complications contractile function of the uterus, entails big number pathological conditions of the mother and fetus. According to our data, out of 30,554 cases of childbirth in urban obstetric institutions, the weakness of labor activity occurred in 2253 women in labor, which is 7.37%. The proportion of primiparas is 84%, multiparous - 16% (second births - 11.4%, third - 2%, fourth and more - 0.6%).
Clinicians distinguish two main forms of violations of the contractile function of the uterus during childbirth: weakness of labor activity and excessively violent labor activity. Moreover, in terms of the frequency of occurrence and the number of violations of the state of the mother and fetus, the weakness of labor activity is many times greater than the violent labor activity, which usually occurs in multiparous women.
There are primary weakness of contractions, secondary weakness of contractions and attempts, convulsive and segmental contractions. Excessively violent labor activity, in which the duration of labor with a full-term fetus is 3-4 hours, is called rapid labor.
The primary weakness of labor activity is manifested by contractions of weak strength, a violation of their rhythm and duration from the very beginning of their appearance and over a longer period of time. For secondary weakness of labor activity, the appearance of the same changes in uterine contraction at the end of the first or second stage of labor is characteristic. A variety of weakness of labor activity are convulsive and segmental contractions. The convulsive nature is manifested by prolonged, for more than 1.5-2 minutes, contraction of the uterus. During segmental contractions, not the entire uterus contracts, but its individual segments. Such contractions of individual segments of the uterus occur almost continuously, and their effect is negligible or extremely small.
The weakness of labor activity in a significant number of women in labor is preceded by a pathology of the condition of the membranes of the amniotic sac. 30.7% of women in labor had premature and 29.8% early discharge of water. There is a belief that the weakness of labor and the failure of the membranes of the fetal bladder in 60.5% of women in this group have the same cause.
We do not consider the untimely discharge of water as a weakness of labor activity. Many women with this pathology of the membranes - their reduced strength - have normal spontaneous labor activity.
In 32.9% of women in labor, abortions were noted in the past (artificial - in 23.4%, spontaneous - in 9.5%). As you know, artificial termination of pregnancy can have adverse effect on the development of subsequent pregnancy and childbirth due to violations hormonal function ovaries and placenta, as well as anatomical defects in the structure of the myometrium. Spontaneous abortion is a direct consequence of the above violations, both on the basis of induced abortion, and congenital or acquired ovarian failure. Term delivery in this group of pregnant women were noted in 82%, up to 38 weeks - in 0.8% and at a term of 42 ped and more - in 17.2%.
With prolonged labor, regardless of their genesis, the frequency of use increases significantly operational methods delivery. In medical hospitals in Ukraine, covering urban obstetric institutions, as well as rural central and numbered hospitals, operative methods of delivery in 1971 were used in 29.15 cases per 1000 births. The most frequent operation is vacuum extraction of the fetus - 16.01 per 1000 births, then caesarean section - 8.2, obstetric forceps-3.54, removal of the fetus by the leg -1.5 and fruit-destroying operations - 1.3.
Weakness of labor and related pathological conditions mother and fetus are the reason for the use of the operative methods of delivery described above (252 per 1000 births). Moreover, vacuum extraction was performed in 142 cases per 1000 births, caesarean section - in 15, obstetric forceps - in 38, skin-head forceps - in 28, fruit-destroying operations - in 15 and extraction of the fetus by the leg - in 14 per 1000 births.
The prolonged course of labor increases the possibility of developing postpartum infection, which is observed 6 times more often than during normal childbirth, provided that a complex of preventive antibiotic therapy is carried out.
Labor anomalies are one of the leading causes of perinatal morbidity and mortality.
From total number 34.7% of women in labor with weakness of labor have pathological blood loss (over 400 ml) during childbirth or the early postpartum period. This pathology is the leading cause of maternal mortality and to a large extent complicates the course of a birth infection. All this points to the great practical importance of this problem.

Causes of labor activity

Despite the huge flow of information on the treatment of labor weakness and attempts to explain the mechanism of development of this pathology, this problem remains the least studied among other major problems of modern obstetrics.
The use of empirically substantiated methods of treating this pathology, the development of which is based on various mechanisms of dysregulation of myometrial cell contraction, often leads to unsatisfactory results and new searches for more effective means.
After the discovery of the mediator function of acetylcholine as a transmission mediator nervous excitement on the effector organ, this concept was used to explain the mechanism of development and course of childbirth. A.P. Nikolaev showed that in the blood of women in labor, amniotic fluid and cerebrospinal fluid, the mediator of nervous excitation, acetylcholine, circulates in a free form. The author suggested that the latter has an effect on arousal muscle cells and stimulate contraction. The release of acetylcholine into the blood, according to the author, is a consequence of the occurrence of excitation in various parts of the autonomic nervous system and the cerebral cortex.
A.P. Nikolaev and a large number of his followers believed that an increase in blood cholinesterase activity is the cause of the destruction of acetylcholine freely circulating in the blood and the development of motor inertia of the uterus. In the experiment, it was shown that acetylcholine enhances the contraction of the uterine horns of sexually mature rabbits in vitro. However, the use of acetylcholine preparations for the treatment of weakness of labor activity in the clinic turned out to be ineffective. Subsequently, it was proved that acetylcholine circulating in the blood does not have a direct effect on the spontaneously excitable system of the uterus during childbirth. The mediator acetylcholine is synthesized in nerve cells, nerve fibers and synapses. Being in vesicles, it is protected from destruction. Cell contraction is accompanied by the release of acetylcholine from synaptic vesicles, which, getting into the intersynaptic gap, leads to a change in the ionic balance and potential on the membrane of the effector cells, followed by a functional response of the excitable object. The mediator acetylcholine undergoes instantaneous destruction after the onset of the effect. The cycle is repeated. The presence of a small number of nerve terminal apparatuses in the uterus identified by modern methods of investigation raises doubts about the existence of a similar mechanism of excitation to contraction of the muscle cells of this organ. If the nerve conductors in the myometrial strip are cut, the processes of self-excitation and the response to tonomomotor drugs do not disappear.
The attempt of many authors to consider the weakness of labor activity from the standpoint of dysfunction of the cerebral cortex and vegetative centers was not successful. Sufficiently convincing facts about the direct participation of the higher parts of the central nervous system in the trigger mechanism of childbirth have not been obtained. However, in providing optimal conditions During the course of the birth process in the whole organism, the coordination of vital functions is provided by central regulatory mechanisms, and their role is indisputable.
With the preparation of preparations of the posterior pituitary gland (pituithrin), and later oxytocin, their high specificity was found in relation not only to the enhancement of spontaneous uterine contractions in vitro and in vivo, but also to the excitation of contractions of the myometrium, which was in a state of functional rest.
In the experiment and the clinic, it was shown that the weakness of labor activity is a consequence of the high activity of blood oxytocinase, which destroys oxytocin. It has been established that with the simultaneous administration of pituitrin and estrogen in case of weakness of labor activity, the tonomotor effect of pituitrin increases. This gave reason to talk about the inhibitory effect of estrogen on oxytocypase. It unfortunately, so far no convincing data has been presented confirming the mechanism of development of the weakness of labor activity described above. Cholinesterase and blood oxytocinase may be important to reduce the level of compounds destroyed by them, however, they do not have a direct effect on the function of organs (uterus). The use of a cholinesterase inhibitor - prozerin - proved to be ineffective in the treatment of weakness of labor, despite the increase in the content of acetylcholine in the blood.
More than 40 years ago, it became known that the sex hormones estrogen and progesterone have different effects on the long-term activity of the uterus: the former enhance it, while the latter inhibit it. Their widespread practical use for the purpose of excitation and inhibition of uterine contractions has become possible only since the synthesis of these hormones. It was also found that the functional state of the uterus can be maintained long time after removal of the ovaries, introducing sex hormones in accordance with the menstrual cycle. With the onset of pregnancy and in the dynamics of its development, the sex hormones of the ovary (in the early period of pregnancy), and later the placenta, have a decisive influence on the normal development of the fetus and the processes that determine the function of the uterus and the reaction of the mother's body to pregnancy. Clinicians have proven that one of the main causes of miscarriage is hormonal insufficiency of the ovaries and placenta. Hormonal correction these disorders (estrogens + progesterone) gave positive effect in all cases of pregnancy pathology of this genesis, if the treatment was timely and sufficient. In the next 15-20 years, an intensive study of the mechanism of action on the genital organs (mainly on the uterus) of estrogens and progesterone began in the state outside of pregnancy and in the dynamics of pregnancy. Of particular interest to clinicians were studies of the mechanism of hormonal regulation of uterine function during pregnancy and childbirth. Summary data of a large number of studies in this direction are presented in the monograph Jung (1965). Estrogen hormones as substances stimulating the spontaneous excitability of the uterus began to be widely used in klipika, often in very large doses.
It has been experimentally proved that the most favorable course biochemical reactions in the tissues of the uterus is observed if the dose of estrogen administered to stimulate the uterus is 300-400 IU / kg. Doses of estrogens that are several times higher than the physiological ones lead to disruption of energy metabolism and suppression of the excitability of the uterus to drugs with an oxytocic effect. At present, a large clinical material has been accumulated on the combined use of estrogen and oxytocin, indicating a sufficient effectiveness of the method in the primary weakness of labor.
Over the past decade, the attention of biologists and clinicians has been attracted by two new biologically active compounds - serotonin and a group of prostaglandins, which have a fairly high selective activity in terms of stimulating the motor function of the uterus. Practical use of these compounds in the clinic for the stimulation and induction of labor has shown their high efficiency.
It must be assumed that in order to ensure the normal contractile function of the uterus, in addition to oxytocin, other uterotonic motor compounds are also needed that accumulate in the uterus and blood of women in labor (serotonin, catecholampins, prostaglandin).

Causes of weakness of labor activity

The reasons for the weakness of labor activity are as follows.
1. Genetically determined inertia of the mechanisms for switching on the functional systems of myometrial cells, which ensure the excitability and mechanical activity of its structures.
2. Insufficiency of the hormonal function of the fetoplacental complex, which determines the inclusion of cellular structures of the myometrium in the functional activity of excitation and contraction.
3. Morphological inferiority of the organ, causing insufficiency of function and inadequacy of the reaction to the complex of hormonal stimulation of the fetoplacental complex.
4. Functional inertness of the nervous structures (brain, spinal centers, regional nerve nodes), providing optimal conditions for the function of the uterus at the time of childbirth and in the dynamics of their development.
5. Fatigue of the uterus due to a violation of the normal anatomical relationships of the fetus and the birth canal (narrowing of the pelvis, large fetus, anomalies in the insertion and position of the fetus, structural changes in soft tissues birth canal).
A large number of other factors identified as possible causes of the development of weakness in labor are subordinate to the above main reasons for the development of defective contraction of the myometrium during childbirth. Let us consider in more detail the mechanism of development of the weakness of labor activity for certain groups of reasons.
We consider the birth act as an unconditioned reflex reaction of the body, which is fixed in the hereditary apparatus of the cellular structures of the uterus and other organs, providing optimal conditions for the development of the function of this organ and the physiological conditions for the life of the fetus. The inclusion of uterine muscle cells in contraction occurs as a result of a change in the direction of specific hormonal stimulation of the gene apparatus of cellular structures. The main hormone influencing the contraction of myometrial cells are estrogens, the content and activity of which by the time of delivery change significantly in the direction of creating effects for optimal excitability reactions and contraction of the myometrium. Optimal levels of circulating estrogens in the blood and their fixation by receptor proteins of hormone-dependent cells stimulate the accumulation and activity of a number of other hormones and mediators (oxytoxin, serotope, prostaglandin Fua, catecholamines, and, apparently, other unexplored compounds with a specific action). The above biologically active compounds provide separate links in a complex self-regulating system of contraction of the muscle cells of the uterus, which is clinically manifested by childbirth. The birth act takes place at the maximum activity of the functions of many organs and functional systems (cardiovascular, excretory, metabolic, endocrine, etc.). The integration of the functions of all organs and systems of the body is carried out by the nervous structures of the brain, in which the dominant of childbirth is created, facilitating interhemispheric communications and subordination of the functions of the whole organism, ensuring the physiological course of the birth act.
If by the time the period of fetal development ends, the regulatory system of myometrial cells, which affects their excitability and contraction, does not respond to impulses emanating from the placenta and fetus, labor will not occur. The progression of pregnancy will continue until conditions arise for the inclusion of these functions of myometrial cells.
In some cases, the system of excitation and contraction of myometrial cells can be brought into an active state by neuropsychic shocks, acute infection, pain shock, vibration. It must be assumed that the excessively strong stimuli described above affect the mechanisms regulating cell function through the same humoral systems that are responsible for the mechanism of excitation and contraction during the physiological course of pregnancy. Confirmation of the correctness of the above statement about the genetic nature of the primary weakness of labor is also the fact that this pathology occurs mainly in primiparous women. The first childbirth is a kind of training for the mechanism of regulation of excitation and contraction of myometrial cells; with repeated births, this pathology is observed less frequently. The use of progesterone to block the contraction of the myometrium at various stages of the development of pregnancy enhances the processes of inhibition of the mechanisms of regulation of the tonomomotor function of cells by the time the uterine development of the fetus ends. We strive for such pregnant women to carry out prenatal preparation in order to prevent labor weakness, which in most of them removes the inertness of the mechanisms for switching on the topomotor regulation of the myometrium.
In women with ovarian dysfunction, especially with dysmenorrhea and menometrorrhagia, when pregnancy occurs, we observe high excitability and contractile function uterus in early and late pregnancy or tonomotor inertness in childbirth.
There is reason to believe that the violation (inhibition) of the regulation of the tonomomotor function of the muscle cells of the uterus can be caused both before and during pregnancy by other non-hormonal factors that are difficult to take into account and prevent.
Along with the cause of labor weakness described above, the latter may occur as a result of hormonal, mainly estrogenic, insufficiency of the fetoplacental complex. Our experimental and clinical researches showed that estrogens are the main hormone that creates optimal conditions for the excitability of myometrial cell membranes and causes a cell response to substances that change the contractile properties of actomyosin. Until recently, it was believed that the leading role in the manifestation of the contractile function of myometrial cells belongs to oxytocin, although the mechanism of this action remains undiscovered. There are now many studies on the important role of serotonin and prostaglandin (F2a) in myometrial cell contraction. Under certain conditions, catecholamines (mainly adrenaline) have a pronounced tonomotor effect on the muscle cells of the uterus. The question arises, which of the above biologically active compounds is primarily responsible for uterine contractions during childbirth? We believe that the uterus, given its biological role in the preservation of the life of the species, must have a duplicate system of specific contraction stimulants that compensate, and sometimes act as independent operating factors in the absence of the main The regulation of uterine contraction during childbirth includes two mutually determined dynamic processes: spontaneous excitability and contraction of muscle cells and energy metabolism, which provides the necessary levels of mechanical activity of the myometrium. A large number of biologically active compounds take part in the regulation of the first and second links of the uterus function, the effective action of which on the effector organ - the uterus - is possible only if there are optimal levels of fetoplacental hormones.
Clinical and experimental studies conducted by us and other authors (Jung, 1965) give reason to believe that compounds that affect the change in excitability and contractile properties of myometrial cells potentiate each other's action, and if one of them is insufficient, they can provide long-term time physiological parameters of uterine function.
When the contractile function of the uterus is weakened during childbirth, due to insufficient levels of circulating oxytocin or a violation of its use by myometrial cells, it is possible to completely restore uterine contraction by administering serotonin and calcium after pre-saturation of the mother's body with estrogens. Our investigations have shown that by successively introducing estrogens, serotonin and calcium, it is possible to overcome the motor inertia of the uterus and induce labor activity at various stages of pregnancy. The complex of biologically active compounds - estrogens, serotonin, calcium - ensures the restoration of the physiological course of the main links of the contractile function of the uterus in case of their violation and is the basis for initiating labor pains at various stages of pregnancy. Let us consider some of the mechanisms of these influences on the myometrium.
Serotonin (5-hydroxytryptamine, 5-HT) belongs to a group of broad-spectrum substances. However, on smooth muscle it has a specific effect. It has been established that the uterus has the ability to accumulate serotonin in large quantities(N. S. Baksheev, 1970; Fahim, 1965). Parenteral administration of labeled amine is accompanied by its accumulation in the subcellular fractions of the muscle cells of the uterus, where it is protected from destruction and can be stored for a long time (Kohren, 1965). With the introduction of 5-HT into the uterine lumen, active hyperemia, tissue edema, and stimulation of mitosis of muscle cells occur, similar to the action of estrogens (Spaziani, 1963). It has been established that there is a close relationship between serotonin and neuro-endocrine regulation carried out by the hypothalamic-pituitary system, and the amine itself is, apparently, a neurohormone with an autonomous, not yet fully disclosed mechanism of action. It has been shown that 5-HT relieves fatigue of muscle cells and restores their normal function (MM Gromakovskaya, 1967).
By studying the content of serotonin in some biological environments and tissues of pregnant women, we found that during pregnancy, the concentration of 5-HT in the blood and uterine tissue increases, reaching the highest values ​​in childbirth.
In order to reveal the essence of the established relationship between the function of serotonin and calcium, N. S. Baksheev rt M. D. Kursky studied the effect of amine on the distribution of Ca45 + + in the uterine tissue and its subcellular fractions. The isotope was administered to animals (rabbits) intravenously.
Under the influence of 5-HT, the accumulation of Ca45 in the uterine muscle increases by 3.8 times, however, the degree of accumulation in each subcellular fraction is different. The most rapid and maximum accumulation of Ca45 occurs in mitochondria (at the 15th minute); this level is maintained for 180 mi p. in other fractions, the intensity of Ca45 accumulation decreases after 30 and 60 minutes. These studies have established that 5-IIT is responsible for the accumulation and metabolism of calcium in muscle tissue uterus both with intravenous and intracisternal methods of its administration.
With the weakness of labor activity in the blood, uterine muscle and amniotic medium, the content of 5-HT is significantly reduced and the loss of calcium by uterine tissues increases. We believe that the biochemical system - fetoplacental hormones, serotonin, calcium - is responsible for providing physiological indicators of the contractile function of the uterus.
If serotonin is applied to a uterine strip that does not have spontaneous electrical activity, then in most cases spontaneous peak potentials appear after the depolarizing current is turned off, which indicates a significant change in the function of cytoplasmic membranes and contractile proteins under the action of amine.
In the absence of calcium ions in the medium, there is a shift in the membrane potential towards depolarization and fast loss spontaneous electrical and mechanical activity, inhibition of excitability and an increase in the permeability of protoplasmic membranes of smooth muscle cells of the uterus for other ions, that is, there is a complete disorganization of cell functions.
The addition of serotonin to a calcium-free solution does not affect the electrical activity and excitability of muscle cells.
If a muscle strip is preliminarily treated with serotonin in Krebs solution and placed in a calcium-free medium, the membrane potential value shifts towards depolarization, but the resistance of cytoplasmic membranes does not decrease, as is the case with the action of one calcium-free solution already in the 1st minute, but remains in within 4-5 minutes. After 5-8 minutes, the magnitude of electrotonic potentials slowly decreases and excitability decreases. Based on these studies, it can be assumed that 5-HT promotes an increase in the accumulation of calcium ions in the muscle cells of pregnant animals and ensures its economical consumption in a calcium-free medium for a long time.
The contraction of the muscle cells of the uterus during childbirth is associated with significant energy costs, the nature of which during pregnancy and childbirth is different. We have found that in the dynamics of pregnancy in the uterus, biochemical and morphological restructuring of the myometrium occurs, which provides the necessary level of motor function of the uterus during childbirth. The main role in these processes belongs to the hormones of the fetoplacental complex. To prove the role of estrogenic hormones, serotonin and calcium in these processes, we conducted experimental studies. If estrogen is administered to rabbits at the end of pregnancy (300 IU / kg for 3 days), an increase in the content of high-energy phosphates (LTP, CP), a decrease in glycogen and lactate , which indicates an increase oxidative processes in the myometrium as a necessary phase for the manifestation of the contractile function of muscle cells.
With the introduction of the same doses of estrogens to non-pregnant rabbits, the amount of actomyosin increases 3 times (from 4.12 to 12.07%), and sarcoplasmic proteins containing enzyme groups, from 35 to 56.3%. The amount of proteins of the tonic fraction (fraction T) decreases by 50% and stromin proteins by 45%.
Significant changes were found in the myometrium of pregnant women in comparison with the state outside of pregnancy.
The content of contractile fraction proteins increases by 53% by the end of pregnancy, accounting for 40% of all myofibril proteins. The amount of sarcoplasmic proteins increases and the content of stromal proteins decreases.
Our studies show that serotonin and calcium administered separately and together (without estrogens) slightly change the fractional composition of proteins. With the introduction of these biological active substances with estrogen, the accumulation of the optimal level of sarcoplasmic and contractile proteins occurs, and the content of adenyl nucleotides also changes, the composition of which approaches that in the pregnant and giving birth uterus.
The system of adenyl nucleotides is the main system of the cell, which determines its energy costs.
We have already noted above that estradiol, serotonin and calcium, administered in a certain sequence, can restore the contractile function of the uterus weakened during childbirth. Normalization of contraction is possible with the restoration of oxidative metabolism.
Energy for the implementation of muscular contraction of the uterus and other muscular organs It is formed in the process of oxidative phosphorylation of carbohydrates (maximum energy yield - with economical consumption of the substrate) and anaerobic decomposition of carbohydrates (minimum energy yield with wasteful consumption of carbohydrates). During normal delivery, the energy of uterine contraction is generated mainly in the cycle of oxidative phosphorylation, with maximum use oxygen. If labor is not completed within 16-17 hours, oxidative phosphorylation decreases, which can be determined by the use of oxygen by the uterine muscle obtained by caesarean section or by experimental fatigue of the uterine horn of animals. With a duration of labor of 18-24 hours, oxygen consumption by the uterine muscle decreases by 7%, 29-36 hours - by 17.2%, 99-121 hours - by 39.5%. The absorption of oxygen and the binding of inorganic phosphate in biological objects are in equimolar ratios.
This process is called coupled oxidative phosphorylation. The measure of oxidative phosphorylation is the P/O ratio (the ratio of esterified inorganic phosphate to absorbed oxygen). In normal childbirth, P/O pancake to the maximum and is 2.3. With a duration of labor of 99-121 hours, this indicator decreases by more than 2 times and is 1.1.
The transition of energy formation to the uneconomical path of glycolytic metabolism of carbohydrates is accompanied by the accumulation of excess products of interstitial metabolism (milk, pyruvic acid).
The energy metabolism of fats is also disturbed, fatty acids and other oxidized compounds accumulate, depleting the tissue and blood buffer system. The consequence of this is metabolic acidosis and even more disruption of the homeostasis of tissues and fluids.
One of the reasons for the weakness of labor activity may be the morphological inferiority of the uterus due to trauma (abortion, surgical benefits in childbirth) and inflammatory processes. The resulting structural changes in the uterus significantly reduce the sensitivity of the mechanisms of regulation of the processes of biochemical and biophysical restructuring of all structures of the myometrium during pregnancy and childbirth. In these cases, even with a normal complex of humoral stimulants of the fetoplacental complex, there are no changes in the muscle cells necessary for the unleashing and normal course of childbirth. To this group of causes, we include overstretching of the muscles of the uterus (multiple pregnancies, polyhydramnios, large fetuses), in which there is often a weakness in labor activity.
Violation of the coordination of the functions of organs and functional systems of the body of pregnant women in the direction of creating optimal conditions for the development of the fetus and organs that ensure its vital activity and birth (placenta, uterus, amniotic medium) can weaken the contraction of the myometrium. These functions are combined by the central nervous system, the disorganization of which function can, in some cases, have a negative impact on the birth act.
To the last group of causes, we include fatigue of the uterus due to significant resistance to the advancement of the fetus from the side of the bone ring of the pelvis or soft tissues of the birth canal. The process of fatigue occurs during various periods of normal labor activity. Our clinical studies have shown that 16-18 hours after the onset of normal labor activity, paroxysms of oxidative phosphorylation occur in the myometrium, indicating a decrease in the use of oxygen in bioenergetic processes and the accumulation of acids and compounds close to them (lactic, pyroviogradic, butyric acids, etc.) that change the pH of tissues and blood. If labor activity cannot be turned off with the help of medications, not only biochemical, but also morphological changes in the muscle cells of the uterus, followed by persistent motor inertia of the organ. The muscle of the uterus in a state of fatigue loses the ability to fix serotonin, catecholamines, calcium. The synthesis of ATP and ADP is disrupted, glycogen stores are rapidly decreasing. With this pathology, it is necessary to prescribe medication rest (sleep) for 6-8 hours. If necessary, labor is stimulated according to the method described below.

Clinical forms of weakness of labor activity and methods of its treatment

The primary weakness of labor activity is manifested by weak and short contractions, which are accompanied by the opening of the cervix and the movement of the presenting part of the fetus into the underlying plane of the small pelvis. The displacement of the presenting part should occur no later than 4-5 hours from the onset of normal labor. With weakness of labor activity, the presenting part of the fetus can be in the same plane for 8-12 hours or more, which increases the swelling of the tissues of the birth canal and the presenting part. The first birth lasts an average of 16-18 hours, and repeated - 12-14 hours. If we take into account that the smoothing of the cervix in primiparas occurs on average within 4-6 hours, then the difference in the rate of opening of the cervix in primiparas and multiparas can be consider insignificant. For full opening the cervix needs 10-12 hours of good labor activity. The number of contractions from the beginning of childbirth to their end is 120-150 for most parturient women. Weak contraction of the uterus can occur due to the normal tone of muscle cells, as well as in the case of hyper- or hypotonicity. Hyper- and hypotonicity of the myometrium during childbirth can significantly reduce the effectiveness of each contraction. When establishing a diagnosis of the nature of the weakness of labor activity, it is necessary to strive to determine the tone of the body of the uterus, the state of which can be influenced to some extent by medications.
One of the varieties of weakness of labor activity is the segmental nature of contractions, which indicates the pathology of the spread of the contraction wave.
With the normal development of the contraction, contraction of the muscles of the uterine body occurs in one of the foci (usually in the area of ​​​​the uterine horn) and spreads down at a speed of about 10 m per 1 s. Due to a number of circumstances, the focus of excitation does not extend to the muscle cells of the entire body of the uterus, but covers only part of it. At short intervals after the contraction of one zone of the uterus, a second, and sometimes a third focus of excitation occurs. Such contractions, if determined on the basis of a zonal change in the state of the myometrium, can last 1-1.5 and even 2 minutes in the absence of progress in childbirth. Discoordinated labor activity increases the energy consumption of the uterus up to its significant depletion with an extremely low effect of childbirth.
One of the forms of labor pathology is the simultaneous contraction of the muscles of the body, cervix and lower segment of the uterus. The contractions of the muscles of the uterus and the lower segment largely offset the effect of the contraction of the body of the uterus, as a result of which conditions are created for the fatigue of the working organ.
Treatment of weakness of labor activity should be preceded by the establishment of a possible cause of this condition. The primary weakness of contractions most often has genetically determined causes or depends on the insufficiency of the hormonal function of the fetoplacental complex. Often there may be a combination of these reasons.
The excitability and contractile function of the muscle cells of the uterus are influenced by oxytocin, serotonin and their combined use with estrogens and calcium, as well as a still little studied compound from the group of prostaglandins - prostaglandin F2a.

Induction of labor with oxytocin

Oxytocin is a biologically active compound with a highly specific action that enhances the contractile function of myometrial cells. It should be noted that oxytocin does not affect the myometrium, which is devoid of the influence of estrogen hormones, which not only sensitize the membrane and contractile proteins of muscle cells, but also create conditions for ensuring energy balance in a working organ. The mechanism of action of oxytocin on muscle cells has not yet been fully elucidated, however, there are data indicating a change in the ionic structure of target cell membranes to the level of the release of spontaneous action potentials. It must be assumed that oxytocin affects the transport of calcium ions in the intracellular structures of myometrial cells, without which contraction is impossible. The method of treating weakness of labor with oxytocin is as follows. 10 units oxytocin is dissolved in 350-400 ml of 5% glucose solution and injected intravenously or subcutaneously, starting with 10-15 drops per 1 minute. If in the next 4-6 minutes the contractions do not become more frequent and do not intensify, the volume of the injected solution is increased to 25-35 drops, and then the rate of inflow of the solution is regulated depending on the activity of the contractions. It should be noted that the effect of stimulation of uterine contractions by oxytocin is directly dependent on the readiness of the myometrium to respond to this hormonal stimulus. The duration of the stimulation period is 2.5-3.5 hours.
To enhance the sensitization of the uterus to oxytocin and increase the release of its own (pituitary) oxytocin and prostaglandin into the blood, as well as the accumulation of serotonin and catecholamines in the uterus, estrogens are prescribed prior to oxytocin stimulation. Estrogen is administered in ether (0.5 ml of ether per 1 ml of an oil solution of estrogen) in the amount of 300-400 units/kg of the mother's weight. Normal labor activity occurs against the background of the highest concentrations of estrogen in the blood. The highest concentration of estrogen in the blood after the introduction of an essential oil solution is observed after 3-3.5 hours, one oil solution (without ether) - after 5-5.5 hours. Oxytocin is administered 3-3.5 hours after estrogen with ether or 5.5 hours from the start of estrogen administration without ether.
The effect of stimulating labor activity is enhanced if estrogens in ether are administered 2 times in 20,000 units. (1st time - 3.5 hours before the start of oxytocin administration, 2nd time - before the administration of oxytocin), as well as with simultaneous intravenous administration of calcium chloride or calcium gluconate (10% 10 ml). On the day and on the eve of the stimulation of labor, ascorbic acid is prescribed (preferably galascorbin 1 g 3 times a day), coamide, vitamins Bi, Bis and cocarboxylase.
If after the introduction of 10 od. oxytocin, a weak labor-stimulating effect was obtained, it is not advisable to continue stimulation with quinine, pachycarpine or prozerin, since these drugs are many times less effective than oxytocin.
If the reaction of the uterus to oxytocin was sufficiently well expressed only during the administration of the drug, after its completion it is necessary to continue stimulation with pachycarpine (3% solution of 2-3 ml in 2-3 hours) or quinine hydrochloride (0.05 g of 1 powder in 30 min 4-5 times a day). The total dose of quinine, exceeding 0.7-1 g, is toxic. We noted above that dimecoline relaxes the muscles of the cervix and accelerates the opening of the latter.
Before and during the stimulation of labor, the appointment of trioxazine (400 mg 2 times a day) is shown - a tranquilizer, which also has some relaxing effect on the tissues of the cervix. When the cervix is ​​rigid, to accelerate its opening, 64-128 units should be injected into its tissue. lidase dissolved in 50-75 ml of 0.25% novocaine. It is necessary to monitor the nutrition of the mother. Other measures (laxatives, hot enemas) with drugs such as oxytocin, serotonin, or prostaglandin F2a are ineffective.

Stimulation of labor by serotonin

Serotonin, like oxytocin, is also used after the administration of estrogens in essential oil and oil solutions. 30-40 mg of serotonin-creatine phosphate is dissolved in 350-400 ml of 5% glucose solution immediately before administration. The drug is administered intravenously starting with 10-12 drops per 1 minute. 5 minutes after the start of administration in the absence of individual hypersensitivity uterus and vascular system you can increase the amount of the drug to 20-30 drops per 1 minute. It is necessary to monitor the tone of the uterus, as well as the strength and duration of its contraction. At the time of administration of serotonin, after 30 minutes and 1 hour 30 minutes from the start of administration, calcium gluconate or calcium chloride (10 ml each) is administered intravenously.
If, as a result of stimulation with oxytocin or serotonin, childbirth did not end, after 16-18 hours from the start of stimulation, drug sleep is prescribed for at least 6-7 hours. Labor should not be stimulated twice a day, since the energy reserves of the uterus and physical strength are depleted women in labor. After rest, the vast majority of women in labor develop good spontaneous labor activity. If necessary, the stimulation is repeated. In the absence of the effect of the action of oxytocin, serotonin is used. However, often the other drug is ineffective.

Induction of labor

Premature discharge of water is an indication for the initiation of labor not earlier than 4-6 hours from the onset of rupture of the fetal bladder. During this time, some pregnant women spontaneously develop labor activity, which does not require medical correction in the future. If there are no contractions by the time indicated above, it is necessary to start initiating labor. To excite uterine contractions, we, just as with stimulation, first administer estrogens, believing that the pathology of the structure of the fetal bladder depends on the estrogen deficiency of the fetoplacental complex. Estrogens increase the excitability of the muscle cells of the uterus, increase the release of oxytocin by the pituitary gland and release from the uterus, and possibly from the placenta, prostaglandin F2 "" increase the accumulation in the uterus of serotonin, a progesterone antagonist, as well as the accumulation and synthesis of catecholamines. Estrogens and serotonin reduce the level and activity of progesterone, as a result of which its inhibitory effect on adrenergic periuterine and intrauterine systems is reduced or completely removed. nervous structures. The adrenergic nerve, approaching the uterus, can form an efferent arc of the spinal reflex, as a result of which uterine contractions begin to be stimulated in further stretching(disclosure) of the neck. Adrenergic innervation increases the sensitivity of the myometrium to oxytocin.
Labor induction will be effective if the oxytocin test is positive. It should be noted that with a positive oxytocin test, the effectiveness of excitation of labor by serotonin significantly increases. The essence of the test is as follows.
Take 1 unit. oxytocin and diluted in 100 ml of 5% glucose solution (1 ml of solution contains 0.01 units of oxytocin). 3-5 ml of oxytocin solution (0.03-0.05 units) is slowly injected into the vein of the elbow bend. The drug reaches its maximum concentration by the 40-45th second. The second test of the readiness of the uterus for childbirth is the degree of "maturity" of the cervix for childbirth. The preparation of the cervix for childbirth consists in its shortening, softening and compliance, as a result of which the canal smoothly passes into the lower segment of the uterus. There is a thinning of the lower edge of the vaginal part of the neck, and the neck itself is located in the region of the wire axis of the pelvis. Practice shows that the above anatomical changes in the cervix correspond to a high degree of excitability of the uterus with the introduction of oxytocin and other compounds similar in effect.
The rate of administration of oxytocin and serotonin to initiate contractions should be somewhat greater than when stimulating labor. After the initial test for 4-6 minutes, the number of drops can be increased by 5-10 every 5-6 minutes and further adjusted depending on the labor activity of the uterus. If no effect is observed with the introduction of 40-50 drops per 1 minute, the rate of administration of oxytocin should not be increased. The same is true for serotonin. It should be borne in mind that there are few pregnant women with premature discharge of water and torpid inertia of the uterus. Their cervix, despite being prepared with estrogens, remains dense for several days, the tone of the uterus is low in the complete absence of spontaneous excitability and reaction to mechanical stimuli. The threat of endometritis, and sometimes the onset of endometritis, are the basis for the use of oxytocin or serotonin to induce labor. However full effect absent. In this category of women, even with the simultaneous administration of the metreirinter (in the absence of contraindications to its use), positive results, so you have to resort to long-term mechanical expansion of the cervix with dilators, and then with your fingers. Usually it is possible to expand the cervix by 3-5 cm in one go. After mechanical stretching of the cervix and application of skin-head forceps (with contraindications to metreyris), another round of labor induction is carried out. It is not uncommon to induce contractions that can later be stimulated by serotonin after oxytocin is administered, or vice versa. We have repeatedly been led to observe such inertia of the uterus that only with the help of mechanical methods it was possible to expand the cervix and remove the fetus.

Initiation of labor activity for medical reasons and in the event of a prolonged pregnancy

It is often very difficult to overcome the inertia of the uterus of pregnant women, especially when the pregnancy is overdue, and this requires a certain amount of time. Labor induction begins with an increase in the excitability of the uterus, which is achieved by the introduction of estrogens at 20,000-30,000 units. daily (estradiol dipropionate) in an oil solution, galascorbin 1 g 3 times a day and 10 mg serotonin intramuscularly 5 hours after hormone administration. Simultaneously with serotonin, calcium gluconate or calcium chloride is administered intravenously, 10 ml of a 10% solution. The period of prenatal preparation lasts 3-5 days, and sometimes longer. It is necessary to monitor the state of excitability of the uterus daily. In some pregnant women, after 2-3 days, arrhythmic contractions appear with a sufficiently high excitability of the organ. With a positive oxytocin test, labor induction with oxytocin or serotonin should be carried out according to the above scheme. If the contractions weaken after stopping the administration of the drug, oxytocin can be injected subcutaneously (2 units every 1.5-2 hours) or intramuscularly - 10 mg of serotonin every 2-3 hours. Pachycarpine and quinine should not be prescribed in the absence of contractions. B vitamins and coamide are prescribed during the entire period of labor induction. If after the first treatment the effect is not obtained, the second should be carried out no earlier than in 1-2 days, continuing the appointment of estrogens and other drugs according to the above scheme. Our many years of experience in the use of the above method of labor induction testifies to its consistently high efficiency and the least number of complications in the fetus.
In the absence of oxytocin and serotonin, pituitrin (10 units) can be used, but it should be administered only subcutaneously, since collapse may occur with intravenous administration. With late toxicosis, serotonin and pituitrin should not be administered.
With secondary weakness of labor activity, when labor has entered the second period, and uterine fatigue and general physical fatigue are increasing, you can use a 1% solution of sigetin, which is administered in an amount of 2-4 ml (preferably in 20 ml of 40% glucose), and then drip introduce oxytocin or serotonin and calcium gluconate. If necessary, resort to operative delivery. If secondary weakness develops at the end of the first period of labor, one of the schemes described above can be applied.
When prescribing medical sleep (rest) to a woman in labor, we use the following combinations of medications: I - trioxazine - 600 mg, etaminal sodium - 200 mg, promedol 2% - 1 ml, no-shpa - 2 ml, pipolfen - 50 mg; II - viadril G - 50 mg intravenously, trioxazine - 600 mg, sodium etaminal - 100 mg, no-shpa - 2 ml, pipolfen - 50 mg; III - sodium hydroxybutyrate (GHB) 20% - 20 ml intravenously, no-shpa - 2 ml, pipolfen - 50 mg. Etaminal sodium can be replaced with noxiron. Discoordinated contractions decrease under the influence of no-shpa, atropine, palerol, aprofen (the latter relaxes the muscles of the cervix).
The weakness of labor almost always worsens the condition of the fetus (acidosis, hypoxia, cerebral edema). Therefore, it is necessary to carry out effective prevention of fetal asphyxia simultaneously with the stimulation of labor. Weakness of labor is a very common diagnosis today. Weakness of tribal forces is more common in primiparous women. Weak labor activity can be primary and secondary. Contractions can be of satisfactory strength, but rare, or frequent, but weak and short. Persistent weak labor activity may be the reason for the appointment of a caesarean section. Despite the fact that weak labor activity refers to complications that occur directly during childbirth, you can try to prevent its development even during pregnancy. Weak labor activity leads to a protracted labor process, causes fatigue in the mother and hypoxia in the child, overwork of the woman in labor, labor bleeding, infection of the birth canal.

In the first place of the anomalies of labor activity is the weakness of labor activity. Weak labor activity is a pathology of the labor process, which consists in weak, short and fading contractions. With the weakness of labor, contractions are weak, rare, short, and the rate of opening of the uterine os is less than 1 cm per hour (and for multiparous less than 1.5-2 cm per hour). Smoothing of the cervix and its opening occurs at a slow pace and therefore remedial measures will be required as soon as the diagnosis of weakness of labor activity is established. At present, the scheme of labor-stimulating therapy according to Stein-Kurdinovsky with the use of oral quinine and intramuscular injection oxytocin), which is due to the fact that the effectiveness oral administration quinine followed by the introduction of oxytocin is very small and hardly adjustable.

Therefore, at present, only the scheme is applied intravenous administration oxytocin or prostaglandins possible combination(Enzoprost or prostenon is injected for 2 hours, then an ampoule of oxytocin is added and uterotonics are administered within 3-4 hours with an assessment of labor-stimulating therapy, so it is imperative to treat weakness of labor in a timely manner. The diagnosis of weak contractions should be made no later than 3 hours from the onset contractions and treatment should begin immediately with active drugs.

NB!labor induction- These are therapeutic measures in the absence of contractions.
Rodostimulating therapy- in the presence of weak contractions.

If you follow medical statistics, then weak labor is a fairly common phenomenon - 10% of all births.

But is it really so? Indeed, in the average generic department, everything is put on stream. And there they don’t particularly listen to the inner feelings of women in labor. Doctors quite often, without special need, just to secure and speed up the process, resort to stimulation of labor activity, referring to its weakness.

The weakness of labor activity is characterized by the presence of contractions weak in strength, short in duration and rare in frequency. With such contractions, the opening of the cervix and the movement of the fetus through the birth canal is slow. It can be primary, secondary, and appear only in the period of exile.

Cyclic weakness of labor occurs in the risk group which consists of the following pregnant women:

1. elderly and young women

2. women with overstretching of the uterus (large fetus, multiple pregnancies, polyhydramnios).

3. Multiparous, multipregnant, numerous abortions with curettage, that is, in the presence of dystrophic and inflammatory changes in the myometrium.

4. In women with a violation menstrual function and hormonal balance

5. hypertrichosis obesity

Cyclic weakness of labor activity develops in the group in which the uterus is unable to respond to normal impulses from the pacemaker. There may be a lack of impulses or a lack of receptors.

The diagnosis of weak labor activity is made on the basis of:

1. characteristics of contractions: weak, short

2. insufficient dynamics of cervical dilatation (normally 1 cm per hour) - 2-3 cm per hour.

3. To clarify the dynamics, external methods of determination and data from a vaginal examination are used.

4. The diagnosis must be made within 2-3 hours.

The weakness of labor activity leads to prolonged labor, complicated by premature or early discharge of amniotic fluid, leads to fetal hypoxia. Increased risk of purulent-septic complications. In the third stage of labor causes hypotonic bleeding.

Causes of weakness of labor activity

There are a number of reasons for weak labor activity:

• hormonal failure: the body of a woman giving birth is such a delicate and sensitive instrument that even a little stress - for example, a rude word - can cause labor to fail. Fear of the unknown process of childbirth for primiparas can also be the cause of weak labor activity. Disorders may also be the cause endocrine system, violation menstrual cycle, metabolic disease;
• features of the physiology of the body: a narrow pelvis in a future mother or a flat bubble;
• pathological processes in the uterus: malformations, inflammation, excessive stretching;
• other reasons: polyhydramnios, large fetus or multiple pregnancy, obesity, post-term pregnancy.

We must also take into account the fact that even in one woman, the first and subsequent births can proceed in completely different ways. Weak labor activity can be encountered even at the birth of a third child. In such cases, the cause of weak labor activity can be constant overwork, lack of sleep.

Prevention of weak labor activity

One of the most important factors for successful childbirth is the psychological attitude of the expectant mother. It is best to attend childbirth preparation courses, where specialists will teach you how to behave during childbirth and help you positively tune in to a difficult and important work- the birth of a new man.

Pre-induction of labor

If the family has already had cases of weak labor activity or there is reason to suspect that the birth will be protracted, you can take care of a safe delivery in advance.

Pre-stimulation can be started at home from 34-36 weeks of pregnancy. It is based on the principle - to do what could not be done recent months: wash the floor in an incline, have sex, lift heavy objects, take hot baths.

You can also make tea with raspberry leaves and drink 2-3 cups a day. But in everything, of course, a measure is needed.

Stimulation of labor in the maternity hospital

Initially held Not drug stimulation - opening of the fetal bladder - amniotomy. This procedure is performed when the cervix is ​​dilated by 2 cm or more.

Very often, after opening the fetal bladder, labor activity intensifies. The mother is observed for several hours. If the amniotomy did not give the desired result, and the process did not accelerate, medical stimulation is used.

The most common method is drug stimulation uterine contractions with the help of uterotonics: oxytocin and prostaglandins. They are administered intravenously. At the same time, the condition of the fetus is monitored using cardiotocography.

To restore the forces of the woman in labor, drug sleep is used. It lasts about 2 hours. It is called with the help of analgesics, in consultation with the anesthesiologist. Sleep is used in very rare cases when the benefits of using this method are much greater than the harm to the fetus.

In some cases, when none of the methods does not help and the condition becomes threatening for the child or mother, an emergency caesarean section is performed.

The usual scenario of labor induction

Often, stimulation is simple and quick. If contractions are present and the disclosure is somehow, but going on, then the plot can unfold as follows: a dropper in the hand, a pill under the tongue and, on command, on the birth table.

The order is to push without pushing. A couple of "kind" words to the poor exhausted head of a woman in labor. And, in conclusion, - hefty aunts fall on their stomachs and simply squeeze a baby out of a woman. The pelvic bones crack, the child is born with a hematoma all over his face. Hooray, a man is born!

Most often, stimulation saves the health and even life of an infant, but sometimes it can also cause childhood disability.

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Secondary weakness of labor activity

What is Secondary weakness of labor activity -

At secondary weakness of ancestral forces initially quite normal active contractions weaken, become less frequent, shorter and may gradually stop altogether. The tone and excitability of the uterus decrease. Essentially, the contractions weaken in the active phase of labor. This is a secondary hypotonic dysfunction of the uterus.

The opening of the uterine os, having reached 5-6 cm, no longer progresses, the presenting part of the fetus does not move along the birth canal, stopping in one of the planes of the pelvic cavity.

Secondary weakness of labor activity develops most often at the end of the period of disclosure or during the period of expulsion of the fetus.

Secondary hypotonic weakness of labor activity may be due to 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 a while.

What provokes / Causes of Secondary weakness of labor:

The causes of secondary weakness are numerous.

• The same reasons that cause the primary hypotonic weakness of the generic forces, but when they are less pronounced and show their negative effect after the depletion of the protective-adaptive and compensatory mechanisms.
• Fatigue of a woman in labor, which may be the result of a sleepless night or several nights (pathological preliminary period), stressful situations, fear of childbirth and negative emotions.
• The resulting obstacle to the further disclosure of the uterine pharynx or the advancement of the fetus through the birth canal: anatomical (cicatricial) changes in the neck - low location of the myomatous node; abnormal anatomical shape of the pelvis, narrowing one of the sizes of the wide, narrow part of the pelvic cavity or the exit plane; clinically narrow pelvis due to a violation of the biomechanism (extension of the head, asynclitic insertion).
• Failure of the abdominal muscles, causing weakness of attempts (multiple births, hernia of the white line of the abdomen).
• Iatrogenic causes: indiscriminate and inept use of anticholinergic, antispasmodic and analgesic drugs.
• Large fetus, posterior occipital presentation, low transverse position of the sagittal suture.

Symptoms of Secondary weakness of labor activity:

The clinical picture of secondary weakness coincides with the primary weakness of labor, but the lengthening of labor occurs most often in the active phase of labor and in the period of fetal expulsion. The opening of the cervix is ​​complete, and the presenting head of the fetus has not sunk to the pelvic floor, it is only a small or large segment at the entrance to the pelvis (distance from the spinal plane in position -2, -1, 0 or +1, +2). The woman in labor begins to push prematurely, unsuccessfully trying to speed up the birth of the child (not heeding the recommendations medical personnel). Naturally, rapid fatigue sets in, fatigue from useless, unproductive work.

Premature attempts can occur reflexively if the cervix is ​​pinched between the fetal head and back wall pubic symphysis or a large birth tumor has appeared on the fetal head and its lower pole can irritate muscle receptors pelvic floor. But this most often happens with a general narrowing of the pelvis, when it has a wedge-shaped insertion of the fetal head.

Treatment of Secondary weakness of labor activity:

The choice of tactics of conducting labor in case of weakness of labor activity

Before proceeding with the treatment of weakness of labor activity, it is necessary to find out the possible cause of its occurrence.

The main thing is to exclude a narrow pelvis, namely this or that degree of disproportion in the size of the fetal head and the mother's pelvis; failure of the uterine wall, unsatisfactory condition of the fetus.

With these types of pathology, any uterine stimulating therapy is contraindicated!

A clinically narrow pelvis is evidenced by the stop of the fetal head at the entrance of the small pelvis or in position "0" (the spinal plane is the narrow part of the small pelvic cavity). The slowdown in the advancement of the fetal head in the "+1" position and below indicates either a posterior view (anterocephalic presentation) or a low transverse position of the sagittal suture.

Myometrial failure can be suspected if there is an appropriate burdened obstetric history (complicated abortion, pathological, "difficult" childbirth, endomyometritis, operations on the uterus - myomectomy, caesarean section).

An important factor in choosing the tactics of conservative or operative delivery is the assessment of the condition of the fetus and its reserve capabilities. To assess the fetus in childbirth, one should take into account not only its body weight, presentation, frequency, rhythm and sonority of the fetal heart sounds, but also data from CTG, ultrasound echography, assessment of the biophysical profile of the fetus, as well as the results of cardiointervalography, the state of the uteroplacental and fetal placental blood flow.

The tactics of the doctor may be different depending on the specific obstetric situation. First of all, it is necessary to provide for the expediency of delivery by caesarean section.

At high risk prolonged, protracted labor ( late age primiparous, aggravated obstetric and gynecological history, infertility, stillbirth, induced pregnancy, breech presentation, large fetal size, post-term pregnancy) the birth plan for primary weakness of labor should be timely determined in favor of caesarean section.

Without preliminary rhodostimulation, cesarean section as the optimal method of delivery is chosen in the presence of:

• a scar on the uterus, the usefulness of which is difficult to determine or it is doubtful;
• with an anatomically narrow pelvis;
• in multiparous because of the danger of rupture of the incompetent myometrium;
• with an unsatisfactory condition of the fetus (IUGR, fetoplacental insufficiency).

A caesarean section is also indicated in case of an unsatisfactory state of health of a woman (the presence of a pathology in which heavy physical exertion is contraindicated). At the same time, young age repeated births are not decisive, leading in the motivation for refusing caesarean section.

Radical management of childbirth takes place in last years, which is due to the concept of modern obstetrics.

• The child should be born alive and healthy without hypoxic-ischemic and traumatic injuries.
• It is necessary to minimize the risk of using obstetric forceps, forcible removal of the fetus using a vacuum extractor or manual techniques, turns and other operations.
• It is necessary to realize the danger of unfavorable outcomes for the mother and fetus during a protracted course of labor with the use of medical sleep-rest, prolonged, many hours, repeated labor stimulation and the need to eventually apply atypical abdominal obstetric forceps.
• For each woman in labor, an individual birth plan is drawn up, taking into account existing and growing risk factors.
• The number of previous births (primiparous, multiparous) should not affect the expansion of indications for caesarean section, performed according to the indication from the fetus.

The combination of weakness of labor activity with prenatal rupture of amniotic fluid with an anhydrous interval of 8-10 hours or more does not leave time to provide sleep-rest to the woman in labor, since there is a risk of intranatal infection of the fetus and the development of an ascending infection in the mother.

Frequency infectious complications increases in proportion to the increase in the anhydrous gap. The maximum anhydrous interval until delivery should not exceed 12-14 hours! Therefore, long-term management of labor with repeated use of medical stimulants is possible rather as an exception in the presence of aggravating circumstances (the presence of contraindications to caesarean section) than the rule. modern tactics childbirth.

Most often, a conservative treatment of weakness of labor activity is chosen, and with the elimination of the cause that caused this complication.

Before proceeding with labor stimulation, an attempt is made to eliminate the causes that caused the violation of labor activity.

Possible causes to be addressed include:

• polyhydramnios;
• functional inferiority fetal bladder (dense amnion, dense adhesion of the amnion and decidua);
• fatigue of the mother.

The complex of preparatory activities includes:

• accelerated preparation of the cervix using prostaglandin E2 preparations;
• amniotomy;
• the use of an energy complex, as well as means that improve uteroplacental blood flow.

With polyhydramnios (which causes hyperdistension of the uterus) or with a functionally defective fetal bladder (in which the amnion has not exfoliated from the walls of the lower segment of the uterus), an artificial opening of the fetal bladder, dilution of the membranes and slow removal of amniotic fluid should be performed. To carry out this manipulation, the presence of conditions and contraindications should be taken into account.

Amniotomy Conditions:

• "Mature" cervix.
• Opening of the cervical canal by at least 4 cm (the beginning of the active phase of labor).
• Correct, longitudinal position of the fetus.
• Head presentation.
• Absence of disproportion of the pelvis and head of the fetus (confidence in full proportionality).
• The elevated position of the upper half of the body of the woman in labor (Fowler's position).
• Full compliance with the rules of asepsis and antisepsis.

You can not open the fetal bladder when:

• "immature" or "insufficiently mature" cervix;
• small (up to 4 cm) opening of the cervix (latent phase of labor);
• anatomically narrow pelvis;
• incorrect position of the fetus (oblique, transverse);
• breech (foot) presentation;
• extension of the head, frontal presentation and posterior parietal asynclitic insertion, in which childbirth through natural birth canal impossible;
• infections of the lower genital tract;
• a scar on the uterus, if there is evidence of a possible inferiority of the myometrium (abortions, medical and diagnostic curettage, endometritis, etc.);
• old ruptures of the cervix of the III degree (rupture to the internal pharynx), in which childbirth through the natural birth canal is very dangerous (risk of rupture of the internal pharynx with the transition to the lower segment of the uterus).

The main method of treating weakness of labor activity is rhodostimulation, which is performed, as a rule, with an open fetal bladder. Stimulation with a whole fetal bladder can cause amniotic fluid embolism, premature detachment placenta, associated with a violation of the pressure gradient in the amnion cavity and intravillius space.

Amniotomy is accompanied by a decrease in the volume of the uterine cavity, which in turn normalizes the basal tone of the uterus, 15-30 minutes after the amniotomy, the frequency and amplitude of contractions increase, labor activity, as a rule, increases.

Treatment of weak labor activity (rhodostimulation)

Stimulation is the main treatment for hypotonic dysfunction of the uterus - primary or secondary weakness of labor.

Before labor stimulation, it is necessary to assess the well-being and condition of the woman in labor, take into account the presence of fatigue, fatigue, if the birth lasted more than 8-10 hours or the birth was preceded by a long pathological preliminary period (sleepless night). In case of fatigue, it is necessary to provide medical sleep-rest.

Before proceeding with conservative management of labor, it is necessary to consider additional complications: lack of effect from previously performed labor stimulation, lengthening of the anhydrous gap with its characteristic inflammatory complications (endomyometritis, chorioamnionitis, intrauterine infection), deterioration of the fetus, the possibility of developing secondary weakness of labor forces and, ultimately, the need to apply obstetric forceps, including abdominal forceps ( atypical).

All this can lead to a very likely risk of obstetric trauma for the mother and fetus, bleeding in the afterbirth and early postpartum periods, fetal hypoxia, inflammatory complications in the postpartum period.

So, as a result of insufficiently thought-out tactics, such childbirth can have an extremely unfavorable outcome: the child will be born dead or in deep asphyxia, with severe traumatic-hypoxic damage to the central nervous system. Due to severe uterine bleeding the question of removing the uterus may arise. After a difficult birth, neuroendocrine disorders subsequently develop, etc.

In this regard, in each individual case, before providing sleep-rest or proceeding with labor stimulation, it is necessary to assess the obstetric situation, conduct an in-depth examination of the woman in labor and her fetus, and decide whether the fetus will withstand the upcoming many hours of conservative labor management.

It is necessary to investigate the blood flow (uterine, placental, fetal) using Doppler ultrasound, to assess the reactivity of cardio-vascular system fetus by dynamic CTG, as well as to identify the degree of protective and adaptive capabilities of the mother and fetus, their anti-stress resistance, which is possible using a new methodological approach using cardiointervalography.

Obstetric sleep-rest should be carried out by an anesthesiologist. If there is no such specialist, the obstetrician-gynecologist prescribes a combination of drugs: promedol 20 mg, diphenhydramine 20 mg, seduxen 20 mg intramuscularly.

After rest, they begin labor stimulation. It is often enough to give the woman in labor a rest so that normal labor activity is restored after waking up. If labor activity has not returned to normal, then 1-2 hours after waking up, they begin to administer drugs that increase the contractile activity of the uterus.

Rules of labor stimulation

• Stimulation must be careful to achieve a physiological (but no more than that) rate of labor.
• They start with the minimum dosage of the drug, gradually selecting (every 15 minutes) the optimal dose, at which 3-5 contractions pass in 10 minutes. The amount of drug administered is regulated according to this criterion.
• Rhodostimulation with oxytocin and prostaglandin F2a preparations is carried out only with an open fetal bladder, with sufficient biological "maturity" of the cervix and opening of the pharynx by at least 6 cm.
• The use of prostaglandin E2 preparations does not always require a preliminary amniotomy. In addition, stimulation with drugs of this class is most appropriate with a small opening of the cervix or uterine os.
• The duration of rhodostimulation should not exceed 3-4 hours.
• Due to the risk of fetal hypoxia or uterine hypertonicity, rhodostimulation is carried out against the background of intravenous drip of antispasmodics (no-shpa).
• With insufficient effectiveness of corrective therapy for 1 hour, the dose of the drug is doubled or the treatment is supplemented with another uterine stimulant (for example, a combination of prostaglandins and oxytocin).
• The drug is chosen in accordance with the imitation of the natural mechanism for the development of labor: with a small neck opening (4-5 cm), prostaglandin E2 preparations are preferred. With a significant opening (6 cm or more), as well as in the second stage of labor, prostaglandin F2a preparations or oxytocin are used. It is advisable to combine oxytocin and prostaglandin F2a preparations in half the dosage (they potentiate each other's action).
• The intravenous method of administering a stimulant is more manageable, controlled and effective. The action of the drug (if necessary) can be easily stopped. Intramuscular, subcutaneous, oral routes of administration of stimulant drugs are less predictable.

For drug protection of the fetus, seduxen (10-12 mg) is administered. Optimal time introduction - the passage of the fetal head through the narrow part of the pelvis.

Which doctors should be contacted if you have Secondary weakness of labor:

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