Obstetrics and gynecology. Anomalies of labor (lecture notes)

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Obstetrics and gynecology. Anomalies of labor (lecture notes)

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Lecture number 14. Anomalies of labor activity

Pathological preliminary period, primary and secondary weakness of labor activity, excessively strong labor activity, discoordination of labor activity, tetanus of the uterus are the main types of anomalies of labor activity.

1. Pathological preliminary period

The pathological preliminary period is characterized by spastic, painful and erratic uterine contractions and the absence of structural changes in the cervix. The duration of the pathological preliminary period can be several days. Untimely discharge of amniotic fluid is the most common complication of the pathological preliminary period. The main causes of this complication are nervous stress, endocrine and metabolic disorders, inflammatory changes in the uterus, the age of the primipara older than 30 years and younger than 17 years.

The main thing in the treatment of the pathological preliminary period is: accelerated preparation of the cervix for the onset of labor and the elimination of painful erratic contractions. With fatigue and increased irritability, the patient is prescribed sedatives (motherwort tincture, valerian root), antispasmodics, painkillers, b-mimetics (ginipral, partusisten). In case of urgent preparation of the cervix for the onset of labor, medicinal substances based on prostaglandin E are introduced into the cervical canal or into the posterior fornix of the vagina.₂. The duration of treatment of the pathological preliminary period should not exceed 3-5 days. With a good readiness of the cervix (mature cervix), labor can proceed naturally. In this case, early opening of the fetal bladder is permissible. With the ineffectiveness of the therapeutic effect, operative delivery by caesarean section is performed.

2. Weak labor activity

Weak labor activity is manifested by a slowdown in the opening of the cervix, an increase in the intervals between contractions, a violation of their rhythm, insufficient strength and duration of uterine contractions, and a delay in the advancement of the fetus. There are primary and secondary weakness of labor activity. With primary weakness from the very beginning, labor activity is ineffective, sluggish, contractions are weak. Secondary weakness occurs during the normal course of childbirth. The weakness of labor delays labor, contributes to the development of fetal hypoxia, fatigue of the woman in labor, lengthening of the anhydrous gap, infection of the birth canal, the development of inflammatory complications, bleeding during childbirth and the postpartum period. The reasons for the weakness of labor activity are very diverse. These can be changes in the function of the nervous system as a result of stress, endocrine dysfunction, menstrual disorders, metabolic diseases. In some cases, the weakness of the birth forces cause pathological changes in the uterus: malformations, inflammatory changes, overstretching. Insufficiency of contractile activity during childbirth is also possible in the presence of a large fetus, with polyhydramnios, multiple pregnancies, uterine myoma, post-term pregnancy. The reasons for the secondary weakness of labor can be fatigue of the woman in labor as a result of prolonged and painful contractions, an obstacle to the fetus being born due to a mismatch in the size of the head and pelvis, an incorrect position of the fetus, and the presence of a tumor in the small pelvis.

Treatment of weak labor activity consists in rhodostimulation with an open fetal bladder. Rhodostimulation is carried out by intravenous drip of drugs that enhance the contractile activity of the uterus (oxytocin, prostaglandin F_2a).

A particularly good effect is observed with the combination of prostaglandin F_2a with oxytocin. If the woman in labor is tired and there is weakness and insufficiency of contractions at night, as well as with a slight opening or unavailability of the cervix for labor, the woman should rest for several hours with the help of obstetric anesthesia. In no case should you continue to stimulate labor, so as not to complicate their course. Then a vaginal examination is performed to determine the obstetric situation and assess the condition of the fetus. After rest, labor activity may return to normal, and treatment is not required. In cases of insufficiency of labor activity after obstetric anesthesia, uterine stimulants are prescribed. Stimulation of labor activity has a number of contraindications. These include a discrepancy between the size of the pelvis of the mother and the size of the fetus, existing scars on the uterus of various origins (after gynecological operations to remove myomatous nodes or after previous births performed surgically using a caesarean section), the presence of symptoms of a threatening uterine rupture, a history of recent septic diseases severe genital organs. If, when using drugs that stimulate uterine contractions, the cervix does not open within 2 hours or the condition of the fetus worsens, then the administration of these drugs should be discontinued due to lack of effect. In such a situation, the issue should be resolved in favor of operative delivery. The choice of method of delivery is determined by the specific situation. With the weakness of labor activity in the first stage of labor, it is best to perform a caesarean section. During the period of exile, it is possible to use exit forceps or perform vacuum extraction.

3. Violent labor activity

Strong and frequent contractions and attempts (after 1-2 minutes), which lead to rapid (1-3 hours) and rapid (up to 5 hours) childbirth, are characterized as excessively strong, violent labor activity. The expulsion of the fetus sometimes occurs in 1-2 attempts. Violent labor activity is dangerous for the mother and fetus, causing deep ruptures of the cervix, vagina, clitoris, and perineum in parturient women. Also, with violent labor activity, premature detachment of a normally located placenta or the development of bleeding is possible. The rapid and rapid course of labor, too frequent and intense contractions are often the cause of fetal hypoxia and birth trauma. To reduce violent labor activity, the woman in labor is given a position on her side, opposite to the position of the fetus, which she maintains until the end of childbirth. The mother is not allowed to get up. To normalize the process of childbirth and reduce too violent labor activity, magnesium sulfate is used intravenously and tocolytics (partusisten, ginipral). It is necessary to reduce the number of contractions to 3-5 within 10 minutes.

4. Tetanus of the uterus

Uterine tetany is rare. It is characterized by constant tonic tension of the uterus, which does not relax at all. The reason is the simultaneous occurrence of several pacemakers in different parts of the uterus. At the same time, the contractions of various parts of the uterus do not coincide with each other. The total effect of the action from the contraction of the uterus is absent, which leads to a slowdown and arrest of labor. In view of a significant violation of the uteroplacental circulation, fetal hypoxia occurs and increases. This can be determined by the violation of his heartbeat. The dilatation of the cervix is reduced compared to the results of the previous vaginal examination. A woman in labor may experience chorioamniotitis, accompanied by elevated body temperature. This condition can worsen the prognosis for mother and child. Uterine tetany can be one of the symptoms of such formidable complications as threatening or incipient uterine rupture, premature detachment of a normally located placenta. The causes of this pathological condition can be significant obstacles to the passage of the fetus, a narrow pelvis, neoplasms, and inadequate use of labor-stimulating drugs.

In the treatment of uterine tetany, anesthesia is used, after which labor activity is restored, and childbirth ends naturally. With tetany of the uterus, a caesarean section is performed in case of symptoms of uterine rupture, premature detachment of a normally located placenta, mechanical obstruction to the passage of the fetus. When the cervix is fully dilated, obstetric forceps are used to extract the fetus or the fetus is removed by the leg in breech presentation.

5. Discoordination of labor activity

Discoordination of labor activity consists in chaotic contractions of various parts of the uterus due to the displacement of the pacemaker zone. Several such zones may occur simultaneously. The left and right halves of the uterus can contract in an uncoordinated way, but this mainly happens with its lower section. The nature of the contractions changes: they become more frequent (6-7 in 10 minutes), become irregular, prolonged. In the moment between contractions, the uterus cannot relax completely. The behavior of the mother in labor is restless. There is difficulty urinating. The opening of the uterine os, despite frequent, strong and painful contractions, occurs very slowly or does not occur at all, as a result of which the fetus almost does not move along the birth canal. Due to violations of the contractile activity of the uterus and its incomplete relaxation, the occurrence of complications is often observed: significant hypoxia of the fetus and its intracranial injury. Violation of the contractile activity of the uterus can lead to untimely discharge of amniotic fluid. The cervix thickens, the edges of the uterine os do not stretch, remain thick and tight.

Therapy of discoordination of labor activity is aimed at eliminating excessive uterine tone. Use sedatives, antispasmodics, painkillers and tocolytic drugs. The most optimal method of pain relief is epidural anesthesia. Childbirth is carried out with constant monitoring of the fetal heart rate and uterine contractions. With ineffective treatment, as well as with the addition of other complications, it is advisable to perform a caesarean section without attempting corrective therapy.

Author: Ilyin A.A.

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