Programmed childbirth

In recent years, there has been renewed interest in programmed birth.

In some cases, artificial induction of labor is performed at the right time without medical indications, when the fetus has reached full maturity and there are no signs of spontaneous labor. Such preventive labor induction during normal pregnancy is called programmed labor.

Programmed termination of full-term pregnancy is currently performed in an average of 10-15% of pregnant women, with better results year after year for both mother and child compared to the expectant management of spontaneous labor.

The main condition for the success of programmed birth is the precise determination of the gestational age, the condition of the fetus and the readiness of the mother's body for childbirth. It has been established that the echographic determination of the biparietal diameter of the fetal head is a more accurate indicator for predicting the date of birth than the date of the last menstruation, therefore, ultrasound data are also used in practice.

The advantages of programmed birth are:

• mother's preparedness, her good mental state;
• childbirth during the daytime, when well-rested, trained staff are present in the delivery room;
• intensive monitoring from the onset of labor;
• shortened duration of labor.

Negative aspects of programmed birth:

• burdening the mother with labor induction techniques;
• more frequent anomalies of fetal head insertion;
• disturbances in uterine contractility;
• uterine hypotension after childbirth.

In cases of complications, programmed labor may be considered the cause. However, these complications are quite rare and most often depend on insufficient assessment of the situation before labor induction.

Necessary conditions for programmed birth:

• cephalic presentation of the fetus;
• full-term pregnancy (40 weeks, or 280 days);
• fetal weight (calculated using ultrasound) not less than 3000 g;
• the fetal head inserted into the pelvic inlet;
• mature cervix;
• the readiness of the uterus for the appearance of regular uterine contractions (demonstrated using cardiotocography data).

It is especially important to observe these conditions for women giving birth for the first time.

Methodology for conducting programmed births

The following technique is used.

The day before, ultrasound examination, cardiotocography, determination of cervical maturity, amnioscopy.

Induction of labor. 7.00 a.m. - enema, shower, the woman is transferred to the delivery room.

8.00 am - amniotomy, cardiotocography.

9.00 a.m. - oxytocin, 5 U/500 ml of isotonic sodium chloride solution intravenously, drip.

Childbirth, cardiotocography (determination of pH from the fetal head), pudendal anesthesia, pain relief (nitrous oxide, etc.).

Research also shows that programmed labor allows choosing the optimal time for delivery, which is especially important, according to the authors, in severe gestosis and extragenital pathology. Delivery is carried out on working days and during working hours. Programmed labor in primiparous women allows reducing the frequency of prolonged labor, improving outcomes for the mother and fetus.

It is believed that active labor management tactics are indicated in uncomplicated full-term pregnancies in order to reduce perinatal losses; in pregnant women with extragenital and obstetric pathology to improve obstetric and perinatal indicators, and are also absolutely indicated (!) in extreme situations, as a preventive measure against maternal morbidity and mortality. Delivery in uncomplicated pregnancy as a preventive measure against its post-term pregnancy is performed upon reaching 39 weeks with a mature fetus and a prepared cervix at an arbitrarily chosen time that is optimal for the woman and medical personnel; it begins with amniotomy early in the morning, after a full night's sleep. With the development of regular labor activity, which, as a rule, begins within 2-3 hours, labor is performed under constant monitoring of the nature of labor contractions, the condition of the woman in labor and the intrauterine fetus, adequate pain relief and measures aimed at preventing complications during labor are carried out.

Delivery of pregnant women with extragenital and obstetric pathology is carried out by the authors according to a delivery program developed for each specific case. It includes:

• preparation of the pregnant woman's body and the fetus for childbirth;
• determination of the optimal timing of delivery for the mother and fetus depending on the nature and severity of the pathology;
• a method of inducing labor in accordance with the readiness of the pregnant woman's body for childbirth;
• individually selected method of pain relief during labor;
• the need for the participation of highly qualified specialists in childbirth - therapists, anesthesiologists, neonatologists and others;
• specific recommendations for managing the first and second stages of labor.

When managing complicated labor, the following recommendations must be followed:

• - in the presence of extragenital diseases, as a rule, involve a general practitioner in drawing up a plan for managing childbirth;
• - decisions on pain relief during childbirth and surgical interventions should be made jointly with an anesthesiologist.

This is very important, since, according to the study, the number of cesarean sections is increasing to 7.4%. However, in 1/3 of cases, operative delivery is performed on an emergency basis. In these conditions, adequate preoperative preparation and rational type of anesthesia are often not provided, and tragic technical errors are made. The number of fatal outcomes as a result of anesthetic interventions has increased alarmingly;

• When speaking about shortening the second period (the pushing period), they mean mainly the application of exit forceps or an exit vacuum extractor, in isolated cases - the application of abdominal forceps or a vacuum extractor. In some women in labor, perineotomy may be sufficient. If it is necessary to completely eliminate the pushing period, the issue of cesarean section should be discussed;
• when the presence of signs of a violation of the vital activity of the intrauterine fetus is established, this means a threatening asphyxia of the fetus. In this case, the birth of a child without signs of asphyxia should be regarded as evidence of the timeliness of the measures taken. Birth in asphyxia indicates a delay in the application of therapeutic and preventive measures;
• if the mother in labor has severe extragenital pathology, especially cardiovascular pathology, the presence of a general practitioner during labor is necessary;
• Suspicion of the possibility of bleeding in the afterbirth or early postpartum period due to hypofibrinogenemia requires providing the maternity ward with all the necessary means to combat it in such cases, both preventive and therapeutic. This also applies to hypotonic bleeding.

Programmed management of labor during pathological pregnancy is closely connected with such concepts as body biorhythms, chronophysiology, chronopathology, chronotherapy and chronopharmacology.

It is known that labor often begins and ends at night. Medicines act differently depending on the time of their administration. If the mother does not have desynchronization phenomena during pregnancy, i.e., a discrepancy between the components of the biorhythmic system of the mother and the fetus, the pregnancy, the onset and course of labor proceed safely. The issue of indications for the management of programmed labor in physiological and pathological pregnancy has not been sufficiently studied to date. It is especially relevant for pregnant women at high risk of maternal and perinatal mortality. Some doctors conduct programmed labor with a division into the preparatory period for them and their management. Programmed labor is carried out on weekdays, labor induction begins at 5-6 am, which allows the labor to be completed during the day. Usually, 3 hours after the onset of labor induction and the opening of the cervix by at least 3 cm, amniotomy is performed, while continuing intravenous drip administration of oxytocin, or PGF2a, or prostegan. Programmed labor, according to the authors, has great advantages (compared to spontaneous labor), especially for pregnant women with various types of obstetric and extragenital pathology and does not have a negative effect on the fetus. A technique has also been developed for performing programmed labor in case of fetal growth retardation (hypotrophy). Delivery of such pregnant women is performed at 37-38 weeks of pregnancy. Labor induction is performed when the cervix is fully ripened and all conditions for performing programmed labor are observed. Labor induction is started with an intact amniotic sac. The drug of choice for labor induction is prostenone (PGE2). The drug has an advantage over oxytocin in that it dilates the placental vessels, accelerates uteroplacental blood circulation, and according to research, activates enzymes of the direct pathway of carbohydrate oxidation in the fetal liver and placenta, which improves fetal energy supply. Oxytocin can cause spasm of the uterine vessels, impede uteroplacental blood circulation and cause a state of hypoxia in the fetus. It has been proven that the stimulating effect of prostenone on the uterus is removed by papaverine, which ensures increased uteroplacental blood circulation and helps normalize the oxygen balance of the fetus.

The management of programmed labor consists of the following:

• selection of the day and time of day for induction of labor, taking into account the biorhythms of labor and the work schedule of the maternity ward staff;
• drawing up an individual birth program (selection of uterotonic drugs) with prediction of their outcome, as well as taking into account the psycho-emotional state of the pregnant woman and the condition of the fetus;
• implementation of monitoring control over the nature of labor and the condition of the fetus;
• thorough pain relief during labor, preferably epidural anesthesia;
• ensuring constant mutual positive communication between the doctor leading the birth and the woman in labor;
• objective information to the woman in labor by the doctor about the condition of the fetus during labor;
• rational high-calorie nutrition for women in labor;
• a favorable environment in the delivery room and a friendly attitude of the staff towards the woman in labor;
• absolute compliance with the rules of asepsis and antisepsis in the delivery room;
• readiness and serviceability of equipment for providing emergency assistance to a newborn in the event of his birth under asphyxia;
• availability in the delivery room of blood of the same group for transfusion and a set of medications in case of the need to provide emergency assistance to the woman in labor.

Early termination of pregnancy involves the intervention of an obstetrician at various stages of pregnancy, including in the last week before spontaneous labor occurs, with the expectation of obtaining a viable child. Planned birth at the optimal time provides good outcomes for the mother and child.

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