How does the pathological preliminary period end? Preliminary period: what is it?

Mikhnina A.A.

When is it time to go to the maternity hospital? This question is asked by every primiparous and often multiparous woman.

There are classic obstetric recommendations on this matter, which talk about emergency situations when you need to rush to the maternity hospital immediately:
- opened uterine bleeding,
— sharp deterioration well-being of a pregnant woman against the background of late toxicosis,
- injuries to the mother that could harm the fetus.
You should also not delay leaving for the maternity hospital if the amniotic fluid has broken before the start of regular contractions, but you still have a couple of hours left.

In other cases, normal onset labor activity It is recommended to come to the RD with regular contractions every 5 minutes.

There is usually no point in arriving ahead of time, since the opening of the cervix will still be small, in fact, the birth of the baby is still far away, and in many maternity hospitals, due to their heavy workload in the emergency room, women are sent to “take a walk” (in other words, they are sent home) to a more significant state dilatation of the cervix, because obstetric care They are usually not required in the first stage of labor.

After reading the recommendations of special psychologists, methodologists on techniques natural birth, Western practitioners of obstetrics (in particular, the popular W. and M. Sears), one can come to the conclusion that there is no need to rush to the maternity hospital until the end of the first phase of labor. A favorable and calm environment at home or a walk for a woman in labor fresh air helps the natural course and development birth process much better than hospital stress. Freedom in taking poses and changing the environment (bath, walk, bed, soft chair, fitball, dance, etc.) helps the uterus open. In a hospital, the freedom of behavior of a woman in labor and the position of her body in space is usually quite limited. Taking into account the growing negativity and distrust of women towards the staff of Russian maternity hospitals today, the desire of many to minimize interventions in the birth process and the desire to be surrounded by loved ones longer, feeling their support, there is a great temptation to come to the maternity hospital at the very beginning of labor, just to climb onto the chair and give birth. .This is where I would like to warn women against possible negative consequences similar actions.

As a preface, I will give a description of the stages of the birth process:

First stage of labor- the longest. It consists of several successive stages (phases).

● I Latent phase: begins with the establishment of a regular rhythm of contractions and ends with effacement of the cervix and dilation of the uterine pharynx by 3–4 cm. The duration of the phase is about 5–6 hours. The phase is called “latent”, because contractions during this period are painless or slightly painful, with physiological childbirth there is no need for drug therapy, the dilatation speed is 0.35 cm/h.

● II Active phase: begins after the uterine os is dilated by 4 cm. Intense labor and fairly rapid further dilation are characteristic. Average duration phase is 3–4 hours. The rate of dilatation in primiparous women is 1.5–2 cm/hour, in multiparous women it is 2–2.5 cm/hour.

● III Deceleration phase: lasts from cervical dilatation of 8 cm to full dilatation. For primigravidas, the duration ranges from 40 minutes to 2 hours. In multiparous women, the phase may be absent. The clinical manifestation of this phase is not always pronounced, but its identification is necessary to avoid the unreasonable prescription of labor inducers if, during the period of cervical dilatation from 8 to 10 cm, there is an impression that labor has weakened. The change in the course of labor is due to the fact that at this time the head reaches the plane of the narrow part of the small pelvis, the fetus should pass it slowly and calmly.

Second stage of labor- expulsion of the fetus.

Starts with full opening uterine pharynx and includes not only the mechanical expulsion of the fetus, but also its preparation for independent life outside the mother’s womb. There is a change in the shape of the fetal head - the bones of the fetal skull are configured to pass through the birth canal.
Duration of this period for primiparous women it is 30–60 minutes, for multiparous women it is 15–20 minutes.

Typically, 5–10 pushes are enough to deliver a baby. With longer attempts there is a decrease uteroplacental blood circulation, which may affect cervical region fetal spine.

The total duration of the first and second stages of labor is on average 10–12 hours for primiparous women, 6–8 hours for multiparous women. Differences in the duration of labor in primiparous and multiparous women are noted mainly in the latent phase of the first stage of labor, while in the active phase there are no significant differences.

Third stage of labor- birth of the placenta.

After the birth of the fetus, a sharp decrease in the volume of the uterus occurs. 5–7 minutes after the birth of the fetus, the placenta is expelled during 2–3 contractions. Before this, the fundus of the uterus is located at the level of the navel. The uterus is at rest for several minutes, and contractions that occur are painless. There is little or no bleeding from the uterus. After complete separation of the placenta from the placental platform, the fundus of the uterus rises above the navel and deviates to the right. The contours of the uterus take shape hourglass, since in its lower section there is a separated child’s place. When an attempt appears, the birth of the placenta occurs. After the birth of the placenta, the uterus acquires density, becomes rounded, is located symmetrically, its bottom is located between the navel and the womb.

In the case of not the first birth, the situation sometimes develops according to a very unexpected scenario, and an increase in contractions to a frequency of 2-3 minutes can occur within an hour or two from their onset. Here, too, you should not trust the advice to postpone leaving for the maternity hospital until the moment of full dilation, because... You may simply not have time and feel the pressure while being several kilometers from the maternity facility. Unless, of course, you are a fan of extreme situations.

So, there is a problem of the pathological course of the preliminary (latent) phase of the first stage of labor. And it is not that rare.
During the latent phase, the woman in labor should experience minimal discomfort throughout the transition from the preparatory phase of labor to the active one. Pain sensations are within normal limits menstrual pain, contractions, although regular, are rare and less painful, more like stretching in the lower abdomen and lumbar region. A woman can remain in this state for quite a long time, lead a normal lifestyle, fully rest, and sleep.

With the pathological course of the latent phase, contractions increase without leading to the necessary dilatation of the cervix. As a result, after several hours of severe pain, by the end of the latent phase, the dilation may not exceed a couple of centimeters. The further course of labor may proceed according to the most different scenarios from the use of cervical softening and labor-stimulating drugs to Caesarean section. Most often, overwork of a woman in labor due to a painful, pathological latent phase leads to incoordination of labor, ruptures in the mother, loss of strength, suspension of labor, fetal hypoxia, poor pushing and, as a result, traumatic measures to remove the child from the birth canal.

In general, advice on when it is still reasonable to appear in the emergency room maternity hospital if not dangerous symptoms described at the beginning of the article, and the amniotic fluid has not begun to recede, is as follows: go to the maternity hospital as soon as you have regular contractions!

Even if they come at intervals of 30 minutes.
Doctors will look at the dynamics of the birth process on site and, if necessary, carry out medical manipulations to avoid unnecessary excesses and complications during childbirth.

And some examples from life (my personal experience):

I gave birth to my first child for 16 hours, having thoroughly “enjoyed” the strong contractions in the preliminary period. Having started at 23:00 with an interval of 15 minutes, the contractions “intensified” by about one in the morning so that I could not get out of the bath, sitting under the shower and breathing them out like a steam locomotive. Otherwise it was very painful, patience quickly ran out. The bath was a great distraction. Only at 6 am the frequency of contractions became once every 8 minutes, and I went to the maternity hospital. There they set the dilation to 3 cm! In total, 7 hours of torment!!! At the same time, I was already pretty exhausted from a sleepless night and severe pain. They gave me a No-Shpa injection and sent me to the hospital. By 8 am, the contractions became discoordinated, then after 5 minutes, then after 8. A new maternity team took over, at 9 am they gave me oxytocin and performed an amniotomy, an hour later - full dilatation. But the fruit is high, it needs to be lowered. And another 3 hours of painful contractions under oxytocin, the child entered birth canal. No pressure was felt. And I no longer have the strength to fight them. The last period of the second phase of labor passed in a blur under the commands of the midwife “push!”, “don’t push”!. I didn’t push well, they used the Kristeller method (pressure on top part mother's abdomen). The baby was born with hypoxia and a minor neck injury. Hypertonicity, increased excitability, poor sleep, poor digestion. For a year then we worked with him on rehabilitation activities: massage, osteopath, swimming pool. It could have been much worse! According to the doctor who presided over this birth, I had that same pathological preliminary period. And I shouldn’t have delayed the visit to the maternity hospital until the morning.

Second birth after 3 years. I was expecting a similar scenario, only shorter duration in time. 8-10 o'clock. As a result, contractions began at 6 am with an interval of 10 minutes, and at 10 am the same day I was already holding my second son to my chest! I arrived at the maternity hospital already fully dilated, but the fetus was standing high, and if the amniotomy had not been performed in a timely manner and the right position had not been selected to effectively lower the child, it is unknown how my birth would have proceeded. The contractions were very strong and intense, but the pushing might not have started on its own with the baby being high up; I might have been exhausted again, and labor would have become uncoordinated. It probably could have ended with an emergency Caesarean section, since there was a suspicion of a large fetus (4 kg) given my narrow pelvis. Fortunately, I fell into the hands of obstetricians just in time! And she gave birth, as they say, “like she sang a song”: quickly, without auxiliary medications and procedures (only superficial episiotomy), the baby was 9/10 on the Apgar scale. In the case of this birth, there was no point in delaying the visit to the maternity hospital, since I might simply not have time to get there :)

These are the different births of one woman.

I wish everyone an easy birth and healthy babies!

– a prolonged prenatal preparatory period, occurring with irregular painful contractions that do not lead to structural changes in the cervix. The pathological preliminary period is characterized by long-term (over 6-8 hours) ongoing ineffective cramping pain, which disrupts the woman’s daily wakefulness and sleep patterns, causes fatigue of the woman in labor and increases the risk of fetal hypoxia. Diagnosis of the preliminary period of labor includes vaginal examination, cardiotocography. In order to relieve the abnormal preliminary period of labor, anesthesia is used, medicated sleep, administration of beta-agonists; sometimes - carrying out caesarean section.

General information

Clinical manifestations of the physiological (uncomplicated) preliminary period of labor, which lasts on average 5-8 hours, are weakly expressed; periodic nagging and cramping pain in the lower abdomen and sacrum do not change the woman’s general well-being. Normal preliminary contractions (false contractions, precursor contractions) can stop and resume after a day, but more often they gradually intensify, become more frequent and turn into regular labor. At the end of the physiological preliminary period, maturation (shortening and softening) of the cervix is ​​observed, and the cervical canal opens by 2-3 cm.

Reasons for the development of the pathological preliminary period of labor

Disturbances in the preliminary period of childbirth are more often observed in cases of pathology of the maternal body: in pregnant women with a labile nervous system, neuroses, and NCD; metabolic and endocrine disorders(obesity, underweight, menstrual dysfunction, sexual infantilism, etc.); concomitant somatic pathology (heart defects, arrhythmia, arterial hypertension, diseases of the kidneys, liver, adrenal glands); inflammatory changes in the uterus (endometritis, cervicitis); gestosis, degenerative processes after abortions.

In addition, the prolongation of the preliminary period can be facilitated by a woman’s negative attitude towards the birth of a child, fear of childbirth, and the age of first-time mothers under 17 or over 30 years old. Obstetric causes of a complicated preliminary period of labor include multiple, low- or high-water pregnancy, large fetus, placenta previa, abnormal fetal position, anatomically narrow pelvis, etc.

Symptoms of the pathological preliminary period of labor

The pathologically occurring preliminary period of labor is characterized by a sharp spastic contraction of the myometrium, leading to the appearance of painful contractions, their protracted course, which does not turn into regular labor. Despite the duration and severity of contractions, the cervix remains firm and long, and the cervical canal does not open. The excitability and tone of the uterus are sharply increased; uterine contractions monotonous, without a tendency to become more frequent and intensified.

The condition of the pregnant woman is disturbed; the woman gets tired, cannot sleep and rest due to constant pain And emotional stress, becomes irritable and unbalanced. A pregnant woman may experience sweating, pain in the sacrum and lower back, shortness of breath, tachycardia, and intestinal dysfunction.

The pathological preliminary period of labor is often complicated by antenatal passage amniotic fluid, anomalies of labor, the appearance and increase of signs of intrauterine fetal hypoxia. In some cases, after the rupture of amniotic fluid, regular contractions appear and labor returns to normal on its own.

Diagnosis of the pathological preliminary period of labor

An external obstetric examination reveals a high location of the presenting part of the fetus, which is located high above the entrance to the pelvis; The tone of the uterus is increased, especially in its lower segment. Carrying out a vaginal examination in pathologies of the preliminary period of labor can be difficult due to the strong tension of the perineal muscles. An internal gynecological examination reveals the presence of spasm of the vaginal muscles and immaturity of the cervix.

During cardiotocography, contractions of varying duration and strength, unequal time intervals between them, and the predominance of the tone of the lower segment of the uterus over the tone of the fundus and body are recorded. A cytological examination of a vaginal smear indicates insufficient estrogen saturation of the body.

Tactics for pathological preliminary period of labor

Tactics when pathological course The preliminary period of labor is determined by its duration, the condition of the pregnant woman, the severity of the clinic, the condition of the fetus and the birth canal. In all situations accompanying the pathological preliminary period of labor, the use of estrogens, analgesics, sedatives, and antispasmodics is indicated.

If the preliminary period of labor lasts less than 6 hours, is accompanied by cervical maturity and the fetal head standing at the entrance to the pelvis, treatment begins with electroanalgesia or acupuncture. If the amniotic sac is intact and the birth canal is mature, amniotomy is performed. If the preliminary period of labor lasts up to 6 hours, but the cervix is ​​immature, sedation (administration of diazepam) and medicinal preparation of the cervix (prescription of prostaglandins E2, estradiol dipropionate, estrone, etc.) are indicated.

During the protracted preliminary period of labor (10-12 hours or more), accompanied by fatigue of the woman in labor, medicated sleep is used. After awakening, 85% of women enter the active labor phase with normal contractile activity of the uterus. In the remaining 15%, due to the absence or mildness of contractions, careful administration of uterotonics (oxytocin, prostaglandin) is indicated. In addition to all of the above, β-adrenergic agonists (hexoprenaline, terbutaline, fenoterol, etc.) are used to relieve the pathological preliminary period of labor.

If it is impossible to achieve active and regular labor, as well as with a burdened obstetric history, a large fetus, breech presentation, extragenital diseases, signs of fetal hypoxia, it is advisable to perform delivery by cesarean section. Maximum term treatment of the pathological preliminary period of labor should not exceed 3-5 days.

Prevention of the development of pathological preliminary period of labor

To exclude an abnormal course of the preliminary period of labor, competent preparation and management of pregnancy, compliance by the woman with the prescribed regimen, and psychoprophylactic preparation for childbirth are necessary.

Particular attention of the obstetrician-gynecologist should be directed to the contingent of pregnant women who constitute a risk group for the development of a pathological preliminary period of labor - primiparas of young and older age, women with a burdened obstetric-gynecological history, chronic inflammation genitals; neuroendocrine, somatic and neuropsychiatric disorders; anatomical inferiority of the uterus; fetoplacental insufficiency; polyhydramnios, multiple births or large fetuses.

Table of contents of the topic "Management of the third stage of labor. Caring for the newborn at birth. Anomalies of labor. Pathological preliminary period.":
1. Third stage of labor. Management of the third stage of labor. Oxytonic drugs in the third stage of labor.
2. Traction by the umbilical cord. Stimulation of the mother's nipples. Active management of the third stage of labor. Bleeding in the afterbirth period.
3. Integrity of the placenta. Checking the placenta. Umbilical cord clamping. Umbilical cord ligation. When to clamp the umbilical cord?
4. Caring for the newborn at birth. Fetal screening assessment at birth.
5. Anomalies of labor. Disorders of labor. Classification of labor disorders.
6. Classification of abnormalities of uterine contractility.

8. Normal preliminary period. Prolonged latent phase. Duration of the pathological preliminary period. Etiology of the clinic of the preliminary period.
9. Differential diagnosis of the pathological preliminary period. Tactics for the pathological preliminary period.
10. Treatment of the pathological preliminary period. Medical rest. Medication sleep.

Physiological course of childbirth possible only if there is formed generic dominant, i.e. when the body is biologically ready for childbirth. The formation of the generic dominant is completed during the last 2-3 weeks. pregnancy, which gives grounds to distinguish the so-called preparatory period (harbingers of childbirth). The preparatory period, in turn, passes into the preliminary period, and the preliminary period into childbirth.

Harbingers of childbirth characterized by many features. Thus, before the onset of labor, the presenting part of the fetus and the fundus of the uterus descend, which is due to the formation of the lower segment of the uterus.

Precursors of childbirth include also: a decrease in the pregnant woman’s body weight (by 400-1000 g), increased urination, an increase in transudate in the vagina and the appearance of mucous discharge, moderate pain in the lower abdomen, lower back and sacroiliac joints. An important harbinger of labor is painless, irregular in frequency, duration and intensity of uterine contractions, described by Braxton-Gix. During the first pregnancy, Braxton-Hicks contractions are usually painless until labor begins, but with each subsequent pregnancy, the contractions become increasingly painful long before labor begins. Contractions of the uterus during pregnancy improve its blood circulation and, along with the processes of hypertrophy and hyperplasia of the myometrium, contribute to the formation of the lower segment of the uterus (fetal receptacle), shortening and softening of the cervix, and its “maturation”.

According to M.P. Nageotte et al (1988), the frequency of uterine contractions increases with increasing gestational age from 0.65 in 10 minutes at 30 weeks. up to 1.0 in 10 minutes - at 40 weeks.

Multichannel hysterography revealed that pacemaker at Braxton-Hicks contractions is in various departments uterus and the wave of contraction spreads over various distances. These contractions are sometimes mistaken for the onset of labor (" false birth").

When f physiological course of pregnancy preliminary period not clinically manifested. Contractions of the uterine muscles in the preliminary period are not accompanied by pain and do not cause prenatal discomfort. Often a pregnant woman wakes up at night due to the sudden spontaneous onset of labor. Moderate painful sensations in this contingent of pregnant women, making up about 70%, appear with the development of regular labor. Their birth proceeds without pathological abnormalities, their duration fits into the optimal period, contractions are mildly painful, and the outcome of childbirth is favorable.

Discussions about the role and significance of the preliminary period have been ongoing in the literature for a long time. Much attention to this problem is due to its serious importance for the prevention of labor anomalies.

Every obstetrician is well aware of cases of pregnant women presenting for childbirth with cramping pain in the lower abdomen and lower back, but without structural changes in the cervix characteristic of the first stage of labor. IN foreign literature this condition is often described as “false labor.” According to the founder of the Kazan school of obstetricians and gynecologists, V. S. Gruzdev (1922), during this period, uterine contractions are often less painful, while in some women, on the contrary, with weak contractions, excessive pain is observed, depending on hypersensitivity uterine muscle (“uterine rheumatism” in the figurative expression of old obstetricians), to which researchers of the older generation gave great value in the pathology of the birth act. E. T. Mikhailenko (1975) indicates that the period of cervical dilatation is preceded by a period of precursors and a preliminary period. According to G. G. Khechinashvili (1973), Yu. V. Raskuratov (1975), its duration ranges from 6 to 8 hours.

Various hypotheses have been put forward about the reasons for the emergence of the preliminary period. One of the most convincing interpretations seems to us from the point of view of the lack of biological readiness for childbirth. Thus, G. G. Khechinashvili, assessing the condition of the cervix in pregnant women in the preliminary period, indicates the presence of a mature cervix in 44% of cases; in 56% the cervix was poorly or insufficiently prepared. According to Yu.V. Raskuratov, who, in addition to palpation assessment of the cervix, performed a functional cervical-uterine test, 68.6% of pregnant women with a clinically pronounced preparatory period had a mature cervix.

Currently, a special apparatus has been developed to determine the degree of maturity of the cervix. Some obstetricians consider cases of a clinically pronounced preparatory period as a manifestation of primary weakness of labor and, based on this assessment, suggest using labor-stimulating therapy as early as possible.

V. A. Strukov (1959) considers it permissible to use even preventive labor stimulation, and to diagnose labor weakness within 12 hours from the moment of contractions. However, it should be emphasized that labor stimulation does not in all cases lead to positive effect. Thus, according to P. A. Beloshapko and S. A. Arzykulov (1961), methods of birth stimulation are effective in no more than 75% of cases.

To date, no unified tactics for managing pregnant women with the preliminary period have been developed. Some researchers argue that in the presence of a preliminary period, the use of tranquilizers, antispasmodics, and estrogens is indicated. A. B. Gillerson (1966) believes that untimely administration of labor inducing drugs does not give the desired effect, and often has an adverse effect on the subsequent course of labor, leading to incoordination and weakness of labor. Some other researchers share the same opinion.

It is important to note that, according to G. M. Lisovskaya et al. (1966), the frequency of anomalies of labor forces during childbirth that began with preliminary contractions was 10.6 times higher than this figure in the group of labor that began without precursors, and according to G. G. Khechinashvili (1974), in women with physiological developing pregnancy primary weakness of labor was observed in 3%, and in those studied who underwent a clinically pronounced preparatory period - in 58% of cases.

Another very important aspect The problem is that the pathological preliminary period increases the number of adverse outcomes in children. Thus, according to Yu.V. Raskuratov (1975), in this group of women in 13.4% of cases the fetus experiences hypoxia, which is the result of neuroendocrine disorders at the end of pregnancy and pathological contractile activity of the uterus.

We examined 435 pregnant women with a preliminary period. There were 316 primiparas, 119 multiparas. 23.2% of the examined women had disorders menstrual cycle, which probably indicates that every 5th woman during the preliminary period has hormonal disorders.

In the group of first-time mothers total percentage complications and somatic diseases was 46.7%, in the multiparous group - 54.3%.

We consider it appropriate to divide the preliminary period into two types: normal and pathological.

Clinical signs of the normal (uncomplicated) course of the preliminary period are rare, weak cramping pain in the lower abdomen and lower back, not exceeding 6-8 hours and occurring against the background of normal uterine tone. In 11% of the women examined, contractions weakened and completely stopped, followed by their recurrence a day or more later. In 89%, preliminary contractions intensified and progressed to labor.

Anomalies of labor are often preceded by a change in the nature of the prenatal preparatory period. In Anglo-American literature pathological preliminary period called “false labour”.

Pathogenesis (what happens?) During the Pathological preliminary period:

The frequency of this pathology ranges from 10 to 17%, coinciding with the frequency of abnormal labor. If normal prenatal contractions of the uterus are clinically invisible, painless, often occur at night and lead to shortening, softening of the cervix and opening of the cervical canal by 2-3 cm, then the pathological preparatory (preliminary) period is characterized by spastic contraction of the circular muscle fibers in the isthmus and reflects prenatal hypertensive uterine dysfunction.

Symptoms of the Pathological preliminary period:

Pathological preliminary period characterized by the following clinical signs.

• Preparatory prenatal contractions of the uterus are painful, occur not only at night, but also during the day, are irregular and for a long time do not pass into labor. The duration of the pathological preliminary period can range from 24 to 240 hours, depriving a woman of sleep and rest.
• There are no structural changes in the cervix (“ripening”). The cervix remains long, eccentrically located, dense, the external and internal os are closed. Sometimes the internal pharynx is defined as a dense ridge.
• There is no proper deployment of the lower segment, which (with a “mature” cervix) should also involve the supravaginal portion of the cervix. The excitability and tone of the uterus are increased.
• The presenting part of the fetus is not pressed against the pelvic inlet (in the absence of any disproportion between the size of the fetus and the woman’s pelvis).
• Due to the hypertonicity of the uterus, palpation of the presenting part and small parts of the fetus is difficult.
• Contractions of the uterus for a long time are monotonous: their frequency does not increase, their strength does not increase. A woman’s behavior (active or passive) does not have any influence on them (it does not strengthen or weaken).
• The psycho-emotional state of the pregnant woman is disturbed: she is unbalanced, irritable, tearful, afraid of childbirth, and unsure of its successful outcome.

The essence of the pathological preliminary period lies in increased tone myometrium, spastic contraction of the internal uterine os and lower uterine segment, where muscle fibers have circular, transverse and spiral directions.

The presence of a pathological preliminary period indicates a pathology of uterine contraction preceding childbirth, insufficient, asynchronous readiness of mother and fetus to initiate labor.

The pathological preliminary period passes into either discoordination of labor or primary weakness of contractions; often accompanied by pronounced autonomic disorders(sweating, sleep disturbance, vegetative-vascular dystonia). A pregnant woman complains of pain in the sacrum and lower back, poor sleep, palpitations, shortness of breath, impaired intestinal function, increased and painful fetal movements.

In the absence of treatment for the pathological preliminary period, signs of hypoxia and a decrease in the biophysical profile of the fetus often appear.

Diagnosis of the Pathological preliminary period:

Clinical and laboratory tests made it possible to identify a violation of autonomic balance in these patients: an increase in the level of adrenaline and norepinephrine in the blood, a decrease in acetylcholinesterase activity of erythrocytes. There is also an increase in the content of prekallikrein, a decrease in the ATPase activity of myosin, antioxidant protection, intensity metabolic processes in the uterus ( low level activity of glucose-6-phosphate dehydrogenase - G-6-FDG, decrease in the content of protein and non-protein SH groups), the predominance of the glycolytic pathway of glucose metabolism.

An increase in the level of norepinephrine (in the absence of changes in adrenaline content and a decrease in acetylcholinesterase activity of erythrocytes) in pregnant women with a pathological preliminary period indicates intensive synthesis and release of norepinephrine from presynaptic membranes, i.e. simultaneous hyperactivity of the adrenergic and cholinergic systems. When comparing the amount of adrenaline, norepinephrine and acetylcholinesterase activity of erythrocytes with the results of determining the contractile activity of the uterus during the pathological preliminary period, it was revealed sharp increase excitability and tone of the uterus.

Analysis of the results of determining the activity of the kinin system showed that in women with an “immature” cervix and a pathological preparatory period, high content in the blood plasma of prekallikrein, which under certain conditions easily turns into kallikrein.

The contractile activity of the uterus depends on the level of substances involved in metabolic processes in the myometrium and the activity of redox processes, which are indirectly judged by the concentration of sulfhydryl (SH) groups, the activity of transketalase and enzymes of the pentose phosphate pathway of glucose oxidation.

We have obtained data on an increase in the content of protein and non-protein SH groups in healthy women at the end of pregnancy compared to patients who had a pathological preliminary period of at least 2-3 days. This can be regarded as a compensatory increase in the power of the antioxidant system in the redox reactions of the body in response to prolonged non-productive contractions of the uterus. A decrease in the number of non-protein SH groups during the pathological preliminary period confirms the tension of the mediator system of myometrial contractile proteins, which determine the force of contraction.

A study of enzymes characterizing the pentose phosphate pathway of glucose oxidation revealed a significantly lower (more than 1/3) level of G-6-FDG activity in the blood of women with a pathological preliminary period compared to healthy pregnant women, which indicates a decrease in the intensity of metabolic processes and biosynthesis of estrogen, as well as insufficient endocrine stimulation of the uterus with a predominance of the glycolytic pathway of glucose metabolism. It has been established that G-6-FDG and transketalase are a regulatory link in the synthesis of estrogens and provide pathways for the metabolism of carbohydrates necessary for the synthesis of ribonucleic acid molecules.

The results of studying indicators characterizing the functional activity of the adrenergic and cholinergic systems during full-term pregnancy and a protracted pathological preliminary period (from 1-3 days) confirm the predominance of parasympathetic tone nervous system. These women were found to have increased activity cholinergic nervous system, higher levels of serotonin, histamine and prekallikrein in the blood, which is accompanied by increased excitability and hypertonicity of the uterus. A decrease in the number of SH groups, a decrease in the content of transketalase and the activity of pentose phosphate oxidation enzymes indicate a low level of reserve capacity for contractile activity of the uterus.

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

Treatment of the Pathological preliminary period:

If the cervix remains “immature,” labor, as a rule, does not develop independently. Either a true post-term pregnancy begins, or the onset of labor takes on a pathological character.

Prenatal discharge of amniotic fluid in combination with a pathological preliminary period, an “immature” cervix indicates disturbances in the neuroendocrine and myogenic regulation of contractile activity of the uterus.

Violation of the integrity of the amniotic sac may be a consequence inflammatory changes membranes with chorioamnionitis, endocervicitis, isthmic-cervical insufficiency, colpitis.

But the main reason for this complication (as our studies have shown) is an uneven, abrupt increase and decrease in intra-amniotic pressure in the uterine cycle (contraction-relaxation) against the background of increased (up to 13-15 mm Hg) basal tone.

The pathological preliminary period must be included in the diagnosis as a nosological form of prenatal pathology of uterine contractile activity that requires treatment.

With timely and adequate treatment, it is possible to accelerate the “ripening” of the cervix, relieve uncoordinated painful contractions of the uterus, and achieve spontaneous development of labor. Therapy is selected depending on the pathogenesis of this pathology.

Apply: electroanalgesia, electrorelaxation of the uterus, drug therapy(antispasmodics, tocolytics, analgesics, prostaglandin E2 preparations).

When tired and increased irritability the patient is prescribed medicated sleep-rest, sedatives(seduxen, droperidol). Tranquilizers during pregnancy are contraindicated due to the risk of impact on the limbic system of the fetal brain, where the centers are formed emotional sphere person.

Depending on the degree of “immaturity” of the cervix, the following is administered:

• antispasmodics of your choice (no-spa 4 ml, baralgin 5 ml) intravenously or intramuscularly 2 times a day;
• analgesics (promedol 20-40 mg, tramal 15-20 mg) at night;
• To urgently prepare the cervix for childbirth, prostaglandin E2 preparations (Prostin E2, Prepedil in the form of a gel) are used, which are injected into the cervical canal or posterior vaginal fornix.

Drugs with a strong oxytocic effect (oxytocin, prostin F2a) cannot be used during the pathological preliminary period due to the risk of increasing spastic contraction of the obturator, circulatory muscles of the internal os of the uterus. The spastic process involves the spiral-shaped fibers of the uterine body, pipe angles, vagina. The severity of the violations gradually increases.

Before appointment medications To correct the preliminary period, it is necessary to have a clear understanding of the risk factors that allow you to draw up a concept for managing labor, assess age, parity of pregnancy and childbirth, anamnesis, the state of health of the woman and her fetus, and the proportional relationship between the sizes of the pelvis and head.

If all data from an objective examination and laboratory parameters allow the upcoming birth to be carried out through the natural birth canal, therapeutic measures repeat at least 2-3 times with an interval of 6 hours. Then re-evaluate the obstetric situation, turning special attention to change the condition of the cervix (“mature”, “not mature enough”, “ complete absence maturation").

The maximum duration of treatment should not exceed 3-5 days.

It is necessary to distinguish between two main options for the obstetric situation in the pathological preliminary period: a combination with a “mature” cervix and a combination with an “immature” or “insufficiently mature” cervix.

The condition of the cervix is ​​the main indicator of the synchronous biological readiness of the mother and fetus for childbirth.

With a “mature” cervix, taking into account the favorable obstetric situation (proportionality of the fetal head and maternal pelvis, etc.), early amniotomy is indicated.

Before amniotomy, it is necessary to administer antispasmodics intravenously, since a rapid decrease in volume can cause hyperdynamic contractions of the uterus (discoordinated contractions). It is impossible to open the amniotic sac if the cervix is ​​“immature”!

If there is no effect from the therapy, the structural “immaturity” of the cervix persists, the indications for delivery by cesarean section should be expanded.

During prenatal rupture of amniotic fluid, the main determining indicator for choosing delivery tactics is the condition of the cervix and fetus.

It should be taken into account that discoordination of contractile activity of the uterus is often accompanied by an increase in body temperature to 37.8-38 °C, at which point surgical delivery is contraindicated.

In case of prenatal rupture of amniotic fluid, satisfactory condition of the fetus and complete readiness of the cervix for childbirth, you can wait 3-4 hours until labor develops on its own, or carry out careful labor stimulation with prostaglandin E2 preparations (together with the administration of antispasmodics).

To treat the pathological preliminary period in the absence of effect from the above therapy, “acute” tocolysis is used, which effectively relieves spastic contractions of the uterine isthmus, reduces basal tone and normalizes uterine excitability.

Tocolytic (β-adrenomimetic) drugs used for this purpose include: ginipral, fenoterol, partusisten. The method of “acute” tocolysis is as follows: 5 ml of ginipral, containing 5 μg of hexoprenaline sulfate in 1 ml, is dissolved in 200 ml of isotonic sodium chloride solution or 5% glucose solution and administered intravenously by drip slowly (6-12 drops/min). Tocolysis is used taking into account contraindications and side effects.

Adequate treatment, as a rule, promotes the development of labor. The presence of a pathological preliminary period indicates that the pregnant woman has an initial pathology of contractile activity of the uterus even before the development of labor.