Discoordinated labor activity: symptoms and treatment. Discoordination of labor activity: what is it, classification, causes and treatment

Description:

With discoordinated labor activity various departments uterus (right and left halves, fundus, body and lower divisions) are reduced chaotically, inconsistently, unsystematically, which leads to a violation normal physiology birth act. The danger of discoordinated labor activity lies in the likelihood of a violation of the placental-uterine circulation and the development of fetal hypoxia. Discoordination of labor activity is often noted when the body of a pregnant woman is not ready for childbirth, including with the immaturity of the cervix. The frequency of development of discoordinated labor activity is 1-3%.

Causes of discoordinated labor activity:

Obstetrics and gynecology distinguish several groups of factors that determine the development of discoordinated labor activity.

Obstetric risk factors may include early rupture of amniotic fluid; overstretching of the uterus caused by polyhydramnios or multiple pregnancies; discrepancy between the size of the birth canal and the head of the fetus; pelvic presentation of the fetus; abnormal location of the placenta (placenta previa) and; late gestosis, the age of a woman is younger than 18 and older than 30 years. Discoordinated labor activity can occur with intrauterine infection of the fetus, anencephaly and other malformations in the child, hemolytic disease fetus (immunoconflict pregnancy).

Among the gynecological factors that provoke discoordinated labor activity are different kinds pathology reproductive system. Violation and discoordination of the birth act is facilitated by uterine defects ( bicornuate uterus, uterine hypoplasia, etc.), past endometritis and cervicitis, tumor processes (uterine fibroids), cervical stiffness due to impaired innervation or cicatricial changes (for example, after cauterization). The physiology of childbirth is adversely affected by the presence of an operating scar on the uterus, disorders menstrual cycle, in history.

In some cases, abnormal labor activity is provoked external influences- unreasonable use of labor-stimulating agents, insufficient anesthesia for childbirth, untimely opening of the fetal bladder, rude manipulations and studies.

Diagnostics:

The discoordinated nature of labor activity is diagnosed on the basis of the woman's condition and complaints, the results of an obstetric study, and fetal cardiotocography.

In the course of a vaginal examination, the absence of dynamics in the readiness of the birth canal is determined - thickening and swelling of the edges of the uterine os. Palpation of the uterus reveals its unequal tension in different departments as a result of discoordinated contractions.

An objective assessment of the contractile activity of the uterus allows cardiotocography. At hardware research irregular in strength, duration and frequency of contraction are recorded; their arrhythmia and asynchrony; the absence of a triple downward gradient against the background of an increase in uterine tone. The value of CTG in childbirth lies not only in the ability to control labor activity, but to monitor the growth of fetal hypoxia.

Treatment of discoordinated labor activity:

For treatment appoint:

Childbirth occurring in conditions of discoordinated labor activity can be completed independently or promptly.

With discoordination and hypertonicity lower segment uterus, electroanalgesia (or electroacupuncture) is performed, antispasmodics are introduced, obstetric is used. With deterioration in the vital activity of the fetus, operative delivery is required.

Discoordination of labor activity - a violation of contractions, characterized by increased tone and lack of coordination between the departments of the uterus.

Pathology is rare, the main reason for its occurrence is the unpreparedness of the woman's body for childbirth.

The reasons

The main factors in the development of discoordination of labor activity:

Vegetative disorders nervous system. Their occurrence is facilitated by stress, attempts to give birth to a child when the body is not yet ready.
Anomalies in the development of the uterus.
Narrow pelvis.
Malposition.
Incorrect insertion of the fetal head into the pelvis.
Myomatous node located in the lower part of the uterus or cervix.
Psychological unpreparedness of the mother for childbirth, fear, increased threshold of pain sensitivity.
Labor induction strong drugs in the absence of indications or without taking into account contraindications (medical error).

Symptoms of discoordination of labor activity

Signs preceding discoordinated labor activity:

An immature cervix during a full-term pregnancy or at the time of the onset of labor (determined by a doctor or midwife by the vaginal route).
Pathological preliminary period (prenatal condition, characterized by irregular contractions and not leading to the opening of the cervix).
Prenatal discharge of amniotic fluid with a small opening of the cervix.
Hypertonicity of the uterus (tension, increased contractions).
The presenting part of the fetus at the beginning of labor is not pressed against the entrance to the small pelvis (determined by a doctor or midwife using external studies).
On palpation, the uterus resembles the shape of an "elongated egg" and tightly covers the child (determined by the doctor).
Often accompanied by oligohydramnios and fetoplacental insufficiency (morphological and / or functional disorders in the placenta).

The main symptoms of discoordination of labor activity:

contractions are sharply painful, frequent, different in strength and duration;
pain is more often in the sacrum, less often in the lower abdomen;
restless behavior of a woman, a feeling of fear;
nausea, vomiting;
there is no cervical dilatation;
uterine hypertonicity.

Severity and possible complications:

1 degree: contractions are frequent, long, painful. The relaxation period is shortened. The opening of the cervix is very slow, tears or tears may form. At vaginal examination found that the fetal bladder has flat shape, there are few front waters.

If an amniotomy is performed or an independent outflow of water occurs, then contractions can normalize, become less painful and regular.

If the fetal bladder remains intact and the uterine contractions are not corrected in time with antispasmodic and painkillers, then the condition will worsen. Childbirth will become protracted, and hypertonicity will increase. Discoordination can turn into weakness of labor activity (this, on the contrary, is a reduced activity of the uterus, leading to a weakening of contractions).

At this stage, early diagnosis of pathology and the beginning of treatment are important. 2 and 3 degree develop very rarely, as there are modern methods diagnostics, which allow to identify the pathology at the stage of the beginning of development. Not less than an important factor is timely appeal women in labor maternity hospital for medical help. With the onset of labor activity (contractions), you should immediately call an obstetric ambulance team.

2 degree develops more often with a clinical narrow pelvis or the use of unindicated rhodostimulation (medical error). And it can also be a consequence of aggravation of the 1st degree.

This degree is characterized by a long painful course of childbirth, the cervix may remain immature after 8-10 hours of the onset of labor. The presenting part of the fetus remains mobile for a long time and is not pressed against the entrance to the small pelvis.

The pressure in the uterus can rise and exceed the norm, and this carries the risk of developing amniotic fluid embolism (amniotic fluid entering the mother's bloodstream). Also, intrauterine pressure may, on the contrary, decrease, as a result of which there is a possibility of premature placental abruption.

At this stage, the outpouring of amniotic fluid will not change the situation, since by this time the anterior waters may not remain. The uterus very tightly covers the fetus and takes the form of an "elongated egg" or "hourglass". This condition is dangerous and threatens to rupture the uterus, as well as mechanical compression and trauma to the organs of the fetus.

The woman in labor behaves very restlessly, screams, becomes uncontrollable. There is vomiting excessive sweating body temperature can reach 39 degrees. It also increases blood pressure.

3 degree the heaviest. In this case, the uterus is divided into several zones, where each takes on the function of a trigger center (normally, there is only one pacemaker, usually in the area of the uterine fundus). Each segment is reduced in its own rhythm and frequency, so they do not coincide with each other. Childbirth in this case can stop.

Contractions become rare, weak and short, but the tone is preserved (this is the only difference from the weakness of labor activity). Hypertonicity is permanent, so there is no relaxation phase. The woman in labor stops screaming, rushing about, but behaves indifferently. This is dangerous because doctors can make mistakes, diagnose secondary weakness and prescribe labor stimulation, which is absolutely contraindicated in discoordinated labor.

The uterus covers the fetus very strongly, which causes it to suffer. Sometimes, at grade 3, a birth tumor is diagnosed in a child through the vaginal route.

With the third degree of discoordination of labor, delivery must be carried out by caesarean section (if there are no contraindications).

Diagnostics

When a woman in labor enters the maternity hospital, the doctor examines medical card(history, course of pregnancy, etc.) to identify risk factors and threatening conditions. Estimated general state patients, somatic health and obstetric situation. It is necessary to exclude a narrow pelvis, wrong position fetus, pathological preliminary period and others possible reasons incoordination of uterine contraction.

The doctor evaluates the nature of labor and its effectiveness every 1-2 hours based on:

complaints of a woman;
the general condition of the woman in labor (pain sensitivity, fear, anxiety, etc.);
cervical dilatation dynamics;
condition of the fetal bladder;
external obstetric studies (determination of the position of the fetus, presenting part, etc.);
frequency, intensity, rhythm of contractions and a period of relaxation;
hardware studies (CTG, external hysterography and internal tocography).

With CTG and external hysterography, a special sensor is attached to the abdomen, and with tocography - in the uterus. These studies reveal the irregularity of contractions, determine the duration, frequency and strength of uterine contractions, as well as intrauterine pressure. With the help of CTG, it is also possible to diagnose fetal hypoxia.

Delivery with discoordination of labor

Childbirth with this pathology can be carried out through natural ways or end with a caesarean section, it depends on the severity and the complications that have arisen.

In the absence of indications for operative delivery, drug therapy. Administered intravenously or intramuscular injection antispasmodics (No-shpa, Baralgin) and painkillers (Promedol).

To eliminate uterine hypertonicity, beta-agonists are used (Partusisten, Brikanil, Alupent). Normally, after 30-40 minutes, contractions resume and are regular.

With discoordinated labor activity, it is necessary to eliminate the defective fetal bladder. Amniotomy (artificial opening of the bladder) is performed only after the introduction of antispasmodics.

It is mandatory to carry out the prevention of fetal hypoxia and placental insufficiency (Eufillin, Reopoliglyukin, Actovegin, Cocarboxylase, Seduxen).

When opening the cervix by 4 cm, epidural anesthesia is performed (done into the spine).

During the period of attempts, an episiotomy (a small dissection of the perineum) is shown, which is done in order to reduce the mechanical effect on the fetal head.

Indications for caesarean section:

burdened obstetric history (adverse outcome of past births, miscarriage, etc.);
somatic diseases (cardiovascular, endocrine, etc.);
fetal hypoxia;
large fruit;
prolongation of pregnancy;
narrow pelvis;
malposition of the fetus or breech presentation;
first birth after 30 years;
discoordination of labor activity of 2 and 3 degrees of severity;
ineffectiveness of drug therapy.

At birth, there must be: experienced doctor obstetrician-gynecologist, anesthesiologist-resuscitator and neonatologist.

Forecast

The prognosis is based on the age of the woman in labor, the state of health of the woman and the fetus, anamnesis, the course of pregnancy, and the obstetric situation.

In most cases, childbirth ends favorably.

Some research on pregnancy

The normal course of pregnancy in the last stages is characterized by the occurrence of contractile activity of the uterine walls, which occurs mainly at night and is not accompanied by painful sensations. Contractions are necessary to soften the cervix, due to which the process of childbirth takes place in normal mode without complications.

With an abnormal course of pregnancy, the coordination of convulsive conditions of the uterine muscles is disturbed, and this threatens the life and health of the mother and fetus. Such pathologies require timely medical care and adjustment of intrauterine processes.

Features and complications of labor

In order to clearly understand what complications can arise during childbirth, you need to understand how the correct delivery goes. If a woman knows what to expect from certain signs of pregnancy, she will be able to recognize the approach of childbirth.

Normal activity state internal organs during childbirth implies an alternation of contractions and relaxations of the uterus. The contractions that accompany the entire process of childbirth provoke the following changes in the body:

softening and opening of the cervix;
promotion of the fetus;
relief from burden;
detachment and release of the placental film.

At healthy pregnancy these changes in the state of the body must occur dynamically and cyclically. The cyclicity consists in equal in duration and strength of the intensity of contractions with the same time intervals for spasms and relaxation. Dynamism is expressed in a stable increase in the contractile activity of the reproductive organ and the duration of contractions. During a gradual increase in contractions, the uterus contracts and contracts, decreases in volume and becomes denser in structure, which contributes to the productive progress of the child through the birth canal. With discoordination of labor activity, the contractile activity of the uterine walls proceeds restlessly, which causes pain and unproductive delivery - the cervix does not open and the child does not move along the birth canal.

Causes of pathology

In gynecological practice, the causes of discoordination of labor activity are conventionally divided into 3 groups:

Physiological features.
Pathologies reproductive function.
General disorders.

To physiological features relate:

premature discharge of amniotic water;
abnormal distension of the uterus due to polyhydramnios or the presence of several fetuses in the womb;
discrepancy between the diameter of the genital tract and the head of the child;
incorrect presentation of the fetus;
abnormal accumulation of the placenta;
phytoplacental insufficiency;
chronic fetal hypoxia;
age of the woman in labor (less than 18 years old or over 30 years old);
intrauterine infection of a child;
hemolytic disease of the fetus;
other anomalies in the formation and growth of the fetus.

Reproductive pathologies include:

anatomically irregular shape reproductive organ;
past illnesses pathological processes endometrium;
tumor formations on the internal and outside uterine walls;
lack of response of the cervix to external stimuli due to the presence of scar tissue;
failure of the menstrual cycle;
abortions.

Common somatic disorders include:

general poisoning of the body;
infectious diseases;
disorders in the work of the central nervous system;
obesity;
anemia
neurocirculatory dystonia (a complex of disorders of the cardiovascular system);
excessive activity of the uterine muscles.

Symptoms of the disorder

Discoordination of labor activity is characterized by the following symptoms:

irregular, but frequent contractions, accompanied by pain in the lower back and lower abdomen;
different degree of tension of the uterine departments, traced by palpation (violation of the synchronization of contractions);
increased uterine tone;
different intensity and time span of duration of spastic states;
uterine bleeding, provoking fetal hypoxia.

Such manifestations of instability are explained mental state women in labor at the start of childbearing. The contractile activity of the uterine muscles occurs as a result of the supply of a nerve impulse to the body of the reproductive organ. With asymptomatic and chaotic impulses, there is a violation of the coordination of the internal synchronous functions of the uterus. Accordingly, fear future mother before childbirth, as it were, it pushes the body to discoordination of a well-coordinated process. Due to panic tension and fear of a woman, her pain increases significantly during attempts.

Severity

Depending on the clinical picture, the duration of attempts and the condition of the woman in labor, discoordinated labor activity is classified according to severity:

I degree is characterized by an acceptable basal tone of the uterus, frequent painful and prolonged contractions, heterogeneous changes in the structure of the cervix.
II degree is expressed in more severe form uterine activity. It occurs either spontaneously, or is a complication of the first degree with illiterate obstetrician management of the child. In this case, the basal tone is significantly increased, the spasm of the circular muscles of the internal os and the overlying uterine sections is pronounced. At the same time, the woman in labor has hyperthermia ( heat), severe sweating, impaired heart rate, increased intracranial pressure.
III degree of severity is most severe - the spasm of the circular muscles of all organs involved in delivery, up to the vagina, increases. Due to the imbalance in cellular level, labor activity slows down and stops.

Diagnostics

Diagnostics is carried out on the basis of the following activities:

examination of the woman in labor, assessment of the general condition;
fetal cardiotocography (registration of heart rate);
examination of the vagina for tightness and swelling of the extreme pharynx;
palpation of the uterus.

Treatment

The goal of treating discoordinated labor is to reduce uterine tone. For this, a woman is prescribed drugs that relieve spastic conditions, painkillers and sedatives. In combination with these drugs, drugs are used, the action of which is aimed at weakening the contractile activity of the myometrium. Drug therapy helps to prevent pathological rejection of the fetus and premature delivery.

With excessive fatigue of a woman in childbirth, prolonged and discoordinated labor activity, the patient is given obstetric anesthesia, which reduces the intensity metabolic processes and tissue oxygen consumption. After rest, the woman in labor recovers metabolic and oxidative functions, which provokes an increase in the action of uterotonic drugs.

If it is impossible to independently resolve the burden, surgical intervention is performed. If the tone of the lower segment of the uterus is increased, drugs are administered that cause spastic conditions, as well as general or local anesthesia, after which the child is removed from the birth canal with special obstetric forceps.

In the event of a danger to the life of the fetus, delivery is carried out by dissecting the uterine cavity (caesarean section). This operation does not require corrective therapy.

If fetal death occurs, embryotomy is performed - a fruit-destroying surgical intervention.

Preventive measures

Preventive measures include:

observation of the expectant mother by a specialist with early dates pregnancy;
strict adherence to all recommendations of the obstetrician-gynecologist leading the pregnancy;
passing the physiological and psychological preparation to childbearing;
control of muscle tone;
avoidance of stressful situations;
compliance correct mode nutrition;
long walks in the fresh air;
competent administration of painkillers to a woman in labor at the time of delivery.

Possible Complications

The negative consequences of discoordinated labor activity can be caused by a violation of the birth process, and sometimes provoke some complications:

at prolonged labor possible intrauterine hypoxia and fetal asphyxia;
postpartum hemorrhage.

Violation of the coordination of labor activity is a serious pathology. If a woman is at risk, she must carefully monitor her health and strictly follow all the indications and recommendations of doctors. It is also important to prepare for childbirth psychologically so that at the initial stage of delivery there are no excessive spastic contractions of the uterus, and the process itself is as painless as possible.

Discoordinated labor activity is a deviation in the contractile activity of the uterus, characterized by uneven frequency and intensity of contractions in different parts organ. In this case, the violation of the consistency of abbreviations can be:

between the bottom and the body of the uterus;
between the right and left halves of the uterus;
between the upper and lower part of the uterus;
between all sections of the uterus.

At the same time, contractions turn out to be ineffective, but at the same time quite painful, and the opening of the cervix of the uterus is delayed in time. Thus, childbirth takes place haphazardly, which is considered a violation of the normal physiological process.

There are three degrees of discoordinated labor activity:

Grade 1: The tone of the uterus is moderately increased, contractions are either too slow or too fast.
Grade 2: a spasm of the circular muscles spreads from the internal os to other parts of the uterus, in addition, the woman in labor has various autonomic disorders;
Grade 3: a prolonged spasm extends to the vagina, which can completely stop labor activity.

Accordingly, the strength of the manifestation of clinical symptoms and the likelihood of complications with the transition to each new degree increase.

Causes of discoordinated labor activity

Although this pathology is not so common (in about two percent of cases), there are quite a few reasons that can provoke it. They can be divided into 4 groups:

gynecological;
obstetric;
external;
somatic.

Gynecological causes of discoordinated labor activity imply that a woman has any diseases of the reproductive system that manifested itself even before pregnancy (for example, various menstrual irregularities or inflammatory processes in cervical canal or in the uterus). This also includes numerous deviations in the development of the uterus itself:

hypoplasia;
stiffness of the cervix;
bicornuate uterus;
separation of the cavity in two (intrauterine septum).

Finally, a past abortion, cauterization of erosion, or any other intervention that left behind a scar or scar can cause discoordinated labor activity.

Obstetric causes, as a rule, make themselves felt during pregnancy or with the onset of childbirth. At risk are women in labor whose age is beyond the framework of a favorable reproductive function - both too young (under 18 years old) and old-bearing women (over 30 years old). The main obstetric factors in the development of discoordinated labor activity:

placenta previa;
pelvic presentation of the fetus;
fetoplacental insufficiency;
early discharge of amniotic water;
late gestosis.

Overdistension of the uterus can also play a role with multiple pregnancy or polyhydramnios, as well as a discrepancy between the size of the fetal head and the parameters of the birth canal. Finally, deviations in the development of the fetus are risk factors:

immune conflict between mother and child by blood type;
intrauterine infection;
malformation of the brain.

To external reasons Discoordinated labor activity can be attributed to errors in the work of obstetricians-gynecologists:

inaccurate actions during the study;
stimulation of labor without special need;
untimely opening of the fetal bladder;
insufficient or incorrectly selected anesthesia.

last group

Symptoms of discoordinated labor activity

Symptoms of this violation of the birth process are differentiated depending on its type. Medicine knows 4 types of discoordinated labor activity:

general discoordination;
hypertonicity of the lower segment of the uterus;
tetanus (tetany) of the uterus;
circular dystocia of the cervix.

However, with any of the listed types, the following manifestations of a violation of the process of childbearing are noted:

pain in the lower abdomen, radiating to the sacrum;
uneven tension of the uterus;
arrhythmic contractions;
increased tone of the uterus;
nausea;
anxiety state;
fast fatiguability.

Now consider the symptoms of discoordinated labor activity, depending on its types.

Symptoms of general discoordination:

protracted course of childbirth;
irregular contractions;
the lack of a certain dynamics in the strength and duration of contractions;
painful sensations.

In this case, the amniotic fluid leaves earlier than expected, and the presenting part of the fetus is above the entrance to the small pelvis or even pressed against it. In this case, there is a threat of fetal hypoxia as a result of impaired placental blood circulation.

Symptoms of hypertonicity of the lower segment of the uterus:

high intensity of contractions;
painful sensations;
insufficient dilatation of the cervix (or no dilatation at all);
problems in moving through the birth canal of the fetal head.

If the contractions of the body of the uterus are weaker than the contractions of its lower segment, then the reason may lie in the underdevelopment or rigidity of the cervix.

Symptoms of uterine tetanus:

thickening of the uterus;
prolonged uterine contractions;
painful sensations;
deterioration of the fetus.

Usually similar condition provoke medical interventions such as turning the fetus, attempting to extract it by applying obstetric forceps, inadequate administration of stimulant drugs.

Symptoms of circulatory dystocia of the cervix:

protracted course of childbirth;
reduction of circular muscle fibers in all segments of the uterus, except for the cervix;
pain in the "constriction" area.

This condition is fraught with hypoxia or fetal asphyxia.

Diagnosis of discoordinated labor activity

Following the complaints of the woman in labor, the doctor conducts an obstetric examination, which, as a rule, shows the unavailability of the birth canal. It is characterized by swelling of the edges of the pharynx of the uterus and their thickening. On palpation of the body of the uterus, uneven tension in its different departments is fixed.

A more complete picture of the condition of a woman and her unborn child is given by cardiotocography. This is a method that combines the principles of doplerometry and phonocardiography. It will characterize in dynamics not only the contractile activity of the uterus, but also the work of the fetal heart, and in some cases its movement. During childbirth, cardiotocography allows you to monitor the development of hypoxia.

Complications of discoordinated labor activity

Discoordinated labor activity is a phenomenon that is dangerous for both the woman in labor and the fetus. The most serious outcomes are:

intrauterine hypoxia - oxygen starvation fetus, which can lead to his death;
amniotic fluid embolism - the ingress of amniotic fluid into the vessels (and later into the bloodstream), which can cause blood clotting disorders and the formation of blood clots;
hypotonic bleeding in the first few hours after delivery.

In addition, discoordinated uterine contractions interfere with the normal progression of the fetus. As a result, its articulation may be disturbed, extension of the head or rear view may occur. There is a risk of spinal extension, limb or umbilical cord prolapse.

A woman in labor may experience complications such as swelling of the vagina or cervix, caused by unproductive attempts. In such a situation, the fetal bladder is defective and does not fulfill its function of opening the cervix of the uterus. It has to be opened to avoid increasing pressure on the uterus, which, in turn, can cause premature placental abruption or even rupture of the organ.

Treatment of discoordinated labor activity

The main goal of treatment is to reduce the tone of the uterus. In addition, it is required to relieve pain and spasms. Methods of treatment are also differentiated depending on the type of discoordinated labor activity.

Treatment of general discoordination and hypertonicity involves obstetric anesthesia, the introduction of antispasmodics. Electroanalgesia is best for calming the uterus.

If the doctor is dealing with uterine tetany, then after the introduction of obstetric anesthesia, he uses α-agonists. β-agonists are used in case of circulatory dystocia. By the way, in the latter case, antispasmodics and lidase are absolutely ineffective. The introduction of estrogen here is also undesirable.

As for childbirth, it can end naturally, and may require surgical intervention. If a birth canal ready for retrieval, then are used obstetric forceps. Otherwise, a caesarean section is scheduled.

With any method of treatment, the obstetrician should carry out therapy that prevents fetal hypoxia. If the tragedy did occur, then a fruit-destroying operation is performed. After removing the dead fetus, the separation of the placenta is performed manually. The doctor must certainly examine the uterus in order to avoid ruptures.

Prevention of discoordinated labor activity

To prevent the threat of the development of discoordinated labor activity, first of all, the attentive attitude of the gynecologist who leads the pregnancy in a woman can. Particularly sensitive attitude is required by patients whose pregnancy is difficult. At the same time, expectant mothers should listen to the advice of a doctor so that the birth process goes without complications.

If the patient is at risk (for example, due to age or abnormalities in the development of the uterus), then drug prevention of discoordinated labor can be prescribed to her. However, in addition to drugs, methods of muscle relaxation, the development of control over the muscles, the ability to easily overcome and relieve excitability will also help. Therefore, do not neglect classes for expectant mothers.

sleep at least 9 hours;
often walk in the fresh air;
enough to move (but not overwork);
eat wholesome food.

During childbirth, the obstetrician's maximum care and adequate anesthesia are required.

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

1. Before giving birth through the natural birth canal in case of complex multicomponent dysregulation of the contractile activity of the uterus, including myogenic (the most ancient and strongest in human evolutionary development), it is necessary to make a prognosis of childbirth, providing for outcomes for the mother and fetus.

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.

Unfavorable factors include:

Late and young age of the primiparous;

Aggravated obstetric and gynecological history (infertility, induced pregnancy, birth of a sick child with hypoxic, ischemic, hemorrhagic damage to the central nervous system or spinal cord);

The presence of any serious illness, in which a protracted course of childbirth and physical activity is dangerous;

Severe preeclampsia, narrow pelvis, post-term pregnancy, uterine scar;

The development of discoordination of contractions at the very beginning of labor (latent phase);

Untimely discharge of amniotic fluid with an "immature" cervix with a small opening of the uterine os; critical anhydrous interval (10-12 hours);

The formation of a birth tumor with a high-standing head and a small (4-5 cm) opening of the uterine os;

Violation of the normal biomechanism of childbirth;

Chronic hypoxia of the fetus, its too small (less than 2500 g) or large (3800 g or more) sizes that do not correspond to the average gestational age; breech presentation, posterior view, decreased blood flow in the fetus.

2. With all the listed risk factors, it is advisable to choose the method of delivery by caesarean section without attempting corrective therapy.

A woman in labor may experience vital dangerous complications: uterine rupture, amniotic fluid embolism, premature detachment of the placenta, extensive ruptures of the birth canal, combined hypotonic and coagulopathic bleeding.

3. In the absence of risk factors or in the presence of contraindications to caesarean section, a multicomponent correction of labor activity is performed.

Rodostimulating therapy with oxytocin, prostaglandins and other drugs that increase the tone and contractile activity of the uterus, with discoordination of labor, is contraindicated.

I degree (dystopia of the uterus). The main components of the treatment of discoordination of labor activity at the I degree of severity are: antispasmodics, anesthetics, tocolytics (?-adrenergic agonists), epidural anesthesia.

Throughout the first and second stages of labor, it is necessary to administer (intravenously and / or intramuscularly) every 3 hours antispasmodic drugs (no-shpa, baralgin, diprofen, gangleron) and analgesic (promedol, morphine-like drugs) action. A 5-10% glucose solution with vitamins is also used (ascorbic acid, vitamin B6, E and A in a daily dosage).

The use of antispasmodics begins with the latent phase of childbirth and ends with the full opening of the uterine os.

Of the most effective methods to eliminate the basal hypertonicity of the uterus, the use of α-adrenergic agonists (partusisten, alupent, brikanil) should be highlighted. Therapeutic dose one of the listed drugs is dissolved in 300 ml or 500 ml of 5% glucose solution or isotonic solution sodium chloride and administered intravenously slowly initially at a rate of 5-8 drops / min, then every 15 minutes the frequency of drops is increased by 5-8, reaching a maximum frequency of 35-40 drops / min. After 20-30 minutes, the contractions almost completely stop. There comes a period of rest of uterine activity. Tocolysis is completed 30 minutes after the onset of normalization of uterine tone or termination of labor.

After 30-40 minutes, contractions resume on their own and are of a regular nature.

Indications for tocolysis of the uterus during childbirth are:

Hypertensive dysfunction of the contractile activity of the uterus and its variants;

Rapid and rapid childbirth;

Protracted pathological preliminary period.

With a short pathological preliminary period(no more than a day) you can apply a tocolytic inside once (brikanil 5 mg).

4. In case of discoordination of contractions, it is necessary to eliminate the defective fetal bladder. The fetal membranes must be separated (taking into account the conditions and contraindications for artificial amniotomy).

Amniotomy is performed immediately after intravenous administration of an antispasmodic (no-shpa 4 ml or baralgin 5 ml), so that a decrease in the volume of the uterus occurs against the background of the action of antispasmodics.

5. Due to the fact that anomalies of labor activity are accompanied by a decrease in uterine and uteroplacental blood flow and fetal hypoxia, agents that regulate blood flow are used in childbirth.

These funds include:

Vasodilators (eufillin);

Drugs that normalize microcirculation processes (rheopolyglucin, glucosone-vocaine mixture with agapurine or trental);

Means that improve the absorption of glucose and normalize tissue metabolism (actovegin, cocarboxylase);

Means for the protection of the fetus (seduxen 0.07 mg / kg body weight of the woman in labor).

All drug therapy should be regulated by the hour.

Childbirth is carried out under cardiomonitoring and hysterographic control. Antispasmodics are constantly dripped. The base solution for antispasmodics is a glucosone-vocaine mixture (10% glucose solution and 0.5% novocaine solution in equal proportions) or 5% glucose solution with trental (5 ml), which improve microcirculation and reduce pathological excessive uterine impulses.

In case of untimely discharge of amniotic fluid, antispasmodics should be administered intravenously. When the cervix is 4 cm dilated, epidural anesthesia is performed.

6. In the second stage of labor, a perineal incision is necessary to reduce the mechanical impact on the fetal head.

Drug prophylaxis of bleeding is carried out using a single-stage intravenous injection of 1 ml of methylergometrine or syntometrine (0.5 ml of methylerometrine and oxytocin in one syringe).

With the onset of bleeding in the early postpartum period 1 ml of prostin F2? is injected into the thickness of the uterus (above the uterine os). Intravenously fast drops pour 150 ml of 40% glucose solution (subcutaneously - 15 units of insulin), 10 ml of 10% calcium gluconate solution, 15 ml of 5% solution ascorbic acid, 2 ml of ATP and 200 mg of cocarboxylase.

Childbirth with discoordination of contractions should be conducted by an experienced obstetrician-gynecologist (senior physician) together with an anesthesiologist-resuscitator. At the birth of a child, a neonatologist must be present, able to provide the necessary resuscitation assistance.

Control over the course of labor is carried out with constant medical supervision, cardiomonitor recording of the fetal heartbeat and uterine contractions, using external or internal tocography. Registration of contractions is carried out by a stopwatch for 10 minutes of each hour of labor. It is advisable to keep a partogram.

II degree (segmental dystocia of the uterus). Considering adverse effect segmental dystocia on the fetus and the newborn, vaginal delivery is not appropriate.

A caesarean section should be performed in a timely manner.

The most effective is epidural anesthesia.

Epidural anesthesia blocks the Th8-S4 segments of the spinal cord, inhibits the action of oxytocin and PGG2?, has an antispasmodic and analgesic effect, which significantly reduces and sometimes even eliminates the spastic state of the uterus. Seduxen (relanium, fentanyl) acts on the limbic structures of the fetal brain, providing protection from pain and mechanical overload that occurs during hypertensive uterine dysfunction during childbirth.

It is advisable to inject 30 mg of fortral once, which provides an increase in the resistance of the fetus to pain. Fortral is similar in structure and protective effect to the endogenous opiate anti-stress system of the mother and fetus. Therefore, in severe cases of discoordination of labor activity, the use of morphine-like drugs (fortral, lexir, etc.) can protect the mother and fetus from birth shock. The drug is administered once to avoid addiction, do not use large doses and do not prescribe it close to the expected birth of the child, as it depresses the fetal respiratory center.

Particular attention is paid to the management of the second stage of labor. Until the birth of the fetus, continue intravenous administration antispasmodics (no-shpa or baralgin), as there may be a delay in the shoulders of the fetus in a spastically reduced uterine pharynx.

As with other forms of discoordination of labor activity, drug prevention of hypotonic bleeding with the help of methylergometrine is necessary.

With discoordination of the contractile activity of the uterus in the afterbirth and early postpartum period, there is a danger of a large number thromboplastic substances into the uterine and general circulation, which can cause an acutely developed DIC. Therefore, childbirth with hypertensive uterine dysfunction poses a risk of coagulopathic bleeding.

In the event that labor activity has weakened after tocolysis, myometrial tone has returned to normal, contractions are rare, short, cautious labor stimulation with PGE2 preparations (1 mg of prostenon per 500 ml of 5% glucose solution) is started. The rules of rhodostimulation are the same as in the treatment of hypotonic weakness of labor, but it should be carried out with extreme caution, controlling the frequency and duration of contractions with a stopwatch. However, such management of childbirth can be carried out only in cases where it is impossible to perform a caesarean section.

It should be emphasized once again that in case of discoordination of labor activity, it is impossible to use drugs that stimulate the contractile activity of the uterus (oxytocin, PGF2 preparations?). However, in those cases when hyperdynamic labor activity turns into hypodynamic, the uterine tone decreases to values characteristic of weak contractions, careful labor stimulation with PGE2 preparations against the background of epidural anesthesia or intravenous administration of tocolytics is possible.

III degree (spastic total dystocia of the uterus). The basic principle of labor management in total spastic uterine dystocia is to attempt to translate hyperdynamic labor activity into hypotonic weakness of contractions, to reduce the basal tone of the myometrium using tocolysis.

It is necessary to completely remove the general muscular and mental tension, restore autonomic balance, and eliminate constant pain.

A favorable outcome of childbirth can be achieved either by a timely caesarean section, or by adhering to a certain system to eliminate spastic (segmental or total) uterine contraction.

Given the violation of the leading regulatory role of the central nervous system in the development of this type of anomaly of labor, the woman in labor must first of all be given sleep-rest for 2-3 hours. If the fetal bladder is intact, it must be eliminated by amniotomy with the preliminary administration of antispasmodics. Delayed amniotomy exacerbates bad influence flat amniotic sac to discoordinated uterine contractions.

After rest, if labor activity has not returned to normal, acute tocolysis is performed (the technique is described earlier) or epidural anesthesia is performed. Before epidural anesthesia, intravenous administration of crystalloids is carried out in order to adequately prehydrate and prevent the risk of arterial hypotension. If the patient received drugs of tocolytic (?-adrenomimetic) action, adrenaline and its compounds should not be used.

After tocolysis (if labor activity has not resumed and has not returned to normal within 2-3 hours), PGE2 preparations are carefully administered for the purpose of labor stimulation.

Choice operational method delivery is explained by the great difficulties that arise when restoring the normal contractile activity of the uterus during discoordination of the birth activity III severity.

However, with a late arrival of a woman in labor or a belated diagnosis of this type of anomaly in labor, it can be difficult to decide on a caesarean section.

First, rapidly developing clinical symptoms autonomic dysfunction (fever, tachycardia, skin flushing, shortness of breath).

Secondly, there is a violation of the condition of the fetus (hypoxia, asphyxia). At caesarean section you can extract a dead or hopeless child.

Thirdly, there is often a long anhydrous period, the presence of an acute infection.

The degrees of discoordination of labor activity are varied. Even the true weakness of contractions and attempts can be combined with elements of impaired coordination of uterine contractions. The hyperdynamic nature of contractions becomes hypodynamic and vice versa.