Prevention and treatment of premature amniotic fluid shedding and prolapse of umbilical cord loops

From the moment a pregnant woman or a woman in labor is admitted to the hospital, bed rest and an elevated position of the woman's pelvis are prescribed. Relatively often, already with the first contractions, and often even before their onset, the waters break and the umbilical cord loops prolapse. The latter is especially dangerous with a small opening of the cervical os. An attempt can be made to tuck in a prolapsed umbilical cord in a pure breech presentation. In the case of a foot presentation, such attempts are unsuccessful (there is no support belt), so this should not be done. If the umbilical cord loops prolapse when the cervical os dilates to 6-7 cm in primiparous women and 5-6 cm in multiparous women, after an unsuccessful attempt to tuck in the umbilical cord, a cesarean section should be performed. If the umbilical cord loops prolapse at the end of the first stage of labor, conservative management is permissible. In this case, the umbilical cord that has fallen out of the genital slit should be carefully wrapped in a sterile napkin moistened with a warm isotonic solution of sodium chloride; If the fetus's heartbeat changes, it must be extracted.

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Treatment of anomalies of labor

In case of untimely rupture of amniotic fluid and absence of biological readiness for childbirth (immature cervix, etc.), preparation for childbirth is carried out over the course of 2-3 hours: prostaglandin E2 in the form of a gel at a dose of 3 mg is introduced into the posterior vaginal fornix, and estrogens are also administered - a solution of folliculin in oil for injection 0.05% - 1 ml or 0.1% - 1 ml intramuscularly; in order to more quickly mature the cervix and enhance the uteroplacental blood flow and the transport function of the placenta, infusion therapy with sigetin is recommended according to the method: sigetin 1% - 20 ml in 500 ml of isotonic sodium chloride solution or in 500 ml of 5% glucose solution is administered intravenously at a frequency of 8-12 drops / min, on average for 2-2.5 hours; At the same time, in order to suppress the contractile activity of the myometrium, a 0.5% diazepam solution is administered intravenously, slowly, 2 ml, prepared in an isotonic sodium chloride solution (10 ml at the rate of 1 ml of the drug over 1 min to avoid diplopia or slight dizziness that occur with rapid administration of the drug). It should be remembered that seduxen cannot be administered in a mixture with other drugs, since it quickly precipitates.

The optimal dose of estrogens has been established in studies and is 250-300 U/kg of body weight. In order to create an estrogenic background, it is advisable to use estrogenic drugs containing mainly estradiol and estradiol fractions - estradiol dipropionate, estradiol enatate, ethinyl estradiol and others, but folliculin should not be used, which contains a mixture of estrone, estradiol and estriol, since estriol has a relaxing effect on the myometrium.

In case of untimely rupture of amniotic fluid and biological readiness for childbirth (mature cervix, high excitability, etc.), stimulation begins immediately; in case of an immature cervix, stimulation begins 1 hour after the end of preparation for childbirth.

When deciding on the need for labor stimulation, it is necessary to take into account that the average duration of labor should not exceed 16-18 hours for primiparous women, 12-14 hours for multiparous women, as well as those cases in which labor does not occur within 12 hours after the amniotic fluid has been released (caesarean section).

Methods of stimulation of labor

Castor oil is given orally 30-60 g and after 30 minutes a cleansing enema is prescribed. Immediately after emptying the bowels, the woman in labor takes quinine hydrochloride 0.15 g every 15 minutes, 4 times and then oxytocin is administered intramuscularly in fractions of 0.2 ml every 20 minutes, a total of 5 injections. If the effect is insufficient, after 2 hours labor stimulation is repeated according to the same scheme and in the same doses, but without the use of castor oil and a cleansing enema.

If the labor stimulation with quinine-oxytocin is insufficient and the woman in labor is tired, she should be given a drug-induced sleep-rest for 5-6 hours with preliminary creation of an estrogen-vitamin-glucose-calcium background and intravaginal administration of prostaglandin E in the form of a gel, which helps increase the number of oxytocin receptors in the myometrium. After the woman in labor has fully awakened, the labor stimulation scheme with quinine-oxytocin can be repeated or oxytocin or prostaglandin can be administered intravenously.

The refusal to use quinine in labor stimulation schemes, as some modern obstetricians suggest, seems premature, because, as shown by the studies of M. D. Kursky et al. (1988), quinine in the concentration range of 10~ ³ -10~ ² M sharply increased the rate of passive release of Ca ²⁺ from sarcolemma vesicles, while sygetin in the same concentration range did not affect this process. The fact that quinine increases the rate of release of Ca ²⁺ ions accumulated by passive equilibration or in an ATP-dependent process indicates an increase in the calcium permeability of membrane vesicles. Quinine increases the nonspecific permeability of the sarcolemma.

The M.E. Barats method can also be used to induce labor. A solution of folliculin in injection oil 0.05% - 1 ml or 0.1% - 1 ml is administered intramuscularly 3 times at intervals of 8-12 hours. After 6 hours, the woman is given 60 g of castor oil and after 1 hour - a cleansing enema, after another 1 hour - quinine hydrochloride 0.15 g - 8 times at intervals of 20 minutes, then oxytocin 0.2 ml intramuscularly 6 injections, each after 20 minutes. It is not recommended to open the amniotic sac. It is not recommended to begin labor induction with amniotomy in case of breech presentation, even purely breech.

Labor stimulation with intravenous oxytocin

If there is no effect from labor stimulation using the quinine-oxytocin method, it is advisable to resort to intravenous oxytocin with opening of the amniotic sac. For this purpose, 5 U of oxytocin are diluted in 500 ml of 5% glucose solution, mixing thoroughly. Intravenous administration of oxytocin should be started with minimal doses - 8-12 drops / min. If there is no increase in labor activity, the dose of oxytocin is gradually increased by 4-6 drops every 45 minutes - 1 hour, not exceeding 40 drops / min. When administering intravenous oxytocin, constant supervision by a midwife and obstetrician is necessary. Oxytocin is contraindicated in polyhydramnios, multiple pregnancy, grade III nephropathy, preeclampsia, in the presence of a postoperative scar on the uterus, narrow pelvis, etc.

When using oxytocin intravenously in the second stage of labor, it is administered starting at 8-10 drops/min with a gradual increase in the dose every 5-10 minutes by 5 drops, bringing the rate of oxytocin administration to no more than 40 drops/min; the total dose is 10 U with 500 ml of 5% glucose solution.

It is believed that when deciding on the possibility of vaginal delivery, the obstetrician should not be afraid to induce labor with oxytocin in cases where this is necessary for the treatment of a prolonged latent phase or a slow active phase of labor. Other abnormalities of labor, such as secondary arrest of cervical dilation or abnormal descent of the presenting part of the fetus, serve as an indication for cesarean section. The authors also believe that the course of labor in breech presentation should be monitored using electronic monitoring equipment, and in case of obvious signs of fetal distress, cesarean section is required. In breech presentation, mild variable decelerations are often observed during labor. They are an indicator of fetal distress only in cases where they are more pronounced, occur against the background of low fetal pH values, or are accompanied by pathological variability from beat to beat on the FSP registration curve. To determine the pH of a fetus in breech presentation, blood can be obtained from the presenting buttocks.

Prostaglandin stimulation of labor

A solution of prostaglandin F2 (enzaprost) is used, which is prepared immediately before administration using the following method: 0.005 g of the drug is dissolved in 500 ml of a 5% glucose solution, resulting in an enzaprost concentration of 10 μg/ml. The administration of the solution should begin with minimal doses - 12-16 drops/min (10 μg/min), followed by a gradual increase in the frequency of drops by 4-6 every 10-20 min. The maximum dose of enzaprost should not exceed 25-30 μg/min.

In case of premature rupture of membranes in women with premature pregnancy, labor induction should begin 4-6 hours after the rupture of membranes.